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"The Judgmental Gaze of the Hospital Chaplain"
Susan J. Dunlap susan.dunlap@duke.edu Vanderbilt Divinity School As you walk into the foyer of the main auditorium at Johns Hopkins University, You immediately notice murals on the wall depicting the university's lofty origins. One wall is given to the great men of medicine. Dressed in turn of the century clothing, with close cropped beards and dignified poses, is a group of physicians gathered around an examining table. They stare off into the distance. On the examining table is a woman lying on her stomach, head resting in her arm, fully exposed except for a sheet that covers her legs and part of her buttocks. She is fair, blond, her curves are clearly visible, and her eyes are closed. In the background is the only other woman, a uniformed nurse. The great medical minds of their day, with their "clinical gaze" have dissected and exposed the truth of the woman's body. Their accomplice, or uniformed henchman, is the other woman, who stood ready to assist. The scene suggests images of a specimen under a microscope, a peep show, and pictures of the British nobility in India with a boot on the head of a slain tiger as the Indian servants gather around. My concern is that the hospital chaplain often takes the position of the uniformed nurse: that of accomplice or henchman. Foucault's "gaze" captures at least two things: One, the "clinical gaze" is the means through the physician claims to have captured the objective, deep truth of a patient's disease, a truth prior to, unfettered by, theories and pre-existing categories. The chaplain's gaze, then, would be the means to capture the objective, deep truth of the moral, spiritual state of another's soul. The second meaning of gaze is surveillance and the self-policing internalizing of it. Foucault: "There is no need for arms, physical violence, material constraints. Just a gaze. An inspecting gaze, a gaze which each individual [under its weight] will [end by] interioriz[ing] to the point that he is his own overseer, each individual thus exercising this surveillance over, and against, himself." So the hospital chaplain's gaze is a means of institutions' exercising power. Power circulates through the position of chaplain to help render patients "docile bodies." So, now I want to tell an extended story. I want to address the issue of the pastoral caregiver's judgment of the sick. The capacity of caregivers to silently whisper in their hearts, "its really their own fault, they shouldn't have been drinking, smoking, eating so much, driving so fast, burning their trash, fixing their own car, working in such a dangerous job, heating their house with a kerosene stove, etc." The chaplain's judgmental gaze exposes the deep truth of another's guilt, and reproduced the much-prized "docile bodies" of the hospital ethos. Here is the story. I was just starting my work as a chaplain at the Burn Center. A pager called me to the Burn Center for a new admission. A 25-year-old white woman, Lisa, had been admitted with major burns on her abdomen. Her 3-year-old son was in the same fire and his injuries were much worse. Several things added to the drama. First, the father could not be reached, and he was not married to Lisa, though they had been living together for eight years and had several children. The intensity mounted when we encountered in the hallway a crying, trembling, stricken woman who told us she was Lisa's sister. I went into Lisa's room and found her in an odd state of crying and laughing, concerned about both her son and her deteriorated fingernail polish. When I told her that her sister was outside waiting to see her, she looked at me blankly and said she didn't have a sister. The Burn Center is locked day and night, and visitors have incentive to present themselves as immediate family in order to gain entrance. For some reason, I kept an emotional distance from these odd and intense events, observing with a third eye that hovered like a TV camera for an emergency room drama series. I went to the little boy's room and saw how very sick he was. His little body was so small in the intensive care bed, and his face was grotesquely bloated from the attempt to replenish body fluid. There were medical personnel and hi tech machinery all around. He was not doing well at all. Then I heard someone say that the mother smoked a pack of cigarettes a day, and, while she slept, this little boy started the fire with her cigarette lighter. My detachment was shattered and I was flooded with feelings of judgment toward Lisa. "How could you leave a cigarette lighter just lying around the house? And why do you smoke in the first place? Especially with small children around. To top it all off, you were not even watching your kid: you were asleep. What is wrong with you? Look what you did to your child." The question of this paper is, What accounted for this judgmental response? When all my clinical training (empathy, presence) and theological belief (forgive 70 times 7) has taught me otherwise? Another way to ask this question, why did I reproduce the judgmental gaze of a mysogynist, medico-centric, individualistic, death-denying culture? Surely this mother had plenty of internal self-critical voices, and I had seen how the staff was already pointing a finger at her supposed carelessness with a cigarette lighter. Why did I, the chaplain, the bearer of grace and mercy, join those voices of condemnation? I went home full of troubled thoughts, trying to dig deeper into my heart and the heart of this mother and son. Upon my arrival home, I was greeted by my precious Anna, two years old and the light of my life. As we gleefully reconnected as mother and daughter, I noticed that she was still holding her little left thumb inside her other fingers, forming a tight fist. Her thumb would not straighten lately, and she did not use that hand at all. My husband and I had been struggling for a couple of months trying to decide whether take the doctor's advice that she have surgery, or to just wait and see. The thought of surgery struck me with deep fear, grief, and, most significantly for this story, guilt. I was racked with guilt that it was all my fault. There was a possibility that the cause of the bend in her thumb was an earlier injury I had ignored. "I should have paid more attention to the original injury. I have sacrificed my daughter's dominant hand at the altar of my inaction. I just have to face the sickening truth that I grievously failed my daughter." Neither grace nor reason could address this deep, sick feeling. So I got home from the hospital, and as the day was ending, I remembered the mother and son still in the hospital, and I remembered the strength of my angry judgment. It began to dawn on me that Lisa and I were both mothers of small children who were injured, and, rather than distancing myself through judgment, I could have stood by her side as another mother, in anguish over the pain of our children and the question of our responsibility. We could have connected as imperfect yet deeply loving mothers, bound by a grief born of that love. As I remembered my harsh judgment of her as a mother, I began to think of the many holes in my own maternal righteousness. I remembered all the times I had placed Anna at risk, leaving butcher knives close to the edge of the counter, forgetting to buckle Anna's car seat, running in the house while she is outside alone. It is sheer chance/grace that Anna has not been hurt. So the question became, if all of us as mothers place our children at risk in sometimes large, sometimes small, ways, why do only some of our children get hurt? The inescapable conclusion seems to be, that we live in a world where random things happen that we as mothers cannot control. Mishap is not egalitarian. Our children's hurts could be laid squarely at the feet of our carelessness. Or we can bring into the equation the chaotic, unpredictable world we live in. So Lisa and I could have stood together as imperfect mothers, and also as co-inhabitants of a world where we cannot control everything that is dangerous to our children. So began a quest that took me into conversations with chaplains, pastors, friends, and family. The question was: why judgment and not solidarity?1 One explanation was usually invoked: standing in judgment of others reduces the anxiety of confronting the fact that we too live as (1) fragile bodies in a world where (2) random and dangerous and uncontrollable things happen. Our thinking goes something like this: "If this terrible thing befell that person, then it could befall me. Unless I find someone/something to blame, I have to admit that we live in a chaotic world in which I, and my loved ones, are vulnerable." This is, of course, could be labeled in classical theological language as the sin of pride, the sin of denying our creaturely finitude and denying our powerlessness as creatures. "Blame and judgment allow us to continue in our denial of how close the edge is all the time," my colleague, the AIDS chaplain, told me. Who else would know more about judging the sick than he? And I think this explanation is true. Pinning the blame, pointing the finger, draws a circle of confinement around an identified danger source. When we believe we have pinpointed how someone else "poorly" handled some danger, we feel we have restored our control over it, and we reassure ourselves that we would never make that mistake. But this psychological explanation of judgment isn't enough to account for pastoral caregivers' capacity to stand in judgment. A historical, social, and feminist account is also required.
Let me speak first of the historical context. There is a long history of associating ill health with immorality. In the Mosaic tradition in Hebrew Scriptures illness was one of the "curses" for disobedience. The plagues in Renaissance Europe were proclaimed God's judgment on a sinful people. Leprosy several centuries ago in Europe was considered a punishment for immoral sexual behavior. Puritans associated illness with divine wrath. In the early Twentieth Century the 'crusaders for fitness' championed health and personal salvation through diet and exercise."2 Contemporary We have our own contemporary version of associating health with morality. For example, we judge the overweight person with heart disease for failing to follow the widely dispersed dictum to "exercise and eat right." To exercise, diet, avoid drinking/smoking/drugs, and deal correctly with stress, is to be virtuous. If you violate these rules of morality, as this thinking goes, then you deserve your illness. Our tendency to judge the sick for their ill-health has a long and venerable history in our Christian, Western past.3 Now, in this story, Lisa is both "the injured one" and "mother of the injured one." I as a chaplain was grappling with a way to be in solidarity with her. Because the words she expressed seemed to be mostly concern for her son, I determined that the best way to be in emotional solidarity with her as "injured one" was through our shared roles as "mothers of injured ones." I believe that the historical and social context of blaming "injured ones" deepened my judgment of her as "mother of injured one." Social Context The American middle class particularly wants to pinpoint blame. We believe we have control over the events of our own lives. We have not been taught by either race or poverty that there is much we cannot control. The news that there are realms where we do not have complete control, such as the body and its vulnerability to disease and injury, can be terrifying. We have not been forced by a degree of social powerlessness to develop mechanisms for coping with a degree of powerlessness over vulnerability to illness and injury. So the impulse to judge is even stronger for the middle class. One of the ways we stave off the realization of our finitude, our vulnerability as bodies, is to distance ourselves from embodiment. We have a very effective tool toward this end with the dualisms firmly entrenched in the Christian West. The West has constructed a bifurcated world, divided along multiple polarities, including "us and them," "self and other," "mind and body," and, of course, "male and female." Such dualisms allow us to project the body and its mortality on Them, the Other, particularly if the other is gendered "woman." We then establish ourselves on the "safe" side of the bifurcated world, that of the immortal spirit and mind, above the fragilities of material life.4 Thus we are able to construct the illusion that we are far, far away from the vicissitudes of both the body and the world we live in. In psychologically-based chaplain training programs we have focused on the problem of establishing an emotional distance as a way to distance ourselves from the fear of our mortality. Here I am focusing on the ways we construct a cultural or social distance by establishing the sick as the Other, associated with the body and its mortality. It was not difficult to convince myself that Lisa was Other. She bore numerous marks of her lower socio-economic status, which certainly qualified her as Other. Like most of us, I was trained at an early age to assess another's class. The first cues were in Lisa's family -- their dress, and the accent and grammar of their speech. Lisa's hairstyle and fingernail adornment were further evidence that she was from a lower class. All of this I undoubtedly read just below consciousness and used it as a way to locate her as not-like-me. Once class is established, we then believe we know much more about a person. In the case of Lisa, I could import notions of the poor as lazy, careless, and irresponsible, qualities that "we" don't have. If she is of another order of human beings, those lazy, careless, irresponsible ones, qualities that I most surely do not have as a member of the middle class, then I am safe. Of course we both share the status of Other as women. Probably the primary, paradigmatic split in Western thought is along gender lines, male and female. Women are associated with the body and the threat of its mortality, as well as the dangerous, out of control realm of sexual desire. But the category of woman has its duality as well. As white women we are subject to the familiar and variously called "madonna-prostitute" construct. We are either pure, maternal, spiritual, nurturing, and self-sacrificing, or we are sexual, dangerous, bad mothers, and selfish. Several things put Lisa at the unrighteous end of this polarity: she was an unmarried mother, she smoked, she placed her child at risk by sleeping and thereby abandoning her child. I also think class splits the category "white woman." Since, as women, we can't escape the body side of the mind-body dualism, do middle class women need poor women to bear the "burden" of embodiment so that we can be safe? Do we need the category "poor woman's vulnerable body" to construct the category "rich woman's safe body?" So why did I distance myself from Lisa? In order to escape the truth that emanated from her injured body and that of her son: that we are all embodied and vulnerable, including those most precious to us, and we all live in a world where random things happen. And how did I do it? By establishing her as Other. "This not-like-me person is a fragile, mortal body. I am not." I created this chasm not only with an emotional distance, which would be the focus in psychologically-based chaplain training programs. But I also constructed a cultural distance by establishing her as the Other, associated with the body and its mortality. Class and Illness But there is more to the story. This is more than a story about discursive constructions of the confluence of illness, immorality, women, and the poor. The fact is, Lisa is statistically more vulnerable to ill health than I am. Not because she is ontologically somehow more bodied than I, but because of her lower socio-economic status. The fact is, the poor do suffer from more health problems, do show more evidence of the fragility of human embodiment. But not for the reasons our prejudices might imply. The poor are not sicker because they are more irresponsible (a moral judgment), or somehow more embodied and mortal by nature (an ontological judgment), but because they lack power. Powerful groups are healthier. We as white middle class people enjoy better health because we can afford better food, we work in safer jobs, we have better health care, our homes have fewer hazards, we don't have toxic dumps in our backyards, and so forth.5 The Risk of Relinquishing Judgment I spoke earlier of the shock to the middle class of news of their finitude. There is a great risk for us in the middle class to acknowledge the correlation of social class and health, to acknowledge that groups with greater social power are healthier than those with less social power. It is easier to see health and illness in terms of individual responsibility. If we were to acknowledge the structural reasons for health status, and relinquish our blame of the individual, then we would be forced to acknowledge three things. First, we would have to question the righteousness of our own health. We are not healthy because we are so moral, but simply because of our social location. Second, we would have to acknowledge that we are not separated from the Other by our ontological transcendence of the body, but by our social power. That means we share mortality, fragility, vulnerability with the Other, the edge is out there for us just as it is for them. Our social power simply allows us to build few more barriers between us and the edge. Third, we "haves" have a great deal at stake in maintaining a system that keeps us healthy and the poor sick. We benefit from social and economic structures that make and keep others sick. So, when we look closely at structural issues behind our good health, what began as a smug claim to our individual moral, healthy lifestyle, becomes a repentant acknowledgment of our benefiting from social injustice. The question of morality moves from the individual to the social, and therefore we have to question our innocence in a system that privileges us and afflicts others. So, why do we have a tendency to chose judgment over solidarity? Because we would have to acknowledge too many fearful things. We live on the edge of mortality. We are vulnerable. We will not be saved by our righteousness. Solidarity means risking coming face to face with these facts about being human. Now the questions become theological. Creatures Afraid of Dependence on the Creator At the root of all of this is surely fear of recognizing our vulnerability as finite creatures. We are the fragile creatures, not the Creator, upon whom we depend for life itself. Human beings, the body-souls that we are, have been created good and for loving relationship with each other and our Creator. Yet we rebel against this state of things because it is too scary, it invites an anxiety that can be intolerable. Our fear drives us to deny our dependence on God, refuse to live in communion with our co-creatures, and seek security in the things we accumulate, the control we grasp, and the emotional fortresses we build. So, my judgment of Lisa is an expression of the human drive to self-secure in the face of our fear of finitude. Her injury, and even more horrifying to me, her son's injury, brings to the fore the precariousness of my corporeal existence and that of my daughter. So I chose to secure myself from such contingency by standing in judgment of her, denying dependence on God, and clinging to the idol of my middle class righteousness, desperately hoping it will save me, my body, and those that I love, from demise. Ultimately, our fear of finitude is our fear of our moment to moment dependence on the grace of God. Stepping into the vast unknown emptiness of the wilderness with only the promise of God's sustaining presence is most terrifying. The predictable misery of the fleshpots of Egypt seem safer than the pillar of cloud by day the pillar of fire by night. After all, we have seen clouds evaporate and fires extinguished. How frightening to know that it is only by the seemingly ephemeral but nevertheless God-sent cloud and fire that we will reach the promised land. Yet the milk and honey are for those who have risked depending on them. It is God's minute by minute, step by step grace through the wilderness that leads us to Canaan's plenitude. The good news is that reminders of our finitude can be received as a call to return to a life lived in grateful dependence on God and a renunciation of our idolatrous ways. And, not only does such repentance bring us back to God, but to each other. To recognize the precariousness of corporeal life can be the occasion of bonding with our co-creatures. This kind of bonding is expressed in Frank's description of the person who lives as a "communicative" body, who "see reflections of its own suffering in the bodies of others" and who "wants and needs to relieve the suffering of others."6 The encounter with sickness and injury, whether it is mine or the stranger's, invites a solidarity with the suffering based on shared acknowledgment of our failings and finitude. The chasm created by judgment is not the only option. A Word About the Quandary of the Liberationist Chaplain: Creaturely Finitude or Social Sin? The liberationist chaplain is faced with a dilemma here. As chaplains we recognize the importance of naming our creaturely finitude in a world where unpredictable, random events happen. As liberationists, however, we have become suspicious of appeals to the chaos of the world as the reason for human suffering. We know that such appeals can hide the injustice that is at the root of so much suffering. For example, when the hurricane floods decimated much of Eastern North Carolina in 1999, it was easy to shake our heads and talk about this as a tragic act of nature. Upon second inquiry, however, it became clear that the poor without flood insurance, who were forced to build on a flood plane, whose homes were poorly built, who were not able to get loans to rebuild, were the hardest hit. Hurricanes are not democratic. That rain in Eastern North Carolina did not fall on the just and the unjust alike, on the rich and the poor alike. It fell on the poor with more devastating results. What could be more appropriately relegated to the realm of the unpredictable and random than the weather? Yet we see that its social effects are not random. Its ill effects are concentrated on the disenfranchised. The liberationist chaplain asks, how do we name the reality of the often random nature of things that threaten our finite bodies, while recognizing that at root of much of what afflicts our bodies are human systems of social injustice? Don't labels of "random, mysterious, unpredictable" mask very real dominating powers? Don't appeal to these categories as explanations for suffering vitiate drives to correct power inequities? As liberationist chaplains, we are often in a quandary over whether to attribute the human suffering to random chaos or to social evil When are you engaging in doomed attempts to control the uncontrollable (chaos, randomness) and when are you naming social evil in a righteous attempt to gain some leverage over it? To name Lisa's fire as just part of the unpredictable things that happen masks the fact that her poverty meant she may have had faulty wiring, poor child care, an alcoholic husband, etc. It seems to me that the chaplain offers care with the questions of creaturely finitude and social sin always there, but without the requirement that they be sorted out. After all, we are there neither to resolve theological questions for ourselves, for the academic community, nor even for the person to whom we offer care. The chaplain's responsibility is to keep the recognition of creaturely finitude and social sin part of care and reflection on care, without succumbing to the pressure to correctly sort out the quandary.
This encounter with Lisa has left a mark on me. I have been chastened by it, and also energized by it. As both mother and chaplain, I am more prone to recognize the inevitability of my flaws, sins, blindnesses, judgment, and I live in daily repentance of it. Rather than be the occasion for chronic self-condemnation, it has been the occasion for basking in, reveling in, the freedom of knowing we minister, we mother, we care, we dwell in the ocean of God's grace. I was reminded of a story Henri Nouwen told about a rabbi who abandoned his congregation because he was weary of all that his work entailed.7 Some of us leave the ministry, either literally or emotionally, because we are overwhelmed with the suffering of others and our own inadequacies. But he returned to his congregation and, as the story says, "waxed strong in his shame." (With Nouwen, I understand this shame not to be self-loathing or a deep sense of humiliation and exposure, but rather a freedom-begetting humility.) After exploring the complexities of my judgment against Lisa, I have returned home to my ministry as one both chastened and free to "wax strong" in full acknowledgment of both my failings and God's grace. Another way to say it is this: I would rather minister after the manner of the prodigal son who came home than minister in the style of his elder brother. The younger brother knew he had failed and he knew he was loved and reveled in the grace that greeted him. The older brother knew neither of his failings nor of the grace in which he had dwelled every moment of his life, and he refused to go in to the party. I hope I can offer care to the suffering with the memory of both my betrayals and the party, the ring on my finger, and the unbridled joy and compassion that welcomed me home. I hope I can wax strong in both humility and celebration.
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