Understanding Clinical Chaplaincy Approach to Biomedical Ethics: An Imminent Need and a Challenge

Abstract

While we, the medical community, have recognized “Spirituality” as a vital component of health, we have not yet clearly defined the term “spirituality” for clinical education, care, and research. Though we have a robust clinical spiritual care program called Clinical Chaplaincy and, though chaplains work so closely with us, medical professionals, we have not yet conceptualized the framework of Clinical Chaplaincy process nor understood how patients are healed through it. With my year-long clinical chaplaincy residency training I realize that only through our experiential understanding we will be able to conceptualize the pieces of the chaplaincy-puzzle. I also, consider that as medical students, you need to be introduced to the “research lab” where the initial understandings of chaplaincy processes are being generated. A complete clinical “Verbatim case report” of the Clinical Chaplaincy process is provided for the reader to inductively study the “qualitative data” of the spiritual care process. This chapter is meant to provide (1) a comprehensive understanding of a clinical chaplain-patient interaction, (2) to highlight how chaplains guide and accompany their patients in their “mindful walk” through their pain and struggles (3) to finally arrive at a deeply and empathetically centered spot within oneself from where (4) the patient would draw his/her own meaning and purpose in the painful loss leading to their healing. The focus in this chapter is to highlight how the chaplain guides the patient through the ethics of medical decision-making process. In this, the mindfulness-based processes of clinical chaplaincy will also be studied.

Appendices

Self-Assessment Questions

In this section, I have provided three clinical case scenarios, which you have to study to understand what kind of religious or spiritual intervention would benefit the patient. In the fourth exercise, you are being asked to develop a simulated clinical case by pairing up with your classmate, to role-play a clinical patient and his/her chaplain, to experience a clinical chaplaincy situation. Finally, you are being asked to visit an actual clinical patient as a volunteer-chaplain or chaplain-intern to provide spiritual care. You would benefit from presenting your clinical verbatim to a chaplain supervisor in your hospital, if any.

Case-1: A 58-year old staunchly religious Muslim patient was brought to the ER with drowsiness, disorientation, shakiness, sweating, headache and pale skin. Initial blood work revealed severe hypoglycemia. On detailed history patient revealed that though he was taking his diabetic medications properly he was also fasting because that was the month of Ramadan.

Question: What would you do in this situation? What kind of intervention is needed here, a religious-counselling or a spiritual care process?

Guidance: Refer to John W. Ehman’s UPenn resource on “Religious Diversity: Practical Points for Health Care Providers.”http://www.uphs.upenn.edu/pastoral/resed/diversity_points.html

Case-2: A 29 year old mother was nervous seeing her 5 year old daughter being rolled towards the operation theater for an emergency appendectomy. While talking to the anesthetist the mother informs that they are Jehovah Witness and blood transfusion is a taboo according to their faith tradition. The anesthetist allays the mother’s anxiety saying it is a minor surgery and he is not expecting a dire need for blood transfusion. But, he also adds that in case of a complication with excessive blood loss the surgical team may decide to offer blood transfusion.

Question: Did the anesthetist attend to the patient’s mother appropriately and honestly? What kind of intervention is needed in such situation, a religious-counselling or a spiritual care process?

Guidance: Refer to John W. Ehman’s UPenn resource on “Religious Diversity: Practical Points for Health Care Providers.”http://www.uphs.upenn.edu/pastoral/resed/diversity_points.html

Case-3: A 63 year old female retired oncology nurse was now admitted with a new diagnosis of lymphoma. She was seen tearful and rolling her rosary most of the day since her admission. A deft nurse approached her and quickly does an assessment of her spiritual care needs. The nurse discovers that one of the patient’s church prayer group member had apparently suggested her to discuss with the priest for atonement of possible sin she may have committed in her past and, that her lymphoma was God’s punishment.

Question: What kind of intervention, Religious or Spiritual care, does this patient need?

Spiritual Care exercise-4: Pair up with your classmate. One of you need to role-play as a clinical patient and share a painful event from your life (share a real event if you feel comfortable or concoct a painful story) with the chaplain (role-played by the other classmate in the pair). The “patient” should share his/her story in bits as it may unfold in your interaction with the chaplain. The “chaplain” may follow the mindfulness-based clinical chaplaincy methodology as he interacts with his “patient.” After the “clinical visit” the “chaplain” should prepare a verbatim case report in the format provided in Table 2 and present it to a chaplain supervisor in your medical college hospital.

Spiritual Care exercise-5: Visit an actual clinical patient in your medical college hospital as a volunteer-chaplain or chaplain-intern to provide spiritual care. After the spiritual care visit prepare a case report in verbatim (follow the format provided in Table 2) and present it to a chaplain supervisor in your medical college hospital.

Key Terms and Definitions

The goal is to explicitly and intentionally add new terms to the students’ vocabularies.

1. Chaplain = a clergyman officially assigned to provide religious/spiritual services to members in institutions such as military, hospitals, schools and, prisons.

2. CPE = Clinical Pastoral Education (See Call-out Box 1)

3. ACPE = Association for Clinical Pastoral Education. (https://www.acpe.edu/)

4. Board of Chaplaincy Certification Inc. (BCCI).

5. Seminary = an education institute for the training of candidates for the priesthood, especially refers to Roman Catholic Christian tradition. Its equivalent, for example, in Islam would be a “Madrasa” and “Veda Paṭhaśālā” in Hinduism.

6. Seminarians are students in seminary schools.

7. Theology is the study of the Divine/God, Its nature and Its relation to the human beings and the world. But, it is also referred to the study of religious faith, practice, and experience of the “Divine” through one’s religious activities.

8. Religion is a set of beliefs that is held by an organized group of individuals concerning the cause, nature, and purpose of the universe, especially when considered as the creation of a superhuman agency or agencies, usually involving devotional and ritual observances, and often containing a moral code governing the conduct of human affairs of that community.

9. Spirituality is a term that refers to all kinds of meaningful activities that affect the human spirit or soul as opposed to material or physical things: It may refer to human search for the sacred in their blissful experiences in the interconnectedness with other humans beings, animals and or the nature. People understand “spirituality” as different from the construct of “religion” and, relate it to acts of compassion and selfless altruistic activities through which they connect with the nature. Thus, “Spirituality” has been defined in numerous ways but, researchers argue that its definition is still not applicable for clinical research and education purposes.

10. “Mindfulness” is a meditative state of observing one’s own thoughts and feelings without judging them good or bad.The term “mindfulness” is derived from Buddhist meditative practices but, it can be seen in the Hindu meditative practices that predates Buddhist tradition and it can be seen as a universal practice in the meditative techniques in the mystical traditions of all religions in this world.

11. “Centering meditation” is a term that is developed from the Christian traditions. One can understand how mindfulness process leads the meditator to “center him/herself,” retracting oneself from all the distractions of the worldly thoughts and worries.

12. “The Cloud of Unknowing” is a meditative state in which the meditator is said to “glimpse” the Divine experientially. This is described a Christian mystical meditative practice in which one has to abandon all discriminatory intellect by surrendering one’s mind and ego identities.

13. Epochē = Suspension of judgment (Greek). This is considered as decisive in avoiding emotional disquiet to reach “ataraxy.”

14. Ataraxy = mental calmness. This is considered as “a must” for religious, scriptural studies. This is also considered as the starting point for empathetic, embodied understanding of the other, i.e. phenomenological process of using the “Self” in the study of the other.

15. Religious professionals have assigned titles such as Priest, Pastor, Minister, Deacon etc. in Christian religions/denominations. Within a religion/denomination there are different terms to denote different hierarchical positions of that religious profession. Similarly, there are different terms in other religious traditions as well.

16. Priest = Can be a “generic” term for clergyman authorized to perform sacred rites in a religious tradition. In certain Christian traditions, such as Anglican, Eastern Orthodox, or Roman Catholicism, “Priests” rank below a “Bishop” and above a “Deacon.” “Pastor” is an equivalent position in protestant tradition. Imam = a Muslim religious/spiritual leader in the Shiite tradition. Purārī = equivalent term for “priest” in Hindu religion; Rabbi= Jewish religious leader trained to lead religious congregation ceremonies and also expound Jewish law; Shraman)

17. Immanent = existing or operating within, inherent.

18. Transcendent = beyond or above the range of normal or physical human experience

19. Metacognition, put simply, is curiously thinking about one’s thinking or questioning them. More precisely, it refers to the processes used to plan, monitor, and assess one’s understanding and performance. Metacognition includes a critical awareness of one’s own thinking and learning about oneself through his/her self-reflective processes. Metacognition is thus a part of one’s meditative process.

20. Theory of Mind: Using our emotional experiences, when we intuitively conceptualize the existence of a non-observable entity called as the “mind” then we are said to have a theory of mind (ToM). Further, this ToM helps us deduce that other individuals also have a mind, and that helps us understand possible thoughts and feelings of others.

21. Mirror-Neurons are a set of neurons that are active not only during an individual’s cognitive and motor functioning but also when that individual sits merely observing the behavior of others. They are called “mirror neurons” because they not only respond to the observed physical activities of other individuals but also involuntarily resonate or mirror the feelings of others.

22. Transpersonal-Mindfulness is described as a chaplain’s ability to transcend the “ego-centric self” to understand the thoughts and feelings of the patient in a first-person experience to provide the embodied care during chaplaincy.

23. Trance-state is an altered state of consciousness that is characterized by easy suggestibility and ready and empathic compliance to the wishes/request of the other. There is an apparent absence of response to external stimuli. This state is popularly seen induced by hypnosis or entered into through a religious-meditative practice.

Recommended Readings and Weblinks

• 1. John W. Ehman. “Religious Diversity: Practical Points for Health Care Providers.”http://www.uphs.upenn.edu/pastoral/resed/diversity_points.html

• 2. Publications of Anton T. Boisen and publications on Boisen by other scholars that came after him.

• 3. Select spirituality-related publications compiled by John W. Ehman, listed as: “Spirituality & Health: A Select Bibliography of Medline-Indexed Articles Published in 2015” (http://www.uphs.upenn.edu/pastoral/resed/bib2015.pdf)

• 4. Alternatively, students will benefit from reading publications by current leading scholars in “Medical Spirituality” such as Russell D’Souza, Harold G. Koenig, Christina Puchalski, Robert C. Cloninger, Kenneth Pargament, George Fitchett, Curtis Hurt and Kevin J. Flanelly.

• 5. Primary (translations of) scriptural texts of major religious traditions of the world (such as Buddhism, Christianity, Hinduism, Islam and Judaism) and their mystical interpretations.

• 6. Clooney, F. X. (2010). Comparative theology: Deep learning across religious borders. Chichester: Wiley-Blackwell.

• 7. Hart, C. W., & Div, M. (2010). Present at the creation: The clinical pastoral movement and the origins of the dialogue between religion and psychiatry. Journal of Religion and Health, 49(4), 536–546. https://doi.org/10.1007/s10943-010-9347-6.

• 8. Ijaz, S., Ijaz, S., Khalily, M. T., & Ahmad, I. (2017). Mindfulness in Salah prayer and its association with mental health. Journal of Religion and Health, 56(6), 2297–2307.

• 9. Johnston, W. (Ed.). (1996). The cloud of unknowing and the book of privy counseling. New York: Image Books.

• 10. Koenig, G. H. (1998). Handbook of religion and mental health. London: Elsevier Science, Academic Press.

• 11. Mitchell, C. M., Epstein-Peterson, Z. D., Bandini, J., Amobi, A., Cahill, J., Enzinger, A., Noveroske, S., Peteet, J., Balboni, T., & Balboni, M. J. (2016). Developing a medical school curriculum for psychological, moral, and spiritual wellness: Student and faculty perspectives. Journal of Pain and Symptom Management, 52(5), 727–736.

Appendix

Table 1 This (below given) is a typical format in which a clinical chaplain records his/her verbatim for CPE-group presentation. The format given in the “Body” of this chapter is for the purpose of aesthetic-reading. Students should follow this format to write their verbatim reports of spiritual care visit only after completing their visitation with the patient and exiting patient’s room

Table 2 Clinical Chaplaincy Verbatim-Exercise table: Choose a partner in your class who would be willing to share a painful (real or made-up) story and interact with him/her empathetically. After completing your interaction, take some time to organize the entire interactions in the following tabular framework for your practice as a spiritual care provider. Present this case to a clinical chaplain supervisor in your hospital