Forgiveness on the Hospital Bed1 The Importance of Forgiveness for Patients in the Context of Hospital Chaplaincy

Jaro Křivohlavý describes forgiveness as conscious effort to “decrease the value of negative thoughts, emotions, motivation, and behaviour towards a person who is seen (comprehended) as an aggressor, and decrease the negative evaluation of what is understood as an offence, an injustice, possibly even a crime, while trying not to forget what had happened”.2 Forgiveness cannot be understood in a simplified manner as a state of psychological well-being in relation to the aggressor. It is rather conscious effort to change one’s internal attitude, directed towards psychological well-being. That is why forgiveness is metaphorically described as emerging from a prison.3


Forgiveness on the Hospital Bed 1
The Importance of Forgiveness for Patients in the Context of Hospital Chaplaincy Dominik Opatrný, Marta Hošťálková "Though forgiveness does not change the past, it opens up the future." This well-known aphorism by Paul Lewis Boes holds not only for the young and healthy. Many hospital patients experience the need to forgive precisely because their life is in danger or coming to an end.
But forgiveness is no simple step. The patient needs support from her environment and talking to a hospital chaplain can be helpful as well. Before we focus on the specific characteristics of forgiveness in hospital patients and the role of the hospital chaplain in the process, it is first necessary to briefly define the concepts employed.
Jaro Křivohlavý describes forgiveness as conscious effort to "decrease the value of negative thoughts, emotions, motivation, and behaviour towards a person who is seen (comprehended) as an aggressor, and decrease the negative evaluation of what is understood as an offence, an injustice, possibly even a crime, while trying not to forget what had happened". 2 Forgiveness cannot be understood in a simplified manner as a state of psychological well-being in relation to the aggressor. It is rather conscious effort to change one's internal attitude, directed towards psychological well-being. That is why forgiveness is metaphorically described as emerging from a prison. 3 Forgiveness must be distinguished from reconciliation, under two aspects. 4 First, reconciliation renews a relation, and therefore can only be reached by both parties to the dispute in cooperation. Second, as the moral theologian Jiří Skoblík notes, reconciliation comprises "harmonizing the relationship of two beings not only mutually, but also with the objective order". 5 A condition of real reconciliation is therefore redressing the injustice, in so far as it is possible. 6 That is why a patient cannot attain reconciliation without the cooperation of the other party. But she can forgive. 7 She cannot buy reconciliation by denying justice. But she can afford to forgive, even when justice cannot be enforced.
1 The study was financially supported by the Czech Science Foundation grant "History and Interpretation of the Bible", no. P401/12/G168. 2 Jaro KŘIVOHLAVÝ, Pozitivní psychologie: Radost, naděje, odpuštění, smiřování, překonávání negativních emocí, Praha: Portál, 2010, p. 111. 3 E.g. Kateřina LACHMANOVÁ, Vězení s klíčem uvnitř, Kostelní Vydří: Karmelitánské nakladatelství, 2012, pp. 16-17 andpassim. 4 Confounding forgiveness and reconciliation can be a source of frustration for someone who wants to forgive but cannot make the disrupted relationship good alone. 5 Jiří SKOBLÍK, Morálka v dialogu: Křesťanský pohled na morální problémy dneška, Kostelní Vydří: Karmelitánské nakladatelství, 2006, p. 38. 6 Absolute justice in the sense of Aristotelian settlement (cf. ARISTOTLE, Nicomachean Ethics 1133b-1134a) is mostly impossible and the injured party must to some extent lower her demands. This is illustrated by the social renewal in the Republic of South Africa, which would have been impossible if absolute justice had been insisted on. Cf. Desmond Mpilo TUTU, No Future Without Forgiveness, New York: Doubleday, 1999, pp. 47-66. 7 Forgiveness is not identical with reconciliation, but it can lead up to it: "Reconciliation begins in the moment when in the mutual relationship with the one who has injured us we begin to signal that we are willing to exchange forgiveness -to give it and to receive it, regardless of the extent of the guilt on either side." Józef AUGUSTYN, Křivda, odpuštění, smíření, Kostelní Vydří: Karmelitánské nakladatelství, 2000, pp. 87-88.

The specific situation of the ill person
The situation of illness markedly affects the process of forgiving, especially when the patient's life is in danger. In this section we will therefore underline three positive and three negative ways in which an illness affects forgiving. For the sake of vividness we also provide case studies.
In the first place, an illness is an opportunity to change one's attitude. It can become an impulse for the patient to forgive and possibly even reconcile, especially if the thought of forgiveness had occurred to her before. 8 Second, an illness helps a person to view problems from a distance. In the process of coming to terms with the diagnosis and the limitations caused by the treatment, the patient's value system usually changes as well. In the face of the illness the injustice, which by constant mental rehearsing (so-called rumination) has grown to gigantic dimensions, can sometimes deflate. The patient weakened by her illness need no longer be afraid that forgiveness will be understood as weakness.
Third, an illness changes the attitudes of others. The other party need no longer prove her superiority. Especially women are ready to "discard all disputes" when they hear that "their opponent" is seriously ill (mercy prevails). If the others are willing to reconcile, or at least improve mutual relations, forgiveness becomes easier for the patient, as the following case study shows.
A 65-year-old oncological patient had not spoken a good word with his neighbour for years. The reason was an argument over the fruit of a tree standing at the boundary of their property lots. Before going to hospital he wanted to reconcile with the neighbour. But when he met him in the street he was unable to say a word. While in hospital he was very unhappy about it. Then he thought of writing a letter to the neighbour asking him to visit him and settle the argument. It worked out, the neighbour came and reconciliation was reached. The tree is old, they will cut it down -why should it grow to mutual resentment? At the end of his life the patient admitted that the argument was over a petty quibble.
But besides these positive effects an illness also brings difficulties into the process of forgiving. Especially men, when ill, often feel "done". They feel that they have no justice left. And despite all effort of the ill person and the help of hospital chaplains it often happens that there is no time for forgiveness to turn into reconciliation. Even though there is no opportunity to communicate the forgiveness to the other, one can still forgive "in one's heart". If the patient is Catholic, the forgiveness can be fortified and confirmed by the sacrament of reconciliation.
The patient's state presents a further limitation. Pain, decrease of physical and mental abilities as well as psychological symptoms can prevent the patient from giving up the role of victim and re-evaluating her attitudes. 9 An 80-year-old oncological patient has lived in dispute with his former colleague for years. Both are practicing Catholics. Due to the length of duration of the conflict and to limited communication it is now difficult to objectively find out what happened at the beginning. The healthy colleague tries to find out the truth, but the ill one is disadvantaged: he is weakened by the serious illness, even in the intellectual sphere.
In this situation the hospital chaplain decided to first of all advocate compassion: truth without love is fanatic, one needs to be compassionate with the ill colleague.
They were further encouraged to sincerely ask each other to forgive all they may have consciously and unconsciously done to offend the other. Clarification of who had done what and how must be left to God the Judge, who best knows the "object of the argument" and sees into the hearts of both.
A third limitation is again to be sought in the attitudes of others. Serious conflicts mostly occur between people who are close to each other. 10 And an illness can bring such a conflict about.
In the 1960s Elisabeth Kübler-Ross described five phases of coming to terms with a lethal diagnosis: denial, anger, bargaining, depression, and acceptance. 11 She was further able to show that the process is not limited to patients; it is also experienced by their closest persons. In that each person proceeds "at her own pace" and at a given time close persons can find themselves in different phases. The patient and her environment react to the illness in different ways, which can become a source of tension. The following case study describes a situation where the patient had already reached acceptance, but her mother-in-law was still in the phase of rejection: A 40-year-old oncological patient, mother of three, has problems with her mother-inlaw, who is unable to accept her illness. She virtually trivializes the illness: "She is fine"; "She has ruined my son's life", etc. Every day the patient fights to forgive her motherin-law, and "manages" to do so, she appreciates every day of her life: "Why make my life more painful than it already is by being angry with my mother-in-law?" The positive aspects of forgiveness in the therapeutic process An illness is not just an opportunity to forgive: precisely in this critical situation forgiveness is desirable, both from the point of view of the patient and for the therapeutic process as a whole. As the end of one's life is approaching one sees not only the successes and positive aspects; failures, insufficiencies, and neglect to do the good also come to the fore, which causes suffering to the patient. It is a great relief for the ill person to have someone close whom she trusts and in whom she can confide with the experience of guilt and inability to forgive. It is a great gift for Christians that they can believe that their trespasses are forgiven by God. That empowers them to communicate their forgiveness to others and to accept the same from them. 12 Of course, it is very difficult for the ill person to communicate the animosity in which she lives. There is progress even when she is able to speak of the animosity and acknowledge that not all about her relationships with others was good and that she is guilty of offence -not only the other. Such conversation is always demanding for the ill person, but relief is brought about already by articulating all that in the atmosphere of security, acceptance, and non-judgement. When the patient decides to forgive, she usually experiences great relief. This can even manifest itself somatically. Psychologists even speak about the positive effect of forgiveness on the functioning of the immune system. 13 But from the point of view of faith a lot more is at stake. Faithful patients are sharply confronted with Jesus' command to forgive (18)(19)(20)(21)(22). In light of the parable of the merciless servant (Matt. 18:35) forgiveness becomes a condition of salvation. There is hope for Christians in that they are not alone to forgive. They can delegate the forgiveness to God, as Jesus and the martyr Stephen did (Luke 23:34; Acts 7:60).
From the point of view of the therapeutic process forgiveness is desirable based on the very definition of health. If the World Health Organization defines health as "state of complete physical, mental, and social well-being", then the third aspect includes ordered relations to other members of the community, i.e., forgiveness.
Further, as stated above, the experience of forgiveness brings relief to the patient and can even positively affect the course of the illness. Forgiveness is directed to mental well-being, and thus also to decreasing anxiety and increasing the quality of life. And these are goals set by contemporary health care.

The role of a hospital chaplain and its ethical context
A hospital chaplain can promote the process of reconciliation in specific ways. In that she does not work on her own. Many churches and religious societies profess the aim of spreading forgiveness and reconciliation. Hospital chaplains then act with the support of these communities. 14 In the process of forgiving the ill person goes through a number of steps, just like the healthy one. A hospital chaplain can help her on the way. The point of departure for our description is the division into four phases proposed by the German Benedictine Anselm Grün: 15 First it is necessary to admit one's pain. Whether the patient speaks of her injuries freely or denies them, she can think of them on the hospital bed. Even an otherwise reserved person is then able to at least hint at the problem in conversation with a hospital chaplain.
Then it is necessary to also admit one's anger. The patient needs a conversation partner to be able to communicate her anger: with others, with herself, with God. When the hospital chaplain creates an atmosphere of trust, the patient dares to take off the mask of self-possession and show her negative emotions. It is important that she obtains assurance that the chaplain does not condemn her for her anger.
Only then as the third step it is possible to objectively assess the situation. Crises in interpersonal relationships need not stem only from real events. They can also be caused by false informa-4 2014 tion or erroneous speculation. Of course, the hospital chaplain does not have the means to objectively assess the dispute, nor is it her task. But as an uninvolved party she can open up new ways of viewing the situation to the patient.
Finally there comes liberation from the power of another. Not forgiving binds a person to her past. It is a means with which the aggressor (real or fictitious) retains power over the victim. By forgiving, on the other hand, the victim liberates herself from the bonds of feeling injured and desiring revenge. In rare cases forgiveness can result in successful medical treatment. A more common, though no less important consequence is that the dying patient is finally able to die in peace.
Throughout such accompaniment the hospital chaplain must be aware that her effort to help the patient does not in itself provide a guarantee that each step she takes will also be correct and moral. That is why she must follow basic ethical rules. Here the well-known four principles of health care ethics according to Childress and Beauchamp can be applied: 16 Principle of autonomy: A hospital chaplain, just like anyone else, cannot force the patient to forgive. Even if she were able to convince the patient, the change would remain superficial. Neither can she speed up the process of forgiving by force, as that would only decrease the resultant effect. 17 Respect for the patient's autonomy therefore requires that the hospital chaplain merely point out the possibility of forgiving -which is in fact the most effective means of reaching the desired end. 18 She must also respect the patient who makes a wrong choice and refuses to forgive.
Another means the hospital chaplain can employ, which does not violate the patient's autonomy but at the same time supports the patient's choice and reaching forgiveness, is prayer.
Principle of non-maleficence: A hospital chaplain must avoid such acts that could harm the patient. First, she must not trivialize the patient's problem, no matter how petty it objectively might be. On the contrary, she must show that she understands how the patient experiences the problem. If she does not, the patient may close up and not say another word. Then it is very difficult to regain the lost trust and renew communication. Obviously, such scenario would traumatize the patient and could make further therapy more difficult.
Second, the hospital chaplain must avoid doubting the involved guilt or transferring part of the guilt to the patient. Even if the patient is paranoid, she may still be right. 19 Principle of beneficence: When the hospital chaplain tries to encourage the patient to forgive, she cannot do so with any other aim than helping the patient. Concerning the measure of her personal involvement, she is not bound by any objective legal obligation (unlike the principle of non-maleficence). 20 Sometimes she can even be morally obliged to protect her health, e.g. against the patient's aggression or from overt work load (immoderate demands of patients).
The hospital chaplain's ministry is based on intrinsic motivation deriving from her own faith and belonging to a religious community, which she represents in the hospital. For a Christian such ministry is first of all a response to Divine love, which she has experienced in her own life. Biblically it is based on the commandment of love for the neighbour (Lev. 19:18;Matt. 22:39; cf. the parable of the last judgment Matt. 25:36) and Jesus' example in caring for the ill.
In some cases the principle of beneficence outweighs the principle of non-maleficence. 21 Sometimes a conversation with a hospital chaplain disturbs a patient, or even makes her angry or reduces her to tears. But such tears and anger ought to have purifying effect. If the hospital chaplain proceeds delicately, such "outflow of emotions" helps the patient in the long run.
Principle of justice: As already stated above, it is not the task of a hospital chaplain to seek justice in disputes. Neither should she encourage the patient to deny real guilt or take it on herself for the sake of forgiveness. 22 That would contradict justice. Nor is it right to try to forget. What is needed is to want to remember without remorse. 23

Conclusion
An illness is a time suitable for forgiveness. But it also brings along a decrease in strength. That is why patients often need support to be able to forgive. Besides their nearest such support is provided to them by hospital chaplains, at professional level.
Such dealing with guilt and facilitation of forgiveness is one of the most difficult parts of a hospital chaplain's ministry. She is faced with anger, hatred, and sin. All this takes place in an extreme emotional situation, so that she must constantly proceed with tact and delicacy. Of course, she is strengthened and enriched by the patient's trust.
This, however, does not come at once. Patients normally test the hospital chaplain at the beginning of their hospital stay, when dealing with the consequences of their illness for their life. Later they begin to ask how their diagnosis will affect their close ones. At that time they already have sufficient trust to allow the hospital chaplain a glimpse of those aspects of their life they are not proud of.
The health care personnel undergo a similar transformation. Nurses overloaded with administration normally say at first that they would also like to have so much time for each patient. Later they come to appreciate how demanding chaplaincy is. At first they view with disfavour when the patient is distressed after a pastoral conversation. Eventually they come to understand that not all anger or tears are bad. Sometimes such emotions are necessary for the patient to come to terms with the past.
In this way forgiveness opens up the future. If the illness can be brought to a halt or cured, then the patient's further life will be freed of the burden of non-forgiveness. If death is inevitable, the patient will be able to leave this world in greater calmness and with greater trust in Divine mercy. 21 Cf. Tom L. BEAUCHAMP -James F. CHILDRESS, Principles of Biomedical Ethics, p. 168. 22 On this cf. a list of what is not forgiveness: Jaro KŘIVOHLAVÝ, Pozitivní psychologie, pp. 109-110. 23 Cf. Kateřina LACHMANOVÁ, Vězení s klíčem uvnitř, p. 35. Kateřina Lachmanová defines forgiveness as the ability to remember in such a way. In that way she links forgiveness to emotions. In this paper we endorse the definition by Jaro Křivohlavý quoted above, which construes forgiveness as conscious effort. Essential is the will not to let a past injury spoil one's life. The pain of great injuries persists, what is important is the attitude one takes to it. Just as with a deep cut: a scar remains, which hurts when the weather is about to change. Most important is that the sore is closed and is not purulent.