<p>Questions about why disability occurs often arise in the context of a prenatal diagnosis. Pastors are frequently called upon to offer theological interpretation and pastoral care in response to such questions. Yet, little is known about how they understand the causes of disability and the ways these beliefs might shape their responses. In this qualitative study, we examined how 25 pastors responded to questions about God’s role in causing disability using a vignette involving a couple who received a prenatal diagnosis of Down syndrome. The pastors’ responses reflected four primary patterns: rejecting divine causation, emphasizing God’s permission, affirming disability as part of the divine design, or reframing such questions as unhelpful or unanswerable. We discuss implications for pastoral counseling and future research aimed at equipping faith leaders to support families encountering genetic disability for the first time.</p>