Adam Hayden reviews Nathan Carlin’s Pastoral Aesthetics: A theological perspective on principlist bioethics (Oxford University Press: 2019).

Nathan Carlin’s Pastoral Aesthetics is a synthesizing project that brings bioethics together with his professional practice of pastoral care. He offers, by his own words, a sort of academic autobiography that grounds theory in his lived experience as a pastor caring for those within his faith community (xi). Carlin’s conversational style advances his gentle critique of bioethics with a disposition informed by critical theory that reminds readers that bioethical principles do not exist in a vacuum. His book is robust, engaging, and welcome in the contemporary medical setting that is fraught with clinician moral injury and the disproportionate suffering and death of Black, indigenous, and people of color at the hands of structural racism, more salient than ever before, as SARS-CoV-2, Covid-19, reveals systemic injustice inherent to the contemporary American model of healthcare. Carlin’s discussion of the Tuskegee Syphilis Study (119 ff.) and Hurricane Katrina (128 ff.) read as especially prescient in light of the current global pandemic. Let’s see what readers can expect from Pastoral Aesthetics.

“[A] common starting point for pastoral theology,” says Carlin, “is human experience” (11). Pastoral theology itself is, “simply defined as the theological discipline that provides the theory that informs practices, broadly conceived, of pastoral care, also broadly conceived” (20). Pastoral theology is “concerned less with coherence than function…how doctrines operate within the lives of individuals” (21). In prizing the situatedness of people in their contexts, pastoral theology offers a new way of looking at bioethics, one that “is satisfying for its fans and critics alike” (12). Carlin’s thesis is that pastoral theologians bring to bear an aesthetic, a sensibility, to bioethics, “a sensibility that is akin to critical art appreciation” (32). This sensibility is “theologically-informed, psychologically-sophisticated, therapeutically-oriented, and experientially-grounded” (13). In short, by appeal to aesthetics, Carlin offers “a new way of looking at things” (32). His book is a critique of the reigning bioethics paradigm but also a critique of its criticisms (15). Carlin manages to accomplish this project without burdensome theory, and his effort to operationalize pastoral theology draws attention to the margins and speaks with the marginalized: “The center is not the only thing worth looking at” (31).

In what follows, I lay out the structure of the book, and I offer a sketch of principlist bioethics, before I introduce the new way of looking at things that Carlin is advancing: pastoral aesthetics. I go on to raise a question drawn from Carlin’s own commentary, is medicine a sort of ministry? And I conclude my review by discussing Carlin’s imagery of people as living documents and their connections as a living web to emphasize the role of justice in Carlin’s portrait of theologically-informed bioethics. Pastoral Aesthetics may be informed by pastoral care and theology, but far from doctrinal, Carlin’s book speaks to a broad audience of bioethicists, palliative care practitioners, scholars of nursing science and medical humanities, chaplains, and parish ministers.

Structure. Carlin’s book is well organized into five chapters, bookended by an introduction and epilogue. His introduction offers a helpful description of the framework repeated in each of the chapters (32ff.); each features a discussion of a bioethics principle (four in total – see below) and an illustration to place the principle in context. Carlin’s unique aesthetic offers an “image” of the pastoral perspective in relation to the principle, largely drawn from his personal experience. As mentioned, his book is “deeply autobiographical” (xi). The final section in each chapter reconciles the principle with the new aesthetic.

Principlist bioethics. Bioethics in its contemporary practice includes clinical ethics, research ethics, and professionalism. Carlin explains that one way of defining bioethics is by way of the conditions that led to its emergence (2): the Nuremberg Trials, the discovery of the DNA molecule, successful organ transplantation, approval of an oral contraceptive, the definition of brain death, Roe v. Wade, and the AIDS epidemic. This is not an exhaustive list—no doubt, the breadth of issues under the purview of bioethics is quite vast!

The well-known Belmont report, at least in bioethics circles, published in 1979 after the scandal of the Tuskegee Syphilis Study, was a move to secularize bioethics (5) from its Jesuit foundations, and it laid the groundwork for the influential Principles of Biomedical Ethics that advocated the principlist approach. This book and its method are a “starting point for anyone entering the field” (7). The four biomedical principles are: respect for autonomy, nonmaleficence, beneficence, and justice. Principlism is taken to be more concrete than theory yet less specific than rules (14). Carlin points out that principlist bioethics is most criticized for privileging autonomy (9), suggesting that decision-making is a purely individual endeavor, divorced from relations and settings. Carlin’s preference for experiential and social dimensions is a clear extension of this chief complaint.

A new way of looking at things: Pastoral aesthetics. I am attuned to an historically sensitive analysis of sacred texts, and Carlin sprinkles insights throughout his book. His mention, albeit brief, of the Synoptic Gospels and his interpretation of later historical patriarchal influence in the Christian sacred texts signal his interest in such an interpretive project. Carlin “does not take traditional religious sources of moral authority such as the Bible,” to answer bioethical questions (11). Instead, consistent with his appeal to human experience, he claims later that, “Nurses have particular moral insights relevant for clinical ethics that need to be heard” (135).

It may surprise readers that a Christian ethicist espousing pastoral theology resists resting moral authority on the Bible. It is helpful to take in view Carlin’s five components of pastoral care, which are far from heretical. These are: (i.) pastoral theology works from the margins for the marginalized; (ii.) pastoral theologians can work with psychoanalytic techniques; (iii.) truths are not universal, they are personal; (iv.) pastoral theology is pluralistic and local, not seeking universals and generalities; and (v.) pastoral theology expresses truth by analogy and with art (24), a point he reinforces later when claiming that “knowing God is accomplished not only by prayerfully studying canonical sacred texts but also by judiciously attending to living human documents” (45), which finds Carlin relating to practices from narrative medicine. To this end, Carlin sides with philosopher Carl Elliott who promotes reading novels as a tool to enrich the study of moral experience. Carlin, quoting Elliott, writes, “fiction writers are better at telling stories than philosophers, lawyers and doctors” (ibid.) Ultimately, Carlin appeals to “helping professionals”: “psychologists, pastors, and psychotherapists,” among others, who are needed to help persons change.

Is medicine ministry? Carlin likens the Christian practice of “spiritual formation” to professionalism among physicians, facilitated by medical educators, “essentially spiritual formation in a secular context” (29). Carlin employs ethicist William May’s conception of the physician, “as one who makes a covenant” (33), and he equates beneficence with the role of the diagnostician (97). He finds his own theological interpretation of a parishioner’s plea for counseling as an act of paternalism (108), which, according to Carlin, is not mutually exclusive with beneficence (107). Carlin writes, “I simply want to point out similarities between religion and medicine to draw attention to the existential longings of which they both participate” (79).

The living human document and living web. Taking human experience as the entry point for pastoral theology, Carlin advocates authentic connection with others as a necessary step toward justice. This includes both local and general applications. In a specific medical setting, Carlin instructs “that caregivers should assume complexity in the lives of their patients” (57). This prescription resonates with the insight offered by sociologist of health, John Murphy and his colleagues who critique electronic medical records for failing to incorporate patient narrative into their records. They write, “Symptoms…should be not merely documented but situated within the stories patients weave to make sense of their lives” (103).

Carlin employs an insight from the 20th century founder of clinical pastoral education, Anton Boisen, who suggests persons, especially patients, be read, like books, as “living human documents” (43), and Carlin follows the extension of this concept toward an analysis of social injustice offered by Vanderbilt Professor of Religion Bonnie Miller-McLemorewho defines the “living human web” to refer to experiences of persons (136). Carlin seeks to emphasize living in the “living human web,” and attending to living in the world, “the experiences and the views of marginalized individuals ought to be prioritized so that the manifestations of systemic sin at the local level may be exposed and addressed” (135). In the end, writes Carlin, “In thinking about what is just for the group, listening to individuals on the margins is not merely useful; it is required” (137). This is because Carlin identifies a theological perspective—his aesthetic, or way of looking at things—”from a perspective of caring for the least powerful” (132).

In Pastoral Aesthetics, Carlin offers a new way of looking at things that together with principlist bioethics, “have a bright and hopeful future” (147). I look forward to watching the evolution of this more experiential, multi-disciplinary, and justice-oriented account to serve persons, parishioners and patients alike.

Adam Hayden, MA, is an independent scholar and research assistant affiliated with Indiana University-Purdue University, Indianapolis. Adam’s own graduate study was abbreviated by his diagnosis with the aggressive brain cancer, glioblastoma, but he continues to apply his training in medical humanities and philosophy toward writing and speaking. Read more about Adam on his personal blog, Glioblastology, and follow him on Twitter: @adamhayden

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