Update

Prayer and Health Care: An "Altared" Responsibility

Once upon a time there was a wise and wonderful teacher who said that in prayer we not only commune with God but also find new strength--new virtue--for daily life. I won't tell you whether that teacher was a theologian or my mother, but that teacher's line is, if you will, the text for this talk.(1)

I want simply to take this reminder of the significance of prayer to the hospital and to all the places where we endure and care in the face of sickness, pain, and death. I want simply to suggest that in prayer we may find new strength--new virtue--for medical ethics, and that in prayer we may find our responsibilities subtly altered and decisively "altared."

I say "simply," but the task I undertake may seem daunting and unpromising. Modern medicine, after all, seems thoroughly "religionless," and a technologically well-equipped hospital seems emblematic of a "world come of age." I take courage for this task in the simple fact that prayer is as common in hospitals as in churches, as common in hospitals as bedpans. As noisily secular as modern medicine is, prayer is still commonplace. When people hurt and suffer, or when they are about to give birth or die, we are likely to find them under the care of a physician and in a hospital--and praying. To be sure, sometimes prayer is regarded as a technology of last resort in hospitals,(2) but the simple fact that it is commonplace suggests that it is not unreasonable and it may be important to ask how prayer might illumine our endurance of pain and suffering and our attentiveness to the sick and dying.

It is conventional that lectures in medical ethics consider a case. So, consider this: in his Harvard Diary, Robert Coles tells the story of a Catholic friend of his, a physician who knows his cancer is not likely to be beaten back, a Christian who knows the final triumph belongs to the risen Christ. The dying man was visited by a hospital chaplain who asked how he was "coping." "Fine," he said in the fashion of all those replies by which people indicate that they are doing reasonably well given their circumstances, and that they would rather not elaborate just now on what those circumstances are. But this chaplain was unwilling to accept such a reply. He inquired again about how the man was feeling, how he was managing, how he was dealing with the stress. Relentlessly he pressed on to questions about denial and anger and acceptance. But finally he gave up with the suggestion that when the man was ready to discuss things, he should not hesitate to call the chaplain. After the chaplain left, Coles' friend did get angry, not so much about his circumstances or his dying, but about the chaplain. The chaplain, he said, was a psycho-babbling fool. And Robert Coles, the eminent Harvard psychiatrist, agreed. What his friend needed and wanted, Coles says, was someone with whom to attend to God and to God's word, not someone who dwelt upon the stages of dying as though they were "Stations of the Cross."(3)

My concern today, however, is not that the church or its representatives will neglect or ignore talk of God for the sake of psycho-babbling talk about "stages" and "phases." My concern is rather with medical ethics, and with the possibility that Christians will ignore or neglect the practice of prayer for the sake of an impartial point of view and the generic moral principles favored by medical ethicists.

Just imagine for a moment that the chaplain who visited Coles' friend had been trained as an "ethicist" rather than as a therapist. Suppose he had been enlisted on some hospital ethics committee and, there, taught a little Mill and a little Kant, taught to respect and protect a patient's autonomy, taught to regard human relationships as contracts between self-interested and autonomous individuals, taught to speak the language of rights (or utility) as a moral "esperanto"--as a universal moral language. Then perhaps you can imagine Coles' friend being visited by this chaplain again, anxious now, not so much with psychological states and stages, as with not interfering with the patient's rights, including, of course, the right to be left alone.

His enthusiasm for a common moral language, for the kind of "esperanto" ethicists like to speak, will make him hesitate to speak in a distinctively Christian voice, hesitate to use and to offer the gifts of prayer and scripture when people are dying or suffering, and face hard medical and moral decisions.

If you can imagine all of that, then you can also imagine that after this visit of the chaplain-turned-ethicist, Coles' friend might complain no less bitterly. The point is not that philosophical skills or generic moral principles are useless. But Coles' friend still needs and wants some good hard praying, not just to have his "autonomy" respected and protected. He still needs and wants someone to talk of God and the ways of God, not a conversation in moral "esperanto," a language he little understands and doesn't really care to learn--not now as he lies dying at any rate. He has decisions to make, to be sure, hard medical and moral decisions about what should be done and what left undone, but he wants to make them prayerfully, oriented to God and to the cause of God, and not just with impartial rationality.

Now imagine something more: imagine that this chaplain-turned-ethicist hears of this patient's angry rebuke. Imagine that he is stung by it, chastened by it, and that he resolves to make one more visit to the room of Coles' friend, this time to pray, perhaps to learn something from the pious sick that he had forgotten under the instruction of medical ethicists.

Let's go with him. "We have come to pray," we say. Before we begin, however, we ask why prayer is so important to him. His reply, I imagine, would go something like this: "It is important because I am a Christian and because I long to live the Christian life, even in the dying of it, and prayer is part of the Christian life. Indeed, it is, as John Calvin said, the most important part, 'the chief exercise of faith,'(4) the part of the whole Christian life which cannot be left out without the whole ceasing to be the Christian life. And, as Karl Barth said, the Christian life is a life of prayer, a life of 'humble and resolute, frightened and joyful invocation of the gracious God in gratitude, praise, and above all, petition.'"(5)

Well, perhaps his response would not go exactly like that. Not very many people quote Calvin and Barth in their hospital rooms--and very few Catholics. Perhaps his reply would rather go something like this: "Prayer is important because it is a practice of piety. As you know, chaplain, the philosopher Alasdair MacIntyre defined a practice as a 'form of socially established cooperative human activity through which goods internal to that form of activity are realized in the course of trying to achieve those standards of excellence which are appropriate to, and partially definitive of, that form of activity with the result that human powers to achieve excellence and human conceptions of the ends and goods involved are systematically extended.'"(6)

Well, okay, probably not. But even if he has not memorized an important and difficult passage from MacIntyre's After Virtue, even if he has never read a philosopher or a theologian, he may still make a reply to which John Calvin, Karl Barth, and Alasdair MacIntyre would nod their heads and say, "Yes, that's what I meant."

He is a Christian. He has learned to pray in the Christian community. And in learning to pray, he has learned as well the good intrinsic to prayer. He has learned, that is, to attend to God, to look to God. And he has learned it not just intellectually, not just as an idea. In learning to pray, he has learned a human activity which engages his body as well as his mind, his affections and passions and loyalty as well as his rationality, and which focuses his whole self on God.

To attend to God is not easy to learn, or painless. And given our habit of attention to ourselves and to our own needs and wants, we frequently corrupt prayer. We corrupt prayer whenever we turn it to a means to accomplish some other good than the good of prayer, whenever we make of it an instrument to achieve wealth or happiness, or life or health, or moral improvement. In learning to pray, Coles' friend has learned to look to God, and after the blinding vision, to begin to look at all else in a new light. In prayer he does not attend to something beyond God, which God--or prayer--might be used in order to reach; he attends to God. That is the good intrinsic to prayer.

In learning to pray, he has learned as well certain standards of excellence which belong to prayer and its attention to God. He has learned reverence--the readiness to attend to God as God and to attend to all else in his life as related to God. He has learned humility, the readiness to acknowledge that we are not gods, but the creatures of God, cherished by God but finite and mortal and, yes, sinful creatures in need, finally, of God's grace and God's future. He has learned gratitude, a disposition of thankfulness for the opportunities within the limits of our finiteness and mortality to delight in God and in the gifts of God. Attentive to God, he has learned care; attentive to God, he grows attentive to the neighbor as related to God. Looking to God, he has learned hope, a disposition of confidence and courage that comes not from trusting oneself and the little truth one knows well, or the little good one does well, but from trusting the grace and power of God. These standards of excellence form virtues not only for prayer but for daily life--and for medicine. The prayer-formed person--in the whole of her being and in all of her doing--will be reverent, humble, grateful, caring, and hopeful. One does not pray in order to achieve those virtues. They are not formed when we use prayer as a technique. But they are formed in simple attentiveness to God and they spill over into new virtues for daily life. "That's why prayer is so important to me," Coles' friend might conclude. "That's why I called it the 'chief exercise of faith,'" Calvin might say. "That's why I said the Christian life was 'invocation,'" Barth might say. "That's what I meant by a 'practice,'" MacIntyre might add.

So, we are ready, finally, to pray with Coles' friend. "But how shall we begin?" we ask, and Coles' friend replies, "With invocation, of course, for prayer is to call upon God and to adore God as the one on whom we depend. To call upon God is to recall who God is and what God has done. We invoke not just any old god, not some nameless god of philosophical theism, not some idolatrous object of someone's 'ultimate concern,' but the God remembered in religious community and in other practices of piety. Invocation is remembrance, and remembrance is not just recollection but the way identity and community are constituted. So we invoke the God made known in mighty works and great promises, and as we do we are oriented to that God and to all things in relation to God.

We invoke God as creator, and as we do, we learn to make neither life nor choice, for nothing God made is god. That is a good and simple gift to medical ethics, when talk of "the sanctity of life" would require our friend to make every effort to preserve his life, and when "respect for autonomy" would prohibit every moral question besides "Who should decide?" We invoke God as creator, and as we do, we learn as well not to turn our back to life or to choice, for all that God made is good. That, too, is a good and simple gift to medical ethics when one doctor would kill or when another would exercise some arbitrary power to keep Coles' friend alive. We invoke God as creator, and as we do, we learn to refuse to reduce the embodied selves God made either to mere organisms or merely to their capacities for agency. And resistance to both forms of reductionism is a gift to medical ethics both at the beginnings and at the endings of life, and in all the care between as well.

Then we invoke God as provider. We do so in remembrance that God has heard the cries of those who hurt, that God has cared. We do so in remembrance of one who suffered and died, and we attend to that cross as the place where the truth about our world was nailed. The truth about our world is the horrible reality of suffering and death. The truth about our world is the power of evil in the story of a cross and in the myriad of sad stories others tell with and of their bodies. The truth about our world is dripping with blood and hanging on a cross--but the same cross that points to the reality and power of evil also points to the real presence of God and the constant care of God.

Invocation and remembrance do not deny the sad truth about our world or about our friend; they do not provide any magic charm against death or sickness; they do not provide a tidy theodicy to "justify" God and the ways of God. But by attention to this God, we may learn that God cares, that God suffers with those who hurt, even in places no medicine can touch. Then our friend--and every patient--may be permitted to cry out, "God, why?" and still be assured he is not abandoned by God. And the rest of us may be formed by such prayer to embody care even when medicine cannot cure, to be present to the sick even when our powers to heal have failed, and to resist the temptation to abandon the one who reminds us of our weakness--and the great weakness of our great medical powers.

Such prayer is not an alternative to medicine, not a technology of last resort; rather, it forms and sustains, as a standard of excellence in medical practice, simple presence to the sick and a refusal to abandon them to their hurt. Such prayer-formed medicine will not always triumph over disease or death, but it will always gesture care in the midst of them and in spite of them.

We invoke God, too, as redeemer and as healer. We make such invocation, too, of course, in remembrance of Jesus, and in the hope of the good future that he made real and present by his works of healing and words of blessing, which God made sure by raising him from the dead. As we invoke this God, as we attend to the redeemer, as we orient ourselves to the healer in prayer, we orient all of life and our medicine--along with our prayers--to God's promise and claim. So, a prayerful people and a prayer-formed medicine will celebrate and toast life, not death, but be able to endure even dying with hope. A prayerful people and a prayer-formed medicine will delight in human flourishing, including the human flourishing we call health. They will not welcome the dwindling of human strength to be human, including the loss of strength called sickness; yet, they can endure even that in the confidence that God's grace is sufficient.

A prayer-formed community will not despise medicine, as if to turn to medicine were to turn against God and God's grace. Medicine is a good gift of God the creator, a gracious provision of God the provider, and a reflection and servant of God the redeemer. To condemn medicine because God is the healer would be like condemning government because God is the ruler, or condemning families because God is "Abba." Or course, if medicine presumes for itself the role of faithful savior or ultimate healer, then its arrogance may be and must be condemned. Perhaps Coles' friend, like other good and honest doctors, is less tempted than many patients to idolatrous and extravagant expectations of medicine. But invocation of God as redeemer should free us all from the vanity and illusion of wielding human power to defeat mortality, or eliminate human vulnerability to suffering. An honest prayer could let the air out of inflated medical promises and restore a modest medicine to its rightful place alongside other measures that protect and promote life and health, like good nutrition, public sanitation, a clean environment, and the like.

Having made invocation, we pause to ask whether we should continue. Coles' friends says, "yes," and we ask "how?" "With prayers of confession, of course," he says. "Those oriented to God are reoriented to all else; it is called, I think, metanoia, a turning, repentance." It seems clear to us that we have no major league sinner here, but we humor him. "What would you confess?" we ask. "Are you a smoker?" "That, too," he says, "but I see a reflection of my life in my doctor, and I don't like it. I have been where she is, angry at the patient who refuses another round of therapy, angry at my own powerlessness to save him, eager to use my authority as a physician to convince him to try again, and eager to avoid him when he refuses to try again or dies before we can. It is no great callousness I confess; it is the failure to acknowledge the fallibility and limits of medical care." "And now I find myself where my patients have been, and I don't like it much better--angry at the doctor who cannot deliver a miracle, judging her much too quickly and severely, angrier still that she would try to tell me how to live while I am dying, eager to render her still more powerless and optionless. It is no great callousness I confess here either; it is the failure to acknowledge the fallibility and limits of my own autonomy."

Confession is good for the soul, of course, but it's also good for medical ethics. It helps us see the fallibility of both medicine and patients. It helps us recognize the evil we sometimes do in resisting evil, the harm we sometimes inflict in the effort to banish suffering and those who remind us of it. A prayer of confession, this form of attention to God, may help the dying turn from despising the doctor because the doctor is a reminder of his sickness and mortality. And it may help the doctor turn from the disposition to abandon the patient because the patient is a reminder of her powerlessness to save him, and to turn from any readiness to eliminate suffering by eliminating the sufferer.

A prayer of confession may form the possibility of a continuing conversation. When the assertion of authority by a physician would ordinarily have put a stop to an argument and reduced the patient to manipulable nature, a prayer of confession may enable the conversation to continue. And when the assertion of autonomy by a patient would ordinarily have put a stop to a discussion and reduced the physician to an animated tool, a prayer of confession may enable the conversation to continue. We may at least talk together longer and listen to each other better, if in confession, we turn from the pretense of being either final judge or final savior, for we are formed by prayers of confession to be critical without condescension and helpful without conceit. And that is a good and simple gift to medical practice and medical ethics.

"There are prayers of thanksgiving to be made, as well," our friend says, and he begins to mention gifts great and small. And not the least among the gifts for which he gives thanks are opportunities to fulfill some tasks, great and small. He thanks God for a little time to be reconciled with an enemy, and for enough relief from pain for the tasks of fun with the family. He gives thanks for the opportunity and the task of being a witness, a "martyr" he says, to demonstrate even in his dying that some things are more important than mere survival, and that many things are more to be feared than death. There is a gift here to medicine and to medical ethics in the simple and joyful acknowledgement that the sick and dying are still living, that they may not be reduced to the passivity of their sick role, and that their choices may not be regarded simply in terms of the arbitrary self-assertiveness of their autonomy. The sick and dying have tasks and opportunities which must be considered both by themselves and their caregivers.

Prayers of thankfulness form us and move us to seek the neighbor's good. Prayers of thankfulness can form medical practice, too. The ideal of much medical practice is philanthropy; the virtue of much medical practice is beneficence. This is not to be despised, for it commends to the physician a love for humankind that issues in deeds of service. But it divides the human race--and a hospital--into two groups: the relatively self-sufficient benefactors and the needy beneficiaries. Prayers of thanksgiving provide a different picture and different relations, a world--and a hospital--in which each is recipient of a gift, in which human giving is put, as Bill May says, "in the context of primordial receiving."(7) Prayers of thanksgiving also commend and form deeds of love and service, but not as a self-important conceit of philanthropy--rather as little deeds of kindness which are no less a response to gift than the prayers of thanksgiving themselves.

There is very little time when we turn finally to petition, and we apologize a little, but our friend will have no apologies. "Prayer is not magic," he says, "it is not a way to put God at my disposal. It is the way to put myself at God's disposal. It is not a technique to get what I want, whether a fortune or fourteen more healthy years. It is not a spiritual technology to be pulled out as a last resort when medical technologies have failed. Prayer is not a means, not even a means to make God present. It attends to God, and as it does, it discovers in memory and hope that God is present. To treat prayer as a means to some other good than the good that belongs to prayer makes prayer a superstition and trivializes God into some great 'scalpel in the sky.'"(8) "May we not then make petition together?" we ask, a little shocked. "Of course we can," he says, "but carefully, for here it is easy to attend to ourselves rather than to God, and to our wishes rather than to God's cause."

So we form our petitions on the model of the one to whom we attend. We pray--and pray boldly--that God's name and power may be hallowed, that God's kingdom may come, that God's good future will be established "speedily and soon," in this man's own lifetime. And because that good future is already established, we pray--and pray boldly--as the Lord taught us, for a taste of that future, for a taste of it in such ordinary things as everyday bread and everyday forgiveness, in such ordinary things as tonight's rest and tomorrow's life, in such mundane stuff as the workings of mortal flesh and the healing of our embodied selves.

But because that good future is not yet--still sadly not yet--we pray no less boldly for the presence of the one who suffers with us, the one who hurts in our pain. And in petition most boldly of all, we offer ourselves ("altar" ourselves) to be some gesture of God's good future and caring presence.

Attentive to God, both our petitions and our deeds must be governed by the cause of God. Death, for example, is not the cause of God. In the good future of God death will be no more. Attending to God rather than to ourselves, to God's cause rather than to our own wishes, we are unlikely to bring a petition for death to our lips. Until that good future comes, however, there will sometimes be good reasons to cease praying for a patient's survival, and surely peace and relief from pain belong to God's cause and may be our petition and our intention. Attending to God in confident hope of God's final triumph frees us from desperately holding on to this life, frees us to let go of it, leaving it in the hands of the one who can be trusted.

Perhaps only a prayer-formed person will see an important moral difference, if not between praying for someone's death and ceasing to pray for someone's survival, then at least between killing and allowing to die, between intending death and letting go a desperate hold on life. It seems increasingly difficult to make that distinction in moral "esperanto," whether the language chosen is utility or autonomy.

Doctors and nurses make intercession, too, of course, as well as patients. They make petition for those for whom they care, and over whom they exercise responsibility. The conscientious doctor and nurse, especially the ones who take themselves too seriously and regard themselves messianically, will be tempted to make prayer a means again, a supplementary technology, to insure the effectiveness of their own work. But such a prayer is no less corrupted into superstition because the petitioner is a medical practitioner, and "God" is no less trivialized as the "great scalpel in the sky" because the bloody hands of a surgeon are lifted up in such a prayer.

Prayers of intercession and petition, this form of attention to God, not ourselves, can and sometimes do, and should form an altered sense of responsibility (and an "altared" sense of responsibility). In petition, the doctor or the nurse hands the one under their care over to the hands of God.

In making petition, medical practitioners let go of the anxious control they have conscientiously assumed. The doctor who prays seriously for a patient can take herself a little less seriously. In making petition, the medical practitioner learns again that she is not Messiah, and she is freed from the intolerable burden of inaugurating God's good future for the patient. She can freely acknowledge the limits of the art and her own limits. The doctor who prays seriously for a patient will be formed to provide the best care she can, of course, but she no longer anxiously substitutes for an absent God. In making petition, the medical practitioner learns again a carefree care. And in that "altared" sense of responsibility, we lay the best medical skills and the worst medical cases before God with bloody hands and lift them up in prayer.

"One final word," Coles' friend says. "We said before that prayer-formed people will not despise medicine. It may also be said that a prayer-formed people will not despise medical ethics, either. Only let it pray now and then. Prayer is not magic for decisions either. It is not a technique to get what I want, even when what I want is an answer or a solution to a dilemma rather than a fortune or fourteen more healthy years. It is not a technology to be pulled out as a last resort when medical ethics has failed to tell us clearly what we ought to do. It does not rescue us from moral ambiguity. Part of what we know to be God's cause may still conflict with another part of what we know to be God's cause. You will still have to work hard, attending to cases, sorting out principles, identifying the various goods at stake, listening carefully to different accounts of the situation. Prayer does not rescue you from all that, but it does permit you to do all that in ways that are attentive to God and attentive, as well, to the relations of all that to God."

In prayer we not only commune with God but find new strength--new virtue--for daily life, and an "altared" responsibility for medicine and medical ethics.

REFERENCES:

(1) The line, I'm sure, could be credited to my mother and to many other pious Christians. It&endash;or something like it&endash;has been said not just "once upon a time" but again and again and time after time in the Christian tradition. I cite, however, the theologian Henry Stob, "God and Man," in his Ethical Reflections. Grand Rapids: Eerdmans, 1979. This talk is drawn from remarks I prepared as the Stob Lecturer at Calvin College and Seminary in 1992.

(2) This is a risk in the renewed attention to the "therapeutic effects" of prayer; see, for example, Dossey, Larry. Healing Words: The Power and the Practice of Medicine. New York: Harper Collins, 1993.

(3) Coles, Robert. "Psychiatric Stations of the Cross." Harvard Diary: Reflections on the Sacred and the Profane. New York: Crossroad, 1990.

(4) Calvin, John. Institutes of the Christian Religion. Ed., John T. Mcneill, trans., Ford Lewis Battles. Philadelphia: Westminster, 1960.

(5) Barth, Karl. The Christian Life: Church Dogmatics IV. 4. trans., Geoffrey Bromiley; Grand Rapids: Wm. B. Eerdmans, 1981.

(6) MacIntyre, Alasdair. After Virtue: A Study in Moral Theory, Notre Dame: Notre Dame UP, 1981.

(7) May, William F. "Images That Shape the Public Obligations of the Minister," Bulletin of the Park Ridge Center 4:1. (1989): 20-37.

(8) May, William F. The Physician's Covenant: Images of the Healer in Medical Ethics. Philadelphia: Westminster, 1983. *

Allen Verhey, PhD
Hope College
Holland, Michigan

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