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of Christian Medicine & Dentistry Vol. 23 No. 1 January 2018

Sharing Comfort through Christ Pain A History of Pain & Faith Pain: A Theology on-the-fly • Palliative Care Practice Living with/ Living without • Pain – What’s the Point? Chronic Pain • Pain Avoidance & Addiction • Pain through a Cultural Lens LUKE’S JOURNAL | January 2018 | 1 www.cmdfa.org.au Published by the About Luke’s Journal Christian Medical and Dental Fellowship of Australia Inc. This Journal is published three times a year by ABN 95 084 292 464 the Christian Medical and Dental Fellowship of Please submit all contributions to: Australia Inc. (CMDFA). The views expressed in the THE EDITORS Dr Paul Mercer articles are those of the authors and not necessarily Ph: 07 3348 9940 those of the CMDFA. Articles are reviewed by the Email: [email protected] editors and members of the editorial committee. Dr Catherine Hollier Material published in the Journal is subject to Ph: 02 4957 5242 copyright. Requests for permission to reproduce any Email: [email protected] part thereof for purposes other than private study Subscription and change of address details to the National listed below. should be directed to the editors. Additional copies for SUB-EDITORS Sue Furby and Dr Winnie Chen passing on to interested colleagues can be obtained from the national office or Branch Secretaries. CMDFA Members of Council of Reference Subscription of Luke’s Journal is given to members Professor Graeme Clark, OA, MD (Hon), PhD, MB, MS, FRACS, FRCS, FTSE of CMDFA. It is also offered to libraries and hospitals Emeritus Professor Louise Brearley Messer AM, BDSc, LDS, MDSc(Melb), at the price of $55 per year including postage within PhD(Minn), GradDipDiv(ACT), FRACDS, FICD Australia. Enquiries and notice of change or address Professor Philip Mitchell [NSW] MBBS, MD, FRCPsych, FRANZCP. should be directed to the national office. Professor Kim Oates [NSW] AM, MD, MHP, FRACMA, FRCP, FRACP, FAFPHM, DCH. Dr Michael Payne [NSW] BDS (Hons). About CMDFA Dr Geoffrey Pike [SA] AM, MBBS, DTM&H, FRACGP Membership of CMDFA is open to graduates and Dr Robert Pollnitz [SA] FRACP. students of medicine and dentistry. Information Professor Ian Puddey [WA] MBBS, FRACP, MD about activities of CMDFA can be obtained from Professor Anthony Radford, SM (Harvard), FRCP (Edin), FRACP, FRACGP, the website at www.cmdfa.org.au or from Branch FFCM, FAFPHM, DTM&H (Liverpool) Secretaries. Further information and application Dr David Simpson, MBBS, FRACOG, FRCP(Edin) details are available through the national office. Professor Laurence Walsh, BDSc, PhD, DDSc, FFOP(RCPA) Dr Grace Warren, A.M., S.Pk., M.D.(Hon Syd)., M.S., F.R.C.S., F.R.A.C.S., Graphic design by Ivan Smith, Lilydale, Vic. F.A.Orth.A.,.D.T.M.&H.(Syd). Printed by Amazon Printing, Warrnambool, Vic. Stock photos: www.dreamstime.com

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2 | LUKE’S JOURNAL | January 2018 Contents guest editorial 5 Toward a definition of ‘pain’ – Dr Mark Alcock 6 Pain – What’s the Point? – Dr Robyn Bain 9 Dental Trauma and Treating Toothaches – Dr ‘Phil Akavity’ 10 A History of Pain – Dr Don Todman 12 Sharing comfort through Christ – Dr Murray Lean 15 When managing chronic pain can hurt – Dr Richard Wong 16 Pain: A Theology on the Fly – Dr Paul Mercer 21 A Pain Vignette 1 – A Doctor’s Work is Never Done – Dr Paul Mercer 22 Pain in Parturition and Procreation Pain and Faith – Dr Joseph Thomas 25 A Pain Vignette 2 – A Broken Heart Humans have a love-hate minimise it peri- and post-operatively. – Dr Paul Mercer relationship with pain. Pain is On a daily basis we are confronted with 26 A multidimensional approach to pain from unpleasant and we try very hard people who have chronic pain, where Genesis 3 to contemporary pain services – Dr Chris Hayes to avoid it. On the other hand, we signals are being sent to the brain from are constantly reminded that there degeneration and disease and which 29 A Pain Vignette 3 – Resistant to Change – Dr Paul Mercer is no gain without pain. That can constantly stimulate nociceptor and/ be the literal kind when you start or neural tissues. Where acute pain 30 Christian Doctors, Chronic Pain and Addiction: A personal reflection – A/Prof Alan Gijsbers exercising for the first time in years, is useful in that it forces us to take or metaphorical as you strive to steps to limit the pain, chronic pain is 33 Reflections on Pain from a Student – Ruth Minter understand concepts and commit useless pain. There are no benefits to facts to memory in your studies. chronic pain and there are few steps 34 Pain avoidance: the role of addiction – Dr David Outridge available to us to mitigate the source of Pain is defined as “An unpleasant chronic pain. This is one of the greatest 38 Pain in palliative care practice the special contribution of Christian sensory and emotional experience challenges in medicine. – Dr Doug Bridge associated with actual or potential 41 in Medicine – Anonymous tissue damage, or described in terms How do the Christian faith and pain of such damage.” (International intersect? Believers and non-believers 42 The person and the field: exploring the life and contribution of Cicely Saunders – Dr Peter Whan Association for the Study of Pain alike are severely challenged by the (2017)1 Pain forces people to respond presence of unremitting pain, and 45 Pain through a Cultural Lens – Dr Ruth Powys to avoid further damage. Pain is the often irreversible or progressive 48 Blinding Pain – John Mark remembered, and avoidance of diseases that cause them. On the one 50 A Light Momentary Affliction Living with Chronic further pain is the motivation for hand, we are encouraged to pray for Pain – Dr Andrea Schofield many decisions we all make in life. healing of the sick. There is no doubt 52 Fire In The Belly: Reflection on Prayer – Peter Park that this is scriptural: “Is any one of 53 Book Review: The problem of pain, CS Lewis 1640 The absence of pain has catastrophic you sick? He should call the elders of (1986) Collins – Dr Paul Mercer consequences. Paul Brand, a giant the church to pray over him... And 54 Thy Word is our Food – Georgina Hoddle in medicine and openly Christian, the prayer offered in faith will make 55 Neurobiology of Glossolalia – Bryan Yap discovered the pathology of leprosy the sick person well.” (James 5:14- was destruction of nociceptors by 15). Many of Christ’s miracles were 56 Zoe’s Place – Helen Bell Mycobacterium leprae, and that physical healings and even raising 58 It’s better to give... the hideous deformities were the people from death. However, there – Emeritus Professor Kim Oates consequence of failure of the body are other instances where healing was to receive warnings that damage was not immediate or granted. Paul’s thorn being inflicted. Congenital analgesia, in the flesh was not removed: “Three the absence of the sense of pain, is a times I pleaded with the Lord to take it fatal condition due to the accumulation away from me. But he said to me, ‘My of multiple and regular . power is made perfect in weakness’.” Themes for Next Editions: (Brand P and Yancey P)2 (2 Cor 12: 8-9). Disabling Disability – We’re all in this together The prevention and treatment of This paradox is puzzling to the believer – copy by 28 February 2018 pain is a core role for physicians and and a roadblock to faith for the dentists. We prevent further tissue unbeliever. Hot Topics in Ethics damage if possible, sometimes inflict – copy by 1 July 2018 pain through surgery and try to continued over page

LUKE’S JOURNAL | January 2018 | 3 GUEST Editorial – Pain and Faith

Perhaps the greatest example of and intensely painful for three years, I do this when the Spirit nudges me to the role of pain in Scripture is the also leading to partial leg paralysis. do so and not with everyone. Others crucifixion. Jesus knew it would be Nothing medicine could offer him may choose a more inclusive approach. agonising, and pleaded for God to seemed to work. It ruined his future let this cup pass him, but “not my plans, and he was a I believe we must seek to relieve pain will but yours be done.” (Mark 14:35- depressed, angry man who turned to to the best of our ability, and with 36). I am convinced that the mode of alcohol to dull the pain. He once met the astounding array of treatments death Jesus endured was deliberately another friend at our home who was and expertise provided by God to us. chosen by God because it was the a Christian, and for whom prayer was We must also walk with those who worst possible suffering one human a way of life. They got talking, and suffer pain and other afflictions, not could inflict on another. Humanity and the praying friend prayed for healing. only by offering analgesia, but to let evil did its worst and appeared to win Three days later, the man in pain was them know they are not suffering when Jesus cried : “It is finished!” (John offered a rarely used, old treatment this alone. We must recognise that 19:30). That was Friday, but Sunday which was thought to give temporary relief of the physical pain is only was coming! (Campolo, 1990.)3 Jesus relief at best. Relief was instantaneous part of the solution, and also to seek endured the worst and triumphed and he has had barely any pain since. understanding of the person who over the grave, and we are all the He ran a half marathon a year or suffers the pain. Addressing both beneficiaries of his journey through so later! In an email soon after the parts of the equation is vital to good pain to triumph. procedure, he asked the praying friend management. With God’s grace, we whether God would heal someone who can be effective agents of healing. l The “why” of unremitting pain and did not believe in Him, and received suffering is always a mystery to us, as an encouraging gracious reply. He is the apparent randomness of people became a Christian as a result. Would Dr Geoff Mitchell being healed or not. However, we do that have happened in the absence of Editorial by Geoff Mitchell, a GP academic with not see the whole picture. God sees the his suffering? research interests in end of life care and complex past, present and future, and knows conditions. what the outcomes are going to be I believe we should pray for our References 1. International Association for the Study of Pain. IASP Pain even before they actually happen. patients. There are differing views taxonomy. Available from https://www.iasp-pain.org/ There may be a reason for delayed on this. Firstly, we can pray privately Taxonomy [accessed 2 December 2017] 2. 2. Yancey P and Brand P.(1997) The gift of Pain. Zondervan or non-healing that we are not privy to God for each person who walks Publishers, Grand Rapids, Michigan. 3. Campolo T.(1990) It’s Friday but Sunday’s coming! From: to. A close friend once developed a through the surgery door. Secondly, we The Kingdom of God is a Party! Thomas Nelson, Nashville, mononeuritis which was chronically can offer to pray for them. Personally, Tennessee.

Challenges in Healthcare Christian Medical and Dental Fellowship Conference Saturday 9 March 2018 – Croydon, Sydney Program and Registration at www.cmdfa.org.au

• The Bible speaks on • Students (Great Student Concession) Suffering and Loss • Discussion & Prayer Groups • Gender Dysphoria • Register your interest • For Recent Grads, Doctors in , Reg to Consultant • Euthanasia Transition, GP Regs, Dentists, Practice Management issues, Lobbying, Family Life and Medical Practice. • Mental Health

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4 | LUKE’S JOURNAL | January 2018 Toward a definition of ‘pain’ The current definition of pain is 2) The phrase “pain is associated with persists. The most common about forty years old, has served actual or potential tissue damage” is example is persistent post us well and is still very clinically telling us what pain’s physiological surgical pain; relevant. Our understanding of the function is – it is our alarm system, neurophysiology has developed to alert us to damage or potential • There is ongoing tissue greatly in that time though, and this damage occurring to our body. The damage or potential tissue new knowledge could be reflected in reason pain is unpleasant is so it damage, but the pain an updated version. motivates us to protect our body experienced is of higher from further damage occurring. proportion than expected for The current definition, which you can the level of tissue damage. find on the international association For example, someone with for the study of pain (IASP) taxonomy “...chronic pain is rheumatoid arthritis who has page is: a biopsychosocial controlled disease with only low levels of inflammation, but still “Pain is an unpleasant sensory and problem, not a purely has severe pain. emotional experience associated biomedical problem...” with actual or potential tissue From a neurophysiological point damage or expressed in terms of of view, it doesn’t matter what such damage” the relationship between pain and 3) “Pain is associated with actual tissue damage is, it is still the same When I give talks on pain to non-pain or potential tissue damage or neurophysiology in the conscious brain. specialists, I try to make sense of this expressed in terms of such Someone with fibromylagia’s pain definition, which is long and wordy. damage”. The “expressed in terms experience is just as real as someone The major points to highlight in the of such damage” phrase tells us who has pain from a broken leg. definition are: that our pain system, which is our body’s alarm system can be faulty, One of the biggest challenges when 1) Pain is a sensory AND emotional just like a car alarm system or a we see patients with chronic pain is experience. We usually only talk house alarm system can be faulty. It helping them understand and accept about the sensory aspects of is possible to experience pain in the that chronic pain is a biopsychosocial pain, which is ironic since it is absence of any tissue damage or problem, not a purely biomedical the emotional aspects that are potential tissue damage. The faulty problem. This is why a biomedically- responsible for suffering. Emotions alarm system can be seen in three focussed approach to its management consist of thoughts, feelings, different basic scenarios: is often not as effective as patients actions and behaviours, and there is would like. l a bidirectional relationship between • Patient experiences pain, and the sensory aspects and thoughts, no tissue damage has ever Dr Mark Alcock feeling, actions and behaviours. been identified. This is the Director of Pain Management Lady Cilento Children’s The biomedical treatments we case in primary pain disorders, Hospital, Brisbane. Mark is a Specialist Pain Medicine use to treat pain are focussed on eg. fibromyalgia, chronic and Anaesthetist, and the clinical lead of modulating the sensory aspects daily headaches, functional the Queensland Paediatric Pain Management Service of pain and don’t address the abdominal pain; at Children’s Health Queensland. He has completed emotional aspects directly, which fellowships in Pain Medicine and Anaesthesia at the are best approached with a • There has been tissue damage, Royal Children’s Hospital in Melbourne, University biopsychosocial model. but it has healed and the pain Hospital Geelong, and the Royal Melbourne Hospital.

Erratum and Apologia We would like to bring your attention to Dr Peter Ravenscroft’s excellent article on Bringing Spirituality into Clinical Practice (Healthy Service edition, Vol 22, No 2, Sept 2017, p20). Unfortunately, the diagrams were mis-formatted and so did not make sense with the text. Corrections have been made online at issuu.com where you can view the diagrams in colour. It is well worth re-reading the article with reference to the corrected diagrams.

LUKE’S JOURNAL | January 2018 | 5 Pain – What’s the Point?

I had the flu recently. For the first to compare the meaning our culture and philosophers did. Physical pain time in years, I couldn’t get up to gives to pain to the rich meaning and intersects intimately with spiritual, get breakfast for my kids. My head comfort that the gospel of Jesus Christ social and emotional pain because ached, my throat felt raw, turning gives to our pain. God has created us as relational beings over in bed felt like the biggest with body and soul intertwined. project I could contemplate. After a The concept of pain in much of the When Jesus commanded us to ‘love few days in bed, I started to feel my current practice of medicine is shaped the Lord your God with all your heart body mending before gastroenteritis by concern for finding successful and with all your soul and with all threw me down again. Cramps, dry analgesic therapies. Evidence Based your (physical) strength and with all retching and aching everywhere. Medicine (EBM), with its positivistic your mind’ (Luke 10:27), he was not emphasis on reproducible, objective separating out discrete aspects of our On reflection, I have been struck by and quantifiable ‘facts’ about human being but speaking to every aspect of how pointless the whole experience pain, has become the key standard us integrated together. It is interesting seemed to me at the time. My prayer for assessing therapeutic legitimacy.1 to observe the way neuroscience was that God would take the pain and Behind EBM is a concept of human illustrates the remarkable extent to discomfort away as soon as possible. health and disease, shaped by which our body, mind and relationships It wasn’t just that I wanted to get back philosophers of medicine such as are interconnected. Physical pain will to the tasks of life and ministry. It was Christopher Boorse, that is rooted profoundly affect the way we relate to also that I found the anxious sense firmly in biology, chemistry, physics God, our thinking and relationships. of isolation and the vague notion and related natural sciences.2 How we relate to God will profoundly that perhaps God was aloof from me A particular aim of Boorse was to affect our experience of pain.4 deeply uncomfortable. I wanted the eliminate any vague value judgements experience over. Having thus wilted in about health and disease that might Reformer Martin Luther’s sixteenth the heat of a mere couple of weeks of interfere with the pursuit of objective, century writings speak with fascinating discomfort though, I wondered how explanatory truth. insight into the way our relationship I would ever cope with chronic pain, with God affects our experience of not only the physical pain but the While EBM has served pain treatment pain. As we, dependent creatures, mental and spiritual pain that creep in well, it has significant limitations. stand before God, experiencing any darkly beside it. Pain doesn’t fit into my Psychiatrist and medical anthropologist of the great variety of pains thrown vision for my life. It seems a pointless Arthur Kleinman pointed out that up amidst the wreckage of a fallen interruption. medicine is for the benefit of human world, Luther describes the two basic beings who are, of course, much theologies by which we can interpret Is there, indeed, any point to pain? more than mere biophysical entities. our experience. Actually, in his Does it have any meaning or purpose? Treatment of pain and disease, Heidelberg Disputation of 1518, Luther Doctors assess, treat and help patients according to Kleinman, must take into addresses his hearers more personally through their pain on a daily basis and account how these are perceived, than that. He identifies the two kinds sometimes do so while experiencing valued and given meaning within of ‘theologians’ we can be in this world: pain themselves. Ensconced in the a community, as well as how they theologians of glory and theologians intricate titrations of pain treatment, are biophysically understood.3 The of the cross.5 Here are three points of however, it can be easy to miss the experience of pain is imbued with comparison between these theologians bigger cultural and biblical stories that social and spiritual meaning whether that are particularly important for us shape the meaning we give to pain. we are conscious of it or not. to hear as we grapple with pain in our It is these meanings of pain that I am current context. seeking to probe in this article. After The Bible, however, pointed to the briefly sketching the basic contours complexity of pain for many long Firstly, theologians of glory do not of pain, I will invoke Martin Luther years before the anthropologists grasp the all-pervasive damage of

6 | LUKE’S JOURNAL | January 2018 sin. They optimistically assume that as somewhat inevitable but also people are better and more attractive meaningful in light of life beyond this than God says they are. They assume “...our secular culture world, our secular culture is shocked that their minds can readily understand is shocked by the by the interruption of pain and sees themselves and the world, as well no purpose in it. Pain is a waste of time as discern right from wrong. The interruption of pain and which takes away from the good life we of the theologian of the sees no purpose in it.” want and expect. glory shows itself in a characteristic self-centredness. The world is made Theologians of the cross, however, for them and their pursuit of the good recognise and lament the awful, all- life. Moreover, embracing the good life pervasive scourge of sin. They join assumes that the life extends only as that meaning and brings profound with the psalmists, with King David and far as they can see. There is no greater terror and despair. The only thing to God’s future Messiah in crying ‘Why, story that extends beyond death – this be done with pain is to track down its O Lord’, ‘How Long O Lord?’ and ‘Lord, life is all there is. source and get rid of it. This is so often where is your love?’ the substance of our culture’s response In our current culture, embracing to pain. We flock to therapists who O Lord, all my longing the good life means prizing radical we hope can cure or patch over the is before you; individual freedom: creating our own problem of our pain with medication, my sighing is not hidden from you. stories and meaning, freely expressing exercise, diet, self-esteem, life My heart throbs; my strength fails me, and fulfilling our dreams, refusing to and distraction. and the light of my eyes be suffocated by the needs of others, – it also has gone from me. holding fast to comfort, health, safety In his book Walking with God Through My friends and companions stand and control, and choosing to do what Pain and Suffering, Tim Keller observes aloof from my plague, makes us happy. that we are more undone by suffering and my nearest kin stand far off. in our western culture than were our (Psalm 38:9-11) If the meaning of life is to choose what ancestors.6 While many cultures other makes us happy, then pain destroys than our own see pain and suffering continued over page

LUKE’S JOURNAL | January 2018 | 7 Pain – what’s the point

This misery can sometimes result all to say to the man in chronic, that God provides in His daily grace, from a person’s sin as in this psalm intractable pain, isolated from loving theologians of the cross also know (see 1 Peter 4:15) but at other times relationships.8 that they have been mercifully caught occurs in spite of innocence (Psalm up in God’s salvation purposes. They 44). Theologians of the cross are Theologians of the cross, however, can long for the new creation, hidden not backward in recognising the know the powerful Lord who reveals beneath the current creation, waiting terrible reality of pain that cannot be Himself on His terms. Luther says: to be revealed. In the meantime, they entirely eliminated by human therapy, ‘He deserves to be called a theologian can trust that the God who shows His technology or policy because its roots […] who comprehends the visible and love to them on the cross has hidden are too deep in this world’s bondage to manifest things of God seen through purposes to their pain. He can use their corruption and decay (Romans 8:20). suffering and the cross.’9 In opposition pain to prise their fingers away from goods that will not last and help them cling to hope in Christ.

“...while my pain is to be lamented and relieved where Reflecting on my brief viral sojourn, I possible, it is also held in the purposeful hands of the realised that I had quite unconsciously slipped into the mindset of a powerful Lord who has shown He is for me.” theologian of glory. But as a theologian of the cross I can know that while my pain is to be lamented and relieved where possible, it is also held in the Theologians of the cross also recognise to all human expectation, God chose purposeful hands of the powerful that the ultimate root of pain is the to reveal Himself to sinners through Lord who has shown He is for me. I sin of all humanity in which they so the pain, weakness, and see now how precious is the help of deeply and wilfully participate, and death of His Son Jesus on the cross fellow theologians of the cross who can for which they deserve judgement. (1 Corinthians 1:18-25; John 14:6). At point me to cross when it seems most The right disposition of human beings the very point at which God seemed hidden. In particular, I see how precious before God is that of humility due to most absent and powerless, He was is the help of a doctor who can show guilt. As Luther says; ‘Although the most wonderfully and sympathetically me the Lord’s mercy in my pain both works of man always seem attractive present in salvation, bearing the physically and spiritually. l and good, they are nevertheless likely punishment of desperate sinners and References 7 1. M. Goldenberg,‘On Evidence and Evidence Based to be mortal sins.’ For Luther, pain breaking the bondage of sin and death. Medicine: Lessons from the Philosophy of Science’. Social helpfully undoes people. It challenges Science and Medicine. 2006; 62: 2621-2632. 2. C. Boorse, ‘On the Distinction Between Disease and human thinking about how life works Those in pain, then, can look at the Illness.’ Philosophy and Public Affairs. 1975 Autumn; 5(1):49-68. and helps to dispel humanity’s proud cross and see that God is near and He is 3. A. Kleinman, ‘Medicine’s symbolic reality’. Inquiry. 1973; illusion that they have the competence for them. Despite the way things may 16:1-4. 4. Kelly M. Kapic, Embodied Hope: A Theological Meditation and strength to rule their own lives. appear, God’s anger is turned away on Pain and Suffering. 2017. Illinois: IVP Academic. 5. Jaroslav Pelikan, H.C. Oswald, and Helmut T.Lehmann, from them, and His love, compassion eds. Luther’s Works, 55 vols, 1999. Philadelphia: Fortress Secondly, theologians of glory and power is turned graciously toward Press, 1999, 31:40. 6. Tim Keller, Walking With God Through Pain and Suffering. have a very small ‘God’. Although them. Theologians of the cross can 2013. UK: Hodder and Stoughton. 7. Luther’s Works, 31:39 our culture’s story of the good life is look to Jesus’ resurrection and know 8. Michael Horton, A Place for Weakness: Preparing Yourself largely atheistic, God isn’t necessarily they are not abandoned to a world for Suffering. 2010. USA: Zondervan. 9. Luther’s Works, 31:40. left out. In fact, He is often co-opted trapped in suffering but have the sure 10. C. S. Lewis, The Weight of Glory. 2013. UK: William Collins. in, especially in situations of pain. hope that sin and all the pain in its The preconceived expectations of train will be definitively eliminated (1 theologians of glory lead them to see Corinthians 15:50; Hebrews 6:19-20). God at work in powerful places of Dr Robyn Bain health, wealth, success and present Finally, theologians of glory desire After many years working as a doctor in the happiness. In reality, however, such too little. As C.S. Lewis says, they Emergency Department, Robyn Bain now works in a ‘God’ is remarkably small and desire only the shallow, momentary, gospel ministry full time. She has recently completed powerless. He is a projection of felt this-worldly cures and distractions a masters degree in bioethics and is continuing needs – there to help them realise to the problem of pain, dismissing postgraduate study in theological ethics. She helps their dreams and express themselves, the cross as apparently lacking in her husband, Andrew, teach ethics at the Queensland boost their self-esteem and quickly power (1 Corinthians 1:18-25).10 Theological College (Andrew is vice principal) where take away their pain. He is a ‘God’ of Theologians of the cross, however, she also trains and ministers to women. Robyn is cheap comfort rather than the Lord desire everlasting joy in Christ. While also the convenor of the Presbyterian Church of who claims victory over the greatest lamenting pain, crying out to God Queensland Committee responsible for addressing scourge of sin and death; a sentimental for relief and thankfully accepting all social and ethical issues (GiST). She especially loves ‘God’ who has nothing much at the analgesia and human kindness raising her two daughters Guinevere (9) and Julia (6).

8 | LUKE’S JOURNAL | January 2018 Dental Trauma and Treating Toothaches

Dr Catherine Hollier first met of extraction forceps. I warned them, Dr ‘Phil Akavity’ at the CMDFA “If you ever take out a tooth without National Conference. She was keen local anaesthetic – I’ll pull out your own to get a dentist’s perspective on pain front tooth without local!” I meant it! for this edition of Luke’s Journal. Standards at the dental camps were So tell us a little bit about lower than Australian standards, but yourself… the instruments were nevertheless Some of you will already have realised cleaned and sterilised in pressure that I am writing under a pseudonym. cookers on wood or kerosene stoves. I don’t quite have the freedom to speak The gloves were washed, dried and openly, so please take what I’m about powdered with flour. By the end of a to say “tongue in cheek”. I AM a “real” week when the gloves were getting dentist, but patients that are eligible fragile, I was only wearing one glove for government subsidies would often on my left hand since this was the only say otherwise. one that touched the patient. The other Dental extractions in Western Nepal! merely held the forceps. The only pain I graduated from a British university, and felt was in my feet and back, thanks to have been blessed to have worked in from developing wisdom tooth buds the wonder of modern anaesthetic. We five countries on four continents. Let’s into the upper anterior sockets, which didn’t stop until the last patient left. face it – I couldn’t be out of work for are later reshaped, so that even the long – even when I’ve tried! Being asked most experienced dentist would I’ve often wondered if there are to share about life abroad is an honour. struggle to know the difference! things that doctors could do that are usually considered the What can you tell us about I know that lots of people fear realm of the dentist. Maybe you dental trauma? going to the dentist because of could answer some of those Since I was recently asked to talk with pain, and toothache is one of questions for me. When do you Australian Emergency Department the most severe pains that many need to do something surgical doctors about how to treat dental of us experience. What can you to a dental abscess? trauma, I’ll use that as a starting tell us about treating toothache? When there is a fluctuant local swelling. point. The common signs of dental Those of you that have ever It is easy to stab with a size 15 blade. trauma are lacerations to the lip and experienced it know that paracetamol face, broken teeth and avulsed teeth. or ibuprofen take the edge off the How do you pull out a tooth? Lacerations are simple for us all, but pain and morphine makes it feel Actually you push in a tooth to a whole tooth recovered from a dirty like the pain is a metre away (not the root fibres and then it is easier to footy pitch is another. recommended by any dentist). Only remove the tooth (usually in a buccal local anaesthetic (LA) will bring true direction). The fear factor is often, “What if the relief (at least for 2-5 hours). tooth is inserted in the socket the Are there any readily accessible wrong way round?” “Good!” is my You’d have to have a “bad” toothache resources for doctors that would response. A tooth can always be to undergo an extraction without like to learn more? reshaped, but if it stays out of the LA. In Nepal, that was common in For those of you that would like socket too long or is too dry, then it the rural west. Although I was the more statistics or real teaching on won’t reattach and we can do nothing “unassigned spouse” without a work dental trauma, check out www. with it. Evidence-based research shows visa, I couldn’t sit around when I saw dentaltraumaguide.org which is among that sixty minutes is the critical time. the local blacksmith doing extractions the best in the world. There’s a small An 8 year old, with an open apex, without local anaesthetic! Training for joining fee ($25) but it’s a fabulous within 60 minutes if the tooth is stored local health care workers began. Dental resource! l in milk or saliva has a 99% success rate, camps were arranged. When a trainee but the percentages drop quickly with had extracted 100 teeth under local Dr ‘Phil Akavity’ is a ‘real’ dentist in the public system time and dryness. Excitingly, recent anaesthetic and supervision, I would who has recently moved to Australia after working studies have used auto-transplants provide them with their own full set abroad.

LUKE’S JOURNAL | January 2018 | 9 A History of Pain As doctors, one of our main functions is the diagnosis and treatment of pain.

From our earliest clinical training, the characterisation of pain and discovering its pathological origin has been our primary role. Seeking from our patients a description of pain – the site, character, radiation and aggravating and relieving factors – has been our method to deduce the diagnostic possibilities. Finally, finding the appropriate treatment has as its aim to relieve pain and, where possible, to deal with the source. In many ways, what makes us a good (or successful) doctor can be summed up in our capacity to reliably diagnose pain and relieve it to the satisfaction of our patients. William Morton, anaesthesia: A painting showing the use of ether in dental surgery, 1846.

Despite this practical approach, there and heartaches. The adjective, painful, Genesis 3:17 there is a hint of God’s is the difficulty of defining what pain is so broad that it can be applied to provision and a hope that the human actually is. Pain is entirely subjective a tooth-ache as easily as to a boil, a race will not be abandoned. When God and felt by all humanity in one form or burst appendix and birth.” The English says, “cursed is the ground for your another. We can describe it, measure physician, Peter Latham, in the 1850s sake” (NKJV), he did not say for your the effects and find the cause, but opined that pain assumed many punishment but rather for your sake fundamentally pain remains a purely guises. In answer to the question, – your welfare. In a sense the worse personal experience. “What is pain?” contended simply thing for a fallen humanity would be a that, “he knew himself perfectly well state immune to pain, because pain is Through history, physicians and what pain is and he could not know it a signal that something is wrong and scientists have sought to define what better for any words in which it could needs to be fixed. is meant by pain. Although pain has be defined. “ Latham insisted, “Things always been enigmatic, in the last 150 which all men know infallibly by their It follows that Christian doctors cannot years enormous strides have been own perceptive experience cannot be be in about the reality of pain made in our understanding. plainer by words. Therefore let pain be and the ultimate solution that comes spoken of simply as pain.” from our saviour Jesus. For clinicians The definition of pain is a more difficult dealing with pain on a daily basis, it question than might be imagined. The For Christian doctors, pain is central to is important to avoid pat answers author Joanna Bourke in her book, our thoughts of what it means to be or over-spiritualised theories about The Story of Pain1, states, “The English human and the relief of pain is part of pain. Reading the book of helps noun, pain, encompasses a host of our God’s loving providence. Christian to remind us about the inscrutability incommensurable phenomena. Pain is doctrine is that pain is a consequence of pain and suffering. There is still a a label that adheres to scraped knees, of the fall (Genesis 3:16). After Adam mystery of pain that demands our headaches, phantom limbs and kidney and Eve sinned, the outcome was respect, and humility that we do not stones. It is assigned to heart attacks human pain and suffering, but from possess all the answers. But this we

10 | LUKE’S JOURNAL | January 2018 do know – that we have a loving God obstetrician in Edinburgh, began to use for chronic pain management in the who sent his Son to suffer the most chloroform for labour and childbirth. community. horrendous pain and to die in our place. This is the central truth that we Subsequently, there was an ethical The great medical missionary, Paul live by and apply our God-given skills to debate about the use of anaesthesia Brand, worked with lepers and was well manage pain. which included some religious acquainted with pain and suffering. He objection to pain relief in labour as reflected that one of the consequences Although relief of pain has been being against ‘God’s will’. In fact, the of leprosy was that they could no central to the work of doctors, it is opposition to Simpson’s methods came longer feel pain in the leprous part of comparatively recently that therapies from only a small number of clergy. the body. He noted that pain protects for pain have been at the clinician’s Much of the resistance to obstetric and is part of God’s love and provision. disposal. In the 1830s, Sir Charles Bell anaesthesia resolved after Queen A leper without pain would burn his in England and Francois Magendie in Victoria was administered chloroform skin and never feel it. Pain tells us that France elucidated the biological basis during the birth of Prince Leopold. something is wrong and protects us of pain in terms of motor and sensory from harm. He stated, “If I had the functions of the dorsal and ventral power to eliminate human pain I would roots of the spinal cord. Through the “The body is a healthy not exercise that right. Pain’s value is nineteenth century, scientific work too great.” defined the pain pathways from body when it responds peripheral nociception to connections to pain.” Paul Brand also reminds us that pain in the spinal cord, thalamus and unifies as he wrote, “I can tell the cerebral cortex. More recently, health of a human body by its reaction neuroscience has defined pain as a to pain. If the body does not react to type of neurological activity in the Opiates derived from the opium poppy pain, I know that something is terribly brain. Pain is the brain’s response to have long been used for the relief of wrong.” 1 Corinthians 12:26 reminds noxious stimuli or, more specifically, it pain as well as for recreational use. us that if one member of the church is the response of certain regions of the In the sixteenth century, laudanum suffers, every member suffers. In the brain to nociception. Pain can thus be (opium mixed with sherry) was church we are bound together through measured and revealed by functional developed as a painkiller. Morphine the pain that we suffer. He notes, “You MRI brain scans. was extracted from opium in a pure can tell something of the health of a form in the early nineteenth century church by the way that it responds to A modern definition of pain comes and was widely used as a painkiller in the hurting, the helpless, the homeless, from the International Association for the American Civil War. In 1898, the the broken, the bruised, the battered, the Study of Pain (IASP) that states, Bayer Company in Germany introduced the bleeding and the impoverished. “Pain is an unpleasant sensory and diacetylated morphine, or heroin, The body is a healthy body when it emotional experience associated with as an effective painkiller although responds to pain.” actual or potential tissue damage or highly addictive. Bayer’s chemists also described in terms of such damage.” developed acetylated salicylic acid, Finally, pain corrects. There is a This definition emerged from the or aspirin, as a simple pain remedy. correcting purpose of pain that tells us gate control theory of pain2 (Melzak From earliest times the use of strong something needs fixing and it directs and Wall, 1967) that introduced the painkillers has come at a cost, namely, us to the solution. In today’s world, idea of a “gating mechanism” in the the potential for addiction. The search many seek relief of pain through drugs, dorsal horn of the spinal cord that for newer synthetic compounds for alcohol or even denial. C.S. Lewis in his allowed the perception of pain to be pain relief without addiction has famous quote (from The Problem of modified. As such, the gate control largely been unfruitful. methadone Pain3) reminds us that pain is like God’s theory and IASP definition make clear (Physeptone) in 1937, oxycodone megaphone to get our attention. Pain that sensory, cognitive, affective (Oxycontin) in 1995 and more recently in itself has a purpose directing us to and emotional processes influence tramadol (Tramal) and tapentadol something amiss and allowing skilful people’s experience of pain. It follows (Palexia) have each had their role in medicine to elucidate its cause. God that treatment of pain may be pain management, but none have uses pain for good in leading us to multifactorial, encompassing not just been free of addictive qualities. Whilst Jesus, who suffered pain in our place, pharmacological treatments, but also recreational drug use has been the and pointing us to a heavenly home social and psychological interventions. scourge of modern society, we are now where pain and suffering will be no witnessing an epidemic of of more. l

A major milestone in pain relief was prescription painkillers. References: 1. Bourke, Joanna, The Story of Pain, Oxford University undoubtedly the development of Press, 2014. surgical anaesthesia. William Morton The development of multidisciplinary 2. Melzack, R. Wall, PD., Pain Mechanisms: a New Theory, Survey of Anesthesiology, April 1967. Volume 11, Issue 2. first demonstrated ether anaesthesia pain clinics has sought to rationalise p89-90. in 1846 at the Massachusetts General medication and use psychological and 3. Lewis, CS, The Problem of Pain, HarperOne, 2015 Hospital (visitors can still visit the Ether other interventions. Unfortunately, Dome and Museum in Boston). Soon such clinics are often under-resourced Dr Don Todman after, in 1848, James Young Simpson, and scarcely able to meet the demand Neurologist, Brisbane.

LUKE’S JOURNAL | January 2018 | 11 Sharing comfort through Christ

Talk given at the National CMDFA • Are we any different from our must not play along with them and Conference on 14.7.17 by Murray colleagues? try to project an image of superiority. Lean. His Bible reading was • Do we see ourselves as more than 2 Corinthians 1:1-7. professionals? Paul can help us a lot in this regard, as we see in our passage 2 Corinthians Medicine and dentistry have always These are important questions for us 1:1-7. He immediately launches been that have attracted to ask ourselves. into the subject of “trouble” (NIV) students with a bent towards or “affliction” (ESV). Literally the altruism. I know I am speaking in In these talks I am attempting Greek word means “pressure”, which generalisations, but I’m still idealistic to develop a Christian model of summarises the whole spectrum of enough to think that at least many compassionate care, and this first life’s difficulties. In these few verses medicine and dentistry graduates have session begins with the premise that “comfort” is mentioned ten times, a reasonable amount of compassion for compassion begins with a correct view “trouble” three times and “suffering” their patients – they genuinely do care, of suffering. four times. Directly or indirectly, the they want to alleviate suffering, they pain and struggle of life are alluded to do have empathy for their patients. The book of 2 Corinthians is the most seventeen times in the space of five And this is particularly so among personally revealing letter apostle Paul verses! This raises for us the whole Christian graduates. wrote, and in it he gives us a peek into paradox of suffering. his innermost thoughts and feelings. Over the ensuing years some of these He suffered much in the course of The paradox of suffering a motivations can become blunted, but his gospel ministry, and had a very pain-free life? “caring” remains an important aspect painful relationship with the Corinthian Most people in the western world of our professions. Perhaps that’s one church. So it is with a real sense of his these days, including many big reason why doctors and dentists own weakness and vulnerability that Christians, don’t know what to make are still among the most respected and he writes to the Corinthians. We see a of suffering. People expect to live trusted people by the general public. very human side of Paul come through a pain-free life, and doctors and But I sense, and it’s only a gut feeling, repeatedly in this letter. dentists are the deliverers of this life. that the personal caring dimension of what we do is being questioned in some quarters these days. The “art “This is not some remote deistic God who distances of medicine” is being challenged and Himself from His creation. This is a God whose heart compromised by endless investigations, expensive machines, a media focus on beats with love for His people.” horror stories, public discussion about waiting lists, Medicare rebates, and the economics of the health system. This is the letter where he lists his Even in some Christian circles we are sufferings (2 Cor 11:23-30) and talks being told that we should expect this As the world becomes less and less about his “thorn in the flesh” (2 Cor pain-free life. We should be able to personal, the need for doctors and 12:7-10). You can’t help feeling sorry have Revelation 21:4 now (“no more dentists who truly care and show for him as you read this letter. Yet death or mourning or crying or pain”). compassion is as great as it has ever what Paul is essentially saying is that And by faith our prayers should be been. weakness and a healthy sense of our claiming these promises here and own vulnerability is actually the way now. So somehow there is a “softness” The question for us is: where does God intends it to be in those whom He around us today which makes it the Christian fit into this world of wants to use in Christian service. The hard for our patients (and perhaps algorithms, Dr Google, robotic surgery “Messiah complex” has no place in the even ourselves) to relate clearly to and 3D printing of body parts? self-identity of the Christian doctor the troubles of life. Any pain is bad, • Does our faith make a difference? or dentist! It doesn’t matter what even evil, and must be resisted and • Do our patients notice anything our patients say about us or what rejected, especially by the medical different about us? pedestals they might put us on, we .

12 | LUKE’S JOURNAL | January 2018 The reality of suffering how a sovereign God can use them Recently one of my friends drew my Yet the Bible is full of teaching on this for His loving purposes attention to the well-known verse: “Cast subject if we only take the time to check • They have a theology of victory but all your on Him because he it out. Until Christ returns “trouble” without a theology of the cross cares for you” (1 Peter 5:7). So often we is going to be a normal part of our emphasise the first half of that verse, human experience. Because of the fall Can I urge you as Christian doctors and but what a difference it makes when we Christians are not spared. We are called dentists to have a robust, biblical view grasp the fact that we have a God who to a life of daily cross-bearing, whatever of suffering? Don’t fear suffering or be deeply cares about us. He’s the “Father that may mean for each of us – but it embarrassed by it. Confront it with the of compassion” and the “God of all doesn’t sound particularly comfortable. resources God provides, both medical comfort”. And he wants to comfort us in and spiritual, but let Him have the final the midst of our troubles in life. Now I’m not suggesting for a moment word. Notice how Paul concluded his that we become cold or stoic in the battle with his “thorn”: “That is why, for Supremely he has demonstrated that face of suffering, or that we abandon Christ’s sake, I delight in weaknesses, in in Christ: our core business of alleviating pain insults, in hardships, in , in and saving lives. But we need to be difficulties. For when I am weak, then I • The One who became human so clear that suffering is always going to am strong.” he could sympathise with us in our be a part of this life and that as health weaknesses (Heb 4:15) professionals we are never going to This brings us to the role of God • The One who wept at the grave of completely win the battle over it, hard Himself in our sufferings. His friend Lazarus as we may try. • The One who wept as he looked out The God of compassion and over Jerusalem knowing all that was Positives of suffering suffering (vv. 3-5) going to happen to that city over On the positive side, God wants to You cannot read verses 3-5 and not be the next 40 years use trouble in our lives for His good struck by the personal nature of God’s • The One who would suffer and purposes. We must not forget that. Pain involvement with us in our troubles. die on a cross, bearing the sin of and struggle are actually an important This is not some remote deistic God mankind pathway to growth and service in the who distances Himself from His • The “man of sorrows, acquainted Christian life. And even when we feel creation. This is a God whose heart with grief” (Isaiah 53:3) as though we failed our patients, we beats with love for His people. Psalm • The One who suffered the wrath of must remember that God, the Great 103:13-14 put it like this: “As a father God in my place and yours Physician, is still at work: has compassion on his children, so the Lord has compassion on those who fear We cannot share literally in the • Refining character (Rom 5:3-5) Him; for he knows how we are formed, “sufferings of Christ”. Only the sinless • Teaching patience, humility and He remembers that we are dust”. That’s trust (2 Cor 12:7-10) us! Dust! But we’re very special to God. continued over page >>> • Disciplining in love (Heb 12:4-13) • Calling us to greater dependence on Himself

As CS Lewis famously said: “God whispers to us in our pleasures, speaks in our conscience, but shouts in our pains: it is His megaphone to rouse a deaf world.” (The Problem of Pain)

And Richard Baxter: “Suffering so unbolts the door of the heart that the Word has easier entrance.” (The Saints Everlasting Rest)

Donald Carson commented in his book on suffering (How Long, O Lord?) that the danger for many Christians is that their theology of suffering is deficient.

• They are comfortable with God’s power in healing but struggle to see God’s power in someone who perseveres in the face of suffering • They see sin and suffering as intrinsically evil but struggle to see

LUKE’S JOURNAL | January 2018 | 13 Sharing comfort through Christ

Son of God could suffer, die, be rejected What troubles have you experienced in greater than we are realistically able by the Father and descend into hell as your life? Don’t waste them. Let them to meet. People have complicated the only acceptable atoning sacrifice. make you more aware of God’s love lives and often we feel out of our So what does it mean for us to “share for you, and better able to pass on His depth in trying to help them. But by abundantly in the sufferings of Christ”? compassion to others. God’s grace there will be times during consultations, at the bedside, even For some it could be a literal physical Personal comment in the dentist chair, when God opens suffering, as it was for Paul himself, and My wife Debbie died nearly seven a door for us to minister his love in a is today for many in the persecuted years ago from breast cancer. During specific way – perhaps even a chance church. But for most of us it could be her 10 year battle she was constantly to share the gospel. As the Holy Spirit other forms of suffering – physical, under specialist care and spent many moves in us, so love… patience… emotional or spiritual – that we an hour in waiting rooms and at times kindness… gentleness… and encounter in the journey of life as hooked up to IV lines in Day Therapy compassion… will become apparent. faithful, cross-bearing disciples of Christ. Units surrounded by fellow patients. I was always amazed at the friends Sadly, our training emphasises the The Christian experience involves our she made over the course of these danger of “getting too close to our identification with Christ’s sufferings visits. She’d keep in touch with them, patients”. We are taught to maintain a by faith in His death and resurrection ringing them and catching up to see level of emotional detachment. I think (Gal 2:20). His sufferings result in our Paul would disagree. Obviously there comfort as we receive forgiveness is a need for common sense and wise and new life in Him. And in turn we “What troubles have you judgement here, but I think he would be take up our cross and follow Him, saying, don’t be afraid to let down your whatever suffering and sacrifice that experienced in your life? professional guard and be a real person. might entail (Phil 3:10). First and Don’t waste them.” There is a real place for us to “weep with foremost, our comfort comes from our those who weep” (Rom 12:15). relationship with Christ. And it is the gospel that must be the source of our When I first moved out of full-time compassion toward others. “We love medicine into pastoral ministry nearly because he first loved us.” (1 John 4:19) how they were going. They were there 30 years ago, it bothered me that I had at her funeral. Total strangers to me, difficulty showing emotion in certain The value of suffering but people who felt her practical, pastoral situations, such as comforting (vv. 3-4, 6-7) Christlike love. In a wonderful way she a family at the bedside of someone Some years ago John Piper wrote an had learnt to “comfort those in trouble who was dying. I didn’t want to be article following his diagnosis with with the comfort she had received a cold detached pastor. I remember prostate cancer entitled “Don’t waste from God”(v.4). Her Christian faith praying specifically about this at the your cancer!” That seems to be the had taken on a whole new legitimacy time. Thankfully it’s not a problem sort of thing Paul is writing here: and power because she was able to these days. Sometimes it’s actually “Don’t waste your suffering”. For all the share with others out of the comfort hard getting through a funeral! tension that may have existed between she experienced from God. Through himself and the Corinthian church, Christ this comfort was very real to • Draw on your own pain and Paul wanted them to know that all the her. She actually looked forward to disappointment, and experiences of trouble and suffering he had been her appointments because of the suffering through had not hardened him against opportunity they gave her. It became • Reflect God’s comfort in these times them but actually made him even more one of her ministries. • Marvel regularly on the sufferings of compassionate towards them. Christ for you in the gospel Final thoughts • Use your own experience to reach His personal experience of God’s Suffering is real. Whether our own out in comforting others comfort had somehow tenderised his suffering or the suffering of others, heart and enabled him to love them we cannot escape it. And for doctors And who knows how the Lord may even more (see vv. 3-4 and 6-7). He and dentists it’s the space we have use you in different situations to bring was able to see how all he had been to live and work in every day. But so glory and draw people to Himself. l through, even the pain the Corinthians is the comfort of the gospel. And as had caused him, was a positive thing. Christians we have the privilege of Dr Murray Lean God was using Paul’s personal suffering entering into the pain of our patients Murray is Senior Pastor at City North Baptist Church to make him a more compassionate and passing on the compassion and Brisbane. Murray initially trained in Medicine man through Christ. In fact, the comfort of our God. and worked for ten years as a Missionary Doctor. implication is that he would be less Following this he studied theology and worked as a effective in comforting others without I realise that time is often limited Pastor and medical doctor in the rural town of Biloela, having suffered! and the needs of our patients are far Queensland.

14 | LUKE’S JOURNAL | January 2018 When managing chronic pain can hurt When asked by the editor to write an opioids, there are some certain to people who are “simply unwilling to article on pain, it is presumably not limited indications for usage of them. even consider any changes…Then it is because of any special insight into Without wanting to replicate a medical not loving to enable them to persist in the topic, but rather the sharing of article, some agreed aims of medical sin by providing them with handouts one’s experience in managing this as a management should be: of food, clothing or shelter. Rather, primary care doctor. • to reduce distress to a bearable level the loving thing to do is to allow them • to help the person function as well to feel the burden of their choice in As compassionate Christian doctors, as possible hopes that this will trigger positive with our professional healing skills and • to minimise the adverse effects of change” (with a caveat about mentally gospel-given insight into the souls of treatments6 incapacitated people). In trying to patients1, we are to treat them with holistically care for our patients, permission, sensitivity and respect Where it can become quite tricky is sometimes as responsible doctors we (to borrow the Saline process motto), in educating patients to accept that need to be firm in pointing out the and in partnership. Their chronic pain pharmacotherapy should only ever harms of opioids whilst offering to (non-cancerous for the purposes of be part of a multimodal plan, not continue to help them, to point them this article) is often complicated by the be all and end all of chronic pain to better options even though they troubled lives which leads to varying treatment. There is limited evidence may not acknowledge it at the time, or responses from health professionals. that drugs are of benefit (particularly even over many years. The risk of regular, heavy usage of opioids) in chronic non-cancer pain opioids is definitely an area of medicine long term. As mentioned above, one As Christians (and health professionals fraught with danger for the patient, as harmful temptation is for patients to be generally), we are not to abandon well as the doctor, and so we need to be prescribed opiates to blunt emotional them but rather seek to journey to the prayerful and wise.2 rather than physical pain. root cause of their situation, to pray for them, to remain open to them Chronic pain is certainly an important A helpful paradigm to monitor returning, to bring them to closer to issue. The National Prescribing Service response is to review: what God wants for their lives. They states that it “is a major cause of distress • Analgesia (reduction rather than may reject our advice and approach but and disability in the community. It can usually full elimination of pain) we are not to reject them. l become a problem in its own right, • Activity (eg. walking, hydrotherapy) References: 1. 1 Peter 3:15 even when underlying predisposing • Adverse effects 2. Matthew 10: 6b conditions are being managed • Affect (the patient’s feelings or 3. Principles of prescribing for persistent non-cancer pain 3 page 1 Professor Milton Cohen. Australian Prescriber optimally.” AVANT, one of the Australia’s emotions) 2013:36:113-5. 4. AVANT. Prescribing drugs of dependence. April 2015 main medical defence organisations, • Aberrant behaviour (clues to 5. Good practice issue. RACGP. Pages 6-7. November 2017 cautions that “the majority of matters unsanctioned use of prescribed 6. Principles of prescribing for persistent non-cancer pain page 1 Professor Milton Cohen. Australian Prescriber related to drugs of dependence opioids) 2013:36:113-5. involve GPs who are at the frontline 7. Page 217-220. Corbett/Fikkert. When helping hurts. of prescribing opioids.” 4 It points out The last A is the hardest if warning that many doctors face challenges with signs are present. Once it’s clear that Dr Richard Wong those patients who are drug-dependent patients are dependent on opioids for Richard is VR GP who hails from Sydney but in the last few years has been working a lot in areas of or seeking, and that this can lead to chronic non-cancer pain, explaining need around Australia and internationally as well by inappropriate prescribing, deaths, an the multiple downsides and minimal dedicating some of his time to short-term medical undesirable black market, extortion of upsides and then following through mission trips. He is currently at the general practice patients who carry opioids and so on. with medication intervention of Dr Paul Mercer, the chairperson of the board of Healthserve in Brisbane and complements this with RACGP reminds us that “opioid overdose (methadone and buprenorphine) can regular hospital work. He is a long term member of and dependence has become such a be helpful. CMDFA and was its NSW secretary for a number of problem in the US – resulting in more years before switching to continue in a similar role than 90 deaths a day – that it has been What should be done, however, if in Queensland. He has shared in teaching roles over 5 the years in both a bible and medical capacity. He has declared a national crisis. No doubt, patients do not acknowledge their also been a long term supporter of TEAR amongst many of the readers will have their own dependence and are not willing to other Christian organisations and is a trainer for the cautionary tales. change despite the best medical Saline Process as well as a PRIME qualified tutor. He is interested in addressing the disparity of healthcare advice to them? The Christian book around the world by using his God-given resources The article goes on to say that with on effectively helping poverty When to help in any way possible through the board of the exponential usage of prescription helping hurts7 addresses a response Healthserve.

LUKE’S JOURNAL | January 2018 | 15 Pain: A Theology on the Fly

Pain – its meaning, significance “faith hope and love.”2 Prayer opens identify the “space” that Huebner has and often-associated suffering our lives to the Spirit who is given to identified, to make a sketch. – has exercised the thinking of “lead us into all truth”. Prayer joins us philosophers and theologians, with fellow pilgrims who bring the As Christian health professionals, we (indeed, most of us) since the rich spread of grace in human life, the may like to start with our strong suit. beginning of time. This will continue fellowship of the Spirit. Evidence-based medicine (EBM) offers for our generation. us much to consider about the human “Christians can work experience of pain. A biomedical We live during a time in history when approach encourages the discipline we know a considerable amount about with quality information of asking the right questions. We pain mechanisms, as well as benefiting on the basis that it also will want to understand the issues from powerful treatments and around the reliability of research technological advances. The dramatic contributes to God’s and also its interpretation. There is increase in the use of narcotics work of ‘reconciling all a very significant body of literature worldwide in the past twenty years to master. To manage our enquiry suggests a seismic shift in the way we things in Christ’.” we may try to identify a respected accept or tolerate pain. review article. Empirical research can be assimilated into a theoretical Chris Huebner1 observes that Theologians delight in reminding framework to understand pain and to “the church’s life is on the run; it’s the church and the world that “all predict the outcomes and benefits of theology is delivered on the fly”. This truth is God’s truth,” so from prayer treatment approaches. Theology on observation about theology caught our investigation could proceed on the fly doesn’t have an unlimited time my eye as I thought about ‘pain’. It multiple fronts. I am aware that I don’t frame in which to operate. We may offers a way forward for our rapidly have the capacity or skill to robustly enlist the aid of an expert in fields of changing context when we may have explore all these possibilities. My hope pain ‘knowledge’ to tutor us. While settled on systematic theological is to suggest a way forward and seek to science flourishes under the gaze of certainties. Huebner makes this further observation, “The Christian theologian does not function primarily as a broker of agreement but seeks to cultivate space for those meaningful disagreements out of which hitherto unrecognised possibilities, new expressions of faithfulness, might emerge”. Many observers suggest we face a ‘perfect storm’ around pain and pain management issues, so now is the time for theology on the fly to swing into action!

Where do we start? The unanimous advice of scripture is prayerful openness to God. Solomon coined the phrase, “The fear of the Lord is the beginning of wisdom,” to catch our attention on this.

Prayer calls us toward humility. Prayer encourages the productive focus of

16 | LUKE’S JOURNAL | January 2018 scepticism, Christians can work with a few evolutionary adaptations along pain regulating system also opens up quality information on the basis that the way. Suffice it to say, Adam was connections to disability and congenital it also contributes to God’s work of already hardwired for the emergence illness. For past generations, leprosy, “reconciling all things in Christ”.3 of ‘thorns and thistles’ in the design with its resulting deformity and danger of his neurology. The gate control for individuals, compounded by social A Christian’s encounter with the mechanisms of the spinal cord also stigma, has been the ‘pain disorder’ to world is always transformational, imply God’s imaginative design be feared. Praise God for dapsone and so theological reflection on pain specifications, which allow checks and reconstructive surgery! mechanisms can trigger imaginative balances on up-regulation of painful and Spirit-inspired outcomes and stimuli. As doctors, we know that our Chronic pain is defined as persistent new lines of enquiry. The social pain-afflicted patients will need self- pain lasting three months or longer. sciences serve a theological project help skills and stress-management The term, “It’s all in your head,” came by identifying cultural, social and practices to work at ‘closing the pain into our vocabulary to try and explain psychological forces at play – both gate’ and re-establishing equilibrium. such pain. Why should an injury, for in the experience of pain and how to That our conscious will and training instance, fail to recover in terms of work towards healing and acceptance. can impact ‘pain gates’, also points pain? We now recognise two such types Consequently, we may need to recruit toward a degree of responsibility of neuropathic pain exist: interdisciplinary skills to understand a for individuals to control their pain. holistic awareness of pain in our times. Gate-mediated reflexes to pain, 1. Peripheral neuropathy, and in conjunction with limbic system 2. Centrally-mediated pain. Let us reflect on a little of the biomedical science around pain. Our Peripheral neuropathic pain can sensory nervous system can identify “Illness arising from intensify. We call this allodynia. a range of painful stimuli – pressure, or disrupting the pain Strength, reflexes, balance and co- heat, cuts, inflammation and chemical ordination can be impacted. Similarly, changes.4 The body depends on pathways help us central sensitisation can impact more nociceptors to warn about pain. Fast recognise that, apart than nociceptors. Any kind of sensation nociceptors respond to severe pain can now become very difficult to and so help a rapid body response. from the warning of tolerate. Our ability to ‘turn down the Slow nociceptors carry information acute pain, pain is volume’ of pain in these deregulated, about dull or aching pain. This isn’t a sensitised states is currently less than “one size fits all” pain warning system. essential to our survival.” perfect. EBM is pointing us toward Furthermore, we should recognise a multidisciplinary approach that is there is a range of specificity and tailored to each individual. This is sensitivity. That will alert us to seek somewhat of a sidestep from the naïve further layers of complexity in the responses, help another human being optimism that medical treatments, nervous system. When nociceptors to recognise the impact of this pain, especially opioids, would free people detect damage, they send electrical or its chronicity for an individual, and from chronic pain. All medications impulses up the nerve pathways respond with compassion or skill, which are useful in an acute context toward the spine until they encounter etc.. We should be hopeful that, over do not translate into good treatments a specialised type of nerve cell called time, good science will help accurately for a deregulated, sensitised nervous an interneuron. Interneurons connect interpret pain in its biopsychosocial system. Sadly, chronic pain often multiple nerves at the spine, and context and help develop better implies and poverty. they act like gates, controlling which treatments, and even cures, for chronic messages get through to the deeper complex pain states. We have reached a point where we structures of the spine and brain. have recognised a rich complexity in Interneurons open the gate to painful As yet we haven’t begun to consider the way the nervous system in the stimuli. Voila! – the gate theory of disease of the pain pathways and body handles painful information pain. In the brain itself there are similar chronic pain disorders. Bypassing detected by the nociceptor warning layers of complexity to the reception the direct question of the ‘why’ of system. We also recognise multiple and response to painful stimuli, such pathologies, the reality of these disease conditions which may including emotional factors and the problems both challenges and instructs trigger acute or chronic pain states. meaning of pain to us. our understanding of pain. That some Whatever the source of pain, we also individuals live with what appear to have identified the challenging role If we were to reflect on the nociceptor be overwhelming conditions and of central sensitisation disorder in ‘warning system’, it may help us receive ongoing support from families complicating chronic pain states. In to consider the wonder of God’s is a testimony to the courage of the this “Theology on the Fly” we can creation. The God of Creation needed human spirit. Illness arising from or observe that all these components to account for the possibility of pain. disrupting the pain pathways help us of pain provide valid entry points for Undoubtedly our pain receptors have recognise that, apart from the warning theological reflection. different challenges than that for Adam of acute pain, pain is essential to our and Eve. There may have even been survival. The absence of a healthy continued over page >>>

LUKE’S JOURNAL | January 2018 | 17 Pain: A Theology on the Fly

We have played our strong suit first up. Where to next? Learning the lessons of history is always wise. Reflecting on how past societies have managed and viewed pain grounds our current awareness. The philosopher, Martin Hegel, coined the phrase, “the slaughter bench of history” to capture the association of violence and suffering that has plagued humanity. Alcohol, primitive narcotics, restraints and even techniques such as a sharp jaw blow to initiate unconsciousness have been used as pain-modifying approaches over time. Essentially, pain control was a trial and error project, with most people enduring pain and living out life with courage. Often people were blamed for their own suffering, as ‘sinner’s deserving punishment’ or some other infraction against the gods. The emergence of the anaesthetic agents, such as ether and nitrous oxide, were accidental observations, as these substances were in vogue as party drugs at the time. A theologian will want to reflect from a service to an exchange-of- medical interventions. In Proverbs 31:6 on suffering, courage and chance goods industry, with an associated the words, “Give beer to those who as components of faith-seeking impersonal, mechanistic type of are perishing, wine to those who are understanding regarding pain. When care. On the other hand, culture does in anguish,” appear to be a mandate Scottish Presbyterians gave the green hold many positives for humanity. for a palliative approach when disease, light to pain relief during childbirth, a The vision of the new heavens and pain and suffering are in the direction great leap forward was triggered. new earth in Revelation where “The of the end of life. The Old Testament glory and honour of the nations will text, the Book of Job, is a neo-theodicy Cultural forces are also worthy of be brought into it”, Rev 21:26 lead us within scripture itself. Job 21:23-25 exploration. We have already noticed into the scriptures as a resource of our captures questions about the meaning some cultures tend to ‘ the Theology of Pain.5 of pain and suffering, “One man dies victim’. Others, such as the Spartans, full of vigour, completely secure and were infamous for denial and discipline How can we encounter scripture at ease, his body well nourished, his in the face of pain. Some cultures have so as to understand the bones rich in marrow. Another man chosen to use pain, in the form of meaning of pain? dies in bitterness of soul, never having torture, as a political weapon. Some One process is to go on a text-mining enjoyed anything good.” Job’s text of the features of our own culture are expedition – to look for as many ultimately takes us to the mystery relevant to the way we understand and verses as possible that mention pain of suffering, standing against the respond to pain. Our age of autonomy and then see if ideas emerge from cosmic sweep of God’s own interests. is one of intense self-mastery. We set this data. We hope it will speak to us Sometimes the Holy Spirit will lead the pace of our own flourishing and in those scattered fragments of his us to words of comfort in scripture. pain is a threat to the good life. In Word. I spent a day laid up with acute Unfortunately, we can also transfer part, this explains the rapid evolution back pain looking for such verses. our own needs into reading scripture of narcotic analgesia in the last 20-30 “My back is filled with searing pain; this way. Self-fulfilling ‘words’ for years. Ours is an age of . there is no health in my body” jumped our own desire will collapse under We become frustrated if we need out at me in Psalm 38:7.6 We easily scrutiny. “Theology on the Fly” will to wait or to suffer. This can also develop an affinity for some verses need more. A theological framework precipitate inappropriate medical care as they do seem to reflect our own might help a simple verse make robust as doctors sense the ‘heat is on’. For circumstances in life. A lament Psalm connections. Linguistic, socio-cultural some, euthanasia is the exit option like this also encourages us to bring nuances will also help. The 4th century from a life of pain. Another feature of our struggles, our pain experiences, Christian theologian, Augustine, saw our times is the commodification of to God as a cry for help. Some verses the scriptures as God’s story7 – a almost everything. Medicine is moving seem to be a simple mandate for sort of autobiography about God’s

18 | LUKE’S JOURNAL | January 2018 great love for the world. Re-engaging I am suggesting in a quick sketch of and sin, and also to reignite the love with scripture as narrative is helping what a ‘theology of pain’ may look this creator-God has for his image- contemporary theologians face current like today – this ‘now, but not yet’, bearers, and so desires from them in challenges. A narrative approach in God’s story. God’s narrative starts return. can also help us see the insights and with God’s own observation that “all weaknesses in other world religions. he had made was very good”. Yet the A theology of pain will seek to learn final vision of the ‘new earth’ also from the interplay of sin, judgement This noted, I want to stay on task and contains the ideas of judgement and and salvation and the stories of the seek insight from the narrative of salvation. If we return to the start of old and new testaments which carry scripture. The Bible is not a ‘flat text’. God’s narrative, we soon discover it. Among the mountains, valleys and It starts strongly, “In the beginning...”. a story of brokenness. The primal places of wilderness in scripture, the The actions of God in creating the image-bearers are required to accept story of Jesus of Nazareth demands cosmos and giving it life, particularly one restriction – to not eat of the particular attention. God’s love for to God’s image-bearers, men and fruit of a particular tree, the tree the word is so deep that he sends his women, are documented as all being of the knowledge of good and evil. only son into the world as a definitive ‘good’. A nervous system with a pain- Curiosity and temptation overtook salvation solution. perception capacity is part of this ‘good’ Adam and Eve, and sin became part creation. God also creates an amazing of the rest of history. God issues a The technical term is incarnation. opportunity for humanity. He says number of curses, on humanity and The life, death and resurrection of to the first humans, “Be fruitful and on creation, because of the rebellion Jesus operate as a major historical increase in number; fill the earth and of sin. These curses will add struggle, earthquake. While we were still sinners, subdue it.” There is a sense that God angst, conflict and suffering to life. Jesus willingly died to pay the penalty wants his image-bearers to be involved of sin. Suffering, associated with pain, in the finishing touches of creation, to will forever stand in the light of this manage the ‘asset’ of creation, to do “That Jesus experienced ‘Christ event’.9 God’s love for the world good work and enjoy the beauty of the pain like us both affirms is exceptional. His commitment to earth in harmony with God. To ‘subdue’ salvation fully engages with material the earth suggests a residual chaos, or the good creation of reality. In His one and only son, God imperfection requiring further creation. the nervous system enters our world through the painful passage of childbirth. As a growing The other bookend of God’s narrative and participates in the child, Jesus will learn the ropes of is what we call ‘the new heavens and redemption won for the growing up through painful falls, cuts the new earth’! The context of this and bruises and the clumsy blows creation will be quite different. Now, rebellion of sin.” of other children. At work with his “the dwelling of God is with mankind, father, Joseph, Jesus will appreciate and he will live with them. They will the painful toil of labour. He will take be his people, and God himself will Death becomes a restrictive end-point a Roman flogging from Pilate’s guard be with them and be their God,” Rev to human flourishing, and pain is now and will accept the pain of nails being 21:3. Among many blessings, there is a threat to human life: Eve is promised driven through his hands and feet. a promise of the end of pain – here the intensification of the pain of childbirth; That Jesus experienced pain like us “old order of things will pass away”! The working the land will now involve both affirms the good creation of the new order includes a garden within a painful toil. God’s narrative quickly nervous system and participates in the vast city. On either side of the river of reveals how sin and its attached curses redemption won for the rebellion of the water of life can be found the tree invade creation. Violence with chaotic sin. of life, whose leaves are for the ‘healing expressions of pain are suddenly with of the nations’. us – Cain kills his brother Abel; Lamech The promise of humanity, which was kills a younger man for an ‘accidental’ never realised because of sin, has been Into the city will come “the splendour injury to his arm. Revenge, rape, revealed in all its grace and truth in of the kings of the earth; the glory and oppression, ethnic cleansing and more Jesus. The gospel writers challenge all honour of the nations.” (Rev 21:26). rapidly unfold in the story. Augustine to identify Jesus – “Who do you say With a little imagination we could find of Hippo sees sin as the consequence that I am?” they ask us. Parting the the science which has contributed to of human anxiety as we face the heavens, we received God the Father’s the diagnosis and effective treatment knowledge of good and evil alone, recognition, “This is my son whom I of pain among this honour. The God- without God. Many pathologies around love; with Him I am well pleased”. given mandate to be “fruitful and pain derive from such anxiety. God’s increase in number, fill the earth and hand regarding sin is quickly revealed Jesus lived the authentic human life subdue it,” etc. appears to come full in the narrative. God exercises both that Adam recoiled from. The eventual circle in this hopeful, open ending to judgement and salvation in history – to the narrative. both moderate the impact of violence continued over page >>>

LUKE’S JOURNAL | January 2018 | 19 Pain: A Theology on the Fly cross and resurrection of Jesus broke the curse of sin and so liberated humanity from the suffering of pain. God’s love compelled him to suffer with humanity in all its pathologies of pain, so that in the new heavens and new earth, pain will be no more!10 As people of faith, our calling is to follow Jesus in living a cruciform life.

This paper is little more than a musing about the theology of pain. There are many areas to go deep and develop a “thick theology”. Healing, compassion, the ethical choices of Jesus and much more are relevant. In his letter to the Colossians, Paul understands Christ as the Great Reconciler. Paul puts it this way, “For God was pleased to have all his fullness dwell in Him, and through Him to reconcile to Himself all things, whether things on earth or things in Finally, any ‘theology on the fly’ needs heaven, by making peace through to return to the scrutiny of the people 12 His blood, shed on the cross” (Col 1: “The eventual cross of God. As the ‘scripture project’ puts 19-20). God’s love has motivated such it, “faithful interpretation of scripture a wholehearted and fully-engaged and resurrection of invites and presupposes participation salvation in Jesus that we can proceed, Jesus broke the curse in the community brought into being hopefully as witnesses to this love by God’s redemptive action”. This which sets us and the world free from of sin and so liberated allows for an orderly, yet spirit-led, sin and its associated ‘curse of pain’. humanity from the reflection. In this open space, we will be privileged to share the rich stories While we wait, and Jesus prepares suffering of pain.” of grace unfolding in our lives. We will the new heavens and new earth, we begin to discern new spiritual practices are given the gift of the Spirit. In the to live an authentic witness to God’s Spirit, God is closer to us than we are to great love in Jesus. To live with, and ourselves. The Spirit is our comforter, beyond, pain. Let us just do it! l the one who empowers us to ‘put on We can begin to do this as we listen to Christ’ in the world. The Spirit energises the stories of our patients. Where is the Dr Paul Mercer a ministry of healing and guides us into light of Christ? Where is the comfort Paul is editor of Luke’s Journal. all truth. The Spirit helps us see pain as of the Spirit? Where is the love of the a gift and mediates the grace we need people of God in these stories? Bibliography to live well in the face of suffering. 1. Huebner, C. K. (2006). A precarious peace: Yoderian explorations on theology, knowledge, and identity. We could also review the way the Waterloo, Ontario: Herald Press. In the ‘now but not yet’ reality of God’s church, through history, has humbly 2. von Balthasar, H. U. (1986). Prayer. San Francisco: Ignatius Press. kingdom, there is more ‘good news’ carried its witness to God’s coming 3. McLeish, T. (2016). Faith and wisdom in science. Oxford, UK: Oxford University Press. that God’s salvation has “a people for kingdom. Where have past ‘theologies 4. Bruce, B. K. (2017). The Mayo Clinic guide to pain relief: God’s name”.11 For the apostle Paul, the on the fly’ brought us? The skills of Course guidebook. Chantilly, Virginia: The Teaching Company. church is a critical component of the critical biblical scholarship will be 5. Middleton, J. R. (2014). A new heaven and a new earth. Grand Rapids, MI: Baker Academic. gospel. Here there is a community of recruited to negotiate controversies 6. New International Version of the Bible (Revision ed.). fellowship in the Spirit, of love for one and expose new potential options. (2011). 7. St Augustine. (1997). The confessions. Hyde Park, New another that is both a glimpse of future If we truly believe the story of God’s York: New City Press. 8. Davis, E., & Hays, R. (2003). The art of reading scripture. hope and a living witness in the world action in creating, judging and saving Grand Rapids, MI: Eerdmans Publishing Company. battling with sin and pain. the world toward a new heavens and 9. Jinkins, M. (2011). Invitation to theology: A guide to study, conversation & practice. Downers Grove, IL: InterVarsity new earth, then we will accept the Press. 10. Fretheim, T.E. (1984) and reprinted (1987). The Suffering The narrative of the scriptures has challenge of dialogue, of reading the of God: An Old Testament Perspective, ovetures to biblical opened up many possibilities for an story with diverse ‘others’. Here our theology. Philadelphia, Fortress Press. 11. Fee, G. D. (2001). To what end exegesis? Essays. Grand on-the-fly theology of pain. As we common experience of pain will test Rapids, Michigan: Eerdmans Publishing Company. 12. Treier, D. J. (2008). Introducing theological interpretation recognise the components of a clear our theology. Is it a genuine theology of of scripture: Recovering a Christian practice. Grand vision of pain, we will want to test it. “faith, hope and love”? Rapids, Michigan: Baker Academic.

20 | LUKE’S JOURNAL | January 2018 A Pain Vignette 1 A Doctor’s Work is Never Done Ally is a 61 year old divorcee, I tried to introduce NSAIDs, regular at this stage that this wouldn’t be the admitted to a nursing home paracetamol and adjusted the sodium case, and that in fact, there was good because of a diagnosis of memory valproate dose for her headaches. news in the sense that she probably decline in association with falls Requests for PRN oxycodone was going to live a much longer life and failing capacity for self-care. appeared to be escalating. Some than she initially expected. There’s also history of episodes of questions were emerging: self-harm and mood instability. Around the same time, blood tests When do primary care practitioners demonstrated that her renal function Other history features include: need to question established had declined, and Ally retained quite 1. Pronounced myoclonic jerks tertiary care diagnoses? a bit of fluid. In retrospect this was (thought by Ally to be epileptic) probably due to the persisting use of 2. Chronic headaches How should we go about further an NSAID, but it allowed me to cease 3. Low back pain assessment and management of her sodium valproate, meloxicam and 4. Complex relationships with an Ally, in this overall context? sertraline and introduce duloxetine only son and try to stabilise her pain request 5. Very poor quality of sleep I tried to read the memory clinic with Targin 5/2.5mg bd. Ally’s medications included: notes as carefully as I could, and 1. Sodium valproate became aware that a neurology I continued to see Ally regularly. As 2. Sertraline assessment had not occurred. Ally she became more confident in my 3. Donepezil confirmed this. She had had a normal presence, she disclosed that her 4. Quetiapine EEG, and her movements, which sleep disorder at night was due to 5. Atorvastatin were quite dramatic at times, were very violent nightmares. She had 6. Oxycodone PRN considered by some of the team as memories of near death experiences 7. Paracetamol pseudo-seizures. I was beginning on at least three occasions at the to form the opinion that PTSD in hands of the violence she received On encountering Ally, I discovered a the context of domestic violence from her ex-husband. These person who was very devoted to her in association with a borderline memories tormented her at night. four year old granddaughter. She was type personality might be a better using an iPad competently. She says diagnosis for Ally. What was also beginning to be she uses it to keep lists and records clear was that Ally was no longer to help her memory. She regularly I continued to work hard at a good requesting PRN oxycodone, and that attends a church associated to the doctor-patient relationship. In this indeed we had begun to achieve facility. context, I asked her permission to much more stability. Her myoclonic arrange a neurology review. I put jerks were reduced in number, and I Prior to the admission, a memory it to her that her headaches were encouraged her at this point to enter clinic had made the diagnosis of becoming quite a problem. The into a relationship with the nursing frontotemporal dementia in the neurologist repeated an MRI, and care facilities chaplain, to explore the context of and borderline after seeing this and examining Ally, pastoral care implications of her past . Ally was also decided that there was no evidence violence, and to begin to pray for thought to have epilepsy. It soon of dementia and that PTSD and healing of her memories. became clear that Ally was very keen personality factors were indeed the for pain relief for headaches and back most likely diagnosis. Another series My work is not yet done. While Ally pain, and her myoclonic jerks seemed of questions started to form in my is on Targin bd it means that there is to have a stress association. mind. still scope for getting her off narcotic pain relief altogether. But I think Ally’s presentation was very unusual, How difficult is it to manage pain there is a good chance that with a and it caught my clinical imagination. in a context like this? What are the holistic approach to her problems, Was this really a case of dementia? options available? she’ll come through this and indeed Why was this lady needing pain relief one day may leave the nursing care in this overall context? I was now faced with breaking the facility as she becomes healed and bad news, that Ally didn’t have well again. l In taking a “patient-centred” dementia. She initially took it quite approach, I discovered that Ally was badly, and was very concerned that divorced in the context of humiliating she would be asked to leave the Dr Paul Mercer domestic violence. nursing care facility. I reassured her See A Pain Vignette 2 and 3 on pages 25 and 29.

LUKE’S JOURNAL | January 2018 | 21 Pain in Parturition and Procreation

It was eerily silent as I walked passed couples who would be able to live the fact that the sensation of pain the labour and delivery suite. I was together, irrespective of gender, was part of original creation. The used to the groans, moans and and they would be presented with a sensory pacinian corpuscles, the non- screams of women who were in matched embryo. This would then myelinated C fibres that transmit the labour pain while in India. This had be implanted into an artificial womb. electrical impulses, the spino-thalamic given way to the sounds of women (Women had long ago refused to be tracts and the sensorimotor cortex pushing their baby out with minimal pregnant and experiments to make were all created to be part of original or no pain after an epidural block in men pregnant were a failure.) At 40 creation. Pain has a protective function, labour (Graham, 20011) in Australia. weeks, the fetus would be declared with a stimuli and response being But this was different. It was as if born, taken out of the artificial womb part of most organisms. Therefore, the birth suite had been altogether and moved to the nursery where physiologic pain was presumably eliminated. ‘designed nannies’ breastfed and always present in creation as part of trained the infant. From the nursery, God’s grand design. Pain, in itself, is The year was 2080 CE and indeed, the children moved to ‘designated not a result of the Fall. The question there were no more birthing suites. schools’ where and training then becomes when, why and how did Women had been completely of children occurred as ‘discerned’ by pain become so pathological that most ‘emancipated’ from the ‘pain of the computer program’s analysis of a of medicine is devoted to pain and parturition and procreation’. The thousand parameters. There were no alleviation of pain? Could looking into so-called ‘modern’ blended family conflicts between parents and children! the story of creation and the origins of (remember the ‘yours, mine and ours’ No more pain, no more diseases, life provide us with some answers? era) had been replaced by ‘matched’ no more tears! Paradise, it seemed, families, seen as the best way to have had been achieved. However, it was John Walton has written an excellent families since 2070. There had been difficult to know if the absence of book where he suggests that the first no divorces, no domestic violence and conflict established harmonious, loving chapter of Genesis is not about material the family court had been shut down relationship. creation at all, but primarily about God for over a decade since the elimination stating his authority over light and of natural human reproduction – a darkness, over time, over seasons and major achievement and the result of “...physiologic pain was over the living things (Walton, 20095). the concerted effort of many medical presumably always This makes the changing scientific scientists, social scientists and ethicists understanding of the origins of life working together with industry experts present in creation as authentic to the understanding of developing the artificial placenta (Bird, part of God’s grand the time and God’s ownership of the 20172). universe and its creation an eternal design.” truth. This understanding would In this brave new world, all men and then allow our science students to women regularly contributed to a explore the theories of origins of life world-wide sperm and egg bank where The pain in parturition and in or origins of the universe as integral both eggs and sperm were stored procreation had become a story from scientific theories attempting to frozen. Large databases of the genomic the dark ages. In fact, not many knew answer the question of “how” and characteristics of each sperm and egg about the story of creation, the Fall or leaving the question of “why” to were maintained and matched to have knew God. theological statements. This gives me perfect genome in each offspring. a perspective on Genesis 1-3 which Disease-bearing genes had been It is often presumed that there was allows me to have integrity of my eliminated by CRISPR-Cas9 genetic no pain before the Fall and therefore faith and practice as a fetal medicine engineering technology (Doudna, pain is a result of the Fall and part of specialist. 20143). No more pain, no more disease! the curse. In Gen 1:28 it is written that male and female had been created Extending the same argument to This brave new world assured marriage in the image of God and blessed to Genesis 2 and 3, we can propose equality and gender fluidity with all procreate and fill the earth with no some of the basis for the origins of gender-specific pronouns banned by mention of pain (NIV, 20114). However, pathological pain. We understand law. Computer algorithms matched very few scientists would challenge that God created the entire universe

22 | LUKE’S JOURNAL | January 2018 and humankind, male and female light than woman in Genesis 3 where Genesis 3, “And Adam was not the together, in His image in Genesis Eve ‘the woman’ is the one to whom one deceived; it was the woman who 1:27, blessed them and told them to the serpent speaks and the one who was deceived and became a sinner.” procreate. However, in Genesis 2, man sins first. We tend to ignore the fact 1Tim 2:14. Again using the Walton is stated as being created first and that Adam ‘the man’ was “with her” and principle, the scientific accuracy or the woman created as a helper suitable his silence, of course, then becomes chronological sequence of the account for man later on. Applying the Walton deafening. However, it appears that in Genesis 3 is not what we look for, principle to Genesis 2, we can then Paul in his letter 2000 years ago to but the theological statements and the see the chapter, not in terms of the Timothy supports the account in inherent intentions. chronological events stated there, but in terms of the theological statements The outcome of the ‘act of and intentions in the chapter. Though disobedience’ by Adam and Eve was not a theologian, I would venture to “We have worked hard the loss of the blessings from God, state Genesis 2 is about relationships to address pain and the the consequent disruption of various – God’s relationship with man; man’s relationships and the resultant increase relationship with the plant and animal problem of pain since of pain. Whilst much has been written kingdom; and relationship between a the very beginning.” about the ‘problem of pain’, I tend man and woman. to agree with Brand and Yancey, who state that pain is a gift from God Genesis 1 establishes that God created (Brand, Yancy, 19936). Essentially, pain male and female in the image of God is part of the beautiful design that we concurrently, so there are have been bestowed with. It is the no grounds for us to increase of pain in procreation that is think that man was stated in the Genesis 3 account, not created first, and the origin of pain. The disruption of then woman as an relationship also begins here with afterthought. We God stating “your desire will be for then no longer your husband, and he will rule over need to find you”. The corruption of all that an explanation was good had begun and we are as to how the both witnesses and participants of omniscient, the disrupted relationships – the omnipotent God abuse of children and women, ‘forgot’ the need the rape and sex of both for the female genders, the violence in marriages, of the species at the agony of those differently the epitome of his sexually-attracted, single mothers creation (when this was provided and their pain, the agony of for in all the lower species) or why bringing up children and the we cannot find a ‘missing rib’ on trauma in intact, as well as one side in man. It is imperative blended, families is all part of that we undo this thinking that is this ‘pain in procreation’. present in all three monotheistic religions and in Christian Disrupted relationships extend teaching, reinforced by Pauline with ramifications to all of writings, “For man did not come creation – primarily between the from woman, but woman from created order and the Creator; man.” secondarily between men; 1 Cor 11:8, and “For Adam was between women; between formed first, and then Eve.” men, women and children as 1Tim 2:13-14 (NIV, 20114). It well as between all humans could be argued that the very and the rest of the created origin of gender order (Romans 1:21-32, 8:20). begins here, from a literal Pain, therefore, not only in reading and application of the Adam and Eve fleeing parturition and procreation Genesis account. the Garden of Eden but also in disrupted statue, Ljubljana, relationship (sexual and Slovenia. Additionally, man is seemingly continued over page >>> presented in a better

LUKE’S JOURNAL | January 2018 | 23 Pain in Parturition and Procreation otherwise), has become pathological, an understanding of the disruption Dr Joseph Thomas with nothing and no-one exempt. of the inherent relationships, the less Joseph is a Senior Specialist in Maternal Fetal successful we will be in eradicating Medicine and Obstetrics at the Mater Mothers We have worked hard to address pain pain. Restoring these disrupted Hospital in Brisbane. After training at the Christian and the problem of pain since the very relationships cannot be addressed by Medical College Vellore, he worked at the Bangalore beginning. The epidural block in labour legislation. Neither gender equality Baptist Hospital and Asha Kiran Hospital, Orissa, India has become standard all over the laws nor marriage equality laws will till 2003. He subspecialised in Maternal Fetal Medicine world in spite of the original objections remove the rampant discrimination in Adelaide after which he moved to Brisbane. He is from the church. Anaesthesia, in its in humans everywhere. The primary passionate about human formation and currently various forms, has made surgeries of all disruption of relationship between he and his family worship at the Creek Road kinds a reality. Speciality ‘Pain Clinics’ God and man, as well as the loss Presbyterian Church. and journals dedicated to pain have of the presence of the Triune God Acknowledgements become numerous. Pain however, should be recognised. The restoration I gratefully acknowledge with thanks, Drs Frank and Val Garlick, continues to be a major problem of the fatherhood of God and the Dr K George, Dr D Todman and the extended Thomas family for reading the manuscript and making valuable suggestions. in life. It assumes sophisticated brotherhood of mankind through the References manifestations in the developed world work of the Lord Jesus and the Holy 1. Graham, M. (2001). ‘Quantitative assessment of motor block in labouring women receiving epidural analgesia’. with the very definition of pain being Spirit is foundational. The misuse of Anaesthesia, 56: 470-6. 7 2. Bird. (2017). ‘Artificial placenta: Analysis of recent difficult (Todman, 2017 ). scripture to reinforce discrimination progress’,. Eur J Obstet Gynecol Reprod Biol, 208: 61-70. and exert power and control over one 3. Doudna, C. (2014). The new frontier of genome engineering with CRISPR-Cas9. Science, Vol. 346, Issue If the eradication of pain is all that is another should stop especially with 6213. 4. NIV. (2011). THE HOLY BIBLE, NEW INTERNATIONAL needed, then the scenario in 2080 regard to gender. When relationships VERSION®. Biblica, Inc .® Used by permission. would be Paradise restored and the are restored and there is harmony 5. Walton JH. (2009). The lost world of Genesis One. Authentic books. consequences of the curses removed. between man and God, man and 6. Brand P, Yancey P. (1993). Pain: The Gift Nobody Wants. Harper Collins. However, the underlying disruption woman, humans and the rest of 7. Todman D. (2017). History of pain. Luke’s Journal, Vol 22 of relationship in pathological pain is the created order, pain will become No 3, 2017. ignored, and we continue to ignore this physiological and part of life and living. to our peril. The more we ignore the Paradise restored! l source of the ‘increase in pain’ without

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24 | LUKE’S JOURNAL | January 2018 A Pain Vignette 2 A Broken Heart “Bill” is a 63 year old truck driver who From a GP point of view, something We stayed “in this moment” for some presented with recurrent chest pain. is missing in this presentation. time. I was now in time deficit with His pain was heavy, retrosternal and We could continue to explore the the appointment . recurrent. He was an ex-smoker who cardiac status with a coronary artery was normotensive and had no signs CT angiogram. We could establish Bill agreed to get grief counselling of heart failure, and normal heart a disciplined medical treatment and return for support. His pain sounds. programme. My internal search quickly resolved. His broken heart process suggested further history was beginning to heal. The pain had been recurrent over taking to establish a bio-psychosocial a few months, and he disclosed context. What would Bill’s doctors have that he had presented to multiple missed if they didn’t inquire into emergency facilities in our city. He I started with the question: “Was his social circumstances? How had been actively assessed for ACS anything important happening in important is a holistic history in on each occasion, and no diagnosis your life around the time the pain your practice? of MI was sustained. A stress started?” echo was normal. There was no Are reframing skills helpful in costochondritis. Bill was anxious and Bill burst into a flood of tears. patients like Bill? “Is it possible uncertain about his health status. Between sobs, he shared the you have a broken heart Bill?” He seemed to be a defeated man. crushing grief he was experiencing could be a useful question. after the sudden loss of his wife. She How would you proceed at this had died of a sudden heart attack. Dr Paul Mercer point?

LUKE’S JOURNAL | January 2018 | 25 A multidimensional approach to pain from Genesis 3 to contemporary pain services

Modern neuroscience highlights the scientific understanding. He proposes • Lastly, related to development fact that the experience of pain is a ‘quadrune’ brain with each of the of the frontal lobes, specifically much about the brain and nervous 4 layers being fundamental to our it seems the medial pre-frontal system. evolutionary development. cortex (or 3rd eye in certain traditions), is our human capacity Two people may have the same bodily • Firstly, at brainstem level, is the for transcendence, for higher structural change, such as a lumbar so-called ‘reptilian’ brain. Primary consciousness, for salvation or disc prolapse, and yet one reports pain functions relate to sustenance, enlightenment. while the other does not. This discord sex and fight/flight or freeze is explained by the understanding that mechanisms. These powerful drives My life as an inhabitant of Planet Earth an interpretation is made at the level relate directly to our ancestors’ is clearly enhanced if I am aware of of the brain about the degree of threat success, or otherwise, in passing and grateful for the fourfold structure - the greater the perceived threat the on genetic material to future of my brain. I can become better more likely the person to experience generations. equipped to tackle the challenges of pain. Hence, pain can be seen as part of my reptilian brain or ‘lizard legacy’ if I a response designed to protect us from recognise that it developed in a bygone danger. “Improving relational age for a specific purpose that does dysfunction... can often not necessarily align so easily with life Humans appear to experience pain in in contemporary times. In observing ways that the rest of the animal world be part of the journey of the chatter of my ‘monkey mind’ I can does not. Our highly developed minds recovery from chronic be grateful for its analytical capacity, and complex social networks create as well as reflective about its potential ample opportunity for amplification pain.” for harm and need for transformation. of the pain experience. The way that Learning about the potential for any we experience pain seems to relate to of the brain areas to be dysfunctional the unique way our consciousness has in terms of contemporary life and its evolved. • Secondly comes the ‘old- ability to lead us into temptation is an mammalian’ brain. Dominant essential aspect of spiritual growth. In this article I will attempt an functions relate to social exploration of foundations in bonding and interaction. Think Now, back to the beginning, and a neuroscience and interpretation of breast-feeding, skin contact and Genesis 3 perspective on the evolution Genesis before examining the building development of more complex of human consciousness. Clearly that is a modern multidimensional social networks. The mid-brain and Genesis can be interpreted in many approach to pain. limbic system are key structural ways along the spectrum – from literal components. to allegorical. Perhaps a multitude of Genesis 3 meanings does not make any single In considering the evolution of human • Thirdly comes the ‘neo-mammalian’ interpretation less true. However, it consciousness, where better to start brain, with the capacity for critical is interesting to consider Genesis in than Genesis 3? But before going analysis and scenario testing. terms of evolutionary brain theory. back to the ancient wisdom, a little Structurally, this correlates with From this perspective the tree in the more contemporary neuroscience. development of the cerebral cortex. centre of the garden may equate The book Thank God for Evolution by On the one hand a blessing, on the to the developing nervous system Michael Dowd1 makes for interesting other a curse when we consider the and the serpent our ‘reptilian’ brain. reading in this controversial space. challenges we now experience with The knowledge of good and evil that Dowd explores parallel unifying ideas rumination and seemingly never- comes with eating the fruit refers to in the Biblical account and modern ending cascades of thought. the evolution of the human brain to

26 | LUKE’S JOURNAL | January 2018 the point of self-awareness. At face of pain amplified. Cognitively, our from the input of multiple health value it seems true that we have a expectations, beliefs and fears professionals. A biopsychosocial capacity to differentiate good and evil have great potential to increase the approach is recommended. Recently that is unique amongst living species experience of pain. In the modern this has been inverted and the term on Earth. There came a fall from the world, an extensive social security ‘sociopsychobiomedical’ coined. state of innocence represented by the capacity, along with technological This recognises, in the context of garden, and there were consequences. advance, has contributed to disability chronic pain, that the sociological and Enmity grew between the serpent rates unseen in societies where basic psychological factors are generally and the offspring of the woman. What requirements for food and shelter more important than the biomedical in better metaphor for our very human are more difficult to attain. This formulation and treatment. struggles with our basic drives. Pain was amplified. Presumably pain exists even in the idyllic state of Eden.

However human brain development meant that pain became more multi- “Relational faceted. A social aspect crept in. The pain followed woman’s desire would be for her husband but he would rule over her. the increasing Or perhaps equally, the man’s desire complexity of might be for his wife and she might decline his advances. Relational pain human interaction followed the increasing complexity of and expectations.” human interaction and expectations. The earth itself became cursed and the ecosystem put under threat as a consequence of the evolving human brain. What better depiction of our current state of ecological crisis? We also became aware of our impending death in a way that the rest of the animal kingdom is not.

Finally, we were banished from the garden with cherubim and a flaming sword guarding the path back. disability can be seen as another factor I work as a pain medicine physician Devastating as this picture is, it also contributing to the amplification of at Hunter Integrated Pain Service, raises the hope that a return to Eden is pain. Neuroscience clearly shows John Hunter Hospital in Newcastle. possible. Perhaps the garden remains that reduced physical activity adds Our team have found the term ‘whole deep within each of us. The return to to nervous system sensitisation and person’ approach2 to be more suitable this state of innocence is possible but increased pain intensity. Environmental than ‘sociopsychobiomedical’ in our only by way of the sword. We need to degradation, mono-cropping and discussions with patients. We then die to self. We need to be prepared production of refined high caloric differentiate the holistic into five to become like little children before foods add a nutritional layer to nervous component parts illustrated by the we can enter the Kingdom of Heaven. system sensitisation and amplification guiding hand shown below left. Making Perhaps this is the Christ-like path that of pain. Pain is no longer the simple change in any of the areas represented Jesus opens for us? experience of the Garden of Eden. can help to retrain the nervous system and reduce the experience of pain. Multidimensional approach Contemporary treatment of pain Behavioural change is the key that can Let us now return to a multi- follows this multidimensional unlock neuroplasticity, bioplasticity and dimensional approach to pain. We framework and often benefits beyond, to whole person plasticity. As need to recognise that pain has a role human beings, we have the capacity to even in an idyllic world such as Eden. change at any stage of life if we choose If I touch a hot saucepan, pain allows to do so (see figure left). me to quickly withdraw my hand before too much damage occurs. An Biomedical treatments such as acute pain response such as this is medication and surgery can play a role clearly a protective gift. However the in changing us for the better. However, evolution of the brain and humanity’s they tend to be more effective for fall from innocence meant that pain acute illness or injury and much less became a more complex gift, if indeed it remains a gift at all. The experience continued over page >>>

LUKE’S JOURNAL | January 2018 | 27 A multidimensional approach to pain so for chronic conditions. Hence the in refined food and sugars, produces therapeutic approach involved ongoing standard approach to treating chronic low-grade bodily inflammation nutritional focus. She lost another 5kg pain involves medication deprescribing which can spill over to contribute to over the following six months. She and avoidance of surgery, except for nervous system sensitisation and pain. started a regular walking program. very carefully selected indications. Changing to a diet high in plant-based She continued to work through the whole foods with reduced amounts mindbody impact of her childhood The mindbody aspect recognises of refined products and sugars has experiences. After six months of that what we think and feel has great an anti-inflammatory effect that can disciplined attention to her recovery capacity to change our physical state. contribute to pain reduction over time. plan, her pain and fatigue had both Unhelpful beliefs and expectations reduced by 80%. In attributing cause can very directly impact our physical to her improvement, she felt that all state – in part via nervous, immune “Healthy individuals aspects of her whole person plan were and endocrine systems. Activation important, however, the mindbody of the stress response rather live in healthy societies, aspect seemed most fundamental. than the relaxation response can inhabit healthy She had been able to work through contribute powerfully to negative to forgiving her father for leaving the health outcomes. On the other hand, ecosystems and family home and his subsequent lack activation of the relaxation response recognise the spiritual of contact and support. The anger and can be a strong contributor to healing. negative emotions suppressed at that connectedness of all time were brought to her conscious The term ‘connection’ is multi- things.” mind and released. Some time later faceted and hence very useful. At she was able to re-establish contact one level it refers to connection with with her father. There was a degree of the people around us. Improving healing of family connections. relational dysfunction such as that To use a de-identified brief case described in Genesis 3 can often be history, Sophia was a 30-year-old Healthy individuals live in healthy part of the journey of recovery from woman experiencing chronic pain societies, inhabit healthy ecosystems chronic pain. At another level there is and fatigue when she was referred and recognise the spiritual environmental connection. This may to our team. When she attended our connectedness of all things. The path be in need of restoration as we think of introductory education seminar, she to healing can be longer or shorter. A the ecosystem damage resulting from particularly noted the importance of metaphoric return to the garden can human behaviour. Spending time in a psychological aspects and nutrition. often play a part. This incorporates a natural environment can be beneficial While awaiting a multidisciplinary dying to self, a letting go of unhelpful in calming an aroused neuroimmnue assessment with our team, she started cognitions, a mindful simplicity, a system. Connection can also be used working with a local counsellor and healthy connection with others and as a term to introduce discussion of changed her diet to reduce refined the planet. The ancient biblical book of deeper purpose and spirituality. There foods and increase vegetable intake. Genesis offers intriguing insights into a is a body of research that correlates When she attended the assessment multidimensional approach to pain for this deeper connection with well-being two months after the education the modern era. l and longevity. seminar she had lost 5kg in weight. References 1. Dowd M. Thank God for Evolution. 2009 Penguin Random At the multidisciplinary assessment House Addressing activity is a fundamental she reported that her pain and fatigue 2. White R, Hayes C, White S, Hodson FJ. Using social media to challenge unwarranted clinical aspect of treating pain. The seemingly began when she was 13 years old. 3. Variation in the treatment of chronic noncancer pain: the natural response is to rest in the face She was diagnosed with fibromyalgia “Brainman” story. J Pain Research 2016;9:701-709. of pain. This can have brief benefit at and chronic fatigue syndrome by a the time of an acute injury. However, rheumatologist the following year. Dr Chris Hayes mobilisation becomes important at an When asked what else was happening Chris enjoyed discussion of spirituality around early stage. From a pain perspective, at the time of pain onset, she said the family dinner table as a child. After marrying and particularly in the context of that her parent’s marriage had ended Cate they attended churches from various chronic pain, maintaining, or often and her father moved interstate. As denominations. They have a shared interest in the increasing, activity helps to wind the eldest of five siblings, she took spiritual dimensions of healing. Chris has an ongoing down a sensitised nervous system and charge of her brothers and sisters fascination with the intent of Biblical writers and reduce pain intensity. while her mother returned to work. how ancient wisdom can inform modern life and In Sophia’s words “my childhood health care. Chris trained in anaesthetics before Nutrition is coming to be recognised ended”, “the weight of responsibility plunging into pain medicine. He has been Director as a component part of the treatment settled on my shoulders”. Sophia of Hunter Integrated Pain Service at the John Hunter of chronic pain, just as it is for other was able to recognise the possible Hospital in Newcastle since its foundation in 1997. chronic conditions, including diabetes link between her teenage emotional He is currently Dean of the Faculty of Pain Medicine, and heart disease. A Western diet, high burdens and the pain and fatigue. Her Australian and New Zealand College of Anaesthetists.

28 | LUKE’S JOURNAL | January 2018 A Pain Vignette 3 Resistant to Change “Scott” is a 55 year old invalid Primary care medicine faces the full 2. Accept that as a person made in pensioner. He has an aggressive force of narcotic overprescribing. the image of God, Scott needs persona and is heavily tattooed. There are multiple factors: healing in his life. Scott is a new patient to you. He had been seeing a kind, Christian • Rising complex pain rates in Is it appropriate to simply offer a GP who has retired. A State Health a world with only “imminent” gospel witness and decline further approval for prescribing oral significance. prescribing? Where would this morphine (Kapanol) 100mg bd was leave the caring/witness of the in place. He requests his “usual” • Associated rising levels of narcotic previous senior colleague? script. use (both prescribed and illegal). 3. As in (2.) but recognise this will How would you manage this • Pressure for early discharge from be a long journey. Serving Scott consultation? hospital leading to poorly planned will mean respecting his integrity, pain pathways. creating the space to openly If you suggest a dose reduction disclose the forces that have because the morphine use is for • The despair of failure to achieve made “pain” such a powerful force degenerative cervical and lumbar self-mastery and success in life. in his life. It will mean ridding pain, Scott is very resistant. You feel the bumps of “lost” tablets. It his aggression and anger. Without spiritual hope, narcotics will mean keeping an eye on all are now the “real opiate of the the medical issues relevant to A good physical review is indicated. people.” Many primary care doctors Scott, and always responding with If the pain is correctly diagnosed, are ill-equipped to manage these integrity and compassion. this dose of morphine is excessive. contexts. All doctors are aware of the If the correct diagnosis has been slow undesirable consequences of long In a person so resistant to change, to emerge, this is an opportunity for term, medically prescribed, narcotic looking for authentic opportunities a careful review. Psychosocial and use. However, on the ground support to move forward in the cycle of spiritual issues are highly likely. In for individuals and practitioners change are important. Both relational terms of the “cycle of change” Scott is through the cycle of change to de- and professional roles need to be firmly a “pre-contemplator.” prescribe is weak. maximised.

With these thoughts I am able to Scott’s bloods are normal. X-rays Opportunities for “education” around negotiate a physical examination in confirms degenerative changes pain, and the problematic use of his next visit, providing the script without operative solutions. Scott narcotics long-term should always be today and asking for blood tests to re-presents for his next prescription. accepted. Scott should be aware of exclude an inflammatory condition. He remains aggressive. Your heart is the legal contractual nature of such sinking. an engagement. Developing a robust, How important is developing a dynamic pain management plan healthy doctor-patient relationship What are the options for a will be a priority. It may be useful to in this context? Christian GP? develop a treatment contract.

Scott agrees to this plan, but 1. Recognise personal limitations If Jesus made friends with tax indicates he is highly likely to resist and involve a pain service to do collectors and sinners, can a doctor change and is prepared to complain the hard work of rationalising develop a “professional friendship” to the medical board if change is narcotic use. This may mean an relationship with someone like forced on him. interim time period where you Scott? agree to simply provide monthly Should Christian doctors continue scripts. A State Health approval Dr Paul Mercer to see patients who pose needs to be obtained. It can See A Pain Vignette 1 and 2 on pages 21 and 25. professional risk? be made clear a zero tolerance option applies and Scott has the 100% responsibility to manage his monthly supply. You may suggest weekly pickups.

LUKE’S JOURNAL | January 2018 | 29 Christian Doctors, Chronic Pain and Addiction A personal reflection

I was stunned by the Isenheim Altarpiece at the Colmar museum in Alsace.

Grunewald had graphically painted the crucifixion and burial of Jesus. Jesus’ body was covered with the ischaemic sores and gangrenous digits of a person suffering from St Anthony’s fire. I could not recall the exact condition but I was struck by the intensity of the suffering and also by the ignorance of the people looking after the victims. All the carers could do was to pray and to care – and they did. No doubt many got better, though others died as carers looked on helplessly.

A Google search quickly dispelled my ignorance. These people were suffering from ergot poisoning, due to eating rye infected by the fungus Isenheim Altarpiece painted by Matthias Grünewald at the Colmar museum in Alsace. Claviceps purpurea. I admired the skill of those who had worked this out, and While we know a lot more medicine, and we often have to sit with people of course I have never seen anyone there is still a lot we don’t know. in distress feeling helpless in the face with this condition today. But I was Chronic non-malignant pain often falls of pain not well controlled by our struck by the courage of those of the into that category. While we insist on medicines. Just as well, for Paul Brand order of St Anthony who looked after a proper clinical diagnosis, often there in his book, Pain – the Gift Nobody these sufferers. How would they have is none and we are forced to treat the Wants1, points out that patients approached the condition? Did they symptoms without addressing the with leprosy and diabetes who have bluff their way through like we doctors unknown underlying pathology. I call anaesthetic peripheries lose their do when we encounter symptoms this red-light medicine. Imagine driving digits. This happens because injuries which we don’t understand? Did they a car and a red light comes on in the and sores are not felt and therefore confidently suggest electric treatment dashboard. A sensible driver would not recognised, and part of patient as John Wesley did for St Anthony’s investigate why that red light has gone education is to teach them to inspect fire? Did they postulate blood-letting on. A silly driver picks up a hammer, their limbs every day to ensure there and purging as Benjamin Rush, the smashes the red light and keeps are no new sores, and if there are, to American Psychiatric Association driving. Chronic pain treatment is a treat them carefully. poster boy did, and probably killed bit like that – treating the symptoms more people than he saved? Rush not the cause. But sometimes we are How do we as Christian medical probably did not see St Anthony’s fire forced to do just that. professionals respond to such but he seemed to have prescribed distress? Some versions of Matthew’s his interventions for many other Not that we are all that effective. Our classification of the diseases Jesus conditions. pain management tools are limited, treated in Matthew 4:24 identify

30 | LUKE’S JOURNAL | January 2018 chronic pain or severe pain as a limb. They tend to have to manage the last twenty years. From initial specialty of our Lord. (KJV ‘divers these complex and difficult diagnoses caution in prescribing opioids at all, diseases and torments’, NRSV ‘various and people within the restrictions of to the recognition that not everyone diseases and pains’, NIV ‘various their time-limited consultations and who needs opioids for pain develops diseases and severe pain’). So we are busy waiting rooms. tolerance, to the idea that even if they disciples of a healer who had a special develop tolerance that is a simple gift. His compassion is highlighted. Not Not only are the diagnoses difficult, biological phenomenon requiring a for him the dispassionate rationalism chronic pain tends to occur in patients higher opioid dose. Thus Stimmel’s so beloved of the enlightenment. He who have difficult personalities. Many book Pain and it’s Relief Without had compassion and he healed. We also have been damaged by life’s events Addiction2 (1997) advocated increasing can have compassion, but the healing and they crave love and understanding. the dose without any dose ceiling is a bit more difficult. Most lack resourcefulness and in an attempt to keep the patient resilience and they believe a magic functioning well. The bottom line here Thomas Sydenham, the English potion will give it to them. And it does! was how well the patient functioned Hippocrates and the Father of English Opioids, after all, stimulate the same in the community, not an arbitrary medicine, a committed Christian, pleasure centres that are stimulated ceiling dose of milligrams of morphine commented that, “one of God’s by intimacy, hugs, maternal care, the equivalent (MME). greatest gifts to humankind is the gift love of a lover - both sex and affection. of opium.” But like all potent tools The picture is quite different a it can be misapplied. Opioids have decade later. With the increase in bad three basic actions. They relieve pain, “Chronic pain treatment opioid prescribing, particularly of the they stimulate the limbic system (the is... treating the oxycodones, and the increase in opioid pleasure centre of the brain), and they deaths in the community, there has relieve withdrawal symptoms in those symptoms not the cause. been a public health backlash against dependent on opioids. Not every But sometimes we are uncontrolled prescribing of opioids person taking opioids feels the rush of and an attempt to limit the dose addiction. A lot of my post-operative forced to do just that.” and duration of opioid prescription. patients say they do not understand This is a very different strategy to the addict, their opioid did not give the successful use of methadone for them a buzz. Others comment that However, the initial powerful effect patients who are opioid dependent, they now understand what ‘the junkies’ of opioids fades and more and more who do not have any pain. In their case see in opioids. However, even the latter opioids are required to relive the there is no limit to the duration or dose group do not automatically become original buzz of the first dose. This of substitution pharmacotherapy, but addicted. Other circumstances are is the basis of addiction – the desire there are strict limits on the prescribing needed for addiction to occur. I believe for pleasure thwarted by increasing and dispensing of methadone. For the latter group is vulnerable if their tolerance, compounded by the patient methadone there is only one trained pain became chronic and their doctor developing a withdrawal syndrome prescriber who has the permit to was generous in their prescribing. Here if they suddenly stop the offending prescribe, and who sees and reassesses the compassionate Christian doctor is substance. The desire for that buzz the patient regularly. Dispensing is vulnerable, for in their attempt to be becomes more and more insistent, and supervised so that methadone is not kind they give in to repeated requests swamps all other needs and drives – given to the inebriated or the sedated for more analgesia, and hence the like the need to save money, to feed patient. Take away doses are limited to patient can develop a dependence oneself and to care for others. one or two doses per week to reduce on their opioids and their doctor. the risk of overdose, and patients are Iatrogenic opioid addiction is a function Pain is a subjective sensation. It is only slowly trusted with further take of the doctor-patient interaction. One unhelpful to say to a patient that they aways. Methadone prescribers are of the great unconscious seductions is are not in pain when they say they trained before they can prescribe so the line, “Doctor you understand. You are. With time, education, and insight, they understand the risks of what they are not like all the others.” they may be able to differentiate are doing. By contrast any doctor can between pain relief from opioids prescribe opioids for chronic pain and Yet these patients crave compassion and the pleasure addictive drugs there are no dispensing precautions. and understanding, and an unfeeling may give them, and they may then dispassionate professional is not decide whether the analgesia they In the liberal 1990s, doctors identified therapeutic. Chronic pain patients receive from their drug is in fact the pseudo-addiction as a condition often find themselves referred to stimulation of their pleasure centre. where the patient had ‘legitimate pain’ many specialists who may not be very With this insight, they may then but was forced to act out as if they helpful. Whenever a patient does not successfully withdraw from opioids. were addicted because no one would fit into neat management categories This will help to decide whether opioids prescribe the appropriate opioid. The specialists take refuge in the line ‘not should be stopped or continued. pseudo-addicted behaviour would my specialty’ or the latest buzz phrase, disappear when a caring doctor ‘not within my scope of practise.’ This Attitudes to opioids for chronic non- leaves General Practitioners out on a malignant pain have changed over continued over page >>>

LUKE’S JOURNAL | January 2018 | 31 Christian Doctors, Chronic Pain and addiction prescribed the right opioid and the some other factor external to the patient was then happy! In the more patient prevents their recovery. Here cautious present, sceptics suggest this they need to recognise the futility of concept may have led to the rise of the their expectation and find strength iatrogenic opioid addiction epidemic within themselves to manage as well driven in part by the pharmaceutical as they can within their limitations. industry.3 Of course to criticise the concept of pseudo-addiction because Chronic pain sufferers will tell of it is not an objective phenomenon calls these ‘pain multipliers’ as they tell for an objectivity which cannot exist. their story. Their pain is exacerbated We are dealing with symptoms like pain by their past traumas, by previous and pleasure which by definition are perceived incompetence and subjective. The debate continues. indifference, by fear, by ignorance, by unrealistic expectations and One of the best services we can offer by thwarted hopes. All of these Christ healing the Sick by Gustave Dore. patients suffering from pain is to dimensions cannot be addressed by a take their distress seriously and to single session or by a single therapist. listen carefully to their whole story, Physiotherapy, occupational therapy, THE HEALER listening as they tell their story - group therapy and other psychological John Greenleaf Whittier not just to the timing and rate of interventions are all important To a young physician... change of symptoms, but also to the in helping patients to manage to emotions that may accompany that live with uncertainty of diagnosis, So stood of old the holy Christ – the fear, the anger, the frustration, prognosis and the opprobrium of Amidst the suffering throng; the abandonment, the outrage at health practitioners who blame the With whom His lightest incompetence and bureaucratic patient for the patient not getting touch sufficed blunders that may be compounding better. While fear and ignorance are To make the weakest strong. their pain experience. We need to best treated with truth and astuteness, That healing gift He lends to them hear of the unrealistic promise and very often the honest therapist has to Who use it in His name; the disappointment of thwarted care sit with the patient in their uncertainty The power that filled and of the therapeutic errors that and ambiguity. His garment’s hem may have occurred in all they have Is evermore the same. experienced. We need to hear of Chronic pain management, then, For lo! in human hearts unseen the indifference shown to them by is an ongoing journey requiring The Healer dwelleth still, some of our colleagues, and show patience, perseverance, hope, and And they who make compassionate understanding. resilience. It calls on both the doctor His temples clean and the patient to live with uncertainty The best subserve His will As we take a history we need to be and even to acknowledge our The holiest task by Heaven decreed, aware of face-saving events (FSEs). ignorance. It requires firm boundary An errand all divine, These FSEs are a certain spin patients setting on unrealistic expectations The burden of our common need can have on their history. They and yet an acknowledgement of To render less is thine. describe that up until that event life legitimate requests which will be met was good, even perfect, but then compassionately and even cheerfully. The paths of pain are thine. disaster struck. That event can be a car Treatment is emotionally costly to the Go forth crash, a injury, a traumatic carer and the carer needs to make sure With patience, trust, and hope; interpersonal event, or the death of their own care is not neglected in this The sufferings of a sin-sick earth a loved one. Since then, life has been difficult struggle. I have found John Shall give thee ample scope. a disaster. However, careful, cautious Greenleaf Whittier’s poem extremely Beside the unveiled mysteries sensitive questioning will usually inspiring – see panel right. l Of life and death go stand, reveal that the patient’s resilience With guarded lips and reverent eyes And pure of heart and hand. prior to the event was not strong, References: 1. Brand, Paul. Yancy, Philip. Pain - the Gift Nobody Wants So shalt thou be with power endued there were plenty of warning signs of Zondervan. 1982. later trouble, and that they have rather 2. Stimmel, Barry. Pain and its Relief Without Addiction From Him who went about Routledge, 1997. romanticised their story. Further, by The Syrian hillsides doing good, blaming where they are now on such And casting demons out. an event, they are stuck and cannot A/Prof Alan Gijsbers That Good Physician liveth yet change. They have an unrealistic Alan is Head Addiction Medicine Service RMH, Medical Thy friend and guide to be; expectation that somehow they will Director Substance Withdrawal Unit, The Melbourne The Healer by Gennesaret be rescued from that disaster. Legal Clinic Richmond and President ISCAST, ICMDA Board Shall walk the rounds with thee. restitution, a withheld apology, or Member, Former Chairman CMDFA.

32 | LUKE’S JOURNAL | January 2018 Reflections on Pain from a Nursing Student

Pain is your friend! Just breeeathe! Does anything relieve it? The one to Relax! Imagine yourself in a quiet ten scale, the Wong-Baker faces etc. place beside water! Close your eyes I’m a nursing student beginning my and listen to your inner voice! You journey with patients and pain. I’ll can do this! You’re doing so well! It’s learn to tell the difference between not really that bad! It’s all in your patients wanting free drugs and ones head! desperately needing medication but not asking for fear that it denotes Anyone who has experienced pain will failure. I’ll learn how a hurting body probably have heard these expressions presents and how to combine my at one time or another. Some are rather compassion for it with an ability to inane, some may be helpful and others step back emotionally and treat it are just plain ridiculous! I can personally effectively. say, after having given birth to six large healthy babies, that being reminded to And we know of course, that pain isn’t breathe while your perineum is being just physical. Our hearts break when stretched to an alarming width makes loved ones attack and reject us, or run you want to attack someone with your after foolishness. Our minds shatter birthing stool! when we experience guilt, failure, disillusionment or the ultimate grief - And yet, we all feel pain. Want to relieve death. Being alive hurts! it. Attempt to relieve it. Maybe even with some of those lines above. We But the best thing we know about pain feel so wretchedly helpless watching a is that it can’t last. There will be eternal patient, dear friend or family member relief from it one day – far outdoing struggle with that familiar enemy. any earthly analgesia. Sin brought pain Everyone experiences pain at some and death into God’s perfect world. time during their life and for a myriad One day, He will recreate a world for of different reasons. It is our ever- those who love Him in which they will present curse. “We feel so wretchedly never feel pain again. He is our ultimate source of pain relief as we wait for that Methods for managing pain are helpless watching a world. diverse and personal. We hear the patient, dear friend or expression “he/she has a high or low In the meantime, take some ibuprofen pain threshold” meaning that he’s family member struggle and just breeeathe! l quieter than we expect or she’s more with that familiar demonstrative in attempting to cope. Ruth Minter People in pain can surprise us. The enemy.” Ruth has been married to her favourite man for patient with a staggering array of twenty-two years and they have three sons and traumas takes it in his stride stoically three daughters aged between 21 and 15. She – real blokes don’t admit they’re relaxation or visualisation. And there’s home educated her children and is convinced she hurting! The next patient insists on always paracetomol! wouldn’t have survived this without a good sense medication for her torn fingernail. of humour, blood pressure medication and a cat Some rely silently on an inner strength. As health professionals, we’re trained who purrs loudly at 3am. She has a degree in music, Others vocalise, causing havoc for the to recognise and relieve pain. Where half a degree in nursing and, if she has spare time, rest of the ward. Some choose music is it? How long has it been there? digs in her garden, reads a good book or chases the therapy, aromatherapy, hypnotherapy, Sharp? Achy? What makes it worse? aforementioned cat off her piano.

LUKE’S JOURNAL | January 2018 | 33 Pain avoidance – the role of addiction

This essay looks at the role of pain in allow some patients to feel hope again blunt instrument, and one that can the development of addiction, and where counselling and social support also do much harm if used unwisely. how we as the church can potentially has failed. There are some substances Therefore, drug use is traditionally minister to sufferers of addiction. which are able to mimic aspects of regulated by society through laws, human experience to the extent that social rituals and boundaries. From the book of Genesis, we see that they can be very attractive. However, an increase in the experience of pain inevitably there are downsides. For In relation to pain experienced by is linked to The Fall. Man was excluded example, human beings, there is indeed much from the Garden of Eden where he that we can do as health professionals could potentially eat from the Tree • methamphetamine can overcome to both cure disease and alleviate of Life and live forever. Scripture fatigue and increase attention, suffering. However, when faced with indicates that these impositions were or in higher doses produce such pain in the absence of a cure, our necessary to limit the effect of man’s an intense reward that whatever instinct to help can lead us to do harm. disobedience and for God’s order to be actions went into achieving Indeed, the attempts by our profession preserved (Gen 3.22), but by deduction that state, will be repeated to to alleviate pain contribute to over (God’s love for man), for the good the exclusion of important 550 deaths per year in Australia,3 and of man as well. C.S. Lewis points out responsibilities; a staggering 17,500 deaths per year in that in the absence of pain, we would the USA from prescription opioid use.4 never seek God; he speaks about pain The interconnectedness of all things as God’s ‘megaphone to rouse a deaf “C.S. Lewis points out means that nothing can be changed 1 world’. Similarly, physical pain imposes that in the absence of without an unintended consequence. a limitation on damage occurring to We, as doctors with experience, the body by compelling the individual pain, we would never become more and more aware of the to act. seek God.” limitations of our profession, that pain in some form is often unavoidable, The suffering consequent upon the and that man’s attempts to completely Fall is described as affecting the avoid it lead to other problems (often sexes differently – man in his role as • hallucinogenic drugs can produce more serious). provider is burdened by frustration a sense of spiritual enlightenment. and hard work; woman by the pains Unfortunately these effects are not The question of why we must suffer of childbearing. Similarly, pain (or based on reality and can lead to is ultimately a mystery, (however as more correctly suffering), manifests permanent perceptual distortions; far as reason can go, Lewis’ book The in the various dimensions of our Problem of Pain is recommended).1 being, e.g. childbirth (physical pain), • opioids produce a relief from Knowing God’s full character as loss (emotional pain), hopelessness various types of pain, emotional and revealed in Christ, we can safely say (mental), frustration (the will), physical, but can also cause a deadly that pain must have been unavoidable shame (moral), loneliness (social) dependence; in God’s deeply laid plans for creation, or meaninglessness (spiritual). Pain which included His foreknowledge of always reflects something wrong • the drug MDMA (‘Ecstasy’) is being The Fall. Jesus himself was not exempt in the structure of either us or the studied for its potential benefits in from experiencing pain. Indeed, his surrounding environment (physical, PTSD through its action of releasing incarnation and suffering is profoundly psychological, social or spiritual), and, oxytocin and promoting social integral to our salvation. We yearn to as such, it is a necessity if we are to bonding,2 but this effect is non- know the reasons for suffering, but avoid destruction. discriminatory, and presents other God usually does not reveal it, e.g. in risks as part of the dance-party the story of Job, he never knew of the Within our medical role, we gain a scene. heavenly challenge by Satan of God to unique insight into the mysterious test Job’s fidelity. We could ask too, if unity between body and spirit. For The unique qualities of many drugs knowing would make pain any easier example, antidepressants are a class can be used powerfully to do good (or to bear, and could we understand of drugs that can ‘lift the spirit’ or feel good), but they remain a relatively such an immense and complex

34 | LUKE’S JOURNAL | January 2018 truth? Ultimately, despite all rational comparing their own behaviours to understandings, (or rationalisations), “...pain in some form is others further to the left on the bell- suffering can only be acceptable by curve of a given moral criterion. We knowing that God suffers with us, often unavoidable, and as Christians cannot do that if we are and that eternal joy will be the final that man’s attempts to honest with ourselves. This is not to say outcome. In His providential love, He that dealing with people with addiction has also provided science and medicine completely avoid it lead is straightforward. On the contrary, to relieve suffering, and even today to other problems (often it takes a very different perspective new understandings of neuroplasticity on progress and an approach which give us reason to believe that chronic more serious).” reflects the multi-dimensional nature pain can be managed. Yet there of the problem. To the ‘bio-psycho- is suffering – a mystery which we social’ model we add ‘spiritual’, since must learn to address, not with ultimately the presence of suffering ‘why’ questions, but ‘how’ (how can I after The Fall. There are other more and man’s dysfunctional approach to it respond)? ‘socially acceptable’ ways to do this, can only be fully understood from that such as behaviour, taking perspective. Even with a relationship with God up ‘causes’, seeking entertainment/ through Christ, sinful man inevitably social activity, personal achievement, How should we approach addiction? responds to suffering in ungodly ways, accumulation of money, etc.. There Various dimensions to the problem which will be dysfunctional and lead are some less socially acceptable ones have come to prominence over the to more pain in the long-run. A cycle such as anger and violence to others, years, but the idea of moral failure is a develops of seeking another form dysfunctional coping mechanisms such widespread belief that contributes to of relief or distraction, followed by as projection or self-directed anger, severe stigma around addiction and disappointment leading to a deepening stealing, ungodly pleasure-seeking, reduces in society’s eyes ‘worthiness’ despair. Thus, the soul tortured by etc.. Irrespective of society’s values, of help. Yet modern mainstream pain and disappointment comes to substance misuse is no greater a sin understandings of addiction one of two positions – either crying in God’s eyes than any other ungodly acknowledge that moral failure is out to God and turning to Him, or method of coping. Nevertheless, it is only a relatively small contributor to expressing anger toward God. This often a very self-destructive one, and the development of addiction. Peer latter interaction with God is not the humbling effect of addiction does pressure is a factor, but less important necessarily evil as we see in Job, as it place the sufferer in the same category than concerned parents often imagine. is an interaction which opens the way as ‘sinners and tax-collectors’, people Public policy on legal availability and for a response. Even rebellion towards with whom Jesus spent a lot of time. taxation of addictive substances is a God is evidently something with powerful determinant of addiction which He can work, as shown by Jesus’ As Christian doctors, we should be prevalence. However, individual preference for hot or cold, rather than no more surprised at substance use vulnerability probably plays one of the lukewarm faith (Rev 3.16). than any other sin we see in mankind. greatest roles in determining addiction, However, dealing with it can be very including genetics/epigenetics, and Substance abuse and addiction are confronting and perplexing. So-called personality development. Trauma, consequences of one of the ways man ‘normal’ people will tend to boost seeks relief from the suffering of life their sense of moral self-esteem by continued over page >>>

LUKE’S JOURNAL | January 2018 | 35 Pain avoidance – the role of addiction and parental influences have ask me after I tell them that I prescribe But here’s where the church can a big effect on vulnerability. Those methadone, is ‘how long before you help: generic recovery services little kids that we see in our practices, get them off it?’ Childhood trauma is a simply are not available in sufficient being raised under circumstances of profound problem taking an average of quantity and quality to help the vast psychosocial inadequacy, become the twenty years for a person to achieve a numbers of people who need help. substance use patients of tomorrow. fair level of stability. Abstinence-based Long-term healing of the personality approaches are associated with a fifty developmental deficits and disorders The implications of this causality are percent mortality rate over the same that so often accompany substance that there is much more to do for period without Opioid Substitution addiction is not well addressed by substance-addicted patients than Treatment, a high price to pay for an mainstream services and results simply detoxing followed by a three- ideal. in the repeated cycling through month course of recovery meetings. services over a long period of time. Of course, this works in some cases, Getting back to the spiritual dimension Personal development in fundamental but these are generally people with of substance use, what is the unique areas such as trust, identity, shame, ‘intact’ personality foundations who contribution that the church can make belonging, value, etc. is spiritual have slipped into addiction. In most in this area? Should we be trying to development, because it is building established cases there is long term cast out the demons of addiction – a healthy sense of fatherhood and restoration and developmental work is it simply a matter of deeper and sonship so essential to relating to God. to be done, and this can take five, ten more heartfelt repentance? Or can we These aspects of child- (and or twenty years, along with life-long make people better by taking them adult personality disorder) are core attention to relapse prevention. away to a Christian environment and business for us as churches, because we are Christ’s body and true family. Families are places of both love and “...religiousness is inversely associated with alcohol structure, places where people are and drug problems, and that people entering nourished and grow under the Father’s (and fathers’) protective hand. They are treatment for addiction have a low level of also places for restoration – as sinners religiousness and spiritual practice.” saved by grace, we are all ‘in recovery’. So, in practical terms, how can the church interact with these very broken In the case of opioid addiction, the make them attend chapel? Is AA/NA and needy members of society, trauma history is such a profound the only type of self-help we should helping to bear their burdens, being influence that if I meet someone endorse (or better still, transform it the missing role-models of brothers, without a history of childhood into a fully Christian format)? There are fathers, sisters, mothers, yet not (which occurs in 90% of robust observations in research over endangering the structures and people cases) then I am looking for a major the years, showing that religiousness in those communities? psychiatric illness (or assume that it is inversely associated with alcohol is too painful to disclose at present). and drug problems, and that people There is no place for spiritual pride Opioids work very well for people with entering treatment for addiction have a amongst Christians, and we all want to co-occurring Cluster-B personality low level of religiousness and spiritual be as vulnerable and honest with each traits simply because they address practice. Attendance at AA and learning other as possible. Yet clearly there is a the pain of trauma. I have seen meditation has been associated with potential for compromise if, say, a police people who try to do a detox from lower rates of relapse, yet the causality officer and a known recurrent offender their opioids (because that is what is of these relationships is far from being attend the same church or the same expected of them by family), quite clarified scientifically.5 Nevertheless, ‘connect group’. In theory it could work, rapidly start to re-live past traumas psychosocial treatments and medical but personal sharing about struggles to the extent that they must restart treatments do work, even in the might be inhibited. There must be their opioids. The reason why opioid absence of an ‘epiphany’. Much of the structures and boundaries in place, for maintenance treatment is so effective, work of recovery is personal growth, the same reasons that a business deal and abstinence-based treatments are and in view of the contribution of between friends must be backed up with so ineffective and dangerous (from personal developmental difficulties, it legal contracts. Human sin and iniquity, lethal overdose), is because it treats the is not surprising that generic assistance and the work of Satan, can wreak pain and stabilises the patient whilst is comparable to, if not as good as, havoc. We only need to think of the they work through the developmental Christian assistance. In the same way terrible stories coming out of the Royal deficits and traumas. This trauma that good parenting is good parenting, Commission into Institutional Responses aspect of opioid addiction is not widely good therapy is good therapy, and to Child Sexual Abuse to realise the awful appreciated. Consequently, almost some services offered by well-meaning consequences of thinking ‘it couldn’t without fail, the first question people Christians can even be bad therapy. happen in the church.’

36 | LUKE’S JOURNAL | January 2018 Clashes of culture or personal habits can also arise, not only the difficulty posed, for example, by the very bad body odour of the homeless man you’ve invited home for lunch, but the recipient of the generous welcome may feel very uncomfortable too. When people who have been raised in various kinds of poverty (social, financial, moral) are immersed in a community full of genuinely ‘nice’ people with nice things, nice manners, educated and thoughtful, not necessarily even snobbish, the potential is created for a sense of inadequacy or jealousy, such that it overwhelms the newcomer. This is not to say that we should only aspire to the lowest common denominator, Regarding the teachings of Jesus about but it means we must be realistic, (and radical generosity and hospitality, we not proud). In this regard, there is often “The abundance of haven’t had a lot of help integrating cultural clustering of people within stability and good values these teachings with the practical churches and into churches. This is aspects of present day culture, e.g. just as normal as ethnic clustering in that we take for granted should we welcome a homeless certain churches. We need to affirm in middle class churches, stranger into our house out of each other’s calling and strengths and obedience to Christ’s teaching? We mutually support each other. A wealthy is a valuable resource are called to be gentle, but wise also. middle-class church community is that is rare in the circles Ministers of the Word need to drill generally a time-poor community. down to the practical applications Though they may not have time to that many addicted of some of these tricky areas so that give to ministering to certain groups, people come from.” members are not left vulnerable to they may be able to support a ministry exploitation. financially. Another example is a mature responsible church person in a The abundance of stability and good busy and demanding job. They might fights, mental health deterioration, values that we take for granted in not have time to give to a cause, but substance relapse or bingeing, should middle class churches, is a valuable may be able to mentor a less mature not cause the church shock and resource that is rare in the circles that Christian who has more time for withdrawal, but be handled calmly many addicted people come from. service. Such networking between and – bedding down another experience I would love to see us tap into that within churches could be enhanced of a parent-like response in the resource but, more importantly, bring by more conscious sharing of needs, sufferer, which cumulatively leads to the added spiritual depth to healing perhaps even social media. growth and a more accurate picture from these issues that is lacking in of fatherhood and sense of identity purely medical and psychosocial In the case of people who have as His child. Behaviour management approaches. l experienced a distortion or poverty plans may need to be developed to References: of parental care, or been victims of encourage desirable, and discourage 1. Lewis CS. The problem of pain. London: Collins; 2012. abuse, such people may have been dysfunctional, patterns of coping in 2. Yazar-Klosinski BB, Mithoefer MC. Potential Psychiatric Uses for MDMA. Clin Pharmacol Ther. 2017;101(2):194-6. through a series of churches, leaving the person with the disorder. There 3. ABS. 3303.0 – Causes of Death, Australia, 2016. In: Australian-Bureau-of-Statistics, editor. Canberra: a trail of burnt bridges behind them. is no shortage of professionally- Australian Government; 2017. These are the group for which we trained people in churches who have 4. NIDA. Overdose Death Rates. In: National-Institute- of-Drug-Abuse, editor. September 2017 ed: National- need a dedicated sub-group of skills to impart, but there is a gap in Institutes-of-Health; 2017. 5. Miller WR, Bogenschutz MP. Spirituality and addiction. informed and mature helpers within the recognition of this somewhat South Med J. 2007;100(4):433-6. churches. It should not fall to just one specialised caring ministry within or two people to try to manage such churches. With a little planning, Dr David Outridge sufferers, but a network, even a roster the necessary expertise could be David is a GP in Newcastle with a special interest in of people. Crises are make-or-break disseminated. We have a majority of addiction medicine. He and his wife Loraine work moments and should be prepared for fairly ‘normal’ people in our churches, alongside an Anglican NGO supporting people with in advance with professional input even ‘boringly normal’ people who substance use problems and those exiting custody. and contingency plans. Events such as are, in fact, an enormous resource for self-harm, court matters, outbursts, helping people.

LUKE’S JOURNAL | January 2018 | 37 Pain in palliative care practice the special contribution of Christian physicians

This year marks the 50th anniversary “Among the remedies which it has Health Organisation’s Collaborating of the opening of the first modern pleased Almighty God to give to Centre for Palliative Care. He played hospice – St Christopher’s hospice in man to relieve his sufferings, none a major role in the establishment of London. is so universal and so efficacious as palliative care in Poland, India and opium.” Argentina. In 2004 he helped establish Improving pain management was one palliativedrugs.com, a unique of the first challenges. It is appropriate Despite this knowledge, morphine website providing an evidence base for to reflect on the achievements of the and heroin (diamorphine) were given palliative care pharmacotherapy, with a hospice/palliative care movement, in inadequate doses, and only when special emphasis on pain management. in particular to note the contribution the patient was experiencing severe The free website has more than 30,000 of committed Christian physicians. pain. With fierce determination and members from 169 countries. The From the hundreds of dedicated meticulous record-keeping, Saunders editorial team publish the Palliative doctors worldwide, who have laboured documented the safety and efficacy Care Formulary, now into its 6th to improve the care of the dying, I of morphine in more than a thousand edition, which has achieved global have chosen five for special mention: patients. recognition. Cicely Saunders and Robert Twycross in England, Balfour Mount in Canada, As well as her research on the benefit As a committed Christian, Twycross Norelle Lickiss and Peter Ravenscroft in of oral morphine, she soon realised was aware of the spiritual dimension Australia. that a patient facing death experiences of suffering, which no amount of more than mere physical pain. She morphine could relieve. In the Oxford coined the term “total pain” to describe Textbook of Palliative Medicine, first the suffering that encompasses a edition, 1993, he wrote: person’s physical, psychological, social, spiritual and practical struggles. “Terminal anguish is a tormented state of mind which relates to longstanding unresolved emotional problems and/or interpersonal conflicts, or to long-hidden unhappy memories often with guilty content. These problems have festered in the mind but have never been brought into the open. As long as the patient Dame Cicely Saunders. Photo: https:// is well enough to control his/her cicelysaundersarchive.wordpress.com/ thoughts and as long as denial can function, all appears to be well. Dame Cicely Saunders is credited with being the founder of the modern With increasing weakness, the hospice movement. As a young Dr Robert Twycross. Photo: twitter onset of drowsiness and inability Anglican nurse working in St Joseph’s to control thoughts, hidden matter hospice in London in the 1950s, she In 1971, she recruited Dr Robert in the unconscious mind is able to observed the unsatisfactory approach Twycross as a Clinical Research Fellow surface... to managing pain. at St Christopher’s. He set a high standard of academic excellence, The possibility of such an outcome The analgesic efficacy of opioids had supervising crucial studies on the use highlights the need to make every been known for hundreds of years. of opioids for pain control, further effort to deal with psychological Thomas Sydenham (1624 to 1689), “the demonstrating the safety and efficacy “skeletons in the cupboard” before father of English medicine”, is credited of regular oral morphine. From 1988 to the patient becomes too weak to with the following quotation: 2005 he was the Director of the World address them. A few, however, resist

38 | LUKE’S JOURNAL | January 2018 every attempt to share what they portrayed in an excerpt from the Teaching and administration as have been hiding.” DVD The Choice is Yours, which was spiritual gifts? produced at his initiative. In the DVD, In the development of palliative care, Listening: a potent analgesic a patient, Roslyn Saxe, talks about Australia has been blessed with many without side-effects her encounter with Dr Mount, and he excellent, wise physicians. In the 1980s responds with his reflection on the and 1990s there was an appreciation interaction. of the need for certification and standards. Palliative medicine was Roslyn Saxe: “Not only was it a viewed with some scepticism and diagnosis of cancer, I was in stage IV. needed energetic, gifted champions to My prognosis was 6 months... they ensure that it developed as a credible decided on very heavy duty chemo. My world collapsed. I was going to die. I did not think I would survive it.

I spoke to somebody when I was in a crisis and she suggested that she would call Dr Bal and he would see Dr Balfour Mount. Photo: me for a consultation one time. I http://alexschadenberg.blogspot.com.au was totally depleted. I did not think I could carry on with any more chemo. Dr Balfour Mount was a urological I went to see him, and 3 hours later, surgeon at the Royal Victoria after talking to him... he validated me Hospital, Montréal, Canada. He as a person, and made me feel very discovered to his comfortable.” Prof Norelle Lickiss. Photo: http://aphn.org/ that the care of the terminally ill in his hospital was grossly inadequate. “...pain control in palliative care requires a Searching for answers, he spent a week visiting Cicely Saunders. “Once comprehensive, multidisciplinary approach. I saw St. Christopher’s, I saw there The relief of total pain requires a total solution, were solutions to that unnecessary suffering...” including physical, psychological, social and spiritual elements.” He was eager to establish a Hospice unit in Québec, but his French speaking colleagues informed him that “hospice” had an inappropriate connotation in French. He therefore Prof Balfour Mount: “The person I’m coined the term “palliative care”. Dr seeing who has advanced cancer, who Mount was steeped in the Christian frequently is experiencing very severe tradition of compassionate service. symptoms... if she’s upset or anxious His father was a missionary doctor or anguished, her symptoms are out working with Sir William Grenfell, of control. And by the time we’d been serving the Eskimos and fishermen of talking and chatting and I had been Newfoundland. With a deep sense of listening and we had been interacting he changed direction and has and I’d been learning from her, she been full-time in palliative care ever said “It’s just the strangest thing: the since. He is the undisputed leader of headache is gone. And my fingers, my palliative care in North America. legs... don’t pain anymore”. Prof Peter Ravenscroft. Although highly skilled in the Roslyn Saxe: “And that went on for 2 Photo: www.researchgate.net use of medication to relieve pain years where a lot of healing took place. and other symptoms, his greater specialty. Professors Norelle Lickiss contribution was his emphasis on the What astonishing humility: “I had been and Peter Ravenscroft were at the psychospiritual distress of palliative listening... and I’d been learning from forefront of this journey towards care patients and their families. The her!” academic recognition. In response treatment of this distress he describes to the persistent efforts of these as “healing”, a “relational process How do we teach ourselves, colleagues two outstanding leaders, the Royal leading to an experience of integrity and medical students to utilise the Australasian College of Physicians or wholeness”. The doctor’s role is immense healing power (including the eventually agreed to recognise intensive, focused, compassionate analgesic potential) of the therapeutic listening. A dramatic example is relationship? continued over page >>>

LUKE’S JOURNAL | January 2018 | 39 Pain in palliative care practice palliative medicine as a separate requirements. Finally, this year, the will wipe away every tear from their specialty. Over a period of more than RACP established a Spirituality Training eyes, and death will not exist any more 10 years, an advanced training program Working Party, charged with developing – or mourning, or crying, or pain”. was devised, and eventually, in 2000, a a training module in this challenging Rev 21: 4 l separate Chapter of Palliative Medicine area. Editor’s note: For more information on the practicalities of was established within the College. addressing spirituality in clinical practice, and of Doug’s work in Palliative care, please see: The terminology is difficult and Ravenscroft, P. Bringing Spirituality into Clinical Practice. Luke’s Journal of Christian Medicine and Dentistry, p20, Vol Most doctors are attracted to medicine imprecise. We may speak of spiritual 22, No. 2, September, 2017 for humanitarian reasons. Few enjoy distress, terminal anguish, an Bridge, D. Dying Healed: A Source of Hope. Luke’s Journal of Christian Medicine and Dentistry, p52, Vol21, No. 3, December administration. However, being in existential crisis, or simply of agitation. 2016. a position of authority provides the What is undoubted is that such distress View Luke’s Journal at www.issuu.com opportunity for setting standards. The increases pain, and increasing the dose committee who wrote the curriculum of opioid medications is unlikely to Dr Doug Bridge for advanced training in palliative solve the problem. Doug is married with three sons. After training as a medicine recognised that spiritual general physician and in tropical medicine, he lived issues become more important as In conclusion, pain control in palliative for two years in a Bangladeshi village. Upon returning patients face the end of life. They care requires a comprehensive, to Perth in 1979, he helped pioneer the development therefore required that advanced multidisciplinary approach. The relief of Palliative Care in Australia and Asia. He was the trainees demonstrate competence of total pain requires a total solution, Head of the Palliative Care Service at Royal Perth in addressing the patient’s spiritual including physical, psychological, social Hospital 1993-2013. He is a Clinical Professor of the needs. and spiritual elements. But even with School of Medicine and Pharmacology, University the world’s best practice, we will not be of Western Australia. He was the President of the Although this was clearly documented able to eradicate all pain and suffering. Australasian Chapter of Palliative Medicine 2014 in the curriculum, for twenty years no That final solution belongs to the next to 2016. His special interest is the psychospiritual attempt was made to teach trainees, world. As the ageing apostle John challenges of dying. or assess their ability to meet the recorded in his apocalyptic vision, “He

40 | LUKE’S JOURNAL | January 2018 Bullying in Medicine

“I have told you these things, so The longer I spent in that environment, were for me. Not only did I have family that in me you may have peace. In the more I believed I was everything and friends, I had a mentor through this world you will have trouble. they accused me of being. I believed the CMDFA who regularly prayed with But take heart! I have overcome I would have laughed at and me and for me. I had nothing left, and the world.” John 16:33 NIV dismissed only weeks earlier. it meant everything to have someone pray with me and read the Bible to me I confess that the words “Christian I was in a new place isolated by work when my strength was fading. ” brought to mind images and location. I was drowning and I of gladiators in big arenas , or of couldn’t understand why I couldn’t Our Lord warns us that this life may being held at gunpoint for professing make things work. not be easy, but he also promises he to be a follower of Christ. will never leave us nor forsake us. We may face trials, but we never face them I know that this is still a reality for alone. some, but for many of us the wolf is very much in sheep’s clothing. The “And surely I am with you always, to Bible says we will face trials of many the very end of the age.” kinds. Just as our Lord and saviour Matthew 28:20 NIV suffered, so may we, and we are instructed to “Be on your guard” and I’d like to encourage each one of us to expect it. stay anchored to Christ, not only for our own sakes, but so that we also may I admit I thought I was too old to be “At night I would... pray have courage to stand firm and stand bullied. I expected after my years in up for our colleagues who may be medicine and in life that behaviour like that God in his mercy being bullied. that didn’t exist anymore and was left would take me to be behind in high school. Even if it did You may never face a firing squad for exist, I thought I would have the self- with him so that I didn’t your faith or run for your life in an confidence and maturity to withstand it. have to face one more arena, but I put it to you that every time we are doing what God calls us to I wasn’t armoured. day in that place.” do and be where he calls us to be we need to be prepared that we may face I wasn’t ready. opposition. As the bullying got worse I would hang “Finally, be strong in the Lord and my head and wait for the pain to be That is our persecution. in his mighty power. Put on the over. I would let them yell, accuse full armor of God, so that you can and embarrass me, often loudly and “We are hard pressed on every side, take your stand against the devil’s very publicly. I refused to be who they but not crushed; perplexed, but schemes.” Ephesians 6:10 wanted me to be. It felt like my spirit not in despair; persecuted, but not was only a flicker, but with whatever I abandoned; struck down, but not There is a song by Casting Crowns called had left, I chose to hold on to my God destroyed.”2 Corinthians 4:8 Slow Fade. It talks about how when and not compromise. It meant the people fall away from Christ it is rarely pain continued and people awkwardly So do not give up meeting together. I an overnight process, but a gradual watched and continued on their way know work schedules sometimes mean accumulation of little, seemingly not wanting to be involved. working on Sundays happens all too meaningless, decisions and events. often. Can I challenge you to make it At night I would fall into bed and pray a priority to support one another and That was what bullying was like for me. that God in his mercy would take me to remind each other of the hope we be with him so that I didn’t have to face have? Even if it is a prayer over the Every time I was knocked down I one more day in that place. phone or a cup of tea. would get up thinking I needed to try harder. Slowly I became more and more Thankfully, he didn’t answer my prayer. May God direct your hearts in God’s isolated and withdrawn. Instead, he blessed me with beautiful love and Christ’s perseverance. friends and family that reminded me of Staying later and later, working who I am in Christ. Peace be with you xx l weekends and missing church, only taking breaks to sleep and get up and Even though I felt lost, God knew Anonymous do it all again. exactly where I was and what his plans Article written by a doctor in training.

LUKE’S JOURNAL | January 2018 | 41 The person and the field – exploring the life and contribution of Cicely Saunders

In 1945, the same year which saw the The words “palliative care” have a ready acceptance both in the medical and break-up of her parents’ unhappy lay conversation around death and dying. The strong recognition of this term marriage, she had a dramatic change is deeply indebted to Dame Cicely Saunders. In an era of incredible advances of spiritual outlook, exchanging in biomedical care and, indeed, life expectancy, Dr Saunders defined and her long-held agnosticism for an articulated a vision around the dying process in our context which is making a actively evangelical Christianity. (This telling contribution to the craft and reputation of medical care. Dr Peter Whan was a position from which she later is a Christian doctor who is working toward a PHD in palliative care studies at moved, adopting a more ecumenical Prince Charles Hospital in Brisbane. His following material is taken from the approach).1 She then trained as a lady introduction to his discourse. It is enriching to hear a story like this. almoner (medical social worker) and began working for the Northcote Trust, Although others in recent centuries based at St Thomas’s Hospital. have been involved in, or have written about, the care of dying In 1947 she became involved in the care people, Cicely Saunders was the first of David Tasma, a Polish Jew dying of doctor of our times to devote the rectal cancer. They had a brief, loving whole of her clinical, administrative friendship during which they discussed and scholarly work to such care. her thoughts about how she wished to spend her life in the service of suffering She was suited to her role as founder people, perhaps involving the creation of this kind of care by her experience of a “home” for people in David’s as lay carer for dying friends and situation. He left her £500 in his will, relatives, combined with her training having said, “I’ll be a window in your and experience as a formal carer, not home”. She continued to work as a lady only as a professional in the fields of almoner, and began to work one evening nursing, allied health (medical social per week as a volunteer registered nurse work) and medicine, but also as a at St Luke’s Hospital, Bayswater, where volunteer. Her experience as a para- she observed the beneficial effect of professional support worker (medical Dame Cicely Saunders. regular administration of opioids. secretary) was also of benefit. Photo: St. Christopher’s Hospice, London At the same time, she began to work She was also suited by the qualities childhood and school years at Roedean part-time as a medical secretary for of her personality. As the British were unhappy. She began studying the thoracic surgeon Norman Barrett, newspaper the Telegraph noted in Politics, Philosophy and Economics one of the doctors whose patients its obituary, “Though she was widely at Oxford, but left to study nursing she assisted in her social work role. revered as a sort of secular saint, it after the outbreak of war. Having When she confided to him that she was was only through being tough and excelled in her studies during her considering a return to nursing to care authoritative, and often downright training at St Thomas’s Nightingale for people dying in pain, he responded, difficult, that she succeeded in forcing School of Nursing, and gained in social “Go and read medicine, it’s the doctors the medical profession to acknowledge confidence, she was unable to continue who desert the dying and there’s so what medicine can do for the dying.” in this profession due to a long- much more to be learnt about pain. standing back problem. You will only be frustrated if you don’t Born Cicely Mary Strode Saunders do it properly and they won’t listen in Barnet, Hertfordshire, on 22nd She then returned to Oxford and to you.” She thus returned once more June 1918, the shy and gawky eldest gained a war degree and a Diploma to St Thomas’s, this time as a medical child of a well-to-do estate agent, her in Public and Social Administration. student, and graduated in 1957.

42 | LUKE’S JOURNAL | January 2018 Her special interest had not waned The field Thus there was a depth of and, through a tennis acquaintance For many people, “palliative care” is a dissatisfaction with the care being of her father, she gained a clinical term shrouded in a cloak of mystery provided even in the most impressive research fellowship in the Department and misunderstanding. This is ironic temples of modernist medicine, and of Pharmacology at St Mary’s Hospital because the word “palliative” comes many of those caught up in such . During this time she from the Latin word pallium, meaning situations, whether as patients, was based at St Joseph’s Hospice in a cloak, and a palliative measure family, community members or health Hackney where she put the principles is one designed to cloak, or cover, workers, realised that a fresh approach she had observed at St Luke’s into disagreeable realities. Unless their lives was needed. Two strong-minded practice, to the initial concern (but have been touched by it, few people women in particular challenged the rapid delight) of the nuns in charge. She understand that palliative care aims predominant ethos and began to then experienced another close, loving to relieve, as far as possible, whatever change the way dying people and their relationship with a Polish man, Antoni makes far-advanced, progressive, life- families were cared for. Cicely Saunders Michniewicz. Grief at his death in St shortening illness distressing. This brief in the UK, and Elisabeth Kübler-Ross Joseph’s in 1960, as well as the deaths introduction is designed to assist any in the US believed passionately that in 1961 of “Mrs G”, a beloved friend and reader unfamiliar with the area to gain there was value in spending time patient, and her own father, almost a better appreciation of the research and effort in being with such people, overwhelmed her, but also intensified reported in this thesis, by drawing learning from them, reflecting on the her sense of purpose. aside the cloak of unawareness that issues that faced them, and working often shields palliative care from to change the ways in which care was She persevered in her project to create a more extensive perception and given to them. The work of these an environment where not only care, understanding. women and other pioneers resulted in but also teaching and research related to the physical, psychological, social and spiritual needs (the “total pain”), of “She persevered in her project to create an dying people and their families could environment where not only care, but also teaching be provided. She used networks of religious, social, family and professional and research related to the physical, psychological, contacts to pursue this goal and began social and spiritual needs (the “total pain”), of dying to disseminate her ideas. This included lecture tours to the US in 1963, 1965 people and their families could be provided.” and 1966, as well as presentations in conferences and lectures in Europe and the UK, together with letters and articles in journals, and compact As the ideology of high modernism the emergence during the final third books. The project progressed with the became increasingly dominant in of the century of a distinctive cluster purchase of land, the construction of health work during the early and of initiatives related to people affected a building, the provision of capital and middle portions of the twentieth by mortal illness. These thoughtful and recurrent funding from various sources, century, increasing emphasis was purposive approaches to being and including the National Health Service, placed on the technical rather than the acting with and for dying people, their and culminated in the opening of St personal. Although this meant that families, and the communities in which Christopher’s Hospice in July 1967. Cicely a number of previously intractable they live, [14] were initially known as Saunders was the founding medical illnesses could be treated, many hospice, hospice care or the hospice director, in which position she served people still came to a point where movement, but now also bear the until she became Chairman (sic) in 1985, serious illness caused suffering, cure name palliative care. They have several and then President / Founder in 2000. was not an option, and there was characteristic features: significantly shorter time for them In 1980, following the death of his to live than previously hoped or • The “unit” for whom person-to- estranged wife in Poland, she married expected. To a large degree, the very person care is provided includes the émigré Polish painter Marian success of positivist health science was both: Bohusz-Sysko, whom she had first responsible for many such situations. — the patient whose mortal illness met in 1963. She received many civil, On the one hand, a person’s biological gives rise to the need for care , professional and public honours, existence could be (and frequently and degrees and awards, including the OBE was) extended beyond the time when — those who function as the in 1967, DBE in 1980, and OM in 1989, they enjoyed psychological, social patient’s family. This includes and fellowships of the Royal Colleges of and spiritual well-being. On the other those who are significant Medicine, Nursing, and Surgeons. Her hand, many interventions (including to, and/or close carers of husband died in St Christopher’s in 1995 the settings and means in and by which the patient, because of a aged 92, and after being diagnosed with they were delivered) militated directly biological relationship, formal breast cancer in 2002, she also died in against such well-being, producing commitment, or friendship. the hospice she had founded, on 14 July significant suffering even if they 2005, aged 87. prolonged life. continued over page >>>

LUKE’S JOURNAL | January 2018 | 43 The person and the field – exploring the life and contribution of Cicely Saunders

weeks or months. Most palliative care patients have • Care is provided to meet the aim of health care should be: “to far-advanced cancer. However, some have other illnesses psychological, social and spiritual, cure sometimes” and “to relieve often”, such as far-advanced heart, lung, or kidney failure. Most are older people, but palliative care is provided for people as well as biological needs. but “to comfort always”. However, of all ages. Other references?? in combination, the above features 2. du Boulay S. Cicely Saunders: The Founder of the Modern • Death is acknowledged as a normal represent a unique approach to the Hospice Movement. London: Hodder and Stoughton; 1984. part of human life, and care is nurture of human life and its potential. 3. Dame Cicely Saunders [Obituary]. The Times 2005 15 July. 4. Dame Cicely Saunders, OM [Obituary]. The Telegraph focussed on maximising comfort, The motivation for providing such 2005 18 July. capability and dignity. That is, the care is usually expressed in terms of 5. Richmond C. Dame Cicely Saunders: Founder of the Modern Hospice Movement [Obituary]. The Independent aim is to heal (bring wholeness to) respect accorded to the unique value 2005 15 July. 6. Saxon W. Cicely Saunders Dies at 87; Reshaped End-of-Life those affected rather than to cure and dignity of every human being. This Care [Obituary]. The New York Times 2005 31 July. the underlying disease. is sometimes, but certainly not always, 7. Richmond C. Dame Cicely Saunders: Founder of the Modern Hospice Movement [Obituary]. BMJ articulated within the framework 2005;331:238. 8. Oransky I. Dame Cicely Mary Strode Saunders [Obituary]. • Care is offered once it is clear of specific religious belief. Cicely Lancet 2005;366(9486):628. that the patient’s illness is life- Saunders’ words summarise such aims 9. Hanks G, Forbes K. Dame Cicely Saunders, OM, DBE, FRCP, FRCN [Obituary]. Pain 2005;118(3):283-4. shortening, and this continues and motivation. 10. Shotter EF. Dame Cicely Saunders [Obituary]. J Med Ethics 2006;32:309. after their death, as support is 11. Doyle D. Tributes to Dame Cicely Saunders. International provided to family members in their You matter because you are you, Association for Hospice and Palliative Care; 2005 ; Available at: http://www. bereavement. and you matter to the last moment hospicecare.com/newsletter2005/aug05/cicely- saunders.html of your life. 12. Twycross RG. A Tribute to Dame Cicely Saunders - Given • Care is flexible, provided at We will do all we can, not only to help at the Memorial Service in Westminster Abbey on 8 March 2006. International Observatory on End of Life Care; whatever location best meets the you die peacefully, 2006 ; Available at: http://eolc- l observatory.net/history/cicely.htm needs of patients and their families, but also to live until you die. 13. Getz F. Medicine in the English Middle Ages. Princeton, NJ: by multi-professional teams whose Princeton University Press; 1998. References: 14. Kellehear A. Health Promoting Palliative Care. 1st ed. members draw on each other’s 1. For the sake of clarity and candour I believe at this point I Melbourne: Oxford University Press; 1999. should state that my own spiritual convictions are those insights and skills. of evangelical Christianity. I trust that I have been able to maintain an attitude of deep respect and admiration for the personal qualities and extraordinary achievements of Dr Peter Whan It is probably true that no single someone with whom I expect I would have disagreed on Peter is a Christian doctor who is working toward some issues. feature from the above list is unique 2. Or rather, “strong poets”, to use the term appropriated by a PHD in palliative care studies at Prince Charles Richard Rorty from Harold Bloom. Hospital in Brisbane. to Palliative Care. As an anonymous 3. This is a person who has a progressive, life-shortening writer stated in the sixteenth century, illness, usually with a life expectancy measured in

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44 | LUKE’S JOURNAL | January 2018 Pain through a Cultural Lens

Ram, 35 years old, has a spinal cord injury following a fall from a tree three months ago. Sita, 58 years old, has residual leprosy-related disability affecting her hands and feet, and significantly reduced sensation. Both are currently inpatients, who complete a survey questionnaire admitting to experiencing severe pain, rated at 8/10, with impact of pain on sleep, mood and daily activities rated at 8 or 9/10 for each domain. Neither has mentioned pain as a problem to the nurses or doctors. Why not?

Brennan et al1 review pain management and quote research that up to 1:4 adults and 1:2 of those over 65 years old suffer from chronic pain. Elderly Nepalese woman taking care her cow. Photo: Dreamstime. Differences in chronic pain processing and impact are multidimensional and longer, and is a positive cultural include pathophysiology, individual “...older Nepalis, resource. neuroregulation and socio-cultural factors. The range of physiological and especially in rural areas, Whitman (2007)6 reviewed the major psychological costs add considerable have no concept of concepts of Hinduism related to economic and social burden across pain and suffering and highlights the world. Pain management is an “” as in the acceptance as both a central concept important aspect of health care and has West. The expectation is in Hinduism and an approach that has been flagged as a fundamental human been studied in the pain literature. She right by Human Rights Watch.2,3 to keep mobile...” notes similarities between acceptance- based strategies and the equanimity Religious cultures and detachment desired in Hindu In Nepal and many Asian countries, thought, where suffering is accepted culture is strongly religious, and sense of their experience and direct and perceived as a just and natural religious practices are deeply rooted their behaviours. Cultural resources consequence of past action and is not and intertwined with all significant provide frameworks of meaning or only regarded in negative terms. community and family events. Nepal culturally-based strategies for patients has ethnic and cultural ties with India. coping with chronic pain. Acceptance theory in It is predominantly Hindu and Hindu- pain medicine Buddhist thought pervades all areas Cultural influences are noted to be McCracken (2004)7 suggests that pain of life. stronger in the elderly.5 Interestingly, control is useful when achieved and older Nepalis, especially in rural areas, when it leads to better overall long-term In a 2014 review of research literature have no concept of “retirement” as in functioning for the patient. However, to better understand the effect of the West. The expectation is to keep if efforts to control pain dominate, cultural experiences on chronic pain mobile, keep tending food production the quality of living may be sacrificed. perception, Pillay et al4 define culture in the garden or fields and even to sit Paradoxically, efforts to control as an “enduring pattern” consisting on the floor. In a recent survey in a emotions, thoughts and sensations of perceptions, structures and beliefs rural area we heard, “If I stop working, I can decrease pain tolerance thus that are stable across various contexts, will die,” and this is probably a common increasing pain experience. Excessive OR the assemblage of “received attitude. This encourages older people knowledge” enabling groups to make to maintain purpose and mobility continued over page >>>

LUKE’S JOURNAL | January 2018 | 45 Pain through a Cultural Lens avoidance of chronic pain is associated Patients, however, were happy to Holistic Care and with greater suffering and disability. accept appropriate pain medications Cultural Impact McCracken argues that acceptance when offered. This highlights the need Health Expectations: theory plus change are a more helpful to ask patients and families not only With previous high incidence of approach than control-based strategies about their pain experience, but also infectious diseases, surgical conditions (reducing problematic thoughts, the meaning and impact of that pain. and maternal and child health issues, feelings, experiences). He defines outcomes from short-term medicine acceptance of chronic pain as “an active Nepali Cultural Beliefs or surgery generally resulted in either willingness to engage in meaningful impacting Pain Experience cure or death. Nepal is undergoing a activities in life regardless of pain- Acceptance transition as people live longer – those related sensations, thoughts, and other Acceptance has roots in beliefs about over 65 years old increased from 4% to related feelings that might otherwise karma – that pain and suffering in the 6% of the population in the seven years hinder that engagement. It is about present is a natural outworking of prior to 2011.10,11 As multimorbidity not engaging in unnecessary struggles consequences of past sins or failures. increases from a rise in non- with private experiences, struggles With acceptance of pain and suffering, communicable diseases, compliance that often intensify the aversiveness of people show stoicism about enduring with medication can be an issue, those experiences and enhance their life symptoms or problems without as people need lifelong medication disrupting influences”. (p4) complaining. without cure of the underlying disease.

Chronic pain in Nepal Indirect patterns of communication: Chronic pain is a significant problem “The ‘western’ concept The purpose of communication in in Nepal and other Asian cultures. Nepal is culturally based around One Indian study8 looking at 50 pain of autonomy is not usual relationships rather than transfer and palliative care patients in one in Nepal where decision- of information. To honour another district of Kerala, found pain was the person (especially if perceived as more predominant physical symptom. making is communal.” important), the best answer is what Benefits of the palliative service you think the other wants to hear, included considerable reduction in rather than information that might pain levels which earlier had been Punishment disappoint. Finding out whether a unbearable, and in the maintenance Pain and suffering can sometimes be patient is taking medication you have and strengthening of hope. perceived as a direct punishment from suggested, or whether there were God or higher powers, so the powers associated side-effects or problems can In a clinical audit of pain experienced by need to be appeased. be challenging. Initial simple answers 95 leprosy-affected (LA) and 41 spinal are usually not the real story. cord injury (SCI) patients undertaken in High view of spiritual healing a mission hospital in Western Nepal9, Traditionally, Hindu holy men have Patients can expect doctors to discern we found 82% LA and 98% SCI had had a key role in healing by appeasing their history (as a spiritual healer experienced pain in the past week, with spirits which are understood to be would know) without them needing 52% LA and 76% SCI suffering more than causing the suffering. to offer this information. So in pain one pain. Moderate-to-severe pain was management it is particularly important experienced by 67% LA and 83% SCI. The church in Nepal has just celebrated for the clinician to ask direct questions There was a moderate-to-severe impact 65 years, and in this short time there about pain. The routine use of pain of pain on sleep in 75% and 48%, on has been considerable growth. Many scores and promoting pain as the 5th mood in 85% and 70% and in activities Nepalis have come to faith through vital sign can facilitate this process. of daily living in 90% and 60% of LA healing or miraculous experiences, and SCI patients respectively. These either of themselves or a family Communal or hierarchical results suggested cultural factors might member. Prayer for healing is an decision-making: be leading to the under-reporting of integral part of Christian communal life The ‘western’ concept of autonomy chronic pain experience of patients in – within regular services, small home is not usual in Nepal where decision- Western Nepal. In focus groups, reasons groups and other fellowship meetings making is communal. It is normal for for under-reporting included: – as people regularly bring their various the patient to leave the consulting • being told previously to expect pain illnesses and ailments to the Lord, room while the doctor discusses and therefore not complaining even expecting His grace and power. People diagnosis, treatment and prognosis when the pain was significantly ask for prayer before seeking medical with the family. A patient may impacting their quality of life; and help, and expect the leaders and therefore not know details of their • pain and suffering were not only church community to visit and actively condition or treatment options, but regarded negatively – they could pray for members who are in hospital. expects the family to know and make potentially deepen a spiritual Mission hospitals can have a significant the best decisions. If the patient is first journey. witness to the healing love of Jesus. asked if they want to be involved in

46 | LUKE’S JOURNAL | January 2018 discussions, the principles of autonomy can still be met but in culturally- acceptable ways.

Caring for people with chronic conditions including pain management requires building trust and moving toward a direct relationship with the patient, whilst simultaneously appreciating that in Nepal, family involvement will still be central. Communication skills are vital, and holistic (physical, psychosocial and spiritual), person-centred care has the potential to be transformative, leading to compassionate and excellent care.

Conclusion Cultural influences and norms have Help the next generation a significant impact on chronic pain management. In the Nepali context, this of Doctors and Dentists can be both a positive resource (when linked with acceptance and getting on share the love of Christ... with a meaningful and active life), but also negative (if this view prevents the person looking for other simple physical MAKE A BEQUEST resources that would improve their quality of life). Spiritual resources are a very significant element in religiously- based cultures like Nepal. l TO CMDFA

References: 1. Brennan F, Carr DB, Cousins M. Pain management: A CMDFA relies so much on the generosity of our members to promote, fundamental human right. Anesth Analg. 2007. doi:10.1213/01. grow and share the Fellowship of Christ through our profession. After ane.0000268145.52345.55. 2. Brennan F, Carr D, Cousins M. Access to pain management-still very taking care of your family and loved ones, consider what a difference much a human right. Pain Med (United States). 2016. doi:10.1093/pm/ pnw222. you can make to the future of your profession by leaving a bequest 3. Human Rights Watch. “Please, Do Not Make Us Suffer Any More …”: to CMDFA. Access to Pain Treatment as a Human Right; 2009. https://www. hrw.org/sites/default/files/reports/health0309web_1.pdf. 4. Thivian Pillaya Hendrik Adriaan vanZylb DavidBlackbeardc. Chronic A bequest is a lasting legacy that links the achievement of one Pain Perception and Cultural Experience. 2014. https://doi. generation to the well-being of the next. It will help CMDFA fulfil its org/10.1016/j.sbspro.2014.01.022. 5. Sakauye K. Cultural influences on pain management in the elderly. ministry to the healthcare profession. Compr Ther. 2005;31(1):78-82. doi:10.1385/COMP:31:1:078. 6. Whitman SM. Pain and Suffering as Viewed by the Hindu Religion. J A bequest to CMDFA can be made in a number of ways: Pain. 2007. doi:10.1016/j.jpain.2007.02.430. 7. McCracken LM, Carson JW, Eccleston C, Keefe FJ. Acceptance and change in the context of chronic pain. Pain. 2004;109(1-2):4-7. • A stated percentage of your estate after your family has been doi:10.1016/j.pain.2004.02.006. provided for. 8. Santha S. Impact of pain and palliative care services on patients. Indian J Palliat Care. 2011. doi:10.4103/0973-1075.78446. • The residue of your estate after debts, charges and other 9. Powys R. Audit of pain incidence and impact on QOL at GPHRC, Nepal. In: 23rd International Congress of the Indian Association for bequests have been deducted. Palliative Care, Pune, India. ; 2016. 10. Mishra SR, Neupane D, Bhandari PM, Khanal V, Kallestrup P. • A specific sum of money, or shares or property. Burgeoning burden of non-communicable diseases in Nepal: a scoping review. Global Health. 2015;11(1):32. doi:10.1186/s12992- 015-0119-7. • , with CMDFA as a beneficiary. 11. Munday D, Powys R. Reflections on the challenges and opportunities for palliative care in Nepal. Christ J Glob Heal. So please prayerfully consider whether you can help the future work 2017;4(3). http://journal.cjgh.org/index.php/cjgh/article/ view/194/445. of CMDFA through a bequest.

Dr Ruth Powys Ruth graduated from Melbourne University in 1980 If you would like help or more information please and is a palliative care specialist. With her husband contact our National Manager: David Brown Gordon, over the past 35 years, they have spent more Tel: 02 9680 1233 • Mob: 0414 340 848 than 15 years in various parts of Nepal, sent by CMS • Email : david @cmdfa.org.au Australia. They are currently seconded to work with International Nepal Fellowship (INF), based in Pokhara, Western Nepal.

LUKE’S JOURNAL | January 2018 | 47 Blinding Pain

over the whiplash pain. I didn’t. This article is written by John Mark, CEO of Newcastle’s Christian radio station 99.7 “Rhema FM”, who has just celebrated 25 years service in Christian Ministry It would be almost two-and-a-half years with Rhema FM. He is not only an administrator in his role, but has also been a after the accident till there would be broadcaster for the past 25 years. This article is from John’s experiences after any improvement. During this time, a traumatic road accident. my pain continued to get worse, with heavier reliance on painkillers and Most people, when they meet or I wore at the time came off, hitting severe neck and headache pain that see someone with chronic neck/ the windscreen and ending up on the was almost blinding. headache pain, are not necessarily passenger seat floor. The whiplash was aware that this person is suffering in like nothing I had ever experienced. My insurers (Workers Compensation) some way. At impact, everything went slow, but didn’t believe there was anything in an instant it also went horrendously wrong with me and sent me to There may be no obvious signs. On fast in forward motion. I was in neck, their own specialists, whose aim, it the outside, they can look well, but chest and back pain and I was taken by appeared, was to discredit me. One underneath the façade that chronic ambulance to hospital in a neck brace. such specialist (acting for the insurers) neck pain sufferers sometimes ‘put on’, often lies a very different reality. In many ways, chronic neck and headache pain is not only silent, it is sometimes invisible to those around us, until they learn or are told about it. It is quite hard for people to grasp or understand how you’re feeling, given they cannot see any physical signs. Sometimes chronic neck/headache pain can be seen in the eyes of the sufferer, or in their movements, sometimes revealing a small glimpse of what’s really going on.

All too often people will say to me “But you look so well – I had no idea!” Or they might say, “You never told me.” As a sufferer, it’s not that I am attempting to cover up my chronic pain. However, I get tired of telling the ‘story’, and so I often say nothing. Is this good or bad? said “What is it you really want, Mr. That’s a good question! Marks, how much?” I responded, “Doctor, here’s what I “Doctor, here’s what I want, I want my On 25th March, 2004, whilst driving to want, I want my ‘life’ ‘life’ back. And so does my wife and work, I entered an intersection with the children. That’s what I want.” green traffic lights in my favour. What back. And so does my happened next was more shocking to wife and children. In complete frustration, and with my experience than anything I’d ever heard GP’s agreement, I arranged for my own about in the media regarding head-on That’s what I want.” MRI to be done. It revealed that I had car collisions. This time it was me. had wedge fractures in my thoracic spine at T2 and T3 as a result of the Another vehicle, travelling in the severe whiplash experienced in the car opposite direction, made a sudden X-rays were carried out on my neck accident. The insurers panicked, and right-hand turn directly in front of but showed nothing. X-rays revealed immediately ordered I be sent out of me, ignoring the red no-turn traffic I had a fractured sternum. No X-rays the region for another ‘independent’ signal, The result was a combined were carried out on my lower back. MRI. The result was identical to the 80 km/h head-on collision, that saw Eventually, I returned to work, but the findings of the first. My case was my 4-wheel drive (no airbags) stop in neck and headache pain continued. finally accepted and liability admitted. less than one metre. The force of the Visits to my GP resulted in prescriptions Only then did treatment begin for my impact was so great that the spectacles for painkillers in the hope I would get accident.

48 | LUKE’S JOURNAL | January 2018 I was referred by my GP to Dr Anthony my neck once a year or thereabouts. this has kept me working and given me Schwarzer – pain specialist in My personal recovery from the RFs a relatively normal life with my family. Newcastle. This proved to be the best often takes five to six weeks. I know thing my GP ever did. At first, it was a someone else with similar injuries, and Someone once asked me, “Why case of conducting ‘block’ injections he recovers much faster. Neck and would God let this to happen to you? of cortisone to identify what would head pain like this is a personal and Where was His protection in all this?” block my pain, at what joint. It was a individual issue. My answer is, “I may never know the carefully planned strategy to identify answer to this whilst on this earth. what worked and what didn’t, with only What significantly and positively However, what I do know, is that on temporary relief achieved. impacted my recovery on a much that day I could have died, but I didn’t. faster basis (post-procedure) was All these long years since that accident, Finally, radiofrequency neurotomies my request for physio treatment to I’ve never known what was going to (RFs) were performed to burn away aid with neck stiffness after the RFs. happen next, until it unfolded before damaged nerve endings growing in Over the years I have been to various my eyes. It was like the best ‘care’ for all the wrong places and the joints. physiotherapists with some success. me was all orchestrated without me The RFs burn each nerve that supplies At other times I have tried massage even knowing. I was led, guided and the joint – one or two per joint. It took therapists and even an osteopath, with directed into ‘hands’ that could help some experimentation with the RFs little or limited relief. However, thanks and care for me. before a combination was found that to my pain specialist, I was referred to worked. The pain specialist did multiple Damien Cummins, a physiotherapist For this I thank my GP, Dr Ken Lambert, burns to ensure he captured the whole who specialises in neck pain. His my pain specialist, Dr Anthony nerve. Basically, the pain message from ability to understand and quickly Schwarzer, and my physiotherapist, the damaged joint and surrounding grasp the impact of my injuries and to Damien Cummins. Also, my wife, Kay, soft tissue is blocked, even though the implement the best treatment plan was and children, to whom I owe a great damage remains. There is no cure for remarkable. debt of gratitude. Finally, to God for the actual damage. His grace and mercy, that I’m still here At last, after so many years, I had a alive and well (well almost). One day, At first the RFs lasted from three to pain specialist who understood and my miracle will come, when I live in no six months, with pain relief treatment could act to relieve my neck and more pain. All that is required for this, on one side of the neck only. Later, it headache pain through RF procedures on my part, is faith, belief and trust. l would be discovered there was a need that returned me to almost normal to conduct an RF on the other side levels of pain. This, in combination John Mark as well. Then success was achieved, with a post-procedure physio who CEO of Newcastle’s Christian radio station 99.7 with longer periods now occurring understood what RFs were about, and “Rhema FM” between RF procedures. Now I only who worked in liaison with my pain need RF procedures on both sides of specialist, achieved good results. All of

Seeking Volunteer Editors Erratum Luke’s Journal would like to apologise to Do you have writing, editing, Dr Denise Cooper blogging, or IT skills? and Dr Catherine Hollier. Denise Cooper’s article “Hot Luke’s Journal is seeking committed Christians to Buttons and Cool help the editorial team in: Reason” (Luke’s Journal Standing • Editing Christian medical articles for our Together in the 3-4 monthly publication Public Square, Nov • Expanding the journal to a web-based 2015) was wrongly attributed to Dr platform Catherine Hollier. If you are interested or would like to discuss the role further, please contact Catherine Hollier (editor) at: [email protected]

LUKE’S JOURNAL | January 2018 | 49 A Light Momentary Affliction Living with Chronic Pain

I was 10 hours into my usual 12- my plans? Will this mean I can never God used it to keep him from being hour shift as a paediatric registrar have children? Why would God allow conceited. Chronic pericarditis feels at Gosford Hospital when the pain this pain? What if this pain never goes very much like a ‘thorn’ in my flesh, started. An unfamiliar, dull, 6/10 ache away? And the most unsettling thought and like Paul, I have pleaded with in my left precordium developed as being: Is this all in my head? God to heal me from lupus (although I washed my hands after assessing many more than 3 times!). God has a febrile neonate. Matter-of-factly C.S Lewis said: “Pain insists upon being given me the same answer: “My grace I said to my resident: “I have chest attended to. God whispers to us in our is sufficient for you, for my power is pain”, to which she questioned with pleasures, speaks in our consciences, made perfect in weakness.” (2 Cor similar matter-of-factness: “Is it but shouts in our pains. It is his 12:7-9) Pain and the limitations that muscular-skeletal?” “Probably.” And megaphone to rouse a deaf world.” God come with it demolish my delusions of we resumed working. has certainly used pain to awaken me, strength and self-sufficiency. It forces but I wonder if it is not so much God me to see my dependence on our It was not muscular-skeletal. It was who has adjusted His volume up, but dependable God. Although God never pericarditis and marked the beginning rather my stubbornness in listening to delights in our pain, it is by His grace of many years of daily chest pain. It Him. Before lupus, I had let the inviting that He allows us to suffer momentarily was the first clue to my diagnosis 9 months later, of the “great pretender”: “Chronic pain is akin to the unpleasant experience systemic lupus erythematosus. Since then, lupus has ravaged at least of having years of accumulated earwax syringed so one new body system each year. I that I can hear God who has been speaking to me experience ongoing pericardial pain, pleurisy, mouth ulcers, arthritis, focal all along clearer still.” headaches and stroke-like symptoms from cerebritis, neuropathic pain from thoracic myelitis, heat intolerance from soundtrack of the world drown out in this life to shift our hope from an autonomic neuropathy, bladder God’s voice. Then, as the helplessness present things to the riches of eternity dysfunction, poor vision from optic of pain shattered the illusion that what with our Saviour. neuritis, burning and tingling from I had was of my own making, it was as peripheral nerve involvement, and if this music was turned off and I could What I’ve Tried numerous side effects from the 20 start to hear God again. Chronic pain is God has provided a plethora of ways medications I am currently on. The akin to the unpleasant experience of to relieve pain – some more helpful various pains are all made worse with having years of accumulated earwax than others in different situations. exertion. At times I cannot walk more syringed so that I can hear God who has Among them I have tried paracetamol, than 10 metres without pain and have been speaking to me all along clearer ibuprofen, codeine, oxycodone, spent many months housebound. In still. There are other times when pain fentanyl patches, amitriptyline, the past 7½ years, I have had fewer can be so consuming that it feels like pregabalin, mindfulness, meditation, than a week’s worth of pain-free days our senses are numbed. However, psychology, , immersion in total. the anguish also presents a unique therapy, heat, ice, physiotherapy, opportunity to choose where we seek exercise physiology, pilates, massage, What It’s Like comfort. Will we look for it in success, acupuncture, turmeric, magnesium, For me, the physical sensation of acceptance, relationships, food or Manuka honey, different diets, pain is relatively bearable. What I find entertainment? Or will we run to the Netflix, comfort eating, prayer for the hardest is my anxiety about the God of all comfort (2 Cor 1:3) who healing, Scripture, study, reading implications of pain: Could I have speaks to us with compassion, grace, books on suffering, a range of a PE? Do I need to go to hospital? love, patience and peace? immune-modulators to treat the Does this mean that my lupus is out underlying disease process of of control? Do I need to increase my When the Apostle Paul wrestled lupus, and I have seen 6 different steroid dose again? Do I need to cancel with physical affliction, he saw that neurologists.

50 | LUKE’S JOURNAL | January 2018 What Has Worked: I am most content are when what is of His love for me. As I look to the Addressing My Heart with Scripture important to God is also important to joy of eternity to come, I can endure What has made the greatest impact me: His glory, His gospel, and that I my present pain. God has provided on my experience of chronic pain is a love Him with all my heart, soul, mind several forms of common grace that deepening in my personal relationship and strength, and help others to do provide some welcome, temporary with God through the study of biblical the same. I know that God can heal. If relief, including good lupus control, counselling. Biblical counselling He chooses to heal me, I will absolutely some dietary changes, gentle exercise, is simply connecting the truths of rejoice in that. But I can be content that health-fund subsidised massages, PRN Scripture to life, so that we grow in He is in control and is working all things paracetamol and edifying escapism.1 our love for God and others, by the together for good (Rom 8:28). The pain However, what sustains me is the hope power of the Holy Spirit within us. I continue to feel and woke up with of the day when pain no longer exists This has helped to address my anxiety because of our Saviour’s grace. surrounding the experience of pain as I look at what is happening in my heart To describe “chronic pain” as “light” towards God. What do I fear when I am and “momentary” may seem like an in pain? How does that fear impact my oxymoron, but it reminds us that even relationship with others? What does chronic pain is always temporary. We Scripture say about my fear and pain? are given a short amount of time on What does it look like to trust God with earth to love, know and serve God and my fears? How can the Psalms help in others, and chronic pain is no obstacle providing the words with which to cry “Over time, through the to that. out to God in the midst of pain? What refining fire of chronic does it look like to honour God when “So we do not lose heart. Though our I’m in pain? How does that impact pain and illness, God has outer self is wasting away, our inner the way I treat others? When I am in given me the deepest joy self is being renewed day by day. pain, my natural inclination is to turn For this light momentary affliction is inward with selfishness, self-pity and I have ever known.” preparing for us an eternal weight of to protect myself from further pain. glory beyond all comparison, as we The presence of pain magnifies my look not to the things that are seen but everyday choices between serving today may not end until Jesus returns to the things that are unseen. For the myself or others. or calls me home. However, if my things that are seen are transient, but lifetime of lupus means that God will be the things that are unseen are eternal.” Community more glorified, more people will know (2 Corinthians 4:16-18 ESV) l

God comforts us in our affliction Jesus, and that I leave this world more References: so that we can comfort others with like Christ – it is well worth my soul. 1. Such as enjoying God’s creation e.g. nature, music, nutritious food, or doing something creative such as His comfort (2 Cor 1:3-4). Another writing, drawing, crochet, sewing. Even escapism can Over time, through the refining fire of serve others e.g. making something for someone else like opportunity pain has brought is special a meal or a present. access to support others through many chronic pain and illness, God has given Resources: different kinds of pain. In God’s good me the deepest joy I have ever known; Chronic Pain: Living by Faith When Your Body Hurts by Michael R. Emlet. A booklet by the Christian Counseling & Educational design, the more I look to how I can joy which has not been shaken even as Foundation (CCEF). serve others, the less I worry about the the lupus continues to progress. I may Why Does it Have to Hurt? The Meaning of Christian Suffering details of my own suffering. I’ve also never practice medicine again, become by Dan McCartney Be Still, My Soul – Embracing God’s Purpose & Provision learnt how to accept help from the a mother, or be pain-free, but what I in Suffering. 25 Classic & Contemporary Readings on the body of Christ. Receiving help blesses have gained in Christ is so much more Problem of Pain edited by Nancy Guthrie. Many thoughtful blogs, podcasts and articles at www.ccef.org others as they get to serve with their than what I have lost or could ever lose God-given gifts. As the different parts in this life. Even the best of what I can of the body work together, it builds up hope for here is only a foreshadow of Dr Andrea Schofield the body of Christ in love (Eph 4:15-16) something even better in Heaven with Andrea is a Newcastle medical graduate (2005) and and this is beautiful to be a part of. Jesus. For me, to live is Christ, to die is is married to Tyler, a GP. She was a paediatric trainee gain (Phil 1:21). until becoming ill with lupus. Through suffering, Contentment she has learnt to trust the sufficiency of God’s Learning to be content is the most Looking to Eternity sovereign grace. Andrea and Tyler ministered in powerful defence against the There is purpose in pain. Not only does Alice Springs until returning to Newcastle in 2013, temptations of living with chronic pain. it expose my sin and idols, my pain where they helped plant Gospel Church. Andrea has Thankfully, Paul divulges the secret: unites me with Christ. Jesus knows served as worship director, in women ministry, and we can do all things through Christ pain – the anguish of imminent death, is currently studying biblical counselling with the who strengthens us (Phil 4:11-13). We the hurt of and loneliness, Christian Counseling and Educational Foundation can trust Him – with our health, our and the immense physical pain of His (CCEF), where she is growing in connecting the finances, with today, tomorrow, and all crucifixion, which He endured for me truths of Scripture to everyday life and struggles. the days after that. When we are weak, and for the joy set before Him (Heb She, together with Dr Catherine Hollier, coordinates the power of Christ makes us strong in 12:2). Pain reminds me of the price paid CMDFA Newcastle and local mentoring. the ways that really matter. The times for my sins and therefore the extent

LUKE’S JOURNAL | January 2018 | 51 FIRE IN THE BELLY Reflection on Prayer

A marker of humility is prayer. and [God] breathed into his nostrils the Incomprehensibly, God has adopted breath of life, and the man became a us as children of God and we are able 1 Thessalonians 5:16-18 exhorts living being’ (Gen 2:7). That we have to call on God as “Abba, Father” even us to rejoice always (v16), pray been ‘enriched in every way’ (1 Cor 1:5) though we were still dead in our sins, continually (v17) and give thanks in all and that there is nothing that we have undeserving of any mercy. Hence, we circumstances (v18), for this is God’s not received. As the apostle Paul puts no longer belong to the old master, will for us in Christ Jesus. it, ‘For who makes you different from Sin, and we belong to Christ. We are His anyone else? What do you have that heirs and co-heirs with Christ. We are Since graduation about three years you did not receive?’ (1 Cor 4:7). now ‘more than conquerors’ (Romans ago, one of the biggest challenges 8:37) and we can join in with our Lord I have faced has been the issue of We were also ‘dead in our on His triumphal procession (2 Cor prayerfulness. The apostle Paul exhorts transgressions... and it is only by grace 2:14). the believers of Thessalonica to ‘pray that we have been saved’ (Eph 2: 1,5). continually’ and I found it extremely We were powerless to save ourselves, Our cupboard is always empty – and difficult to practice that in my daily and yet, at the right time, Christ yet, in Christ, it is also always over- work. Despite going to work in my car demonstrated His own love for us flowingly full. This amazing grace has energised to do so, I often realised that (Rom5:6). transformed our lives, not because of I left God behind in the car. what we have done, but because of what He had done. Oftentimes, I thought I was merely busy and that busyness had distracted Despite multiple definitions and me from God. Many times I thought, interpretations for the exhortation to “I just need to make more time.” But ‘pray continually’, I think the marker of frequently I found myself coming full- humility is the attitude of prayer. These circle, back to where I had started. Why two are inseparable for those who was that? rely on God. Regardless of our level of training and competence, we can only That is when I came to listen to a rely on God more, not less. sermon on prayer with the analogy of a cupboard – that we pray when our Etymology is often a helpful way to cupboard is empty, and that we need understand the meaning of a word. to realise that our cupboard is empty. Humility derives from the Latin word This has helped me to realise that humus, which means ground. We can our prayerfulness is deeply related to only guess as to why its derivatives humility. In considering these two cases, a evolved to represent humility, but I question remains – Why do I not pray? think today we have another way to Consider these two cases. What stops me from praying? look at it – we have been formed from the ‘very ground’ – the humus – and Consider that there really is a God who I cautiously explored my heart, and that is who we are. is larger than anything that you can found that the issue lay at the core imagine. That He has said, ‘“Let there of my old self. There was pride at the I pray for all of us that we would be light” and there was light’ (Gen1:3). centre of my lack of prayer. It was the remain deeply rooted in our humus A God who is so large that this world old desire for self-sufficiency, for which identity and realise the magnitude of cannot contain Him. That ‘all things are the only cure is the Gospel itself, that God and our place in relation to him, from Him, through Him and for Him’ tells me the new identity that I have in transformed through Christ by no (Rom 11:6). Consider that such a God Christ. merit of our own. In order to provide is victorious over death, has ‘overcome for the sick and the lost, humility is the world’ (Jn 16:33) and that He is the Before, we were ‘powerless to save vital for the compassionate care Christ ‘King of kings, and Lord of lords’ (Rev ourselves’ (Rom 5:6), but now ‘the old commands of us. We can only do so 19:16). has gone, and the new has come’ (2 Cor with prayer. l 5:17) through the saving work of Christ Then consider, in comparison to such who has ‘transferred [us] from the Peter Park a God, who we are. That we have been kingdom of darkness into the kingdom Peter is a PGY3 based in Western Health and from formed ‘from the dust of the ground of the son He loves’ (Colossians 1:13). CMDFA Victoria.

52 | LUKE’S JOURNAL | January 2018 Book Review The Problem of Pain CS Lewis 1640 (1986) Collins

When it comes to “pain”, this text by opening, an unveiling, a daily surrender highly regarded Christian author CS of itself. Lewis is pragmatic here. Our Lewis, invites attention. free will is readily rebellious and so he appeals to Jesus’ observation of When others seek to write about pain an “ongoing tribulation” till he returns there will be quotes from Lewis’s again. discourse. Perhaps the most famous is that pain “insists on being attended to”. To help us move forward from this God, says Lewis, “whispers to us in our point, Lewis moves from argument and pleasures, speaks to our conscience, but logic to suggest the image of a dance. shouts in our pain: it is His megaphone It is a dance where the self is “flying to to rouse a deaf world” (p.74). This is a and fro” with the great master leading key observation for Lewis. This book is the revelry. As we draw “nearer to its a theodicy - it is a reasoned attempt to uncreated rhythm, pain and pleasure explain the pain and suffering we will sink almost out of sight. We recognise almost certainly encounter in life. As a that God is love, God is good. In the end theodicy, it seeks to avoid bringing pain this happy, good, loving God does not back to God as its source. While God exist for us, but we for God. may have a role in pain and suffering, for Lewis the human experience of pain So, should Lewis’ work be the last word can always be located with us. It is a on the problem of theodicy? The answer consequence of free will. While what we call “our own life” remains is no. Why not? agreeable, we will not surrender it back “If God were good, He would wish to to God. Lewis argues that “no doubt 1. It is written in 1940. Not only is its make His creatures perfectly happy, pain as God’s megaphone is a terrible language and take on the world a and if God were almighty He would be instrument; it may lead to final and little quaint for us today, it is not able to do what He wished. unrepentant rebellion. But it gives the aware of the diabolical genocides But the creatures are not happy. only opportunity the bad man (person) of Hitler’s Germany, of Russia’s salt Therefore God lacks either goodness, can have for amendment. It removes mines, of Rwanda and Cambodia’s or power, or both.” the veil; it plants the flag of truth within killing fields. the fortress of a rebel soul.” 2. The argument of the “free fall” has This is the problem of pain, in its merit to a point but fails to deal with simplest form. Lewis uses the skill of Lewis develops his arguments through the impact of natural disasters and a classic scholar with additional solid traditional theological categories, i.e. genocidal events. theological skills, to assert the “doctrine creation, fall, sin, suffering, hell and 3. It assumes a certain creational of the free fall,” that is, in Adam and heaven. While he acknowledges that stability (God-given) in life that is Eve, the choice to eat of the fruit of the humanity can achieve “simple good’, now challenged by the science of knowledge of good and evil was a choice he argues that when our souls become chaos. away from God. For Lewis, the creation wicked (turned away from God to 4. Lewis acknowledges he applies his story in Genesis (he is not a seven day our self) they will certainly use this own imaginative bias to some of the creationist) suggests the “proper good possibility to hurt one another, and this challenges he is aware of. of a creature is to surrender itself to perhaps accounts for fourth-fifths of 5. Lewis is a Western, male academic. its creator – to enact intellectually, the sufferings of men. Weaknesses are apparent because of volitionally, and emotionally, that these contextual realities. relationship which is given in the mere The surrender of the self to the love of fact of its being a creature. When it does God in Christ is crucial for all humanity. Undoubtedly, however, this theodicy so, it is good and happy.” This side of eternity, Lewis is cautious has enough substance to remain an about the complete transformation of ongoing contribution to the “problem of Genesis guides us to the conclusion people who are now in Christ. While God pain”. l we are rebels. Our self-will is inflamed desires to fill us with love, this requires and swollen with years of usurpation. a continual self-abandonment – an Dr Paul Mercer

LUKE’S JOURNAL | January 2018 | 53 Thy Word is our Food

confirming the words of the prophet The author spent forty years in a spiritual desert, without the Word, and Isaiah (Isaiah 55:1-2). We also need came to Christ after living and working in Italy. Italy has a Biblical link to water to maintain our bodies, which are Jesus and his disciples – in particular to Paul, who was imprisoned by the 60% made of water. Romans. Almost twenty-five years of her working life was spent in a medical institute involved in research on diabetes, nutrition and metabolism which Yeast-free bread referenced ancient Aramaic, Greek and Latin Christian texts on these topics. In Exodus 23 God gave Israel She was baptised in the waters of Port Stephens seven years ago. the instructions for the Feast of Unleavened bread, and Jews partake in this experience at Passover. Christians From the pyramid of the Take responsibility remember that Passover meal as Jesus Mediterranean diet to the God has given us all the responsibility prescribed at the Last Supper – we can temple of the spirit of taking care of and feeding our drink of the wine and eat the bread, bodies (Ephesians 5: 29-30) and our knowing we are doing this in memory This paper aims to take us together spirit (Fry, 1982) as members of the of Him (Matthew 26). Buckwheat was on a short biblical journey from the Body of Christ. In fact, God speaks to us used to make this bread, which even Old Testament Exodus out of Egypt about the quality of the food that we today is recommended for those who to modern times. eat and even as far back as in Leviticus are intolerant to gluten. He explained that food offered as a It is meant as a guide to the communion sacrifice must be eaten Salt and water importance of being healthy to the same day or the day after. In those Jesus said, “You are like salt for the better serve both the Lord and the days, food was kept in storage wells whole human race. But if salt loses its people we support and care for in our (Jeremiah 38) and whatever was left saltiness, there is no way to make it professional lives. We will acknowledge on the third day must be burnt. If it salty again. It has become worthless, that the water and salt in our food were eaten on the third day it would be so it is thrown out and people trample and bodies (which are the temple of rotten and not acceptable. on it,” Matthew 5:13. Modern medicine the Spirit – 1 Corinthians 6:18), and steers us away from taking excessive the use of some herbs, spices and salt, yet we need a balance of water ancient foods are to be maintained in “Spiritually, we need the and salt in our bodies to keep us balance for our well-being: “as we offer Word of God to keep us healthy and able to function. Research through Jesus a continual sacrifice of has looked at the various types and praise,” Hebrews 13:15. alive, and physically, we sources (Psalm 104:10, Fidanza, need salt and water for 2000) of water and salt, and how Do not be worried they affect our physical and spiritual Even before Jesus came, the ancient our bodies to survive.” health (Batmanghelidj and Day, Jews knew of God’s creation and 2008). The SALINE Process alludes to provision of food and drink (Psalm the importance of the physiological 104). However, in Matthew 4:4 it is This may also be taken as a warning balance of salt and water to sustain recorded that Jesus said: “People do to us in modern times not to eat food healthy life. Spiritually, we need the not live on bread alone, but by every that is left over for more than 3 days Word of God to keep us alive, and word that comes from the mouth of as it could (even in a fridge) contain physically, we need salt and water for God.” This was His answer to the Devil bacteria harmful to our health. Wise our bodies to survive. after spending forty days and nights advice is given in Leviticus 6 and 7, 11 in the desert without food. More than and 19 regarding foods we may eat and Stay healthy physical food and drink, we need how they are to be prepared. Types Remember that a healthy tree bears the Word of God. We are reassured and modes of food preparation can be good fruit (Matthew 7:17; Luke 6:22) in Matthew 6: 25 to keep the faith, found in Ezekiel 9 and 1 Chronicles 22. and that the harvest is large. But since “That is why I tell you not to worry there are few workers to gather it in, about everyday life – whether you Water “Pray to the owner of the harvest that have enough food and drink... Isn’t life Jesus said, “Anyone who is thirsty come he will send out workers to gather in more than food, and your body more to me” John 7:37. By this He means his harvest,” Matthew 9:37-38. In order than clothing?” thirsty for the Word of God. He was to be able to serve the Lord we need to

54 | LUKE’S JOURNAL | January 2018 Neurobiology of Glossolalia

Glossolalia is the experience of anxiety, psychosis and mania. “speaking of tongues” as described in Furthermore, it has been found that pray to Him to provide what is needed Christianity. According to Goodman1, 80% of practitioners of glossolalia have to sustain our bodies and spirits, and glossolalia is described as an induced greater emotional stability and reduced be part of that workforce that goes dissociative hyperarousal state while neuroticism than those who do not out for Him. He has done this also by others have described it as a state practice glossolalia.4 However a few providing doctors of medicine and of possession in different cultures. other studies have not shown the same other healthcare workers to assist us in However, the exact physiology of it results.5 these efforts (Sipser and Lew, 2008). remains uncertain. Glossolalia has been shown to have The Bible mentions many foods, herbs According to James2, glossolalia stress-reducing benefits in non- and spices that are for us to eat, eg. figs is composed of four main criteria. worship activities. Whilst practicing and grapes, honey and almonds, lamb, First is ineffability, which states that glossolalia, a reduction in circulatory mint and cinnamon. These you will, or the experience defies a standard cortisol and an elevation in α-amylase have already, tasted. God would not expression. It is a unique experience activity (common biomarkers of have mentioned these if they were not with varied patterns of sounds and stress reduction in the saliva) has good for us, and He wishes us to enjoy words individualised to a specific been shown.6 However, there were them (see recipes)!* person at a specific time. Second increased levels of physiological stress is a noetic quality, which states the during worship. So perhaps it is time to look at how experience carries a specific value healthy we are – both physically and to the practitioner while holding a In conclusion, the neurobiology of spiritually, to scrutinise what we eat sense of authoritative knowledge. The glossolalia continues to remain a and drink, how and when we pray, remaining components are transiency mystery. With the limited sample and, at times when the Lord asks and passivity. size, research studies and financial us, to abstain from food or drink (or resources, we are unlikely to achieve something else in particular) so that Neuroimaging studies have shown a good understanding of the He can heal and start something new that attention-focusing tasks require neurobiological processes surrounding within each of us. l increased frontal lobe activity via glossolalia. However we can ascertain

References: perfusion scans. According to Newberg the ineffability, noetic quality, Batmanghelidj, F. and Day, P. (2008) The Essential Guide to et al3 who performed the first SPECT transient and passivity components of Water and Salt. Credence Publications. Tonbridge, UK Benson, H. and Stark, M. (1996) Timeless Healing; The Power scans on active glossolalists, reduced glossolalia based on the observational and Biology of Belief. Simon and Schuster Ltd, London, UK Fidanza, F. (1998) The Mediterranean Diet and Health: The cerebral activity was recorded in the and neuroimaging studies. As is written Seven Countries Study. ANDID Notizie, Italgraf Publisher, prefrontal cortex, supporting the in 1 Corinthians 14:2, “For anyone Rubiera, Italy Fidanza, F. (2000) In search of the ancient roots of the passivity and dissociative aspect of who speaks in a tongue does not Mediterranean diet. Diab.Nutr.Metab., Kurtis, Milan, Italy SALINE Process: IHS Global www.international saline.org/ glossolalia. Furthermore, there was a speak to people but to God. Indeed, resources: accessed 28 May 2017 lack of clear lateralisation of the frontal no one understands them; they utter Sipser, W. and Lew A. (2008) Seven Things Your Doctor Forgot to Tell You. A guide for optimal health. Rockpool lobes which, surprisingly, suggests that mysteries by the Spirit.” l Publishing, Sydney, Australia Holy Bible , New Living translation (2007) Tyndale Publishers, expressive language areas of the brain Carol Stream, IL, USA may not be affected by glossolalia. Bryan Yap Fry, T (1982) The Rule of St. Benedict of Norcia. The Liturgical Press, Minnesota, USA However, limitations of the study Bryan is a 4th year UQ medical student. Footnote: included the subjective nature of References *Recipes published in Luke’s Journal, Vol. 22, No. 2, 1. Goodman, F. D. (1972). Speaking in tongues: A cross- September 2017, p41 reporting and the limited sample size. cultural study of glossolalia (1st ed.). Chicago: University of Chicago Press. As is written in Romans 8:26b, “for we 2. James, W. (2004). The varieties of religious experience. Georgina Hoddle do not know what to pray as we ought, New York: Barnes & Noble Inc. 3. Newberg, A. B., Wintering, N. A., & Morgan, D. & Waldman, Georgina is a Registered Nurse who returned to the but the Spirit Himself intercedes for us M.R. (2006). The measurement of regional cerebral profession eleven years ago after a long sojourn blood flow during glossolalia: A preliminary SPECT study. with groaning too deep for words.” Psychiatry Research Neuroimaging, 148, 67-71. overseas. She has attained a Masters in Applied 4. Francis, L. & Robbins, M. (2003). Pesonality and Linguistics (TESOL; Macquarie Uni) and has worked glossolalia: A study among male evangelical clergy. Originally, glossolalia was believed Pastoral Psychology, 51, 5. on projects involving understanding multicultural to be a form of psychopathology by 5. Louden, S. & Francis, L. (2015). Are catholic priests communication in healthcare with two Australian in england and wales attracted to the charismatic the scientific community. However, movement emotionally less stable? British Journal of Universities. She is currently a Clinical Nurse Educator Theological Education, 11(2), 65-76. with an Agency and is seconded to a Government small scale studies have shown no 6. Lynn, C. D. (2012). Glossolalia is associated with differences in biomarkers of stress and arousal among department. Georgina is also Vice-President of difference in personality traits or risks apostolic pentecostals. Religion, Brain & Behavior, 1(3), Nurses Christian Fellowship Australia (NCFA) and the for mental illness such as depression, 173-191. NCFA SALINE Co-ordinator for nurses.

LUKE’S JOURNAL | January 2018 | 55 Zoe’s Place

There are very few topics of surgical abortions.1 This number is conversation that are more likely only an estimate, as no precise figures to cause either an awkward silence, are kept on abortion in Australia. This or a heated debate of nuclear estimate comes from South Australia, proportions, than that of abortion. Western Australia and Northern Territory figures, and from Medicare The subject of life before birth seems rebates paid to private patients.2 The capable of stirring such strong and real numbers, I suspect, are probably intense emotion that we don’t often devastatingly higher. broach it, for fear of waking the sleeping beast of opinion. We fear that Needless to say, I accepted the position our own opinion might offend. We fear of Executive Director at Zoe’s Place in that our opinion won’t be liked. We fear 2015, and I can honestly say that I have that we don’t know enough to support not regretted that decision, even for a our opinion. We fear that we, as a moment. That’s not to say it has been person, won’t be liked. an easy journey. I was labelled “naive and gullible” by a close family member And so I must admit that I, too, almost for taking on such a position with “a succumbed to fear, and was filled with group of people who obviously have just a little apprehension when I was a hidden agenda”. A work colleague approached to consider accepting advised me that women with unwanted with tenderness and kindness to this the position of Executive Director of pregnancies “should just put them woman who found herself tangled Zoe’s Place. Zoe’s Place is a pregnancy in a bucket and get on with their up in the world of prostitution. Jesus support centre that provides free life”. Another work colleague advised knew her history, but still accepted and counselling to women negotiating the me that “there’s absolutely nothing ministered to her. We don’t find Jesus storm of an unexpected pregnancy in positive about a 15 year old that’s standing beside the well, condemning the Newcastle and Lake Macquarie area pregnant.” and shaming this woman with placards of New South Wales. Zoe’s Place also displaying disturbing images of the provides post-abortion counselling, effects of prostitution. As a good friend as well as mentoring to women who “She thought, like most of mine says, “we want to be known for choose to continue their pregnancy. what we’re for, rather than what we’re At the time I was offered this position, other deceived women against”. Zoe’s Place was still in the planning in her position, that and preparation stages and had not At Zoe’s Place in June, I met an officially been launched. it was just a simple international student Sophie3 who procedure that would is studying at the local university. Despite the fact that I am passionate She had returned to Australia after a about all things ‘women and families’, allow her to move on recent holiday to her home country to and consider myself a champion with her life.” visit her fiancé, only to discover she of child protection, I still felt a little was pregnant. During Sophie’s first anxious about accepting this role. counselling appointment, she talked And it wasn’t just because the job about all the reasons why she couldn’t description went for three pages! However, there have been so many have this baby. As we talked together My apprehension was because my moments at Zoe’s Place that have about her options for this pregnancy, assignment, if I was to accept this far outweighed those difficult times the obstacles fell away one by one, and position, meant signing up for a a thousand-fold. I am so thankful God’s truth replaced the false beliefs front row position in a battle of epic that the Holy Spirit has given me that crowded her thinking. Her baby proportions. It is a battle that the extraordinary empathy for the was not merely “a clump with no brain enemy is waging primarily through women we see at Zoe’s Place, which or organs” as a friend had informed lies, and through the dissemination has enabled me to listen to their her. She even laughed in disbelief when of misleading or deliberately false struggles and circumstances in a I told her that at 6-7 weeks gestation information. And it is a battle where the non-judgemental way. The story of her baby’s heart had most likely already daily casualties are precious little lives. Jesus’ encounter with the woman started to beat. Sophie was surprised at the well in John chapter four is a to learn that there were possible Each year in Australia it is estimated constant reminder to me of what true complications from having an abortion that 80,000 children are lost through Christ-like love looks like. Jesus spoke that may affect her ability to conceive

56 | LUKE’S JOURNAL | January 2018 equipped with accurate information Thirdly, you can partner with your about abortion. Did you know that local pregnancy support centre around 97% of babies who are aborted financially. Zoe’s Place is a not-for- are perfectly healthy?4 Were you aware profit organisation and we rely solely that abortion due to rape accounts for on fundraising to provide our services less than 1% of all abortions?5 Or that free of charge to the women we only 0.35% of all abortions performed see. Most other pregnancy support are to save the mother’s life?6 Don’t services operate in a similar manner. be fearful, but instead be prepared Financial and prayer support from to engage in a conversation about you individually, or through your abortion and be able to support your church, means more women in your beliefs with truth. We need to start community can be reached and lives having these difficult conversations saved and changed. that we seem to fear. Fighting in a battle requires weapons I was deeply saddened recently to hear and you can’t fight the enemy’s attacks the story of a young woman from a without being adequately armed. Our loving Christian home who, at 25 years weapons must include Christ-like love of age, found herself unexpectedly and empathy, as well as the spiritual pregnant after a one-night stand with armour of God. The spiritual war a friend. She went on to tell me that it has already been won by Christ, but was her mother who had suggested until the very end, the battle against that “maybe you should get rid of it”. abortion will continue to be waged. My Indeed, her mother accompanied constant and fervent prayer is that eyes her to the abortion appointment, will be opened, ears will begin to listen, driven by her father. I found this story and God’s people will step up and take or carry a child later. She also seemed simply heart-breaking. Why is there no their positions on the front line of this genuinely surprised to hear of the difference in a Christian household? battle. l psychological impact abortion would Perhaps because Christians too are References: 1. Pratt, A., Briggs, A. & Buckmaster, L. 2005 Parliamentary have. She thought, like most other fearful of having these awkward Library research Brief. How Many Abortions Are There deceived women in her position, that it conversations. Each Year in Australia? Retrieved from https://www. emilysvoice.com/get-informed/abortion-facts/ was just a simple procedure that would 2. https://www.emilysvoice.com/get-informed/abortion- facts/ allow her to move on with her life. 3. Name has been changed to protect privacy of client “...only 0.35% of all 4. https://www.emilysvoice.com/get-informed/abortion- facts/ Sophie returned for her second abortions performed 5. Ewing, S. (2005). Women and Abortion: An Evidence- Based Review; a meta-analysis of Australian and appointment at Zoe’s Place the International research on why women have abortions. following week. I was absolutely are to save the Compiled for a Women’s Forum Australian parliamentary submission. Retrieved from https://www.emilysvoice. delighted to learn that Sophie had mother’s life?” com/get-informed/abortion-facts/ 6. Croft, S., Cotton, D. & Cotton, C. (2006). Abortion on decided to keep her baby. I showed her Australia into the 21st Century. NSW Right to Life, citing a picture of what her baby looked like Australian Bureau of Statistics figures, citing Dr David van Gend. Backyard Distortions: Putting the Abortion at this early stage. Her hands flew up to Campaign in Perspective, Bulletin of Ovulation Method Research and reference Centre of Australia, 26 (2), 12-16. her face and she said “I think I’m going Secondly, find out about your local Retrieved from https://www.emilysvoice.com/get- to cry!” Later that week, I spoke with pregnancy support centre. Become informed/answers/ Sophie after she’d seen her baby for familiar with the services that they Useful Websites : Emily’s Voice – www.emilysvoice.com the first time at an ultrasound. I’ll never offer to your community. Consider WECARE (World Expert Consortium for Abortion Research and forget the joy and animation in her partnering with them or being Education) – www.wecareexperts.org.au Pregnancy Help Australia – www.pregnancysupport.com.au voice. In just one short week, Sophie available to receiving referrals from Elliott Institute – afterabortion.org had fallen in love with the little life them. Women who continue their growing within her. God’s truth, spoken pregnancies will need a general Helen Bell in love, undoubtedly sets people free. practitioner to care for them. At Zoe’s Helen is a 39 year old happily married mother of Place, we are fortunate enough to two small boys. Helen was appointed Executive It is so easy to feel overwhelmed by the have five wonderful local Christian Director of Zoe’s Place in 2015, and is currently magnitude of the struggle against the general practitioners that have agreed employed one day a week. Helen also works part- tide of abortion. But, as Edmund Burke to accept referrals from us and care time as a registered nurse in her local Emergency once said, “All that is necessary for the for our women. It’s reassuring to know Department, a position she has held for the past 13 triumph of evil is that good people do that we can trust these professionals years. Prior to her nursing degree, Helen completed a nothing.” to love and care for our clients in the Bachelor of Music degree. She has also completed an same Christ-like way. If you have a Advanced Diploma Counselling and Family Therapy As a medical professional in your local patient who is unexpectedly pregnant, (Christian), and has spent time working with Family community, there is so much that refer them to your local pregnancy and Community Services as a Child Protection you can do, should you be willing to support service so that they can receive Caseworker. engage in this battle. Firstly, become the counselling and support they need.

LUKE’S JOURNAL | January 2018 | 57 It’s better to give...

The Bible is explicit regarding the has a higher chance of a successful Some request no displays of Christian’s attitude to giving: “Do not campaign. public recognition. Others prefer lay not up for yourselves treasures anonymity. Anonymous displays on earth”, “The Lord loves a cheerful 2. Show donors the difference of generosity are good and have giver”, “It is better to give than to they’re making. Biblical precedents. However, all receive”, “The love of money is the Donors want to see their donations donors, including anonymous ones, root of evil” and a plethora of other being used to help others. That is appreciate being thanked. While such verses. As followers of Christ, why personal campaigns where an public displays of recognition may we try to live out these principles, individual sponsors a child, or buys not be desirable to some, a simple but, being human, we do it with material to help a family from a personal acknowledgement, such as varied success. developing country build a vegetable a handwritten note or a phone call, garden, etc. are so effective. Donors is always appreciated. If the thanks is Considering the Bible’s clear teaching are actively able to engage with the expressed by someone senior in the about giving, fundraising for Christian real people they’ve helped provide for. organisation, it is even more powerful. causes should be more effective Whilst Biblically this shouldn’t drive Good fund-raisers know the difference than that of the general community. our desire to give, it is a good way to between public acknowledgement that However, no one is completely free encourage and assure donors that their is sought by some, and personal thanks from temptation: Scottish theologian gifts are truly contributing to the cause. that is appreciated by all. and preacher, William Barclay, gives an example of a congregation singing the 5. Be honest with donors about well-known hymn Take My Life as the “Donors want to see overhead costs. collection is taken. As the collection All charities have to use some of the plate nears him, one parishioner their donations being donations they receive for fundraising surreptitiously feels amongst the coins used to help others.” and administrative expenses. In order in his pocket, trying to find a couple to gain the good faith of donors, of low value ones. As the plate reaches fundraising and administration him, the singing reaches the line “Take expenses should be transparent. my riches and my gold, not a mite 3. People like to give towards things Australian research by Givewell, says would I withhold…” that they can touch, that they can that on average, 19% money raised see and that last. by charities goes towards fundraising The principles of fundraising are Many donors like to give towards expenses and administration. However different from the principles of something that is specific and that they there is wide variation – between Christian giving. However, when can see, perhaps even with a plaque 4-50%, depending on the charity. It is fundraising is directed towards attached to it bearing their, or their worth doing some homework before Christians and Christian groups, fundraising group’s, name. Hence, a donating to see where your money bearing the Biblical principles of specific piece of equipment may be actually goes. Some telemarketers and giving, in conjunction with the broader more appealing for an individual, or a on-street fundraisers operate under a principles of community fundraising, community group, to purchase. Very system where they are enabled to keep will be beneficial. few can afford an entire building, a significant amount of the donation. so dividing it into parts, such as a As Christians we have a responsibility The following seven principles combine lecture theatre, a study room, or a to use our money, including our these concepts, without sacrificing the library may be more attractive. Even donations, wisely. This means that in merit of either. ‘selling’ individual bricks or pavers can general, rather than donating through be effective in helping people feel a third party, it is wiser to donate 1. Appeal to the donor’s emotions, connected to their contribution. Some directly to the charity. Being upfront if possible. donors appreciate being able to name with donors about what percentage of Even the most rational individual can a portion of a building in memory of a raised funds goes towards the stated be influenced by powerful stories that loved one, feeling that they have made cause is a great way to establish trust. tug at their heartstrings. This is one of a gift that will last. the reasons that children’s charities can 6. Nurture and inform donors. be so successful: the need of a sick or 4. Donors like to be thanked. Donors give when they care about suffering child evokes a strong sense Some donors like public thanks and a charitable cause. If they care, they of sympathy. Although Christians know having their name mentioned and may donate regularly as they can not to be manipulative, an honest and displayed. They may see this as a afford it. They are more likely to do truthful appeal, pitched to win the way of encouraging others, as well as this if they are thanked appropriately hearts as well as the minds of donors, recognising their own contribution. and told about what their donation is

58 | LUKE’S JOURNAL | January 2018 helping to achieve. Some fund-raisers I have seen two donors approach in order to maximise the chance of think donors should be asked to different organisations with requests success. Tailoring the request and give more generously in subsequent that the organisations rejected, even following up with gratitude will donations. Others have found that though the proposed gifts were each encourage “cheerful givers”. l this may alienate a donor. Where the over $1 million. One organisation said organisation can’t go wrong is to be the idea didn’t interest them. The other Emeritus Professor Kim Oates genuinely grateful and to keep in said the proposed donation wasn’t Kim is a paediatrician whose various roles have touch. enough. The donors then went to other included Professor of Paediatrics and Child Health organisations that were able to work at Sydney University and Chief Executive of the 7. Respect the wishes of donors. out a way that the principle of what the Children’s Hospital at Westmead. He has a long It is hard for a donor to know what donor wanted could be aligned with standing interest in child development and the an organisation needs unless the the organisation’s needs. The donors problem of . He now teaches patient organisation makes it clear. Sometimes then made the gift and, because their safety and leadership at several medical schools here a donor may approach an organisation wishes were respected, continued to and overseas. Kim has been a member of CMDFA for with a specific project in mind. This contribute to those organisations. as long as he can remember and with his wife, Robyn, may pose a challenge if the project worships at St Philip’s Church, York Street, Sydney. is not in line with an organisation’s Conclusion needs, or if the donor thinks their gift When planning to will achieve far more than it can. The fundraise for a worthy solution is to respect what the donor cause, keep the wants to do, talk to them about what above principles your organisation needs and then try in mind to find a way where the needs of both can be accommodated.

“...in general, rather than donating through a third party, it is wiser to donate directly to the charity.”

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