Abstract
Dear Editor:
At first blush, I share Sean Morrison's critique of approaches that conflate spirituality with religion, 1 and I have seen a number of other research articles over the years that correlate regular religious practice—and particularly what I would categorize as patients' religiosity—with more and not less burdensome interventions at the end of life. This is not surprising to me given that I am unaware of any major religious tradition in the last hundred years that has seriously engaged conversations with their adherents around possible differentials between life as a sacred gift and simple biological existence without capacity for relationship or meaning.
I question, however, Dr. Morrison's statement that we have no understanding of whether spiritual distress is adaptive or maladaptive. While I have no validated, objective study and metrics on which to make these judgements, I believe that I and many other clinicians from a variety of disciplines have seen numerous examples in which it can be either. I believe that when such distress comes from the person's awareness of their normal human imperfections, i.e. “I am a person that makes mistakes,” it can be highly adaptive in leading them to heal relationships, seek forgiveness for harming others, etc., thus leading to a considerable sense of peace. I consider this highly adaptive. But I have also seen such distress that springs almost entirely from an inappropriate sense of shame, i.e., “I am a mistake,” and this is highly maladaptive and destructive in human lives, all the more so at the end of life.