We post an ethical or situational concern that has arisen in a facility where one of our readers works. It has no identifiers included. It gives you only the facts of the case. Then, you can respond to that concern. This is an ongoing dialogue, with comments added as they come in. (Responses are posted below the case) In the following issue, assuming it has been resolved, we give you the outcome from the facility where the incident took place.

We hope that this new addition will help to inform not only those who are dealing with the issue, but will enable all of our readers to learn from the experiences and perhaps mistakes of others.

CaseConference #1: (Responses are posted below the case)

Even the most seasoned chaplains are occasionally astonished at a patient’s story or question. In the midst of the astonishment, we chaplains are challenged to respond with appropriate care. Quickly we assess dynamics and options, assessing internally and/or interpersonally. Afterwards we may muster the courage for peer review. Below is one such story. For beginning information, the chaplain has been open about her breast cancer. She has given permission to the nurses with whom she works to tell patients that she has breast cancer if the nurse thinks it would be of benefit.

Because the chaplain sees all first dose chemotherapy patients and because a nurse made a referral, she met a young woman who had recently been diagnosed with breast cancer and with the patient’s mother. The woman’s nurse had told her that the chaplain had a mastectomy and breast reconstruction surgery, an implant. The patient reported to the chaplain that she was anticipating a mastectomy. The patient then asked the chaplain about her experience. The chaplain talked about her experience with great detail, including about the pain.

The patient expressed appreciation to the chaplain for being so open and honest. She told how horrified she had been by what she read on the internet. Then she hesitated before asking if she could see the reconstructed breast. Astonished, the chaplain clarified what the patient had asked. Surprised at the courage of the woman, the chaplain agreed to show her the breast, especially since the chaplain wished she had learned this information in advance of her treatment. Because of the clothes she was wearing, she had to pull her entire dress up to her shoulders, hoping no one would open the curtain and see her partially clothed with the patient and mother.

More astonishment followed. The patient asked to touch the breast. The chaplain moved closer and allowed the woman to touch the breast. With eyes full of tears, the patient simply whispered, “Thank you.” The chaplain’s mind flashed to the call of Isaiah, “Whom shall I send?” to which Isaiah answered, “Here am I. Send me.”

After the chaplain redressed, they talked more, comparing experiences with chemotherapy and side effects such as nausea. When the chaplain stood to leave, the patient again thanked her and noted that there was no one else with whom she could have had such a meaningful conversation. The chaplain said, “I was sent.”

Did the chaplain cross any boundaries and if so was she appropriate in crossing them? Was she within her role as chaplain to share her own story with the patient? Are there risk management issues that need to be considered?

Send your comments about CaseConference to info@PlainViews.org.

RESPONSES to CaseConference #1:

In my opinion, any boundaries the chaplain may have crossed were human-made rather than God-given, and, by responding in compassion and love, I feel she was totally appropriate in crossing them. She seemed to be checking in with her Inner Guidance about what the most loving response could be, and then acted as she was guided. I think that's the highest service a chaplain can offer: Spirit-led action for the greatest benefit for others.

When our own life stories can be of service to others, and when our Inner Guidance prompts us to be open about our lives, then I believe it is an essential part of our role as chaplain to share what we've experienced and how we've grown from it, trusting that Holy Spirit will utilize that for the good of all involved.

I know of no risk management issues to be considered when so clearly listening for and following Spirit's direction.

Rev. Connie Vinci
Independent Interfaith Minister
Michigan

What a fascinating scenario.

At the first reading I was astonished that the chaplain would do this. Was it crossing a boundary of professionalism? Would it have been more appropriate to make a referral to "Reach for Recovery".

On the other hand, I began to open a door to those moments in ministry when I "revealed" something of my own woundedness while in a deep consultation with a patient. I suppose it would be easy to rely on the technical definitions of professional boundaries. However, there is a sense that in my life as I approach retirement, that I have less to hide and more to share about my journey into wholeness. It makes me ponder Jesus' willingness to show his side to Thomas in order that he might believe.

So, I come out the other end of this pondering moment thinking about how this chaplain helped another person consider what it means to be whole by revealing her own wounds. With the knowledge that nurses have used this chaplain's experience before with cancer patients and that it is not only her head knowledge but also her "body knowledge" of what this surgery is like, I believe she gave the patient a great gift.

George Burn
State College, PA

I must say at the beginning that I am a man and therefore my response may be influenced by my gender, probably so.

I would like to know a bit more about the chaplain, rhetorically speaking. I wonder how the chaplain defines power differential. I also wonder about the chaplain’s understanding of safety and secrecy. Then, I wonder about the chaplain’s childhood experience around being exposed.

Depending on the chaplain’s response to the above curiosity the chaplain may reflect about “next time”from an internal versus an external locus of control. The following are my responses on what was presented.

The patient seemed to hook unresolved trauma in this chaplain that prevented some thought on safety. I view her actions as unsafe, for the patient and herself.
•It was unsafe for the patient because, while her curiosity was appeased, no medical or technical issues were addressed. An advance practice nurse or physician would have used this live demonstration to educate the patient on the medical aspects and the chaplain could address the emotional, psychological, and physical aspects concurrently. The theological and spiritual aspects could then be addressed in the private setting.
•It was unsafe for the chaplain because she had no support on the professional aspect. This event, I think, needs a witness and documentation. Surely the patient will talk about this meaningful conversation with others. The chaplain may find herself asked again and again for the same service; how will she say no to the next request? At some point this will reach the other members of the treatment team; how will they view the secrecy? (Recall the fear of someone walking in) I think on an intuitive level the chaplain was feeling embarrassed and not clear on how to express her feelings.

The power differential is at work in this scenario. I think that regardless of the gender to gender situation the chaplain carries the power of her position. The patient was in normal expectation to make her request. The chaplain crossed the boundary because she responded out of her pain, history, whatever. I also noticed that the chaplain made no point to talk about the boundary crossing by the nurse who exposed her to this situation. Is it ok for her peer to tell her story? Is it ok for her peer to set up this situation? Not in my mind is the answer OK to either of these questions.

The professional,in my view,that needed to be included in the fulfillment of the request is the nurse who "outed" the chaplain. The nurse would have witnessed the impact of her actions and provided documentation support should this event become a risk management issue.

I hope to hear other responses, particularly around the impact my gender influencing my response. Thank you for the opportunity

Roy Sanders
Director Spiritual Care/Clinical Pastoral Education
Truman Medical Center Hospital Hill

A boundary was certainly crossed in exposing a "private" part of one's body to a patient, even if they had agreed mutually that this would meet a patient's need. If it had been a male family member asking to see and touch the breast so that he could envision his wife's experience, such an exchange would have been inappropriate due to the potentially sexual overtones. In this case, it would seem that there was no difference between this exchange and a chaplain exposing an amputated leg stump and allowing a patient anticipating a similar surgery to learn more about what such a procedure entails and what the outcome looks like. It was certainly caring and appropriate for the chaplain to make herself available to a vulnerable patient in this way. They touched "holy ground" in such an exchange of deep thoughts and feelings. She seemed "within her role." I don't see any risk management issues since the exchange was through mutual consent and as a result of the patient's initiation.

A larger question for me is that the conversation then continued in a clinical vein, "they talked more, comparing experiences with chemotherapy and side effects..." I don't see any comments about a
spiritual assessment being done, helping the patient tap any faith resources that have helped her in the past, an opportunity for prayer, etc. When I share a portion of my story with a patient, in addition to
modeling self revelation and building trust, I always try to make sure that the conversation returns to spiritual needs and doesn't stay in the social or "support group" mode. Of course, just because such aspects of the conversation are not mentioned does not mean they didn't take place...this is not an exhaustive verbatim. Still, I would caution that whenever we share our story with a patient or family member, that we remain aware that our primary role as chaplain includes the use of spiritual and religious language and resources.

Alex Chamberlain, BCC
Boise, Idaho

It's a strong chaplaincy program in oncology that refers the chaplain to all first dose chemotherapy patients. In my chaplaincy I covered five different types of units. I had to rely on staff referrals and the
occasional 'cold call,' should I feel so led by the Spirit, to choose which patients to visit.

The decision to let patients know that the chaplain has (or had?) breast cancer is best based on the spiritual and pastoral context of each visit. When presented as introductory information it directs the pastoral relationship instead of letting the pastoral relationship develop from the patient's initiative and from the chaplain's assessments of the patient's pastoral situation. In the presented case, the nurse assesses if informing the patient of the chaplain's medical history "would be of benefit." We rely on pastoral need assessments of staff for all the referrals we receive. Still, the staff's informing the patient of the chaplain's personal medical history will influence the pastoral relationship even before the chaplain begins the visit.

Presenting oneself as a particular 'type' of chaplain, in this case as one with a similar medical history, raises the question of the chaplain's sense of personal and pastoral 'authority.' This is how the issue was presented in my CPE days. I prefer to think of it as an issue of professional confidence. Presenting as a 'type' of chaplain operates as a claim to a basis of relationship, a claim of inclusion (or exclusion, depending on the claim and circumstances) in the world of the patient/family/client. It operates as a move toward a more intimate relationship without letting the patient indicate the intimacy she would like to establish. In response,this patient responded in kind, a significantly raising the intimacy level.

The knowledge that the chaplain was a breast cancer survivor let the chaplain and patient 'step over' the process of the initial exploration of the pastoral relationship. That saves time but can preempt the patient's raising or discovering other issues of pastoral concern.

I see no ethical or pastoral problem with the chaplains intimacy of nakedness and the patient's touching the chaplain's breast. I might have asked a nurse to be present if the mother were not (or even though she was present), but I would need to assess my motivations in 'diluting' the patient's request for such intimacy before deciding the best course. One motivation is self-protection. If I'm allowing such physical intimacy, I would want to have an observer present as a witness that the intimacy, while physical, did not violate or abuse. The presence of such an observer is a big shift in the relationship and a big response to the request for intimacy. So I need to be as self aware as possible of all and any reasons why I am 'limiting' or 'defending against' the increase in intimacy, or if I have a fear that the patient will seen inappropriate intimacy. If so, do I fear a weakness, a lack of authority to limit intimacy to appropriate limits? Also, the hospital or the Chaplain's department may have policies on nakedness in the patient's room (usually policies regarding the patient's nakedness).

The chaplain had reconstructive breast surgery. Hopefully, the reconstruction was well done with careful limitation of scarring. What if the chaplain had not had reconstructive surgery? What if the chaplain had
disfiguring results?

These questions point to another approach to the visit. The chaplain could have said, "I can/cannot show you my breast reconstruction, but I'd like to know what concerns are behind your request." Asking what prompts the request to see the chaplain's breast could get to the real issue the patient has. Discussion about what the patient had seen on the Internet would be a rich pastoral opportunity. This topic, the Internet information,could have been processed in the presented visit. As the case was presented, it wasn't. Why not? Did the chaplain need to leave because the visit became so intense? The topic of the horrible things read on the Internet remains a pastoral issue to address in a subsequent visit.

Asking the patient her concerns could have happened earlier in the visit. When the patient asked the chaplain about her experience the chaplain could have responded with something like "I'm happy to share my experience with you. Do you have specific concerns about your experience?" The chaplain did not check into the patient's concerns. Instead the chaplain "talked about her experience with great detail." Here the chaplain significantly increased the level of personal intimacy. This served as an invitation to the patient to ask for a more intimate sharing of the chaplain's experience, the request to show her breast.

Why did the chaplain decide to share her breast cancer experience with great detail? To what extent did the chaplain have a need to share her experience? To what extent did the chaplain need to raise the level of intimacy? The chaplain could explore these questions and increase her awareness of the energies within herself that can influence her pastoral care, energies that control the visit instead of the patient directing the visit. In other words, what needs and who's needs were being addressed there? The patient asked about the chaplain's experience. The chaplain could have responded, "When I first was diagnosed, I didn't know what to expect and had lots of fears. What concerns do you have that my experience might address?" This invites the patient to set the focus and intensity and intimacy of the visit.

Those are my impressions.

Sincerely yours,
Brian Clougherty

First, I claim and own my perspective as a male chaplain responding to this case. I begin with that as I am certain that my enculturation as a Euro-American male will be in some way reflected in my response. Certainly I will attempt to bracket my personal experience, but it is always with me at some level.

It seems to me that two separate boundary issues are at stake in this case. One has to do the the chaplain's personal disclosure regarding her story. The second one has to do with boundary issues related to touch and body boundaries.

Regarding the first boundary issue, my only concern is that the chaplain had little knowledge of the patient's story before offering self-disclosure. In the case as presented it is not clear whether or not the patient had shared enough of her story for the chaplain to assess the presence of a past history of boundary abuse in the patient's experience. That is, were past boundary violations part of the motivation of the patient's interest in hearing the chaplain's story? Without assessing this matter the chaplain opens herself up to participating in a patients ongoing inability to set appropriate boundaries for herself. Put another way, the chaplain participates in the ongoing abuse of the patient's boundaries.

My comments regarding the second boundary issue take this ethical theme a bit farther. That is, do physical boundaries constitute a second level of intimacy and/or privacy that deserve greater care and protection? If one responds yes to this, then one might hesitate to allow the physical touching by the patient. At the very least--even if one answers no to this question--the chaplain should only proceed with assurance that the touching is not playing out a story of boundary abuse in the patient's life. That is, again the patient's persoanl history needs to be assessed before proceeding.

Obviously the chaplain has great compassion for this patient and intends to respond in the moment with a caring spirit. The fact that the patient's mother is present hopefully will safeguard the patient's and chaplain's personal boundaries to a certain extent. Yet one might pose the question as to what would the chaplain have done if the visit was interrupted by a physician, nurse, or visitor (male or female). Does the chaplain want to deal with explanations that would be necessitated in the event of such an interruption. Is the chaplain correct in assumeing that the patient's bedside as a private and confidential space--versus a public space.

Thank you for sharing this excellent case. I wonder how male chaplains would have responded had the issue been one of testicular cancer. For me, the same issues would surface.

Rev. John B. Hartman II, D.Min.
Chaplain, Columbus, GA.

How interesting that all but one of your first responses came from male chaplains.

In response to the questions:
As the case is reported:
Yes, the chaplain crossed a boundary.
Yes, the chaplain put both herself and the patient at risk.
Yes, there seemed to be some benefit for the patient.
Yes, there seemed to be some benefit for the chaplain.

Here are my questions:
Could the chaplain have paused, found a gown and a nurse, slipped into the gown so as to show her breast with a nurse present, thereby reducing the risk factor (less exposure, another professional present)?

Has the chaplain taken some time to reflect on this with a peer/supervisor to better understand what motivated such a spontaneous response on her part? Yes, the Spirit does inspire – but the Spirit does also lead one to Wisdom…

Here are my comments:
Without a doubt, the unconventional presents itself daily to the chaplain who is open (“Let the one who has ears to hear/hear and eyes to see/see). Without a doubt, the Spirit leads us into areas of tender ministry where, when we risk vulnerability, we create a space where deep healing can happen.

But still… there are good reasons for taking care. Risk-taking has to be balanced with safety – for patients and chaplains. A first visit, a visit filled with high emotion, full exposure of one’s body – are all red flags. For example, what if the patient had had some previous experience with sexual abuse that she had not revealed? And there was another possible way to address the request.

In caring, sometimes we touch to give; sometimes we touch to take. Sometimes the lines get blurred. I think the lines were blurred in this case.

Cherie Baker, Chaplain/Director
Washington County Hospital
Hagerstown, Maryland

When Thomas put his fingers into the wounds on the hands of Jesus, it dispelled his fears, doubts and uncertainties, which in my opinion is a great illustration to the case in point. I have to restrain myself from jumping in celebration for the courage of the Chaplain and her openness. I am not sure that I would do the same. Did she cross boundaries? Of course she did. She could have refused and missed out on a great opportunity for pastoral care. It just shows how much we as Chaplains need to be willing to go to minister to others. Although, being able to work within the system of standard that determines what is appropriate and within professional boundaries is great, but it is during these unique incidents that we really become the wounded healers.

However, at the same time, what if, at the moment of the patient touching the Chaplain’s breast, the Chaplain realizes that the patient was getting sexual pleasure out of the whole experience and a doctor walks in at the same time to find her being disrobed and a patient fondling her breast! It would have been Catastrophic! BUT! The Chaplain was right in her pastoral assessment before she offered pastoral care and so there was no problem. The risk to me was worth it.

Rev. Reginald Mortha
Chaplain
Rush University Medical Center

In CPE we were taught to listen to our "gut feelings" and learn from what they were telling us. Both I and my "gut feelings" were horrified at what took place between the chaplain and the patient. In my view, the patient made a most inappropriate request and the chaplain allowed herself to be manipulated into granting the request. The chaplain stated that she spoke about her experience "in great detail." I saw that statement as a red flag and agree with a number of other respondents that there were many other ways that the visit could and should have been focused. The talking and exposing seemed to meet a deep need on the part of the chaplain rather than the patient. As for the risk, can you imagine the scenario of another staff member walking in on a chaplain naked in the room with a patient. Even if there were no sexual overtones, common sense dictates that this is poor judgment. The chaplain should have been there to offer spiritual support, using her own experience as a means to relate to the patient in ways that someone else without that experience would not be able to. If the patient had technical questions about what her breast would look and feel like after surgery, these questions would most appropriately be addressed by the doctor or her/his staff . The chaplain seems to be assigning a depth to the encounter that was not there but that she needed to be there in order to justify her actions. I feel that the visit was handled poorly and its ramifications should be the subject of much reflection on her part.

Chaplain Barbara Wojciak
Birmingham, AL

I believe several boundaries were crossed with this chaplain. However, I believe, too, that this chaplain used her discretion “within the moment”. Sometimes policy and procedure can be our “best friend” when it comes to being asked by a patient to do something that would put the chaplain at risk.

I wonder if this chaplain became enmeshed with this patient in a short period of time. Is it possible for this chaplain to enter into another conversation, similarly, without bringing her own story into the mix? Rather, she can use her story and the components of what she went through without there being reference made to herself. Example: a bereaved person called my office inquiring about support groups. In the midst of the conversation, she unloaded a fear, in that her purse had been stolen from her house; she was being a “Good Samaritan”, allowing a stranger to use her phone for supposed car trouble. She went through the whole scenario of feeling violated. I had just had my purse stolen in a similar manner a month prior. Because of this experience, I was able to ask her questions that were in relation to her experience without bringing my own story into the picture.

Because this chaplain had been through the same experience as this patient, I wonder if there is a way she can couch her conversation, keeping it about the patient, without bringing her own story into the picture, but rather, drawing from her experience to be very present to this patient- especially addressing fears and grief that accompanies a loss of anything.

Rev. Amy Jo Jones, BCC
Chaplain/Grief Support Center Coordinator
Big Sky Hospice
Billings, MT

I, too, have had breast cancer. In 2001, I had a lumpectomy, chemo, and radiation therapy.

I, too, have shared my experience with breast cancer patients. This seems natural to me because I attended a breast cancer support group for two years and have attended Healing Journeys conferences, where I have received great support and information from women who went before me.

As a chaplain, I am careful to respond to the lead of the patient, as I think this chaplain did. It is my conviction that the reassurance the patient needed outweighed the risk of any negative reaction. I have found patients that do not want to talk about their condition, and I respect their need for privacy. But far more often, I find women with an enormous need to share their fear and to learn from the experience of other women. Women, by and large, need to talk it out with other women.

P.S. How a male chaplain would react to a male patient may be another story entirely.

Mary Eve Peek
CPE Student
UC Davis Medical School
Grass Valley, California

This chaplain has chosen to take this story to the national airwaves as a National Public Radio commentary (October 21 broadcast of All Things Considered) with her name on it. I felt very uncomfortable hearing it and wondered if she had discussed the matter with any colleagues or ethics specialists before choosing to let potentially the entire country in on this intimate moment.

Certainly, I am not a woman, but if I were a prostate cancer survivor with a penile implant, I would have stopped well short of demonstrating to a male patient (even if his father were present in the room) how it was working. I'm sure that my faith group supervisors, my endorsing agency, my employing agency and my professional certifying organization would have significant questions about the appropriateness of such actions and might well bring charges. I don't think the ethics of the matter are really so different when the chaplain and patient involved are female.

Jon Altman
APC Associate Chaplain
Currently United Methodist Church local clergy
Petal, MS

The facts as presented could pose some risk management issues. The interaction between the chaplain and the patient, although out of the ordinary, could be defended as a judgment call on the part of the chaplain in this case. However, I am concerned that the chaplain was routinely making herself available for these kinds of consultations by having the nurses share her personal medical history with cancer patients. I could envision a complaint that would allege that the chaplain was representing herself as an authority based on her experience and that this was reinforced by the nurses.

Kevin Dahill
President and CEO Nassau-Suffolk Hospital Council
Executive Vice President Healthcare Assoc. of New York State

First I applaud my fellow chaplain for being bold enough to share healing in such a powerful way. I feel that by showing the outcome and letting the patient identify the inner emotions by touch, it brought order to chaos before surgery. Given this young patient a view of what future holds and voiding out of her mind the distorted images of her self.
Regarding the crossing the boundaries. One is free to share our own healing story, if it would benefit the patient to promote healing, we can show our inner self and let the patient feel our spiritual wounds, I believe the limitation come in the "what we show" and the degree of physical "touch" . In this case, the showing and touching worked for the patient and the chaplain, however, it could have gone terrible bad, for the chaplain and hospital. Because there are two sides of every story, in this case we have patient and her mother and for the chaplain, only, her self. How about asking the RN's help to keep guard?

Chaplain Arturo R. Malacara
Uvalde Memorial Hospital
Uvalde, Texas

I am in awe of the courage and authenticity of the chaplain who showed her reconstructed breast to the woman about to undergo a mastectomy.

Clearly she was aware of the multifaceted risks involved--yet she still answered as a "faithful servant".

Although I am a rabbi--I couldn't help but remember the narrative of "doubting Thomas"--who only "got it" when he touched the wounds. Although the patient wasn't necessarily a doubter, she was certainly anxious--certainly uncertain--and the chaplain allowing her to touch her own "wound" clearly strengthened and healed her.

Amazing....

Rabbi Cary Kozberg
Columbus, Ohio

Thank you for such a challenging encounter. I believe this is a sample of a pastoral encounter no one could have created or imagined. It has to be truth, because fiction must make sense. I am moved by the connection between the three women. The chaplain and the patient definitely make a strong connection, but I imagine the mother was deeply moved as she witnessed this exchange between the minister and her daughter. Martin Buber described this sacred moment of connection between people as a "queer lyrical moment".

Was the case conference writer a male. The writer never used the possessive pronoun with "the breast". I am sure the patient asked to touch "your" (the chaplain's) breast and that the chaplain allowed the patient to touch "her" breast not the breast. It sounds like the room is getting crowded with the chaplain, the patient, patient's mother, and of course, "the breast". Although "the breast" is reconstructed, I imagine her breast is not detachable like some snap on tool. This must say something about our comfort level with our bodies.

Bob Duvall
Gwinnett Hospital System
Lawrenceville, Georgia

I think that it would have been different if the chaplain had initiated the suggestion ("Would you like to see how mine looks?") But she didn't. She answered the patient's request with a deeply empathetic response.

I think that's incarnational. Her stigmata are the marks of her healing and of hope for others. I am reminded of Jesus giving Thomas exactly what he asked for and what he knew Thomas needed. "Here, put your fingers in the marks of the nails..."

Agreed we all need to be aware of boundaries and agreed that this was a situation in which the chaplain probably went "boldly where no one has gone before". But that's one of the things that keeps ministry interesting for me.

What a great thing for the case manager to be able to disagree and yet to affirm the chaplain in her ministry.

Respectfully,
Glen A. Krans
CDR, CHC, USN