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The Ethics of Comfort
Bioethics has a sister discipline called “medical humanities,” which is concerned with works of literature and the arts that have medicine as their subjects, and with autobiographical writings of physicians and others who care for the sick. “Narrative ethics” is where bioethics and medicine humanities overlap in a shared effort to understand how medical narratives – factual, fictional, deliberate, or “found,” embedded chart notes, procedures, and other structures of health care – describe ethical norms or provide opportunities for ethical reflection. In this column and in next month’s column, I will look at two recent novels – both Pulitzer Prize winners – that may be of interest to chaplains looking for narratives that convey something of the experience of doing chaplaincy and raise important ethical questions: Why do we do what we do? Who benefits? Which of our duties are unique to us? Which are shared among colleagues? What is the place within health care from which we can do the most good? Are we in that place right now? If not, how can we get there?
In her novel, March, (2005) Geraldine Brooks imagines the story of the absent father – Mr. March – in Louisa May Alcott’s Little Women: Alcott tells us that March had joined the Union army as a chaplain during the Civil War. Brooks imagines a scene between this chaplain and the colonel in charge of the regiment to which he has been assigned. The colonel asks: “Why do we have chaplains?”
The book of army regulations has little to say on the matter. Odd, isn’t it? In that one institution where order is everything, where every man has a place and a duty, the chaplain alone has no defined place and no prescribed duty. Well, in my view your duty is to bring the men comfort.” Then he glared at me and raised his voice. “That’s your role, March, damn it. And yet all you seem to do is make people uncomfortable.”
This fictional account of a supervisor’s perplexity – what do they do, anyway? – which Brooks based on the memoirs of Civil War chaplains and medical personnel, may ring true when we try to fit contemporary chaplains into another institution where “order is everything”: the hospital. Because chaplains may still have “no defined place and no prescribed duty” within that hierarchy, they may find it difficult to answer the question, “why do we have chaplains?” when it is asked by someone whose place and duties are fixed and secure. (No one ever asks why we have surgeons, or phlebotomists, or accountants – their place and their duties within this hierarchy are clear, so the question is superfluous.) And reporting relationships may define chaplains’ “place” in ways that don’t match chaplains’ own perception of their duties: a chaplain who reports to the director of volunteers may have difficulty overcoming the perception that chaplaincy is merely another group of volunteers to be managed.
Yet this fictional colonel may be onto something when he asserts that if chaplains have a single overriding duty, it’s to “bring comfort.” This word can be read theologically: In the Hebrew scriptures, the prophet Isaiah is commanded to “Comfort, comfort my people,” and in the Christian tradition, the “Comforter” is a name for the presence of God in the world. But it also makes sense to people who have never heard of Isaiah. The dictionary offers two current definitions of “comfort,” a medieval word rooted in the Latin for “to strengthen greatly”: To give strength, hope, assistance, or encouragement; and to console and ease grief. If “comfort” is a good that can and should be offered within health care institutions persons who are sick, suffering, or dying because we recognize that these are persons in need of comforting, then the colonel may be right: if the chaplain’s role isn’t to bring comfort, then why do we have chaplains?
Other health care professionals can bring comfort, too. In her splendid new book, Final Exam: A Surgeon’s Reflections on Mortality (2007), Pauline Chen recalls a case in which she performed palliative surgery on a patient, Alfred, who had advanced liver cancer, then helped Alfred’s family to arrange hospice care at home. When Alfred’s brother-in-law phoned to tell her that Alfred had died, she began “saying what I always did . . . I wish I could have cured him, I wish I could have done more.” The brother-in-law reminds her that she had been the one who made certain that Alfred’s wishes – to die at home, not in the ICU – had been carried out:
It was then that I realized that I had done more. I had comforted my
patient and his family. I had eased their suffering. I had been present for them during life and despite death.
For a surgeon, to offer comfort means to “do more,” because comfort is not a surgical procedure. It is not part of a surgeon’s prescribed duty. However, Chen recognizes that the ability to offer comfort is an ethical aspiration, as well as a practical matter of figuring out what to say and do when you cannot cure: in comforting Alfred and his family, “I had caught a glimpse of the doctor I could become.”
But for chaplains, is offering comfort a professional duty, something that all chaplains must master, just as all surgeons must master certain skills? If so, what are the practical expressions of this duty – how do chaplains bring comfort in ways that are recognized by those in need of comforting?
And is it ever appropriate for chaplains to make people “uncomfortable,” or to refuse to offer comfort? If so, who, and why?
(And to anyone whose answer to these questions is “I comfort the afflicted and afflict the comfortable” – please give us examples, from your own practice, of both parts of that familiar sentence.)
I welcome your comments – and your own thoughts on the books discussed in this column.
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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