Commentary
The Rashomon Effect: Another View of Medicine, Religion, and the American Medical Association B.J. Crigger, PhD
Abstract What is the story of medicine and religion at the American Medical Association (AMA)? Where did the Department of Medicine and Religion originate? What did the program ac complish? Why was it all but com pletely discontinued after scarcely a decade? The surviving records support more than one interpretation. Exploring the broader organizational context helps tell a richer story. In this issue of Academic Medicine, Daniel Kim and colleagues open a window on a fascinating bit of history: that of the
Editor's Note: This is a Commentary on Kim DT, Curlin FA, Wolenberg KM, and Sulmasy DP. Back to the Future: The AMA and Religion, 1961–1974. Acad Med. 2014;89:1603–1609.
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hat is the story of medicine and religion at the American Medical Association (AMA)? Where did the Department of Medicine and Religion (DMR) originate? What did the program accomplish? Why was it all but completely discontinued after scarcely a decade? Reconstructing the story of a program from documentary records is always something of an uncertain proposition. Historical documents preserve the sub stance of decisions taken, but are largely silent about the reasoning behind those decisions. Surviving records support more than one interpretation, and relevant information is scattered through multiple record systems, making it difficult to find. Inevitably, historians have to read between the lines. Dr. Crigger is director of ethics policy, American Medical Association, Chicago, Illinois. Correspondence should be addressed to Dr. Crigger, American Medical Association, AMA Plaza, 330 N. Wabash Ave., Chicago, IL 60611-5885; telephone: (312) 464-5223; e-mail: [email protected]. Acad Med. 2014;89:1582–1585. First published online June 20, 2014 doi: 10.1097/ACM.0000000000000371
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AMA’s formal experience with religion and medicine during the 1960s and early 1970s; however, reconstructing the story of a program from documentary records is always something of an uncertain proposition. Equally important is taking account of such factors as the role of the AMA’s House of Delegates in policy making, of state and county medical societies in carrying out program activities, and of the influence of charismatic individuals on decisions regarding programs and activities. Before the medical community decides what
lesson(s) to draw from the story of the AMA’s Department of Medicine and Religion, it should try to understand that story as completely as possible.
Exploring the broader organizational context helps tell a richer story. Before the medical community decides what lesson(s) to draw from the story of the AMA’s DMR, it should try to understand that story as completely as possible.
with that which Kim and colleagues find in other sources. Though Kim et al speculate about why the AMA sought a relationship with clergy, the minutes themselves say nothing about what motivated the Board to seek such a consultation in the first place.
Where Did the Program on Medicine and Religion Originate?
The life of the AMA as an organization revolves around the interplay of gover nance, which comprises the House of Delegates (hereafter, simply the House) and the Board of Trustees (hereafter, simply the Board), and of operations— that is, AMA staff. In the case of the AMA’s formal experience with religion and medicine in the 1960s and early 1970s, governance was the responsibility of the Board’s Committee on Medicine and Religion (CMR) and operations that of the DMR. As a matter of procedure, the program was created by the Board. Formal outreach from the AMA to clergy is first mentioned in the minutes of the September 1961 meeting of the Board, at which its members voted to “approve employment of Dr. Harrison Ray Anderson, Pastor of the Fourth Presbyterian Church of Chicago (retired), as a consultant on church matters.…”1(p35) This information aligns
As Kim et al note, the available materials leave out much that historians might wish to know. Records preserve the substance of decisions taken, but are largely silent about the reasoning behind those decisions. Relevant information is scattered through multiple record systems, making it difficult to find. Inevitably, historians have to read between the lines.
In April 1962, the AMA’s Council on Miscellaneous Activities recommended that the Board adopt a program proposed by the Rev. Dr. Paul McCleave “as outlined, which included establishment of an advisory committee, to be composed of approximately 10 physicians and 10 clergymen.”2(p14) The Board accepted the proposal and promptly appointed an advisory committee, the CMR. The CMR, which held its first organizational meeting in May of that same year, included not only members of the Board but also clergy from across the country, and it was staffed by its eponymous department. The Board informed the House about the new program, directed by the Rev. Dr. McCleave, in its year-end report that November.3 What Did the Program Accomplish?
The primary sources of information about the CMR and DMR are the minutes of the (semiannual?) CMR meetings and the DMR’s (annual)
Academic Medicine, Vol. 89, No. 12 / December 2014
Commentary
reports to the House. Predictably, these documents are positive in tone: The medicine and religion program is accomplishing great things! Such records are informative, and I have no doubt we can trust that the information is accurate, so far as it goes. The question is, Does that information go far enough? Materials (e.g., brochures, manuals) developed by the DMR and retained in separate records can provide some additional insight; however, even with these, the historical data are limited.
into their curricula in some form, and a further four intended to launch offerings in 1968.7(p71) The record does not report, however, what the courses covered, who taught them, or how many students took them. Some 150 seminaries indicated interest in incorporating some training on medicine and religion; 20 agreed to participate in a pilot project with a county medical society, 11 actually launched the pilot, and 7 completed it.13,14 But the pilot seems nowhere described.
How the program defined its focus was somewhat fluid. Its delineated areas shifted from “mental health; hospital chaplaincy; medical, theological, and nursing school curricula; and pastoral clinical training centers” in 1962,3 to state and county medical society programs, medical and nursing school education, theological education, and continuing education for American medical missionaries serving overseas in 1965.4 By 1969, three remained: state and county programs, theological education, and medical education.5
The film The One Who Heals, one of the program’s earliest efforts, was widely distributed through the efforts of, in part, the AMA’s Communications Division. As Kim and colleagues report, it was well received; however, it was also criticized as “too emotional, having no conclusion, [and depicting] too many emergency situations.”8(p6)
The records are silent about any program activities with respect to mental health (however, McCleave6 published individually in this area); education for medical missionaries foundered when publishers did not follow through on promises to provide medical textbooks for the department to send to the field,7,8(p2) and little seems to have come of early contact with professional nursing organizations.8(p4),9 As Kim and colleagues write, AMA records indicate that over time, varying numbers of state medical societies organized medicine and religion committees and sponsored sessions for physicians and clergy.5,7,10 Still, to maintain continued success at the grassroots level, the program had to rely on the state committees, a potentially uncertain proposition.7(p10),11 The records show that medical schools and seminaries were surveyed to ascertain interest in having educational materials on medicine and religion.12(pp12–13) Historical documents indicate that in 1967 eight medical schools offered elective courses, another six incorporated medicine and religion
A program manual for state medical societies and theological seminaries survives. The manual includes brief papers by physicians and clergymen (and the odd lawyer) in each of six topics (e.g., the clergyman’s role in catastrophic illness, privileged communication).15 It offers discussion questions, as well as information on planning and conducting programs and on using the resource materials. But beyond the observation that, as of February 1968, seven states had made use of it,8(p5) the record is silent about how well it was received and how extensively it was used. Kim et al take the records at face value and conclude that the program had “obvious successes” and “was highly impressive in both size and quality.” But what the available information does not reveal is whether the program made a difference—for physicians, clergy, and most important, patients. Did it bring medicine materially closer to treating the whole person? It may have touched many lives deeply, but the record, as it stands, cannot elucidate that. In fairness, I am looking for outcome measures from a program that lived and died in an era that did not yet focus much even on process measures. Yet, even taken on its own terms, discerning whether the program on medicine and religion was a
Academic Medicine, Vol. 89, No. 12 / December 2014
success relative to other AMA activities of its time is not possible. Why Did the Program End?
Kim and colleagues find the Board’s stated fiscal reason for discontinuing the DMR to be unpersuasive and speculate that “the CMR’s demise was due in significant part to the controversial role” the committee played in the “abortion politics” of the AMA. That debate likely did play a role, but to read the record as indicating that the CMR as a body was, in effect, punished for taking a stand against liberalizing AMA policy reads rather too deeply between the lines. Fiscal considerations unquestionably did play a role in the decision. The action was taken as part of a much broader endeavor to address concerns about fiscal responsibility that began with a directive from the House in June 1968.16 That effort included reducing the size of councils and committees (by attrition) and reducing the maximum tenure of service, holding meetings at AMA headquarters in Chicago, reducing the number of council and committee meetings held each year, and minimizing the use of consultants.17 To fully answer the question of whether the CMR’s stance on abortion contributed to its fate, it’s important to have a clear view of the process of policy making in the AMA. Whatever its flaws, the House is a deliberative, democratic body. Simply explained, matters of policy, such as the AMA’s abortion policy, are brought to the House in the form of resolutions and reports. Input on a proposed policy is gathered through a reference committee process in which any interested member of the House may offer testimony; action is then recommended to the House on the basis of testimony heard. The House may adopt a proposed policy, edit it (with certain exceptions), not adopt it, or refer it to the Board either for a decision or further consideration. Controversial matters, such as abortion, often come before the House several times before a final decision is reached. The House amended AMA policy on abortion over a series of meetings between 1965 and 1970. In 1965, on the basis of its review of recent
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developments in state law, the Board’s Committee on Human Reproduction recommended that AMA liberalize its policy to support legislation permitting a physician to terminate a pregnancy when the pregnancy resulted from rape or incest, when continuing the pregnancy might “gravely impair the physical or mental health of the mother,” or when there was “substantial risk” that the child would be born with “grave physical or mental defect.”4(p88) The report was referred back to the Board with instructions to provide further input on the “moral-ethicalspiritual-religious” element of the question, along with “(2) the legal element, (3) the medical element, and (4) the customs, usage, tradition, and orientation of society in each state.”4(p92) Having undertaken the requested consultations, the Board brought a revised report forward in 1967 with substantially the same recommendations. The House adopted the report this time, doing away with a blanket prohibition on abortion that had been policy since 1871.18 In November 1969 a resolution seeking to liberalize policy still further came before the House, at which time the reference committee heard clear opposition to the proposal.5(p312) Six months later, however, the issue came to the House yet again in the form of a Board report and five separate resolutions. In lieu of action on the individual items, the reference committee recommended adoption of a substitute resolution that, in the committee’s own words, “embodie[d] a number of the points made in two of the resolutions before it.”19 At this time (June 1970), the reference committee remarked on the “impressive shift” in testimony from six months prior.19 The House concurred with the committee and adopted the substitute resolution, liberalizing policy still further such that the AMA’s official policy allowed a woman and her physician to make decisions about abortion.19(p339) Members of the CMR may well have disagreed with one another on the matter of abortion; AMA’s archival records are largely silent in this respect. Paul Rhoads, chair of the CMR from 1966 through 1970, seems to have taken a neutral, if not liberal view.
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In an address to the South Carolina Medical Society in 1968, he observed that “almost all the existing state laws regarding abortion are outmoded” in permitting abortion only to save the mother’s life, and that a majority of physicians supported the AMA’s 1967 policy.20 For his part, in 1970 the Rev. Dr. Paul McCleave, director of the DMR, but not a member of the CMR, urged the committee to prepare a statement answering the question “What Is Life?”21(p6) Notably, Rev. Dr. McCleave is last listed as the director of the DMR in the November 1970 Proceedings of the House. I read a different story from the records than do Kim and colleagues. I read a program founded in a lofty vision searching for concrete ways to make that vision real in the world, but not confidently finding them. I read a program that came to an end amid a tangle of organizational dynamics— some logistic (e.g., depending on local chapters to maintain CMR momentum, wrangling with publishers), some fiscal (e.g., reducing the number of Board committees), some philosophical (e.g., deciding on an abortion policy, defining life). But more than anything, I read a program that could not quite recover from the departure of its charismatic founder. If the AMA’s Paul B. McCleave is indeed the same Presbyterian pastor who spoke to the Helena, Montana, Community Chest Kick-Off Dinner in 1956—“one of the most forceful, sincere young speakers in the state” in the words of the local paper22—that seems all the likelier. Lessons Learned
The possibility of illuminating the full reason(s) behind the dissolution of the CMR (and, two years later, the DMR) is slim, if not nonexistent. Realizing that the surviving records support more than one interpretation is vital. Drawing conclusions about what happened to the AMA’s formal religion and medicine program in the early 1970s without further historical information is as irresponsible as making diagnoses without taking a medical history or performing a physical exam.
Acknowledgments: The author extends her thanks to Amber Dushman, senior archivist at the American Medical Association, for her kind assistance in accessing archival materials. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Disclaimer: The views expressed are the author’s own and do not necessarily represent the position of the American Medical Association.
References 1 Minutes of the Board of Trustees of the American Medical Association. September 8– 9, 1961. Located at: Field Service Collection, AMA Historical Archives, Chicago, Ill. 2 Minutes of the Board of Trustees of the American Medical Association. April 6–7, 1962. Located at: Field Service Collection, AMA Historical Archives, Chicago, Ill. 3 American Medical Association. Proceedings of the House of Delegates. Sixteenth Clinical Meeting. November 26–28, 1962:27. http:// ama.nmtvault.com/jsp/viewer.jsp?doc_id =House+of+Delegates+Proceedings%2 Fama_arch%2FHOD00001%2F0000007 3&query1=&recoffset=100&collection_ filter=All&collection_name=House+of+Del egates+Proceedings&init_width=640&sort_ col=date+. Accessed June 3, 2014. 4 American Medical Association. Proceedings of the House of Delegates. 19th Clinical Convention, November 28–December 1, 1965:41. http://ama.nmtvault.com/jsp/viewer. jsp?doc_id=House+of+Delegates+Proceedi ngs%2Fama_arch%2FHOD00001%2F0000 0081&query1=&recoffset=100&collection_ filter=All&collection_name=House+of+Del egates+Proceedings&init_width=640&sort_ col=date+. Accessed June 3, 2014. 5 American Medical Association. Proceedings of the House of Delegates. 23rd Clinical Convention, November 30–December 3, 1969:39. http://ama.nmtvault.com/jsp/ viewer.jsp?doc_id=House+of+Delegates +Proceedings%2Fama_arch%2FHOD000 01%2F00000089&query1=&recoffset=10 0&collection_filter=All&collection_nam e=House+of+Delegates+Proceedings&in it_width=640&sort_col=date+. Accessed June 3, 2014. 6 McCleave PB. The spiritual treatment of the alcoholic by the clergy. Mod Treat. 1966;3. http://silkworth.net/religion_clergy/01063. html. Accessed April 10, 2014. 7 American Medical Association. Proceedings of the House of Delegates. 21st Clinical Convention, November 26–29, 1967:71. http://ama.nmtvault.com/jsp/viewer. jsp?doc_id=House+of+Delegates+Proceedi ngs%2Fama_arch%2FHOD00001%2F0000 0085&query1=&recoffset=100&collection_ filter=All&collection_name=House+of+Del egates+Proceedings&init_width=640&sort_ col=date+. Accessed June 3, 2014. 8 Minutes of the American Medical Association’s Committee on Medicine and Religion. February 23, 1968. Located at: Field Service Collection, AMA Historical Archives, Chicago, Ill.
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Commentary 9 American Medical Association. Proceedings of the House of Delegates. 22nd Clinical Convention, December 1–4, 1968:70. http:// ama.nmtvault.com/jsp/viewer.jsp?doc_id =House+of+Delegates+Proceedings%2 Fama_arch%2FHOD00001%2F0000008 7&query1=&recoffset=100&collection_ filter=All&collection_name=House+of+Del egates+Proceedings&init_width=640&sort_ col=date+. Accessed June 3, 2014. 10 American Medical Association. Proceedings of the House of Delegates 18th Clinical Convention, November 30–December 2, 1964:43. http://ama. nmtvault.com/jsp/viewer.jsp?doc_id= House+of+Delegates+Proceedings% 2Fama_arch%2FHOD00001%2F0000 0077&query1=&recoffset=100&colle ction_filter=All&collection_name=H ouse+of+Delegates+Proceedings&in it_width=640&sort_col=date+. Accessed June 3, 2014. 11 Minutes of the American Medical Association’s Committee on Medicine and Religion. March 17, 1972. Located at: Field Service Collection, AMA Historical Archives, Chicago, Ill. 12 Annual Report of the Field Services Division. 1967. Located at: Field Service Collection, AMA Historical Archives, Chicago, Ill. 13 Program Guide for County Medical Societies. 1969. Located at: Field Service Collection, AMA Historical Archives, Chicago, Ill.
14 American Medical Association. Proceedings of the House of Delegates 24th Clinical Convention, November 29–December 2, 1970:32. http://ama.nmtvault.com/jsp/ viewer.jsp?doc_id=House+of+Delegates +Proceedings%2Fama_arch%2FHOD000 01%2F00000091&query1=&recoffset=10 0&collection_filter=All&collection_nam e=House+of+Delegates+Proceedings&in it_width=640&sort_col=date+. Accessed June 3, 2014. 15 Medicine and Religion Program Resource for County Medical Societies or Program Chairmen. Located at: Field Service Collection, AMA Historical Archives, Chicago, Ill. 16 American Medical Association. Proceedings of the House of Delegates 113th Annual Convention, June 16–20, 1968:158. http:// ama.nmtvault.com/jsp/viewer.jsp?doc_id =House+of+Delegates+Proceedings%2 Fama_arch%2FHOD00001%2F0000008 6&query1=&recoffset=100&collection_ filter=All&collection_name=House+of+Del egates+Proceedings&init_width=640&sort_ col=date+. Accessed June 3, 2014. 17 American Medical Association. Proceedings of the House of Delegates 26th Clinical Convention, November 26–29, 1972:69–71. http://ama.nmtvault.com/jsp/viewer. jsp?doc_id=House+of+Delegates+Proceedi ngs%2Fama_arch%2FHOD00001%2F0000 0095&query1=&recoffset=100&collection_ filter=All&collection_name=House+of+Del
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19
20 21
22
egates+Proceedings&init_width=640&sort_ col=date+. Accessed June 3, 2014. American Medical Association. Proceedings of the House of Delegates 116th Annual Convention, June 18–22, 1967:41. http://ama. nmtvault.com/jsp/viewer.jsp?doc_id=House +of+Delegates+Proceedings%2Fama_arch% 2FHOD00001%2F00000084&query1=&reco ffset=100&collection_filter=All&collection_ name=House+of+Delegates+Proceedings& init_width=640&sort_col=date+. Accessed June 3, 2014. American Medical Association. Proceedings of the House of Delegates 119th Annual Convention, June 21–25, 1970:338. http:// ama.nmtvault.com/jsp/viewer.jsp?doc_id =House+of+Delegates+Proceedings%2 Fama_arch%2FHOD00001%2F0000009 0&query1=&recoffset=100&collection_ filter=All&collection_name=House+of+Del egates+Proceedings&init_width=640&sort_ col=date+. Accessed June 3, 2014. Rhoads PS. Medical ethics and morals in a new age. JAMA. 1968;205:517–522. Minutes of the American Medical Association’s Committee on Medicine and Religion. February 20, 1970. Located at: Field Service Collection, AMA Historical Archives, Chicago, Ill. Independent Record [Missoula, Mt]. September 9, 1956:20. http://www. newspapers.com/newspage/35759863/. Accessed April 10, 2014.
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The Rashomon Effect: Another View of Medicine, Religion, and the American Medical Association B.J. Crigger, PhD
Abstract What is the story of medicine and religion at the American Medical Association (AMA)? Where did the Department of Medicine and Religion originate? What did the program ac complish? Why was it all but com pletely discontinued after scarcely a decade? The surviving records support more than one interpretation. Exploring the broader organizational context helps tell a richer story. In this issue of Academic Medicine, Daniel Kim and colleagues open a window on a fascinating bit of history: that of the
Editor's Note: This is a Commentary on Kim DT, Curlin FA, Wolenberg KM, and Sulmasy DP. Back to the Future: The AMA and Religion, 1961–1974. Acad Med. 2014;89:1603–1609.
W
hat is the story of medicine and religion at the American Medical Association (AMA)? Where did the Department of Medicine and Religion (DMR) originate? What did the program accomplish? Why was it all but completely discontinued after scarcely a decade? Reconstructing the story of a program from documentary records is always something of an uncertain proposition. Historical documents preserve the sub stance of decisions taken, but are largely silent about the reasoning behind those decisions. Surviving records support more than one interpretation, and relevant information is scattered through multiple record systems, making it difficult to find. Inevitably, historians have to read between the lines. Dr. Crigger is director of ethics policy, American Medical Association, Chicago, Illinois. Correspondence should be addressed to Dr. Crigger, American Medical Association, AMA Plaza, 330 N. Wabash Ave., Chicago, IL 60611-5885; telephone: (312) 464-5223; e-mail: [email protected]. Acad Med. 2014;89:1582–1585. First published online June 20, 2014 doi: 10.1097/ACM.0000000000000371
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AMA’s formal experience with religion and medicine during the 1960s and early 1970s; however, reconstructing the story of a program from documentary records is always something of an uncertain proposition. Equally important is taking account of such factors as the role of the AMA’s House of Delegates in policy making, of state and county medical societies in carrying out program activities, and of the influence of charismatic individuals on decisions regarding programs and activities. Before the medical community decides what
lesson(s) to draw from the story of the AMA’s Department of Medicine and Religion, it should try to understand that story as completely as possible.
Exploring the broader organizational context helps tell a richer story. Before the medical community decides what lesson(s) to draw from the story of the AMA’s DMR, it should try to understand that story as completely as possible.
with that which Kim and colleagues find in other sources. Though Kim et al speculate about why the AMA sought a relationship with clergy, the minutes themselves say nothing about what motivated the Board to seek such a consultation in the first place.
Where Did the Program on Medicine and Religion Originate?
The life of the AMA as an organization revolves around the interplay of gover nance, which comprises the House of Delegates (hereafter, simply the House) and the Board of Trustees (hereafter, simply the Board), and of operations— that is, AMA staff. In the case of the AMA’s formal experience with religion and medicine in the 1960s and early 1970s, governance was the responsibility of the Board’s Committee on Medicine and Religion (CMR) and operations that of the DMR. As a matter of procedure, the program was created by the Board. Formal outreach from the AMA to clergy is first mentioned in the minutes of the September 1961 meeting of the Board, at which its members voted to “approve employment of Dr. Harrison Ray Anderson, Pastor of the Fourth Presbyterian Church of Chicago (retired), as a consultant on church matters.…”1(p35) This information aligns
As Kim et al note, the available materials leave out much that historians might wish to know. Records preserve the substance of decisions taken, but are largely silent about the reasoning behind those decisions. Relevant information is scattered through multiple record systems, making it difficult to find. Inevitably, historians have to read between the lines.
In April 1962, the AMA’s Council on Miscellaneous Activities recommended that the Board adopt a program proposed by the Rev. Dr. Paul McCleave “as outlined, which included establishment of an advisory committee, to be composed of approximately 10 physicians and 10 clergymen.”2(p14) The Board accepted the proposal and promptly appointed an advisory committee, the CMR. The CMR, which held its first organizational meeting in May of that same year, included not only members of the Board but also clergy from across the country, and it was staffed by its eponymous department. The Board informed the House about the new program, directed by the Rev. Dr. McCleave, in its year-end report that November.3 What Did the Program Accomplish?
The primary sources of information about the CMR and DMR are the minutes of the (semiannual?) CMR meetings and the DMR’s (annual)
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reports to the House. Predictably, these documents are positive in tone: The medicine and religion program is accomplishing great things! Such records are informative, and I have no doubt we can trust that the information is accurate, so far as it goes. The question is, Does that information go far enough? Materials (e.g., brochures, manuals) developed by the DMR and retained in separate records can provide some additional insight; however, even with these, the historical data are limited.
into their curricula in some form, and a further four intended to launch offerings in 1968.7(p71) The record does not report, however, what the courses covered, who taught them, or how many students took them. Some 150 seminaries indicated interest in incorporating some training on medicine and religion; 20 agreed to participate in a pilot project with a county medical society, 11 actually launched the pilot, and 7 completed it.13,14 But the pilot seems nowhere described.
How the program defined its focus was somewhat fluid. Its delineated areas shifted from “mental health; hospital chaplaincy; medical, theological, and nursing school curricula; and pastoral clinical training centers” in 1962,3 to state and county medical society programs, medical and nursing school education, theological education, and continuing education for American medical missionaries serving overseas in 1965.4 By 1969, three remained: state and county programs, theological education, and medical education.5
The film The One Who Heals, one of the program’s earliest efforts, was widely distributed through the efforts of, in part, the AMA’s Communications Division. As Kim and colleagues report, it was well received; however, it was also criticized as “too emotional, having no conclusion, [and depicting] too many emergency situations.”8(p6)
The records are silent about any program activities with respect to mental health (however, McCleave6 published individually in this area); education for medical missionaries foundered when publishers did not follow through on promises to provide medical textbooks for the department to send to the field,7,8(p2) and little seems to have come of early contact with professional nursing organizations.8(p4),9 As Kim and colleagues write, AMA records indicate that over time, varying numbers of state medical societies organized medicine and religion committees and sponsored sessions for physicians and clergy.5,7,10 Still, to maintain continued success at the grassroots level, the program had to rely on the state committees, a potentially uncertain proposition.7(p10),11 The records show that medical schools and seminaries were surveyed to ascertain interest in having educational materials on medicine and religion.12(pp12–13) Historical documents indicate that in 1967 eight medical schools offered elective courses, another six incorporated medicine and religion
A program manual for state medical societies and theological seminaries survives. The manual includes brief papers by physicians and clergymen (and the odd lawyer) in each of six topics (e.g., the clergyman’s role in catastrophic illness, privileged communication).15 It offers discussion questions, as well as information on planning and conducting programs and on using the resource materials. But beyond the observation that, as of February 1968, seven states had made use of it,8(p5) the record is silent about how well it was received and how extensively it was used. Kim et al take the records at face value and conclude that the program had “obvious successes” and “was highly impressive in both size and quality.” But what the available information does not reveal is whether the program made a difference—for physicians, clergy, and most important, patients. Did it bring medicine materially closer to treating the whole person? It may have touched many lives deeply, but the record, as it stands, cannot elucidate that. In fairness, I am looking for outcome measures from a program that lived and died in an era that did not yet focus much even on process measures. Yet, even taken on its own terms, discerning whether the program on medicine and religion was a
Academic Medicine, Vol. 89, No. 12 / December 2014
success relative to other AMA activities of its time is not possible. Why Did the Program End?
Kim and colleagues find the Board’s stated fiscal reason for discontinuing the DMR to be unpersuasive and speculate that “the CMR’s demise was due in significant part to the controversial role” the committee played in the “abortion politics” of the AMA. That debate likely did play a role, but to read the record as indicating that the CMR as a body was, in effect, punished for taking a stand against liberalizing AMA policy reads rather too deeply between the lines. Fiscal considerations unquestionably did play a role in the decision. The action was taken as part of a much broader endeavor to address concerns about fiscal responsibility that began with a directive from the House in June 1968.16 That effort included reducing the size of councils and committees (by attrition) and reducing the maximum tenure of service, holding meetings at AMA headquarters in Chicago, reducing the number of council and committee meetings held each year, and minimizing the use of consultants.17 To fully answer the question of whether the CMR’s stance on abortion contributed to its fate, it’s important to have a clear view of the process of policy making in the AMA. Whatever its flaws, the House is a deliberative, democratic body. Simply explained, matters of policy, such as the AMA’s abortion policy, are brought to the House in the form of resolutions and reports. Input on a proposed policy is gathered through a reference committee process in which any interested member of the House may offer testimony; action is then recommended to the House on the basis of testimony heard. The House may adopt a proposed policy, edit it (with certain exceptions), not adopt it, or refer it to the Board either for a decision or further consideration. Controversial matters, such as abortion, often come before the House several times before a final decision is reached. The House amended AMA policy on abortion over a series of meetings between 1965 and 1970. In 1965, on the basis of its review of recent
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developments in state law, the Board’s Committee on Human Reproduction recommended that AMA liberalize its policy to support legislation permitting a physician to terminate a pregnancy when the pregnancy resulted from rape or incest, when continuing the pregnancy might “gravely impair the physical or mental health of the mother,” or when there was “substantial risk” that the child would be born with “grave physical or mental defect.”4(p88) The report was referred back to the Board with instructions to provide further input on the “moral-ethicalspiritual-religious” element of the question, along with “(2) the legal element, (3) the medical element, and (4) the customs, usage, tradition, and orientation of society in each state.”4(p92) Having undertaken the requested consultations, the Board brought a revised report forward in 1967 with substantially the same recommendations. The House adopted the report this time, doing away with a blanket prohibition on abortion that had been policy since 1871.18 In November 1969 a resolution seeking to liberalize policy still further came before the House, at which time the reference committee heard clear opposition to the proposal.5(p312) Six months later, however, the issue came to the House yet again in the form of a Board report and five separate resolutions. In lieu of action on the individual items, the reference committee recommended adoption of a substitute resolution that, in the committee’s own words, “embodie[d] a number of the points made in two of the resolutions before it.”19 At this time (June 1970), the reference committee remarked on the “impressive shift” in testimony from six months prior.19 The House concurred with the committee and adopted the substitute resolution, liberalizing policy still further such that the AMA’s official policy allowed a woman and her physician to make decisions about abortion.19(p339) Members of the CMR may well have disagreed with one another on the matter of abortion; AMA’s archival records are largely silent in this respect. Paul Rhoads, chair of the CMR from 1966 through 1970, seems to have taken a neutral, if not liberal view.
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In an address to the South Carolina Medical Society in 1968, he observed that “almost all the existing state laws regarding abortion are outmoded” in permitting abortion only to save the mother’s life, and that a majority of physicians supported the AMA’s 1967 policy.20 For his part, in 1970 the Rev. Dr. Paul McCleave, director of the DMR, but not a member of the CMR, urged the committee to prepare a statement answering the question “What Is Life?”21(p6) Notably, Rev. Dr. McCleave is last listed as the director of the DMR in the November 1970 Proceedings of the House. I read a different story from the records than do Kim and colleagues. I read a program founded in a lofty vision searching for concrete ways to make that vision real in the world, but not confidently finding them. I read a program that came to an end amid a tangle of organizational dynamics— some logistic (e.g., depending on local chapters to maintain CMR momentum, wrangling with publishers), some fiscal (e.g., reducing the number of Board committees), some philosophical (e.g., deciding on an abortion policy, defining life). But more than anything, I read a program that could not quite recover from the departure of its charismatic founder. If the AMA’s Paul B. McCleave is indeed the same Presbyterian pastor who spoke to the Helena, Montana, Community Chest Kick-Off Dinner in 1956—“one of the most forceful, sincere young speakers in the state” in the words of the local paper22—that seems all the likelier. Lessons Learned
The possibility of illuminating the full reason(s) behind the dissolution of the CMR (and, two years later, the DMR) is slim, if not nonexistent. Realizing that the surviving records support more than one interpretation is vital. Drawing conclusions about what happened to the AMA’s formal religion and medicine program in the early 1970s without further historical information is as irresponsible as making diagnoses without taking a medical history or performing a physical exam.
Acknowledgments: The author extends her thanks to Amber Dushman, senior archivist at the American Medical Association, for her kind assistance in accessing archival materials. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Disclaimer: The views expressed are the author’s own and do not necessarily represent the position of the American Medical Association.
References 1 Minutes of the Board of Trustees of the American Medical Association. September 8– 9, 1961. Located at: Field Service Collection, AMA Historical Archives, Chicago, Ill. 2 Minutes of the Board of Trustees of the American Medical Association. April 6–7, 1962. Located at: Field Service Collection, AMA Historical Archives, Chicago, Ill. 3 American Medical Association. Proceedings of the House of Delegates. Sixteenth Clinical Meeting. November 26–28, 1962:27. http:// ama.nmtvault.com/jsp/viewer.jsp?doc_id =House+of+Delegates+Proceedings%2 Fama_arch%2FHOD00001%2F0000007 3&query1=&recoffset=100&collection_ filter=All&collection_name=House+of+Del egates+Proceedings&init_width=640&sort_ col=date+. Accessed June 3, 2014. 4 American Medical Association. Proceedings of the House of Delegates. 19th Clinical Convention, November 28–December 1, 1965:41. http://ama.nmtvault.com/jsp/viewer. jsp?doc_id=House+of+Delegates+Proceedi ngs%2Fama_arch%2FHOD00001%2F0000 0081&query1=&recoffset=100&collection_ filter=All&collection_name=House+of+Del egates+Proceedings&init_width=640&sort_ col=date+. Accessed June 3, 2014. 5 American Medical Association. Proceedings of the House of Delegates. 23rd Clinical Convention, November 30–December 3, 1969:39. http://ama.nmtvault.com/jsp/ viewer.jsp?doc_id=House+of+Delegates +Proceedings%2Fama_arch%2FHOD000 01%2F00000089&query1=&recoffset=10 0&collection_filter=All&collection_nam e=House+of+Delegates+Proceedings&in it_width=640&sort_col=date+. Accessed June 3, 2014. 6 McCleave PB. The spiritual treatment of the alcoholic by the clergy. Mod Treat. 1966;3. http://silkworth.net/religion_clergy/01063. html. Accessed April 10, 2014. 7 American Medical Association. Proceedings of the House of Delegates. 21st Clinical Convention, November 26–29, 1967:71. http://ama.nmtvault.com/jsp/viewer. jsp?doc_id=House+of+Delegates+Proceedi ngs%2Fama_arch%2FHOD00001%2F0000 0085&query1=&recoffset=100&collection_ filter=All&collection_name=House+of+Del egates+Proceedings&init_width=640&sort_ col=date+. Accessed June 3, 2014. 8 Minutes of the American Medical Association’s Committee on Medicine and Religion. February 23, 1968. Located at: Field Service Collection, AMA Historical Archives, Chicago, Ill.
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Commentary 9 American Medical Association. Proceedings of the House of Delegates. 22nd Clinical Convention, December 1–4, 1968:70. http:// ama.nmtvault.com/jsp/viewer.jsp?doc_id =House+of+Delegates+Proceedings%2 Fama_arch%2FHOD00001%2F0000008 7&query1=&recoffset=100&collection_ filter=All&collection_name=House+of+Del egates+Proceedings&init_width=640&sort_ col=date+. Accessed June 3, 2014. 10 American Medical Association. Proceedings of the House of Delegates 18th Clinical Convention, November 30–December 2, 1964:43. http://ama. nmtvault.com/jsp/viewer.jsp?doc_id= House+of+Delegates+Proceedings% 2Fama_arch%2FHOD00001%2F0000 0077&query1=&recoffset=100&colle ction_filter=All&collection_name=H ouse+of+Delegates+Proceedings&in it_width=640&sort_col=date+. Accessed June 3, 2014. 11 Minutes of the American Medical Association’s Committee on Medicine and Religion. March 17, 1972. Located at: Field Service Collection, AMA Historical Archives, Chicago, Ill. 12 Annual Report of the Field Services Division. 1967. Located at: Field Service Collection, AMA Historical Archives, Chicago, Ill. 13 Program Guide for County Medical Societies. 1969. Located at: Field Service Collection, AMA Historical Archives, Chicago, Ill.
14 American Medical Association. Proceedings of the House of Delegates 24th Clinical Convention, November 29–December 2, 1970:32. http://ama.nmtvault.com/jsp/ viewer.jsp?doc_id=House+of+Delegates +Proceedings%2Fama_arch%2FHOD000 01%2F00000091&query1=&recoffset=10 0&collection_filter=All&collection_nam e=House+of+Delegates+Proceedings&in it_width=640&sort_col=date+. Accessed June 3, 2014. 15 Medicine and Religion Program Resource for County Medical Societies or Program Chairmen. Located at: Field Service Collection, AMA Historical Archives, Chicago, Ill. 16 American Medical Association. Proceedings of the House of Delegates 113th Annual Convention, June 16–20, 1968:158. http:// ama.nmtvault.com/jsp/viewer.jsp?doc_id =House+of+Delegates+Proceedings%2 Fama_arch%2FHOD00001%2F0000008 6&query1=&recoffset=100&collection_ filter=All&collection_name=House+of+Del egates+Proceedings&init_width=640&sort_ col=date+. Accessed June 3, 2014. 17 American Medical Association. Proceedings of the House of Delegates 26th Clinical Convention, November 26–29, 1972:69–71. http://ama.nmtvault.com/jsp/viewer. jsp?doc_id=House+of+Delegates+Proceedi ngs%2Fama_arch%2FHOD00001%2F0000 0095&query1=&recoffset=100&collection_ filter=All&collection_name=House+of+Del
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egates+Proceedings&init_width=640&sort_ col=date+. Accessed June 3, 2014. American Medical Association. Proceedings of the House of Delegates 116th Annual Convention, June 18–22, 1967:41. http://ama. nmtvault.com/jsp/viewer.jsp?doc_id=House +of+Delegates+Proceedings%2Fama_arch% 2FHOD00001%2F00000084&query1=&reco ffset=100&collection_filter=All&collection_ name=House+of+Delegates+Proceedings& init_width=640&sort_col=date+. Accessed June 3, 2014. American Medical Association. Proceedings of the House of Delegates 119th Annual Convention, June 21–25, 1970:338. http:// ama.nmtvault.com/jsp/viewer.jsp?doc_id =House+of+Delegates+Proceedings%2 Fama_arch%2FHOD00001%2F0000009 0&query1=&recoffset=100&collection_ filter=All&collection_name=House+of+Del egates+Proceedings&init_width=640&sort_ col=date+. Accessed June 3, 2014. Rhoads PS. Medical ethics and morals in a new age. JAMA. 1968;205:517–522. Minutes of the American Medical Association’s Committee on Medicine and Religion. February 20, 1970. Located at: Field Service Collection, AMA Historical Archives, Chicago, Ill. Independent Record [Missoula, Mt]. September 9, 1956:20. http://www. newspapers.com/newspage/35759863/. Accessed April 10, 2014.
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