The modern pastoral care movement has an extended relationship with the discipline of bioethics. The gradually evolving dialogue includes discussions of such topics as palliative care, patient autonomy, the patient as a person in the system of care, and the rights and responsibilities due subjects in research protocols. In this essay, I discuss what is required of pastoral care professionals in this dialogue between medicine and religion and explore the nature of the contribution of pastoral care to contemporary bioethics. I also suggest future avenues for creative engagement, particularly in the area of organizational ethics.

FORERUNNERS IN THE DIALOGUE
As early as the 1920s, leaders from medicine and religion advocated a dialogue between the two fields. Among them Richard Cabot, of the Massachusetts General Hospital in Boston, proposed clinical training in hospitals for seminarians and clergy and wrote at length about the nature of the doctor-patient relationship.¹ In 1954, Joseph Fletcher—a professor at the Episcopal Theological School in Cambridge, Massachusetts, who directed one of the prototypes of clinical pastoral training in Ohio—advocated in his Morals and Medicine for a patient's right to know the truth about the diagnosis and course of treatment for disease.² Carl Nighswonger, chaplain at Chicago's Cook County Hospital, made invaluable contributions to Elizabeth Kubler-Ross's pioneering work on the stages of dying.³ And Seward Hiltner of Princeton Theological Seminary, an individual significantly engaged in the development of clinical training of future clergy, was directly involved in a federal commission mandated to investigate and make recommendations about the treatment of human subjects in the Tuskegee study and the conduct of the research. These and other individuals laid the groundwork for pastoral care professionals to work with medical colleagues in the field of bioethics.

LINKING CARE AND CONCERN
It is noteworthy to consider the degree to which medicine and pastoral care share common ground and deal with similar concerns about the care of the patient. An understanding of this common ground establishes the degree to which the disciplines are bound up with one another. Every year I teach, with other medical school faculty, a foundational course for first-year medical school students entitled "Medical Ethics and the Physician-Patient Interaction." A piece on therapeutic aspects of the clinical encounter is required reading for the initial meeting of the course. The author outlines a series of affective therapeutic strategies that enable and enhance communication within helping relationships. The strategies include "offering hope"; "touching," including specifically the laying on of hands; "facilitating self-forgiveness"; and "giving reassurance."⁴ These aspects of the therapeutic, and in this case, the doctor-patient relationship sound quite similar to what are commonly understood to be priestly or pastoral offices. Such therapeutic interests are, of course, held in common by chaplains, doctors, nurses, social workers, and others dedicated to the provision of humane care to the sick. The related communication skills are at the same time critical to making sound, fair, reflective choices at the bedside.

Specific attitudes and values necessary for the identity of pastoral care professionals—empathy, self-awareness, and flexible critical thinking—are the product of a formal theological curriculum integrated with supervised pastoral training in the clinical setting. Professional pastoral care came into being in the United States in the 1920s under the leadership of visionary, intrepid, and quirky souls who over time persuaded doctors and hospitals to recognize the importance of theologically sophisticated and clinically trained clergy as one of the basic resources for the care of the ill. These early leaders were also able to convince theological educators of the importance of this training for the ministry. In many cases this training, which came to be known as Clinical Pastoral Education (CPE), became either a requirement or highly recommended for all those seeking ordination. In many, if not most, basic programs of CPE, there is an exposure to bioethical issues and concepts. For any person choosing pastoral care or pastoral supervision of students as a career calling, the period of clinical training lasts for at least a one-year internship and generally longer. It may well include the expectation that pastoral care trainees become knowledgeable about and involved with the process of ethical decision making in patient care. This clinical activity may be complemented with additional grounding in the basic principles and concepts of bioethics—autonomy, beneficence/nonmaleficence, justice, and fidelity—their application in clinical care, and their theological implications.

TAKING ON A LABOR OF LOVE
My own story provides an illustration of how and why this sort of training and exposure is essential. The year I began my formation as a chaplain was 1969—an era that demanded "relevance" in education. Accordingly, what was studied in the classroom should have direct consequences in the world of choice and action. Theory and practice, means and ends were meant to be interdependent and mutually enhancing. My CPE provided me with ways to think critically about the connection between the theory and practice of ministry. I gradually became convinced that theology could not only be talked about, criticized, and interpreted but could be understood and practiced in concrete, human relationships, including pastoral ones. My internalizing of the clinical method of learning liberated me to listen with greater clarity and ever deepening respect to the layers of meaning behind ancient words and liturgical rites. Because of my training, I was better prepared to understand the nature of the crises shared with me in hospital rooms and on the streets of the Crown Heights, Brooklyn neighborhood of New York where I was a parish priest. For example, I came to grips with some of the ethical, psychological, and cultural issues involving honesty and secrecy for my parishioners and their families, most of whom were first or second generation immigrants from the Caribbean, who were dealing with terminal illness and death. And where possible I was able to intervene and then reflect critically about my own pastoral practice.

This process of professional development parallels what happens to medical students and interns when they begin to care for patients in their clerkships and residencies. Anyone who has undergone this or a similar experience knows it to be a rite of passage—among the most exciting and fulfilling in all of adult life, for it confirms a future filled with promise even as it makes exhausting and rigorous professional training and formation, quite literally, a labor of love.

LISTENING FOR THE DEEPER QUESTION
I was taught and continue to believe that theology is conversation, a conversation between past and present, text and event, between the reading of the Bible and the daily newspapers as the theologian Karl Barth claimed. But in the contribution of pastoral care to bioethics, this conversation includes an expanded set of participants with a particular set of questions. Part of the method of theological reflection in Barth's Church Dogmatics⁵ involves a series of propositions in which elements of doctrine are stated and then commented or elaborated upon by a range of authorities and sources, each of which has relevance to a thorough grasp of the doctrinal or dogmatic topic at hand. But what if this conversation were opened to include the voices and concerns of ordinary people facing life crises and ethical choices such as those regularly confronted in hospitals, long-term care facilities, and their own homes? To include these voices and their concerns, on one hand, enriches and expands the range and depth of formal theological reflection and, on the other, provides an opportunity to acknowledge their demands for self-determination and justice in bioethical discourse and consultation. As is the case with formal theological conversation, it is understandable that because of tradition and inertia the power to pronounce, comment, and decide will gravitate in the direction of those in the medical world, who historically have most often been consulted for answers. Making certain that the concerns of patients, particularly related to faith and the inner life, become integral to the decision-making process is central to the role of pastoral care in bioethics. While inclusion of patient and surrogate voices is rightfully the concern of all dedicated and sensitive professionals, it remains for pastoral care to be especially attentive to this area.

For example, what is a family really afraid of or unclear about when they block a decision to remove life support or to provide only palliative care near the end of their loved one's life? A member of the pastoral care staff at our hospital was asked to consult with a family whose elderly relative was in the intensive care unit. The family members were aware that there was no apparent hope for significant improvement, let alone cure, and yet they appeared paralyzed and unable to make any decisions about ceasing medical interventions. There had been no precise advance directive written, but the family members claimed to know their relative very well. The efforts of the pastoral care staff member, a Roman Catholic sister, assisted this family in several ways. First, they were able to express their grief at the prospective loss of a loved one. Second, the pastoral care staff member assisted them in obtaining clear and current communication from the medical staff about prognosis and any additional options for treatment. This communication had been shared previously but required a sensitive and careful review before the family could move in the direction of making a decision. Last, some members of the family voiced a concern about whether the church taught that everything possible should be done to sustain life. Listening carefully and responding with respect to the family members expressing this belief, the pastoral care staff person shared that life is sacred in the eyes of God and the church, that it is possible to provide support and comfort while not extending life, and that this approach could be seen as appropriate and, in fact, a benefit. Relieved, and with assurance that they and their loved one would not be abandoned or left alone, the family accepted comfort care measures as not only medically realistic but morally acceptable.

The lessons from this story are several. It would have been clearly beneficial to have written an advance directive and appointed a surrogate well in advance of the medical crisis to carry out the relative's expressed wishes. Second, the story underlines the particular role of pastoral care in facilitating communication and self-forgiveness on the part of the family. They were reassured that their decision on behalf of their elderly relative was morally and religiously fitting, thus relieving them of an unwarranted burden of guilt. Third, it points out the need for continuing education and review for all persons about ethical issues and decision making. In this case, the family might well have profited from up-to-date knowledge about end-of-life decisions reflecting contemporary religious teaching.

PASTORAL CARE IN ACTION
It is far easier to make choices embodying a person's values and attitudes about life and health if these issues are addressed prior to an immediate crisis. And it is critically important for clinicians to understand something of the religious and cultural factors affecting families' and individuals' choices and behaviors. Pastoral care professionals can enhance the conversation between religion, medicine, and bioethics in a variety of public ways. They have an obligation to use their expertise and communication skills by speaking to congregational and other groups, writing articles for newsletters and denominational publications, and serving on commissions and panels concerning issues such as end-of-life and surrogate decision making, human cloning, stem cell research, the abortion debate, and public policy regarding humane care for the mentally ill.

Pastoral care professionals can also use their formal theological education, integrated with first-hand clinical involvement, to enlighten those involved in the direct provision of care. In New York City, our hospital regularly serves the needs of Holocaust survivors, many of whom are approaching the end of life. Understanding and addressing their particular life experiences is part of their care. Our department's rabbi not only serves these persons and their families through pastoral care at the bedside, but also addresses staff concerns by educating them in seminars and in-service activities about what it might mean for a survivor to enter into a large, imposing institution such as a teaching hospital. The rabbi explains further that individuals and families with a Holocaust history might react to hospitalization with fear, wariness, suspicion, and an apparent lack of cooperation. Like most hospitals, we base our self-image upon a demonstrated and consistent adherence to the principle of beneficence, "to help and do no harm." That self-understanding is challenged by those who react to care with ambivalence, mistrust, and transparent anxiety. In the hospital, medical tests ordered for the survivor are performed by strangers. It is not hard to comprehend why any person who had experienced trauma of the proportion of the Holocaust might experience hospitalization as potentially threatening and resonant with a horrific past.

REACHING INTO THE PATIENT'S WORLD
To see the world from the survivor's perspective is the first step in establishing a trusting relationship between staff and patient. Identifying what the survivor has gone through assists staff in assessing a potential source for anxiety and resistance to treatment and helps them to adjust their expectations and act accordingly in their professional roles. If, as the psychoanalyst Heinz Kohut suggests, such empathy is "vicarious introspection . . . the capacity to think and feel oneself into the inner life of another person,"⁶ then the work of the pastoral care professional in this and similar situations helps staff build a bridge into the patient's world. While this process of empathy does not involve touching in a tactile sense, it does encourage touching in an emotional sense, the kind of touching that is part of the common ground of values shared among all healers. In this example of efforts to understand the inner world of the Holocaust survivor, as well as in other less dramatic ways, the purpose of pastoral care is to help patients communicate their otherwise unexpressed needs and concerns, including cultural and religious ones, and where possible to convey the therapeutic empathy that exists at the core of healing.

ESTABLISHING COMMON GROUND
Another way of appreciating the methodological contribution of pastoral care to bioethics is to consider this conversation among caregivers, patients, and loved ones as a type of apologetics. As Paul Tillich defines it, "Apologetics is an answering theology . . . In order to answer a question one must have something in common with a person who asks it. Apologetics presupposes common ground, however vague it may be."⁷

It is obvious that a pastoral care professional can empathetically understand and respond to questions or statements like "What should I do?" "Do I really have any choice in all this?" or "I've been a believer all my life but now, after what I've been through with this treatment, I'm not so sure I can trust the doctor and the staff." An apologetic approach in bioethics presumes that there is common ground and thus a potential opportunity to mediate competing interests among all parties having a stake in resolving questions and conflicts. If adequate communication between patients, families, and staff can be sustained, then there is an opportunity to clarify distortions and misperceptions that make for prolonged and seemingly intractable debate.

PASTORAL CARE AND HEALTHCARE ORGANIZATIONS
A more problematic aspect of apologetics exists in the area of organizational ethics and the place of pastoral care in that emerging enterprise. Communication and the inclusion of differing perspectives in bioethical decision making in the clinical setting appear to differ from finding common ground with those involved in making critical judgments and administrative decisions regarding organizational issues, such as budget construction, preferential treatment of some individuals or groups, hiring and personnel matters, and the general conduct and tone of organizational activities and politics. There is an argument that suggests that pastoral care professionals should not be encouraged to join in discussions at the level of corporate decision making due to ignorance and lack of experience in business matters and an anti-business bias among clergy. There is also the fact that involvement in organizational concerns and ethics takes away from vital clinical and teaching time for pastoral care department heads and Clinical Pastoral Education supervisors. On the other hand, it can be forcefully argued that the involvement and presence of pastoral care professionals might well aid in the area of organizational ethics given that they are used to significant responsibility, command the respect of others due to their day-to-day conduct and the identification of their role with high purpose, and are eminently educable in the area of organizational matters given their experience and proven capacity for disciplined reflection.⁸

Making a decision about becoming involved in organizational ethics entails an assessment of the following questions: Will the pastoral care professional be compromised by being asked to act as a spokesperson for administration, thus becoming, in effect, like the "court prophets" described in Hebrew scripture? Does the pastoral care professional have a well developed, articulate ethical outlook and political philosophy suited for involvement in major institutional decision making? Can the professional pastoral caregiver do more than vacillate between passivity and outrage in the face of perceived organizational and systemic dysfunction? Rather, in the face of institutional crisis can the pastoral caregiver think and act with a blend of skepticism, tolerance, patience, and moral courage? And can one considering engagement in organizational ethics learn from experience, appreciate the pressures endured by institutional decision makers, advocate for change, and at the same time be willing to accept verdicts and outcomes that do not immediately appear prudent or fair?

To respond to these questions, one must, as with all sound ethical reflection, balance competing goods and interests. Being involved in organizational ethics may well require an innate ability to distinguish between means and ends, a capacity to separate expediency and deliberate or semi-deliberate rhetorical obfuscation from the overall mission of an institution or organization.

ULTIMATE CONCERN IN A HEALTHCARE SETTING
Theological training teaches much about what Tillich calls "ultimate concern." In the case of hospitals, that can be understood as dedication to the humane care of the sick as it is guided by the highest clinical practice standards and grounded in enlightened science and research. Tillich also warned that "ultimate concern" must not be mistaken for penultimate concern, which in hospitals often revolves around organizational interests and necessities such as dealing with employee dissatisfaction, facing inspections from regulatory agencies, and implementing of budgetary restructuring. An acute understanding of the difference between ultimate and penultimate concern already informs the contribution of pastoral care to clinical ethics at the bedside. The challenge of pastoral care's ongoing contribution to bioethics will be for those practitioners who choose involvement in organizational ethics to retain a strong and committed hold on this reality.

ACKNOWLEDGMENT
This essay grows out of a presentation given at the New York-Presbyterian Network Hospitals Bioethics Committees' Colloquium in October 1999.

NOTES
1. David J. Rothman, Strangers at the Bedside: A History of How Law and Bioethics Transformed Medical Decision Making (New York: Basic Books, 1991), 103–104.