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BY: MARTIN LEEVER, PhD; BRIDGET DEEGAN-KRAUSE, MDiv; FR. RICHARD M. LELIAERT, PhD; KENNETH RICHTER, DO; and PEGGY NELSON, RN, MSN

Dr. Leever is associate professor of philosophy; and Bridget Deegan-Kraus is university minister for health professions, University of Detroit Mercy. Fr. Leliaert is manager of spiritual support services, Oakwood Medical Center, Dearborn, MI. Dr. Richter is medical director of the rehabilitation program and services; and Peggy Nelson is chair of the ethics committee and clinical nurse specialist for pain and palliative care, St. Joseph Mercy Oakland Hospital, Pontiac, MI.

Pastoral care professionals fulfill an integral function in health care institutions. Because illness frequently is accompanied by spiritual reflection, hospital chaplains often can provide comfort even when doctors have exhausted all treatment alternatives. Spiritual support can give meaning to suffering and loss that might otherwise be experienced as cruel, pointless misfortune. Indeed, according to the code of ethics of the National Association of Catholic Chaplains (NACC), chaplains are obligated to "promote the well-being of the whole person, being attentive to spiritual, biological, sociological and psychological needs."¹

Chaplains also must respect the self-determination of patients and their families. However, just as health care professionals may be asked to perform services that are not medically indicated, hospital chaplains may be asked to perform services that are not spiritually indicated. In particular, a patient may request something of a chaplain that is inconsistent with the faith tradition the chaplain represents.

In these circumstances, the chaplain knows that he or she has an obligation to provide comfort. But the chaplain also knows that the spiritual services he or she provides have power only because, from the believer's perspective, they are rooted in objectively valid theological doctrines.

This kind of dilemma often presents itself in the form of requests to baptize deceased infants, a practice that is inconsistent with Catholic doctrine. At a time of such profound loss, such a ceremony may provide comfort to grieving parents. Clearly a chaplain has a professional obligation to provide comfort to the parents and to honor all reasonable wishes. However, for reasons we will discuss below, to provide this comfort by accommodating the parents' request seems to misapply the sacrament of Baptism and violate a chaplain's obligation to remain true to doctrines of Catholicism.

We shall therefore argue that, while it is imperative to attend to the grief of the bereaved parents, there are strong reasons to refrain from baptizing deceased infants. In defending this view, we will discuss the nature and purpose of Baptism and the importance of maintaining the integrity of this sacrament. After addressing some likely objections, we will discuss the profound need for an official, church-sanctioned ritual when an infant passes away.

Baptism, Heaven, and Limbo
In order to appreciate the nature of the dilemma, we must briefly consider Baptism as a sacrament in the Catholic Church. One of the sacraments of initiation, Baptism marks the beginning of a person's life in the church. The word "baptize" literally means to wash or immerse. In the case of the sacrament of Baptism, the sin of the person being baptized is metaphysically washed away. This cleansing and initiation as a child of God makes possible a person's participation in salvation. Indeed, it is precisely this connection between salvation and Baptism that moves parents to request Baptism even after an infant has passed away.

Those who insist that their deceased infant be baptized are likely motivated by the old doctrine of "limbo." "Limbo" was said to be the place of dwelling for the souls of infants who died without being baptized. The Catholic position on the fate of those infants who die before Baptism has undergone substantial modification over the years. St. Augustine seems to have had the harshest view. While in his early writings, Augustine held that unbaptized deceased infants suffer no punishment for their original sin after death, he later argued that such infants suffer the same misery and punishment as any other person who has died without salvation.² This view was radically altered by St. Thomas Aquinas. Against Augustine's grim view, Aquinas argued that infants who die before Baptism do not suffer because they have no personal sin or guilt.³ Indeed, according to Aquinas, limbo was not a painful or lonely state, but rather one of perfect natural happiness. Nonetheless, Aquinas still held that because the souls of those in limbo do not share in the beatific vision, they do not go to heaven per se.

If we focus on the current actual beliefs of the church, we see that the Catechism of the Catholic Church contains language that seems to reinforce the view that Baptism is necessary for salvation.

The Lord himself affirms that Baptism is necessary for salvation [Jn 3:5]. He also commands his disciples to proclaim the Gospel to all nations and to baptize them [Mt 28:9, n. 20]. Baptism is necessary for salvation for those to whom the Gospel has been proclaimed and who have the possibility of asking for this sacrament. The church does not know any means other than Baptism that assures entry into eternal beatitude; this is why she takes care not to neglect the mission she has received from the Lord to see that all who can be baptized are "reborn of water and the Spirit." God has bound salvation to the sacrament of Baptism, but he himself is not bound by his sacraments.⁴

Passages such as this would understandably deepen a parent's sense of desperation to baptize a deceased infant. However, Fr. Benedict M. Ashley, OP, PhD, and Fr. Kevin D. O'Rourke, OP, JCD, draw our attention to the last sentence in this passage: "God has bound salvation to the sacrament of Baptism, but he himself is not bound by his sacraments."⁵ This sentence is significant because it indicates, as Frs. Ashley and O'Rourke point out, that "the Catholic Church does not deny that the grace of Christ in ways known only to God can be given to anyone in the world without Baptism."⁶ If this is correct, then to say that "Baptism is necessary for salvation" somewhat overstates the logical relationship between Baptism and salvation. If it is possible to achieve salvation without Baptism, then it would be more correct to say that Baptism may be a sufficient condition for an infant to achieve salvation but not a necessary condition. Indeed, Frs. Ashley and O'Rourke note that "theologians today generally are of the view that infants dying before Baptism can already be graced through the prayer of the church (especially of the child's family) and by that grace of Christ will enter into the intimate mystery of God."⁷ There are various layers of support for this view, not the least which is God's universal salvific will, God's will that all people be saved. Consider the following biblical passage.

First of all, then, I urge that supplications, prayers, intercessions, and thanksgivings be made for everyone, for kings and all who are in high positions, so that we may lead a quiet life and peaceable life in all godliness and dignity. This is right and is acceptable in the sight of God our Savior, who desires everyone to be saved and to come to the knowledge of the truth (1 Tm 2:1-4; emphasis added).

In addition to the above passage reflecting God's salvific will, other biblical passages highlight Jesus' special connection with children. For example: "Let the children come to me; do not prevent them, for the kingdom of God belongs to such as these" (Mk 10:14).

Moreover, Catholicism allows for what has been called "Baptism of desire." This means that a person can achieve the intended salvation of Baptism by desiring to be baptized even though circumstances may preclude an actual Baptism. Ordinarily this is only thought to be valid for adults or older children (since only they would possess the capacity to fulfill the desire to be baptized). However, there is a close connection to the issue of unbaptized infants. Given that Baptism usually is performed on infants at the request of the parents, the relevant desire is really that of the parents. Hence, if an infant dies before the parents' desire for the child's Baptism can be realized, there are theological reasons to hold that that desire can achieve the same salvific end as an actual Baptism.

Given all this, it would seem that there are good reasons to believe that Baptism is not necessary for salvation in this context. Among other things, hospital chaplains should underscore this point when they are faced with requests to baptize deceased infants. Another important fact is that the church is quite clear that it is improper, and, indeed, impossible, to baptize a deceased person. It is to this point that we now turn.

The Church's Position
The Catholic Church's position on the inappropriateness of baptizing deceased infants can be found in a number of statements. First, the Ethical and Religious Directives for Catholic Health Care Services (ERDs) does, at least indirectly, speak to the issue. Directive 17 says: "Except in cases of emergency (i.e., danger of death), any request for Baptism made by adults or for infants should be referred to the chaplain of the institution. Newly born infants in danger of death, including those miscarried, should be baptized if this is possible. In case of emergency, if a priest or deacon is not available, anyone can validly baptize."⁸

Though we find no clear, direct statement of a position on baptizing the deceased, the inappropriateness of it is implied. That is, it would make little sense to speak of an "emergency" in which someone other than a chaplain may perform a Baptism if doing so after a person has died was an accepted sacramental practice. It would make no difference whether a chaplain arrived before or after the person had passed away.

Although the above ERD passage implies the impropriety of baptizing the deceased, the clearest and most direct language is found in the Catechism of the Catholic Church. Regarding the special circumstance of deceased infants, the Catechism states:

As regards children who have died without Baptism, the Church can only entrust them to the mercy of God, as she does in her funeral rites for them. Indeed, the great mercy of God who desires that all men should be saved, and Jesus' tenderness toward children which caused him to say: "Let the children come to me, do not hinder them," allow us to hope that there is a way of salvation for children who have died without Baptism. All the more urgent is the Church's call not to prevent little children coming to Christ through the gift of holy Baptism.⁹

Similarly, in its "Instruction on Infant Baptism," the Sacred Congregation for the Doctrine of the Faith states: "As for infants who have died without Baptism, the Church can do nothing but commend them to the mercy of God, as in fact she does in the funeral rite designed for them."¹⁰

Given the implication of the texts we have considered, deceased infants ought not to be baptized. To do so would violate the integrity of the sacrament of Baptism and diminish its power and significance. While the church and those who carry out its ministry have a fundamental obligation to be responsive to human suffering, doing so need not and should not require performing services that are untrue to their core beliefs.

Although the language from both the Catechism and the "Instruction on Infant Baptism" make it clear that deceased infants are not to be baptized, it also clearly suggests that, as we noted in the second section above, there is a strong theological foundation for the hope that a deceased infant will be graced into salvation or eternal beatitude without Baptism. This point, coupled with the possibility of a Baptism of desire and God's universal salvific will makes baptizing a deceased infant both inappropriate and unnecessary for salvation.

Objections and Responses
Before offering some suggestions on how to address requests to baptize deceased infants, we will address some of the likely objections to our position. Probably the most obvious objection would be that, while it may be true that the church's official position is that Baptism is a sacrament only for the living, providing comfort to a grieving parent is simply more important. Hence, from this perspective, it may be permissible to baptize a deceased infant when it will provide comfort to the parents.

As appealing as this argument might be, it is, nonetheless, problematic. No doubt situations involving a deceased infant require extraordinary pastoral sensitivity and skill. However, one must bear in mind that the only reason baptizing a deceased infant would provide comfort to a grieving parent is that he or she mistakenly believes that performing the observable actions of Baptism will make it an actual Baptism. If the parent were to know that no "real" Baptism would occur, he or she would find no comfort in it. Hence, to lead a person to believe that his or her deceased child is truly being baptized is a deception, a benevolent deception, but a deception nonetheless.

Some might argue that such a deception is warranted. That is, even though it would be prima facie wrong to deceive a person by leading parents to believe that their deceased infant is being baptized, such a deception may be justified in order to provide comfort to the parents. Notice, however, that it is precisely this sort of justification that has been offered in defense of deceiving patients for benevolent reasons. Few would agree that it is permissible to intentionally mislead a patient in order to prevent his or her emotional suffering.

Another possible objection might be rooted in respect for patient autonomy. It could be argued that respect for patient autonomy would justify accommodating a parent's wish to baptize his or her deceased infant. However, there are at least two problems with this argument. First, we already have noted that it is deceptive to lead parents to believe that a deceased infant truly is being baptized. If this is true, then such a deception also would undercut the autonomy of the parent, since deception undermines a person's capacity to make rational decisions.

Second, respect for autonomy should not obligate a chaplain to provide what is, in a certain sense, "sacramentally" futile. That is to say, baptizing a deceased infant seems in some ways analogous to providing medically futile treatment. Admittedly, the moral significance and appropriateness of the term "medical futility" remain an open question. Nonetheless, most will agree that a doctor should not be obligated to offer treatment that, in his or her professional judgment, will not achieve what the physician and the patient agree to be relevant goals.

It is true that withholding treatments that are not medically indicated or appropriate may be difficult when a family insists that they be tried. A refusal to initiate a futile procedure likely will be emotionally upsetting to the family or patient. However, a physician is committed to promoting the goals of medicine and is not a mere instrument of the patient's will, although the patient is a partner in the therapeutic relationship. Both the patient and the physician enter into the therapeutic relationship bound to a set of core values. Among other things, integrity implies acting in ways that are consistent with those values. The physician cannot be obligated to provide treatment that is inconsistent with the values of the medical profession. Hence, respect for the integrity of the physician and the profession of medicine suggests that a physician is not obligated to provide modes of treatment that have no reasonable hope of success.

Accommodating a request to baptize a deceased infant, then, is analogous to complying with a request for futile treatment to the extent that it amounts to performing a service that cannot achieve its goal. As we have noted, going through the physical motions of a Baptism does not achieve the goals of a "real" Baptism. As with a refusal to provide futile care, a reluctance to honor a parent's request to baptize his or her deceased infant may deepen the sadness of the grieving parent. However, as stated above, to expect a hospital chaplain to "baptize" a deceased infant is to compromise his or her professional integrity and the integrity of the sacrament. Asking a chaplain to baptize a deceased infant is asking him or her to do something inconsistent with the theology he or she represents.

Some might take issue with the futility analogy, arguing perhaps that no pastoral intervention in which one calls upon God's name is ever futile. Certainly, this is true. However, one must bear in mind that a judgment of medical futility is always relative to some treatment goal.¹¹ A treatment may be futile and therefore inappropriate with regard to one goal, but appropriate with regard to another. Removal of a bowel obstruction may be curatively futile for a terminally ill hospice patient, but appropriate with respect to palliative goals. Similarly, one could say that Baptism might effectively achieve other important sacramental goals aside from initiating a person into a faith community. Sacraments such as Baptism allow us, for example, to assign meaning to a particular event and reinforce our hope. In some cases, as in the Anointing of the Sick, it may provide comfort. However, since the Baptism of a deceased infant cannot achieve the goal of initiating that infant into a life in the church and is not needed for the baby to go to heaven, it is futile with regard to these goals. Moreover, since there are alternative ways that may meet the spiritual and emotional needs of grieving parents, ways that do not challenge the integrity of the sacrament, these alternatives should be pursued. Indeed, this will be our focus in the next section.

Finally, and this may be the most important point, a practice of accommodating requests to baptize deceased infants only eclipses the real need for a legitimate official response from the church, an official rite that could address the needs of bereaved parents. An official ceremony that is developed and accepted by the church would be one way to begin to address the problem we have been discussing. Let us now consider this kind of resolution along with others in greater detail.

Some Practical Suggestions
At this point, we would like to focus on some practical ways of addressing the problem of requests to baptize deceased infants. First, one should avoid the kind of problem we have been considering by baptizing those infants who are at risk of death. We might also recommend training nurses and physicians to perform emergency baptisms when a chaplain is not available. As Frs. Ashley and O'Rourke explain, little is required to perform an emergency Baptism. It would simply involve pouring water on the child and saying, "I baptize you in the name of the Father, the Son, and the Holy Spirit."¹² This would require very little staff training.

Similarly, if there is any doubt whether the infant is dead, a kind of conditional Baptism should be performed. This would simply consist in prefacing the Baptism with gently and reverentially delivered words, such as, "If you are still alive, I baptize you . . ." Since our determination of the exact point at which life has left the body is imprecise, there can be genuine doubt up to several minutes after the child appears to have died.

To set up our next suggestion, it might be helpful to revisit our earlier comparison of baptizing deceased infants and honoring requests for medically futile treatment. Much of the recent discussion of futility has focused (and rightly so) on avoiding conflicts between the patient and the professional judgment of the physician. In particular, we would do well to consider some of the important lessons from an article on medical futility by Ronald P. Hamel, PhD, and Michael R. Panicola, PhD, that appeared in this journal last year.¹³ Hamel and Panicola emphasize the importance of effective communication. One important aspect of communication, especially in end-of-life circumstances, has to do with the way in which treatment alternatives are presented to the patient or family. Hamel and Panicola advise against what they refer to as the "buffet approach" in which all possible alternatives are presented to a family or patient.¹⁴ Such an approach invites conflict between what the family wants, on one hand, and what the physician believes to be medically appropriate, on the other.

For the same reasons, Hamel and Panicola also advise against the use of open-ended questions, such as, "What do you want us to do?"¹⁵ Instead, Hamel and Panicola recommend that physicians present only "treatment options that are medically appropriate and that offer hope of benefit to the patient."¹⁶ Finally, they discourage statements about what cannot be done. They suggest, rather, that "emphasis might be placed on what can and will be done, rather than on what will not be done."¹⁷

All of these points apply to the issue of baptizing deceased infants. If the parent does not raise the issue of baptism, the chaplain should not go out of his way to point out that baptisms are not performed in such circumstances. Rather, just as physicians ought only to offer those treatment alternatives that promise some possibility of benefit, hospital chaplains should offer only those spiritual services that are appropriate, including the provision of an empathetic, listening presence. In anticipation of the family's pastoral needs, the offering of some kind of blessing and naming ritual would be most appropriate (see Box). Indeed, chaplains should focus the conversation on what they can and will do for the parents and the deceased infant, as opposed to what is no longer possible or appropriate.

Many chaplains also offer creative ceremonies. Grieving families have a distinct need for some kind of healing ritual, some kind of prayerful response at the time of the death of their precious infant. Truly, the obligation of chaplains and those who care for these families to reduce suffering and create a peaceful healing is the ultimate good and necessary work of all those in this type of ministry. Pastoral ministers respond to such crises every day with creative rituals that name the child and entrust this child to God's mercy; that pray for the parents and call on God's compassion and mercy; that use Scripture and touch and song — that even use water as a healing, refreshing sign of God's love and ever-flowing healing presence. These rituals are not Baptisms per se, but they provide the touch and comfort of the church that is called for; they remind us and signify that, indeed, in the eyes of our merciful God, this child "belongs." Thereby we provide good, effective, and responsive pastoral care without risking violating the integrity of the sacrament and the teaching of the church.

Nonetheless, we also provide responsive pastoral care by continuing to act as advocates for the real pastoral needs of our patients and families. Given our experience, the authors would argue that "all the more urgent is the church's call" to respond to the pastoral need for some kind of "official" church rite for deceased infants. Such a rite could be created from the collected "best practices" of countless pastoral ministers and other health professionals who have created such healing rituals as that of "blessing and naming." Indeed, the NACC has advocated that the creation and inclusion of such a rite in the Roman Catholic Church's official Rites for the Dead. Perhaps such a rite might follow the current "Christian Initiation for the Dying" in the official Pastoral Care of the Sick: Rites of the Anointing and Viaticum, especially since this ritual book is currently being revised.¹⁸

The authors would like to thank Linda Thompson, Larry Valentine, and the Rev. Mark Jensen for their helpful suggestions.

NOTES

1. National Association of Catholic Chaplains, Standards Code of Ethics, no. 130.32. To read them, access the website and type "standards" in the Search NACC box.
2. St. Augustine, Enchiridion, Henry Paolucci, ed., Henry Regnery Company, 1961, section XCIII, pp. 107-108.
3. St. Thomas Aquinas, The De Malo of Thomas Aquinas, Richard Regan, ed., Oxford University Press, New York City, 2002, section 5, article 4, pp. 407-408.
4. Catechism of the Catholic Church, Liturgical Press, Collegeville, MN, 1994, para. 1,275.
5. Benedict Ashley and Kevin O'Rourke, Health Care Ethics: A Theological Analysis, 5th ed., Georgetown University Press, Washington, DC, 2000, p. 453.
6. Ashley and O'Rourke.
7. Ashley and O'Rourke.
8. U.S. Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services, Washington, DC, 2001, p. 15.
9. Catechism of the Catholic Church, para. 1,261.
10. Sacred Congregation for the Doctrine of the Faith, "Instruction on Infant Baptism," in Austin Flannery, ed., Vatican Council II: More Postconciliar Documents, Costello Publishing Company, Northport, NY, 1982, pp. 510-517.
11. Susan Rubin, When Doctors Say No: The Battleground of Medical Futility, Indiana University Press, Bloomington, IN, 1998, pp. 45-46.
12. Ashley and O'Rourke, pp. 453-454.
13. Ronald P. Hamel and Michael R. Panicola, "Are Futility Policies the Answer?" Health Progress, July-August 2003, pp. 21-24.
14. Hamel and Panicola, p. 22.
15. Hamel and Panicola.
16. Hamel and Panicola, p. 23.
17. Hamel and Panicola; first two emphases added.
18. Pastoral Care of the Sick: Rites of the Anointing and Viaticum, Catholic Publishing Company, New York City, 1983, pp. 234-250.

St. Joseph Mercy Oakland's Naming Ceremony

Opening Prayer
Leader: As we do not know the path of the wind, or how the body is formed in a mother's womb, so we cannot understand the work of God, the Maker of all things. We do know, however, Loving God, that your beloved Son took children into His arms and blessed them. Give us the grace to trust in your love for this child and family.

Reading
Come to me, all you who are weary and find life burdensome, and I will refresh you. Take my yoke upon your shoulders and learn from me, for I am gentle and humble of heart. Your souls will find rest, for my yoke is easy and my burden light (Mt 11:28-30).

Leader: What name do you give your child?
Parents: Let his/her name be called [child's name]

Blessing
Leader: Our help is in the name of the Lord.
All: Who made heaven and earth.
Leader: The Lord be with you.
All: May He also be with you.

Leader: Let us pray. Lord, Jesus Christ, Son of the Living God, who said: "Let the little children come to me, and do not stop them; the Kingdom of God belongs to such as these," pour out the power of your blessings on [the child's name] and consider the faith and devotion of these parents.

Petitions
Leader: My brother(s) and sister(s), let us ask our Lord to look lovingly on this child whom we are here to name.
All: Lord, hear our prayer.
Leader: In your special love and kindness for children, bathe this child in your light; as you entrusted him/her to this family, accept him/her once again into your loving arms.
All: Lord, hear our prayer.
Leader: Bless the lives of his/her parents. May they always remain united in faith and love.
All: Lord, hear our prayer.

Closing Prayer
Leader: Merciful God, comfort our friends whose hearts grieve, and grant they may so love and serve you in this life that together with this, your child, they may obtain the fullness of your promises in the world to come.
Amen.