Journal of Religion and Health, Vol. 14, No. 1, 1975
The Minister as Consultant to the Medical Team H A R M O N L. S M I T H Since I come to this topic as neither a parish clergyman nor a hospital chaplain, b u t as a teacher in a university, theological seminary, and medical school and as a sometime consultant to the medical staff in a university medical center, I should probably qualify the remarks I am about to make by t h a t initial confession. ! do not intend, rehearsing these roles, to disqualify myself (though some might!) from addressing the topic, but only to acknowledge that my opinions are influenced by both the particular things I do in relation to a medical staff and the kinds of things some of m y students, who are pastors- and chapplains- and physicians-to-be, reflect in their hospital ministrations. At the outset, it should be reiterated (although this is already well known and acknowledged) t h a t the medical center is almost unique in our society as a place filled with richness and variety in h u m a n dilemmas, a place surfeited with suffering, success, pain, and happiness. From obstetrics wards to intensive care units one can find the full spectrum of h u m a n joy and tragedy, satisfaction and anger, remission and repair, grief and despair. And because hospitals are frequently t h o u g h t , by both some physicians and some patients, to be so thoroughly scientific and clinical, so objective and impersonal, so completely pathologically oriented and antiseptic t h a t decency and order do not allow for even the most r u d i m e n t a r y social amenities or sensitivity to basic h u m a n feelings--because these kinds of thoughts are sometimes e n t e r t a i n e d by a substantial n u m b e r of people, it should be emphasized t h a t medical and surgical problems have definite moral and spiritual (or, as I have s u b s t i t u t e d as a surrogate, h u m a n ) aspects. I might, add that, in m y experience, this is true for staff as well as tbr patients. If the primary ~bcus of the physician is upon diagnosis and t r e a t m e n t of a pathologic condition, the focus of pastors and chaplains is customarily upon the personal and interpersonal dynamics t h a t are elicited by what is h a p p e n i n g to or with patients. T h e focus of clergymen has come to be with patients r a t h e r t h a n with staff, I think, for a variety of reasons. Among t h e m are these: T h e practice of medicine, particularly in the medical center, is widely t h o u g h t by physicians The Rev. Harmon L. Smith, Ph.D., a priest in the Episcopal Church, is Professor of Moral Theology in the Divinity School and Professor of Community Health Sciences in the Medical School of Duke University. He has published books and articles on medicine and ethics, frequently lectures at other universities and medical schools, and is regional editor for the United States of the journal Science, Medicine and Man. 7
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Journal o[ Religion and Health
themselves to be a "closed shop"; what is sometimes called the "white-coat mystique" serves, on hospital turf, to remind everybody (including clergymen) of a hierarchy of functional importance. It is not altogether unexpected, therefore, that many clergymen (except, perhaps, chaplains, who themselves wear white coats!) would feel a definite professional inferiority in relation to staff. Whether that feeling is an accurate reading of staff intention (or more or less deserved!) is functionally irrelevant if one understands the ways in which behavior is an expression of perception, the ways in which action is an indication of awareness. Finally (in this inexhaustive list) I am told by physicians that past experiences with the sometimes damaging ineptitude of pastors makes them (the physicians) reluctant or indifferent or opposed to seeking out the advice and assistance of' clergymen. On the other side, ministers sometimes think (in very repressed and subliminal ways, to be sure) that scientists are usurpers of a position and prominence and expertise that used to be theirs; that medical centers are the modern equivalent of medieval cathedrals; and that costumed staff are the vested clergy of a new religion. To the extent that this is so, ministers are understandably deferential toward the new priesthood, especially when they are encountered within the temple! That sense of inferiority, I am glad to say, is fast disappearing: Theological education (except in the Jewish and Roman Catholic traditions) has until recently tended to neglect the preparation of parish clergy for the demands of hospital ministry. In that vacuum, Protestant pastors in particular have quite r plainly had no professional identity or competence in the hospital setting. That also, I am happy to observe, is a deficiency that is rapidly being remedied; and increasingly sensitive and sophisticated professional and postgraduate programs in clinical pastoral education are more and more prominent in seminaries and hospitals throughout the country. Now that some stability is being achieved in minister-patient relationships, I would expect some increasing attention to be paid to the relationship between minister and medical staff; and that brings me to the subject of this brief essay. I have already indicated, perhaps only tacitly, that the minister relates as consultant to the medical team in two primary and discrete ways: as a pastor concerned with the personal and interpersonal dynamics of patient care and as a counselor concerned with staff decisions that are made on behalf or in the interest of particular patients. Since my own relations with medical staff focus mainly in the latter function, some reflections on the former function by Chaplains John Swift and Edwin Heathcock, who were interns at the Duke Medical Center a few years ago, will be instructive. What these two men have to say in these excerpts may not be reflected in the experience of all ministers who undertake visitation of hospitalized parishioners; but many (if not most) trained and practicing hospital chaplains will probably agree with Chaplains Swift and Heathcock in their description of some of the assumptions that underlie the work done in hospitals by chaplains: "First, the most basic assumption is that there is an integral place in the hospital setting for the chaplain [because]... all people are religious. Some, who
The M i n i s t e r as Consultant to the M e d i c a l T e a m
9
claim to be atheistic or agnostic, may curdle a little at the idea that everyone is religious, but [ t h a t ] . . . comes from a narrow understanding of what is 'religious.' Religion is an ultimate concern about the meaning of life and e x i s t e n c e . . , and all people are actively involved with questions of meaning. In the hospital setting where physical and emotional illness is treated, where life and death often hang in a balance, where illness may cause basic changes in life styles, where relationships are temporarily or permanently altered, the questions of meaning are greatly intensified. It is in this context t h a t . . , the chaplain who is trained to think in religious categories . . . . to deal with questions of meaning, has a unique position and is an integral part of the approach to whole persons. This is not a paramedical position, where the chaplain exists only to fill gaps of medical treatment, but rather a full, professional discipline in its own unique contributions to the enriching and healing of human life . . . . "A second assumption . . . is that distinctly religious questions do not have to be verbalized in traditional religious vocabularies . . . less than one-third of the people we see are comfortable using religious language . . . [and the distance between us narrows when the patient stops pulling] out the phrases and words which he thinks will satisfy our need to talk religiously... [and] talks about what he is living with. This is not to say that the chaplain avoids 'God-talk,' for a person's religious beliefs often reveal the way he views his own life; [and] the manner in which a person arranges his symbols of' God is a clue to the way he organizes his whole life. "A third assumption is that the way a person arranges his symbols of G o d . . . can be either healthy or unhealthy." At this point, Chaplains Swift and Heathcock present a rather long catalogue of ways by which this judgment can be made. Two or three of their points will suffice as illustrative of what they mean: "(1) Healthy religion builds bridges, rather than barriers, between persons; (2) Healthy religion strengthens a basic sense of trust and relatedness to the universe; (3) Healthy religion stimulates the growth of inner freedom and personal responsibility... [and] provides effective means of helping people move from a sense of guilt to forgiveness; (4) Healthy religion does not accommodate itself to the neurotic patterns of our society, b u t . . , strengthens self-esteem and emphasizes the goodness and acceptability of life. "A fourth assumption is that the ~haplain meets people in both a relational [or tacit] way and a cognitive way. The relational aspect of the meeting is to be with, to share with, the patients as they face their particular dilemma. The cognitive aspect of the meeting is to help a patient make some sort of sense out of the situation by providing symbols in which to express the understanding." Perhaps death is one of the clearest instances of what is being got at here: Seldom is a psychiatrist called to be with a bereaved family, but the chaplain is usually called--perhaps because grief is not pathological (though it may become that) but, in the first immediacy, an honorable human emotion that needs to be expressed. "A fifth assumption with which the chaplain operates is that his principal implement is his own being, his own person, with his willingness and skill to
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Journal of Religion and Health
c o m m u n i c a t e with the patient. We have nothing m a g i c a l . . , a l t h o u g h there are t i m e s when we wish we did . . . [we] do have some secondary tools which m a y e n h a n c e the healing process a n d mobilize the built-in forces which m o v e toward h e a l t h (e.g., prayer, scripture, a n d s a c r a m e n t s ) a n d these can be quite i m p o r t a n t when t h e y e n c o m p a s s the full scope of the p a t i e n t ' s situation a n d feelings. " A sixth a s s u m p t i o n is t h a t there are professional decisions which have to be m a d e in the relationship with a p a t i e n t . T h e s e are decisions a b o u t the p a t i e n t ' s a c c e p t a n c e of u s - - w h e t h e r the chaplain is stereotyped, whether t h a t stereotype is positive or negative, whether there is an openness to a helping relationship. " A s e v e n t h a s s u m p t i o n is t h a t the chaplain has power which is s o m e t i m e s awesome. Some p a t i e n t s see us as wise men, or prophets, or advice-givers; some others ascribe s u p e r n a t u r a l knowledge to us. S o m e see us as h a v i n g an 'in' with God a n d thus able to m a n i p u l a t e the Deity in certain ways; some see us as i n t e r m e d i a r i e s between God and M a n ; a n d some see us as the personification of all the horrible experiences t h e y ' v e h a d with ministers a n d churches. We are u n c o m f o r t a b l e with power vested in us because of some s u p p o s e d special connection with God, b u t c o m f o r t a b l e with the power which arises out of realistic recognition t h a t we s t a n d in a caring tradition, a n d therefore will take people seriously." * N o w t h a t is not an exhaustive s t a t e m e n t , nor do I t h i n k C h a p l a i n s Swift and H e a t h c o c k i n t e n d e d it to be; b u t it is indicative of a range of concerns t h a t pastors have with p a t i e n t s who are in hospital, s o m e t i m e s having strange a n d bizarre things done for and to t h e m . And in the measure to which somatic health is related to the whole p e r s o n - - t o psyche, a n d u n d e r s t a n d i n g ; to fears, and .anxieties; to hopes and a s p i r a t i o n s - - t o the extent t h a t s o m a t i c health is related to whole persons, a n d not merely to the specific pathology t h a t is the i m m e d i a t e occasion for their hospitalization, the minister relates to the medical staff as a m e m b e r of the healing t e a m . T h e other p r i m a r y and discrete way in which the minister relates to medical staff is, as I indicated earlier, as a counselor who is concerned with the staff a b o u t decisions m a d e on behalf or in the interest of p a r t i c u l a r patients. Because of intensive s t u d y of theology, ethics, philosophy, psychology, a n d other disciplines, the minister ought to be able to give informed a n d discriminating professional opinions on ethical questions and m o r a l decisions. In addition, though p e r h a p s less i m p o r t a n t l y except in special cases, a pastor ought also to be able to indicate the formal position (if there is one) of a church, or different churches, on p a r t i c u l a r questions of m e d i c a l practice. I have found, over the p a s t 12 years, t h a t the theological ethicist's role as counselor to m e d i c a l staff occurs in b o t h formal and informal a r r a n g e m e n t s . On occasion I have been t e l e p h o n e d by a physician w h o m I did not know personally and asked for m y opinion a b o u t a case; more often the informal consultations * The foregoing excerpts are taken from a seminar presentation by John Swift, Chaplain of the Toronto (Canada) General Hospital, and Edwin Heathcock, now in the Department of Pastoral Care and Education, Southwest Texas Methodist Hospital, San Antonio, during their chaplaincy internships at Duke Medical Center. I wish to express my appreciation to both of them.
The Minister as Consultant to the Medical Team
11
have been with friends who telephone or stop me in the hospital corridor. In these situations, which I call "informal," the moral gravity of the conversation is serious but not alarming or critical. As often as not, these are "curiosity pieces." Perhaps one example will suffice. A few years ago a friend who is a pediatric psychiatrist described a 12-year-old patient who was admitted with contractures of both hips and knees, was incontinent of both feces and urine, and had developed a large decubitus over one hip. He had a normal myelogram and none of the physical findings usually seen in children his age with acute leukemia. Despite radiation treatment to the spine and several weeks of steroid therapy, no change was produced in the boy's physical status except for some improvement in bone marrow. His contractures were removed through nursing care and physical therapy, but nothing altered the progressive enlargement of the decubitus, which became periodically infected. His emotional status deteriorated to the point where he required sedation in order to tolerate starting I.V.'s. A week or so following his admission it was learned that the boy's mother was a "root doctor" and that she had "put a hex on him when she got mad at him" some weeks prior to admission. Now certain questions returned, in view of the boy's condition and negative tests for lead or other metal poisoning: Could there be, despite the absence of physical and laboratory pathology findings, any positive correlation between the boy's condition and the hex put on him by his mother? Is there precedent for such a correlation among certain religious groups? What is the relation between psyche and soma in a case like this? Considering the boy's deteriorating psychological condition, could he tolerate the psychic trauma attendant to surgery on his hip? When I checked on the boy through another friend, a pediatric hematologist, a couple of weeks later I was told that the boy had been operated on, the hip explored, and debridement accomplished with removal of the right femoral head; that the patient had tolerated the procedure well, but was little improved, although his hematologic and neurologic status were stable; that a diverting colostomy was being considered to obtain improved bowel function and avoid further fecal contamination of the decubitus ulcers; and that continuing laboratory studies were being done in the hope of making a diagnosis. So far as I know, my earlier conversation with the pediatric psychiatrist was inconsequential in the management of this boy's case; but since I d o n o t k n o w , I tend not to treat these "informal" conversations frivolously! The more formal consultations ordinarily occur in committees or with the chaplain acting as an adjunct member of the medical team itself. In this context, where the decisions taken have less to do with the discrete management of a particular patient than with protocols and procedures that will likely affect an entire class of patients, the role of the theological consultant is twofold: to participate in discussion of the morally problematic features of the decision, and to vote. The former, I think, is almost always easier than the latter--not because I a m fundamentally indecisive (like the fellow who, when asked, "Do you have trouble making decisions?" answered, "Well, yes and no"!) but because I know the tendency in some quarters to regard decisive judgments as definitive, to think
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that making some particular choice in this moment obligates one to make the same choice at some future moment. Voting on a specific program or proposal would be immeasurably easier if it were not widely attended by the naive and spurious notion that one's ability to be decisive is de facto evidence of his willingness to be definitive. Making that point might itself be worth the time and energy otherwise required by participation in committees! I was once, for example, on a committee that was asked to review a proposal for bilateral lung lavage involving experimental human subjects. After the data from successful animal experimentation were before us, the crucial question was whether this experiment should be allowed with human subjects. Despite the fact th at volunteers were ready to submit themselves to this experiment, I felt obliged to question whether there were some limits beyond which (if it were in our power to prevent it) we should not allow experimental subjects to submit themselves, and whether this was one of those situations in which the potential risks so far outweighed the potential benefits as to warrant prohibition of the procedure, at least for the present. In that context, I wanted to think myself (and get the committee to think) about whether there are any boundaries in the use of human experimental subjects that we presently ought not cross. Putting the question that way was meant to ask only about doing this e x p e r i m e n t now. If that strikes you as a mere semanticism, or a crawfish sidestepping of the issue, I would only remind you that the history of science and medicine is replete with tragic experiments that were undertaken before their time had come. And to say this is not to question the heroism of those whose lives were sacrificed in these experiments or to question the vision of those who proposed and conducted them; it is to question a much more basic human attribute, and that is the "wisdom" that informed these premature ventures. Beyond this, there is a widely agreed-upon professional proposition holding that experiments ought to be conducted under a protocol that insures the maximum possible addition to scientific knowledge. On both counts--the lack of humane w ~ [ ~ and of maximum possible addition to scientific knowledge--I thought the proposal failed to warrant approval. Medical literature contains a growing number of articles on ethics, which doubtless complement the codes of ethics that have been adopted by both national and international bodies. But these are not standard fare for medical students; neither are they much in evidence in professional meetings. Even if they were given the widest possible circulation and acquaintance they would still not suffice to resolve the moral dilemmas generated by galloping scientific research and a therapeutic technology that makes today's extraordinary procedures tomorrow's customary medical practice. Unless these codes and guidelines and memoranda are constantly examined and reflected upon in their application, and thus opened to further revisions and formulations in the light of new experience and technology, they will function (as I fear they commonly do) as an interesting artifact with little conscious bearing on the life-and-death questions of medical practice. So the second discrete function, as I see it, is simply to assist
The Minister as Consultant to the Medical Team
13
the medical team to be ethicists--to help them see that asking questions about justice, charity, wisdom, and temperature (Plato's "four cardinal virtues") assists them in pushing forward the meaning of the practice of their vocation as physicians. I would not venture to describe these things (much less advocate them!) if they were not already happening or if my experience with both physicians and clergymen did not confirm the view that interdisciplinary and interprofession~l colleagueship is both increasingly necessary and increasingly possible. I have argued in another context that, among many reasons for this, two stand out as especially prominent. The acquisition and accumulation of knowledge is occurring at such an accelerated rate that it is difficult, if not impossible, for a single discipline any longer to assimilate and apply its expertise responsibly to the full range of human affairs affected by it. The biological analogy may be that of neurologic overload. The second reason may be less obvious, but I think no less valid: unlike earlier times when, in a struggle for their very existence, science and technology seemed often to be regarded by friend and foe alike as ends in themselves, ! detect now a rather remarkable moral sensitivity among many scientists and technologists (and physicians) for the ends to which their knowledge and skills may be put. Concurrently, I sense a new kind of openness toward other disciplines and professions--an openness that not only tolerates well, but also actively solicits, mutuality and collaboration in matters of common human concern. The dominant attitude in Western culture, and therefore in Western medicine, has been a denial of tragedy; we have looked instead to the expansion and explosion of knowledge and technology to give us progressive control and mastery of the world, and we have supposed that there is no mystery that defies an adequate and human resolution. In the measure to which this is so, we have undermined and repressed the human capacity for experiencing and affirming the tragic vision, or meaninglessness, or essential "conflictedness." Our vision is now bifocal; there is no single way to look at things; and no one answer can ever again be unambiguously sustained. The struggle for mastery must be accompanied by an awareness of tragedy, an acknowledgment of the mystery of the reality of overwhelming human suffering; and that, I suppose, is precisely the place where ethical theory and moral practice most clearly employ and express the meaning of grace as this was developed in biblical theism and the Judaeo-Christian tradition: Grace, in this context, is the capacity to act decisively without the self-justifying choices we would like to have had. This is a strange way of tasking, I know, in a technocracy; but unless we can discriminate between choosing decisively and choosing definitively, we have already abdicated the moral struggle and an important dimension of what it means to be men and women and not gods.
The Minister as Consultant to the Medical Team H A R M O N L. S M I T H Since I come to this topic as neither a parish clergyman nor a hospital chaplain, b u t as a teacher in a university, theological seminary, and medical school and as a sometime consultant to the medical staff in a university medical center, I should probably qualify the remarks I am about to make by t h a t initial confession. ! do not intend, rehearsing these roles, to disqualify myself (though some might!) from addressing the topic, but only to acknowledge that my opinions are influenced by both the particular things I do in relation to a medical staff and the kinds of things some of m y students, who are pastors- and chapplains- and physicians-to-be, reflect in their hospital ministrations. At the outset, it should be reiterated (although this is already well known and acknowledged) t h a t the medical center is almost unique in our society as a place filled with richness and variety in h u m a n dilemmas, a place surfeited with suffering, success, pain, and happiness. From obstetrics wards to intensive care units one can find the full spectrum of h u m a n joy and tragedy, satisfaction and anger, remission and repair, grief and despair. And because hospitals are frequently t h o u g h t , by both some physicians and some patients, to be so thoroughly scientific and clinical, so objective and impersonal, so completely pathologically oriented and antiseptic t h a t decency and order do not allow for even the most r u d i m e n t a r y social amenities or sensitivity to basic h u m a n feelings--because these kinds of thoughts are sometimes e n t e r t a i n e d by a substantial n u m b e r of people, it should be emphasized t h a t medical and surgical problems have definite moral and spiritual (or, as I have s u b s t i t u t e d as a surrogate, h u m a n ) aspects. I might, add that, in m y experience, this is true for staff as well as tbr patients. If the primary ~bcus of the physician is upon diagnosis and t r e a t m e n t of a pathologic condition, the focus of pastors and chaplains is customarily upon the personal and interpersonal dynamics t h a t are elicited by what is h a p p e n i n g to or with patients. T h e focus of clergymen has come to be with patients r a t h e r t h a n with staff, I think, for a variety of reasons. Among t h e m are these: T h e practice of medicine, particularly in the medical center, is widely t h o u g h t by physicians The Rev. Harmon L. Smith, Ph.D., a priest in the Episcopal Church, is Professor of Moral Theology in the Divinity School and Professor of Community Health Sciences in the Medical School of Duke University. He has published books and articles on medicine and ethics, frequently lectures at other universities and medical schools, and is regional editor for the United States of the journal Science, Medicine and Man. 7
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Journal o[ Religion and Health
themselves to be a "closed shop"; what is sometimes called the "white-coat mystique" serves, on hospital turf, to remind everybody (including clergymen) of a hierarchy of functional importance. It is not altogether unexpected, therefore, that many clergymen (except, perhaps, chaplains, who themselves wear white coats!) would feel a definite professional inferiority in relation to staff. Whether that feeling is an accurate reading of staff intention (or more or less deserved!) is functionally irrelevant if one understands the ways in which behavior is an expression of perception, the ways in which action is an indication of awareness. Finally (in this inexhaustive list) I am told by physicians that past experiences with the sometimes damaging ineptitude of pastors makes them (the physicians) reluctant or indifferent or opposed to seeking out the advice and assistance of' clergymen. On the other side, ministers sometimes think (in very repressed and subliminal ways, to be sure) that scientists are usurpers of a position and prominence and expertise that used to be theirs; that medical centers are the modern equivalent of medieval cathedrals; and that costumed staff are the vested clergy of a new religion. To the extent that this is so, ministers are understandably deferential toward the new priesthood, especially when they are encountered within the temple! That sense of inferiority, I am glad to say, is fast disappearing: Theological education (except in the Jewish and Roman Catholic traditions) has until recently tended to neglect the preparation of parish clergy for the demands of hospital ministry. In that vacuum, Protestant pastors in particular have quite r plainly had no professional identity or competence in the hospital setting. That also, I am happy to observe, is a deficiency that is rapidly being remedied; and increasingly sensitive and sophisticated professional and postgraduate programs in clinical pastoral education are more and more prominent in seminaries and hospitals throughout the country. Now that some stability is being achieved in minister-patient relationships, I would expect some increasing attention to be paid to the relationship between minister and medical staff; and that brings me to the subject of this brief essay. I have already indicated, perhaps only tacitly, that the minister relates as consultant to the medical team in two primary and discrete ways: as a pastor concerned with the personal and interpersonal dynamics of patient care and as a counselor concerned with staff decisions that are made on behalf or in the interest of particular patients. Since my own relations with medical staff focus mainly in the latter function, some reflections on the former function by Chaplains John Swift and Edwin Heathcock, who were interns at the Duke Medical Center a few years ago, will be instructive. What these two men have to say in these excerpts may not be reflected in the experience of all ministers who undertake visitation of hospitalized parishioners; but many (if not most) trained and practicing hospital chaplains will probably agree with Chaplains Swift and Heathcock in their description of some of the assumptions that underlie the work done in hospitals by chaplains: "First, the most basic assumption is that there is an integral place in the hospital setting for the chaplain [because]... all people are religious. Some, who
The M i n i s t e r as Consultant to the M e d i c a l T e a m
9
claim to be atheistic or agnostic, may curdle a little at the idea that everyone is religious, but [ t h a t ] . . . comes from a narrow understanding of what is 'religious.' Religion is an ultimate concern about the meaning of life and e x i s t e n c e . . , and all people are actively involved with questions of meaning. In the hospital setting where physical and emotional illness is treated, where life and death often hang in a balance, where illness may cause basic changes in life styles, where relationships are temporarily or permanently altered, the questions of meaning are greatly intensified. It is in this context t h a t . . , the chaplain who is trained to think in religious categories . . . . to deal with questions of meaning, has a unique position and is an integral part of the approach to whole persons. This is not a paramedical position, where the chaplain exists only to fill gaps of medical treatment, but rather a full, professional discipline in its own unique contributions to the enriching and healing of human life . . . . "A second assumption . . . is that distinctly religious questions do not have to be verbalized in traditional religious vocabularies . . . less than one-third of the people we see are comfortable using religious language . . . [and the distance between us narrows when the patient stops pulling] out the phrases and words which he thinks will satisfy our need to talk religiously... [and] talks about what he is living with. This is not to say that the chaplain avoids 'God-talk,' for a person's religious beliefs often reveal the way he views his own life; [and] the manner in which a person arranges his symbols of' God is a clue to the way he organizes his whole life. "A third assumption is that the way a person arranges his symbols of G o d . . . can be either healthy or unhealthy." At this point, Chaplains Swift and Heathcock present a rather long catalogue of ways by which this judgment can be made. Two or three of their points will suffice as illustrative of what they mean: "(1) Healthy religion builds bridges, rather than barriers, between persons; (2) Healthy religion strengthens a basic sense of trust and relatedness to the universe; (3) Healthy religion stimulates the growth of inner freedom and personal responsibility... [and] provides effective means of helping people move from a sense of guilt to forgiveness; (4) Healthy religion does not accommodate itself to the neurotic patterns of our society, b u t . . , strengthens self-esteem and emphasizes the goodness and acceptability of life. "A fourth assumption is that the ~haplain meets people in both a relational [or tacit] way and a cognitive way. The relational aspect of the meeting is to be with, to share with, the patients as they face their particular dilemma. The cognitive aspect of the meeting is to help a patient make some sort of sense out of the situation by providing symbols in which to express the understanding." Perhaps death is one of the clearest instances of what is being got at here: Seldom is a psychiatrist called to be with a bereaved family, but the chaplain is usually called--perhaps because grief is not pathological (though it may become that) but, in the first immediacy, an honorable human emotion that needs to be expressed. "A fifth assumption with which the chaplain operates is that his principal implement is his own being, his own person, with his willingness and skill to
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Journal of Religion and Health
c o m m u n i c a t e with the patient. We have nothing m a g i c a l . . , a l t h o u g h there are t i m e s when we wish we did . . . [we] do have some secondary tools which m a y e n h a n c e the healing process a n d mobilize the built-in forces which m o v e toward h e a l t h (e.g., prayer, scripture, a n d s a c r a m e n t s ) a n d these can be quite i m p o r t a n t when t h e y e n c o m p a s s the full scope of the p a t i e n t ' s situation a n d feelings. " A sixth a s s u m p t i o n is t h a t there are professional decisions which have to be m a d e in the relationship with a p a t i e n t . T h e s e are decisions a b o u t the p a t i e n t ' s a c c e p t a n c e of u s - - w h e t h e r the chaplain is stereotyped, whether t h a t stereotype is positive or negative, whether there is an openness to a helping relationship. " A s e v e n t h a s s u m p t i o n is t h a t the chaplain has power which is s o m e t i m e s awesome. Some p a t i e n t s see us as wise men, or prophets, or advice-givers; some others ascribe s u p e r n a t u r a l knowledge to us. S o m e see us as h a v i n g an 'in' with God a n d thus able to m a n i p u l a t e the Deity in certain ways; some see us as i n t e r m e d i a r i e s between God and M a n ; a n d some see us as the personification of all the horrible experiences t h e y ' v e h a d with ministers a n d churches. We are u n c o m f o r t a b l e with power vested in us because of some s u p p o s e d special connection with God, b u t c o m f o r t a b l e with the power which arises out of realistic recognition t h a t we s t a n d in a caring tradition, a n d therefore will take people seriously." * N o w t h a t is not an exhaustive s t a t e m e n t , nor do I t h i n k C h a p l a i n s Swift and H e a t h c o c k i n t e n d e d it to be; b u t it is indicative of a range of concerns t h a t pastors have with p a t i e n t s who are in hospital, s o m e t i m e s having strange a n d bizarre things done for and to t h e m . And in the measure to which somatic health is related to the whole p e r s o n - - t o psyche, a n d u n d e r s t a n d i n g ; to fears, and .anxieties; to hopes and a s p i r a t i o n s - - t o the extent t h a t s o m a t i c health is related to whole persons, a n d not merely to the specific pathology t h a t is the i m m e d i a t e occasion for their hospitalization, the minister relates to the medical staff as a m e m b e r of the healing t e a m . T h e other p r i m a r y and discrete way in which the minister relates to medical staff is, as I indicated earlier, as a counselor who is concerned with the staff a b o u t decisions m a d e on behalf or in the interest of p a r t i c u l a r patients. Because of intensive s t u d y of theology, ethics, philosophy, psychology, a n d other disciplines, the minister ought to be able to give informed a n d discriminating professional opinions on ethical questions and m o r a l decisions. In addition, though p e r h a p s less i m p o r t a n t l y except in special cases, a pastor ought also to be able to indicate the formal position (if there is one) of a church, or different churches, on p a r t i c u l a r questions of m e d i c a l practice. I have found, over the p a s t 12 years, t h a t the theological ethicist's role as counselor to m e d i c a l staff occurs in b o t h formal and informal a r r a n g e m e n t s . On occasion I have been t e l e p h o n e d by a physician w h o m I did not know personally and asked for m y opinion a b o u t a case; more often the informal consultations * The foregoing excerpts are taken from a seminar presentation by John Swift, Chaplain of the Toronto (Canada) General Hospital, and Edwin Heathcock, now in the Department of Pastoral Care and Education, Southwest Texas Methodist Hospital, San Antonio, during their chaplaincy internships at Duke Medical Center. I wish to express my appreciation to both of them.
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have been with friends who telephone or stop me in the hospital corridor. In these situations, which I call "informal," the moral gravity of the conversation is serious but not alarming or critical. As often as not, these are "curiosity pieces." Perhaps one example will suffice. A few years ago a friend who is a pediatric psychiatrist described a 12-year-old patient who was admitted with contractures of both hips and knees, was incontinent of both feces and urine, and had developed a large decubitus over one hip. He had a normal myelogram and none of the physical findings usually seen in children his age with acute leukemia. Despite radiation treatment to the spine and several weeks of steroid therapy, no change was produced in the boy's physical status except for some improvement in bone marrow. His contractures were removed through nursing care and physical therapy, but nothing altered the progressive enlargement of the decubitus, which became periodically infected. His emotional status deteriorated to the point where he required sedation in order to tolerate starting I.V.'s. A week or so following his admission it was learned that the boy's mother was a "root doctor" and that she had "put a hex on him when she got mad at him" some weeks prior to admission. Now certain questions returned, in view of the boy's condition and negative tests for lead or other metal poisoning: Could there be, despite the absence of physical and laboratory pathology findings, any positive correlation between the boy's condition and the hex put on him by his mother? Is there precedent for such a correlation among certain religious groups? What is the relation between psyche and soma in a case like this? Considering the boy's deteriorating psychological condition, could he tolerate the psychic trauma attendant to surgery on his hip? When I checked on the boy through another friend, a pediatric hematologist, a couple of weeks later I was told that the boy had been operated on, the hip explored, and debridement accomplished with removal of the right femoral head; that the patient had tolerated the procedure well, but was little improved, although his hematologic and neurologic status were stable; that a diverting colostomy was being considered to obtain improved bowel function and avoid further fecal contamination of the decubitus ulcers; and that continuing laboratory studies were being done in the hope of making a diagnosis. So far as I know, my earlier conversation with the pediatric psychiatrist was inconsequential in the management of this boy's case; but since I d o n o t k n o w , I tend not to treat these "informal" conversations frivolously! The more formal consultations ordinarily occur in committees or with the chaplain acting as an adjunct member of the medical team itself. In this context, where the decisions taken have less to do with the discrete management of a particular patient than with protocols and procedures that will likely affect an entire class of patients, the role of the theological consultant is twofold: to participate in discussion of the morally problematic features of the decision, and to vote. The former, I think, is almost always easier than the latter--not because I a m fundamentally indecisive (like the fellow who, when asked, "Do you have trouble making decisions?" answered, "Well, yes and no"!) but because I know the tendency in some quarters to regard decisive judgments as definitive, to think
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Journal o[ Religion and Health
that making some particular choice in this moment obligates one to make the same choice at some future moment. Voting on a specific program or proposal would be immeasurably easier if it were not widely attended by the naive and spurious notion that one's ability to be decisive is de facto evidence of his willingness to be definitive. Making that point might itself be worth the time and energy otherwise required by participation in committees! I was once, for example, on a committee that was asked to review a proposal for bilateral lung lavage involving experimental human subjects. After the data from successful animal experimentation were before us, the crucial question was whether this experiment should be allowed with human subjects. Despite the fact th at volunteers were ready to submit themselves to this experiment, I felt obliged to question whether there were some limits beyond which (if it were in our power to prevent it) we should not allow experimental subjects to submit themselves, and whether this was one of those situations in which the potential risks so far outweighed the potential benefits as to warrant prohibition of the procedure, at least for the present. In that context, I wanted to think myself (and get the committee to think) about whether there are any boundaries in the use of human experimental subjects that we presently ought not cross. Putting the question that way was meant to ask only about doing this e x p e r i m e n t now. If that strikes you as a mere semanticism, or a crawfish sidestepping of the issue, I would only remind you that the history of science and medicine is replete with tragic experiments that were undertaken before their time had come. And to say this is not to question the heroism of those whose lives were sacrificed in these experiments or to question the vision of those who proposed and conducted them; it is to question a much more basic human attribute, and that is the "wisdom" that informed these premature ventures. Beyond this, there is a widely agreed-upon professional proposition holding that experiments ought to be conducted under a protocol that insures the maximum possible addition to scientific knowledge. On both counts--the lack of humane w ~ [ ~ and of maximum possible addition to scientific knowledge--I thought the proposal failed to warrant approval. Medical literature contains a growing number of articles on ethics, which doubtless complement the codes of ethics that have been adopted by both national and international bodies. But these are not standard fare for medical students; neither are they much in evidence in professional meetings. Even if they were given the widest possible circulation and acquaintance they would still not suffice to resolve the moral dilemmas generated by galloping scientific research and a therapeutic technology that makes today's extraordinary procedures tomorrow's customary medical practice. Unless these codes and guidelines and memoranda are constantly examined and reflected upon in their application, and thus opened to further revisions and formulations in the light of new experience and technology, they will function (as I fear they commonly do) as an interesting artifact with little conscious bearing on the life-and-death questions of medical practice. So the second discrete function, as I see it, is simply to assist
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the medical team to be ethicists--to help them see that asking questions about justice, charity, wisdom, and temperature (Plato's "four cardinal virtues") assists them in pushing forward the meaning of the practice of their vocation as physicians. I would not venture to describe these things (much less advocate them!) if they were not already happening or if my experience with both physicians and clergymen did not confirm the view that interdisciplinary and interprofession~l colleagueship is both increasingly necessary and increasingly possible. I have argued in another context that, among many reasons for this, two stand out as especially prominent. The acquisition and accumulation of knowledge is occurring at such an accelerated rate that it is difficult, if not impossible, for a single discipline any longer to assimilate and apply its expertise responsibly to the full range of human affairs affected by it. The biological analogy may be that of neurologic overload. The second reason may be less obvious, but I think no less valid: unlike earlier times when, in a struggle for their very existence, science and technology seemed often to be regarded by friend and foe alike as ends in themselves, ! detect now a rather remarkable moral sensitivity among many scientists and technologists (and physicians) for the ends to which their knowledge and skills may be put. Concurrently, I sense a new kind of openness toward other disciplines and professions--an openness that not only tolerates well, but also actively solicits, mutuality and collaboration in matters of common human concern. The dominant attitude in Western culture, and therefore in Western medicine, has been a denial of tragedy; we have looked instead to the expansion and explosion of knowledge and technology to give us progressive control and mastery of the world, and we have supposed that there is no mystery that defies an adequate and human resolution. In the measure to which this is so, we have undermined and repressed the human capacity for experiencing and affirming the tragic vision, or meaninglessness, or essential "conflictedness." Our vision is now bifocal; there is no single way to look at things; and no one answer can ever again be unambiguously sustained. The struggle for mastery must be accompanied by an awareness of tragedy, an acknowledgment of the mystery of the reality of overwhelming human suffering; and that, I suppose, is precisely the place where ethical theory and moral practice most clearly employ and express the meaning of grace as this was developed in biblical theism and the Judaeo-Christian tradition: Grace, in this context, is the capacity to act decisively without the self-justifying choices we would like to have had. This is a strange way of tasking, I know, in a technocracy; but unless we can discriminate between choosing decisively and choosing definitively, we have already abdicated the moral struggle and an important dimension of what it means to be men and women and not gods.
