10

Sacred Space and the Prophetic Voice

of the Hospital Chaplain

Margaret Mohrmann

Ottawa, April 11, 2013

I count myself quite fortunate in my career in medicine and in bioethics to have had, every step of the way, consistent, fruitful, and enlightening relationships with people who provided spiritual care for patients and, not incidentally, for me—especially hospital chaplains, but also certain Child Life specialists, social workers, art therapists, many others. They taught me, from my earliest days in medicine, how essential it is that persons whose primary focus is attention to the spiritual needs and struggles of patients and families—and their clinicians—be widely and abundantly available in hospitals. My experience with these remarkable mentors, seeing the world of the hospital and the experience of my patients through their eyes, has unquestionably framed the way I understand the ethics of medical care, my own career, and, for that matter, my own spiritual life.

So, as you may imagine, when some years ago the Hastings Center (the bioethics think tank in New York) asked me to participate in a task force meeting to discuss ethical issues involved in the move toward “professionalization” of hospital chaplaincy, I jumped at the chance—and found myself immersed in quite an interesting topic. One result of my participation in that meeting was an essay I wrote for the Hastings Center Report about ways of thinking about the ethical grounding of a profession of hospital chaplaincy.

In that essay, I began by pushing chaplains—as I’d like to push you today—to think clearly about what it is you do. Spiritual care is your field, but, of course, hospital chaplains do not have a monopoly on the spiritual care of patients. Compassionate and thoughtful attention to a patient’s explanation of suffering, search for transcendence, construction of meaning, expression of faith or loss of it, reliance on prayer or ritual, a patient’s bafflement, fear, hope, or any of the many other possible manifestations of engaged spirituality—attention to these things has long been within the domain of good nurses and good doctors and good therapists. Clinicians may—and often do—offer patients some level of “spiritual” care that attends to the deep questions of meaning, purpose, and connection to others that arise during a serious illness. When that is done well, it can be a very good thing—and I, for one, wish there were more of it—but it is a kind of bonus, a nice but unexpected and unrequired addition to the skills we expect our nurses and doctors to have.

In contrast, spiritual care is the primary, even the sole focus of your work. Unlike nurses and doctors, you have been specifically educated—in a rather lengthy and well-supervised process of study, practice, and self-examination—in the theory and methods of spiritual care of patients and their families, of persons in the grip of illness, disability, loss, dying. And that makes you inescapably the representatives, the spokespersons for spiritual care within our hospitals. No matter how much we clinicians may claim to offer care that could be considered, in some fashion, ‘spiritual,’ we know—or at least we should know—that this is not our field of expertise and that it is not something to be played around with by amateurs. We must turn to you—and sometimes, maybe often, we have to be reminded that we must turn to you—for the explanation and demonstration of what constitutes depth and excellence in spiritual care of the sick and why what we doctors and nurses do, at best, is not enough and, at worst, could risk spiritual and moral violation. We must turn to you for the explanation of why any level of commitment to providing spiritual care in a hospital necessarily brings with it a commitment to providing trained, dedicated hospital chaplains. There are vital distinctions to be drawn between the compassionate, attentive clinician who can recognize and acknowledge a spiritual struggle when she hears one, and the experienced hospital chaplain who knows how to stay with and assist the patient through that struggle. Your voice is the defining voice of spiritual care.

But your voice is much more than that. You also have, you are a prophetic voice, and one no healthcare institution can afford to do without. Prophecy, at its heart, is responsibility, and I mean that in at least two ways. On the one hand, prophecy is itself a response – the prophet responds to a call, to a message heard, to an inspired interpretation of the situation around him or her. And, on the other hand, the prophetic voice always calls for, one could say demands a response from those who hear it, those to whom it is directed. In calling you to use this prophetic voice, then, I need to talk also about responsibility and some of its ethical parameters.

When I wrote that essay about the ethics of hospital chaplaincy, I discussed three frameworks for thinking about it, but the central one, the one with the most ink, identified the ethics of hospital chaplaincy as an ethic of accountability, of responsibility. And an ethic of accountability, at a minimum, means that you should be able to give an account of:

1) what you and your colleagues do—which requires criteria that do define your field and distinguish it from others;

2) whether you do it well, and how—which requires modes of evaluation and descriptions of what counts as “doing it well” that can serve as standards of quality; and then

3) whether you could do it better, and how—which requires mechanisms for enforcement of standards and improvement of quality.

These last two clearly dovetail with the need of healthcare institutions—the places where you practice—to be able to meet their own ethical obligation to insure quality control of the care they allow to be given in their name.

I’m not saying anything new when I note that this matter of setting standards, monitoring and enforcing them, and working to improve the quality of spiritual care interventions can generate consternation and resistance among chaplains, who quite understandably find it difficult to imagine ways of categorizing and judging the work that won’t outrageously distort it. It is one thing to measure, say, the timely delivery of an accurate dose of the right medication or the complication rate from an operative procedure, and quite another to gauge the quality or the outcome of a discussion of spiritual matters at the bedside. Methods used for assessing medication delivery could scarcely be expected to do justice to the work you do.

On the other hand, programs for training persons to do this work – programs in clinical pastoral education – have long considered themselves able to make judgments about trainees on the basis of nonquantifiable characteristics like your responsiveness to the needs and views of patients and colleagues, your willingness to change and grow within the work, your ability to refrain from preaching and from pushing your own take on spirituality or religion onto an unsuspecting and vulnerable patient. In other words, standards of practice exist. They may need to be more clearly articulated or modified in some ways, but these standards can form a basis for evaluation of the quality of your interactions, which is an integral part of any ethic based in responsibility.

But that said, an ethic of accountability is also going to press you to look beyond these matters of definition to ask, What else? Beyond these traits that make for a good presence at the bedside, what else may be your responsibility in a health care setting? Well, let’s consider the implications of the fact that your work does happen at the bedside, usually in a hospital or some offshoot of the hospital, like a hospice or some other setting in which medical care is being delivered.

Martha Jacobs, who is a chaplain at the forefront of the professionalizing process in the US, has said that chaplains don’t so much espouse theology as ask the kinds of questions that theology raises. When I heard her say that, I thought of Paul Tillich (20th C theologian) and his broad definition of a theologian as someone who is not necessarily a believer, but someone whose primary focus—intellectually, spiritually, psychologically—is on what Tillich called “matters of ultimate concern.”

The kinds of questions theology and spirituality raise are about matters of ultimate concern, and I would argue that medicine needs often to be reminded that precisely these matters—these fundamental searching questions about ourselves and about what is beyond us, about life and pain and God and love and death—these questions that define and haunt our humanness are always right at the surface in the work of health care, whether or not they’re recognized, whether or not they’re couched in what we may think of as religious or spiritual language. As you know better than I, chaplains bear responsibility not for answering those questions—they’re the great unanswerables—but for hearing them, holding them, sometimes voicing them, complicating them, easing them—and you also bear responsibility for assuring that they are recognized and honored more generally in our healthcare institutions. Let me explain what I mean by that last claim – because this is your prophetic voice, the voice that responds to what’s going on and that calls for the response of others.

Sociologist Daniel Chambliss in his eye-opening book, Beyond Caring, identified the hospital as a site of thorough-going routinization. He said that we who work there become so inured to what we do that we no longer see how odd and disturbing it really is—how odd to cut people open, to infuse toxins into them, to know their bodies so intimately, to witness death after death, to be perpetually a stagehand in a theater in which life’s most dramatic moments are played out over and over. An important consequence of routinization is not only that we forget how odd our chosen work can be, but also that moral issues routinely go unnoticed because they are so deeply embedded in what we do every day. Chambliss said, “The great ethical danger . . . is not that when faced with an important decision one makes the wrong choice, but rather that one never realizes that one is facing a decision at all.”

This point about recognizing and responding to moral issues in the health care setting can equally well be said of recognizing and responding to spiritual issues there. Chambliss could as well have said that the great spiritual danger is not that when faced with a patient’s spiritual struggle one says the wrong thing, but rather that one never realizes one is facing a spiritual issue at all. In the midst of the routines of the place where we go to work every day and the dominance of medical discourse in that place, health care professionals—and even patients and those who love them—may fail to recognize that questions of lasting spiritual significance are at stake in the recurring, predictable events and situations that typify a hospital. You are the ones obligated to respond to these questions when they arise, but I would challenge you to see that you are also responsible for seeing that the issues are noticed in the first place, noticed by all, and taken seriously. The fact that the work of health care is shot through with spiritual significance, for recipients and providers alike, needs to be held up to the light over and over, needs to be spoken of openly, acknowledged, wrestled with, celebrated, and mourned—and this is surely the responsibility of the “spiritual professionals” in the hospital.

Margaret Urban Walker—a philosopher and occasional commenter on matters of medical ethics—has asserted that ethicists in the health care setting should be not so much expert engineers who offer technical problem-solving approaches to moral dilemmas, but skilled architects who create what she called “moral space”—by which she meant a real or virtual space within which all of us who work with the sick and the dying can freely air our convictions and our bafflement, and discern together ways of proceeding morally in the face of inescapable uncertainties and conflicting commitments—the two characteristics of medical care that make it so ripe for ethical conflict—uncertainty and conflicting commitments. The development of moral space—of locations and opportunities within the hospital for interprofessional conversations about what matters morally—can potentially convert the climate, the culture of the entire enterprise into one truly moral space in which the inevitable ethical dilemmas of medicine are consistently acknowledged and are dealt with inclusively, and early, and well.

Taking Walker’s lead, I ask that you see yourselves as responsible for creating “sacred space,” space in which it can be openly acknowledged that holy things are happening, things that are “set apart”—the fundamental meaning of “holy”—things that matter spiritually, that are of ultimate concern to everyone involved. A hospital chapel is only the most obvious example of sacred space—and may not even be the best example. Patients’ bedrooms and family waiting rooms surely also qualify, but we need to be reminded of that—that they, too, are sacred spaces. Hospital corridors are not the same kind of space as these hotel corridors, or as subway stations or shopping malls; they are not simply work places, not even market places. We have to look to you, the specialists in spirituality, to denominate them and even more spaces as sacred—operating rooms, nurses’ stations, clinic exam rooms, radiology imaging suites—so that we all may remember that these places where we spend our days are places in which important spiritual transactions are occurring. And, of course, you can see that the act of “creating” sacred space, much like creating moral space, is most often a matter of naming it so out loud, naming it what we already know it to be.