facing death, gazing inward

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Facing Death, Gazing Inward: End-of-Life

and the Transformation of Clinical Subjectivityin Thailand

Scott Stonington

Published online: 15 May 2011 Springer Science+Business Media, LLC 2011

Abstract In this article, I describe a new form of clinical subjectivity in Thailand,

emerging out of public debate over medical care at the end of life. Following the

controversial high-tech death of the famous Buddhist monk Buddhadasa, many

began to denounce modern death as falling prey to social ills in Thai society, such as

consumerism, technology-worship, and the desire to escape the realities of exis-

tence. As a result, governmental and non-governmental organizations have begun to

focus on the end-of-life as a locus for transforming Thai society. Moving beyond theclassic outward focus of the medical gaze, they have begun teaching clinicians and

patients to gaze inward instead, to use the suffering inherent in medicine and illness

to face the nature of existence and attain inner wisdom. In this article, I describe the

emergence of this new gaze and its major conceptual components, including a novel

idea of what it means to be human, as well as a series of technologies used to craft

this humanity: confession, facing suffering, and untying knots in the heart.

I also describe how this new subjectivity has begun to change the long-stable

Buddhist concept of death as taking place at a moment in time, giving way for a new

concept of end-of-life, an elongated interval to be experienced, studied, and usedfor inner wisdom.

I am happy to be a nurse because it is an opportunity to become the right kind

of person. Nurses get to see suffering every day. We have more opportunity

than any other profession to face suffering, to understand nature, and to

receive merit.

Ampha, a young nurse in a provincial hospital in Northern Thailand

S. Stonington (&)

Anthropology, History and Social Medicine, University of California,

San Francisco, San Francisco, CA, USA

e-mail: [email protected]

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Cult Med Psychiatry (2011) 35:113-133

DOI 10.1007/s11013-011-9210-6


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Prelude: A Hospital Room in Northern Thailand

Can we talk English? asks Jae, in English. We are in a provincial hospital in

Northern Thailand, home to some of the best public medical care in Asia. We are

sitting on a rolled-out straw mat on the floor, a hint of tradition in this very high-techplace. I am a student, both of medicine and of anthropology, and my fieldwork on

end-of-life care in Thailand has led me to this hospital, where Jaes mother, who is

dying from lung cancer, is an arms length away, drifting in and out of

consciousness. Her cousin had this [disease], before, explains Jae, If she hears

us talk, she might guess. Jae has not told her mother that she has cancer, or that she

is dying. Non-disclosure of cancer diagnosis and prognosis is the rule rather than the

exception here in Northern Thailand. Instead of discussing medical matters, Jae and

I spend many hours sitting on her mothers floor, simply being here to give her

mother encouragement (kamlang hai). Periodically, I leave the room to give Jaetime alone with her mother.

I step out into the hall, where I run into Nurse Ampha, a poised, kind woman with

scholarly round glasses. I feel like Nurse Ampha is a schoolteacher, and I treat her

that way since I feel like an ignorant and eager young student in Thailand and

especially here in the hospital.

What do you think about this case? I ask her.

It is not good, she says. I think at first shes going to talk about the lung cancer

quickly colonizing Jaes mothers body. But instead, she surprises me by talking

about Jaes unwillingness to tell her mother her diagnosis. Most clinicians inThailand do not disclose diagnoses, so I am surprised she considers this as a

problem. The mother, Nurse Ampha explains, will have no chance to prepare her

mind for the final moment. How can she know she needs to meditate and chant if

she doesnt know what is happening? This is not a real end-of-life case. She uses

the English for the words end-of-life. When Nurse Ampha talks to Jae about her

mother, she pushes gently on her, saying maybe if you talked with your mother,

you could chant together, or is there anything your mother would want to do with

this last period of life if she knew she was dying? Apparently, these are important

components of a real end-of-life case.

Nurse Ampha tells me about a lecture she heard at the Hospital Accreditation

National Forum in Bangkok about using the end-of-life to wake people up to the

nature of their minds. It was one of many lectures she has attended about preventing

burnout in the workplace by finding spiritual meaning in medicine again. Nurse

Ampha looks exhausted from a long work shift in the understaffed hospital, but her

eyes light and her posture rights when she talks about Jaes mother and the coming

final moment. As she later explains to me, helping patients face the end of life is

inspiring and energizing. And Jae, by denying her mother explicit knowledge about

her pending death, is also denying Nurse Ampha the opportunity to play this role at

the end of the dying womans life.

Several months later, Nurse Ampha introduces me to another patient, Mali, a

woman dying of pancreatic cancer. Mali not only knows her diagnosis and

prognosis, she has also chosen not to take any opiate pain medications, to use

mindfulness meditation to control her pain while she dies. She has a glow to her,

114 Cult Med Psychiatry (2011) 35:113133

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both from her jaundiced skin and from her gentle smile. As long as she meditates

around the clock, she feels no pain, or more precisely, her body has pain, but her

mind does not suffer from it. But as soon as she loses her mindfulness (sati),

usually while talking to me or to the doctors, her pain comes crashing back upon

her.When I ask Nurse Ampha about this case, she says, finally, a true end-of-life

patient. Later, she explains, I am happy to be a nurse because it is an opportunity

to become the right kind of person. Nurses get to see suffering (khwm thuk) every

day. We have more opportunity than any other profession to face suffering, to

understand nature, and to receive merit. She imagines her role as a health care

worker as that of a spiritual seeker who uses the experience of the end of life to

attain wisdom. This figure, the seeker of wisdom, is not of a clinician with technical

nursing skill or with astute powers of observation, but someone who can use

experience of the human condition to transcend suffering.I have always been interested in meditation, Ampha explains to me one day in

the hall. In Buddhism, we teach that life has suffering in itwe are all born, get

old, have pain, and die. These are natural things. If we dont accept the truth of

nature, we will suffer and be without peace when we die.

I ask her, So have you always wanted your patients to know their prognosis?

She thinks for a moment. No, she says. It is a new thing. I first heard about it

from a lecture by Phra Paisal Visalo. He is the expert on facing death. There are

trainings, too. This is not the first I have heard of the famous monk Paisal Visalo, a

disciple of the great teacher Buddhadasa, and now a proponent of a Buddhismengaged with the social ills of modern Thai societyconsumerism, inequality, and

social change. Somehow, being an expert on facing death has become part of this

agenda.

Introduction: From Outward to Inward Gaze, from Death

to End-of-Life

In the past several years, Ampha has undergone a transformation. She has developed

a new kind of clinical subjectivity in which the purpose of clinical practice is to

face suffering in order to become the right kind of person. This is very different

in concept and practice from her previous way of being. Prior to thisin nursing

school, and in most of her life practicing nursingher career was solely about her

patients, not about herself. She had an outward gaze. Now, she is hoping to use

clinical practice to gaze inward, to become a moral being.

Amphas transformation raises an epistemological question: what do we assume

clinicians to know and how do they acquire this knowledge (Foucault1963)? It also

raises a hermeneutic question: what technologies do individuals use to build inner

meaning and identity (Foucault 1984; Foucault et al. 2001)? For most scholars of

clinical training and practice, the motive force between knowledge and meaning is

in the direction of knowledge. The purpose of self-cultivating practices in clinicians

is to produce an assumed incontrovertible knowledge derived from experience and

observation, what Foucault termed the clinical gaze. In his own words, The

Cult Med Psychiatry (2011) 35:113133 115

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clinical gaze is a gaze of concrete sensibility, a gaze that travels from body to

body, and whose trajectory is situated in the space of sensible manifestation. For the

clinic, all truth is sensible truth (120) (Foucault 1973). The gaze is the gaze

precisely because it is outward, and because it is concrete and sensible. Clinicians

only cultivate their inner selves in as much as it helps them observe, diagnose andcure the other.

In this article, I describe the emergence of a form of clinical subjectivity in

Thailand that turns the gaze inward instead of outward, in which the usually

assumed relationship between knowledge and self-cultivation is inverted. Nurse

Ampha gazes outward to craft her inner self. And as I hope to show, this inward

clinical subjectivity applies not only to health care workers, but to patients as well.

In fact, it unites them in a single identity, a single gaze. Ampha wants to face

suffering in order to become the right kind of person, and she wants this for her

patients as well.This new form of clinical subjectivity is coincident with a related transformation:

the appearance of a category of time and experience, the end-of-life. Death and

dying have long been core concerns of Buddhist philosophy and practice, but death,

as an interval, has been cast as a moment in time more than as a period to be

experienced and explored. The Pali Canon (the core Theravada Buddhist text)

teaches that death serves several functions: as something to study, by meditating on

corpses and decay, in order to understand the transience of all things (asuph-

aphwan) (Keyes 1987; Klima2002; Vajiranana Mahathera 1975); as a looming

and unpredictable threat that should motivate urgent spiritual practice before it istoo late (maranasati) (Panyapatipo2007); and as a critical moment in which ones

mind-state partially determines ones future rebirth (Keyes 1987; Payutto 2003).

Buddhism has long been focused on death as a concept to be contemplated or as an

important event that takes place at a single moment in time.

In the last 20 years, however, a new concept has been built in Thailand, a concept

of a period of time known as the end-of-life, an elongated interval that is to be

experienced, to be approached through a particular form of subjectivity. This term is

sometimes used in English, highlighting a global component to its origins.

Sometimes it appears as a relatively new phrase in Thai (raya sut thi khong chwit,

lit: the last interval of life) (Komatra2007). This new concept is the result of a series

of social forces and political events that have placed death and dying at the heart of

debates about modernity, consumerism, autonomy, and social change in Thailand.

And as I hope to show in this article, these debates have given rise both to a new

category of end-of-life and a new type of clinical subjectivity, an inward gaze.

It is no coincidence that Ampha has chosen a dying patient as the site for her self-

transformation. This is what leads her to look for a real end-of-life case. There is

something about this new category end-of-life that provides the best opportunity

to face suffering. The controversy about death in Thailand has generated a

re-imagining of clinical practice as a path to spiritual salvation, a path to becoming a

certain kind of human who faces the truths of suffering to understand ones own

mind and access its true, liberated nature.

In the first portion of this article, I trace the historical and political roots of this

novel form of clinical subjectivity. I begin with the history and politics of death and


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dying in Thailand, including a set of ethical frameworks that patients and clinicians

have historically used to approach the end of life, as well as recent shifts in these

frameworks due to events that have brought death and dying to the forefront of

national debate. This contextual history is a brief summary of a more detailed study

of the end-of-life experiences of thirty patients in Northern Thailand, with resultspublished elsewhere (Stonington2009). This summary is necessary for understand-

ing the context from which new forms of clinical subjectivity are arising. In the

second portion of the article, I describe the novel form of clinical subjectivity that is

emerging in Thailand around end-of-life care, based on ethnographic data from

clinical training seminars, policy documents, and government meetings. I describe

its conceptual components, including a novel conception of what it means to be

human, as well as a series of technologies of the self used to craft this humanity,

including confession, facing suffering, and untying knots in the heart.

Dying in Northern Thailand

Northern Thailand is home to great contradictions of medical modernity. It has

remote villages with dirt roads and farming economies alongside ultra-high-tech

urban hospitals with fully equipped intensive care, radiology and surgical

capabilities. It has physicians and nurses highly skilled in scientific knowledge

and experimental rationality as well as animistic and Buddhist spirituality. It has a

well-renowned universal health care system, so that individuals who may have hadlittle access to modern medicine out in rural villages may suddenly find themselves

receiving high-tech health care when they fall seriously ill, usually at the end of life.

A common figure of this cohabitation of pre-modern and modern is the rural farmer

who ends up in the intensive care unit at the end of life, strapped to cybernetic

machines of artificial life.

Prior and concurrent to the emergence of the novel form of clinical subjectivity

that I present in this article, dying in Northern Thailand has been governed by two

ethical frameworks. First, family members have to pay back a debt of life (pen n

chwit) to their elders, usually today by providing high-tech hospital care. But even

more essentially, children must give their parents heart power or encouragement

(kamlang hai), a form of emotional support that fills up the heart (hai kamlang

hai) and prevents a worrying mind (khit mk) from harming the body. Since a

worrying mind harms the body, diagnosis and prognosis are often kept from the

patient, to protect them from the harmful effects of suddenly running out of heart

power (mot kamlang hai), which can shock someone to death. For a fuller

description and analysis of this ethical framework, see (Stonington and Ratanakul

2006; Stonington2009).

A second ethical framework takes over in the last hours of life, when it is

important for a dying elder to take her last breath at home. The place where body

and mind separate is vital to the spiritual outcome of the individual. Some feel that

hospitals are bad places to die because they are haunted; thus hospital death risks

creating an unhappy spirit or a ghost instead of a beneficial rebirth. In contrast, the

home is an ideal place to die because it is sacred and contains familiar items that put


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individuals at peace at the moment of death. For a more detailed description of this

framework, see (Stonington2009).

The key to these two ethical frameworks is that death is conceived of as taking

place in a moment (the last breath taken at home), and not as requiring particular

knowledge or subjectivity (not knowing that one is dying or why). In fact, thepurposes of the debt of life and heart power are to push life exchange until the last

minute, to make death as short a part of existence as possible, and to avoid knowing

that death is coming for fear of hastening death with that knowledge.

This approach is not contradictory to that found in thousands of years of Buddhist

doctrine, although the focus is very different. A prominent monk in a forest

monastery in Thailand summarized the traditional focus on death in Buddhist

doctrine to me as follows: Death serves two functions in Buddhism. It is a source

of useful disgust and useful fear. The disgust is an antidote to lust; the fear is an

antidote to laziness (Phra Dhammavidu, personal correspondence, Wat SuanMokh). Death gives rise to repulsion that teaches us the impermanence of all things

and thus liberates us from ego, lust and desire; and it is a source of fear about the

brevity of our lifetime and thus as an incentive to diligently meditate with the time

that remains.

Each of these perspectives culminates in a particular form of meditation. Most

Thais have been exposed to asuphaphwan, one of the five major categories of

Buddhist concentration meditationa meditation on foulnesses, focused on

contemplating corpses at ten different stages of decay, described as bloated, livid,

festering, split, gnawed, mangled, mutilated, blood-stained, worm-infested, andskeleton (Klima2002; Payutto2003; Vajiranana Mahathera1975). But much larger

in public consciousness is the mindfulness of death,maranasati, one of the ten core

mindfulness meditations (anusati). One popular text explains that mindfulness of

death is a cure for the curse of heedlessness. When people are young, it explains,

they mistakenly believe they are young forever. They misunderstand the nature of

human existence because death might come at any moment. Our bodies are

impermanent and their nature is to fall apart. Thus we should practice meditation

and acquire wisdom, almost as an emergency in the present moment (Panyapatipo

2007).

A third major feature of death in the Buddhist canon is as a critical component of

transition to rebirth. The content of ones consciousness (winyn) at the moment

of death is a large part of the karma (kam) that is still stuck to a persons

consciousness, and it is this karma that causes the consciousness to be reborn again

into a new body. Because of this, the narrative biographies of many great spiritual

leaders include analyses of their last moment of life, as a kind of window into their

level of spiritual attainment (Keyes1982).

Prior to the emergence of the form of subjectivity I describe in this article,

death has largely been emphasized as a concept to be contemplated by the living

as a tool for spiritual practice and also as an object, a moment in time. The

wisdom that could be attained from death had little to do with the actual process

of dying itself. One could think about death to fight lust, or to become motivated

to practice. But of the experience of dying, only the exact moment of death

mattered.


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Politics, Death, and Subjectivity

In the last 20 years, political events have destabilized this understanding of death

and made room for new ways to think about dying. In 1993, the famous Buddhist

monk Buddhadasa died of a stroke. For many great monks in Thailand, the mannerof their death becomes an important component of the legacy and biography they

leave behind, often leading to sainthood or mystification of their spiritual powers,

sometimes reaching beyond spiritual issues to broader social debates (Keyes1982).

Similarly for Buddhadasa, a set of historical coincidences occurred around his

death, pulling a host of political and social issues into the meaning of his death.

Buddhadasas teachings focused on the concept of nature, of understanding the

reality of life and death (Buddhadasa 1956; Santikaro 1993; Buddhadasa and

Dhammavicayo1994). He was highly critical of the Thai Buddhist clergy (sangha)

and the increasing consumerism of Thai society. He had written an advancedirective, formerly an unknown and unfamiliar concept in Thailand, stating that he

wanted to die peacefully in his forest monastery. But upon his stroke, he was rushed

by doctors and disciples to a large academic hospital in Bangkok, where he spent

several weeks in the intensive care unit (Jackson 2003). Meanwhile, controversy

raged in the Thai press about autonomy, knowledge, and self-determination, using

death and dying as the focal point. Many argued that the choice to ignore the great

teachers wishes to die a natural death unveiled misguided forces in Thai society:

the use of spiritualism and social hierarchy to trump individual choice, and the

worship of high-tech materialism over the nature that Buddhadasa had emphasizedthroughout his life (Prawase 1993; Anothai2002).

His death was also coincident with a complex and important political crisis in

Thailand. In 1992, a series of pro-democracy protests and subsequent massacres by

the Thai military led to an outpouring of debate about democracy, human rights,

autonomy, religion, and modernization. Buddhadasa died shortly after this, in the

midst of political and social theoretical controversy. As a result, reformists latched

on to Buddhadasas death as a site for critiquing Thai society as a whole. Death and

dying were taken up as key examples of the breakdown of democratic imagination

in Thailand, of the inability of Thais to determine their own destinies. Although

Buddhadasas death alone likely would have raised complex political issues because

of his teachings and important social role, the timing of his death amplified its

political and social implications. Death and politics became inseparably mixed [for

analysis of this political history, see (Stonington2009)].

Part of this political crisis involved the health care workforce. Doctors and nurses

had long been seen as powerful holders of moral authority in Thai society. But

health care workers had come under the same fire for consumerism and materialism

as monks. Because of this, and because of challenges in training, development, and

paying salaries, public hospitals had long struggled to fill the ranks of health care

workers. Long hours, low pay, and the new attractions of the private sector were

luring good students away from health care (Komatra 2005; Suriya et al. 2005).

A small minority of clinicians, public-service rural doctors and nurses, had been

intimately involved in the politics of protest that led to the overthrow of military


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rule. These activist clinicians emphasized health care as a key sector of Thai society

requiring reform in the atmosphere of social transformation occurring at the time.

Buddhadasas death spurred a critique of biomedicine and the notion of good

death. And because of other events at the timehealth care workforce crisis,

criticism of the Buddhist clergy, and democratic reform politicsa broad set ofother political issues became wrapped into Buddhadasas death. As I argue in this

article, the avenue that reformists envisioned out of the crisis was by constructing a

new form of clinical subjectivity, a way to get both health workers and patients to

turn away from their outward gazes and look inward instead. Part of this

transformation included the introduction of a new conceptual category, the end-of-

life, an interval of time expanded beyond the momentary nature of death, a period

of time that should be experienced, studied and used to attain wisdom.

Facing Death

In order to understand the nature of existence and be free from suffering,

explained Phra Paisal, the most important thing is to face reality. This is true in all

things. Therefore, the first requisite for having a peaceful death is to accept death, to

know and accept that one is going to die.

It was early morning, before the opening activities on the third day of a 4-day

training entitled Facing Death Peacefully (phachen khwm ti yng sangop),

hosted by Phra Paisals Buddhist organization, the Buddhika Network (Paisal andBridaa2006, Paisal2006, Kanajariyaa2006). Phra Paisal and I were sitting out on a

veranda overlooking a lush garden at a conference center outside of Bangkok. I had

come to the training looking for the source of Nurse Amphas desire to use end-of-life

care to become the right kind of person. Though I was a participant in the training, I

asked for an audience to clarify some of the history and agenda of the movement. Phra

Paisal was one of Buddhadasas foremost disciples. After Buddhadasas death, Phra

Paisal has spent his career attempting to transform Thai society toward Buddhadasas

spiritual vision. He balances a desire for a low-profile, humble monastic existence

with the public face required for addressing broad social problems. His programs are

far reaching, including teaching and writing on peace and non-violence, ecological

preservation, religious reform, and volunteerism. Perhaps the most popular of his

programs is this one on facing death, largely brought into public awareness because of

his translation into Thai of the Tibetan Book of Living and Dying.

The training, as well as the broad social agenda of his organization Buddhika, can

all be understood via the word pachen, to face or confront. Buddhika was formed in

2001 by Phra Paisal explicitly to fill a vacuum that was being left by the wane of

traditional religious authority in Thailand. People had begun to lose faith in the

conservative Thai sangha. According to Phra Paisal, this was because the clergy

remained locked in a ritualistic spirituality based on distant and inconceivable

enlightenment, divorced from the real problems of modern life. Swept up by

globalization and social change, people were quickly leaving the clergy behind and

turning to alternative forms of spirituality. Phra Paisal felt that many of these forms of

spirituality were thinly masked forms of consumerism (Trungpa and Baker 1973),


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in being a nurse and interacting with patients. When she told me this, I was unable

to contain my surprise about such a broad social program coming from a public

health bureaucracy.

Why is HA interested in this? I asked.

We are in a crisis in healthcare in Thailand, she explained. Everyone is afraidof being sued. We are understaffed and overworked. No one wants to be nurses and

doctors anymore. They want to be business people. We need a way to make

healthcare attractive again.

Seeing my interest, Ampha gave me the small book on the philosophy of

humanized health care produced by the HA organization (Piyasagol 2005). The

introduction contained the following explanation:

Being human (manut), at its profoundest level, is the state of entering truth

(khwm hing), goodness (khwm d) and beauty (khwm ngm). Other

animals (sat) cannot enter this state. Even angels (thwad) cannot enter this

state. The ability to enter truth, goodness and beauty is a characteristic only of

humans. And when a human enters truth, it gives rise to freedom (isaraphp),

supreme health (sukhaphp lonlua), and love for humanity (phan manut) and

all existence (thamacht thang man).

If health workers enter into being human, it will have several effects. First,

health workers themselves will have abundant happiness (khwm suk yng

lonlm). Now they are all stressed, work is hard, and they cannot take it.

Everyone is afraid of being sued. If they can enter into the heart of humanity,

they can reduce and eliminate their stress and be truly happy. []Second, patients and families will be happy because they will have contact

with health workers who have entered into truth, goodness and beauty. []

This has been shown scientifically to help cure disease. []

What is the best way to enter truth? To encounter suffering (prasop khwm

thuk). Healthcare workers have a great opportunity to encounter suffering

every day.

This document is a manifesto for the reform of medicine, beyond the modern,

into the heart of humanity (khwm pen manut). The word manut is difficult to

translate, and human is a complicated choice. It calls to mind the rich

conceptualization of anthropos, explored most extensively by Paul Rabinow

(Rabinow2003). In English, human has contradictory undertones. If one appeals

to a common humanity, human is infused with ethical goodness that transcends

the animal existence of man. But other uses, like: Oh, well, you are only human!

imply the flaws inherent in being the creatures that we are. In all, human stands in

for a profile ofwhat we are, our condition as moral beings.

Manutis slightly different. In daily speech, it is often used interchangeably with

khonperson. But in philosophy and religion, manut is opposed to khon, and is

used precisely to differentiate ordinary people from those individuals who have

engaged in enough introspective spiritual practice to encounter and embrace

wisdom. In fact, many of my interview participants felt that the daily usage of

manut as similar to khon was actually a slippage into Thai language from the

English use of the word human, and that the more authentic meaning was the


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way that manut appears in religious texts. In Buddhism, humans have a telosa

potential state of perfection, and thus an ultimate goal of livingin the form of the

enlightened being (uttarimanutsatam)which translates literally as a human (manut)

who has become so aligned with the wisdom of Buddhist teaching (thamma) to be

freed from the cycle of suffering.Manut, then, is a person (khon) walking the path tohumans telos, interested in gaining the wisdom that will take her there.

Already, out of this basic explanation of humanity, a kind of ethical figure begins

to emerge, a new imaginary of a clinical subject. Humanized health care proposes to

reform medicine by creating an idealized image of the health care worker who

pursues wisdom through the practice of medicine. Wisdom is further detailed as

consisting of truth (khwm hing), goodness (khwm d) and beauty (khwm ngm),

which in turn have complex definitions. Humanized health care contains a complete

ethical framework, the center of which is manut, the human, whose purpose is

primarily to face and understand the truth.This figure of the health care worker as seeker of wisdom proposes a flip in the

clinical gaze. Instead of crafting oneself to gaze outward, to confidently know

concrete facts about anothers body in order to treat it, the gaze is inverted. One

gazes outward to face truths that will craft an appropriate inner self. The reward for

practicing this kind of medicine, according to the manifesto on humanized health

care, is abundant happiness. Or in the words of Nurse Ampha, it is finding true

value in ones occupation. The result is a new kind of clinical subjectivity.

These philosophies have found their way into the mechanics of medical care,

particularly into the rapidly growing field of palliative care. In the 1970s, this newinternational medical field emerged in Western countriesa modified version of

hospice, emphasizing hospital-based and doctor-dominated expertise in care of the

dying. This movement accelerated with the AIDS epidemic and a need for expertise

to deal with the medical, spiritual and administrative consequences of a dramatic

increase in the death of young patients in hospitals. Also core to the disciplines

development were cancer care and the increasingly complex decisions required with

evolving cancer therapies (Clark2007).

The field arrived in Thailand in 1992 in the hands of Dr. Temsak Phungrassami,

a radiation-oncologist from Songkhla who trained in Palliative Care in Australia and

returned to teach the discipline in Thailand. He began by translating his Australian

mentors handbook on Palliative Care (Maddocks 1992) into Thai. After Buddha-

dasas death in 1993, Dr. Temsak began to include a book about the teachers death

in his courses (Prawase1993). Over the following 10 years, the discipline took off

dramatically in Thailand (Wright et al.2010). Those hoping to design palliative care

programs looked to Dr. Temsak as the source of wisdom and practical experience.

Buddhadasas death, and the social issues surrounding it, became central in the

teaching agenda of the evolving discipline.

In the mid 1990s, a set of philosophically minded doctors at the Ministry of

Public Health started a network of people interested in caring for patients at the end

of life. The motivation for those involved in the network was similar for allfrom

doctors, nurses, and alternative medicine practitioners to monks and individual

meditators.


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Why did you get involved in this field? I asked Dr. Sakon Singha, President of

the palliative care network at the time of interview in 2009.

Originally I trained as a surgeon, he explained. But I was not happy. I was just

putting people back together, like a mechanic. I thought that maybe I wanted to be a

scientist, so I went to study a PhD in transplant immunology in the UK. But I wasstill not happy. When I returned from England, I saw Dr. Temsak, who had started

working in end of life care. He was so happy. And I thought to myself, I want what

he has. I dropped everything and started studying end of life care with Temsak.

Since then, I have been happy. I am lucky to spend every day thinking about the

truths of nature.

Thus two figures emerge from these movements, from Buddhika and Humanized

Health Care and the new medical discipline of Palliative Care. One is the patient

who faces reality, and by so doing understands the nature of existence. The other is

the health care provider who encounters suffering as an opportunity to acquirewisdom. These two figures push on one another. They co-create. As nurses and

doctors embrace the figure of the healer with true value, they begin to push patients

to know about their deaths, to bring medical realities into the open so that their

spiritual correlates become available for discussion. As patients embrace the figure

of the patient who seeks wisdom through experience, they begin to push on their

doctors and nurses to become the kind of practitioners who can discuss death openly

and with spiritual wisdom. The dialectic interaction between these two new and

idealized ways of being creates a healer-patient relationship that is full of persuasion

and motion.

A Knot in the Heart

This motion can be seen in one of Buddhikas central conceptual technologies for

facing death: the knot, or pom. In general Thai, pom can be used to refer to a

literal knot, but it appears more often in idioms for social or psychological

complexity.Pom panh, literally knot-problem, means the heart of a situation, the

part of something that must be loosened or untied for a problem to be solved. In

psychology, pom means a psychological complex. In Buddhikas lexicon, pom is

imported as a specific technical term to describe something that prevents peaceful

death, a knot of mental worries that ties up a persons mind, preventing her from

letting go and moving through death with an empty heart. The term was invented by

Nurse Fong, a core teacher in the Facing Death workshops and the senior nurse in

Dr. Temsaks department of radiation oncology in Songkhla. Nurse Fong developed

the term over dozens of years caring for terminal patients to describe the obstacles

she observed in peoples lives and minds that prevent them from letting go of life

peacefully.

I started using this word maybe twenty years ago, Nurse Fong explains to those

who come to learn about death from her. I almost died myself. I didnt want to die

because I was worried (hang), I still had something [in my heart]. I was

unconscious, but I could hear everything. And I made a contract with the Messenger

of Death (yomatt) that I would return and understand what was in my heart. And so


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I started working with dying patients. She made a commitment with Death to come

back and understand pom, the obstacle that sits in ones heart at the edge of death,

blocking peace.

Nurse Fong has built the concept ofpom out of so many peoples stories that by

now she thinks only in stories. The word itself is an accumulation of a thousandintimate moments trying to push through the wall at the edge of patients deaths.

Each time someone asks for a definition ofpom, she reveals one of these moments.

She never forgets anyone, a Buddhika training leader told me, she thinks with

stories, and she never tells the same one twice. She must have hundreds

I recorded dozens of these hundreds, myself. Here is one:

One patient I remember fell from a truck while at work and lost 97% of his

brain function. The patient cried when I said the right thing I figured out his

pomand went straight to the right point, and he cried tears even though he was

unconscious. But before I could talk about his pom, I had to find out what it

was from his relatives. I asked his wife what he was like before he was

unconscious. One day, before the accident, he had said to his relatives that he

wanted to make merit (tham bun) by making an offering to monks

(sangkhathn), and that he missed his son, who was paralyzed.

I was called to a palliative care consult because his wife wanted to remove

the endotrachial tube [respiratory life-support]. But we could not remove the

tube, because it is unethical. So I went to the patients room to ask his wife

why she wanted to remove the tube. I asked the wife, and she said that she

could not care for her husband because she had to take care of the paralyzedson as well. She wanted to sacrifice her husbands life for her sons.

I didnt think that he could live much longer, because of the brain damage.

So I told the wife: you must be prepared, your husband may die soon.

I told her to make an offering to monks in her husbands stead. When she

was done, I told her to go to her husband and tell him that she did this and

that he need not worry about it anymore. And I told her to tell the husband

that he does not need to worry about his son anymore because she is taking

good care of him. And then we arranged for her to bring the paralyzed son

to the hospital to tell his father in person that he is okay, to say I amhealthy and strong. You dont have to worry. All of these things were to

untie the patients pom. And when all of this was done, the patient cried,

even though he was unconscious.

[] I told the patient that he had nothing left to worry about, so he should

think about the yellow edge of the monks robes, to hold on tight to the robe.

[The monk will lead him to heaven]. I told him: if your physical body

(sangkhn conditioned thing) cant hold on, just let it go, and your mind

will follow it. [] And the patient cried again, and died in peace very

quickly. We were surprised because a few days earlier he was completelyunconscious and would not react to anything. And now, he cried tears in

response to what I said, and died peacefully.

Pomis the knot of worries and fears that ties a person to this life and that causes

the mind to hold on. It resides within a persons consciousness and radiates outward


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into their attachments in the external world. It is a mystery, both seen from the

outside and from the inside, and it must be investigated, understood and then

released.

Nurse Fongs stories all involve similar elements. Patients shed tears once their

pom is uncovered and untied. There is often a performance by those who love thedying patient, a performance that goes straight to the right point to release the

knot. The pom is specific more than it is generalit is about the particulars of a

persons mind and situation. The pom is like a tense muscle, wrapped around the

mind of the dying patient. One must simply find the right trigger point, press it, and

then watch a wave of relaxation open into the patients mind.

Buddhika uses this concept to help train people to face the truth of human

existence at the end of life. It combines the knot (pom) and the concept of facing

(pachen) to stretch the moment of death out until it includes an experience that can

be faced. These technologies are designed to transform death into an experience thatcan be engaged practically. Thepomis the name given to the aspect of inner identity

that must be transformed with this new form of clinical subjectivity. We turn

outward to the truths of suffering, to the nature of existence, in order to then turn

inward to untie the knots in our own hearts.

Confessional Technology

On the first day of Buddhikas training, I am still disoriented. My Thai isinadequate. Standing in the hall before the afternoons activities, I ask a participant

to tell me what is happening next. She is a nurse from an intensive care unit outside

of Bangkok. Thai people are not used to sharing about themselves with strangers,

she says. This is a big problem. How can we care for people at the end of life if

were afraid to ask about intimate things? How can we know what to ask if we dont

know how to share ourselves? We need to learn to break this habit in Thai culture.

The next exercise is about this, about listening and telling.

One way to release a pom is to talk about it. If we tell our story to others, we

cannot trick ourselves into hiding from aspects of reality. Thus, Buddhika employs a

series of confessional technologies.

In the conference room, we break up into pairs, and engage in deep listening,

staring into our partners eyes for long uninterrupted minutes, and then listening to

them tell a story without breaking eye contact. Following this we sit in a larger

sharing circle to tell stories about mistakes and sorrows from our past.

As I sit down in the circle, I think of the myth that foreigners learn about Thai

culture that they should not expect ever to get close enough to someone to hear their

emotions. And I think that I have never seen anyone cry in public in Thailand.

I have sat in open patient wards and watched families swallow unbearable tragedy

and keep face for the people around them. But in our sharing circle, as people begin

to tell their stories, the sorrow becomes thicker and thicker in the room. A woman in

her thirties tells about her alienation from a schizophrenic father. A politician tells

about relentless pressure from her parents to succeed, with the stress of their

judgment weighing on her every hour and every failure. A doctor tells about losing


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his little brother to cancer, about holding him by the shoulders in his hospital bed as

he died. At points, there is uncontrollable crying. At the end of our sharing, Phra

Paisal summarizes the process we have just been through:

When we talk about our selves (tua ton

), it is difficult because we slam upagainst the reality of the self that we are in this moment and the selves that we

have been before. Often our suffering is not from fighting with others, but

because we fight with ourselves, because we cannot accept an aspect of who

we are or used to be. We have all made mistakes and suffered losses in the

past. If we look deeply at our mistakes, we will see that they are not our self in

the present moment, they are part of past selves. We misunderstand them to be

part of us. Talking about ourselves shows us this aspect of reality, and if we

can accept this reality as it is, we can reconcile (khun d) or make a truce with

(sangop sk) or befriend (pen mit) our former selves. This will increase our

happiness, our steadiness and harmony in life.

When we arrive at the end of life, if our present self can get along with our

past selves, it will help heal us, help sustain us until we pass the end of life

moment. But if we cant get along with our past selves, they may return to

demand payment for moral debts (thuan bn khn) or haunt us (lk ln) and

avenge us (ke khen) in our last moments. This is a terrifying idea. We need

to befriend our selves, before we get to the last moment, or it will come and do

us violence (ruk rn) in our weakest moments, especially at the moment when

our breath stops. We must have the bravery to open and look deeply into our

selves, to accept (ym rap) and face (pachen) this truth.

As Phra Paisal explains, the moment of death, though important, is not enough.

There is work to do in the period of life that precedes death, in the content of the

fears and challenges to character that arise during the process of dying. During this

period, we must have the bravery to face the truth and investigate it as material for

understanding nature and acquiring wisdom.

Confession is one of the technologies of the inward gaze. We must look outward to

encounter the truth of nature, the truth of suffering. We must then use this experience to

turn inward and craft our inner self so as to become free of suffering. And again, this

process is dialectic between clinician and patient. We not only must become clinicians

who gaze inward, but we need to elicit other peoples knots, other peoples obstacles,

and help them to gaze inward. And in turn, by revealing their stories, we will face the

truths of nature more intimately, and in turn gaze inward more deeply.

Imagination as Partial Experience

Confession as a tool for revealing the disconnections between our past and present

selves does little, however, to prepare us for the actual experience of our end of life.

How can we prepare in advance for an experience we have never had? To do so, the

Buddhika trainings use imagination, enactment, and encounterstools designed to

use the important period of the end-of-life as an experience that contains the truths

of nature.


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17/21

of gaze is this? We are imagining ourselves in the midst of the suffering that is

inherent in the nature of human existence, and we are using the vivid experience of

this suffering to understand our own minds and to free ourselves from illusion and

pain. These clinicians are not training in empathy to better understand patients

and treat them more effectively; they are using their patients suffering toexperience a simulation of their own suffering, and then facing that suffering to craft

an inner self. They are using patient experience to turn themselves into humans

(manut), or as Nurse Ampha says, into the right kind of person.

Finding Reality to Face

Thot and I walk through the crowded halls of Nakhon Pathoms Provincial Hospital,

the central public hospital for a province neighboring Bangkok. We have come hereon a field trip from the Confronting Your Death Peacefully training to practice our

new-found skills on real patients. Thot is walking slower and talking faster than

usual, and from this, I know that he is nervous. He has also reverted to teaching me

about Buddhadasa, a familiar and comforting topic for him. Thot is my roommate at

Buddhikas training. I know from long evening chats that his goal here has little to

do with learning to care for dying patients. His impoverished childhood was fraught

with suffering and his family was full of mental illness. Thot threw himself into

studies, became a dentist and devoted his life to making money. But the sorrows and

insecurities from his childhood plagued him, and the more money he made, the lessstable and happy he felt, until he finally turned to religious teachings to learn how to

free himself from suffering. In his meditation practice, he discovered mostly fear,

a fear of death and of connecting with other people. He came to the Buddhika

training to learn to face and release his fear, and he hopes that after the training, he

will be able to use his work as a path to spiritual freedom.

Now we are walking through the hospital, with its throngs of patients and

families and its open-air gardens, and I can feel the fear mounting in Thot as he

walks next to me. Since my medical Thai is still awkward, we have agreed that

today I will just accompany and watch. This makes Thot feel more comfortable,

because he is worried I will accidentally open a Pandoras Box. But as he later

explains, it is also terrifying, because he needs to run the show.

The head nurse of the neurological ward greets us and tells us sparse details about

the patient we were going to visit: She is hopeless, with a degenerative neuro-

muscular disorder, but no one knows how long she has to live. Also, the patient does

not know that she is dying, so dont talk about dying. After this description, the

nurse tells us the room number and turns back to her work.

The patients door is open. We look in on a short hall that leads to a hospital bed

and a mat rolled out on the floor beside it. A middle-aged woman, with a girlish face

and a pear-shaped body steps up expectantly from the floor to greet us. Thot steps

in ahead of me, his nervousness exploding out of him, and begins speaking rapidly.

He says various iterations of: We are volunteers. Were here to give moral support

(hai kamlang hai). The patient is connected to a respirator, but not through the

mouth, through a tracheotomy. The middle-aged woman introduces herself as the


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patients daughter, and says that her mother can understand things, but cannot talk

because of the respirator. We sit and say hello to the patient, who is lying still,

strapped into the machines of modern medicine. She smiles broadly back at us. Over

our shoulder, the daughter tells us that they want to cure her mothers disease and go

home. Thot, clearly flustered by the patients inability to talk, tentatively reachesinto touch the patients hand. The daughter smiles at this and tells Thot that her

mother is unable to feel her body below the neck.

At this piece of information, Thots legs begin to shake. For 2 days, we have role-

played about how to talk to patients and how to touch patients, and here is a woman

who cannot talk and cannot feel. Nothing about what is happening fits the image in

Thots mind of how this interaction should go. Clearly, there is a knot (pom) in the

room preventing the family from talking about death, but suddenly the way to

unlocking it is opaque. Thot stands up quickly, fumbling: Im sorry, we have to leave.

I am not good at talking, not good at talking. We are just here to give moral support (haigamlang hai). Nothing more. Good luck, get well. And we shuffle out of the room.

Outside in the hall, Thot is visibly upset, perhaps even angry. They did not

prepare us enough to do that. We have not been trained to deal with situations like

that. How are we supposed to find out the patients pom in there? I just dont know

what to do

But later, at dinner, his perspective has shifted. Thoughts about the experience

overflow: Being in the actual room, it was not about dying. It was about the family,

and about talking. I didnt know what to say. I didnt know them and there was no

time. I am not used to talking to people like that, about things that matter so much.How can I know what to say? I dont know how to just be in a place like that. This is

so good for me.

This last phrase, this is so good for me, strikes me. As he has explained several

times, Thots purpose for being at the training has little to do with learning to take

care of dying patients, about walking into a room of strangers and asking them

intimate and dangerous things. How, then, is it good for him?

There is something in me that keeps me from facing suffering, he explains.

I dont want to talk about it with people. It is uncomfortable. If I can understand

why, then I will understand myself.

Thot has an image of himself, of the kind of person he wants to be. This is an

ethical figure, a new kind of clinical subjectivity. He wants to be the kind of person

who faces suffering, and uses the emotions that he finds there to understand the

nature of his own mind. He wants to face the truth, and reveal that truth to others.

When he arrives at his own end-of-life, he wants to encounter the difficulties there

and study them. And now, while he is not yet dying, he wants to practice health care

in a way that brings him face-to-face with those realities. He wants to use health

care practice, normally an outward gaze, to force himself to gaze inward instead.

Conclusion: Clinical Subjectivity, Clinical Practice

In July 2007, the movements around the end-of-life in Thailand coalesced into a

conference in Bangkok with over five hundred participants, entitled Culture, Death


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and the End-of-Life (Komatra 2007). Participants were largely hospital adminis-

trators and medical educators, coming to learn palliative care to teach in their

schools and wards. The keynote talk, by the famous physician Prawase Wasi, was

about Buddhadasas death, about the rifts in Thai society that it laid bare, and the

kind of humanized medicine that it called for. Phra Paisal gave a talk about deathbefore death, about experiencing the end of life as a tool for honing the mind. Few

emotions were shared. The conference was not about grief, or about counseling. It

was about the mind, and using the experience of the end of life as a tool for

understanding it.

The centerpiece of the day was a documentary about the work of palliative care

clinician Dr. Temsaks experience caring for a cancer patient named Supaporn at the

end of her life. Supaporn had been a meditator her whole life, and when her breast

cancer came, she talked her doctors into not treating it. She decided that she wanted

to use the experience to study suffering. The tumor became necrotic, opening herchest up into a giant black hole of putrid dead tissue. She removed the bandages

frequently to study it. She studied the pain and the nausea. She did not want opiate

medications, until the end when the pain became so intense that it overwhelmed her

ability to focus on it. She had to talk her doctors at various points into the merits of

her approach. They were so used to fighting disease that they felt powerless in the

face of letting it be.

When I asked Dr. Temsak about the documentary, he said: We wanted to create a

legend (tamnn), an ideal (tua bep) of the way that someones end of life could be.

We hope that the legend will spread so that people know what is possible.This legend, of the patient and clinician who use the end of life to attain inner

wisdom, is what haunts Nurse Ampha as she stands outside her patients room,

wishing she could talk about death with the dying woman, wishing she could go into

her room and directly face the reality of suffering. The legend is also what causes

Ampha to gently push on her patients daughter, saying, maybe if you talked with

your mother, you could chant together, or is there anything your mother would

want to do with her last time if she knew she was dying? A new kind of clinical

subjectivity has emerged, a shift of the clinical gaze from outward concrete

sensibility, to inward ethical self-formation. It is a common subjectivity that unites

both patient and practitioner. And so patient and practitioner push on one another,

nudging the new subjectivity into existence. Supaporn talked her physicians into

facing suffering and looking inward; Ampha gently persuades her patients daughter

toward the same.

This new gaze is inward instead of outward, but it crafts the concrete realities of

dying in Thailand. Patients are beginning to know about their diagnosis and

prognosis and make their own decisions. Clinicians, like Nurse Ampha and the

thousands of clinicians who have attended the clinical training sessions, are shifting

their care at the end of life to reflect the need to experience suffering with a clear

mind. Doses of opiates, palliative radiation and surgery, radiographs and labsall

of these concrete technical practices are shifting their purpose toward crafting a

particular form of inner self. Or according to Nurse Ampha, they are turning toward

becoming the right kind of person, toward facing suffering and understanding

nature.


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Acknowledgments I would like to thank Preeyanoot Surinkaew, Vincanne Adams, Sharon Kaufman,

Temsak Phungrassami, Charles Keyes, Komatra Chuengsatiansup, Felicity Aulino and Phra Paisal Visalo

for comments on this manuscript. I would like to thank the Pacific Rim Research Program, the Blakemore

Foundation, the Fletcher-Jones Foundation and the National Institutes of Health for financial support.

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