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Chaplaincy in the Modern Health Care System: Presence, Dying, and Community in the Advance and Subversion of Biopolitics

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Chaplaincy in the Modern Health Care System: Presence, Dying, and Community in the Advance and Subversion of Biopolitics View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by ETD - Electronic Theses & Dissertations Chaplaincy in the Modern Health Care System: Presence, Dying, and Community in the Advance and Subversion of Biopolitics By Richard Randolph Coble Dissertation Submitted to the Faculty of the Graduate School of Vanderbilt University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY in Religion May, 2017 Approved: Bonnie J. Miller-McLemore, Ph.D. Ellen T. Armour, Ph.D. Jaco J. Hamman, Ph.D. Kathryn Schwarz, Ph.D. Copyright © 2017 by Richard R. Coble All Rights Reserved ii ACKNOWLEDGMENTS This work is several years in the making, beginning when I first set foot in the hospital and unsteadily took on the title of chaplain. I am greatly indebted to the CPE supervisors who aided me in embodying that identity, with its many privileges, heartaches, and contradictions: John deVelder, Ralph Ciampa, Jim Browning, and Christopher Brown. I am also especially thankful to my CPE residency colleagues Nikki Kelley Kleinberg, Janis Rye Nelson, Linda Joy Goldner, and John Howard for our many long conversations about our work and for the mutual support we gave to one another. Thanks also my current supervisor Mary Lou O’Gorman for allowing me to carry on that work today as well as the pastoral care department of St. Thomas Hospital for permission to use screen shots of our charts for the purposes of this dissertation. I am also indebted in the Revs. Jim West, the late Max Patterson, and Mary Louise McCullough for fostering and supporting my interest and call to the ministry of care. I am indebted to Robert Dykstra and the late Donald Capps for introducing me to the academic world of pastoral care and theology during my MDiv at Princeton Theological Seminary. They both taught me to look thoughtfully at my own experiences, including all the messiness, shame, and beauty that they carry, as the starting place for pastoral theological reflection and care. I am also greatly thankful for the guidance, support, and patience of my dissertation committee, especially my advisor Bonnie Miller-McLemore, who taught me the personal and political nature of pastoral care, and who skillfully helped me think through the many issues and conundrums I faced while developing my argument for this dissertation. Thanks also to Ellen iii Armour and Kathryn Schwarz for their expertise and patience in helping me grasp the political and phenomenological theories employed in this dissertation. And thank you to Jaco Hamman for his direction in understanding the nature of hospital chaplaincy today as well as his guidance as director of the Program in Theology and Practice. I am also thankful to my many colleagues at Vanderbilt who encouraged and challenged me throughout my program. I am especially thankful to Jonathan Stotts, Brandy Daniels, Peter Capretto, and Laine Walters Young, as well as Megan DeWald from PTS, for discussing and debating with me as I developed my ideas for this work. I owe Jonathan Stotts a debt of gratitude not only for his help with the dissertation but for his companionship, aid, and thoughtfulness throughout our time together at Vanderbilt. Finally, I cannot thank enough my wife and partner Lindsey Williford, whose love, support, and patience made this work possible. Supporting a spouse through eight years of graduate education is an incredible task, which she has done with care, grace, and kindness throughout. Thanks also to our labrador Duke, who patiently slept beside me in my office every day while I wrote and researched this work. And thank you also to our son Joseph, who brings us and everyone who meets him so much joy and inspiration. Thanks also to my parents Randy and Mary Jane for encouraging my love for scholarship. It has been a saving grace. iv TABLE OF CONTENTS Page ACKNOWLEDGEMENTS……………………………………………………………………………………iii Chapter I. Introduction……………………………………………………………………..…...……………..……..1 Focus and Problem of the Project………………..………………..…….………..……..…….6 Two Powerful and Inadequate Solutions…………....................…………………...….…….11 Argument and Chapter Outline………………………………..………………….…..….…..19 Method…………………………………………………………..…………………………...22 Conclusion…………………………………………....………..………………………...…...29 II. Modern Hospital Chaplaincy: Negotiations…………………………..…………….......................……32 Negotiating a Foundation: Boisen and Cabot on Modern Chaplaincy………………..……….37 Anton Boisen’s Research Agenda…………………………………………………….40 Richard Cabot’s Care of the Soul……………………………………………………..45 Trajectories and Tensions……………………………………………………………..46 Spirituality and Contemporary Arguments for Professionalization…….……………………..49 Spirituality as Professional Foundation…………………………………………….....50 Spiritual Care on the Health Care Team: Integration, Assessment, and Charting.........56 Falling Out of the Frame………………………………………………………………65 Conclusion……………………………………………………………………………………69 III. The Biopolitical Sphere: Theories of Spirituality and Chaplaincy Care………………………………71 Introduction…………………………………………………………………………………...74 Theories of Spirituality………..………………………………………………………………76 Spirituality as American Individualism……………………………………………...77 Commoditized Spirituality…………………………..……………………………….84 Theories of Biopolitics………...……………………………………………………………...91 The Hospital and Spiritual Care as Pastoral Power………………………………….94 Foucault’s Pastoral Power…………………………………………………….94 Winnifred Fallers Sullivan, Pastoral Power, and Normative Spirituality…..…98 Esposito’s Immunity Paradigm……………………………………………………..104 Conclusion: Embodiment and Theories of Political Change…...…………………………...112 IV. Medicine as Biopolitical Apparatus: Progress, Commodification, and the Omission of Death in Current Health Care Systems…………………........…………………………………..……….………117 Death and the Clinical Gaze………………………………………………………………….122 Current Narratives and Trends: Progress, Distribution, and Consumerism….………………128 v Progress and Expense………………………………………………………..………129 Consumerism and Disparities………………………………………………………..131 The Costs of Buying…………………………………………………………………135 The Affordable Care Act: Progress and Limitations……..………………………………….139 Invisible Deaths………..…………………………………………………………………….145 Making Death Opaque: Treatment, Prognosis, and Futile Care…….………………146 Making Death Invisible: Coding, Advance Directives, and Changing the Conversation…..149 Conclusion…………………………………………………………………………………..155 V. Bio-Psycho-Socio-Spiritual Medicine: The Turn to Patient Experience and the Advance of Medical Power….………………………………………………………………………………………157 Chaplaincy and the Biopsychosociospiritual Turn……………………………………...........160 Resistance and the Naming of Death in the Biopsychosociospiritual Turn…………161 Acceptance as the Ideal State of Dying……………………………………………...167 A Mixed Assessment………………………………………………………………...179 Chaplains’ Work in Death Care……………………………………………………………..180 Presence as Being With and Refusal………………………………………………...182 Humanistic Psychology in Chaplaincy Presence……………………………………184 Empathy and the “Truth” of the Patient……………………………………………..187 On Doing More……………………………………………………………………...190 Conclusion……….………………………………………………………………………….192 VI. Loss as Subversion: Tracing the Chaplain’s Experience in Care…………...……………………...194 Self-Loss and the Turn to Experience……………………………………..………………....196 The Chaplain’s Self-Loss via Freud and Kristeva….………………………………………..198 Psychological Self-Loss……………………………………………………………..202 Self-Loss in Chaplaincy Experience: Implications and Limits of Psychoanalytic Theory……………………………………………………………………………….208 Jean-Luc Nancy, Being-with, and Self-loss as the Exposition of Finitude…..……………...212 Nancy on Community……………………………………………………………….215 Self-Loss, Chaplaincy, and Biopolitics: Implications and Limitations of Phenomenology………………………………………………………………..……221 Conclusion……..…………………………………………………………………………….227 VII. Speaking Loss in the Language of Spirituality: On “God” and God’s Withdrawal……….……..230 Experiencing a Community of Loss………………………………………………………….233 Chaplain as Marker of Meaning……………………………………………………………..235 Charles Gerkin and the Hermeneutics of Pastoral Care……………………………..236 The Strategic Hermeneutics of Interfaith Chaplaincy……………………………….239 Transcendence and Self-Loss: Rethinking our Symbols beyond Gerkin……………242 The Withdrawal of God in Moments of Loss………………………………………………243 Différance and the Tensions of Presence……………………………………………245 Différance and the Withdrawal of God……………………………………………...248 Openings within the Name of God…………………………………………………..250 God, Power, and Community………………………………………………………..254 God, Withdrawal, and the Sense of Death…………………………………………..257 vi Nancy and Gerkin in Conversation…………………………………………………..261 Conclusion: Self-Loss and a Biopolitics of Life………………….…………………………262 BIBLIOGRAPHY………………………………………………………………………………………272 vii CHAPTER 1 INTRODUCTION Let us walk together, for a moment, in my memory of entering a large, university hospital, a medical center connected to one of the top research universities in one of the major cities in the United States. First, before entering, we cross the bridge over the river that divides this city. Regard for a moment those sleeping under the bridge, the series of sleeping bags, a few tents. The bridge is quite high, so we can only see the spot from far away, populated with bodies long neglected in our city. But they are there nonetheless, and we will need to think about the connection between such indigent lives and the medical center later in the dissertation. Now we walk through the university to which this hospital is connected. Feel the awkwardness
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