Click here to view the original July 24, 2009 story.

JANE STROM: Happy Birthday.

AL (Jane Strom’s father): Thank you.

JANE STROM: Do you know how old you are?

AL: Yeah.

JANE STROM: How old are you?

AL: I don’t know.

JANE STROM: How old are you? You are 90, 90 years old…

LUCKY SEVERSON (Contributing Correspondent): Not long ago, Dr. Joel Strom and his wife, Jane, were so convinced that Jane’s father was close to death, notwithstanding the attention he was receiving from ten specialists, they put him in a hospice, and then he got better.

DR. JOEL STROM (Cardiologist and Professor, University of South Florida Medical School): Part of it was that he had one person who took care of him. They cut out all the referrals because they didn’t expect him to live long, and they cut out all the medicines.

SEVERSON: Dr. Strom is a cardiologist and a professor at the University of South Florida Medical School. Like every doctor we spoke with, Strom is fed up with the health care system.

DR. STROM: It’s not a broken system. There is no system. Medical care is haphazard. Medical care is disorganized. There are pockets of superb care. There are pockets of very mediocre care.

SEVERSON: If Medicare costs are any measure, Miami-Dade County should have the best senior care in the country. The federal health program spends over $16,000 a year per patient. That’s about double the 2006 national average. Brian Keeley is the CEO of Baptist Health South Florida, the largest nonprofit health care system in that part of the state. He says huge Medicare costs do not translate to better health care.

BRIAN KEELEY (CEO, Baptist Health South Florida): We know that more can be injurious to people, and more health care services, more aggressively providing those services, can result in lower levels of care.

SEVERSON: He says there are several factors that bloat health care costs in the Miami area.

KEELEY: There’s a huge imbalance between the number of specialists and primary care physicians, and we have such a high percentage of specialists down over here, they utilize resources more, technology more.

SEVERSON: Dr. Strom, a specialist himself, says one reason there is such a shortage of primary care physicians is that Medicare doesn’t reimburse them enough for patient visits.

DR. STROM: If you spend a lot of time with a patient you will starve to death as a physician because you will only get paid for a certain amount of time. In fact, a lot of physicians will actually steer patients to their offices to have tests performed, because they collect both the professional component, and if they own the equipment, the technical component.

SEVERSON: Dr. Gloria Weinberg is a geriatrician and chair of the department of medicine at Mount Sinai Hospital in Miami Beach. She says when young doctors, fresh out of medical school and burdened with school loans, discover how much less a primary physician earns, they choose a specialty where they can make more money.

DR. GLORIA WEINBERG (Geriatrician and Chair, Department of Medicine, Mount Sinai Medical Center): If you look at the reimbursement, you are going to come away after paying expenses, if you are lucky, with $40 or $50 an hour. That’s not going to help the youngsters go into a field of medicine and pay off loans and do everything else that needs to be done.

SEVERSON: Here in Miami, a typical senior citizen will see a doctor 106 times during the last 2 years of their lives. Not just one doctor, several—specialists who will then prescribe a battery of expensive tests and procedures: MRIs, ultrasounds, CAT scans, and an astonishing assortment of drugs. It’s because that’s the kind of care patients around here often demand. Dr. Weinberg:

DR. WEINBERG: Patients are very sophisticated. They come, and they say, “I have a headache.” You take a headache history. They are not satisfied if you say, “You don’t need a scan.” They want a scan. If you are pushed, and you are suspicious enough, and perhaps you suggest a CT, which is less expensive than an MR, some of them will come to you and say, “I want an MR. I hear it’s more sensitive.” We have had patients in our center tell us, “If you don’t do what I’m asking I’m going to sue you.”

SEVERSON: The threat of lawsuits forces many doctors to practice defensive medicine, ordering more tests and procedures to protect themselves from being sued. Health care professionals here cited malpractice suits as another factor behind spiraling costs, and Medicare fraud in South Florida, particularly in the home health care industry, has been described as rampant.

KEELEY: The Miami Herald reported about a month ago that the FBI and CMS [Centers for Medicare & Medicaid Services] indicated that fraud was about $2.5 billion per year in Miami-Dade County. That, in and of itself, is a huge, huge difference, comparing our cost structure to the rest of the country.

SEVERSON: About 50 million Americans are uninsured, and that includes 30 percent of the population around Miami. Many of that number are undocumented and in the US illegally. Whatever their status, most who need care end up in a hospital emergency room where, by law, they cannot be refused treatment.

DR. WEINBERG: It’s our ethical responsibility to treat that patient as we would any other. That patient can go down the path of having a cardiac catheterization, ultimately having a pacemaker, a defibrillator at $30,000, ongoing medical care, and then we face the problem, when we discharge the patient, where does the patient get the follow-up care, and the hospital doesn’t get reimbursed for it.

SEVERSON: Perhaps the biggest chunk of Medicare expenditures, something like 30 percent, goes to end-of-life care for aging Americans. Professor Anita Cava directs the University of Miami business ethics program. She says Americans need to rethink the way we look at end-of-life medical care.

PROFESSOR ANITA CAVA (Director, University of Miami Business Ethics Program): I think we in the United States really need to reconsider our relationship with end of life and to realize it’s a natural process and that perhaps ending life in a more humane and comfortable way at home with family, rather than trying to prolong it for another day or week or month, is perhaps the best way to go.

SEVERSON: Joe Gasperovich would take exception to the ethical argument for withholding expensive medical treatment for aging, failing Americans. He was born in 1919 and would prefer to prolong his life as long as possible.

SEVERSON (speaking to Joe Gasperovich): If they say we need to go do a $1,000 CAT scan, is there a point, an age you reach where you should say no, I’ve lived 90 years?

MR. GASPEROVICH: No, I want more.

SEVERSON: You want more years?

MR. GASPEROVICH: Everybody—nobody want to die.

SEVERSON: Dr. Weinberg says the decisions about the ethics of distributive justice for society as a whole are often much more difficult when the doctor is meeting with a patient one-on-one.

DR. WEINBERG: The health care dollars, an inordinate amount, go to taking care of people in the last 6 months of their lives. But how do you know when those last 6 months are? You have a person who has worked all their life, paid taxes, done very well, and now they are 80, and they have a heart attack. That may be the person who lives 10 or 15 more years. Are we going to say no just because of age? That’s a very, very slippery slope.

SEVERSON: There is a huge ethical discussion about who should make these end-of-life decisions—the patient, the family, doctors, the government? Brian Keeley says some decisions are easier to make. For instance, Medicare should only reimburse for treatments and drugs that are known to work.

KEELEY: It ought to be evidence-based. If something is proven not to work, I don’t think the federal government ought to be paying for it. I don’t think anybody ought to be paying for it, except for the private patient.

SEVERSON: Dr. Weinberg says too many patients receive expensive treatments and surgery in their final years that very likely won’t prolong their life.

DR. WEINBERG: So if you have an Alzheimer patient who, your own belief may be, it’s time to let this person go naturally, and the family is telling you, “I’m the surrogate, and I’m insisting that a feeding tube be put in,” you cannot make the decision not to put the feeding tube on your own, even though you think it’s futile care, at least in the state of Florida.

SEVERSON: Dr. Weinberg says her 95- year-old mother has a living will that stipulates she will not be kept alive on a ventilator. Brian Keeley says preparing for end of life is not something that’s culturally accepted in South Florida.

KEELEY: Other parts of the country where people plan for end-of-life care, with the use of hospices and palliative care and what have you—down here there’s less usage for that, so people go to die in the hospitals.

SEVERSON: Everyone seems to agree that health care reform is urgently needed and that health care should be a right and not a privilege and that it should extend to everyone. They also agree that South Florida is a good place to start.

For Religion & Ethics NewsWeekly I’m Lucky Severson in Miami.

Note: Since this story first aired in July 2009, Dr. Joel Stroms’ father-in-law, Al Godin, passed away.

REV. CHRISTINE WILEY (Covenant Baptist Church): We pray for health, O God, that you would pour your spirit into them and heal their bodies, O God.

LUCKY SEVERSON, correspondent: Reverend Christine Wiley has been ministering to AIDS patients in Washington, DC since the early1980s. Back then people were dying from a disease they didn’t understand and had no idea how it was spreading. Reverend Wiley first met AIDS patients when she allowed the health clinic across the street to move into her church when the clinic’s roof fell in.

WILEY: What I found was a profound privilege of being able to work with people who had contracted this disease, and being able to talk with them to help them get to a place where they had hope and understood that they were still loved by God.

Rev. Christine Wiley

SEVERSON: Twenty years later, Reverend Wiley is still preaching and teaching about HIV-AIDS, which we now know a lot about. We know that it’s preventable and treatable, and yet it has reached epidemic levels in the nation’s capital. The most recent statistics are sobering. Three percent of local residents have HIV or AIDS—triple the number that is generally considered a “severe” epidemic. But among African-Americans residents, the overall rate is above four percent, which is higher even than parts of West Africa. And among the District’s black men the infection rate is even more alarming—almost seven percent. Authorities are worried that the number is actually higher because so many residents are spreading the virus without knowledge they’re infected. This is Bishop Rainey Cheeks at the Inner Light Ministries Sunday worship service.

BISHOP RAINEY CHEEKS (Inner Light Ministries): We live in a city that has the highest infection rate in the country. We live in Ward 8, and it has the highest infection rate in the city, and here we still operate in a state of ignorance, and the Scripture tell us “my people perish for lack of knowledge.”

SEVERSON: Bishop Cheeks is not your typical preacher. He is openly gay and has been HIV-positive for 25 years.

CHEEKS: People would say, what would Jesus do? And I say stop asking that question. Do what he did. Heal people. Love people. He said feed, clothe, shelter people. That is all HIV is asking us to do.

SEVERSON: The church has long been the most influential institution in the African-American community. But Bishop Cheeks says when it comes to AIDS, too many black pastors have been silent, or preaching when they should have been teaching.

CHEEKS: Throughout our history, the information has always been disseminated through the church. Imagine if all the churches on Sunday morning gave just the facts and where they could go get help. How many people would we reach?

Bishop Rainey Cheeks

WILEY (preaching): Have you ever felt persecuted just for living, just for being who you are?

SEVERSON: At the Covenant Baptist Church, Rev. Wiley, who has a doctorate in pastoral psychotherapy, tells her members who have the disease that they are not sinners, that God loves them, and she explains ways to safeguard against the virus to anyone who will listen. Some think the epidemic has passed and don’t want to listen. Some don’t want to know. That’s why Rev. Wiley offers weekly AIDS testing like this, right in church. She says she discovered that many African Americans do not view the black church as a safe place to get counseling about AIDS.

WILEY: There is such a heavy stigma. Then often it’s not talked about. And, of course, within the context of the church one of the things that is difficult is interpretation of Scripture. Many persons within the black church, generally speaking, are very conservative. We find that the issue of sex is not talked about at all in many, many churches, and so if you don’t talk about sex it’s difficult to even talk about risky behavior.

SEVERSON: Bishop Harry Jackson’s Hope Christian Church is typical of many black churches, if not most. Many members here consider drug abuse, premarital sex, and homosexual activity as sins.

BISHOP HARRY JACKSON (Hope Christian Church): Black clergy typically are very conservative socially, and they are much more liberal in terms of other issues. But the heart of the black church is the preaching, and the preaching has to be from the Bible, and that biblical message has been the source of the conservatism of the church, and it’s also the strength.

JACKSON (speaking at rally): And I would rather be biblically courageous than politically correct.

SEVERSON: Bishop Jackson has been a leading spokesman in the District in favor of marriage only between a man and a woman. He agrees that black pastors have not done enough, but sees the problem more as the breakup of the black family.

JACKSON: We haven’t done the preventative work that puts it in the mind of a young teenage girl or boy, hey, you shouldn’t have sex this early. You’re having all the babies out of wedlock, all these things, and I’ve got to take responsibility for it. The only institution that stands between our community and what I’m going to call basically the destruction of family as we know it today is the church.

WILEY: We’ve got to talk about drug addiction. We’ve got to talk about sex. We’ve got to talk about relationships, because women who are heterosexual and have relationships are also having relationships with men who sleep with men.

SEVERSON: Nationwide, the leading cause of HIV-AIDS is still men having sex with men. But here in the District the principal mode of transmission for new cases is heterosexual for both men and women, and 70 percent of those infected are over 40 years old.

CHEEKS: We put condoms out right here in the church on Sunday. You can walk and pick them up right here, and people go, isn’t that a little extreme? Well, what do you call extreme? Saving someone’s life?

SEVERSON: Bishop Jackson remains skeptical about the reliability of condoms and is firmly convinced that abstinence only is the best policy. He blames much of the problem on immoral behavior and the prevailing culture.

JACKSON: The moral message is not being grasped. The culture is shaping much more what happens in the black church. If I say it this way, in all deference to our stars, Beyonce may be listened to more than the bishop.

SEVERSON: And the bishop has no intention of bending his message about the sin of premarital and homosexual sex, although he doesn’t oppose testing and wants his church to do more to help those who are infected.

WILEY: Even with a person who is a conservative we still have to acknowledge that there is a disease in our community, and it has not gotten better. It has gotten worse.

JACKSON: It may be that we’re going to reach people that trust us and trust our interpretation of Scriptures. But if you don’t believe the Gospel as we believe it, maybe you will not feel comfortable coming to us for help, and maybe that’s where someone else has to work, and my point would be we at least need to touch the people we can touch, and I’m not so sure we’re touching them yet.

SEVERSON: On that point they would all agree.

CHEEKS: I’m more concerned with how do we save our community more than I need to be right or any of that. How do we save our community? And then we can have all the other theological debates later on. But right now, we are in trouble.

SEVERSON: For Religion & Ethics NewsWeekly I’m Lucky Severson in Washington.

BOB ABERNETHY, anchor: As Congress assembles a health care reform package, a longtime expert on medical ethics writes in a recent issue of Commonweal magazine that there has been an important idea missing from the debate—the concept of the common good. The expert is Daniel Callahan, founder and now president emeritus of the Hastings Center. His new book is Taming the Beloved Beast.  He joins us from New York.

Mr. Callahan, welcome. How do you define the common good?

DANIEL CALLAHAN (Senior Researcher and President Emeritus, The Hastings Center): I mean by the common good our life together, the stranger and the neighbor, the friend we know and the person—people we don’t know. The common good I think of as essentially a social concept. Aristotle said human beings are social animals, and I think that is true, and it seems to me that as we think about our own life, either in politics or health reform, we have to think not only of ourselves and our family but also of the neighbor, the stranger, the person we don’t know, and somehow knit that together into some meaningful whole.

ABERNETHY: And was there a time in this country’s history when the idea of the common good was very strong, very prevalent?

CALLAHAN: Well, in a curious sense, its not like—Europe has a much stronger sense of the common good, in great part because of their wars and other terrors they have gone through. In this country I think there has been ambivalence and uncertainty about the common good. We really—freedom has been our main catchword, the main value we have gone by, justice a little bit less so. But the idea of working together for the common good is something—it certainly is come at in times of warfare, but it’s sporadic. It often doesn’t mark our common life together, and a great number of people really, I think, are just enormously ambivalent. They want to help the poor, but of course they don’t want to raise their taxes. They’d like health care reform and they see the need for cutting costs, but they don’t want to give up anything themselves. So we are very torn on the common good, I think.

ABERNETHY: Is that why it has been so difficult to put together health care reform, because nobody wants to give up anything?

CALLAHAN: That’s a very powerful part of it. Now some of it is different politics. Republicans and Democrats differ on the role of government. But it is very striking that even the Democrats, who started out talking about cost control, immediately backed down and said of course we can’t take anything away from people. But, of course, we can’t control costs unless we do, unfortunately, take some things away from people.

ABERNETHY: And that’s the idea in your new book, Taming the Beloved Beast, isn’t it, that technology, medical technology, has become so important, but also so expensive, that there have got to be some kind of limits, some kind of controls. Is that right?

CALLAHAN: Exactly right. Technology is probably the main thing that drives up health care costs in this country. Everybody loves it. Doctors love it, patients love it, and it’s part of American culture, and it’s done wonderful things. It keeps us alive longer, it keeps us healthier. Yet, at the same time, the cost of it all is beginning to really corrode, even destroy, the heath care system. It’s one of those wonderful cases of when is enough enough, and when does a good thing turn into a bad thing?

ABERNETHY: And, very quickly, are we going to get a good, in your judgment, a good health care reform?

CALLAHAN: I think we’ll get a good reform in the sense that we’ll probably see a much enlarged coverage of the uninsured, and we’ll see certain changes, improvements in health care for children and Medicaid. At the same time, we will not be able to control costs under the present bill, and I think that’s going to create enormous problems in the very immediate future.

ABERNETHY: Daniel Callahan of the Hastings Center, many thanks.

Daniel Callahan

The aim of health care should be, within a finite life span, to help us to have a good chance to progress from being young to being old—but not to go from being old to being indefinitely older; to relieve us of our most burdensome physical and mental suffering—but not always fully or perfectly; to rehabilitate us as best it can if we are disabled—but to understand that some of us will live our lives with chronic illnesses and disabilities; and to help us achieve as pain-free and peaceful death as is possible—but knowing that goal will not always be possible. Medicine ought not to seek an indefinite extension of life or aim to enhance our nature beyond the ordinary standards of good health, or search out medical ways of excessively fighting our decline and frailties, many of which are now and always will be unavoidable. Just as death ought not to be taken as the ultimate enemy of human life, health should not be taken as the ultimate good.

As Judith Feder and Donald W. Moran have observed, “To be serious about cost containment, it will be necessary to admit that containing costs will require affecting the decisions that individual Americans make every day in all the settings in which they make them.” Whether Americans can be brought to think differently about health, to expect less and to settle for less, and to be willing to forgo some health care they might like, or even need, for the sake of the public good, takes a utopian, or maybe a counter-utopian elixir of hope and imagination. I see no plausible alternative.

As individuals, we are in a position similar to our health care system problem if we do not learn to rein in our aspirations for perfect health, to live with some of our needs that might otherwise be medically dealt with, to run some risks with our health, understand that an elevated level of this or that reflects a possibility of harm only, not a death sentence, and to recognize (even if begrudgingly) that a cure of one of our otherwise lethal diseases will not save us from some other one. Cured diseases are always succeeded by a final and fatal disease. If we as individuals do not bring some greater realism to our health, some willingness to put up with our mortality and vulnerability, and the anxiety that goes with its recognition, then there is no hope that costs can be controlled, hardly any technologies that can be limited or denied.

There is, to be sure, an obvious objection to my line of thought here. Even if, as individuals, we limit our medical appetite, there is no guarantee that any money saved by our altruism will go to other more serious social or health needs. True enough, and that is one of the serious penalties for living in a society without universal health care and the circumscribed budget that should go with it. But it is also true, as we can see with voting, that it is a bad mistake to think that, with a large electorate, our individual votes are irrelevant. The danger is not that one vote will harm the election process. It is that, if everyone thinks that way, then the process will indeed be harmed. So, if only a few of us begin to change our views of health care, and then a few more, that might indeed make a difference.

My scenario may be fanciful, but as individuals we need an open discussion on what counts as good or bad choices, wise or imprudent ones, and our social obligations to our community as we make them. Such a discussion need not be, and ought not be, coercive. It might, however, help shape some rough consensus, moving us at least in the right direction There is an obvious truism, usually ignored in health care, that the collective, aggregate impact of our private choices can affect the public good. Hence, it is worth the effort to see if those private choices can be nudged in a helpful direction. That direction would be, following my finite model of health care, toward less, not more, and even much less.

BOB FAW, correspondent: At Le Bonheur Children’s Medical Center in Memphis, Tennessee, four-year-old Ethan Barker might seem carefree. But his parents, Chris and Tamara, are frightened about Ethan’s upcoming brain surgery. So when neurosurgeon Dr. Stephanie Einhaus asks if the family would like to pray, they readily agree.

DR. STEPHANIE EINHAUS (praying with family): We come before your throne today, Lord, asking for your blessing on this sweet child of yours.

FAW: Ethan’s surgery is delicate. Einhaus takes a bone from his skull and modifies it to cover a space created by an earlier surgery.

DR. EINHAUS: (in operating room): …the bone of the skull is kind of in two layers and so you can split it like an Oreo cookie…

FAW: For this skilled practitioner, praying benefits her as much as the patient’s family.

DR. EINHAUS: If I’m having a hard time doing something, getting a catheter in a fluid space, I’ll just pause and in my own head I will pray, “Please, Lord, help me get this right.”

FAW: Einhaus says praying with families helps them with the stress and gives them hope.

DR. EINHAUS: It helps them to hold on to something to get through, you know, that crisis that’s going on. Most people want to do it. They’re like, they’re so relieved.

FAW: Eleven-year-old Holly Barkley, about to undergo surgery to drain fluid from her brain, does not face a crisis.

DR. EINHAUS (to patient): How’s your head feeling?

FAW: But her family also wants to pray.

DR. EINHAUS (praying with family): I pray that you will let this family feel your power, let them feel your peace, Lord…

FAW: Prayers like that, family members agree, can bring comfort.

CHRIS BARKLEY: It puts a sense of comfort in you. Normally, doctors don’t do that, and it probably makes people feel closer to the doctor. You want them to care just as much as you do.

LAURA YOUNG (Holly Barkley’s mother): It was more of the Lord was on our side, and it told me then it was going to be okay, and you know I was ready to—if anything came out negative, I was ready to face it.

DR. EINHAUS (to Ethan’s family): Hello. We are all done, and it went great.

FAW: Einhaus, raised Catholic and now a Southern Baptist, was once reluctant to pray with patients in the beginning for fear of being ridiculed. But as time went on she felt more comfortable asking patients if they would like to pray.

DR. EINHAUS: Once you start doing it you realize how much people really like doing it and how powerful it can be as a support for not only the patient but for the families.

FAW: You regard your role as a physician as a kind of ministry.

DR. EINHAUS: I do, I absolutely do.

FAW: In this part of the Bible belt, many patients—like Marletta Scott, facing difficult triple bypass heart surgery at Methodist South Hospital—say they would welcome a chance to pray with their doctor, even though Marletta Scott’s doctor, heart surgeon Alim Khandekhar, happens to be Muslim.

MARLETTA SCOTT: He did explain to me that, overall, that, you know, it was in the Lord’s hands and that he’d be watching over him as well as me during this procedure. I mean, and that’s all that we can ask for.

FAW: That makes you feel good, that gives you comfort?

MARLETTA SCOTT: Yeah, it does.

FAW: in his 32 years of professional experience, Khandekhar says he has found that patients with faith often recover faster.

DR. ALIM KHANDEKHAR: Because they rely not only on the doctors, the medicine, but they rely on a power that is more powerful than all of them, that puts them at ease with themselves, at ease with the decision they are making.

FAW: What all this suggests, especially in this part of the country, is a growing trend by physicians to treat physical and spiritual problems together. After all, says the founder of this Memphis clinic, 50 percent of the patients who come here for primary care do not have medical problems.

DR. SCOTT MORRIS (Founder, Church Health Center, and United Methodist Minister): Many of our physical complaints come about because of our spirits being broken. What they need is a way for us to help them deal with this spiritual devastation.

FAW: So here at the Church Health Center, which since 1987 has treated 60,000 low-income people without health insurance, the spiritual needs of a patient are addressed before they ever see a doctor.

DR. MORRIS: From my point of view, if we want to be healthier, you must have a healthy spirit as well as a healthy body. We know, I think, in our heart of hearts, that being at peace, being bathed in what a person perceives as the love of God, makes people healthier faster.

FAW: But mixing prayer with medicine can cause problems, especially when the goal of reducing suffering conflicts with the wishes of devout patients. For example, a recent AMA [American Medical Association] study found that patients of faith demand and get more aggressive treatment than is medically warranted, and there are also concerns that a patient can be exploited if a doctor uses prayer to proselytize, to promote certain beliefs.

PROFESSOR MARK MUESSE (Associate Professor of Religious Studies, Rhodes College): It might take the form of a particular kind of prayer that the patient might be uncomfortable with. It might include accepting certain kinds of creedal statements that the patient would not otherwise accept.

FAW: At Rhodes College, where he teaches comparative religion, Mark Muesse also worries that praying with a patient could compromise a doctor’s relationship with a patient.

PROF. MUESSE: There could be a boundary crossed there, that a doctor begins to lose his objectivity in relationship to a patient. You’re losing some of the critical distance, I think, that’s oftentimes necessary for proper medical treatment.

FAW: Physicians like Einhaus counter that even if that boundary is crossed, no harm need result.

DR. EINHAUS: No matter what, you’re going to develop a relationship with your patients, okay? So the fact that I’m praying with them may make that bond a little stronger, but in no way would it affect my judgment.

FAW: And that element of compassion, physicians argue, is what is often missing in the training many doctors receive.

DR. KHANDEKAR: During my training, you know, being a cardiac surgeon, I don’t think that part has been stressed enough. It helps me to have another power behind me to do what I do. I do not think enough doctors use this power.

FAW: Here, though, that recognition—that the spiritual can affect the physical—seems to be growing.

PROF. MUESSE: In the past, you know, doctors would take care of the body, and the ministers and the chaplains would take care of the soul, but now we’re seeing that those two things cannot be separated.

FAW: Shortly after his surgery, Ethan was almost as playful as before. Holly, too, was doing just fine. For each, medical technology prevailed.  But in this medical theatre, more and more physicians seem to be sharing a belief that there is more at work here than science and skill.

DR. EINHAUS: We’re not always in control. God’s always in control, and so things may not turn out the way we want them to. We may not like it.  We may not understand it this side of eternity. But we have to trust that he is still in control and that if they go and they die, that heaven is really a good place.

FAW: Here, where there is recognition that when in comes to healing, fixing the body alone is an incomplete, indeed, flawed approach.

For Religion & Ethics NewsWeekly this is Bob Faw in Memphis, Tennessee.

FAMILY MEMBER: She’s been fighting cancer for five years, twice. She has emphysema of the lungs real bad. It’s gotten worse, they said, since she’s been in here, and right now she is fighting a bad stroke. They are not sure, but they are saying something like it could affect her left side and maybe her brain.

BETTY ROLLIN, correspondent: Did she leave any instructions about what to do?

FAMILY MEMBER: No, she did not.

ROLLIN: And that’s a major problem, says Dr. Jeff Gordon, an internist at Grant Medical Center in Columbus, Ohio. Dr. Gordon has had dying patients who have not made their wishes known and haven’t realized that some extreme measures are almost always futile.

DR. JEFF GORDON (Grant Medical Center): Most people think, that is for elderly people especially, that heroic measures like CPR and ventilator support is really effective, and the truth is, in older people with complicated medical problems, it just doesn’t work effectively, so the bottom line is people suffer needlessly at the end of life.

Ventilator–there is a plastic tube that goes through the mouth into the windpipe, and just imagine the gagging kind of feeling. Now we give high levels of sedation to inhibit that, but that alone, now think of yourself, these people typically have to be restrained so that they don’t just reflexively reach up and pull that tube out, and so they have their arms restrained. They can’t move freely, and think of yourself being on your back restrained, just the muscle aches and pains that you would develop.

ROLLIN: Dr. Gordon points out that sometimes aggressive treatment is a good idea.

DR. GORDON: Intensive care and heroic measures are awesome when they are used in the right people. The right people typically are younger people that have a chance of survival and having a good outcome.

ROLLIN: Dr. Philip Hawley, who is director of the intensive care unit, says the state mandate is to keep life going no matter the cost, so although doctors think their patients should be allowed to die peacefully, their hands are tied by custom and law.

DR. PHILIP HAWLEY (Grant Medical Center). We have people who are terminal on aggressive life support measures. Clearly they are not going to survive. We are spending all this time and money taking care of them. They are suffering, and it’s completely inappropriate.

DR. GORDON: What people need to do is talk about this with their family, with their physician, in advance. If they get a life-threatening illness, a lot of times they won’t be able to. Maybe they won’t be coherent, or they’ll be on a life-support machine. They can’t express their wishes, then they put their family in a bind, so they feel guilty, they don’t know for sure, and then what often happens is the sort of default is, well, let’s do everything, as much as possible.

ROLLIN: And sometimes families disagree about what to do. It’s hard for some to let go, which complicates things further.

DR. HAWLEY: If we could get families to deal with this we would not have this problem. We feel we as physicians should be able to step in and say we’ve got to stop the madness.

DR. GORDON (speaking at church service): Lord, help us have perspective. That’s what changes lives. That’s what gives us hope.

ROLLIN: Dr. Gordon, who is also a nondenominational pastor, was surprised to find that patients who are religious often want more aggressive treatment at the end of life than others.

DR. GORDON: I have even encountered people that are people of faith, and they are, what I think, pursuing futile-type measures, and they say well, we are going to let God have his way here, and I try as gently as possible to say we are not really letting God have his way. We are forcing the issue here.

Jill Steuer

(speaking to patient): Has anyone talked to you about this?

PATIENT: Oh, no.

DR. GORDON: No, no. It’s a topic that doesn’t get talked about.

ROLLIN: Dr. Gordon practices what he preaches by getting patients, as well as their families, to talk about what they want at the end of life while they still can, and he tries to make both patients and families aware of realistic rates of recovery.

DR. GORDON (speaking to patient): I just want you to understand is that those kind of things like CPR and breathing machines in somebody that’s got the problems that you have are not very effective. You need to decide whether that is something you would want or not, but you need to have all the facts about it, too.

ROLLIN: One of the reasons conversations like this rarely happen between patients and physicians, says Dr. Gordon, is that physicians are paid to treat, not to talk, which is not to say that some don’t talk anyway.

DR. GORDON: The person that needs to have this conversation is the primary care physician. They are going to have to call family members, they are going to have to gather these people, and besides that it’s a very difficult conversation, and so we are underpaying them. They are going to have to make a financial sacrifice to have this discussion, and then we wonder why it’s not happening.

ROLLIN: There are three things people can do to make their end-of-life wishes clear: Sign a durable power-of-attorney naming a person to make decisions if they are unable; sign a living will which is about long-term life-sustaining treatments; and deal with the DNR question—whether if your heart stops you want to be resuscitated or not.

Jill Steuer, who has metastatic breast cancer and has been given four months to live, has decided to stop any kind of treatment and receive hospice care.

JILL STEUER, RN: I’ve been through all the chemotherapy, and there is no chemotherapy to help me anymore. I don’t want to be stuck. I don’t want to have any extra medications. I want to just go peacefully. The only medications I want are going to be the ones that are going to comfort me. That’s all I want.

ROLLIN: Jill Steuer is a nurse and researcher at Grant Hospital.

JILL STEUER: I’ve seen patients who have died horrible deaths, where their families wanted everything, the doctors wanted everything, but it was not to be, and that scared me. I’m not sure they realize that it’s okay to say “I’ve had enough.” Even now people will stop me in the hallway and they’ll say keep up the good fight, keep up the good fight, and I think some people are afraid that they are going to disappoint others if they just say let’s have nature take its course. I’m putting up a good fight, but my goal is not to live a long and painful year or two. I would much rather say at this point in time I want the next four months to be as interesting as the last 57 years have been.

For Religion & Ethics NewsWeekly, I’m Betty Rollin in Columbus, Ohio.

SAUL GONZALEZ, correspondent: Unlocking and interpreting the secrets hidden in DNA used to be the province of scientists and medical researchers. But now it’s a growing business, one that’s selling genetic information directly to American consumers, making a DNA test as easy to buy as housewares or clothing.

JACK LORD (CEO, Navigenics): You know, I think for the history of man people have always wanted to see something about their future, and now, through the power of genetics and genomics, we are able to look into the future in a science-based way.

GONZALEZ: Jack Lord is the CEO of Navigenics. It’s a California-based company that for a fee of $999 offers its clients a personalized DNA test, one that pinpoints genetic markers indicating possible future threats to their health.

Jack Lord

JACK LORD: It’s really simple. It’s some saliva that we collect. We analyze that and then give you a report that shows what your risks are compared to people in the population at large. So today we test for 28 conditions, and they range from chronic conditions like diabetes or heart disease, to cancers like melanoma or prostate cancer or breast cancer, to other conditions that are generally silent diseases like glaucoma and macular degeneration, celiac disease, to Alzheimer’s disease.

GONZALEZ: Navigenics is one of a growing number of new companies selling genetic tests directly to the public. All of them promise their clients better health and a better life by getting up close and personal with their DNA.

MIKE GODFREY (Navigenics Client): Once you log into the Navigenics site, you get a snapshot page here that just really outlines in these square boxes what you are at a high risk for, what you are at average risk for, and what you are at lower than average risk for.

GONZALEZ: Mike Godfrey, who works in corporate communications for a hospital in San Diego, is a Navigenics client. When he first got his DNA results back, Godfrey was surprised by his relative risk for several illnesses when compared to the rest of the population.

GONZALEZ (speaking to Mike Godfrey): …diabetes, Alzheimer’s disease, heart attack, brain aneurysm, obesity….

MIKE GODFREY: …atrial fibrillation, obesity…

GONZALEZ: That would seem to be a lot to be worried about.

MIKE GODFREY: …Graves disease, which I never even heard of before. So to be honest, in my initial reflection when I looked at this, I went whoa!

Personal trainer to Mike Godfrey: One more. That’s all you need. Just one more.

Mike Godfrey

GONZALEZ: Although he says he’s not overly concerned, Godfrey’s DNA test results have spurred him to think more about his health and spend a lot more time at the gym.

GODFREY: When you look through all of those orange boxes that we went through and you take a look, almost all of them say that you should keep your weight down, that you should stay in shape, that you should eat better. It was validation to me that, yeah, that was the right move and your money is being spent in the right place and the work you are going through is going to be worth it in the end.

GONZALEZ: Lord says his company offers tests only for treatable or preventable illnesses, giving clients an edge in anticipating and avoiding future health problems.

JACK LORD: And it is with that information that they can start to understand what they might do today to prevent an illness. If you know that in advance you can start going to your doctor more frequently to be checked, or you might start a medication that prevents that condition much earlier than when you become symptomatic.

SARAH CROSBY-HELMS (Navigenics Client): It doesn’t say you are going to die, here’s why. It says here are some things you are prone to, and here’s how you can prevent them from showing up in your body later.

GONZALEZ: Sarah Crosby-Helms, another Navigenics client, discovered through her test that she had a higher than usual genetic risk for both colon cancer and Crohn’s disease. The information got Crosby thinking about how much she really wanted to know about future threats to her health.

SARAH CROSBY-HELMS: For me, I would rather know that I have this genetic predisposition than to not know, and if that means that…

GONZALEZ: Ignorance isn’t bliss?

Sarah Crosby-Helms

SARAH CROSBY-HELMS: No, ignorance for me is not bliss.

GONZALEZ: The direct-to-consumer genetics testing industry says it promises its clients a glimpse over their health care horizon, warning them of possible dangers and threats to come. But critics aren’t so sure. They worry that the technology is being oversold and that it raises a host of both ethical and public policy concerns.

ALEXANDER CAPRON (Professor of Law and Medicine, USC): We don’t know everything about the relationship between genes and diseases, and even what we do know doesn’t really tell you that much about what should you do now.

GONZALEZ: Alexander Capron is a professor of law and medicine at the University of Southern California and the former director of the ethics program at the World Health Organization. He’s concerned that as genetic tests become more common, a growing number of people will overemphasize DNA as the road to a long life and personal happiness.

ALEXANDER CAPRON: There are so many other things that are equally or more important and that are actually things that we should be more concerned about in our environment, in our human relations, in social justice, so that all people have an opportunity to have a life in which they can flourish and so forth, and not just narrowly, well, what’s your genetic code? I would also be aware that you could have some surprises that you really don’t want to know, that you would just as soon not have on your mind. What should you do now? What difference should this make in the way you behave, in the health care you get, in your relationships with loved ones, your plans for your future? Should you not take a certain job because the payoff in that job won’t come for ten or twenty years, and you have got a gene that says you have a twenty percent chance of getting breast cancer or something? What should you do with that information?

GONZALEZ: There are also concerns among some health experts about the regulation of direct-to-consumer DNA testing. Currently, no federal agency such as the Food and Drug Administration or Federal Trade Commission has come up with rules to monitor the companies’ marketing claims, testing practices, or the validity of results.

Alexander Capron

ALEXANDER CAPRON: I think we are still in early days on the regulation side, and the FDA has more work to do here. The field has grown, I think, faster than anyone expected.

GONZALEZ: Worried about the licensing, utility, and accuracy of direct-to-consumer genetic tests, some states, such as California and New York, have sent cease-and-desist letters to prominent DNA testing companies. Then there are the privacy worries and whether someone’s genetic information could leak out to insurance companies or employers. Lord acknowledges protecting genetic data is crucial to his company’s reputation and future.

JACK LORD: Privacy is to Navigenics like safety is to Volvo. We have to have — our brand is dependent on privacy and the integrity of privacy and security, and the visual that we use is imagine walking into a bank vault and inside that bank vault there are safe deposit boxes, and the only way you open that safe deposit box is if you have a key, and the bank has the key, and that’s the way we have built our systems. You have control over how that information is accessed, what it’s accessed for, and who actually has access.

GONZALEZ (speaking to Mike Godfrey): You’ve just shared a great deal of your genetic information with us. Do you have any privacy concerns, sharing it with us and by extension an audience across the country?

MIKE GODFREY: Obviously, I don’t.

GONZALEZ: Mike Godfrey’s confidence comes partially from the genetic nondiscrimination privacy act passed by Congress in 2008. It prohibits health insurers from denying coverage based solely on a person’s genetic predisposition.

MIKE GODFREY: My feeling is that those laws will be continued to be updated and that there won’t be much risk to me in the future or to anybody who does this. I think that this will become a pretty standard approach as you go into the future, for adults and maybe even for children when they are very young.

GONZALEZ: As he uses his genetic results to guide his heath decisions, Godfrey is also a test subject. He’s one of thousands of Navigenics clients who have volunteered to be monitored for the next twenty years as part of a scientific study. It’s purpose? To find out how—and if—people change their lifestyles after finding out what’s in their DNA.

Personal trainer to Mike Godfrey: Bring it all the way up.

For Religion & Ethics NewsWeekly, I’m Saul Gonzalez in Los Angeles.

DEBORAH POTTER, guest anchor: What role does faith play in a delivery room? If you ask one doctor in Atlanta, the answer is a big role. Dr. Joseph Tate delivers babies the old-fashioned way, using methods some obstetricians call risky. But his patients say God guides his hands. Mary Alice Williams has our report.

MARY ALICE WILLIAMS: Babies always surprise you, and most expectant mothers hoping for this joy, and chaos, fully expect to deliver a healthy baby — naturally.

UNIDENTIFIED WOMAN: Thank you Dr. Tate.

WILLIAMS: The birth of Sarah Miller’s two daughters surprised her and her husband Bill. She was unable to dilate enough to allow for natural birth. They were delivered by cesarean section.

SARAH MILLER: It makes it very hard to breast-feed. It makes it hard to do anything and bond with the baby, and I just want a vaginal birth.

UNIDENTIFED BIRTH HELPER (to patient): This baby is so good.

WILLIAMS: Vaginal birth after c-section — or VBAC — carries a rare but real risk of uterine rupture, life-threatening to both mother and child. Most obstetricians won’t risk it.

Dr. JOSEPH TATE (DeKalb-Gwinnett OB/GYN, Norcross, GA): She’s going to do it this time.

WILLIAMS: Dr. Joseph Tate risks VBACs all the time, even when the odds are against him.

Dr. TATE: I didn’t say to Sarah — I could say to her, “Look, you had two shots at it, and you didn’t perform. Tough. I’m going to do a cesarean.” I got to look at it positively. I will give her a fair shot at it, as long as she and the baby are doing well. That’s always the bottom line.

WILLIAMS: Dr. Tate, known as “Doc T,” is the sole practitioner of DeKalb-Gwinnett OB/GYN in Atlanta. It’s a family business. His wife Phyllis and daughter Elizabeth work in the office. He hasn’t had a vacation in 13 years because he works a super-human schedule.

Dr. TATE: We have, oh, another one, two, three, four that are within a week, another four that are two weeks within, another five that are three weeks.

WILLIAMS: Orthodox Jewish women make up about 20 percent of Dr. Tate’s practice. The rest are women of all faiths. How many babies has he delivered?

Dr. TATE: Somewhere over 5,000.

WILLIAMS: Sarah and Bill are hoping to make it five thousand and one.

Ms. MILLER: Well, I’m connected with a lot of mother groups online, and basically Dr. Tate’s name comes up over and over again, because there is nobody else.

WILLIAMS: That online mother’s forum is the International Cesarean Awareness Network — ICAN.

KATE SANDHAUS: Doc T is the only actual OB who participates. This is a one-in-a- million doctor. This is not just any doctor.

WILLIAMS: Kate Sandhaus, just three weeks before delivering her second child, arrived on Doctor Tate’s doorstep desperate for a VBAC after her first was born by a frightening emergency c-section. Doc T agreed to help her.

Ms. SANDHAUS: He’s available to all of us in a way that — I just — I don’t know any other doctors like that. I think that Doc T is committed to doing what’s right. He’s not swayed by what’s convenient, and the reason he practices medicine the way he does is because of his faith.

WILLIAMS: Doc T is an Orthodox Jew, a faith that requires of men many obligations, including praying three times a day.

(to Dr. Tate): What does prayer do for you?

Dr. TATE: It’s a communication with God. Judaism is establishing your own relationship with God. It’s a personal relationship. We don’t believe that God just kind of sets things out here and then you willy-nilly go your own way. We believe he does take a personal interest.

WILLIAMS: Dr. Tate is a pillar of the men’s study group at Beth Jacob synagogue in Atlanta. His rabbi, Ilan Feldman, calls him his go-to guy and a stickler when establishing the religious calendar.

Rabbi ILAN FELDMAN (Congregation Beth Jacob, Atlanta, GA): He’s got a clock which is connected to Pueblo, Colorado, an atomic clock because he’s that precise, and no matter what the synagogue clock says, when his clock says it’s time to begin, we begin.

WILLIAMS: On the Sabbath and high holidays Orthodox Jews may not carry things outside the home. So Doc T, a crack engineer long before he was called to obstetrics, constructed an eruv — a religious boundary that binds the entire community into one household.

Rabbi FELDMAN: So that for the purposes of Jewish law, an individual would be able to carry or transport items outdoors on the Sabbath on Shabbat.

WILLIAMS: As for Dr. Tate using his cell phone and delivering babies on the Sabbath, Jewish law makes exceptions.

Rabbi FELDMAN: Jewish law does have adjustments, so to speak, for people who are serving matters of life and death, and certainly a medical doctor like Dr. Tate would be governed by that exception.

(to Rabbi Feldman): Do you suspect that his Judaism makes him a better doctor?

Rabbi FELDMAN: There’s no question about it. In my opinion, the defining quality of a doctor beyond his training and his intelligence is his humility, and Dr. Tate is devoted and humbly in the service of his patients and of their Creator.

MICHELLE FRANK: People all around America, especially in the Orthodox Jewish community, really know about him — just a great asset to us.

WILLIAMS: Michelle Frank belongs to Dr. Tate’s synagogue. Three years ago in New York — with 26 people descending for Passover Seder — she went into premature labor. Rachel was born by cesarean.

Ms. FRANK: Physically it was really atrocious. I actually couldn’t even sit up for about 36 hours after she was born. It was just excruciatingly painful.

WILLIAMS: She’d been assured delivering naturally the next time would be no problem. She was in for a shock, as are many women in her circumstances.

Ms. FRANK: They’re absolutely not getting to do it. You have major hospitals in Atlanta who deliver, say, 16,000 babies a year, and they have c-section rates close to 40 percent.

WILLIAMS: Nationally, more than 9 out of 10 births following a c-section are surgical deliveries. Emory University Hospital Midtown, where Dr. Tate delivers, supports VBACs. But studies show more than a quarter of hospitals don’t or if they do can’t find doctors to perform them. Dr. T delivered Michelle’s new baby Danielle by VBAC.

Ms. FRANK: You’re on cloud nine. It’s so unbelievably amazing. It’s just the way that a woman was made to deliver a baby.

WILLIAMS: (to Ms. Frank): Do you think that his Orthodox Jewish faith makes him a better doctor?

Ms. FRANK: I think it makes him a better doctor, because I think that it helps to instill a lot of confidence in him. He does things that no other obstetrician will do. Whether they can or can’t they just won’t, and he’ll tell you that he really feels like God just sort of guides his hands in his deliveries, and some of the things that he does, and some of the stories that have been told, there’s just no way to do that on your own. I mean, you have to have help, and he attributes that help to God.

Dr. TATE: When you understand that there is another power in the world, and it is not just about you, then God gives you the ability sometimes to do things beyond what you particularly can do.

WILLIAMS: Natural births mean less blood loss and risk of infection for the mother and fewer respiratory problems for the newborn. But on this Sabbath day, there’s a problem with Sarah. Her tailbone is blocking her baby’s birth.

Dr. TATE: What I don’t tell people always is when I’m in tough situation I’ll close my eyes and I’ll say a silent prayer, and I want Him to let me know if this is something that can be done, let me do it, let me do it well. But if it’s something that can’t be done, well, let me know, and if I need to do a cesarean to—that’s the right thing, then we’ll do that. I need help, and I’m not ashamed to ask for it.

WILLIAMS: The result? A healthy seven-pound, two-ounce girl delivered naturally. This baby surprised everyone.

Ms. MILLER: Thank you so much.

WILLIAMS: And before you know it, this tiny newborn will join this crowd — every one of whom was delivered by Dr. Tate.

I’m Mary Alice Williams for RELIGION & ETHICS NEWSWEEKLY in Atlanta.

BOB ABERNETHY (Anchor): As the president and Congress wrestle with health care reform, their debate has centered on how to provide health insurance for everyone and how to pay for that. But the president and many others also say the increasing costs of care must come down.

PRESIDENT BARACK OBAMA (at press conference): “We’ve got to change how the health care delivery system works so that doctors are paid for the quality of care, not the quantity of care.”

ABERNETHY: In our special report today, Lucky Severson examines why health care costs are so high in one city—Miami, Florida

JANE STROM: Happy Birthday.

AL (Jane Strom’s father): Thank you.

JANE STROM: Do you know how old you are?

AL: Yeah.

JANE STROM: How old are you?

AL: I don’t know.

JANE STROM: How old are you? You are 90, 90 years old…

LUCKY SEVERSON (Contributing Correspondent): Not long ago, Dr. Joel Strom and his wife, Jane, were so convinced that Jane’s father was close to death, notwithstanding the attention he was receiving from ten specialists, they put him in a hospice, and then he got better.

DR. JOEL STROM (Cardiologist and Professor, University of South Florida Medical School): Part of it was that he had one person who took care of him. They cut out all the referrals because they didn’t expect him to live long, and they cut out all the medicines.

SEVERSON: Dr. Strom is a cardiologist and a professor at the University of South Florida Medical School. Like every doctor we spoke with, Strom is fed up with the health care system.

DR. STROM: It’s not a broken system. There is no system. Medical care is haphazard. Medical care is disorganized. There are pockets of superb care. There are pockets of very mediocre care.

SEVERSON: If Medicare costs are any measure, Miami-Dade County should have the best senior care in the country. The federal health program spends over $16,000 a year per patient. That’s about double the 2006 national average. Brian Keeley is the CEO of Baptist Health South Florida, the largest nonprofit health care system in that part of the state. He says huge Medicare costs do not translate to better health care.

BRIAN KEELEY (CEO, Baptist Health South Florida): We know that more can be injurious to people, and more health care services, more aggressively providing those services, can result in lower levels of care.

SEVERSON: He says there are several factors that bloat health care costs in the Miami area.

KEELEY: There’s a huge imbalance between the number of specialists and primary care physicians, and we have such a high percentage of specialists down over here, they utilize resources more, technology more.

SEVERSON: Dr. Strom, a specialist himself, says one reason there is such a shortage of primary care physicians is that Medicare doesn’t reimburse them enough for patient visits.

DR. STROM: If you spend a lot of time with a patient you will starve to death as a physician because you will only get paid for a certain amount of time. In fact, a lot of physicians will actually steer patients to their offices to have tests performed, because they collect both the professional component, and if they own the equipment, the technical component.

SEVERSON: Dr. Gloria Weinberg is a geriatrician and chair of the department of medicine at Mount Sinai Hospital in Miami Beach. She says when young doctors, fresh out of medical school and burdened with school loans, discover how much less a primary physician earns, they choose a specialty where they can make more money.

DR. GLORIA WEINBERG (Geriatrician and Chair, Department of Medicine, Mount Sinai Medical Center): f you look at the reimbursement, you are going to come away after you pay expenses, if you are lucky, with $40 or $50 an hour. That’s not going to help the youngsters go into a field of medicine and pay off loans and do everything else that needs to be done.

SEVERSON: Here in Miami, a typical senior citizen will see a doctor 106 times during the last 2 years of their lives. Not just one doctor, several—specialists who will then prescribe a battery of expensive tests and procedures: MRIs, ultrasounds, CAT scans, and an astonishing assortment of drugs. It’s because that’s the kind of care patients around here often demand. Dr. Weinberg:

DR. WEINBERG: Patients are very sophisticated. They come, and they say, “I have a headache.” You take a headache history. They are not satisfied if you say, “You don’t need a scan.” They want a scan. If you are pushed, and you are suspicious enough, and perhaps you suggest a CT, which is less expensive than an MR, some of them will come to you and say, “I want an MR. I hear it’s more sensitive.” We have had patients in our center tell us, “If you don’t do what I’m asking I’m going to sue you.”

SEVERSON: The threat of lawsuits forces many doctors to practice defensive medicine, ordering more tests and procedures to protect themselves from being sued. Health care professionals here cited malpractice suits as another factor behind spiraling costs, and Medicare fraud in South Florida, particularly in the home health care industry, has been described as rampant.

KEELEY: The Miami Herald reported about a month ago that the FBI and CMS [Centers for Medicare & Medicaid Services] indicated that fraud was about $2.5 billion per year in Miami-Dade County. That, in and of itself, is a huge, huge difference, comparing our cost structure to the rest of the country.

SEVERSON: About 50 million Americans are uninsured, and that includes 30 percent of the population around Miami. Many of that number are undocumented and in the US illegally. Whatever their status, most who need care end up in a hospital emergency room where, by law, they cannot be refused treatment.

DR. WEINBERG: It’s our ethical responsibility to treat that patient as we would any other. That patient can go down the path of having a cardiac catheterization, ultimately having a pacemaker, a defibrillator at $30,000, ongoing medical care, and then we face the problem, when we discharge the patient, where does the patient get the follow-up care, and the hospital doesn’t get reimbursed for it.

SEVERSON: Perhaps the biggest chunk of Medicare expenditures, something like 30 percent, goes to end-of-life care for aging Americans. Professor Anita Cava directs the University of Miami business ethics program. She says Americans need to rethink the way we look at end-of-life medical care.

PROFESSOR ANITA CAVA (Director, University of Miami Business Ethics Program): I think we in the United States really need to reconsider our relationship with end of life and to realize it’s a natural process and that perhaps ending life in a more humane and comfortable way at home with family, rather than trying to prolong it for another day or week or month, is perhaps the best way to go.

SEVERSON: Joe Gasperovich would take exception to the ethical argument for withholding expensive medical treatment for aging, failing Americans. He was born in 1919 and would prefer to prolong his life as long as possible.

SEVERSON (speaking to Joe Gasperovich): If they say we need to go to a $1,000 CAT scan, is there a point, an age you reach where you should say no, I’ve lived 90 years?

MR. GASPEROVICH: No, I want more.

SEVERSON: You want more years?

MR. GASPEROVICH: Everybody—nobody want to die.

SEVERSON: Dr. Weinberg says the decisions about the ethics of distributive justice for society as a whole are often much more difficult when the doctor is meeting with a patient one-on-one.

DR. WEINBERG: The health care dollars, an inordinate amount, go to taking care of people in the last 6 months of their lives. But how do you know when those last 6 months are? You have a person who has worked all their life, paid taxes, done very well, and now they are 80, and they have a heart attack. That may be the person who lives 10 or 15 more years. Are we going to say no just because of age? That’s a very, very slippery slope.

SEVERSON: There is a huge ethical discussion about who should make these end-of-life decisions—the patient, the family, doctors, the government? Brian Keeley says some decisions are easier to make. For instance, Medicare should only reimburse for treatments and drugs that are known to work.

KEELEY: It ought to be evidence-based. If something is proven not to work, I don’t think the federal government ought to be paying for it. I don’t think anybody ought to be paying for it, except for the private patient.

SEVERSON: Dr. Weinberg says too many patients receive expensive treatments and surgery in their final years that very likely won’t prolong their life.

DR. WEINBERG: So if you have an Alzheimer patient who, your own belief may be, it’s time to let this person go naturally, and the family is telling you, “I’m the surrogate, and I’m insisting that a feeding tube be put in,” you cannot make the decision not to put the feeding tube on your own, even though you think it’s futile care, at least in the state of Florida.

SEVERSON: Dr. Weinberg says her 95- year-old mother has a living will that stipulates she will not be kept alive on a ventilator. Brian Keeley says preparing for end of life is not something that’s culturally accepted in South Florida.

KEELEY: Other parts of the country where people plan for end-of-life care, with the use of hospices and palliative care and what have you—down here there’s less usage for that, so people go to die in the hospitals.

SEVERSON: Everyone seems to agree that health care reform is urgently needed and that health care should be a right and not a privilege and that it should extend to everyone. They also agree that South Florida is a good place to start.

For Religion & Ethics NewsWeekly I’m Lucky Severson in Miami.

BOB ABERNETHY, anchor: Scientists have long found an association between relaxation and health. Now, there is new evidence that meditation and other spiritual practices have a beneficial and measurable effect on the brain. In a new book, “How God Changes Your Brain,” Andrew Newberg reports that meditation improves memory and reduces stress and that the kind of God you worship can affect the structure of your brain. Lucky Severson has the story.

VINCENT FEDOR (meditating and reciting mantra): Sa, ta, na, ma…

LUCKY SEVERSON: As unlikely as it may seem, Vincent Fedor is practicing meditation.

VINCENT FEDOR: …and you go into the whisper sa, ta, na, ma…

SEVERSON: Vincent and his wife, Judy, started meditation after they answered a questionnaire about improving their memory. That was one objective of Dr. Andrew Newberg. The other was that he wanted to scan their brains while they did it. Here are Vincent’s scans before he learned to meditate and after he had been doing it for eight weeks.

DR. ANDREW NEWBERG (University of Pennsylvania, with brain scans): Okay, so it is asymmetric, more active here than here, and after meditation it’s more active here than here. So simply doing the practice of the meditation he has altered the activity in this very, very important part of the brain, and this is really important, because this means he has changed the way his brain is working.

SEVERSON: Since meditating Vincent feels he’s become a better high school track coach.

VINCENT FEDOR: I think I’ve become a calmer, more tolerant person. If the situation comes up I don’t go to the angry side. I go take the calmer road. And you know, I think the kids see this. I think I’ve become a better coach because of it.

NEWBERG: It makes sense that if by doing this practice he has increased the activity in that frontal lobe, he’s actually able to improve the way in which he monitors his emotional responses to people and perhaps can treat them with more compassion.

SEVERSON: Dr. Newberg has studied nuns who do repetitive prayer, and he has seen the same kind of results. He’s been studying the effects of meditation and prayer on the brain for several years and is considered one of the leading experts in a new field called neurotheology.

DR. NEWBERG: We’ve learned that being religious or spiritual has a very profound effect on who we are, has a very profound effect on our biology and on our brain, and what we’ve found more recently is that not only does it have a profound influence on who we are, but it actually can change our brain and to change ourselves over times.

SEVERSON: Here at the University of Pennsylvania Center for Spirituality and the Mind, images of the brain are taken during or after a person prays or meditates.

Dr. NEWBERG: The more you use a part of the brain the more blood flow it gets and the brighter or more red it looks on the scans.

SEVERSON: Over the years Dr. Newberg has adapted a 12-step mediation exercise that includes sound, movement, and breathing.

JUDY FEDOR: Sa, ta, na, ma. The first two minutes the mantra is sung. The second two minutes the mantra is whispered. The third sequence is silence, back into the whisper and finishing with the song. After that it’s deep breathing, holding in, that’s done three times, body relaxes, and the mantra is completed.

The minute I can start doing it and moving my fingers my body gets calmer. It’s very soothing. To me it gets almost in a passive mode, and then you have energy afterwards because you became so calm.

Dr. NEWBERG: Religion and spirituality do help to lower a person’s feelings of depression, anxiety, gives them some meaning in life, helps them to cope with things, and that’s going to have a potentially very beneficial effect.

SEVERSON: But Newberg has made another discovery, a controversial one, that our belief system, how we view God, can make a huge difference in how it affects our well being.  If we believe in a loving God it can have a positive effect, even prolong our lives. But believing in a judgmental, authoritarian God can produce fear, anger, and stress, and that’s not healthy.

Dr. NEWBERG: When it ultimately turns towards hatred, and whether it’s people who believe in abortion versus those who don’t, whether it’s just one religion versus another, when you hear rhetoric which is hateful, filled with anger, that turns on the different parts of the brain that are involved in our stress response and our anger response.

SEVERSON: George Handzo is a chaplain with the Healthcare Chaplaincy of New York City. He says Newberg’s conclusions, that a person’s belief in a certain kind of God can be unhealthy, is bound to be controversial among people of faith.

CHAPLAIN GEORGE HANDZO (Healthcare Chaplaincy of NYC): They’re saying that there is one word of God, and God commands us to follow that word, and if we want to save people from God’s anger and condemnation we’re obliged to get other people to believe as we do

Dr. NEWBERG: I’m not arguing that people need to change their beliefs per se.  I mean if they feel that their perspective on God is right, I mean then that’s terrific.  But I think that  what we have to all be careful about is the anger and the hatred. That’s what has detrimental effects both on the individual as well as on society as a whole.

SEVERSON: Skeptics of Newberg’s work question if science should be delving into religion and spirituality in the first place, and they ask if his research has actually proven much of anything.

HANDZO: Faith is, by definition, reliance on things you cannot see and cannot know. Faith is something we believe God gives to us. It’s not something we invent. As a person of faith, this whole debate about what is going to be knowable is not a particularly interesting question to me.

Dr. NEWBERG: You know, if we get a brain scan of somebody while they’re experiencing being in God’s presence, as I’ve always said, that doesn’t prove that God was in the room. It doesn’t prove that God wasn’t in the room. What it proves is that when the person had the experience of interacting with God this is what change was going on in their brain.

DONNA MORGAN: Can I just praise the Lord right now? I feel like if I don’t praise the Lord I’m going to bust…Thank you Jesus. Thank you Jesus…

SEVERSON: Dr. Newberg has found there are some religious practices where the person is intensely focused and others where they just allow themselves to be taken over, for example,  speaking in tongues. Dr. Newberg has scanned the brains of people of all belief systems, of people with no faith, and those of deep conviction, like Donna Morgan, who is a Pentecostal.

DONNA MORGAN: When are you in that realm of praise you just give over to the Holy Spirit. Then you let him take control, and when he’s taking control, right, you can speak in tongues, if you’ve been given that gift.

Dr. NEWBERG (with brain scans): Speaking in tongues you’re going to see that the frontal lobes are going to decrease in activity. So that means the frontal lobes, the part of the brain that normally makes them feel like they are in control of what they are doing, is shutting down.

SEVERSON (to Dr. Newberg): It is shutting down because…

Dr. NEWBERG: It is consistent with the feeling that they are not in charge of the process.

SEVERSON: There are some who argue that certain people are predisposed or hard-wired toward transcendent experiences, and some are not. It’s an argument Chaplain Handzo disagrees with.

HANDZO: I don’t believe in a God that creates people, especially selectively, in a way that makes it difficult for them to access this God. That’s not my God.

Dr. NEWBERG: I think to some degree we all are hard-wired to be able to think about things on these levels. It’s just a matter of how much we engage that and if we find a path that does help us to engage that for ourselves.

SEVERSON: Newberg says people of faith shouldn’t worry that his research will ever diminish their faith.

Dr. NEWBERG: I don’t think that our science is going to be able to definitively prove that God exists or doesn’t exist. It is, ultimately, a leap of faith.

SEVERSON: Newberg believes the number one activity that can exercise your brain and enrich your life is faith.

Dr. NEWBERG: When you have those kind of positive, optimistic beliefs in the world, in God or religion, depending on the person, that that really, over the long haul, seems to be the thing that really provides a benefit for us in terms our mental state and in terms of our physical health and well-being.

SEVERSON: As for his own faith, he describes himself as a searcher who is still searching. For Religion & Ethics NewsWeekly, I’m Lucky Severson in Philadelphia.