A Case Study of Spiritual Care Provision to a Patient with a Psychiatric Disorder Requesting Physician-Assisted Dying in the Netherlands
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religions Article “If Only I Could Start All over . ” A Case Study of Spiritual Care Provision to a Patient with a Psychiatric Disorder Requesting Physician-Assisted Dying in The Netherlands Carmen Schuhmann 1,* , Marianne C. Snijdewind 2, Lisa van Duijvenbooden 3 and Geert E. Smid 1,2 1 Humanist Chaplaincy Studies for a Plural Society, University of Humanistic Studies, 3512 HD Utrecht, The Netherlands; [email protected] 2 ARQ National Psychotrauma Centre, 1112 XE Diemen, The Netherlands; [email protected] 3 Independent Researcher, 5611 AA Eindhoven, The Netherlands; [email protected] * Correspondence: [email protected] Abstract: In a growing number of countries, legislation permits physicians—under strict conditions— to grant a request for physician-assisted dying (PAD). Legally allowing for the possibility of granting such a request is in accordance with central humanistic values such as respect for autonomy and self-determination. The Netherlands is one of few countries where severe suffering from a psychiatric illness qualifies as a ground for a request for PAD. Central in this article is a case description of spiritual care provision in the Netherlands by a humanist healthcare chaplain to a patient requesting PAD because of psychiatric suffering. We discuss what we may learn from the case description Citation: Schuhmann, Carmen, about how spiritual caregivers may support patients who express a wish to die, and about their Marianne C. Snijdewind, Lisa van contribution to the care for patients with a psychiatric disorder who request PAD. Duijvenbooden, and Geert E. Smid. 2021. “If Only I Could Start All over Keywords: spiritual care; physician-assisted dying; secular chaplaincy; humanist spiritual care; . ” A Case Study of Spiritual Care The Netherlands; euthanasia Provision to a Patient with a Psychiatric Disorder Requesting Physician-Assisted Dying in The Netherlands. Religions 12: 672. 1. Introduction https://doi.org/10.3390/rel12090672 In a growing number of countries, legislation permits physicians—under strict conditions—to grant a request for physician-assisted dying (PAD) from a patient (Emanuel Academic Editors: Gaby Jacobs and et al. 2016). In four of these countries—Belgium, the Netherlands, Luxembourg, and Hans Zollner Canada—the suffering underlying these requests may stem from a psychiatric illness (Emanuel et al. 2016). In the Netherlands, the conditions a physician must adhere to in Received: 8 July 2021 the context of PAD are called the due care criteria. Although a guideline has been issued Accepted: 18 August 2021 Published: 24 August 2021 specifically for PAD based on psychiatric suffering (Levensbeëindiging op Verzoek bij Patiënten met een Psychische Stoornis [Termination of Life on Request from Patients with Publisher’s Note: MDPI stays neutral Mental Disorders] 2018), the more substantive of these criteria still seem to be more difficult with regard to jurisdictional claims in to assess when the request was made in relation to suffering from a psychiatric illness published maps and institutional affil- (Evenblij et al. 2019). According to one of the criteria, the physician should be convinced iations. that the request by the patient is voluntary and well-considered. There is discussion about how mental illness affects the ability of patients to have a well-considered wish to die, and about the possibility of distinguishing between suicidality and a well-considered wish to die in psychiatric patients (Pronk et al. 2020). Another criterion states that the physician should be convinced that the suffering of the patient is unbearable and without prospect Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. of improvement. For all requests for PAD, it seems difficult to assess whether suffering This article is an open access article is unbearable: “unbearable suffering has not yet been defined adequately and views on distributed under the terms and the concept are in a state of flux” (Dees et al. 2010, p. 339). As for requests by psychiatric conditions of the Creative Commons patients, there is also discussion about the conditions under which psychiatric suffering Attribution (CC BY) license (https:// can qualify as irremediable (van Veen et al. 2020). creativecommons.org/licenses/by/ Several authors point at the existential dimension of unbearable suffering in the 4.0/). context of a request for PAD (Berghmans et al. 2013; Dees et al. 2010; Dees et al. 2011). In a Religions 2021, 12, 672. https://doi.org/10.3390/rel12090672 https://www.mdpi.com/journal/religions Religions 2021, 12, 672 2 of 9 qualitative study among 31 Dutch patients who had requested PAD, Dees et al.(2011) found that all patients named existential motivations, related to unbearable suffering, for their request for PAD. Following Geertz(1973), worldviews may be understood as collective meaning frameworks that both describe and prescribe how to make sense of existence, in particular of existential challenges such as severe suffering. According to Geertz, religious responses to suffering characteristically emphasize how to endure suffering: “how to make of physical pain, personal loss, worldly defeat, or the helpless contemplation of others’ agony something bearable, supportable—something, as we say, sufferable” (p. 104). The notion that suffering may eventually be unendurable, and that ending life may be a valid response to such suffering, may thus conflict with traditional religious convictions. Empirical research shows that an increase in public support of PAD in various countries is correlated with a decline in religiosity (Cohen et al. 2006; Emanuel et al. 2016; Halman and van Ingen 2015; Marsala 2019), and that religious commitment of individuals is associated with opposition to PAD (Aghababaei 2013; Cohen et al. 2006; Fortuin et al. 2020). Considering or approving the option to end one’s own life or request assistance with dying in the context of unbearable suffering reflects core humanistic values such as respect for autonomy and self-determination. The thought here is that the patient should have the final say if and how he or she wants to live life or end it. Considering this, PAD may be characterized as a secular practice that is in accordance with central values in humanism. The importance of addressing the existential dimension of the suffering of patients as well as physical and psychosocial dimensions is increasingly recognized in healthcare (LeMay and Wilson 2008; Puchalski 2013). Healthcare chaplains are traditionally the obvious professionals to provide care directed at existential struggles of patients. Chaplains nowadays tend to describe their work in terms of providing spiritual care rather than in terms of providing religious care (Doehring 2015; Orton 2008; Pargament 2007). This designation of chaplaincy underscores that chaplaincy care is not restricted to religious people, as spirituality is more and more seen as a universal human experience instead of a synonym of religion (de Jager Meezenbroek et al. 2012). Now that spiritual care is often accepted as an integral dimension of healthcare, healthcare chaplains are becoming part of healthcare teams rather than working at the margins of healthcare organizations (Pesut et al. 2012). This development is especially visible in the context of palliative care (Puchalski et al. 2014). In this context, there is also a growing body of research into spirituality, spiritual care, and the role of chaplains in care provision (Steinhauser et al. 2017). By contrast, when it comes to patients with psychiatric disorders (PPD) requesting PAD, not much is known about the (potential) role of spiritual care for these patients, about how healthcare chaplains provide spiritual care, or about how this care relates to the care provided by other healthcare professionals involved. In this article, we explore a case of spiritual care provision in the Netherlands by a humanist healthcare chaplain (LvD) to a patient requesting PAD because of psychiatric suffering. By reflecting on the case, we explore how to understand spiritual care provision to PPD who experience their suffering as unbearable, without prospect of improvement. Furthermore, we address the question of how spiritual care provision to PPD requesting PAD fits in with the care for these patients in general, in particular with the assessment of whether the patient’s request is voluntary and well-considered. 2. Results 2.1. Case Description: Introducing Anna The following case description is based on an in-depth interview of Lisa (LvD), a healthcare chaplain in a large mental health institution in the Netherlands. Part of this case description was published previously (van Duijvenbooden 2017). The case is about the chaplaincy care that Lisa provided to Anna, a woman in her seventies, during the last two years of Anna’s life. Anna had regularly been hospitalized (both voluntarily and involuntarily) because of severe depression, suicide attempts, and manic episodes with psychotic features. Lisa met Anna when the former chaplain, who had provided chaplaincy care to Anna whenever she was confined to the institution, had retired, and Anna was once Religions 2021, 12, 672 3 of 9 again hospitalized after a half-hearted suicide attempt. Anna was an educated woman, which was, even though she was in an unkempt state, evident from the way in which she spoke, the vocabulary that she used, and her subtle sense of humor. She felt very much out of place in the institution and experienced every hospitalization as traumatizing. The healthcare professionals in the institution therefore always tried their best to keep Anna’s hospitalizations as short as possible. As soon as her situation had somewhat stabilized, she was allowed to move back home where she would attempt to pick up her life again, supported by outreaching care. There were no people in her life with whom she had a close relationship. Repeatedly, Anna expressed her desire to die. By the time that Lisa came into contact with Anna, this desire was taken seriously into consideration within the institution, and a psychiatrist explored possibilities of PAD together with Anna.