The role of religious beliefs for the acceptance of xenotransplantation. Exploring dimensions of xenotransplantation in the field of hospital chaplaincy

The Changsha Communiqué (2008) calls for a greater account to be taken of the ethical aspects of xenotransplantation as well as of public perception. This also applies to the field of hospital chaplaincy. So far, there has been no empirical exploration of the assessment and acceptance of xenotransplantation by pastoral workers in German‐speaking countries. In view of the prospect of clinical trials, in‐depth research is both sensible and necessary, since both xeno‐ and allotransplantation can have far‐reaching consequences for patients, their relatives, and the social environment. In addition to the tasks of health monitoring, questions of the individual handling with and integration of a xenotransplant must also be considered. They can affect one's own identity and self‐image and thus also affect religious dimensions. Hence, they make a comprehensive range of accompaniment necessary.


| INTRODUC TI ON
At the end of 2018, research into the transplantation of animal cells, tissues, and organs attracted broad media attention. Munich scientists had succeeded in transplanting a baboon with a genetically modified pig's heart, which it lived with for six and a half months. 1 This was a considerable success compared to earlier xenotransplantations. It now seems more realistic that in a few years genetically modified animal organs, in this case pig hearts, will be transplanted to humans, while clinical trials with islet cells are already under way. Therefore, the prospective examination of these new medical possibilities also appears to be more urgent for all those who could accompany and care for patients and their relatives in the future.

Consultation on Regulatory Requirements for Xenotransplantation
Clinical Trials in its principles calls for a greater account of the ethical aspects of xenotransplantation as well as of public perception.
"Because of these wider community risks, xenotransplantation clinical trials and procedures need to be effectively regulated.
There should be no xenotransplantation in the absence of effective regulation by the government of the country. Regulation should have a legal basis with powers to ban unregulated procedures and enforce compliance with regulatory requirements. The regulatory system should be transparent, must include scientific and ethical assessment and should involve the public." 2 This also applies to the field of hospital chaplaincy. While there are empirical studies on the assessment and acceptance of xenotransplantation, 3,4 there is no empirical exploration of the assessment of pastoral workers in German-speaking countries. In the face of prospective clinical trials, in-depth research is both sensible and necessary.
Since both xeno-and allotransplantation can have far-reaching consequences for patients, their relatives, and the social environment, in addition to the tasks of health monitoring, questions of personal contact and integration must also be considered. They can affect one's own identity and self-image and thus also affect religious dimensions. Hence, they make a comprehensive range of accompaniment necessary. 5

| Self-image and tasks of hospital pastoral care
In the three major monotheistic religions, it is part of their established practice to take care of the sick. [8][9][10][11][12] In the 20th century, special pastoral care has been developed in hospitals in German-speaking countries. This so-called hospital pastoral care is usually provided by professional pastoral workers on behalf of the respective religious community. The integration into the medical-care team varies from hospital to hospital. For some years now, a Jewish and Islamic pastoral care or accompaniment of patients has been developed gradually, which is largely based on voluntary work.

Conclusions:
Xenotransplantation can affect the identity work of patients and relatives also in religious terms. In order to provide better pastoral and psychosocial support for these persons within the framework of the hospital, it is important to reflect on such challenges at an early stage and to develop concepts for pastoral further training and pastoral care in xenotransplantation.

K E Y W O R D S
Christianity, Dialogue Board, hospital chaplaincy, Islam, Judaism, pastoral care, theology,

| Religious aspects of transplantation
Serious illnesses can often plunge people and their relatives into deep crises. In such cases, a comprehensive psychosocial care can help in which not only medical nurses, psychologists, and social workers but also hospital pastoral workers are involved. This often results in implicit references to religious and pastoral aspects, such as religious images and metaphors. We, therefore, asked for general experiences from the accompaniment of transplantation patients and the specific religious dimensions. In supporting the patients during such crises, the affiliation of patients or hospital pastoral workers to a particular religion or denomination plays hardly any role. Rather, the respective hospital pastoral workers provide comfort and assistance and also represent the dimension of transcendence. Experience shows that patients usually ask themselves similar questions, such as the meaning of the disease, and struggle with why the disease affects them.
In such encounters and conversations, explicit religious references can also be made. Some patients draw strength from prayers and religious rituals, or re-examine their faith because of their illness. It is possible that patients struggle with God, feel left alone by Him and are disappointed by Him. In the context of the Dialogue Board, a practicing Catholic cancer patient was reported who drew strength from the sacrament of the Eucharist during her illness. Yet, after a relapse, this ritual had suddenly lost its power for her. In such conflicts with one's own faith, various religious images and patterns of interpretation can become virulent.
Depending on the religious-cultural origin and individual religiosity, the illness can be interpreted differently, for example, as God's punishment or as a test. Muslim hospital pastoral workers, for example, reported from their experience that the Koran's promise that no soul would have to endure more suffering than it could bear was perceived as relieving.

According to the experts, problems arise when Muslim and
Jewish patients cannot observe religious regulations and ritual acts due to inpatient treatment in hospitals. The following aspects, as the discussion showed, were significant in the experience of the hospital pastoral workers: Many Muslim patients suffered from the fact that they could not perform ritual washings due to the conditions of the hospital stay. The pastors made clear that in the case of illness this religious duty does not bind and that the washings could be carried out symbolically with the help of a stone. This elaboration possesses a special authority if given by Muslim hospital pastoral workers, that is, if coming from an internal perspective. As far as Jewish dietary laws are concerned, it helps patients to point out that they apply only to food ingested through the mouth, but not to artificial feeding by means of a stomach tube. This explanation has a relieving effect.
A further conflict may arise from the duty, which is more firmly an- in hospitals can question existing religious norms with regard to their "lifability" and has insofar a self-critical potential for its own religious traditions.

| Religious aspects of xenotransplantation
Prospective considerations were made concerning the application of xenotransplantation. We, therefore, asked about possible religious implications, associations, and images. Key questions referred to the image of God as Creator, to ritual purity, to the sanctity of life, to the relation of body and soul, and to coping with death.

| Effects on identity and self-image as well as anthropological aspects
According to the unanimous opinion of the participants in the In general, a technical understanding of the human being was viewed critically. If failing organs are only interpreted as a weakness and as a component that can be replaced at will without considering the biographical reference, the physical as well as the body-soul integrity could be overshadowed.
Another topic in the discussion was the question whether, in view of the idea of God's likeness of man, a xenogenic organ could be perceived as a flaw. No final answer was given to this question.
Instead, it was discussed whether God's likeness could be conceived of physically at all.

| Emotional reaction
A xenotransplantation, according to the prospective considerations, could also represent a considerable emotional burden. The concerns expressed by the pastoral workers covered three areas.
The first thoughts revolved around the phenomenon of disgust.
One participant reported on a conversation with a transplant patient about xenotransplantation in the run-up to the conference.
Under no circumstances could he have imagined receiving a pig organ. The special feature of this disgust is that it is an "inner disgust". The pig organ as a foreign body is located inside the patient's body. This makes it impossible to physically distance oneself from it. This could result in a disgust for oneself that cannot be physically relieved.
In Jewish and Muslim view, the pig is regarded as an impure animal, which can clearly impair the acceptance of porcine organs.
Although the medical use of pig organs can be legitimized by religious law in Islam and Judaism, the pastors suspected that many re- Two further feelings were mentioned which are in a tense relationship to each other. One emotion could be compassion for the animals from which the donor organs originate. A second feeling could be the relief of the xenotransplant recipients that no one "had to die for them". This kind of burdensome experience is reported in cases of allogeneic transplantations. It is important for a successful transplant treatment that patients, and their relatives are able to express and process such feelings before and after the operation. Only then receiving a xenogenic organ can be brought into a reconciled and authentic self-relationship.

| Aims and recommendations
Three desiderata or recommendations for action emerged from the Dialogue Board. They were developed through group work processes, where each group contained members of at least two dif-

| Initial, advanced, and further training for hospital pastoral workers
Even though xenotransplantation has a lot in common with the current practice of allotransplantation, it also has specific aspects.
Therefore, it is recommended to develop a specific further education offer for hospital pastoral workers who will be active in this field. It should be holistic and include the following areas in particular.
First of all, it should impart relevant basic medical knowledge in the field of rapidly developing xenotransplantation.
Additionally, this should be embedded in a comprehensive psychosocial and spiritual approach. It is precisely because xenotransplantation can address a variety of emotional and affective aspects that these should also be taken into account in the accompaniment.
It is an important task of pastoral accompaniment, which can hardly be carried out by the other occupational groups in the hospital due to time reasons, to endure burdening feelings such as disappointment, anger, grief, or powerlessness or to offer the patient a space at all and to give the security to be able to allow these feelings and to give them an expression. Furthermore, it can be a matter of locating such emotions in life history and developing their specific meaning on the basis of the respective life themes of the patient. Hopes and healing resources should also be discussed.
The holistic approach also includes looking at relatives and the wider social environment, because the support of family and friends is an important resource for the patients to deal with their situation and to make a coherent decision. With regard to the long-term success of a xenotransplantation, the social acceptance conditions play a considerable role.
The situation of the donor animal should be a further component of further training. For it cannot be ruled out that relevant questions may arise in pastoral accompaniment. Pastoral workers should be able to give competent information, take a stand and discuss animal ethical aspects in such conversations. Furthermore, the status of the animal is to be discussed theologically on a fundamental level, for instance as a fellow creature with its own value or as a farm animal, whereby in this respect the different ways of use as food and as organ supplier are to be considered again.

Ultimately, it would be advisable if hospital pastoral workers
were familiar with the complexity of xenotransplantation and at the same time develop their own position and attitude in order to be able to accompany patients, relatives, and hospital staff in an appropriately person-centered manner.

| Contact points for patients
With the decision for a xenotransplantation begins a lifelong dealing with the new organ or tissue. Therefore, the further accompaniment of the patient and his relatives is to be understood as a long-term process. Experience with allotransplantations has already shown that doubts may arise afterward for a variety of reasons and that psychological stress or disorders may arise. Further medical aftercare, observation, and treatment can also develop into stress situations. Last but not least, it is difficult to predict how the social acceptance and especially the reactions in the personal environment of the patients will develop, so that here, too, a need for support may arise. For this reason, a long-term contact point for xenotransplant patients (and, if necessary, for their relatives) seems to make prospective sense.
In addition to professional pastoral care for xenotransplant patients, open self-help groups are a suitable place to work on experiences with xenotransplantation. Churches and religious communities could initiate such groups if necessary or support them institutionally and financially.

| Interreligious cooperation and joint statement
In the social context of Western and Central Europe, the sole consideration of Christianity no longer seems appropriate. Different

| OUTLO O K
The Dialogue Board offered a first occasion for mutual exchange and formulated some cornerstones to be further discussed in theological research and pastoral practice. The continuation and further development of this format of an expert discussion represent an important building block for the development of a pastoral care concept for dealing with xenotransplantation. From a comprehensive understanding of therapy and health it follows that, in addition to biomedical progress, psychosocial, and pastoral dimensions should also be taken into account. The closer xenotransplantation comes from bench to bedside, the more attention and support practiceoriented research requires.