Chaplaincy for the 21st century, for people of all religions and noneBMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k5223 (Published 13 December 2018) Cite this as: BMJ 2018;363:k5223
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Meta-analyses of published relative studies on interventions for patients with advanced or terminal cancer have concluded that spiritual care helps improve their physical, psychosocial, and spiritual well-being. 
Another systematic review of published relative studies revealed that religiosity/spirituality also improved the quality of life of dialysis patients. 
Competing interests: No competing interests
As has been so cogently argued in this article, the role of a healthcare chaplain does not require a particular belief, but a certain skill-set. This set of skills must include a willingness and ability to ‘walk with the patient’ and to signpost to religious or belief communities where explicitly requested. A chaplain should be a non-judgemental supportive ‘friend’ and crutch for those most in need, irrespective of belief.
It is encouraging to see NHS chaplaincy slowly evolving into a service that recognises the needs of all patients, sometimes staff, for pastoral support. Yet, this one NHS profession is still wholly reserved for applicants who belong to or are sponsored by a faith or belief community. The arrival over the past couple of years, in a handful of hospitals, of paid NHS chaplains with a humanist belief system is a progressive development that nevertheless papers over the cracks in a discriminatory service.
When most of the population claimed to belong to the Church of England, it may have seemed appropriate to restrict chaplaincy applicants to those approved by the Church of England. As the population has diversified, so has the composition of local chaplaincy teams. The issue, though, is not about a delicate balancing act of denomination-specific chaplains trying to cater to everyone’s personal beliefs. This rather misses the point as well as being unachievable.
NHS appointments should no more be predicated on the candidate’s belief than on gender or skin colour. Belief is not neutral; some mainstream religions still struggle with accepting homosexuality or abortion for example. Patients, particularly those struggling with severe illness or their mortality, should not have to second guess the reaction of the person appointed by their local NHS to provide pastoral care to them.
The status quo denies opportunities to suitable applicants and undermines the trust of many patients that the chaplain will be suitably non-judgemental and supportive. For example, in 2015, the hospital chaplain, Rev Canon Jeremy Pemberton was stripped by the Bishop of his licence to preach in his home Diocese because he married his long-term male partner. He was thereby denied a promotion to an NHS job within his Diocese. What message does that send to local gay patients?
The main obstacle to non-discriminatory chaplaincy services seems to be a confusing conflation of religiosity with pastoral care. If some people feel so strongly that the religious element of chaplaincy is intrinsic to the role, then there is nothing to stop them from encouraging and financially supporting their religious communities in providing denominational chaplains outwith the NHS budget to serve the particular needs and wishes of their religious community. There is no reason why our NHS should fund such a discriminatory service. Upwards of £30 million pounds annually is no drop in the ocean.
21st century chaplaincy has a way to go to keep up with the times. Adding a succession of belief-specific chaplains is not equality but tokenism.
Competing interests: I chair the Secular Medical Forum (SMF) of the National Secular Society. The SMF advocates non-discrimination on the grounds of belief and works to protect patients from the imposition on them of other people's beliefs
Please note correction to my previous response which should read " I have no financial interest or conflicts"
Competing interests: No competing interests
Thanks for dealing with this topic in a thought provoking and sensitive way, and for referring to some of the ground-breaking work which is going on in Scotland. After several years involved in a cross disciplinary study concerning how spirituality is understood and applied by general practitioners, I would offer a few thoughts. Firstly, my support for the ethical entitlement of patients for spiritual or existential care from someone with whom they can find a connection, and that they can trust. In this respect some patients may well prefer someone not religiously categorised.
However, is part of the problem that we need to reconsider religious/non – religious categorisations? It is well evidenced now that theism is not constrained to “religious” people, neither is non-theism to non-religious people. All chaplains and many health carers will be familiar with the example of a patient who does not regularly attend religious services or affiliate with a religion but who is uncertain about whether there is a deity or not, having a degree of provisional or partial belief/disbelief. This person may well consider there to be a spiritual aspect to their life and pray on occasions. Dis affiliation with religion is empirically not synonymous with affiliation with humanism or secularism and we must be alert to the possibility that this assumption is built into research or debate. If chaplains are to care for this complex mosaic of belief, then rather than a smorgasbord of providers with particular labels, the ability for all chaplains to negotiate both theological and secular forms of existential frameworks may be important. This does of course raise other debates, such as to what degree do all forms of spiritual or existential framework contribute to positive health, or adaptive responses to illness.
As a GP it is my observation that chaplaincy is one area where we lag behind our hospital colleagues in terms of our claims to holism. The difficulty of applying spiritual care in general practice may be compounded by variations in the degree to which GPs are alert to existential aspects of care, by differences in the approaches of individual GPs, and by lack of clarity in what constitutes acceptable spiritual care(1–3). It is additionally possible that medicine experiences general difficulties in reconciling the perceptual – physical accounts of reality: the patient as an integrated spiritual and physiological being(4). Among others we have recommended that these may call for a paradigm shift in medical science, adopting contemporary forms of human science, such as critical realism, which reduce this dichotomy(5).
It is refreshing to see chaplaincy teams coming to terms with the diversity of world views which our patients and our society celebrate, working across traditional belief boundaries to relieve distress and share humanity. This itself has powerful symbolic, and perhaps spiritual value which is worth fostering and affirming.
1. Appleby A, Swinton J, Wilson P. ‘I’m not sure if there is any point to all this doc?’: a qualitative study into GPs responses to existential questions. Br J Gen Pr. 2018 Jun 1;68(suppl 1):bjgp18X697061.
2. Appleby A, Swinton J, Wilson P. What GPs mean by “spirituality” and how they apply this concept with patients: a qualitative study. BJGP Open. 2018 Apr 17;2(2):bjgpopen18X101469.
3. Appleby A, Swinton J, Bradbury I, Wilson P. GPs and spiritual care: signed up or souled out? A quantitative analysis of GP trainers’ understanding and application of the concept of spirituality. Educ Prim Care. 2018 Oct 19;0(0):1–9.
4. Appleby A, Swinton J, Wilson P. GPs — at home with science and the humanities? Br J Gen Pr. 2017 Dec 1;67(665):571–2.
5. Cruickshank J. Positioning positivism, critical realism and social constructionism in the health sciences: a philosophical orientation. Nurs Inq. 2012 Mar 1;19(1):71–82.
Competing interests: I have a research interest in spirituality in primary care. I have financial interest or conflicts.
Over the years I have enjoyed several of your 'seasonal articles', and I took great pleasure in this one also. Whilst it explored the challenges we face as a developing profession, it did not naively present the growing diversity of Healthcare Chaplains as if in battle, but rather as we are, collectively searching for new, broader paradigms. I think further interviews with some of our Scottish members operating with a Spiritualty centred model would have added a further richness to the picture, as well as showcasing their significantly integrated models of working to support staff that will bear further reporting.
Whilst some wish for a new role title for the Healthcare Chaplain to resolve any misunderstanding of what we do amongst colleagues and patients, I feel this is rather like the debate about the title 'Junior Doctor'; new titles sound attractive until you explore them more fully and the consequences of change. I rather believe the way forward involves the modern face of Chaplaincy working towards greater visibility. Such work id part of what we do as a College, and interesting pieces like yours are a help on this task. Perhaps most important, however, are encounters between Healthcare Chaplains and MDT colleagues in challenging clinical situations where we can demonstrate our worth and gradually bring about a fuller understanding of our expanded and existential role in the 21st Century.
I am sure my on-call colleagues will hate me saying this as Christmas approaches but, if you haven't called a Chaplain into a situation recently, why not give it a try and see who turns up? I hope it will be a competent individual with skills to assess and support a wide range of cultural, religious, existential, spiritual and pastoral needs, and who addd genuine value to the care of patients/relatives and staff.
Dr. Simon Harrison TSSF.
Competing interests: No competing interests