“This survey makes me realize how much I have to learn. Thank you.”
This anonymous comment from a pastor who completed an online survey connects with a core aspect of The Center for Bioethics & Human Dignity’s (CBHD) mission: to provide resources that are credible, current, and comprehensive. The Center designs resources for a variety of audiences. Perhaps no resources are more timely than helping those who guide their congregation through the uncertain waters of difficult bioethical decisions.
The purpose of this survey, as part of my doctoral studies, was to assess pastors’ familiarity with a range of bioethical issues, the values and ethical frameworks they employ in resolving dilemmas, and the kinds of resources they rely on for help. Secondarily, respondents were asked their willingness to be interviewed for a future study that subsequently became the subject of my dissertation research. Analysis of the results of this online survey among pastors underlines the relevance of investigating what pastors know, their moral framework, and identifying their needs for credible bioethical resources.
The discussion that follows is an abbreviated account of the study.
In the summer of 2014, CBHD sponsored “Clergy Awareness of Health Issues,” an online survey (“the clergy survey”) to assess pastors’ awareness of health issues faced by their congregations, their comfort level in providing counsel, and their ethical perspectives.[1] At the time, the only published study of this kind surveyed pastors in the Reformed Churches in South Africa.[2] The purpose of CBHD’s pilot survey was to create, administer, and assess a survey instrument, analyze the data, and use the findings to create an instrument that could be used in a future, large-scale study.
Nearly 200 people responded, and 173 completed the rather demanding survey, which took an average of 15–30 minutes to complete. They responded to invitations from a variety of CBHD communications, as well as announcements from various denominational leaders and emails from colleagues. In addition to soliciting basic demographic information and pastoral experience, the survey investigated the pastors’ comfort level in providing guidance on a range of ethical issues, their encounters with specific medical issues, and the theory base or authority they relied on for guidance.
The typical respondent was male (88%), Generation X, that is, between 35 and 54 years old (42%), with an MDiv degree (46%), and was pastor of a congregation of less than 250 members (52%). The largest denomination represented was Evangelical Free Church of America (26%), followed by non-denominational, Lutheran, Baptist, Presbyterian and Reformed (<10% each). A total of 23 denominations were represented. About 20% of the men and 58% of the women participated on an ethics committee, such as at a hospital, a research committee, or a “sanctity of human life” team.
The majority of pastors had been consulted at least once on a bioethical issue. Frequency of being asked increased with age, beginning with 59% of Millennials (18-34 years), with 84% of Generation X (35-54 years) and 87% of Baby Boomers (55-64 years) reporting nearly the same frequency, and dropping to 75% for the Silent Generation (67 and older). A more significant factor was years in ministry. Four in ten Millennials have served in church ministry for more than 5 years. The vast majority of Gen Xer’s have been in ministry for 6–29 years (79%), with 20% serving less than 6 years, and 1% with 30 or more years of experience. Baby Boomers are increasingly skewed toward 30+ years of experience, with only a handful (5%) serving 5 years or less, 22% serving 6–15 years, 32% serving 16–29 years, and 42% with more than 30 years. The Silent Generation does not reflect this trend, with even distributions for the first three phases: 0–5 years (12%), 16–15 (12%), 16–29 (12%), 30–39 (20%), and 40+ (44%).
Most pastors received ethics training in seminary, but that does not necessarily correlate with exposure to bioethical issues they might encounter in congregational ministry. Over 90% of pastors said they had received some type of formal ethics training. The author had previously surveyed 31 institutions in the Association of Theological Schools, focusing on those that seemed to be more evangelical. A review of their MDiv curriculum and course catalogs (where available online) identified 21 schools that required any course in ethics, such as professional ethics or Christian ethics. Thirteen seminaries offered electives that explicitly or plausibly included biomedical or bioethical issues. Furthermore, some bioethical issues may have been included under other courses that addressed such topics such as sexuality, social morality, the Christian life, or the witness of the church in society.
Beyond seminary training, some denominations provide guidance on bioethical issues. More than half of the respondents were aware of formal statements on bioethics issued by their denomination. While such sources may provide guidance for pastors, some denominations do not or have not issued statements on bioethical issues.[3]
The respondents were asked their comfort level on providing moral guidance for a range of issues they might encounter. They were most comfortable with counseling on marriage, death and grief, finances, and aging parents, followed by end-of-life medical decisions, addiction, and depression (Table 1). They were least comfortable with addressing infertility. Not surprisingly, participation on an ethics committee was associated with higher comfort levels than for non-participants on all issues except providing moral guidance on marriage or finances (Table 2).
Those who had experience participating on an ethics committee expressed a higher level of comfort in addressing medical decisions, end-of-life decisions, dealing with death and grief, and aging parents, than those who did not have experience (see Table2).
The issues respondents had encountered (whether these were raised by members in their congregation was not determined) most frequently within the previous five years were cancer care (62%), drugs for a behavioral disorder (57%), chronic pain management (48%), care for the physically disabled (48%), and chronic disease management (46%). The issue encountered least frequently was male circumcision (10%). A minority had been consulted on at least one issue of reproductive ethics: contraceptive use by married couples (30%), prenatal testing (23%), abortion for an unwanted pregnancy (21%), IVF (20%), abortion for reasons of the baby’s condition or health (16%), and artificial insemination by husband (15%).
Most pastors strongly agreed that moral rules should be in accordance with God’s will (90%) or biblical teaching (86%). They also strongly agreed that “moral discernment requires cultivation and practice” (87%). Most strongly disagreed that moral goodness is based on what benefits the greatest number of people (92%), or that moral decisions are determined by cultural values (90%).
The respondents were most supportive of a divine command or rule-based (deontological) ethical approach. They were least supportive of relativism, utilitarianism, or intuitionism (“listen to your inner ‘instinct’.”) A majority (59%) also objected to pure consequentialism (“The consequences of my actions are the most important factor for me to consider.”) (see Chart 1).
All of the respondents agreed that “It is important to integrate faith into the decision-making process.” Over 90% agreed that pastors should seek current information on developments in medical technologies, and that they should help their members on bioethical issues. They also agreed that “bioethical issues should be approached through interdisciplinary inquiry and well-developed educational programs to assist pastors in thoughtful decision-making.” Despite high levels of agreement that the pastor is responsible to engage moral teaching from the pulpit (90%), they also agreed that members should not rely solely on their pastors for guidance in bioethical issues. Many (79%) wanted their members to know the church’s or denomination’s official viewpoint on bioethical issues.
Overall, participants indicated some familiarity with reproductive and medical issues. Over three-fourths of the pastors had at least one conversation about a bioethical issue, most often in the hospital and less frequently at an extended care facility, venues often associated with end-of-life and other serious medical decisions. The least common reproductive issues were artificial insemination of an unmarried woman, gestational surrogacy, artificial insemination of a married woman by donor, genetic testing of an IVF embryo, and umbilical cord blood donation. It may be that most members of their congregations do not utilize or consider using these technologies. Some pastors had a sense that they should be more involved in providing moral guidance in these areas. One observed, “My congregation looks to their doctors and selves [sic] rather than me for info on these matters. Maybe I am doing something wrong?”
While the majority of respondents had never been consulted on most reproductive issues, a higher number had been consulted on most medical issues. Specific medical issues related to artificial respiration, withdrawal of treatment, and organ donation, for example, may suggest decisions made with dying and death in mind. The only medical issues where >50% had never been consulted were genetic counseling and testing, cosmetic (elective) surgery, physician-assisted suicide, participation in medical research, and parental consent for a child’s procedure. The medical issue where the smallest number had never been consulted was regarding behavioral drugs (such as antidepressants and Ritalin). It is possible that pastors and members of their congregations consider these to be medial judgments only, without ethical dimensions.
One pastor noted that abortion, a familiar reproductive issue, was not raised in his congregation. “Most of the abortion questions I receive come from my volunteer work at a crisis pregnancy center, and not from my congregation.” This suggests that even though a pastor may be comfortable in addressing an issue, his congregation may not consult him, perhaps because they do not need or want guidance on abortion, or are not comfortable in consulting him. However, another pastor who responded that he was very comfortable with abortion issues also reported he had been frequently asked about these issues.
As noted above, participation on an ethics committee was linked with a higher comfort level in advising on medical issues. Pastors who had never participated were more comfortable with the “traditional” issues of marriage and finances. Ethics committee participants would be more familiar with hospital settings and participating in ethical discussions on difficult medical cases. They may be less likely to be involved in providing moral guidance on issues such as marriage and finances. Overall, all participants were least comfortable with counseling on infertility, although ethics committee participants were least comfortable with finances. Female respondents had a higher rate of ethics committee participation than male respondents (58% vs. 20%). Hospital chaplaincy is a more common pathway for evangelical clergy who are female than is congregational ministry. Because respondents were predominantly evangelical, a higher percentage would have been likely to serve on ethics committees.
Not surprisingly, the likelihood of being consulted on any bioethical issue increased with years of experience, with the highest frequency for those with 16–20 years of experience (93.33% had been consulted), regardless of their generation. Those with <5 (62.16%) or >40 years (63.64%) were equally likely to have been consulted. The pastors were not asked whether they were “second career” clergy.
The majority of respondents agreed that access to information and knowledge about some health situations is valued. All but one (99%) agreed that the fiancée of a person who is HIV positive deserves to know that status. However, using genetic information about a serious disease that might manifest later in life to get preventive care such as gene therapy, was valued by only 19%. The majority of respondents also agreed that scientific reasoning has a bearing upon ethical decision-making (73%), and that it is important for pastors to keep up on developments in medicine, technology, and science (93%). Only 31% knew where to get genetic counseling or information about genetics, which is not surprising. Even though gene-based therapies are burgeoning, only one in four physicians has been trained in the use of genetic testing, and less than 10% are confident about using genetics for prescribing treatment.[4]
Despite their strong agreement with keeping up with developments in science, when asked to rank the relative importance of various resources in developing competence, formal training was ranked first by only 13%, and second by 6% of the respondents. Personal research or research conducted with others fared even worse, with only one respondent (<1%) ranking it first, and eight (6%) ranking it second. Almost equal numbers gave study of Scripture (34%, 49 respondents) or biblical worldview (35%, 50 respondents) highest priority. Overall, study of Scripture had the highest average ranking. This is consistent with the high levels of agreement with three ethical statements that reflect a divine command/rule based ethical theory (90%, 86%, and 46% “strongly agreed”). Formal training was ranked fourth, after study of Scripture, a biblical worldview, and prayer. Competence in resolving complex ethical dilemmas in bioethics cannot be developed through Bible study and prayer alone. Formal training of some sort is a natural prerequisite to understanding and applying the relevant principles and tools of bioethical analysis. Formal training was ranked first by 13%, and last (#10) by 2%.
When asked about bioethics resources they used, in addition to those shown described above, 27 (16%) submitted comments, organized around categories of resources (Chart 2).
Membership in a particular generation—age—can be a factor in how a pastor provides guidance on bioethical issues. The widest gap between generations was seen in whether respondents agreed with the statement that regardless of the source of authority, the individual bears sole responsibility for their decision. Only 17% of Millennials and 19% of Baby Boomers agreed, while 37% of Generation X and more than half of Silent Generation (55%) agreed. It is possible that members of the Silent Generation interpreted the question as having to do with personal responsibility for the consequences of one’s choices, while the Millennials and Baby Boomers rejected the individualistic, autonomous, subjective nature of the statement. Millennials tend to make decisions in groups or community, and both Millennials and Baby Boomers prefer participative leadership, which includes group input into decisions, over authoritarian styles.[5] This may translate into reticence to place sole responsibility for making decisions upon the individual (see Table 3).
The survey findings are not generalizable, and should not be extrapolated to a larger clergy group. The small sample size and the nature of the questions may have skewed the population. Participants responded to communications from CBHD or from an organizational leader friendly to CBHD, and as a result likely are members of networks connected in some way with The Center for Bioethics & Human Dignity. The length of time required to complete the survey might have deterred all but the most committed respondents. It is possible, then, that the participant group might have greater awareness of bioethics and health issues their congregation faces than do other clergy. This highlights the need for better clergy education in seminary and beyond, to help them grapple with the ethical consequences of rapid changes in medicine and technology.
The survey instrument needs to be improved. It included too many detailed items, many of which, we learned, are outside the common experience of clergy. Other questions, particularly those about value judgments and ethical approaches, were confusing (“Some of the questions were difficult to answer as phrased . . . leaving me to be somewhat ambivalent where I might have been otherwise more decisive.”). Any future study should take these comments into account, using an instrument that is better tailored to pastoral experiences.
A number of respondents commented that pastors need to be prepared to deal with bioethical issues, to “know how to access hospital resources,” and to foster “much more ethical and Biblical discussion BEFORE [sic] things take place instead of after. Christianity has been playing catch-up to science for years.” Their strong agreement (over 90%) that “bioethical issues should be approached through interdisciplinary inquiry and well-developed educational programs to assist pastors in thoughtful decision-making” reinforces the value of credible, accessible bioethical resources for pastors reflecting a Christian perspective.
One pastor’s comment points to this need: “I think this survey is long overdue and am glad you are taking the approach to see how CBHD might partner with clergy.” In that light, CBHD has identified as one of its two strategic priorities in the coming years to help pastors guide their congregations to wisely face difficult decisions about medicine, science, and technology.
[1] I want to express my deep appreciation to all the survey respondents, particularly those who subsequently volunteered to be interviewed and participated in my doctoral research study.
[2] Magdalena C. de Lange, “Dealing with Bioethical Dilemmas: A Survey and Analysis of Responses from Ministers in the Reformed Churches in South Africa,” HTS Teologiese Studies/Theological Studies 68, vol. 1 (2012): 1–10, https://doi.org/10.4102/hts.v68i1.882. A survey completed shortly thereafter examined clergy attitudes about end-of-life decisions: Michael Balboni et al., “The Views of Clergy Regarding Ethical Controversies in Care at the End of Life,” Journal of Pain & Symptom Management 55, no. 1 (2018): 65–74. See also Justin Sanders et al., “Seeking and Accepting: U.S. Clergy Theological and Moral Perspectives Informing Decision Making at the End of Life,” Journal of Palliative Medicine 20, no. 10 (2017), https://doi.org/10.1089/jpm.2016.0545; Michael Balboni et al., “U.S. Clergy Religious Values and Relationships to End-of-Life Discussions and Care,” Journal of Pain & Symptom Management 53, no. 6 (2017): 999–1009.
[3] The Christian BioWiki is an online guide to statements on bioethical issues from a wide spectrum of 50 denominations and movements, and 5 organizations. “Home,” Christian BioWiki, last modified December 17, 2018, ChristianBioWiki.org.
[4] “Physicians as Guardians of Genetic Knowledge,” The Lancet 377, no. 9770 (2011): 967, https://doi.org/10.1016/S0140-6736(11)60367-X. See also, K. D. Christensen et al., “Are Physicians Prepared for Whole Genome Sequencing? A Qualitative Analysis,” Social and Behavioural Research in Clinical Genetics 89, no. 2 (2016): 228–234, https://doi.org/10.1111/cge.12626.
[5] Shih Yung Chou, “Millennials in the Workplace: A Conceptual Analysis of Millennials’ Leadership and Followership Styles,” International Journal of Human Resource Studies 2, no 2 (2012), https://doi.org/10.5296/ijhrs.v2i2.1568; Esther Gergen, Mark Green and Sarah Ceballos, “Generational and Gender Differences in Implicit Leadership Prototypes,” Business Management Dynamics 3, no. 9 (2014): 44–54; Amy Glass, “Understanding Generational Differences for Competitive Success,” Industrial & Commercial Training 39, no. 2 (2007): 98–103, https://doi.org/10.1108/00197850710732424.
Paige Comstock Cunningham, “Are Pastors Prepared? Results of a Survey on Clergy Awareness of Health Issues,” Dignitas 25, no. 2 (2018): 3–9.
