BioethicsWalk addresses
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Being Present in the Grey Area
For the past seven years, I’ve spent a lot of time hanging out with professional chaplains. I got curious about this profession when I was working on a research project at The Hastings Center on the ethics of patient safety. At the time, I was also doing my M.Div. and the Center was my field education site. My ordination-track classmates were immersed in CPE, so I heard a lot about chaplains: about supervisors, verbatims, being sent to the morgue on your first day at the hospital, supporting grieving parents as they decided whether to withdraw life support from their son after a car accident left him with castastrophic brain injuries....
When The Center's research project took up the issue of disclosure, I figured that, if I looked into it, I’d find chaplains involved in disclosure. Weren’t my classmates, even as CPE students, in the room for all those “difficult conversations”? Surprise! Once I began to get to know and talk with professional chaplains about their place within the health care hierarchy, and about their professional culture’s knowledge and beliefs concerning medical error and its aftermath, I developed a much more nuanced, more clinically grounded, understanding of chaplains and chaplaincy, and of the barriers – some institutional, some self-imposed – that stood between chaplains and involvement in improving health care, in this case, by honoring the ethical obligation to disclose mistakes.
I learned that chaplains shared some of the same worries and believed some of the same persistent myths as physicians and nurses – if “we” tell the truth, if “we” apologize, we’ll get sued. I learned that chaplains, because of their uncertain – and unreimbursed – status within healthcare institutions, sometimes preferred to “fly below the radar,” by “being present” to patients and families but invisible to decisionmakers, a problematic decision that worked against their inclusion and involvement in improving policy and practices. I learned that some chaplains more readily identified with the clinicians involved in adverse events than with the injured patients and their families. I learned that other chaplains were deeply distressed by their inability to be present to injured patients and their families, if their institution’s practice was to quarantine these patients and families in “legal” or “risk management,” as threats, rather than as, perhaps, the most vulnerable persons in the system.
As these conversations continued and as I made fewer faux pas, I learned more about how chaplains did encounter the “grey area” of ethics, beyond the particular issue of medical error. I learned that many, perhaps most, professional chaplains serve on ethics committees; that some serve on IRBs; and that the ones on the IRBs seemed to be having more fun. I learned that most professional chaplains can recite the “Georgetown mantra” – Beauchamp and Childress’s four principles of biomedical ethics – but that, for some, this was “bioethics.” I learned that time-pressed chaplains may have few on-the-job opportunities for the challenges (and pleasures) of thinking about and discussing cases and theories; about what the “least worst” course of action may be in a particular situation (in health care, there is often no “best” course of action), and what steps can be taken to translate ethical reasoning into ethical policy to guide ethical practice.
I also learned that chaplains don’t like reading about chaplains. But I don’t believe that, or would never have agreed to write this monthly column on bioethics, for chaplains.
Nancy Berlinger is Deputy Director and Research Associate at The Hastings Center. Her research interests focus on clinical ethics and include end of life care; ethics in health care chaplaincy; conscientious objection and moral distress in health care; and patient safety and the resolution of medical harm. Her broader interests include bioethics issues in cancer care, narrative ethics, and medical humanities.
As Deputy Director, she manages the Center’s organizational capacity-building initiative, Bioethics and the Public Interest, which has received major support from the Ford Foundation.
Berlinger is the author of After Harm: Medical Error and the Ethics of Forgiveness
(Johns Hopkins, 2005), which will be released in paperback in fall 2007. She serves on the ethics research group of the Joint Commission, the ethics faculty of the American Society of Healthcare Risk Managers (ASHRM), the bioethics committees at Montefiore Medical Center, Bronx, New York and at Richmond of New York, and the editorial board of Medical Ethics Advisor
. She is a frequent presenter at grand rounds and other ethics education programs for health care professionals. She volunteers on the Chaplaincy Service at Memorial Sloan-Kettering Cancer Center in New York City.
She is a graduate of Smith College and holds the Ph.D. in English Literature from the University of Glasgow and the M.Div. in Christian Ethics from Union Theological Seminary.
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