Since discussions of medical ethics often focus on a case, consider Eve. Eve was a fixture at Christ Church. She married and buried her husband there. She raised her children there. For fifty years she sat in the same pew and joined with fellow members in offering prayers of invocation, thanksgiving, confession, and petition. For fifty years she looked at the stained glass windows of the Good Shepherd, Jesus blessing the children, and the resurrected Christ welcoming all. For fifty years she sang hymns about God's providential care and listened to countless sermons about God's grace and how we are to respond with faith, hope, trust, and love. For most of those years she read the scriptures with her Sunday School class while facing pictures of Christian martyrs.

At eighty-four years old, Eve elected to have major surgery despite her age and a significant chance that she would not survive the operation. She chose surgery because her heart had become so bad that she could no longer participate in the church and family activities that she loved.

Paul, Eve's pastor, visited the night before surgery. They talked about her faithful life and the hope and risks of surgery. Eve responded that God had been good to her and that matters were now in God's hands, as they had always been. They read Psalm 16 together: "Protect me, O God, for in you I take refuge."

Although surgery went well, Eve's recovery did not. She looked and felt good initially. But her heart would not stay in sinus rhythm, her kidneys began to fail, and her lungs filled with fluid. Two weeks after surgery Eve was on a respirator and maximum doses of heart and kidney medications. The doctor told the family that there was some chance that Eve would recover and recommended starting dialysis. The family agreed.

At that point, Pastor Paul, who stayed with Eve and her family throughout the two weeks, intervened. Paul pressed the doctor to explain to the family what "some chance" of recovery meant. The doctor responded that Eve probably had a two or three percent chance of getting significantly better. Although chilled by this news, the family was still inclined to start dialysis. Paul then gently suggested that continuing treatment seemed inconsistent with Eve's life and with the family's own trust in God.

After prayerful consideration, Eve and her family decided against dialysis and asked for the respirator's removal. Christ Church was filled for Eve's funeral service. The service itself was filled with tears and laughter—the latter celebrating the well-lived life of one who trusted that we are in God's hands.

Unlike typical case studies in medical ethics, Eve's case starts long before and separate from hospitalization and culminates after her death. I begin with this case because it illustrates my contention that for Christians the pastor's relationship to medical ethics extends from the pew to the bedside.

Reflecting the dual focus on pew and bedside, my argument has two distinct sections. The first section does not deal with what first occurs to most of us when we hear someone say "ethics" or "medical ethics"—that is, a forced choice between undesirable alternatives or a violation of moral norms or the principles and procedures we adhere to in making decisions. Instead, the first section directs our attention to concerns that are antecedent to this type of ethics by contending that, for Christians, medical ethics is an outgrowth of congregational life. More specifically, I argue that both moral medical decision making and medicine as a morally worthwhile social practice are dependent on preceding theological convictions and qualities of character. I then argue that the pastoral responsibilities of communicating Christian convictions and helping shape Christian character constitute a significant pew-based, that is, congregation-based, relationship to medical ethics.

Many will recognize this first section as an argument for concerns arising from character or virtue ethics. Central to virtue ethics is a shift in the focus of ethical reflection. Since the eighteenth century, moral theory has tended to focus on moral quandaries, rules, principles, and methods for determining the moral status of specific acts. By contrast, virtue ethics shifts the focus by concentrating on "background" issues, such as character traits, personal commitments, community traditions, and the conditions for humans to excel and flourish.¹ The first section of this paper argues for this shift in focus. However, instead of an extended technical discussion of virtue theory, I use Eve's case to argue for the importance to medical ethics of background issues, such as convictions and character. And, consequently, I locate much of the pastor's role in medical ethics in the background.

Without losing sight of these background concerns, the second section deals more directly with what most understand when they think of medical ethics. This section discusses the pastor's role at the bedside by sketching interconnected images of ministry: the pastor as priest, theological interpreter, medical translator, prophet, and friend. I use these images to highlight aspects of the pastoral bedside task and to suggest how that task intersects with medical ethics. Thus, for instance, I argue that the pastor's priestly role of representing the faith community's and God's presence to the patient helps limit medicine to its proper authority.

A caveat about the scope of this project is in order. Due largely to my own social location, this paper addresses how the pastor in the Christian congregation or parish intersects with and informs aspects of medical ethics. How these issues work out for leaders in other faith traditions is not my explicit concern. Further, while some aspects of the second section are applicable to Christian clergy in noncongregation-based ministries—hospital chaplains, for example—I do not directly address these ministries.²

CONGREGATIONAL LIFE
Christian Convictions
In her wonderful book Stewards of Life, Sondra Wheeler observes that virtually "every serious decision about the treatment of the sick has theological implications."³ Wheeler is right. In Eve's case, for example, the decisions to not start dialysis and to remove the respirator presumed certain theological convictions, including the need to "honor your parents." Remembering the serenity with which Eve approached this risky surgery, the family realized, with help from the pastor, that continuing to deny death's approach was to dishonor their mother and her convictions.⁴

The family also shared Eve's belief that her life was in God's hands and that death is not the last word. Eve raised her family in the church. They always attended Good Friday and Easter services. They grew up with that window of the resurrected Jesus and those same pictures of the martyrs. They knew that suffering and death are not the worst evils. With Pastor Paul's help, they gradually realized that to deny death not only dishonored their mother, it belied their own faith in God.⁵

This contrasts sharply with the physician who recommended dialysis while suggesting that Eve might still recover. It is possible, indeed likely, that the physician made the recommendation in part because he viewed death as the end and final defeat. Although seldom explicit, this view is common in our culture. When death is viewed as the ultimate defeat, fighting death to the bitter end becomes the medical imperative. Thus, when we compare the doctor's actions to those of Eve and her family, we see that convictions about death that are at heart theological lead to different medical decisions.

Like the decision to forgo dialysis, Eve's decision to pursue surgery rested on theological convictions, specifically about the purpose of life. As a Christian, Eve viewed life as a good directed to God and others. Life is for relationship to God, worship of God, and serving God through the church; life is for relating to and caring for others. Yet Eve's health left her unable to participate in church or to join in family activities. Eve cherished life and would never have aimed at her own death.⁶ Her decision for surgery aimed instead at getting well enough to participate more fully in the purposes of life: worship, relationships, service.

End-of-life decisions are not the only ones to rest on theological beliefs. Other examples include abortion and issues of justice. Two years ago, a young woman, still in high school, told me and some of her peers that she was pregnant. Someone soon raised the question of abortion. The young woman responded immediately, "Oh, I couldn't do that." When pressed for a reason, she offered religious convictions; talking about the limits of human freedom and about the unborn being precious to God. Her religious convictions ruled out abortion. So too, when medicine wrestles with questions of justice—such as who gets the transplant or how health care should be distributed—it wrestles with "an area that the prophets and epistle writers persist in viewing as a theological matter."⁷

Medical decisions presume beliefs that are at bottom theological, although these convictions are often implicit and unconscious. They assume that we are essentially autonomous or interdependent, that life is merely a personal project or necessarily involves vocation and service, that we are embodied selves or merely bodies or trapped in our bodies, that our worth derives from our social contribution or our being-in-relation to God.

To realize this dependence on theological premises is to recognize that, for Christians, medical ethics is an outgrowth of congregational life and pastoral leadership, for it is in our churches that we discuss and learn, or fail to discuss and learn, Christian theology. It was in the church that Eve learned the convictions that led to her surgery and then to forgoing further treatment. Lacking a congregational context like Eve's, or failing to talk explicitly in church about beliefs and their real world implications, Christians slowly adopt assumptions that are often at odds with Christian beliefs.

Christian Character
Although our beliefs are important, moral decision making requires more than mere intellectual assent to certain claims. Determining and doing the right requires our having developed the appropriate tendencies, dispositions, and capacities; it requires our having developed the requisite virtues. Some examples will clarify what I mean.

Over a lifetime, Eve acquired virtues she drew on in her decision for surgery. We see hope both in her desire for healing and in the serenity with which she approached death. Truthfulness is visible both in Eve's description of her current life, its value and its limits, and in her recognition that surgery might fail.

Contrast Eve with Harold, another member at Christ Church. Harold successfully hid his fifty years of heavy smoking from fellow church members. To those few who knew his secret, Harold insisted that it was a harmless habit. Harold developed serious lung and circulatory problems, but he continued to smoke, claiming that smoking had nothing to do with his "minor" problems. As things progressed, Harold's physician frequently hinted that there was little point in additional treatments or therapies, but Harold could not hear this limit. Indeed, for the last six months of his life, Harold was repeatedly rushed to the hospital, admitted to various treatment and rehabilitation programs, and then sent home again. Harold continued to insist that he was getting better and would often note, "I just don't know what is wrong with me."

The difference between Eve and Harold does not rest on their beliefs. They believed the same things. The difference is that those shared beliefs were not rooted in Harold's character in the form of the virtue of truthfulness. Harold never intentionally lied; he simply did not have the ability to look at himself and the world honestly. He lacked the quality of truthfulness. Deficient in this characteristic, Harold never faced his impending death. The result was that instead of getting ready to die, instead of having those important conversations with family, instead of getting his house in order, Harold spent much time and money (private and public) in treatment programs that provided marginal improvement at best.

In the stories of Eve and Harold we see that moral decision making requires well-formed character. It is important to recognize, however, that moral decisions depend on character at multiple levels: our character informs not only how we handle the decisions that we confront but also what decisions we confront.

I treat the latter point first. Character significantly influences what we see as choices before us. In Harold's case, character not only informed his decisions, it determined what he encountered as a choice. Harold's inability to be truthful about his impending death meant that he never encountered or viewed treatment as an option that might be declined.

Our virtues and vices enable us to perceive certain choices and incline us to overlook others. A physician or nurse who has internalized a concern for justice will notice when someone is being treated unfairly or when the real underlying question is one of distribution. Those who lack the virtue of justice are unlikely to recognize when it is at stake.

Similarly, I notice that some nurses quickly sense when a patient does not understand the doctor's explanation of treatment options, while other equally caring nurses never recognize the patient's confusion. The difference, I suspect, is that the former have acquired characteristics and skills—that is, virtues such as patience, sympathy, and the ability of imaginative listening—that enable them to recognize when communication and patient understanding is amiss.

Beyond influencing what decisions we confront, well-formed character is vital to deciding well. Lacking the requisite virtues, we are far less likely to find the right course or to see it through. Consider how vital the virtue of courage is to moral medical decisions. In our litigious age, doctors often need courage to reject unnecessary tests. Lacking courage, the tests will be ordered, perhaps under the guise of thoroughness or patient autonomy. Nurses need courage when deciding whether to approach a doctor who discounts a patient's wishes or when contemplating whether to submit an incident for ethics review. Patients need courage when they consider asking for another opinion or contemplate rejecting their doctor's recommendation.

Moral medical decisions rest on character: character informs both what moral choices we confront and how we decide them. Yet to realize the importance of character is to realize that congregational life and pastoral leadership are related to medical ethics. Church life and pastoral leadership is, or ought to be, eminently concerned with shaping Christian character, for the church is the principle place in which Christians seek to become the kind of people God is calling them to be.

Medicine Needs the Church
The argument that medical ethics is, for Christians, an extension of congregational life can be extended to suggest that the practice of medicine needs the church or church-like communities. Stanley Hauerwas claims that what we value about medicine depends on health workers and patients alike belonging to communities like the church.⁸ It is in the church and church-like communities where people acquire the convictions and character necessary to sustain medicine as a morally worthwhile activity.⁹

Consider, for example, the commitment to stay with the sick in the midst of pain, fear, and helplessness, even when we cannot cure or they cannot pay. I take it that most Christians, perhaps most people in our society, would accept this commitment as one of medicine's central purposes.

Note, however, that this commitment assumes certain convictions and qualities of character: we are essentially social creatures who need each other, and we owe each other care even when it is uncomfortable, financially unprofitable, or risky. This commitment also assumes a host of virtues, including courage, fidelity, and hope. It takes courage not to flee when we are confronted with disease, sickness, and death. And we cannot trust our doctors and nurses to remain with us in crucial moments if they lack fidelity and hope.

The problem is that these convictions and virtues are not supported by the broader culture. Our culture prizes autonomy and freedom above interdependence and obligations. Our culture idolizes effectiveness and the technological control of nature. Ours is an ethos of the marketplace, where skills are commodities to be purchased by autonomous consumers. We Americans share few socially accepted examples of courage—except perhaps the soldier, who may not be the best role model for health workers. Our culture's notion of fidelity is seen in the divorce rate and the preponderance of absentee fathers.

The commitment to remain with the sick assumes convictions and character that are increasingly at odds with this dominant ethos. To the extent that medicine still exhibits this commitment, it exhibits a morality that is out of step with our culture. To the extent that medicine is becoming something less morally worthy, we need look no further than the society shaping the convictions and character of those who practice medicine.

There are, in fact, good reasons to be distressed about medicine's direction. The doctor/patient relationship is starting to look more like a contract than a covenant. Patients increasingly sue physicians for failing to meet their expectations. Hospitals compete over patients, cut staff to improve profit margins, and send people home before they are ready. And, in a great irony, medicine's technologically driven imperative to cure is now being resisted with appeals to autonomy that would force another—the very one we have asked to cure us—to help us die.

Yet, as Stanley Hauerwas and Charles Pinches point out, we should not ascribe

blame to the institution of medicine for our present state of ill health . . . The simple fact is that we are getting precisely the kind of medicine we deserve. Modern medicine exemplifies a secular social order shaped by mechanistic economic and political arrangements, arrangements that are in turn shaped by the metaphysical presumption that our existence has no purpose other than what we arbitrarily create.¹⁰

The problem with modern medicine is not the institution of medicine itself but the wider society that shapes medicine and its practitioners.

Our society cannot be trusted to form the kind of people necessary to sustain medicine as a morally worthwhile activity. This is why Hauerwas suggests that medicine needs communities, like the church, whose convictions and practices might shape a people capable of morally worthy medicine.¹¹

Pastoral Implications
This dependence on well-formed people has profound implications for pastoral moral leadership. Pastors help shape the convictions and character of their parishioners and help their congregations become the kind of communities that facilitate the formation of Christian beliefs and virtues.¹² The following discussion illustrates how the pastor facilitates the formation of Christian convictions and character by attending to everyday matters, such as funerals, prayer, and visual images. This discussion also highlights the connection between such formation and medical ethics.

Communicating convictions. To consider the importance of clearly communicating Christian theological convictions and their possible moral implications in medical settings, let us return to Eve's case. Besides the biblical prescription to honor your parents, Eve's case includes the beliefs that (1) God cares about us and can be trusted; (2) death is not the end; and (3) we are created for the purposes of worship, fellowship, and service. These beliefs are not rules or prescriptions for action, nor are they commonly discussed in standard works on medical ethics. Yet Eve's case turned on such obviously theological notions.

Pastors need to be aware that such basic theological convictions do real work in parishioners' lives outside of worship. Knowing this, it behooves pastors to be explicit about what Christians believe and to illustrate how those beliefs function in shaping lives and informing decisions, including medical decisions.

For example, funerals and Ash Wednesday offer opportunities to remind parishioners that they are made of dust and should be unashamed of their finitude. Christians know that it is fine to be finite, that it is okay to be dust, because God views these earthen vessels as good, and because they commune with a God who breathes life into their clay bodies.

To illustrate how these convictions function in the life of a Christian, the pastor can allude to their implications in end-of-life decisions. Much of modern technological medicine is a denial of our finitude. We pour as much as 80 percent of medical dollars into the last two years of life, because we do not know that the end of life is at hand and because we deny our finitude and the propriety of death. People who know themselves to be divine breath-filled dust do not need to so deny death.

Another example of Christian convictions and their potential medical implications is the apostle Paul's vision of the church as a body.¹³ Pastors can rightly highlight the implications of this image for Christian medical decision making. If Christians are as interdependent as the parts of a body, then they should seek the counsel of other parts of the body when making major medical decisions. So too, in making those decisions, they need to ask whether the contemplated course is commensurate with building up the body.¹⁴

Shaping character. Pastors must also attend to character formation. Here the issue is broader and subtler than merely explicating Christian beliefs from the pulpit or in Sunday School. Pastors must consider matters as diverse and mundane as prayer, visual images, music, and church potlucks because every choice, experience, and relationship has "some effect—no matter how small—on the person we are in process of becoming."¹⁵

To illustrate let us again return to Eve's case. She offered prayers with the same congregation for fifty years. If Eve learned to pray well during those fifty years, if she learned to attend to and wait on God, then in the process she acquired virtues such as humility, patience, and solidarity.

When we pray well we cease to be preoccupied with ourselves and cease to be the center of our own attention. We thereby begin to acquire humility. So too, as we rightly learn prayers of confession, we learn to own our limitations, failures, and rebellion. And as we learn to pray prayers of petition, we are reminded of our needs and our dependence on God and others. Humility is therefore a virtue of prayer. In learning to pray rightly—learning to attend to God, learning to confess and petition properly—we also grow in humility.

Humility is also essential to moral medicine. Humility is part of what enables physicians to recognize their limits and part of what prevents them from taking advantage of vulnerable patients. Humility enables patients to recognize honest, human mistakes by doctors and nurses for what they are: the normal consequences of well-intentioned but limited people endeavoring to offer care. Lacking humility, patients will sue for any perceived mistake or failure, irrespective of genuine incompetence or negligence. Finally, patients require humility to open their bodies to strangers and to grant these caregivers invasive authority. When patients lack humility, medicine loses its authority and starts to look like one commodity among others from which we may pick and choose.

Other prayer-formed, medically relevant virtues include patience and solidarity. As Michael Duffey notes, prayer teaches the prayerful to wait:

Prayer is the suspension of time and the adoption of a patient and quiet heart in order that we might be led into deeper communion with God. Praying requires stepping out of the current of activities in which we are caught up . . . Prayer is first of all the intention to create an opening, a space where we might wait for the stirrings of God.¹⁶

Learning to pray thus means learning to wait, learning patience.

Prayer also teaches solidarity. This is seen in the Lord's Prayer, where Christians are taught: pray to our Father, ask for our daily bread, and seek forgiveness for our debts. Solidarity is also learned in intercessory prayers, where one presents another's need to God.

Morally worthy medicine also needs these virtues. It is difficult to imagine how one could be a good doctor, patient, or nurse, without patience. How can we remain with each other in our sickness if we have not learned to wait? Similarly, how can medicine expect to stand with those who cannot pay or cannot be cured unless health workers have acquired a deep sense of solidarity with those whom they serve?

Prayer is thus relevant to medical ethics. It is also an issue of pastoral leadership, for Christians learn how to pray from and with others in the church. They learn how to pray as they stand in the liturgy and pray prayers of invocation, confession, petition, and so on; as the Psalms are read aloud and as the congregation recites the Our Father; as prayer is modeled by teachers, friends, and those viewed as saints. They learn to pray as others teach them how.¹⁷

Congregational life involves many other character shaping practices besides prayer, for example, viewing the windows of Jesus and pictures of Christian martyrs. Such images have power to shape. They provide pictures of the ends and purposes of life, present role models to be emulated, and "create assumptions about how the world really is."¹⁸ Routinely viewing pictures of martyrs would lead one to expect suffering as part of faithful Christian existence. The image of Jesus the Good Shepherd could affirm one's self-worth, while the image of the resurrected Christ might make one less anxious about death.

This ability to shape is relevant to medical ethics. One who expects suffering is likely to respond differently to end-of-life decisions than is one who views suffering as an evil to be avoided at all costs.¹⁹ The person who has learned his or her self-worth is less likely to be bullied into or out of medical procedures. And Eve is a perfect example of what happens when death is less feared.²⁰

Prayer and images are only two aspects of congregational life that bear character shaping implications. Nevertheless, it should already be clear that pastoral moral leadership requires attention to mundane, everyday matters. There is nothing earthshaking about prayer and pictures of martyrs. Such matters present no obvious dilemmas or conflicts. Indeed, they are so mundane that they usually escape our attention. Yet, it is in and through them that Christians become, or fail to become, the kind of people they should be. Thus, pastoral moral leadership includes such seemingly insignificant matters as helping parishioners learn to pray well, evaluating the images to which they are exposed, testing whether music cultivates emotions and desires befitting Christians, asking whether potlucks encourage Christian friendships, exploring how the Lord's Supper might train the believer in community and forgiveness, and so on.

These everyday pastoral concerns are indirectly relevant to medical ethics. Patients, nurses, and doctors will confront the right questions, choose the right answers, and engage in the right actions only if they are rightly formed. Moreover, medicine's moral value as an expression of solidarity with the sick depends on character-shaping communities whose ethos is at odds with our culture's.

Pastor's role. In short, the pastor's role in medical ethics is neither cursory nor centered at the bedside, and it has surprisingly little to do with medical moral dilemmas or the four standard principles of medical ethics. The focal point of the pastor's relationship to medical ethics is the pew: pastors help or fail to help parishioners acquire the requisite convictions and character.

This conclusion does not mean that pastors should spend an enormous amount of time thinking about medicine's requirements. The foremost reason for teaching Christian convictions is not that medicine needs them, but that we believe them to be true and relevant to our whole lives. Likewise, serving medicine is not the primary reason for cultivating Christian character; the primary reason is that God calls and enables us to become a certain kind of people.

Nevertheless, pastors must remain cognizant of medicine. As any active pastor or priest can attest, medicine suffuses the lives of parishioners. Indeed, institutionalized medicine seems to have become more culturally powerful and "pervasive in our lives than the church ever was and surely far more powerful than it is today."²¹ Since Christians cannot and should not avoid medicine, they need to help each other acquire the convictions and character required to meet medicine as Christians.

Medicine pervades the lives of parishioners—whether as patients, families of patients, or health workers. Pastors do not teach and seek to cultivate character because of medicine, but since virtually all North American Christians confront Western medicine and medical decisions, pastors must ask whether church teaching and practices equip parishioners to morally navigate contemporary medicine well.

Pastors can, for instance, ask whether they sufficiently teach Christian convictions about the purposes and nature of life, and they can use medical examples to illustrate the repercussions of such convictions. Pastors can similarly ask whether the congregation provides sufficient opportunities to grow in patience, humility, solidarity, and so on. So too, when privileged to stand with a patient like Eve, the pastor can ask what convictions and practices enabled her to make the choices she did. When standing with a patient like Harold, the pastor can ask how the congregation may have failed to help Harold become more truthful.

AT THE BEDSIDE
Although the pastor's greatest contribution to medical ethics is in the pew, Eve's case reminds us that pastors also play an important role at the bedside. Pastor Paul read scripture with Eve the night before surgery, visited her and her family throughout the ordeal, and intervened in the family's discernment process. This extensive involvement is common when parishioners know and trust their pastors. I unpack this involvement at the bedside by using a series of partial, interconnected images of ministry: priest, theological interpreter, medical translator, prophet, and friend.²²

Priest
Perhaps the central dimension of the pastor's role at the bedside is that of priest.²³ This dimension is not limited to churches with formal liturgies or an officially sanctioned priesthood. Even in less formal traditions, such as Baptist or Mennonite, the pastor's presence has a symbolic and ritual function. Specifically, the pastor represents the church community and often represents God's own loving and faithful presence.²⁴ As many pastors can attest, parishioners often view the church as virtually absent—irrespective of how many congregational members visit—until the pastor appears. Yet when the pastor makes himself or herself readily available, those same parishioners see the church as overwhelmingly present. Moreover, the extraordinary comfort that many find in unhurried pastoral visits is understandable once we grant that those visits symbolize God's own presence.

This priestly function includes the rituals of prayer, scripture reading, confession, and Communion. Pastors offer prayers of invocation, gratitude, and intercession; they sometimes also offer prayers that voice the feelings, thoughts, and fears that patients themselves dare not express. Such prayers console and often strengthen the patient's resolve to cling to God. Sometimes they even bridge the chasm that patients sense between themselves and a seemingly distant God. Similarly, the pastor's reading of Scripture allows patients to affirm the faith that they share with the biblical writers and to listen to God's Word for comfort and encouragement.²⁵ Although many would not call it "confession," patients often acknowledge their sins in the pastor's presence. In these moments, the "priest" is especially evident: the pastor both verbally expresses God's promise of forgiveness and physically demonstrates the patient's reconciliation to God and the church by remaining present.²⁶ In many traditions, the patient's participation in Communion is a comparably powerful reminder of God's love and presence in the midst of suffering.

Pastors fulfill this priestly function to serve God, not to serve medicine. But this dimension of the pastor's role does affect medical ethics. Minimally, Christian patients will make more consistently Christian decisions when they experience their faith community's support and know themselves reconciled to God. It is easier to calmly and honestly face uncertain or even life-threatening decisions when we know that we are not alone.

This priestly function serves another task vital to medical ethics; it helps to counteract medicine's excessive authority. In our day, medicine and psychology provide the major metaphors for healing, and laity often heed medical advice "with the kind of deference given religious disciplines in earlier centuries."²⁷ My personal experience is that many parishioners, especially older ones, obediently accept "doctor's orders" without questioning or understanding those orders. This excessive authority is visible in Eve's case: Eve's family initially accepted without question the physician's recommendation to start dialysis and still inclined to dialysis even after hearing that Eve's chance of recovery was slim. This reaction reflects their unquestioning acceptance of the physician's authority. If they were looking for a medical miracle, then it also reflects medicine's hegemonic control of healing metaphors. The pastor's priestly function helps curb this immense authority. By symbolically representing God's presence, calling in prayer on the one true redeeming God, and reading passages wherein God through Christ is healer, the pastor helps the patient take medicine and his or her doctor a little less seriously.

H. Phil Gross, a retired orthopedic surgeon and professed Christian, writes that he only prayed silently for himself and his patients. The major reason for not praying aloud, he says, is that such prayer can be construed as a lack of authority and confidence.²⁸ I believe that Dr. Gross was wrong never to pray aloud, but he was right about prayer's ability to rein in a physician's authority. As Allen Verhey points out,

One cannot invoke the one true God and take a presumptuous medicine too seriously . . . When we invoke God as redeemer, we are freed from the vanity and illusion of wielding human power to defeat mortality or to eliminate the human vulnerability to suffering. An honest prayer could . . . restore a modest medicine to its rightful place alongside other measures that protect and promote life and health.²⁹

I concur with Verhey. Prayer's ability to restrain medicine's authority is enhanced when combined with the pastor's priestly representative function.

Theological Interpreter
The pastor's task as theological interpreter includes two related elements: helping patients search for theo-logical meaning and helping patients properly understand their traditions. Regarding the former point, hospitalization often occasions a search for meaning. Whether faced with a life-threatening procedure or merely with the strangeness and inconvenience of hospitalization, many ask questions of meaning. Am I being punished? Do I somehow deserve this suffering? Where is God in this? What am I to learn from this experience?

The pastor can gently guide the parishioner in this search for meaning.³⁰ This guidance takes various forms. Pastors can point out appropriate scriptures or discuss the role of suffering in the life of a disciple or ask what it means to believe in a God who suffers. Pastors can also suggest worthy lessons that can be learned from the experience. For example, I suggested to a parishioner that her frequent but not serious hospital stays were an occasion for her to grow in patience—a virtue she recognized was not well developed in her life. So too, pastors can sometimes legitimately suggest that a parishioner view his or her illness as an opportunity for growth in humility, trust, or hope.

In guiding the search for meaning, pastors must sometimes challenge a patient's theological assumptions. If a parishioner assumes too simple a connection between sin and suffering, for instance, then the pastor may need to challenge this linkage—perhaps by pointing to Job or to Jesus' explicit rejection of a simple correlation between sin and suffering or to Jesus' own innocent death. Of course, the pastoral goal in pointing to Job and Jesus is not merely to challenge assumptions but to offer a more profound engagement with suffering—that is, an invitation to wrestle with the meaning of suffering and to cling to God's presence, even when such meaning eludes us.

In addition to guiding the search for meaning, the pastor also helps the patient or family properly understand their tradition. Faithful adherents of a tradition often misconstrue its beliefs or implications. Consider as examples the cases offered by Don Browning and William O'Brien.

Browning's case is that of "Margaret and the Will of God." Browning notes that Margaret and her family held "to a rigid version of Reformed Christianity . . . in which all life's fortunes, good or bad, were regarded as the direct will of God." Browning says that these beliefs were not "just idle chatter. Margaret did not comply well with even the simple routines of her everyday care."³¹ After all, why should she? If God decides that she will be sick, then she will be sick. And if God decides that she should get better, then she will get better.

For our purposes, it is the chaplain's response that makes this case noteworthy. The chaplain acknowledged God's providential governance, but challenged Margaret's understanding of that rule by using scriptural arguments to show that God's providence does not mean that God wills particular sicknesses. Instead, argued the chaplain, God's providence is such that we can strive with it toward health. The chaplain must have been caring in his conversation and skillful in his use of scripture, for the effect on Margaret was profound. Her attitude and behavior changed; she started to cooperate with her treatment.

O'Brien's case concerns sixty-five-year-old Thelma.³² Thelma was ventilator dependent. Thelma had a large, growing, inoperable tumor in her face and sinus cavity. She had a history of pulmonary embolism, heart disease, asthma, lupus, and diabetes. Thelma was lucid, but she grew understandably frustrated and asked for the ventilator's removal.

Thelma's request sounds unremarkable, given the circumstances. But Thelma and her loving family were devoted Catholics who worried that withdrawal, and the resulting death, amounted to suicide or euthanasia. They feared that Thelma's death would leave her rejected by God and by her church. Thelma's family had cared for her the past eight years and was willing to continue that care. They strongly resisted Thelma's request.

As a Catholic priest, Father O'Brien helped Thelma and her family move toward a more accurate understanding of their shared tradition. By clarifying the distinction between "killing" and "letting die," O'Brien helped them to see that, from a Catholic perspective, Thelma was neither committing suicide nor asking for euthanasia. Thelma was instead asking to be allowed to die. Once relieved of their fears about suicide, the family, guided by Father O'Brien, directed their energy toward caring for and assuring each other.

We see the theological interpreter at work in both Browning's and O'Brien's cases. The chaplain helped Margaret and her family come to a more classic expression of their Calvinist faith. O'Brien helped Thelma and her family move toward a fuller and more accurate understanding of Church teaching. In both cases, the person responsible for pastoral care did more than help an individual in her private search for meaning. Accepting the authority of their respective traditions, the pastors directed patients and their families toward more complete understandings of those traditions.

As with the priestly image, pastors do not fulfill their function as theological interpreters to serve medical ethics. If they fulfill this function well, they serve God and their parishioners, and they do so in the belief that the theological claims are true. Nevertheless, this aspect of the pastor's role is relevant for medical ethics. The pastor as theological interpreter is primarily concerned with beliefs and convictions, although the search for meaning sometimes also includes character growth. But as we saw earlier, convictions and character matter to medical ethics.

The moral implications of the interpretive function are obvious in the cases discussed by Browning and O'Brien. Margaret's care and Thelma's death hinged on their gaining better understanding of their respective theological heritages. Without this understanding, Margaret had no reason to comply with her treatments and Thelma's family had every reason to resist her decision.

Note too that the standard principles of medical ethics—such as the principles of autonomy and beneficence — could not substitute for this interpretive function. Granting Margaret's autonomy or talking about beneficence does nothing to address her lack of self-care.³³ Indeed, the lack of self-care could be claimed as an autonomous right. Even worse, to emphasize Thelma's autonomy would disregard the moral claims that her family rightly makes on her. As a good Catholic, Thelma may not make her decision in isolation. Her faith and her family have a voice that she is morally obligated to hear. Unlike a generic appeal to autonomy, Father O'Brien recognized these moral connections. He also recognized that Thelma and her family were misunderstanding their faith. Attending to either the principle of autonomy or the pastor's interpretive function might have arrived in Thelma's case at the same physical action—removing the respirator. The latter, however, honored Thelma's existing moral commitments in a way that the former could not.

Translator
The pastor's role at the bedside also includes translation, where he or she works toward mutual understanding between all parties, including the patient, family, and hospital staff.³⁴ As translator, the pastor helps patients and their families "hear" each other, asks questions of medical personnel that patients and families find difficult to voice, and ensures that patients and their families understand what they are being told about tests or treatment options.³⁵

Pastor Paul acted as a translator, as an agent of communication, when he pressed the doctor to explain Eve's chance of recovery. Suspecting that relevant information was being left out, Paul asked the doctor a question that the family could not bring themselves to ask.

The chaplain in Browning's case also acted as translator. Margaret was hospitalized with severe kidney problems when dialysis was still scarce and kidney transplantation was new. Seeing Margaret's lack of self-care, the hospital committee charged with determining her course of treatment concluded that she lacked the intelligence and background to follow the routines and procedures that would make such treatments effective. The chaplain objected to this conclusion. He realized that Margaret's behavior, which was perfectly consistent with her world view, was being interpreted by the committee as a lack of intelligence. The chaplain argued that what the committee saw as signs of mental deficiency were actually signs that Margaret looked at the world differently. Thus, besides helping Margaret reinterpret her tradition, the chaplain acted as translator by helping the committee to understand Margaret's view of God's providence.³⁶

Facilitating open communication is a task shared with others in the health care setting, including nurses, social workers, and ethics consultants.³⁷ People in these roles are often positioned to recognize breaks in communication and understanding. Nevertheless, there are several reasons that pastors are especially well situated to this task.

First, there is a good chance that the pastor and the patient already know and trust each other. In contrast, the patient experiences the hospital as a virtual "universe of strangers."³⁸ Amid those strangers, the pastor offers an established relationship of trust in which the patient may explicitly or implicitly confess questions and concerns that he or she would not otherwise admit. Moreover, because the pastor knows the patient as a real person outside the hospital, the pastor may notice when the patient's care, mannerisms, or decisions seem unbefitting his or her identity.

Second, it is socially acceptable to acknowledge need and express vulnerability to a minister. There is a social stigma attached to admitting need; yet, many who would never admit need or questions to a doctor, nurse, social worker, or ethics consultant are free to talk to their pastor.

Third, the pastor and parishioner operate out of the same world view. They share beliefs and convictions that health workers may not share. As Browning's case suggests, understanding each other's convictions is no small matter. Behavior or wishes that seem odd to hospital staff may be perfectly comprehensible to one who shares the patient's world view.³⁹

To fulfill this function of translator well, the pastor must cultivate a climate of trust, security, and openness to human vulnerability. The pastor also must exhibit a basic familiarity with the clinical and moral language used in the hospital setting. For example, it helps to know the difference between a nasogastric and a PEG tube. It helps to know what a respirator does or how violent—and often futile—resuscitation is. It helps to know what is meant by DNR (do not resuscitate) or PVS (persistent vegetative state) or EEG (electroencephalogram). Pastors do not need a technical understanding about such matters, but a modest level of understanding is essential if they are to help bridge communication gaps.⁴⁰

Similarly, pastors need a basic working knowledge of matters such as living wills, health care proxies, informed consent, and the four principles of bioethics: autonomy, nonmaleficence, beneficence, and justice. As translators, pastors take these notions and relate them to language and convictions that are more natural for their Christian parishioners. Conversely, pastors sometimes need (as best as possible) to translate patient and family concerns into the moral language of modern medicine.

Prophet
In invoking the image of prophet, I suggest two aspects of the pastor's role at the bedside: (1) challenging parishioners to live and die in a way consistent with what they profess, and (2) explicitly advocating for patients whose voices are ignored or drowned out.

Pastor Paul acted as prophet when he gently suggested to Eve's family that continuing treatment was not in keeping with their trust in God. Paul's gentle suggestion reminds us that being a prophet at the bedside does not require harsh, caustic, or demanding speech. The words may be gentle, the tone quiet. What is required is hard honesty about making decisions that are faithful to what one believes. Pastor Paul exhibited this honesty in Eve's case.

Such hard honesty is conspicuously absent, however, from Harold's case. Harold lived and died his last few months in a way that belied his faith in God. Harold never admitted the harmful effects of his addiction or that he was dying. Perhaps the pastor should have been more prophetic in Harold's case. Perhaps he should have reminded Harold that Christians need not deny their sinfulness or their mortality. Perhaps what Harold needed was a soft but clear word from his pastor: "Harold, you are dying. Spend your time with your family. Spend your time getting things in order."

Being a bedside prophet also means advocating for the patient whose voice is unheard. The chaplain in Browning's case not only translated Margaret's world view, he championed her cause. The chaplain challenged the committee's conclusion that Margaret lacked the mental resources for treatment. He also challenged their assumption that perceived intellectual capacity should determine treatment: "He argued that Margaret was a human being and for that reason alone was deserving of treatment."⁴¹

Pastors should not underestimate the need for prophetic patient advocates. Institutional medicine is still basically benevolent, but the cultural and economic forces shaping a different, less caring kind of medicine are strong. Pastors need to watch out for patients who are poor and for patients who lack family as advocates.

I pastor a small urban church, and my parishioners go to any of four local hospitals. I see much good care at these hospitals. But in the last few years I have also seen: the grossly inadequate pain management of an elderly person afraid to complain; the discharge to an unsupervised apartment of a scared, elderly, confused woman who was both incontinent and unable to walk; the failure to determine proper medication levels before discharge, resulting in multiple readmissions; nursing assistants who repeatedly failed to close the door, pull the curtain, or cover an unconscious, naked patient; technicians and support personnel who allow patients to believe that they are trained nurses; physicians who do not present patients with all their treatment options; and doctors and families who ignore a patient's advance directives.

The patients in these instances were unable to advocate for themselves and lacked family to advocate for them. With the current cultural and economic pressures on medicine, pastors will need to fulfill their prophetic function in part by becoming patient advocates.

This prophetic function at the bedside may, of course, inform the pastor's prophetic role beyond the hospital walls. Many difficulties confronted within the hospital are systemic. The second-rate or shortened care a patient receives often has more to do with limited or absent health insurance or a health maintenance organization's focus on the bottom line than it does with the particular doctors and nurses involved. Nurse or physician error is often ultimately rooted in hospital organization, not health worker incompetence. So too, patient care is directly influenced by the exorbitant cost of medications and indirectly influenced by the way drugs are marketed to physicians and public alike. I believe that when such systemic issues emerge in the pastor's advocacy at the bedside, they should inform aspects of the pastor's prophetic task outside the patient's room, outside the hospital walls. These experiences within the hospital could prompt us, for instance, to ask how the church should voice its concerns within public debates about universal health coverage, error reporting, Medicare, drug costs, and so on.

The reach of the pastor's prophetic task beyond the bedside is a reminder that the direction of influence is not unidirectional. What happens at the bedside also informs our activity within the congregation and in "the world."

Friend
Sometimes pastors are fortunate enough to have their parishioners also become their friends. I do not mean that they pal around together or that it is a peer relationship. Rather, I refer to that deep connection between people who share common values and goals, who have come to know, respect, and trust each other, and who desire each other's well-being.

This image of friendship hints at moral aspects of care at the bedside that do not easily fit within the other images. Consider, for instance, what it means for a friend to visit, or hold your hand, or cry with you. Friends do not visit out of duty or obligation or because they fill a specific social role. Friends visit because they care about you—with all your particular needs, wants, commitments, experiences, and idiosyncrasies. Friends visit because they prize what you bring to the relationship.

There is something deeply affirming and solidifying about a visit from a friend that is not encompassed by the images of priest, interpreter, translator and prophet. When the pastor is lucky enough to be a friend, the visit involves mutual care, even though it is more focused on the patient. When the pastor is a friend, the patient is affirmed as an utterly unique individual who knows that he or she has received and given more than a priestly visit.

Relatedly, friends listen. Careful, empathetic, and imaginative listening skills are also vital to the pastoral dimensions of interpreter and translator, but good friends listen in a way that is not entirely captured by those images. Good friends often understand what we mean even though our words are not carefully chosen. Friends are frequently the best at understanding what we mean, not what we say. Conversely, friends are sometimes called upon to listen even when they do not understand what we mean or what we are talking about. At such times, what is important is not the understanding but the personal affirmation implied by the act of listening. Indeed, sometimes we need our friends to listen even when we are not speaking at all.

Friends are also those whom we are most likely to invite into our moral discernment. Pastors are often involved in a patient's moral deliberation, but that involvement is most profound when the pastor is a friend. In deliberating with true friends, we do not need to ask about what some abstract rational person would do. When deliberating with friends, we are not even limited to asking what a believing Christian should do. When friends discern together they ask a different question: "What should you—my friend, an individual whom I value, a person with a unique story—do?"

CONCLUSION
The Christian pastor's relationship to medical ethics extends from the pew to the bedside. It starts in the pew, for it is in the church that we acquire the convictions and character vital both to deciding well and to sustaining medicine as a praiseworthy practice. It extends to the bedside since pastors are, or sometimes become, priests, interpreters, translators, prophets, and friends.

NOTES
1. See also Joseph J. Kotva Jr., The Christian Case for Virtue Ethics (Washington, D.C.: Georgetown University Press, 1996), 5.