the hastings center report vol 38

8/10/2019 The Hastings Center Report vol 38

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V O L U M E 3 8 , N O . 6 November- December 2008

T HE H AS TI NG S C ENTE R

Can we measure good chaplaincy?A new professional identity is tied to quality improvement

Reprinted from


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A set of essays from the November-December 2008 issue of theHastings Center Report.

Can We Measure Good Chaplaincy?

The essays collected here examine the professionalizing profession of chap-

laincy, the goal of patient-centered care, and the special challenges of defin-

ing, measuring, and improving quality in less-standardized areas of health

care delivery. The essays emerge from the research project, Professional Chaplains

and Health Care Quality Improvement, which was undertaken collaboratively by

The Hastings Center and HealthCare Chaplaincy, a multifaith, not-for-profit center

for pastoral care, education, research, and consulting. The project was made possible

by a generous grant from the Arthur Vining Davis Foundations.

Gregory E. Kaebnick

Editor

Hastings Center Report


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H A S T I N G S C E N T E R R E P O R T 1November-December 2008

It can be really hardor really easyto explain whatI do for a living. Chaplains share academic training

with clergy, but we complete clinical residencies andwork in health care organizations. Our affinities are withthe patient and family, but we may also chair the ethicscommittee or serve on the institutional review board,and we spend a lot of time with staff. We must demon-strate a relationship with an established religious tradi-tion (in my case, United Church of Christ), but we servepatients of all faiths, and of no faith, and seek to protectpatients against proselytizing. We provide something that

may be called pastoral care, spiritual care, or justchaplaincybut even among ourselves, we do not al-

ways agree about what that thing is.There are many, many definitions of spiritual care in

the context of health care.1 They all tend to have some-thing to do with transcendence: how the suffering indi-vidual grapples with issues of identity, meaning, and pur-pose. They may or may not be expressed in terms of reli-

gion or culture. While any caregiver can tend to the spir-itual needs of a suffering person, the chaplain is thehealth care professional expert in providing spiritualcare.2

Chaplains do what needs to be done, in the setting inwhich they find themselves, to ensure that care is focusedon the emotional and spiritual needs of the patient and

the patients family, particularly in times of suffering,stress, or grief. When I worked as the solo chaplain in acommunity hospital, I was paged to the emergency roomfor codes. If the patient did not survive, I would help thenurses clean the bodyand also the roomas part ofcaring for the grieving family, who were about to come inand say their goodbyes. I had learned from experience tosee this scene through their eyes: Had we treated theirloved one with respect? Had we tried hard enough? Inthat job, I also became experienced at translating thesigns and symptoms of imminent death for families sit-ting by the bedside: What is happening to the body as

the organs are shutting down? What do those lines andnumbers on the monitor mean? Why does the breathingsound like that? Nurses and physicians know these things

without having to think about them; the chaplain isoften the one who observes what the family does notknow, and who offers comfort by explaining what can beexplained.

And sometimes, we sit with the patient and familyand say nothing. Our presence seems to comfort them,and remind them that they are neither alone nor forgot-ten during this most difficult time.

Sometimes, too, chaplains do what needs to be donesimply by showing up, hanging around, and making

time for staff. Sitting with staff, even joking with them,may help them defuse and debrief after a difficult clinicalsituation. A chaplain tends to know if a particulardeathan unexpected death, or the death of a well-likedpatientwas a hard death for a team, and will check in

with them. Sometimes the staff members for whomchaplains make time are senior administrators, who relyon chaplains to help them keep the patient, and the fam-ily, and the staff, and the community in mind, lest any beforgotten in the ever-tightening reimbursement market.In my community hospital, our CEO had me sit in on

What Are WeDoing Here?

Chaplains inContemporaryHealth Care

B Y M A R T H A R . J A C O B S

ESSAYS

Martha R. Jacobs, What Are We Doing Here? Chaplains in Contempo-rary Health Care, Hastings Center Report 38, no. 6 (2008): 15-18.


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2 H A S T I N G S C E N T E R R E P O RT November-December 2008

all disclosures of medical errors: as he put it, my presence inthe room was a reminder that the institution took the pa-tients and familys suffering seriously. Among ourselves, chap-lains may consider this a part of our prophetic role, al-though it is a role we do not always claim for ourselves.

There was a time when chaplains got their jobs by defaultbecause they could not lead a congregation. This may say

something about how religious denominations used to viewthe care of the sick: as a fall-back option, rather than as a vo-cation in its own right. Today, professional chaplainslikephysicians, nurses, mental health professionals, and social

workersare called to care for the sick and the suffering: thisis where we all want to be; this is our vocation. From the per-spective of religion, chaplaincy is a specialized form of min-istry: our academic training is in seminary, and after receivinga masters-level graduate education, we complete at least 1,600hours of supervised clinical pastoral education training in anaccredited, hospital-based program and demonstrate ourcompetency in twenty-nine different areas.3 For example, wemust have a working knowledge of the psychology and soci-

ology of religion and be attentive to the diversity of culture,gender, sexual orientation, and spiritual and religious practiceamong patients and families.4We are also trained to assess pa-tients spiritual and religious resources and needs and to work

with them on the specific issues and concerns that arise whena person is hospitalized. The goal of our specialized, hospital-based training is to prepare chaplains to work in intensemedical environments.5 Very intense: professional chaplainstypically work in end-of-life care, in the intensive care unit,and in trauma. The chaplain is the one staff member whose

job description allows her to sit with a dying patient, or witha grieving family, as long as needed. The nurses and physicians

may want to do this, but they have to move onto other pa-tients, other families, other needs.Sitting with a dying patient or a grieving family is not only

intense: it is also time-intensive. If a hospital defines qualityas making the numbersthat is, counting the number ofvisitsand a chaplain spends five hours with one family inthe ER, as I did more than once during traumas, then thechaplains numbers are not going to look good. And this isone of the challenges chaplaincy faces as it professionalizes: do

we define quality as quantity, care as customer service? (Thatwould make some administrators very happy.) Or do weclaim that prophetic role, and use it to advocate for betterhealth care? And can we make the case that better health care

includes better care of the whole person, with attention to therole of religion and culture in a patient and familys ability tocope with illness? Can we make the case that better healthcare includes better care of the whole staff as well?

Like other health care professions, the structure of con-temporary health care chaplaincy is shaped in part by thestandards of the Joint Commission, which accredits and cer-tifies more than fifteen thousand health care organizationsand programs in the United States. To satisfy standards thatrecognize a patients right to have his or her cultural, psy-chosocial, spiritual, and personal values, beliefs, and prefer-

ences respected, and that require hospitals to accommodatepatients right to pastoral and other spiritual services, hospi-tals may hire one or more professional chaplains, with theone-person department being the norm even in some largehospitals.6 The Quality Commission of the Association ofProfessional Chaplains endorses a ratio of one chaplain forevery fifty patients hospitalized for more than three days, one

chaplain for every seventy-five patients with shorter stays, andone chaplain for every one hundred outpatients undergoingdialysis, chemotherapy, and other procedures.7 However,these are not one-size-fits-all formulas, and hospitals of equiv-alent size serving similar populations may vary greatly in thesize of their professional chaplaincy staffs. As the Joint Com-mission does not specify that their standards must be met byprofessional chaplains, some hospitals, especially in rural areas,may rely on an on-call list of local clergy, or they may employa chaplain who has some pastoral care training but lacksboard certification.8 This is an acknowledged tension in ourprofession. While all chaplains are accustomed to working

with local clergy, our colleagues in ministry are not usually ac-

customed to working in intense medical environments, norare they trained to care for patients from religious traditionsother than their own. A chaplain who is not board-certifiedmay also lack training in the care of diverse patient popula-tions. We worry about practice variation just as other healthcare professionals do.

We also worry about job security. Most chaplaincy servicesare not reimbursed, so hospitals must choose to make the in-vestment in us.9We tend to be a good return on investment.Press Ganey, a patient satisfaction survey used by approxi-mately two thousand of the five thousand hospitals in theUnited States, reports that patient satisfaction with how well

their emotional and spiritual needs were met highly correlateswith their overall satisfaction.10 However, this presents anoth-er tension: the patients that chaplains spend the most time

withdying patientsdo not fill out patient satisfaction sur-veys. Therefore, we may not ever be graded on our best work.

Are hospitals equally concerned about meeting the needs oftheir dying patients, as well as the needs of patients who re-cover? If so, there should be a better way to quantify whatchaplains do for patients.

Quality in end-of-life care and quality in chaplaincy are in-tertwined: we areor should bethe people in any hospital

who are genuinely good at death and dying. The NationalHospice and Palliative Care Organizations Guidelines for Spir-

itual Care in Hospicedescribes the hospice chaplain as an in-tegral member of the hospice team in charge of the spiritu-al plan of care that will be carried out by team members inresponse to the needs of a patient and family.11Any patientmay experience troubling questions as part of a serious illnessor a major loss, whether that loss is a limb or a function (suchas mobility, memory, or language). These questions may beexpressed in religious or nonreligious terms. A patient of reli-gious faith may ask, What is the point of this suffering? A pa-tient with no religious faith may ask, How am I going to getthrough this? Sometimes, patients who do not have religious


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faith nonetheless use religious language, as this language maybe part of their culture. The chaplain helps the patient andfamily discuss the questions that matter most deeply to themand that may be essential for them to express candidly as theyconsider their treatment decisions, hopes, and fears.

What chaplains do is most needed and best used when apatient is dying, has a poor prognosis, or has suffered a life-al-

tering loss. Terminally ill patients acknowledge a greater spir-itual perspective and orientation than other patients, and spir-itual care has been part of the hospice movement since St.Christophers was founded by Dame Cicely Saunders in1967.12As hospice has moved upstream, with the recogni-tion by the palliative care move-ment that the values of hospicealso resonate with patients whoare living with chronic, progres-sive conditions but are not end-stage, chaplaincy has moved

with it. Many chaplains are nowmembers of their hospitals pal-

liative care teams, helping thepatients served by these teamsgrapple with the encroachmentof disease or disability on life asthey have known it.

As chaplaincy has grown inprofessional training andstature, and as chaplains havegrown into our own profession,

we recognize that we need tostandardize our practices, bothin the interest of quality and so

that we can negotiate with insti-tutions over funding and de-ployment. The six major chaplaincy cognate groupsthe

American Association of Pastoral Counselors, the Associationof Clinical Pastoral Education, the Association of Profession-al Chaplains, the Canadian Association for Pastoral Practiceand Education, the National Association of Catholic Chap-lains, and the National Association of Jewish Chaplainshave created common standards for certification and a com-mon code of ethics, and are now working on practice stan-dards. HealthCare Chaplaincy and other organizations in ourfield are working on developing better ways to define andmeasure quality in the settings in which chaplains work

long-term care facilities and hospices in addition to varioustypes of hospitals.13 Empirically minded chaplains have calledon their colleagues to do more and better research into ourpatients spiritual needs so that we can legitimately claim pas-toral care as our area of expertise. These researchers remind usthat chaplains must decide what questions to ask and how totry to answer them.14 If we believeand we dothat theusual patient satisfaction tools have not adequately reflectedour work, then we have a professional responsibility to devel-op tools that allow our contribution to health care quality im-provement to be assessed accurately and thus give us a basis

for further improvement. Compared to other health care pro-fessions, however, we do not undertake enough research, and

we do not write and publish enough. As managing editor ofPlainViews, an electronic newsletter read by more than 7,800chaplains worldwide, I am continually urging my colleaguesto put aside their reluctance to write about and claim whatthey do.

Part of the work of growing into a profession is bringingother professions into conversations. The essays that followgrew out of an October 2007 meeting at The Hastings Cen-ter that brought chaplains together with bioethicists, clini-cians, and health services researchers to discuss the role of

chaplaincy in efforts to improvehealth care. The set includes asociological account of chap-laincy, a critical perspective onthe ethical theories that mayground our practice, a call forchaplaincy to embrace patient-centered care as a concrete, in-

terdisciplinary quality improve-ment goal, and a proposal forchaplaincy and clinical ethics to

work together on QI. This essayset also includes a summary of afocus group study that askedchaplains something they hadnever been asked before: whatwe think about QI. May the di-alogue continue.

1. See the principles of spiritualcare in the National Hospice and

Palliative Care Organizations Guide-lines for Spiritual Care in Hospice,

(Alexandria, Va.: National Hospice and Palliative Care Organization,2001), 4.

2. Ibid., 5.

3. There are also long-term care, congregation-based, and prison-based CPE programs.

4. Common Standards for Professional Chaplaincy, http://profes-sionalchaplains.org/uploadedFiles/pdf/common-standards-professional-chaplaincy.pdf, accessed July 19, 2007.

5. J.L. Gibbons and S.L. Miller, An Image of Contemporary Hospi-tal Chaplaincy,Journal of Pastoral Care43, no. 4 (1989): 355-61.

6. Joint Commission on Accreditation of Healthcare Organizations,Comprehensive Accreditation Manual for Hospitals: The Official Hand-

book (Oak Brook, Ill.: Joint Commission Resources, 2005), standardsRI2.10.2 and 2.10.4.

7. S.K. Wintz and G.F. Handzo, Pastoral Care Staffing and Produc-tivity: More than Ratios, Chaplaincy Today21, no. 1 (2005): 4.

8. K.J. Flannelly, G.F. Handzo, and A.J. Weaver, Factors AffectingHealthcare Chaplaincy and the Provision of Pastoral Care in the UnitedStates, Journal of Pastoral Care and Counseling58, nos. 1-2 (2004):127-30.

9. The Association of Clinical Pastoral Education establishes stan-dards, certifies supervisors (faculty), and accredits programs for clinicalpastoral education. The ACPE, Inc., is nationally recognized as an ac-crediting agency in the field of clinical pastoral education by the U.S.

Any caregiver can tend to the

spiritual needs of the

suffering, but a chaplain is

the expert, helping the

patient and the family

discuss the questions that

matter most deeply to them.


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4 H A S T I N G S C E N T E R R E P O R T November-December 2008

Secretary of Education through the Department of Education. Suchrecognition enables the ACPE, Inc., and/or its programs and students toparticipate in federal programs such as the International Student VisitorProgram, the veterans educational benefits program, Medicare Pass-Through reimbursement funding, and in some cases the federal studentloan deferment program. Recognition by the U.S. Department of Edu-cation requires regular and rigorous review of the agency and its stan-dards and processes for accreditation.

10. P.A. Clark, M. Drain, and M.P. Malone, Addressing PatientsEmotional and Spiritual Needs, Joint Commission Journal on Qualityand Safety29, no. 12 (2003): 662.

11. National Hospice and Palliative Care Organization, Guidelines forSpiritual Care in Hospice, 5.

12. T.P. Daaleman and L. VandeCreek, Placing Religion and Spiri-tuality in End-of-Life Care,Journal of the American Medical Association284 (2000): 2515.

13. Other important centers of research on quality in pastoral care in-clude the Department of Religion, Health and Human Values at RushUniversity Medical Center, the Department of Pastoral Care and Edu-cation of the University of Pennsylvania Health System, and the De-partment of Chaplain Services at the Mayo Clinic.

14. A.J. Weaver, K.J. Flannelly, and C. Liu, Chaplaincy Research: ItsValue, Its Quality and Its Future,Journal of Health Care Chaplaincy14,

no. 1 (2008): 16.

Hospital chaplains do not have a monopoly on thespiritual care of patients, just as teachers do not havea monopoly on teaching. Spiritual care of the ill and

dyingcompassionate and thoughtful attention to a patientsexplanations of suffering, yearnings for transcendence, con-structions of meaning, expressions of faith or loss of it, re-

liance on prayer or ritual, bafflement, fear, hope, or any of themany other possible manifestations of spirituality in crisishas long been within the domain of good nurses and gooddoctors. Nevertheless, spiritual care is the primary and ar-guably the sole focus of chaplains work, and just as we recog-nize a teaching profession even though nonprofessionalsalso teach, we can justifiably recognize hospital chaplaincy as

a profession that specializes in spiritual care of patientsandthen turn to the task of specifying the defining criteria for theprofession, including its ethical grounding and governingtenets.

As chaplains acknowledge, physicians, nurses, and otherclinicians mayand often dooffer patients spiritual carethat attends to the deep questions of meaning, purpose, andconnection to others that arise during a serious illness. (Al-though some patients may frame their questions in religiousterms, it should be noted that religious is not a synonym forspiritual, but rather describes a sizable subset within the cat-egory of the spiritual.) The difference between chaplains andother clinicians is that chaplains are specialists in spiritual

care; it is what they do, rather than part of what they do.Chaplains tend to distinguish themselves and their work

from clinicians who also offer spiritual care by referring towhat they do as pastoral care. But for this distinction to rep-resent a salient difference, it will have to be explained. One

way of understanding the distinction would be to regard spir-itual care as only vaguely or incidentally (if not tendentiously)religious, whereas pastoral care hones in on the specific reli-giousness of the patient. This understanding would highlighta potential difficulty lurking for an avowedly interfaith pro-fession in its use of the term pastoral, a word closely tied tothe Christian traditions fondness for shepherd imagery.

Alternatively, is the spiritual care provided by clinicians aform of screening only, perhaps with some empathic connec-tion added, and are chaplains then the professionals equippedto take the conversation further, into realms of assessmentand some analogous sort of therapy? Adept practitioners ofancient moral philosophies, such as Stoicism and Epicure-anism, understood and often referred to their teaching astherapy. They seem to have considered their therapeutic taskto be identification (diagnosis) of the student/patients specif-ic diseasehis particular erring thoughts and bad habitsfollowed by provision of appropriate bracing, life-altering the-ories and methods intended to redirect and heal the suppli-cant.1 If chaplaincy seeks to be something more or other than

a form of palliation, then an analysis of the ways in which thepractice is and is not intended to be therapeutic may be use-ful for elucidating professional goals and methods. It is alsothe case that a language of therapy will affect, for good andfor ill, the communication bridge of translation and interpre-tation that is sometimes necessary when justifying the pres-ence of clerical professionals within a secular health care insti-tution.

Thus, one fundamental challenge for the nascent profes-sion of chaplaincy is to assert that which not only defines butalso distinguishes the kind of care provided by trained and

B Y M A R G A R E T E . M O H R M A N N

Ethical Grounding for a

Profession of HospitalChaplaincy

Margaret E. Mohrmann, Ethical Grounding for a Profession of Hospital Chap-laincy, Hastings Center Report 38, no. 6 (2008): 18-23.


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certified chaplains. Theologian John Cobbs admonition isrelevant here:

The pastors task is to be present with and to hear the suf-ferer, to let the parishioner know that expressing fear, anger,and loneliness is acceptable. I do not dispute the validity ofthis approach, which in many cases is no doubt the best onepossible.

The question of why can be appropriately understood anddealt with psychologically, but to treat it only that way failsto take the questioner with full seriousness as a humanbeing. A pastor who has not reflected about the question,

who has nothing to say, has atruncated ministry.2

Cobb is referring here to aclergypersons response to aparishioner asking difficult ques-tions about God in the face ofsufferingquestions also likely

to be encountered by hospitalchaplains. He distinguishes be-tween psychologically significantmethods of presence and accep-tance and the more specificallypastoral task of reflective re-sponse to the questions them-selves. He thereby provides a

way of expressing the distinctionbetween, on the one hand, thespiritual care that may also beoffered by other clinicians, and

on the other, chaplains profes-sional pastoral care. The impli-cation is that chaplains claim tooffer pastoral care entails an obligation to provide care withsubstantive content, reflecting their professional educationand trainingcare that includes but goes beyond the comfortof a listening ear.

Defining what hospital chaplains doand whether pas-toral is an appropriate adjective for the sort of care theygiveis one fundamental task inherent in becoming a recog-nized profession. The move toward professionalizing alsobrings with it the need for professional ethics. This require-ment raises not only the question of what the specific ethical

tenets of chaplaincy are or should be, but also a more basicquestion about what constitutes its theoretical grounding:How and on what basis should professional ethics for hospi-tal chaplaincy be conceptualized? In what follows, I considera few approaches to answering this basic question, none of

which is likely to be the winning response and each of whichlikely should have a place in a fully formulated chaplaincyethic.

Chaplaincy Ethics as a Form of Medical Ethics

Is a professional ethic for hospital chaplaincy better under-stood as a theological-religious ethic for a particular kind ofhealth care professional, or as a health care ethic for a particu-lar kind of theological-religious-pastoral professional? Themultiple alternative terms employed in that question point

out a complication attributable to the interfaith designationof chaplaincy. The interfaith commitment constrains any re-liance by the profession on the settled ethical frameworks ofspecific religious traditions and suggests that chaplaincy mustlook beyond the religious stances of its practitioners to con-

sider how the practice itself, lo-cated in and defined by the pro-vision of medical care, shapesand even determines the profes-sions ethical obligations.

This issue, however, bringsup a significant distinction be-tween chaplains and other

health care professionals. Doc-tors, nurses, pharmacists, andrespiratory therapists are eachpart of a single profession.Nurses, with rare exceptions,are nurses only; the nursingprofession is their one source ofprofessional obligation. Hospitalchaplains, on the other hand,are members of two profes-sions: They are ordained or oth-erwise officially recognized as

trained leaders by their faithtraditions (a requirement forboard certification as a hospital

chaplain), and are thus members of the clerical profession.They are also members of this newly forming profession ofhospital chaplaincy, which is seeking to establish itself assomething other than a variant wholly subsumed within theclergy. Hospital chaplains then have differing, and potentiallyconflicting, moral obligations entailed by their adherence totwo relatively distinct professionsan issue I explore furtheronly after setting out ways in which chaplaincy ethics andmedical ethics may coincide.

What are the similarities between the ethics characteristic

of faith traditions and the professional ethical understandingsthat govern nurses, physicians, and clinical therapists of vari-ous sorts? Clearly each formulation is identifiably ethics, sinceeach is concerned with, among other things, how we conductourselves, interact with one another, and care for those de-pendent on us. When situated within the health care setting,each insists on the primacy of the patient. Medical ethicstends to ground the patients central status in general princi-ples of respect for persons and in more specific, relationship-generated obligations of care for others well-being. Theologi-cal or religious ethics tends to base similar principles and

Chaplains are obligated to

provide care with substantive

content, reflecting their

professional education and

trainingcare that includes

but goes beyond the comfort

of a listening ear.


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obligations on claims about common humanity, with or with-out reference to a creator-god, and on (divine) injunctions tolove others. But the two ethical frameworks are agreed onmuch that might be called an ethic of caring for patients, thepractice that forms the large area of overlap in the work ofthese professions.

Another way in which these versions of professional ethics,

and others, are similar is in the matter of multiple fidelitycommitments. Both clinicians and chaplains have personalobligationsto self, family, and friendsthat at times rivalthe call to attend to patients. Chaplains and health care pro-fessionals alike have moral obligations toward the institutionof which they are a part, and these, too, may at times conflict

with other professional commitments.But obligations within each profession may also conflict.

Physicians may find that their commitment to the care of apatient conflicts with important duties to train future doctorsor to carry out research likely to be of benefit to others. Goodand compelling imperatives to educate and to create newknowledge do not simply fade away upon hearing of the pri-

macy of the patients need. Part of a physicians professionalethical obligation is to find the morally appropriate balanceamong his or her commitments in each situation. Chaplains,too, have obligations to their profession of chaplaincyin-cluding the education of future practitionersthat may onoccasion interfere with optimal care of the patient. Both clin-ical and clerical professionals find themselves in the positionof deciding between the need of the trainee to gain experienceand the need of the patient for the most experienced caregiv-er. It does not help either profession to have a code of ethicsthat speaks only of the primacy of the patient without regardto how this necessary balance is to be recognized and managed

morally.Some health care professionals struggle with whether theirwork is or should be governed primarily by the ethical codesof their profession or by their personal ethic, which is oftenbased on religious beliefs. Current controversies surroundingconscientious objection to providing certain legal medicaltreatments indicate that professional ethical assertions andpractitioner behaviors do not track together in every instance.

However, this marks a point at which the problem of mul-tiple fidelity commitments diverges for chaplains, whose posi-tion within two professions complicates the issue further. Re-gardless of the interfaith aspirations and intentions of the pro-fession of chaplaincy, its practitioners are situatednot only

by personal belief, but by prior training and professional initi-ationwithin a specific faith tradition that compels their al-legiance. The conflict between chaplains professional obliga-tions to patients and their professional obligations to theirown faith tradition is not equivalent to the conflict of profes-sional and personal ethics characteristic of clinician dilemmas.For clinicians, there are arguments available to justify the pri-macy of the professional commitment or, on the other hand,to recognize exceptions to that primacy. For the chaplain,however, who or what adjudicates between commitments totwo professional codes? How should a chaplainwho upon

entering a tradition-specific clerical profession promised towitness faithfully and overtly to the existence of God, under-stood in specific, tradition-determined waysbalance thatprofessional obligation with what appear to be generally ac-cepted obligations of interfaith chaplaincy not to so witness toones patients?3

I have no doubt that most, if not all, chaplains and hospi-

tal teaching programs have managed to resolve this potentialconflict. If they have not, they are not likely to be serving aschaplains or surviving as programs. My point is not that theconflicts are unresolvable, but that this matter of dual profes-sional allegiances must be explicitly considered when drawingup a professional ethic for hospital chaplains, in terms of whatis being asked of those who profess chaplaincy in relation totheir other professional commitments, and in terms of whatconstitutes an authentic description of chaplaincy ethics.

This fundamental question about the various moral re-sponsibilities of chaplains raises a related questionto whomare chaplains responsible?and leads us to consider a second

way of conceptualizing the ethics of hospital chaplaincy.

Chaplaincy Ethics as an Ethic of Accountability

Whatever the relation of chaplaincy ethics to medicalethics (or, for that matter, to business ethics, whichseems to have more to do with medicine than ever before),there is a real need for a shared ethical language within thehealth care enterprise. The best candidate for a commonidiom is likely to be some version of the language of responsi-bility, of accountability. An ethic of accountability for a pro-fession entails that the profession should be able to give an ac-count of:

1) what its professionals dowhich requires criteria that de-fine the field and distinguish it from others;

2) whether they do it well, and howwhich requires modesof evaluation, requiring explicit descriptions of what countsas doing it well that can serve as the professions standardsof quality; and

3) whether they could do it better, and howwhich re-quires mechanisms for enforcement of standards and im-provement of quality.

Thus, for the nascent profession of hospital chaplaincy, the

moral requirement of accountability encompasses both anobligation to set standards of practice (and then to monitorand enforce them) and an obligation to participate in effortsdirected at quality improvement.

The focus on accountability does not remove but may helpus maneuver the chaplains conflicting fidelity commitments.It seems clear that, for chaplaincy as well as for medicine, ac-countability is most particularly owed to patients. Even if pa-tients are not the ones to whom chaplains must give their ac-count, they are nevertheless the ones to whom and for whomchaplains are responsible, and the ones whose vulnerability


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demands high standards of professional activity and constantefforts toward higher quality work.

This matter of setting standards, monitoring and enforcingthem, and working to improve the quality of chaplain inter-ventions generates consternation and resistance in some chap-lains, who understandably find it difficult to imagine ways ofcategorizing and judging their work that do not outrageously

distort it. It is one thing to measure the prompt delivery of ac-curate doses of appropriate medications, quite another togauge the quality or the effect of a chaplains discussion ofspiritual matters at the bedsideand the unmodified imposi-tion of methods used for assessing the former may well not do

justice to the latter.On the other hand, programs

for clinical pastoral education(CPE) have long consideredthemselves able to make judg-ments about their trainees onthe basis of such nonquantifi-able characteristics as their pres-

ence with patients, responsive-ness to the needs and views ofpatients and colleagues, willing-ness to change and grow withintheir work, ability to refrainfrom preaching to patients orstaff, and some degree of adher-ence to the interfaith commit-ments of chaplaincy. There areprocesses already in place forprofessional board certificationof hospital chaplains and super-

visors of chaplaincy training,and for accreditation of CPEprograms. In other words, stan-dards of practice for hospital chaplains clearly exist, even ifthey need some modification. These standards can be evaluat-ed, codified, and adopted, and they can then form the basisfor trajectories of quality improvement.

That said, an ethic of accountability would press the pro-fession of chaplaincy to ask itself, What else? Beyond thesetraits that make for a good chaplain at the bedsideopennessand responsiveness, perhaps also gentleness, calm, and anaversion to preachingwhat else may be the responsibility ofchaplains in a health care setting? There is certainly the issue,

revealed by Cobbs injunction to pastors, of some yet-to-be-delineated obligation to provide care with substantive con-tent. But aside from these aspects of direct bedside interac-tion, what are the moral implications for the profession of thefact that chaplains work happens in a hospital, or hospice, orother setting in which medical care is being delivered?

Chaplain and theological educator Martha Jacobs has saidthat chaplains, rather than espousing theology, should be ask-ing the kinds of questions that theology raises. Her cogentclaim brings to mind Paul Tillichs expansive definition of atheologian as not necessarily a theist, a believer, but as some-

one whose primary focus is on matters of ultimate concern.The kinds of questions theology raises are about matters of ul-timate concern, and I would argue that medicine needs oftento be reminded that such matters are always present in the

work of health care, whether recognized or not, whethercouched in transcendent language or not. Chaplains bear re-sponsibility not for answering or solving them, but for keep-

ing them visible, recognized, no longer ignored.Sociologist Daniel Chambliss has identified the hospital as

a site of thorough-going routinization, one important conse-quence of which is that moral issues often go unnoticed. He

writes, The great ethical danger, I think, is not that whenfaced with an important deci-sion one makes the wrongchoice, but rather that onenever realizes that one is facing adecision at all.4

The same may be said of rec-ognizing and responding tospiritual issues in the health care

setting. Such issues pervade seri-ous illness, childbirth, disability,dying, and the difficult deci-sions that so often attend them,and they are indeed matters ofultimate concern for most peo-ple, regardless of their religiousaffiliation or belief. In the midstof the routines of the setting,health care professionals andeven patients may fail to recog-nize that questions of lasting

spiritual significance are at stakein daily, recurring, predictableevents that typify the hospital.

Chaplains are the professionals obligated to respond to thesequestions when they arise, but they are also responsible forseeing that the issues are noticed in the first place and thentaken seriously. The fact that the work of health care is shotthrough with spiritual significance, for recipients andproviders alike, needs to be held up to the light daily, spokenof openly, acknowledged, wrestled with, celebrated, andmournedand this is surely the responsibility of the chap-lains, the spiritual professionals in the hospital.

Philosopher Margaret Urban Walker asserts that ethicists

in the health care setting should be regarded less as expert en-gineers, offering technical problem-solving approaches tomoral dilemmas, than as skilled architects, creating moralspace within which those who work with the sick and thedying can freely air both their certainties and their bafflement,and discern together ways of proceeding morally in the face ofirreducible ambiguities and conflicting commitments.5 Thedevelopment of such spaceslocations and opportunities

within the hospital for interprofessional conversations aboutwhat matters morallycan potentially convert the entire en-terprise into one truly moral space in which the inevitable

Chaplains should be

candid about what they do

that can be done as well by

someone else, what they

generally do better than

others, and what can be

done well only by them.


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ethical dilemmas of medicine are consistently acknowledgedand are dealt with inclusively, early, and well.

Taking Walkers lead, I suggest that chaplains see them-selves as professionals responsible for creating sacred space

within the hospital, space in which it can be openly acknowl-edged that holy things are happening, things that are setapartthe fundamental meaning of holythings that

matter spiritually to everyone involved. A hospital chapel isonly the most obvious example of sacred space (although theeffect of its existence on the institutions self-understandingshould not be underestimated or, for that matter, overvalued).Patients bedrooms and family waiting rooms surely also qual-ify, but we need to be reminded of that. And we look to chap-lains to denominate even more spaces as sacredoperatingrooms, nurses stations, clinicsby taking them seriously asplaces where important spiritual transactions are occurringand by calling the rest of us to do likewise. The ultimate goal

would be recognition, by the institution as a whole, that theentire health care enterprisenow including board rooms,kitchens, record rooms, and communication centers as well

is sacred space, full of infinite meaning.A commitment to reclaim the sacredness of the place

where human suffering, frailty, and hope come for help, andwhere help of various kinds and efficacy is provided, may en-tail a further commitment for chaplains to be courageous par-ticipants in and critics of their hospitals organizational struc-tures and ethicsto be an effective voice at the table wherethe decisions about space, money, and their uses are beingmade. Might this also be a standard for chaplaincy practice, ameasure of quality that can be improved?

Whatever the answer to that question, the idea of sacredspace puts the accountability of the chaplain squarely within

the pastoral aspect of the profession that distinguishes itfrom other professions engaged in the care of the sick anddying. Therefore, it is time to turn to a model for ethics thatmay seem to be most surely suited to the work of chaplains asthe ministers they are.

Chaplaincy Ethics as an Ethic of Ministry

To minister is to serve; an ethic of ministry is, therefore, anethic of service. Although ministry, like pastoral, is aterm that bears the weight of one particular religious tradi-tion, it is nevertheless a word that chaplains of all faiths canclaim as an appropriate tag for the patient-centered services

they offer. In what follows, ministry could be replaced withservice and minister with servant, but the latter termbrings its own baggagesome of which plays into problems

with ministry/service discussed below. Like the other ap-proaches explored in this essay, an ethic of ministry keeps theneeds of the patientthe one being servedat the forefront.

And, like an ethic of accountability, it also diminishes, with-out eliminating, the strength of moral obligations that do notdirectly involve the patients welfare.

A ministerial ethic may seem the most natural candidatefor a professional ethic for chaplaincy, but there are problems

with it that require the corrective lenses of other ethical ap-proaches, especially that of justice. I have already alluded tothe difficulty entailed by the professions interfaith designationas it limits chaplaincys ability to call on the ethical under-standings of specific religious traditionswhich are, however,likely to be the source for individual chaplains senses of theirethics of ministry. In addition, perhaps the most important

thing to be said about any ethic of ministry is that it is poten-tially dangerous, both to the servant and the served.

There are apt lessons in this regard to be found within thedecades-long debate over the feminist ethic of care. The cor-rectives offered by more recent entries in that discussion high-light two salient dangers for ethical frameworks centered oncaring, and both dangers seem equally applicable to an ethiccentered on ministry. The first concern has to do with thepower of the servant over the served, a sort of imperialism ofempathy in which the actual needs and desires of the onecared for may be ignored or overwhelmed by the caregiversinterpretation of what service is called for. For example, thedepth and seriousness of a patients questions about personal

responsibility in relation to illness may be swept aside by achaplains certainty that self-blame is spiritually toxic; a pa-tients desire to prepare spiritually for death may be overriddenby a chaplain whose focus is on healing and hope for an earth-ly future. In those who choose to care for others, the rescueimpulse is often quite strong and can distract attention from

what is actually going on in an encounter. In the context ofmedical care, where the vulnerability of patients and the dom-inance of caregivers is already manifest and largely in-escapable, a responsible ethic of ministry will include safe-guardsor, at least, warningsagainst a well-intentioned butpowerful and potentially heedless urge to help.

The second concern arising from consideration of an ethicof care can be construed as the reverse of the first. Withoutclear boundaries in place, it is possible for the needs of the onecared for to take precedence over any needs of the caregiverfor the served to so dominate the servant that ministry be-comes a form of bondage. Persons, including chaplains, whoare involved in the direct care of the sick are vulnerable, for ex-ample, to the patient who claims to derive comfort from theministrations of only one particular caregiver, engendering inthat clinician a feeling of obligation that may keep him or herin the hospital well beyond reasonable work hours. As men-tioned previously, the work of health care is characterized byconflicts among fidelity commitments for all its various pro-

fessionals. Physicians, nurses, and chaplains alike are pulled si-multaneously by their obligations to patients, to the hospital,to their trainees, to their colleagues, and to the creation of newknowledge. They also experience conflicts between these mul-tiple work-related duties and the duties of their nonprofes-sional livestheir commitments to self, family, and friends. Aresponsible ethic of ministry will include explicit attention tothe chaplains welfare and the limits of the works demands.6

This matter of setting limits also raises the issue of profes-sional boundaries, already mentioned in terms of the profes-sions need to distinguish the care it gives from the sort of spir-


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itual care offered by other health care providers. To clarify andpromote recognition of such boundaries, chaplains should becandid about what they do that can be done by someone elseas well as it is done by chaplains, what they do that is general-ly done better by chaplains, and what they do that can bedone well only by chaplains. Further, chaplains must consider

what should not be done by chaplains. For example, it is not

unusual for an experienced chaplain, well versed in the lan-guage and practices of the hospital, to act as the interpreter ofunintelligible or minimalist medical explanations to patientsand families. Is this an appropriate role? Are chaplains trainedto carry out this taskand should they be? Should it be astandard of practice?

There are other questions, of similar practical relevance,that should be asked: Should chaplains serve as cultural bro-kers? As mediators and conflict resolution facilitators? Theprocess of defining chaplaincy as a profession calls for settinglimits, even if broad, on what counts as appropriate profes-sional work for chaplains. Setting these limits must precedethe establishment of standards for the performance of that

work, and it can only then be followed by consideration ofquality improvement.

There are obviously more questions than answers in thisdiscussion, questions that are rightly answered only by thechaplains forming this profession. However, it does seem thatany professional ethic for chaplaincy must contain a thought-ful consideration and explanation of the particular ethicalobligations entailed by the health care context of chaplaincy,not only because of the central status and vulnerability of pa-tients, but also because of the intensity of commitment andthe confusion that characterize the work of health careproviders. It must include careful attention to the demands,

dangers, and limitations inherent in a moral practice of min-istry, justifying the practice and safeguarding both the practi-tioners and their patients. And it must delineate and justifythe responsibilities of chaplains, transforming their multiplelines of accountability into an ethical framework for chaplain-cy as responsible health care ministry.

1. M.N. Nussbaum, The Therapy of Desire: Theory and Practice in Hel-lenistic Ethics (Princeton, N.J.: Princeton University Press, 1994).

2. J.B. Cobb, Jr., The Problem of Evil and the Task of Ministry, inEncountering Evil: Live Options in Theodicy, second ed., ed. S.T. Davis(Louisville, Ky.: Westminster John Knox Press, 2001), 181.

3. There are now interfaith seminaries in the United States, some ofwhose students enroll in order to become hospital chaplains. It remains

to be seen whether the educational content of their professional voca-tional preparation is sufficiently robust to constitute its own tradition,especially if interfaith includes both theist and nontheist faiths, and toengender allegiances that produce the sorts of conflicts I refer to here.That is, the hypothetical conflict of a deeply theist chaplain asked toavoid talk of God with a nonreligious patient could be mirrored in thatof a thoroughly interfaith chaplain confronted by a deeply traditional-ly religious patient who desires specific practices and references to a veryparticular God.

4. D.F. Chambliss, Beyond Caring: Hospitals, Nurses, and the SocialOrganization of Ethics (Chicago, Ill.: University of Chicago Press, 1996),59.

5. M.U. Walker, Keeping Moral Space Open: New Images of EthicsConsulting, Hastings Center Report 23, no. 2 (1993): 33-40.

6. In many medical centers, chaplain trainees are categorized as med-ical house staff, subject to the same limitations on work hours that applyto interns and residents. In some medical departments, the constraintson house staff time have led to significantly increased demands on thetime of junior faculty, a development that the profession of chaplaincyshould certainly try to avoid as it works to protect the well-being and thetime of both its members and its aspirants.

Chaplains often describe their work in health care astranslation between the world of the patient and the

world of hospital medicine. Translators usually workwith texts, interpreters with words. However, when chaplainsuse this metaphor, it describes something other than a discretetask associated with the meaning of words. While medicalprofessionals focus on patients medical conditions, chaplainsseek to read the whole person, asking questions about whatpeoples lives are like outside of the hospital, what they careabout most, and where they find joy and support in the

world. Chaplains offer a supportive presence that serves to re-mind patients and caregivers that people are more than justtheir medical conditions or their current collection of con-cerns. Some chaplains are skilled at translating patients expe-riences and sources of meaning in real time, allowing medicalteams to better understand the person they are treating.Translation is also defined as metamorphosis. Chaplains

B Y R A Y M O N D D E V R I E S , N A N C Y

B E R L I N G E R , A N D W E N D Y C A D G E

Lost in Translation:The Chaplains Rolein Health Care

Raymond de Vries, Nancy Berlinger, and Wendy Cadge, Lost in Translation:The Chaplains Role in Health Care, Hastings Center Report 38, no. 6 (2008):23-27.


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provide this sort of translation when they are alone with pa-tients, listening to their deepest concerns, helping them rede-fine their lives.

Unlike a professional interpreter, who helps patients andclinicians communicate when they do not share a commonlanguage, the chaplain is not just a conveyor of the spoken

words of others. A patient, family member, nurse, or physician

may seek out the chaplain for help in translating a situation: Isthe family in denial? Is the team giving up? Is the patient readyto go home, like her husband says, or ready to rest, like shesays?

Ironically, chaplainsskilled at mediating between pa-tients and hospital staffoften have no one they can rely onto advocate for them at budget time, no one who can trans-late the tangible benefits chaplains provide to patients, fami-lies, and staff into terms hospital administrators can under-stand.

The Professional Chaplaincy and Health Care Quality Im-provement research project was initiated, in part, in responseto this dilemma: If chaplains wish to be recognized as a health

care profession, they need to be able to describe, to themselvesand to others, what constitutes quality in their area of pa-tient care. Like other health care professionals, they need tospecify how their profession and their day-to-day work in thehospital contribute to the ongoing task of quality improve-ment in health care. This is no easy task. The work that chap-lains do is difficult to measure in conventional QI terms: theprecise duties of their job are unspecified, and chaplains oftenfind themselves improvising to meet the needs of patients andcaregivers. In this situation, how can chaplains define theirrole in improving health care? External perceptions of chap-lains and chaplaincy also complicate this translational task: is

chaplaincy best understood as a specialized form of religiousministry, inbut not ofthe health care setting? Or is ittruly a health care profession, and if so, what is the nature ofthe health care service that chaplains provide, and how is it rel-evant to patients health care needs and their treatment? Is it,in some way, both of these? Without attention to these broad-er sociological questions, it is difficult for chaplains to seethemselves as a professionalizing profession, and to make thespecial nature of their work understood to the administrators

who must make decisions about investing in services that haveno reimbursement code.

Raymond de Vries and Wendy Cadge, two of the authorsof this essay, were invited by project codirector Nancy

Berlinger, the third author, to participate in this project as so-ciologists who would observe, reflect, and offer a series ofthinking points about the profession and future of hospitalchaplaincy. De Vries comes to the project as a sociologist ofbioethics (another occupation struggling with its identity andplace in worlds of medicine and science) and with expertise inthe sociology of culture and the professions. Cadge is a sociol-ogist of religion who studies, among other things, the formaland informal presence of religion and spirituality in hospitals.The three of us offer our thinking in the spirit of continued

conversation and with deep respect for the work of health carechaplains.

The Road to Professionalization

Seen from the point of view of the social sciences, the desireof chaplains to strengthen their professionto more clear-ly define their work and to establish agreed-upon standards ofpractice for those eligible to be called chaplainis a pre-dictable stage in the natural history of an occupational group.Changes in society and technology bring with them changesin the division of labor. Not only does the nature of and needfor work change (think of the new occupations created by thecomputer revolution); so, too, does the way the work of soci-ety is divided among occupational groups.

Sociologists have long observed the comings and goings ofoccupational groups, and they pay particularly close attentionto the strategies and social conditions associated with the suc-cessful and unsuccessful efforts of these groups to secure aplace in the division of labor.1As chaplains consider the work

they must do to establish their profession, insights derivedfrom the sociology of occupations are useful. The followingmetaphor, drawn from the sociology of work and occupations,offers a helpful perspective on chaplains place among otheroccupational groups:

Think of all the work that has to get done in a society as thelandform upon which a city is based. The division of labor isthe street grid that defines this landform: some areas arezoned for manufacturing, others for services, some for re-spectable tasks, others for deviant ones; some areas are iden-tified for the market, others for domestic labor. Each zone. . . is a site for potential ecological struggle. Some are se-

curely occupied by well-entrenched occupations. Others arescrapped over: some want to annex new areas to territorythey already control; some wish to abandon a declining areain order to colonize a more desirable one; others desire totake over a neglected patch and displace or organize the ex-isting occupants to improve it.2

Similarly, as chaplains seek to stake a claim in the terrain ofhealth care they are, in some cases, seeking to annex areasthat others control, and in other cases they are moving intoterritory abandoned by other professions.

Also relevant to the situation of chaplains are the ideasabout labor markets developed by Eliot Freidson, the preemi-

nent twentieth century sociologist of the professions. Accord-ing to Freidson, human labor may be divided into foureconomies of work based on the nature of labor markets.Best known, of course, is the official labor market, where workis legally and economically recognized, included in measuresof production, and categorized in the census lists of job titles.But alongside the official market for work exist three othermarkets: the criminal labor market, the informal labor market,and the subjective labor market. It is this last marketthe sub-

jectivethat is most pertinent to chaplaincy. Freidson definedthis arena as the market where goods and services are traded


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without direct economic exchange, and he saw it as both thecradle and the grave of many occupations. Chaplaincy can beunderstood as work that moved, or perhaps is moving, fromthe subjective to the official labor force: having begun asvolunteer work by clergy whose real job was ministeringto a congregation, it is now an occupation paid to be a pas-toral presence in health care settings.

As chaplains seek to map out their territory in the world ofworkto move their occupation from the subjective labormarket to the official labor marketthey must overcome cer-tain challenges generated by their history and the nature oftheir work.

No clear jurisdiction. First,hospital chaplains do manythings. This jack-of-all-tradesapproach serves the needs of anew occupation wellin seek-ing to establish a foothold, occu-pational groups are wise to servethe needs of established profes-

sionals and ingratiate themselveswith occupations that have morepolitical power. But what worksto get ones foot in the occupa-tional door harms efforts to pro-fessionalize. In some ways, beinga chaplain is a vacuum identi-tythe work of chaplains canbe seen as filling the many vacu-ums that arise among the jobs ofother professions in medical set-tings. Chaplains fill a void rather

than offering a well-defined ser-vice. In order to secure a place asa profession, an occupational group must have a clear bound-ary around its work. It is difficult to stake a jurisdictionalclaim with an ambiguous definition of ones jurisdiction.

Disagreement within the occupational group. Not surpris-ingly given the many tasks and varied educational back-grounds of chaplains, disagreement exists within the groupabout the proper definition of a chaplain. The leaders of themain professional groups of chaplains have established cre-dentialing standards to answer two basic questions: Whatmust a professional chaplain know, and what kind of trainingis required to gain that knowledge? On the other hand, these

same leaders have not yet reached agreement on standards orscope of practice: What should all chaplains do, or refrainfrom doing, in recognition of a duty of care? What are theboundaries in which they do these things? Disagreementsabout the answers to these questions slow the move towardfull professional status. Those who prefer the status quo andthose who feel threatened by the move toward professionalstatus can undermine efforts by the occupational group toprofessionalize.

Self-defining. Because chaplaincy is not yet broadly recog-nized as a distinct profession, others may feel entitled to use or

be granted the title chaplain when they are doing certainthings. For example, clergy who do not work as health carechaplains may claim the title chaplain when they are visitinghospitalized members of their congregation. Volunteers inchaplaincy departments are frequently called chaplain bypatients and family members. These realities work against ef-forts to distinguish the work of professional chaplains, and

they make it difficult for other professional groups, and thepublic, to see chaplaincy as a distinct health care profession. Apatient in a U.S. hospital is unlikely to encounter a volun-teer physicianthe category of physician is understood tobe a professional category. However, understaffed pastoral

care departments rely on volun-teers to meet specific, often reli-gious, needs of particular pa-tient groups. An internist

would be professionally remissif she called herself a surgeonsolely on the grounds that bothinternists and surgeons have

medical degrees. However, acommunity clergyperson mightdefend his right to be calledchaplain even though theonly thing he or she shares witha health care chaplain is thesame postgraduate degree.Defining what professionalchaplains do, what volunteersdo, and what community clergydo with respect to chaplaincy,and determining which of these

activities are health care servicesand which are religious services,are further challenges for this profession.

Challenging others turf. In staking their claim for a pieceof property in the world of medical work, chaplains trespasson the work of others. Some occupational groups will notmind giving up a bit of their property (see dirty workbelow), but others will be more reluctant. Two groups thatmay resist incursions in their work are social workers and localclergy. Many of the tasks that chaplains do can be seen as tasksthat social workers dofor example, making arrangementsfor family members or helping to solve disputes between med-ical staff and patients and families. It is likely that some med-

ical social workers will not look kindly on those who threatentheir livelihood. Also, local clergy may see professional, hospi-tal-based chaplains as encroaching on the important workthey do with members of their congregations.

Taking over dirty work. Sociologist C. Everett Hugheswas the first to examine how dirty work is passed among andwithin occupational groups, typically flowing down the lad-der of prestige. Chaplains may not regard the work they do asbeing dirty, but in the eyes of more established profes-sionssuch as physicianstalking with patients about spiri-tual concerns or ensuring that their pastoral care needs are

If chaplains wish to be

recognized as a profession,

they must be able to describewhat constitutes quality in

their area of patient care.

But chaplaincy work is

difficult to measure.


14/23

met are distractions from the real work of medicine and canbe a source of discomfort for members of these professions. Asa presence that relieves physicians from this unpleasant work,chaplains can use this aspect of their job description to ad-vance their efforts to professionalize.

The theology problem. Chaplains are products of recog-nized faith traditions: they graduate from seminaries, divinity

schools, or rabbinical schools; most are ordained; and they arerequired to document their relationship to a recognized faithtradition as one of the requirements for chaplaincy certifica-tion. However, once certified, many are called on to be mul-tifaith and to be available to patients who reply none whenasked if they have a religious preference. Deploying chaplainsoutside of the religious tradi-tions in which they were trainedfurther confuses their profes-sional identity: most other pro-fessions do not work this way.(One that does is clinicalbioethics, an interdisciplinary

field in which many practition-ers were trained in a specific aca-demic or professional discipline,rather than in bioethics. How-ever, this may change as moreuniversities offer bioethics de-grees that can function as a pro-fessional credential.)

This problem is compound-ed by the fact that some chap-lains work in faith-based institu-tions that have their own reli-

gious ethos. In these situations, chaplains may be responsiblefor adhering to religious guidelines in delivering health careservices, but they may also be called to serve a multifaith pa-tient population. How chaplains in these settings negotiatethe institutional religious ethos is an open question.

No agreement on best practices. As part of the health carework force, chaplains are being asked to join the quality im-provement movement. But unlike medical work where inter-ventions can be tested in rigorously controlled clinical trials,chaplaincy work is difficult to measure. Quantity is frequent-ly substituted for quality: chaplains may be encouraged tomake the numbers by focusing on the number of patientsvisited each day, rather than on the quality of the encounter

with each patient and the outcomes for that patients care.The lack of evidence for the medical efficacy of practices thatmay promote patient well-being presents another challenge tochaplaincy. (It is a challenge sometimes shared with palliativecare and integrative medicine: these services differ from chap-laincy in that they are not perceived as religious, however,and they are done by members of recognized medical profes-sions.) In this climate, chaplains are inclined to argue amongthemselves over best practices, once again dividing the occu-pational group and slowing efforts to professionalize. If mem-bers of the occupation cannot agree on how to define and

measure their own work, then why should society grant themprofessional status?

Many credentials, no license to practice. Chaplains who areordained clergy are already members of a professional catego-ry. (Some chaplains come from faith traditions that do not or-dain clergy or do not ordain women.) However, ordination,board certification, or specialized certifications available to

chaplains are not the equivalent of a state license to practicemedicine, nursing, clinical social work, or clinical psychology.This is one important mark of a professionstate recogni-tion of an occupation as a profession by using licensure toclose the marketto prevent competition from those notproperly certified. Sociologists disagree about the politics of li-

censure. Some believe that statelicensure is given in response tothe demands of a well-orga-nized occupational group, whileothers believe that states grantlicensure only when closing themarket is in the interest of the

state. Chaplains do not have tosettle this debate, but regardlessof which theory is correct, theydo have work to do if they areto gain the advantages of licen-sure.

Soft skills. The work of med-icine is often divided into cur-ing and caring, with the hardskills of curing or controllingdisease accorded much more re-spect than the soft skills of

caring or healing. The harder the skill, the more the pres-tige: thus the status of surgeons is much higher than that offamily doctors or palliative care specialists. Chaplains areclearly on the caring, soft side of medicine, and while this willnot prevent them from claiming professional turf, it will bethe turf of the ancillary medical occupations.

Salaried, yet responsible to patients and families. Likenurses, chaplains who are paid by health care organizationsare in a difficult position. Their paycheck makes them an-swerable to their employer, but their duty is to meet the needsof patients, families, and staff. Often, these obligations coin-cidegood care for patients and staff members benefits thehospitalbut there are cases where chaplains (and nurses) are

asked to bite the hand that feeds them by calling attention tocare that is not as good as it could be and to unreasonable or-ganizational demands on staff. This situation presents chal-lenges to the autonomy of the occupation that more estab-lished professions do not face. Also, while nurses are a largeprofession that is often unionized and whose services are indemand, chaplains are a small profession that lacks the collec-tive power to protect their autonomy at the negotiating table.


Chaplains should think

about how to translate the

meaning and value of their

work into terms that hospital

administrators can

understand.


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Self-Interest and Public Interest

In their journey toward professional status, chaplains mustfind a way to balance professional self-interest and the in-terest of the people they serve. The official party line of mostprofessions is that all their organizational efforts are undertak-en on behalf of their clients, but decades of sociological analy-

sis show this claim to be hollow. The best-known examples ofprofessional self-interest come from the field of medicine,

where we have seen doctors in the United States consistentlyresisting changes that would improve access to health care.The American Medical Association famously fought the legis-lation that created Medicare (health care for the elderly anddisabled) in the 1960s, arguingwith a strong dose of self-in-terestthat the plan would reduce the quality of care for all.More recently, white coat rallies calling for malpractice re-form have at times cast physicians as the victims of greedy, liti-gious patients.

The bedside orientation of chaplains may make themless likely to put professional interests ahead of the interests of

patients and families. However, some chaplains tell us thatthey avoid these uncomfortable conflicts by flying under theradar. This metaphor suggests that chaplains may view theiremploying institutions or their professions as antagonistic totheir interests: a pilot flies under the radar to avoid gettingshot down by the enemy, not merely to avoid being noticed.

Our review of the strategic plan of the Association of Pro-fessional Chaplains shows how easy it is to conflate profes-sional and patient interests. Here are the seven goals of the

APC described in their 20072008 strategic plan:

Goal A: Increase collaboration and interaction with other

appropriate chaplaincy, spiritual care, and human serviceorganizations.

Goal B: Increase awareness of the value of Board CertifiedChaplains.

Goal C: Increase members ownership of the APC.

Goal D: Increase the participation by those of diverse back-grounds in activities of the APC at all levels.

Goal E: Identify and develop resources sufficient to fundand accomplish APC programs.

Goal F: Nurture the spiritual life of APC members.3

The first five of these goals are about building the credential-ing organization itself. With the possible exception of the finalitem, none of these goals seeks to improve the capacity ofchaplains to meet the spiritual, emotional, and physical needsof patients, families, or health care workers. Also absent fromthese explicit goals is a commitment to conduct or contributeto research that could provide empirical evidence of the valueof chaplains to patients. Doubtless the drafters of these goals

sincerely believe that strengthening the credentialing organiza-tion will improve service to clients. However, the sociology oforganizations teaches us that means often become ends.

How can chaplaincy avoid the extremes of flying belowthe radar (which works against unifying the profession) andthe self-interested move of reducing the goals of health care tothe goals of health care organizations? How can the profession

correct these errors of translationself-understandings thatseem to offer security but in fact may create barriers to profes-sional maturation by perpetuating a vision of a profession asinsular or marginal?

Here are our recommendations. Chaplains and their orga-nizations should think about how to translate the meaningand value of their work into terms that hospital administratorsand others in decision-making positions can understand. Inhealth care, translations must be clear and accurate if they areto provide an adequate basis for understanding and policy.Chaplains should make a practice of translating from the ter-minology of health care systems into that of their own profes-sion. By paying close attention to the nature of institutional

decisions about patient care, how various patient care profes-sions are deployed, and the concerns of decision-makers ingeneral, chaplains will be able to identify research questionsthat can yield reliable information about the chaplains contri-bution to patient care. These activities should not be confused

with making the numbers or merely reacting to institution-al concerns.

We also encourage chaplains and their organizations tolook for examples of individual chaplains or chaplaincy de-partments that are proficient translators and to analyze whatmakes them good at explaining the value of what they do toothers.

Finally, because chaplains seek to work in the complex cul-ture of health care delivery, and because claiming a profes-sional role in this culture means acknowledging ones organi-zational responsibilities, we encourage chaplains who aspire tolead chaplaincy departments to receive some training in healthcare organization and management. We also encourage orga-nizations that offer continuing education to chaplains to rec-ognize this need and provide credit for this training.

Acknowledgments

Raymond de Vries work on this project was supported by agrant from the National Library of Medicine (NIH,1G13LM008781).

1. This discussion of the sociology of occupations is borrowed froman analysis of the professionalization of bioethics found in R. de Vries,R. Dingwall, and K. Orfali, The Moral Organization of the Profes-sions: Bioethics in the United States and France, forthcoming in Cur-rent Sociology57, no. 4 (July 2009).

2. Ibid.

3. Association of Professional Chaplains, 20072008 Strategic Plan,http://www.professionalchaplains.org/uploadedFiles/pdf/Strategic%20Plan%202007-2008%20-%20no%20imp%20points-portrait.pdf.


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chaplaincy in establishing standards for training programs andcompetencies for trainees?

At this stage in the evolution of chaplaincy and clinicalethics, each profession has some clear accomplishments andfoundational elements upon which to build, but there aremore for chaplaincy than for clinical ethics. Despite some di-versity among chaplaincy interest groups, chaplains, pastoral

counselors, pastoral educators, and students regulate them-selves through a common professional code of ethics that of-fers basic values, standards of practice, and a mechanism foraccountability. Accreditation is available for clinical pastoraleducation (CPE) programs that adhere to requirements forthe admission of trainees and toexplicit standards related toCPEs specialized teaching,training, and supervision. Pro-grams for training future CPEsupervisors also exist. The U.S.Department of Education andthe Centers for Medicare and

Medicaid Services provide astamp of approval for thesechaplaincy and supervisorytraining programs by reimburs-ing for the trainees supervisedhours of pastoral care. Successfulchaplain trainees completing therequired number of units andhours of CPE training can becertified (not licensed) aschaplains. The Spiritual CareCollaborative, representing the

various chaplaincy certifyingbodies, has identified a commonset of competencies and exper-tise for certification. Certification affirms that core competen-cies have been achieved, and it provides credentialing for pro-viding pastoral care services in a clinical setting. Continuingeducation credits are required annually to maintain certifica-tions.

Clinical ethicists lag behind. A set of core competencieslimited to ethics consultation was developed by a national taskforce made up of twenty-one scholars from medicine, nursing,law, philosophy, religious studies, regulatory agencies, and theCollege of Chaplains (the precursor to the current Association

of Professional Chaplains). The core competencies were setforth as voluntary guidelines, and the task force membersunanimously concluded, when their report was published in1998, that certification of individuals or groups to do ethicsconsultation is, at best, premature.1Although various acade-mic and training programs in bioethics and clinical ethicshave emerged and some grant academic degrees, no clinicallybased training or fellowship programs are accredited or pro-vide a basis for certification because no accrediting or certify-ing body exists. Based on the identified core competencies forethics consultation, the American Society for Bioethics and

Humanities will soon publish a recommended and voluntaryeducation guide for improving proficiencies in the corecompetencies for ethics consultation. The ASBHs leadershipand members have debated whether to develop a code ofethics for the organization, or at least for clinical ethicists, anda task force has studied the issue. To date, however, there is alack of consensus about moving forward with such a docu-

ment. Finally, absent certification (or licensure), continuingeducation units are not required for clinical ethicists.

Despite their respective progress toward emerging identi-ties, gaps remain for both chaplains and clinical ethicists, es-pecially in the areas of evaluation and, correspondingly, quali-

ty improvement. In an evidence-based environment such ashealth care, a clear need existsfor concrete methods and mech-anisms to evaluate effectivenessand impact based on standardsof performance. But to date, theefforts of both chaplaincy and

clinical ethics have been limited.Simply counting the number ofpastoral care visits or ethics con-sultations addresses quantity butnot quality. Patient and familysatisfaction scores can be deceiv-ing, and they do not take intoaccount the nuances and sub-tleties of chaplains and clinicalethicists proper roles. Indeed,chaplains and clinical ethicists

work may not always contribute

to satisfied clients. Some whoare served by themfor in-stance, a patient who orders a

chaplain out of a hospital room because the chaplain is awoman, or a family member who strongly disagrees with anethics consultants recommendation to disclose medical prog-nosis to an adult patient with decision-making capacitymayexpress high dissatisfaction with the respective services ren-dered. And even if a patient is satisfied, a hospital may be un-able to measure that satisfaction according to the same scale ituses to gauge success in more objective areas. For instance, the

work both chaplains and clinical ethicists do advocating forpatients will not necessarily decrease a patients length of stay

or help to more efficiently utilize hospital resources.Although neither chaplaincy nor clinical ethics has been

able to fully identify or develop its role in modern health care,both make their own unique contributions to the care of pa-tients, families, and staff. The many commonalities of bothprofessionalizing professions warrants their increased collab-oration to address the similar challenges that each faces.

1. American Society for Bioethics and Humanities, Core Competenciesfor Health Care Ethics Consultation (Glenview, Ill.: 1998), 31.

Chaplains and clinical

ethicists together could

identify, recommend,

and promote quality

improvement methods

useful to both groups in

the clinical context.


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Seasoned clinical ethicists have a saying: You cannot bitea wall. The saying refers to that demoralizing moment oftaking in the scale of a (really) big challenge in health

care. We have two options when we find ourselves up againstthis wall. One is to ignore it. This means ignoring the needsof people who are sick, or lack access to health care, or couldbe harmed by care that is not as good as it could be. A healthcare professionals duty of care is a duty to act in the interestsof those for whom one cares. Merely feeling awfulits ashame about that wallis the same as ignoring the wall, fromthe perspective of those who suffer because of the walls exis-tence.

The second is to be ethical. We can find a crack in the walland work away at it. The trick is to avoid the temptation tobite off just a bit and declare victory, rather than staying con-nected to others working on the whole wall. It would be a

pity to take down just enough of the wall to build a silo.Quality improvement in health care can look like yet an-

other unbitable wall. And yet, the Institute of Medicine gaveus six ways of looking at the QI wall in its influential 2001 re-port, Crossing the Quality Chasm. The report described sixgoals, or aims, for QI in health care: it should aim to make

health care safe, effective, patient-centered, timely, efficient,and equitable.1

Different health care professions have focused on one ormore of these now-classic six, with particular attention tosafety and effectiveness. Health care, as an enterprise, has afundamental obligation to distinguish safe from unsafe andeffective from ineffective. Certain health care professions and

clinical specialtiespharmacists and anesthesiologists, amongothershave acknowledged safety to be their distinctive QIgoal. They have described problemsmedication labeling,equipment designand have recommended solutions in-tended to increase safety and also effectiveness, given that un-safe care is ineffective care. They have pledged, as a matter ofprofessional ethics, to keep working away on this bit of theQI wall.

It is now time for health care chaplains to step up to thiswall. The goal of patient-centered care should be stronglyidentified with this profession. Patient-centered care is a wor-thy goal and one that chaplains can contribute to, significant-ly and measurably.

Why QI? Ethics and Tactics

But why should chaplains choose any QI goal? And whypatient-centered care in particular?If chaplaincy wants to be taken seriously as a health care

serviceif chaplains want to be taken seriously as health careprofessionalsthen they cannot hold themselves apart fromthe ethical obligations of the health care enterprise. Doing so

would reduce the delivery of spiritual care to something thatone does for ones own fulfillment and for the incidental oroccasional benefit of others.

It is the nature of chaplaincy to be in solidarity with thesuffering person, which in health care is usually the patient orthe patients caregiver. It is also the nature of most chaplainsto prefer to be at the bedside. If chaplaincy cannot identify

with patient-centered care as its distinctive QI goal, then it ishard to make the case that another profession ought to. Andits hard to imagine why chaplains would not want to work tomake care better for the patients in the other beds, mindfulthat they themselves cannot be at every bedside.

Also, it makes good tactical sense for the profession ofchaplaincy to commit itself to patient-centered care as its QIgoal. Thanks to the wide dissemination and discussion of theIOM report, no health care institution can easily argue for a

definition of QI that does not include these six. If chaplaincy,as an institutional service, went on record as saying, in effect,Well help you with the goal of patient-centered care, thenchaplaincy can claim to share the credit for institutionalprogress, even as it will be held more accountable for showingprogress. Good tactics can converge with good ethics.

Defining QI.If we accept that the price of admission toprofessional status includes involvement in QI, and if we ac-cept that chaplains, as a matter of ethics and tactics, may havea particular affinity for QI activities aimed at advancing pa-

B Y N A N C Y B E R L I N G E R

The Nature ofChaplaincy and theGoals of QI:Patient-Centered Careas ProfessionalResponsibility

Nancy Berlinger, The Nature of Chaplaincy and the Goals of QI: Patient-Cen-tered Care as Professional Responsibility, Hastings Center Report 38, no. 6(2008): 30-33.


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tient-centered care, then how should chaplains go aboutdoing this?

First, they should become familiar with a good workingdefinition of QI. A recent Hastings Center project on the eth-ical issues raised by quality improvement defined QI assystematic, data-guided activities designed to bring aboutimmediate, positive changes in the delivery of health care in

particular settings.2 Conducting systematic, data-guided ac-tivities to advance patient-centered care is different from thedesire, however sincere, to provide patient-centered careorthe belief, however sincere, that one is already doing so.3

Defining patient-centered care. Next, chaplains shouldbecome familiar with how themost influential organizations

within the QI movement definepatient-centered care:

Institute for Healthcare Im-provement: Care that is trulypatient-centered considers pa-tients cultural traditions, their

personal preferences and values,their family situations, and theirlifestyles. It makes the patientand their loved ones an integralpart of the care team who col-laborate with health care profes-sionals in making clinical deci-sions. [It] puts responsibility forimportant aspects of self-careand monitoring in patientshandsalong with the toolsand support they need to carry

out that responsibility. [It] en-sures that transitions between providers, departments, andhealth care settings are respectful, coordinated, and effi-cient.4

Agency for Healthcare Research and Quality: In a patient-centered model, patients become active participants in theirown care and receive services designed to focus on their indi-vidual needs and preferences, in addition to advice and coun-sel from health professionals.5

IOM: providing care that is respectful of and responsiveto individual patient preferences, needs, and values and en-suring that patient values guide all clinical decisions.6

National Quality Forum: care [that] is centered on what

patients need and want, rather than on what is convenient forproviders.7

These definitions are not identical, but they are quite sim-ilar. Patient-centered care encompasses both the individualpatient and the coordination of care in the interests of all pa-tients. In a four-hundred-bed hospital, there should not befour hundred customized models of patient-centered care,but rather one model that can reflect the needs and prefer-ences of each patient with respect to his or her diagnosis andtreatment goals, as well as

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