Boer, Theo A
Protestant Theological University
The Netherlands

When family violence takes subtle forms: A narrative from a Dutch context

(A response to CH Thesnaar)

1. INTRODUCTION

Domestic abuse is of all times and all places, and depending on contextual factors, it will take many different forms. Christo Thesnaar’s contribution elsewhere in this volume, about human dignity, domestic abuse, and domestic violence provides an impressive insight in the vicious circle of abuse from a South African context.1 In the case of Ellen Pakkies, this emanates into the utter tragic of a mother killing her son. After a long history of son-mother abuse, Ellen is visited by her son who once again displays his usual state of apathy. This time she decides to make him talk once and for all, so she puts a rope around his neck and tightens it. He swears at her, tries to grab a plank off the floor, but this time she is in charge. She will teach him a lesson. And before long, she has killed him.

One of the reasons why the story is so heartbreaking is that it runs counter to everything we, as parents or as children, conceive to be the normal course of events in families. It will not be hard to find similar examples of domestic violence in other developed countries. Substance abuse is widespread in Europe, especially amongst citizens with a low socio-economic status. Still, the extent of violent crimes in South Africa and the gap between the socio-economic classes there justify the conclusion that the story presented by Thesnaar is much more typical for a South African context than it is for a European one. And there is another element in this account which strikes as un-European: the story told, the heuristics used, the analysis made, and the questions asked, illustrate the presence of a living tradition of highly qualified Protestant theology.

In this contribution, we present a story of abuse taken from a radically different context which, on a closer look, is strikingly similar to the one recounted by Thesnaar. It is taken from the context of a euthanasia procedure, i.e., an assisted death of a patient by his doctor, at his request. We will start by shortly explaining the legal and medical-ethical framework surrounding the story. After the narrative is told we conclude by raising three points of discussion.

THE CONTEXT OF THE DUTCH EUTHANASIA PROCEDURE

The Netherlands and Belgium are the two countries in which euthanasia and physician assisted suicide have a legal status. As for The Netherlands, it is still a crime to kill someone even at his or her explicit request but doctors (and only doctors) who have acted under a set of well defined due care criteria will not be prosecuted. The most important criteria are:

(1) the patient and the physician have together reached the conclusion that the suffering is unbearable and that there are no prospects of improvement; (2) there is a lasting and informed request from the patient. This criterion is pivotal in the current euthanasia practice: without an explicit request, the term, ‘euthanasia’ does not even come into consideration. The criterion includes that the patient has received all the necessary information about his condition and about the array of palliative options. It is also presupposed that the patient or the physician do not experience undue pressure from the side of the relatives; (3) a second doctor has seen the patient and can confirm the suffering and the voluntary character of the request; (4) the physician reports a euthanasia case with the necessary documentation to a Regional euthanasia review committee (RERC). There are in total five such committees, each consisting of a lawyer, a physician, and an ethicist. A committee receives a report after a euthanasia has taken place and does not condone a euthanasia beforehand. When a case meets the criteria, it is closed; if one or more criteria are not met, a report is sent to the Prosecutor General.2

In 2010, 3,200 euthanasia cases were reported, being about 2% of all deaths.3 ‘Are the Dutch moving down a slippery slope?’ is a question often asked by critics.4 Although we see a steady increase of euthanasia cases in recent years, it still is an exceptional death. It occurs almost exclusively within the realm of terminal cancer in patients with no longer than weeks to live. Many, if not most doctors experience euthanasia as unusual and burdensome. The tight review procedure, in combination with the reluctance on the side of doctors to perform euthanasia, prevent euthanasia from becoming a standard medical procedure. But occasionally there are signs pointing to the ‘normalization’ of euthanasia.

3. CASPER AND HELEEN

Casper de Vries is a 42 year old man who works as a road constructor.5 He and his wife Heleen, who is a waitress, have been married for twenty years. Together they have three sons aged 10, 8, and 5. They live in a comfortable but small apartment at the outskirts of Utrecht. The marriage has not been especially happy. Casper and his wife have a history of conflicts; shortly after the birth of their second child they were on the brink of a divorce but then agreed to stay married so as to raise the children together.

In June 2005, after some weeks of increasing fatigue and dyspnoea, Casper is diagnosed with lung cancer. The oncologist offers him some palliative treatment, including surgery, and gives him somewhere between 8 and 12 months. After recovering from the first shock, and after the surgery, Casper and Heleen decide to make the best of the remaining time. Casper’s condition allowing, they do some travelling and spend time with relatives and friends. The malign process in Casper’s body develops slower than expected and after a year Casper is still relatively fit: he is even able to do some light work on a part time basis.

September 2006. In the next year, Casper’s condition gradually deteriorates and he is forced to stop working altogether. The couple’s feelings are mixed. On the one hand, they see it as a blessing that Casper has outlived even the most optimistic prognosis. They are more a couple than ever before and the children have enjoyed the investments made in their family life. But with Casper being at home and now becoming bedridden, the couple increasingly resumes their previous quarrels. The family budget shrinks as a consequence of Casper’s illness. Heleen has to make up for the loss of income and runs double shifts, but as Casper needs more care they decide that she will stay home and to take care of Caspar in his last months. His life insurance will make up for it after his death.

Again, the illness is not as aggressive as predicted. After a year, in September 2007, Casper suffers from heavy dyspnoea, fatigue, nausea, and pain. The physician now openly discusses the possibility that Casper will die within a couple of weeks. Heleen then brings up the option of euthanasia. The physician, who is neither opposed to euthanasia nor especially in favour of it, calmly explains the palliative options and indicates that euthanasia comes in only as a last resort. ‘I have never liked euthanasia, and my reluctance has only grown in recent years,’ he writes in his journal. Very professionally, he addresses Casper: ‘Casper, what do you think?’ The answer is crystal-clear. ‘I really prefer a natural death doctor,’ he says, ‘I don’t like the idea of a planned death. That’s why I never signed an advance directive. I have suffered so much in the past years, so I think I can take those last couple of weeks.’ They decide that Casper will be on oxygen during the nights and will have increased dosages of morphine. Whenever there is something wrong, they may call the doctor.

October 2007. Heleen phones the physician with an alarming message: ‘Doctor,’ she shouts, ‘the cancer is destroying our whole family! We want to discuss this euthanasia right away!’ The physician comes and listens to the reports of the family members. The youngest child, now seven years old, has resumed peeing in bed; the middle child has serious difficulties containing his number two. The school results of the two oldest children have plummeted. In the presence of the doctor ánd the children Casper and Heleen have a painful dispute. Heleen says that Casper’s demands are beyond limits: does he realize the strain he puts on the other family members? Does he know what two and a half years living together with an ailing husband means? Casper accuses Heleen of running away from her responsibilities and of wanting to kill him. The physician’s attempts to pacify the problem fail, Heleen leaves the apartment slamming the front door. ‘She’s been doing that consistently,’ Casper tells the physician cryingly, ‘running out on me and coming home hours later. What am I to do here in bed, alone, desperate, not able to help myself and wetting myself eventually? How long has it been since I was able to play soccer with the boys in the park? My oldest son hasn’t spoken to me for a week and none of the three any longer kisses me goodnight.’ ‘I don’t know what to do,’ the doctor writes in his journal, ‘the couple is like cat and dog. The family is in disarray, the wife is a bundle of nerves; despite the sedatives I give her she yells and screams and traumatizes the boys. None of the other relatives is willing to assist more than a couple of hours. But when I suggest Casper that a nursing home would be the best option, he heavily protests.’

November 2007. The physician has arranged nursing care two times a day and this brings some relief, but also stress: ‘I have seen twenty new faces in just three weeks time now,’ Casper complains. During the doctor’s weekly visits, the couple continues to quarrel, and Heleen continues to bring up the option of euthanasia. The doctor gets entangled in the quarrels and the despair of the family and is barely able to withstand the wife’s pressure. Heleen insists that Casper writes an advance directive. Casper gives in, but in his own special manner: ‘I hereby state that I want to die my own death. Signed, Casper de Vries, November 13, 2007.’ It is a clear text of protest, but no one seems to notice. ‘I want to die my own death, not the one you have in mind for me!’ The physician writes in his files: ‘November 13, 2007. Euthanasia request made.’ Even after that date, Casper goes on saying that euthanasia is not the death of his choice. ‘OK, you give me that injection if that will make you happy!’, the physician witnesses Casper saying to Heleen. But then Casper gives in. ‘I have seen my grandmother in my sleep,’ he tells his physician on November 28th, ‘and she said it would be right for me to come.’ In the final week before the scheduled euthanasia takes place, the stress diminishes. Heleen knows that her suffering will soon come to an end. Casper receives the anointing of the sick from his Roman Catholic pastor and is at peace with his decision to have euthanasia.

Three weeks after the funeral, Heleen introduces her doctor to a handsome middle aged man. ‘He has meant so much to me during these difficult months with Casper,’ she says, ‘if it wouldn’t be for him, I couldn’t have survived.’

4. COMMENTS

The Committee which reviewed this case concluded that that there was nothing so wrong with it that it would justify a verdict ‘incorrect.’ Casper was suffering from an incurable illness with no prospects of recovery; like most other people who receive euthanasia, he was in severe pain and suffered from nausea, extreme fatigue, and dyspnoea. His written directive was poor, if not outright useless, but there is no law which prescribes the necessity of a written request, and it suffices that his own physician and the second opinion doctor affirm his verbal request.

It was this story which came to mind when reading the narrative of Ellen Pakkies who kills her dearest son Abie. Both Abie and Casper die in the arms of a loved one. Their deaths are in a certain respect wished and welcomed by their loved ones, in both cases these loved ones are partially responsible for their death. Ellen and Heleen have been caring and patient for years, but they cannot take it much longer. In the case of Casper, nothing illegal was done, but in both cases, there is a situation of moral accountability if not guilt on the side of the loved ones. No doubt Abie’s death was more violent and problematic than Casper’s, and in no way we should downplay the extreme tragic of this specific narrative. Still, one would rather not be part of any of these two stories. In both cases we can have sympathy for the suffering of the loved ones, despite the strong intuition that this is not the way a son, or a spouse, should die.

So let us concentrate on the parallels: family members playing an important role in the premature death of a child and a spouse, not because they do not love them, but precisely because they love and care. Abie’s addiction destroys the wellbeing of his family, similar the way Casper’s illness has a devastating effect on the wellbeing of his wife and children. Just like Ellen Pakkies is an abused woman and a loving mother, Heleen de Vries is a caring spouse and an overstressed and traumatized mother of three. In the case of Ellen and Abie, there is a history of violence and abuse, in the case of Casper and Heleen, it is one of verbal conflict.6 Since Euripides’ Medea we know what tragedies are. Neither story can be described in terms of good guys and bad guys only; rather, all parties are entangled in patterns of conflict, abuse, neglect, violence. The similarity in the stories of Ellen and Abie, and Heleen and Casper, is that none of the key characters stands as a victim only. Tragically, many offenders are victims themselves and victims in turn traumatize others.

This brings us to a first point of discussion. From a Biblical hermeneutical view, Thesnaar suggests that both the victimizer and the victim should be seen as fully human beings, as relational human beings who are seeking healing and wholeness. Few would disagree with this claim; however, some may want to thematize another notion: guilt. To the extent to which someone has played a part in the abuse – the victim to a much lesser degree than the victimizer, if at all –, this guilt needs to be addressed to complete the picture. Some may want to object that that language of guilt may have a dehumanizing, disempowering and retraumatizing effect on human beings. In fact, in the case of a woman being raped, the suggestion that the victim may be partly responsible herself for what happened, must be strongly rejected. But insofar as there is guilt, bringing this up may also have a liberating effect: he who bears responsibility is implicitly acknowledged as being a moral actor, i.e., someone with the freedom to do what is right and to withstand mechanisms and reflexes of abuse. St. Paul’s words to the Romans that all humans are sinners (Rom 3,23), no one excepted, is an affirmation that all humans, no one excepted, bear responsibility for their share in the origins of moral evil. Perhaps one of the keys to regaining control over one’s life is to acknowledge one’s freedom and responsibilities. To some, ascribing guilt may be felt as offensive to the sense of worth and dignity of human beings. But if we assume, as is the case in the good part of the historic Christian community, that ‘guilt’ exists in a manner comparable to the way in which a terminal disease ‘exists’, discerning and acknowledging guilt may be indispensible in restoring actorship, autonomy, and a sense of dignity.

Secondly, both narratives illustrate the need for an interdisciplinary approach. In reviewing the narrative of Casper and Heleen, the RERC considered this problematic situation from as many perspectives as possible. Medically, Casper’s situation was reasonably sound. Lung cancer without a perspective of healing in a terminal phase. Casper receives the usual forms of palliative care, including morphine, sedatives, anti-emetics, oxygen, and home care. Some mistakes made by care professionals add to the chaos, but in the end, and given Dutch jurisprudence, these are not serious enough to justify legal or disciplinary measures. If the oncologist would have pictured a more realistic life expectancy, the De Vries family might have been better prepared for the years of hardship that were to come. But predictions are hard to make, and the oncologist may have wanted not to arouse false hope. The fact that Casper refuses to be transferred to a nursing home is a symptom of the poor reputation of this sort of care, despite the fact that the Dutch system of palliative care stands out as the number four in Europe.7 When Casper and Heleen finally accept home care, they complain that they have seen numerous faces in just a few weeks. Undesirable as this may be – but what else is there to expect in a health care system which has adopted market mechanisms? Did the home physician make mistakes? When invited by the RERC for further explanation, he declared that he had been very well aware of Heleen’s pressure; in fact, this pressure was the main reason for postponing the euthanasia for so long. Others may want to argue that the fact that euthanasia is a legal option in the Netherlands is in itself a systemic flaw: once euthanasia has become a respected option in palliative care, patients and their relatives will no longer be prepared to consider other palliative options. The supply of euthanasia may have stirred the demand in this case. Still, seen within the Dutch context, what is wrong with Heleen reading the papers and bringing up the possibility of euthanasia?

As the theological ethicist of this RERC, it was my task to focus on the question what kind of a family it is, and what kind of a society, in which a situation like this could happen. The family situation is not fully untypical for families in the Netherlands: both partners have a job, three young children need love and attention, the housing situation is agreeable but without much privacy. Moreover, the two partners have a record of conflicts and hurts. Paradoxically, the fatal diagnosis seems to dampen the hardships of narrow housing and marital quarrels, but when Casper’s life stretches beyond the pessimistic predictions of the oncologist, the negative mechanisms return stronger than before. The small housing, the emotional immaturity of Casper and Heleen, financial problems, all of these would have been bearable for a short period of time, but not for years, and more consistent help from members of the extended family would have helped to master the worst crises.

In the end, not only Casper is a victim, but the whole family. From other cases reported to the Committee, it becomes clear that the suffering of a loved one is real suffering on the side of the bystanders. Witnessing a loved one die from cancer causes trauma and stress for years. Many patients refer to previous experiences at the deathbeds of parents, spouses, or siblings as a major reason for a euthanasia request. In this narrative, the decisive reason for this euthanasia is the unbearable suffering of the family. Tragically, it is hard to tell what should have been done to prevent this misery, and by whom. The interdisciplinary approach of the Committee illustrates rather than solves the complexity of the problem. If only there was one single cause, one bad guy, one clear solution, or one official who could step in and help!

Finally: what could the Church have done? Thesnaar’s account misses a precise articulation of the relationship between the academy and the church, between Practical Theology and the work of the pastor. No doubt, academic theologians have a mission to serve the Church, and no doubt the Church, in turn, has a mission to serve the people in the name of Christ. What features as utterly saddening, however, is that the Church seems to be absent in both stories. To be sure, in the narrative of Casper and Heleen there is a Roman Catholic pastor, coming in at the very end, unaware of the saddening circumstances which have led to the euthanasia request. Thesnaar may be right in pointing to our calling to restore and mend the divided community, and I agree that it is our mission to journey with Ellen and her family towards identity, growth, transformation, development in faith, and finding meaning in their own situation, just like it is our task here to journey with the Caspers and the Heleens. But how, one would ask, how? Despite a brilliant and well documented plea for an interdisciplinary approach, it remains hard to see what Practical Theology could have done to prevent the misery of the Ellens, Abies, Heleens, and Caspers. Perhaps our conclusion should be that the only way in which Practical Theology can be useful in lingering misery and preventing tragedy, is through active involvement of local Christian communities. If this is true, the two narratives are, more than anything else, an invitation to local communities to be aware of their social and pastoral responsibilities in the sphere of both prevention and intervention.

Contact details:

Dr Theo Boer

Associate Lecturer of Ethics

Protestant Theological University

The Netherlands

Associate Researcher

Department of Philosophy – Ethics

Utrecht University

taboer@pthu.nl