Professional Chaplaincy and End of Life Care

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I recently presented the following at a Gerontology conference.

The impetus for this project was a hospice meeting several years ago (I have been a companionship volunteer for a local hospice organization for nearly four years). The theme of the meeting was “Spirituality and End of Life Care.” A panel of local religious leaders from different faith backgrounds discussed their commitment to end of life care for people of all faiths, and I felt inspired to learn more. Shortly after, I spoke to a good friend of mine, a rabbi, who had attended a similar meeting in another city. In that meeting, however, a religious leader on the panel decried interfaith services, saying that he could not help someone of a different faith find comfort unless they were willing to join in his faith.
It caused me to wonder: is this a legitimate response to chaplaincy care? Should a chaplain offer spiritual services to a patient of another faith? This first paper is my exploration of the issue, essentially a look at the history of clinical chaplaincy and the theological disagreements between conservative and liberal Christians concerned with professional chaplaincy.
The next exploration in the series is here.

@ 2013 Jamie A. Duncan

Originally presented 6 April 2013 at the 34th annual Southern Gerontological Society, Charlotte, NC

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Professional Chaplaincy and End of Life Care:

Theological and Ethical Concerns

1. INTRODUCTION

From as early as 500CE, the Catholic Church associated illness with sin and strictly governed medical practice in Europe. Since the Protestant Reformation and the French Revolution, medicine increasingly became subject to scientific inquiry, while many hospitals in the West continued to be managed and staffed by religious organizations. In the 20th century, the healthcare industry developed into state-run, non-profit and for-profit institutions, although a number of “religiously sponsored institutions” continue to provide healthcare.¹ Likewise, medical staffing altered over time from volunteers and untrained nuns to clinically trained professionals. The influx of reliable federal funding from programs like Medicare began in the mid-1960s, enabling increased financial independence for many hospitals. The decrease in religion’s dominance of healthcare coincided with a steady decline of support among Americans for organized religion.² This period also saw the advent of the “professional chaplain,” a spiritual therapist trained both in theology and medical ethics, an independently accredited employee of the healthcare industry who bridged the ever-widening gap between religion and medicine in the United States.

Historians have not given sufficient attention to the development of professional chaplaincy, but the accreditation organizations have made an effort to tell their own stories. For example, John Rea Thomas, the former coordinator for the history of the Association for Clinical Pastoral Education, Inc., describes what he feels is an important aspect of the Clinical Pastoral Education movement’s impact that has been ignored:

Although overlooked by historians, CPE has made one of the greatest contributions to ecumenism in the past forty years. Seminary students met students of other traditions as members of the same CPE group and began to experience each other as colleagues in ministry. For the most part they carried these relationships to their later parish assignments. CPE supervisors did not form perfect communities in their CPE programs and regional meetings, but they dealt relatively honestly with their own feelings and those of their students. This modeled “examining one’s own relationships and experiences in ministry.”³

Ecumenism is intrinsic to modern professional chaplaincy as a service to cultural pluralism, and all faiths and creeds are openly welcome to accreditation, including designations of non-belief. However, the source of ecumenism in the CPE movement dates to the interfaith efforts of its founders, liberal mainline Protestants from New England in the early 20th century. In 1925, physician and Transcendentalist Richard C. Cabot of Brookline, Massachusetts, founded the first program of supervised pastoral training within a medical institution, based on medical residency programs. That same year, Anton T. Boisen, a Congregationalist who had converted from Presbyterianism, was hired as the hospital chaplain of Massachusetts’s Worcester State hospital. A former mental patient, Boisen used his tenure to explore the relationship between religion and psychology, initiating a trend of therapy within the burgeoning movement. He explained: “In times of crisis, when the person’s fate is hanging in the balance, we are likely to think and feel intensely regarding the things that matter most.”⁴

In 1930, Pastor Samuel Eliot of the Unitarian Church of Boston instituted the first CPE organization, the Council for Clinical Training of Theological Students.⁵ Accreditation organizations developed significantly after World War II, and, in 1967, the standard-setting Association for Clinical Pastoral Education, Inc., (ACPE) was founded by unifying four smaller groups. Although liberal mainline Protestants dominated the early development of the CPE movement, national expansion increased its diversity. For instance, the Southern Baptist Association of Clinical Pastoral Education was founded in 1957 and the first Roman Catholic priest completed a CPE program by the late 1960s.⁶

Currently, the role of the professional chaplain is to act as a spiritual counsel to patients, health care staff and physicians of all faiths, and participate as a member of medical ethics committees, all without ever supplanting physician authority. The chaplain’s primary role is to advocate the patient’s “spiritual values” during medical treatment decisions, subject to peer review and oversight by a bioethicist.⁷ In 2001, a consensus article written by representatives of the five largest chaplaincy organizations in North America titled “Professional Chaplaincy: Its Role and Importance in Healthcare,” emphasized “spirituality” as a broad human experience, of which “religion” was a cultural component. The article states:  “Many persons both inside and outside traditional religious structures report profound experiences of transcendence, wonder, awe, joy, and connection to nature, self, and others, as they strive to make their lives meaningful and to maintain hope when illness strikes. Support for their efforts is appropriately thought of as spiritual care.”⁸ As such, the professional chaplain is a paid employee of the medical institution, primarily responsible for patient advocacy regardless of the cultural background or religious affiliation of either the patient or the chaplain.

According to Rev. James C. Johnson, M.Div., chaplains specialize in the treatment of “spiritual distress”. In his survey of professional chaplaincy literature, he defines spiritual distress as “a disruption of the life principle which pervades a person’s entire being and which integrates and transcends biopsychosocial nature,” (Gordon, 1982, p.226).⁹ According to Johnson, spiritual distress can affect the results of a patient’s treatment, so that the chaplain’s roles of patient advocacy and spiritual counseling are actually clinical in nature, making the chaplain part of a larger team of healthcare professionals whose primary focus is holistic patient care.⁹ This characterization of professional chaplaincy harkens to the very origin of the CPE movement, when Anton Boisen first examined the relationship between therapy and faith.

Professional chaplaincy is currently governed by nationally recognized accreditation organizations that developed as part of the Clinical Pastoral Education movement. Certification requires theological education, pastoral experience and endorsement by the applicant’s religious order.⁹ Although chaplains often remain accountable to their faith communities, training involves “intensive clinical residencies in medical or psychiatric facilities,”⁹ specifically focused on administering to a variety of faiths in a medical setting. As a result, unsolicited proselytization is prohibited as an unethical violation of patient rights. Mission work, a common aspect of the Christian faith, is not allowed by the doctrines of professional chaplaincy, as patient rights and institutional policy take precedence over doctrinal authority.

For this study, I surveyed chaplaincy literature written by and about Christian chaplains, although the concerns were also applicable to other faiths. Ecumenical Christians, for instance, explore how to retain religious authenticity while fulfilling clinical responsibilities in a non-religious institution, a concern that may also affect other religious leaders in a multicultural setting. Exclusivist Christians are concerned that the religious authority of chaplains is subjugated to institutional policies and that chaplains are therefore prohibited from witnessing to the terminally ill, deemed from this perspective as the chaplain’s most important responsibility.¹⁰ Again, a system that prohibits a particular faith community’s practice in defense of multicultural tolerance is an ethical issue applicable to all religious clergy, but the literature discussing the issue happens to be written by Christians.

Therefore, I will focus on the Christian theological perspectives of professional chaplaincy as presented by authors from liberal and conservative Protestant, Catholic and Eastern Orthodox backgrounds. Some of the authors have chaplaincy experience, while others are religious leaders, and the remaining are scholars. The following two sections of the paper will explore the ecumenical and exclusivist theological perspectives, respectively. Given the brevity of this survey, I limit my inquiry to a summary of key points, concluded with a brief reflection on the relevance of this discussion to end of life care and patient autonomy.

1. ECUMENCIAL PERSPECTIVE

Professional chaplaincy is historically a Christian service now framed as a multicultural discipline open to all human belief systems in practice and service. As a result, the primary Christian response has been ecumenical in nature, seeking to welcome all spiritual paths while attempting to maintain ecclesiastical authority.

Authors Kurt W. Schmidt and Gisela Egler collaborated to acknowledge the dilemma of multiculturalism in institutional medicine and disavow absolutism in favor of a “pluralistic” model of service, professing that every faith has legitimate paths to salvation equal to that of Christianity. All patients, regardless of faith, are equal in their experience of a spiritual crisis during extreme illness. They say:  “Precisely because all patients in their sickness are in need of religious care and attention, chaplains should and may also visit people of other faiths.”¹² The religious beliefs of either the chaplain or the patient should not interfere with the potential “religious dimension” of the relationship between them.¹² According to the authors, the Holy Ghost¹³ will guide the Christian chaplain to understand the appropriate limits of this relationship, on the basis of what is “beneficial” for the patient.¹⁴ This perspective simply reframes the parameters of professional chaplaincy in Christian terminology. The universal perspective of human spirituality here defines Christianity as one of many possible beliefs, all of equal merit.

For author Brad Mellon, the history of Christian caregiving matches well with modern medical ethics, “including self-determination, doing good, avoiding harm, and seeking justice,”¹⁵ so that the theological aims of Christian chaplaincy need not contradict institutional policy. In a multicultural setting, the chaplain must ideally be firm in his or her own theological convictions, he says, respecting the beliefs and earning the trust of the patient, family and caregivers. To demonstrate, the author explores a few hypothetical case studies dealing with common medical ethical dilemmas. In the example of counseling a patient considering assisted suicide, for instance, the author points out that the chaplain’s first responsibility is to the law, and next to his or her theological perspective and the philosophical position of the facility. The chaplain is to remain open to the patient’s needs, offering honest counsel. If the patient’s decision runs counter to the chaplain’s theological perspective, he suggests the chaplain offer deference to “an alternative pastoral caregiver.”¹⁶ This is an extremely rare ethical problem for a chaplain to experience, but the hypothetical case demonstrates Mellon’s perspective that a chaplain must operate primarily as an employee of the medical institution and secondarily as a theological authority. Even so, he argues that the ethical goals of the chaplain align with God’s will, fulfilling a theological goal as well,¹⁷ suggesting that the chaplain proselytizes by example if not in words.

The German author Christoph Schneider-Harpprecht discusses Christian theological approaches in a pluralistic society by arguing against the segregation of denominations in chaplaincy programs. Estranged from the faith of their community, patients in a hospital setting primarily have what he refers to as purely “secular”¹⁸ needs, focused on treatment. These include:

…the necessity to overcome sickness and disease, the critical aspects of surgery,cancer treatment, chronic disease and its consequences for the family, and in the        context of such work, economics and social relations. Religious questions, the relation to God and to the church, prayer and the need to rely on faith traditions in the vast majority of cases appear as entirely subordinated to the psychological task of coping with illness and treatment.¹⁸

Therefore, the effort to have a “personal encounter”¹⁹ is paramount to denominational authority;¹⁸ the chaplain must acknowledge the doctrinal limits of his or her tradition in that encounter and allow the Holy Spirit to bridge the gap of cultural differences.²⁰ This practice amounts to remaining humble to the counseling experience and “being present” for the patient in a time of need. From this perspective, he says, the needs of the patient are “secular,” and the chaplain’s counsel is therefore devoid of theological controversy.

Pastor Christoffer Grundmann focuses his definition of chaplaincy solely on that moment described by Schneider-Harpprecht as a “personal encounter.” While serving as chaplain for a small hospital specializing in terminal illnesses, he developed an ethos of chaplaincy focused on what he termed “existential solidarity.”²¹ Chaplains may practice this by understanding the situation soberly, offering companionship to the patient as a stranger in great need, and by understanding the limits of dogma, in which “any genuine perspective of life is deemed ridiculous.”²² Suffering on this level is a spiritual crisis in which belief that normally provides hope can actually add to the suffering. If a chaplain approaches a patient with “ready-made answers” from experience or Biblical texts, he says, this “is actually a subtle means of not getting really exposed to the situation.”²³ The chaplain must remain authentic, honest about the experience, and share in the patient’s moment of greatest need. Promotion of one’s own particular denomination is inappropriate in this situation unless requested. After all, chaplains “are ordained to proclaim this good news in obedience to the word of God. They don’t own it.”²⁴ He explains that suffering can stretch the limits of faith beyond human understanding and a chaplain’s most noble duty is to share that moment in humility and with authenticity.²⁵

In each of these approaches, we find one common value:  Christian chaplains from the ecumenical perspective suggest sublimating doctrinal authority to the level of lived experience in order to put the needs of the patient before the duty of the pastor without violating the theological aims of the faith. For some authors, this requires a fully ecumenical understanding of Christian salvation that accepts the equal legitimacy of other faiths. For others, the process of counsel sublimates the need for theological authority and the faith fills the resulting gap. For all, the nature of Christianity and traditional pastoral care adapts to a culture of diverse religious beliefs by embracing a shared human experience broadly described as “spirituality.”

 

III. EXCLUSIVIST PERSPECTIVE

Detractors of the ecumenical perspective defend the absolutism and exclusivity of Christian salvation as the foundation of its validity, arguing that Christianity without exclusivity is not Christianity at all. Often hostile, the negative reaction characterizes the ecumenical response as “un-Christian,” “post-Christian,” a “de-Christianization” of the faith tradition and “generic” or “secular.”

Reverend Edward Hughes, who suggests Christian chaplains lead by example, represents one of the simplest responses. Although his perspective is exclusivist, his advice is broadly applicable. He suggests that chaplains mimic Mother Teresa and Father Porphyrios, who served as models of Christian service, neither promoting nor ignoring the subject of conversion. Administering to the ill is Christian duty, he says, but the chaplain must acknowledge limits:  “He should see himself as a human companion to those who need human love and care; surely motivated, informed, and sustained by his inner spiritual life, but not for the purpose of taking over or even sharing the function of their own religious pastor.”²⁵ By so doing, he says, the chaplain’s behavior exemplifies a relationship with God that becomes a form of ministry of its own.

Another author, H. Tristram Engelhardt, Jr., Eastern Orthodox philosopher and bioethicist, argues that the “post-traditional Christian”²⁶ health care institution’s primary goal is “social justice”²⁷ rather than the historical purpose of the “traditional Christian health care institution,”²⁸ which he claims was proselytizing about salvation. He argues that the “traditional Christian hospital chaplain,” whose primary responsibility was proselytizing “right belief” in a hospital setting and protecting traditional Christian values in a public space, has been jeopardized by the late 20th century advent of the “professional” chaplain, a “secular” position accredited by national societies specifically to defend the “liberal” values of pluralism and tolerance.²⁹ He says, “The primary goal of the chaplain ceases to be that of guiding patients toward repentance, conversion, and salvation, and instead becomes that of bringing patients to spiritual and psychological peace toward the goal of successful health.”³⁰ As a result, he says, “secular professionalism” has eroded the integrity of Christian chaplaincy.

Another author, Mark J. Cherry, argues that public policy institutionalizes immorality under the guise of tolerance and equality in reaction to cultural pluralism, resulting in the decline of Christian chaplaincy.³¹ He says that public policies such as Oregon’s Death with Dignity Act³² imply social obligation, in which detractors are characterized as intolerant, and theological opposition is viewed as merely one perspective among many. He describes the effect of public policy and institutional standardization on chaplaincy concerns as such: “Institutional practice and governmental policy is ever more embracing and coercively enforcing such a fully secularized understanding of religion and culture, in which the search for meaning is fully individualized, all spirituality is generic and interchangeable, and all cultures, practices and religions affirmed as equally good.”³³ The problem, he argues, is that the exclusivity of Christianity has been denied as a compassionate response to the diverse populace, whereas the right path “requires more than rational understanding, but a way of life:  a conversion to authentic Christianity.”³⁴

Professor of Philosophy Christopher Tollefsen argues that chaplain legitimacy is subject to the authority of institutional policy. By acquiescing to the will of the establishment, the chaplain compromises his doctrinal authority and fails to serve the patient properly. He explains: “What is of primary value is their role in a smoothly functioning social practice.”³⁵ “Generic” chaplains serve postmodern multiculturalism, which engenders “individualistic relativism”³⁶ in lieu of any consistent moral authority. Further, he argues that the theological perspective of these “generic” chaplains devalues religious worship and belief in lieu of a meta-God, “a single being which is the source of all the various, and mutually incompatible creeds of the various religions.”³⁷ This perspective validates all beliefs as equal and, therefore, is devoid of centralized authority. In the absence of theology, then, generic chaplaincy “is to minister to the social order, and the experiential domain.”³⁸

Possibly the most prolific Christian critic of ecumenical Christianity and professional chaplaincy is Roman Catholic bioethicist Dr. Corinna Delkeskamp-Hayes. She characterizes professional chaplaincy as “generic,” embracing ecumenical tolerance to the point of spiritual irrelevance. Further, professional chaplaincy promotes the belief that churches are “human institutions which regulate and orient, in their respectively different ways, individuals’ salvific ways of worshipping that Tri-une God,”³⁹ which inherently tolerates the diversity of worship that is opposed by the “one catholic and apostolic church”³⁹ she holds to be true. This criticism is particular to her faith as a Roman Catholic, but difficult to argue outside the realm of that perspective.

Remember that Schmidt and Egler had eschewed exclusivity in preference to pluralism. Delkeskamp-Hayes claims the authors’ negative portrayal of exclusivity is the result of “their own secularizing bias”⁴⁰ and not a valid Christian response. She condemns their pluralistic approach because it ignores “Christ’s missionary imperative”⁴¹ and is culturally respectful to the point of ecclesiastical irrelevance. In an effort to appeal to a pluralistic society, she says, the authors have “cut their Christian faith in pieces”⁴² and reduced Christianity to “a humanist utopia, which means in effect denying the fallen state of our world. This is tantamount to cutting off the foundation of Christ’s redemptive mission.”⁴³ She writes elsewhere that illness is directly associated with sin, as a result of the Fall.⁴⁴ Therefore, it is imperative for her that the chaplain addresses the patient’s sin in order to treat the illness, yet this behavior is prohibited as unethical by the agencies that govern professional chaplaincy, rendering that role irrelevant.

Likewise, she criticizes author Brad F. Mellon, who argued that the secular goals of the professional chaplain aligned with the will of God. Further, he suggested that chaplains should refer patients to another spiritual advisor if that patient’s ethical decision ran counter to the chaplain’s theological perspective. Delkeskamp-Hayes accuses Mellon’s approach of compromising spiritual integrity and urges that chaplains take more of a stand for the spiritual growth of the patient:  “Restricting the pastor’s function to a mere ‘reassurance’ is to deprive his clients of the chance of experiencing the tragic nature of their choice, and of facing the (inevitable) guilt it involves. It amounts to having the chaplain abuse his clerical authority for the sake of hindering spiritual growth.”⁴⁵ Here, the author accuses the chaplain of abusing the authority of the position if he or she does not perform the pastoral duties of proselytization. Again, Delkeskamp-Hayes’ theological perspective is that sin causes illness and the chaplain is hindered from administering to that illness if he or she cannot perform the pastoral duty of missionary work.

In contrast to the ecumenical perspective, the exclusivist position embraces the absolutism of Christianity as the only path to salvation. The worldview of this perspective criticizes the postmodern culture at large as antagonistic to “traditional” Christian values, the result being a decline in doctrinal authority and the rise of “generic” spirituality and apparent moral relativity, the result of multiple perspectives in a multicultural setting. These authors argue for a return to “traditional” doctrinal authority within the field of professional chaplaincy. Although such a tradition might be found within the parallel movement of corporate chaplaincy, for instance,⁴⁶ the history of the Clinical Pastoral Education movement proves to have been ecumenical from its origins.

1. CONCLUSION

In the end, the U.S. healthcare system remains patient-centered in a pluralistic society, which requires medical professionals to respect all belief systems, despite whatever theological concerns any one religious group may have. Even hospitals managed by religious institutions operate within the confines of this multicultural society and have equal responsibilities to patients of all faiths. Medical centers rely on professional chaplains who remain accountable to both their faith communities and peer review, subject to institutional policy; yet, community religious leaders and chaplains of particular faiths are also welcome to visit patients. Further, patients may refuse visitation from a staff chaplain or may request visitation from community leaders or chaplains of their respective faiths if they so desire.

Even so, the literature I reviewed indicates a relevant internal discussion about the potential conflicts chaplains may experience in a clinical setting. After all, absolutism does provide the foundation of validity within a faith community and the professional chaplain’s doctrinal authority may become subjugated to institutional authority. Religious leaders in all settings struggle with meaning in a pluralistic society. And it is valuable to discuss whether a chaplain can maintain authenticity while administering to a patient of another faith, given the differences in precious rituals and beliefs that may create a gulf between them in understanding and personal meaning.

A chaplain involved in the care of a terminal patient must consider these issues carefully in service to the person, the family and the caregivers. As a profession, the primary concern of clinical chaplaincy has always been patient care. The history of the CPE movement has been an effort to provide a valuable service to patients within the institution of healthcare, and patient autonomy has always taken precedence over doctrinal authority. After all, the professional chaplain’s first priority in the clinical setting is patient advocacy. As Pastor Grundmann suggested, each encounter requires the authenticity of the chaplain, because every patient is unique.

 

*          *          *

For more than thirteen years, hospice chaplain Kerry Egan has counseled the terminally ill. She is often asked what her patients want to talk about with their chaplain, and she says the answer has remained constant over the years. She explains:

Mostly, they talk about their families: about their mothers and fathers, their sons and daughters. They talk about the love they felt, and the love they gave. Often they talk about love they did not receive, or the love they did not know how to offer, the love they withheld, or maybe never felt for the ones they should have loved unconditionally.⁴⁷

This had surprised her while she was still a divinity student, but not any more. After all, she says, this is how meaning is made, and this is how God is experienced:  not in “theology and theory,” but in relationships and experiences; “in living life.”⁴⁷

 

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1. Mary Martha Thiel and Mary Redner Robinson, “Physicians’ Collaboration with Chaplains: Difficulties and Benefits,” The Journal of Clinical Ethics8 (1997): 95.
2. Lydia Saad, “U.S. Confidence in Organized Religion at Low Point: Catholics’ Confidence Remains Significantly Lower Than Protestants’,” Gallup, http://www.gallup.com/poll/155690/Confidence-Organized-Religion-Low-Point.aspx?ref=more(2012).
3. John Rea Thomas, BA, BD, MA, “A History of ‘Clinical Training’ and Clinical Pastoral Education in the North Central Region (1932-2006).” edited by History and Research Committee of the NCR (2006): 41-42.
4. “ACPE Standards & Manuals.” edited by Association for Clinical Pastoral Education, Inc. Decatur, GA, 2010, ii.
5. John Rea Thomas and Robert D. Leas, “ACPE History Corner”, The

Association for Clinical Pastoral Education, Inc.  (accessed April 5, 2013).

6. Thomas, “A History of ‘Clinical Training’ and Clinical Pastoral Education in the North Central Region,” 33.
7. APC Board of Directors, “Guidelines for the Chaplain’s Role in Health Care Ethics,” ed. Association of Professional Chaplains, (Schaumburg, IL, 2000), 4.
8. “Professional Chaplaincy: Its Role and Importance in Healthcare,” ed. Larry VandeCreek and Laurel Burton, The Journal of Pastoral Care 55 (2001): 8.
9. Rev. James C. Johnson, M.Div., “An Introduction to Health Care Chaplaincy,” In Navigating the Maze of Professional Relationships: Parish Nurses, Health Care Chaplains, and Community Clergy, ed. DMin and Sue Mooney Larry VandeCreek, BSN. (Binghamton, NY: Haworth Press: 2002), 2.
10. Johnson, M.Div., “An Introduction to Health Care Chaplaincy,” 10.
11. Kurt W Schmidt and Gisela Egler. “A Christian for Christians, a Muslim for the Muslims? Reflections on a Protestant View of Pastoral Care for All Religions,” Christian Bioethics4 (1998): 243.
12. Schmidt, “A Christian for Christians,” 250.
13. Schmidt, “A Christian for Christians,” 244.
14. Brad F. Mellon, “Faith-to-Faith at the Bedside: Theological and Ethical Issues in Ecumenical Clinical Chaplaincy,” Christian Bioethics9 (2003): 61.
15. Mellon, “Faith-to-Faith at the Bedside,” 66.
16. Mellon, “Faith-to-Faith at the Bedside,” 65.
17. Mellon, “Faith-to-Faith at the Bedside,” 67.
18. Christoph Schneider-Harpprecht, “Hospital Chaplaincy across Denominational, Cultural and Religious Borders: Observations from the German Context,” Christian Bioethics9 (2003): 97.
19. Schneider-Harpprecht, “Hospital Chaplaincy across Denominational, Cultural and Religious Borders,” 105.
20. Schneider-Harpprecht, “Hospital Chaplaincy across Denominational, Cultural and Religious Borders,” 101.
21. Christoffer H. Grundmann, “To Be with Them: A Hospital Chaplain’s Reflection of the Bedside Ministry to Terminally Ill and Dying People,” Christian Bioethics9 (2003): 83.
22. Grundmann, “To Be with Them,” 79.
23. Grundmann, “To Be with Them,” 82.
24. Grundmann, “To Be with Them,” 89.
25. Grundmann, “To Be with Them,” 83.
26. 11. Rev. Edward Hughes, “Two Contemporary Examples of Christian Love,” Christian Bioethics4 (1998):  280
27. H. Tristram Engelhardt, Jr., “The Dechristianization of Christian Health Care Institutions, or, How the Pursuit of Social Justice and Excellence Can Obscure the Pursuit of Holiness,” Christian Bioethics7 (2001): 152.
28. Engelhardt, “The Dechristianization of Christian Health Care Institutions,” 153.
29. Engelhardt, “The Dechristianization of Christian Health Care Institutions,” 152.
30. H. Tristram Engelhardt, Jr., “The Dechristianization of Christian Hospital Chaplaincy: Some Bioethics Reflections on Professionalization, Ecumenization, and Secularization,” Christian Bioethics9 (2003): 140.
31. Engelhardt, “The Dechristianization of Christian Hospital Chaplaincy,” 149.
32. Mark J. Cherry, “Foundations of the Culture Wars: Compassion, Love, and Human Dignity,” Christian Bioethics7 (2001):  300.
33. Cherry, “Foundations of the Culture Wars,” 304.
34. Cherry, “Foundations of the Culture Wars,” 307.
35. Cherry, “Foundations of the Culture Wars,” 312.
36. Christopher Tollefsen, “Meta Ain’t Always Betta’: Conceptualizing the Generic Chaplaincy Issue,” Christian Bioethics4 (1998): 309.
37. Tollefsen, “Meta Ain’t Always Betta,'” 308.
38. Tollefsen, “Meta Ain’t Always Betta,'” 311.
39. Tollefsen, “Meta Ain’t Always Betta,'” 314.
40. Corinna Delkeskamp-Hayes, “Generic Versus Catholic Hospital Chaplaincy: The Diversity of Spirits as a Problem of Inter-Faith Cooperation,” Christian Bioethics9 (2003): 6.
41. Corinna Delkeskamp-Hayes, “A Christian for the Christians, a Christian for the Muslims! An Attempt at an Argumentum Ad Hominem,” Christian Bioethics4 (1998): 300.
42. Delkeskamp-Hayes, “A Christian for the Christians,” 287
43. Delkeskamp-Hayes, “A Christian for the Christians,” 297.
44. Delkeskamp-Hayes, “A Christian for the Christians,” 303.
45. Corinna Delkeskamp-Hayes, “Resisting the Therapeutic Reduction: On the Significance of Sin,” Christian Bioethics13 (2007): 105-127.
46. Corinna Delkeskamp-Hayes, “The Price of Being Conciliatory: Remarks About Mellon’s Model for Hospital Chaplaincy Work in Multi-Faith Settings,” Christian Bioethics9, (2003): 76.
47. Chad E. Seales, “Corporate Chaplains and the American Workplace.” Religion Compass6:3

(2012): 195-203.

7. Kerry Egan, “My Faith: What People Talk About before They Die,” CNN Belief Blog.

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