The Spirit Ambulance: Choreographing the End of Life in Thailand 9780520975231

Citation preview

california series in public anthropology The California Series in Public Anthropology emphasizes the anthropologist’s role as an engaged intellectual. It continues anthropology’s commitment to being an ethnographic witness, to describing, in human terms, how life is lived beyond the borders of many readers’ experiences. But it also adds a commitment, through ethnography, to reframing the terms of public debate—transforming received, accepted understandings of social issues with new insights, new framings. Series Editor: Robert Borofsky (Hawaii Pacific University) Contributing Editors: Philippe Bourgois (UCLA), Paul Farmer (Partners In Health), Alex Hinton (Rutgers University), Carolyn Nordstrom (University of Notre Dame), and Nancy Scheper-Hughes (UC Berkeley) University of California Press Editor: Naomi Schneider 1. Twice Dead: Organ Transplants and the Reinvention of Death, by Margaret Lock 2. Birthing the Nation: Strategies of Palestinian Women in Israel, by Rhoda Ann Kanaaneh (with a foreword by Hanan Ashrawi) 3. Annihilating Difference: The Anthropology of Genocide, edited by Alexander Laban Hinton (with a foreword by Kenneth Roth) 4. Pathologies of Power: Health, Human Rights, and the New War on the Poor, by Paul Farmer (with a foreword by Amartya Sen) 5. Buddha Is Hiding: Refugees, Citizenship, the New America, by Aihwa Ong 6. Chechnya: Life in a War-Torn Society, by Valery Tishkov (with a foreword by Mikhail S. Gorbachev) 7. Total Confinement: Madness and Reason in the Maximum Security Prison, by Lorna A. Rhodes 8. Paradise in Ashes: A Guatemalan Journey of Courage, Terror, and Hope, by Beatriz Manz (with a foreword by Aryeh Neier) 9. Laughter Out of Place: Race, Class, Violence, and Sexuality in a Rio Shantytown, by Donna M. Goldstein 10. Shadows of War: Violence, Power, and International Profiteering in the TwentyFirst Century, by Carolyn Nordstrom 11. Why Did They Kill? Cambodia in the Shadow of Genocide, by Alexander Laban Hinton (with a foreword by Robert Jay Lifton) 12. Yanomami: The Fierce Controversy and What We Can Learn from It, by Robert Borofsky 13. Why America’s Top Pundits Are Wrong: Anthropologists Talk Back, edited by Catherine Besteman and Hugh Gusterson 14. Prisoners of Freedom: Human Rights and the African Poor, by Harri Englund 15. When Bodies Remember: Experiences and Politics of AIDS in South Africa, by Didier Fassin 16. Global Outlaws: Crime, Money, and Power in the Contemporary World, by Carolyn Nordstrom 17. Archaeology as Political Action, by Randall H. McGuire 18. Counting the Dead: The Culture and Politics of Human Rights Activism in Colombia, by Winifred Tate

19. Transforming Cape Town, by Catherine Besteman 20. Unimagined Community: Sex, Networks, and AIDS in Uganda and South Africa, by Robert J. Thornton 21. Righteous Dopefiend, by Philippe Bourgois and Jeff Schonberg 22. Democratic Insecurities: Violence, Trauma, and Intervention in Haiti, by Erica Caple James 23. Partner to the Poor: A Paul Farmer Reader, by Paul Farmer, edited by Haun Saussy (with a foreword by Tracy Kidder) 24. I Did It to Save My Life: Love and Survival in Sierra Leone, by Catherine E. Bolten 25. My Name Is Jody Williams: A Vermont Girl’s Winding Path to the Nobel Peace Prize, by Jody Williams 26. Reimagining Global Health: An Introduction, by Paul Farmer, Jim Yong Kim, Arthur Kleinman, and Matthew Basilico 27. Fresh Fruit, Broken Bodies: Migrant Farmworkers in the United States, by Seth M. Holmes, PhD, MD 28. Illegality, Inc.: Clandestine Migration and the Business of Bordering Europe, by Ruben Andersson 29. To Repair the World: Paul Farmer Speaks to the Next Generation, by Paul Farmer 30. Blind Spot: How Neoliberalism Infiltrated Global Health, by Salmaan Keshavjee (with a foreword by Paul Farmer) 31. Driving after Class: Anxious Times in an American Suburb, by Rachel Heiman 32. The Spectacular Favela: Violence in Modern Brazil, by Erika Robb Larkins 33. When I Wear My Alligator Boots: Narco-Culture in the U.S. Mexico Borderlands, by Shaylih Muehlmann 34. Jornalero: Being a Day Laborer in the USA, by Juan Thomas Ordóñez 35. A Passion for Society: How We Think about Human Suffering, by Iain Wilkinson and Arthur Kleinman 36. The Land of Open Graves: Living and Dying on the Migrant Trail, by Jason De León (with photographs by Michael Wells) 37. Living with Difference: How to Build Community in a Divided World, by Adam Seligman, Rahel Wasserfall, and David Montgomery 38. Scratching Out a Living: Latinos, Race, and Work in the Deep South, by Angela Stuesse 39. Returned: Going and Coming in an Age of Deportation, by Deborah A. Boehm 40. They Leave Their Kidneys in the Fields: Injury, Illness, and Illegality among U.S. Farmworkers, by Sarah Bronwen Horton 41. Threshold: Emergency Responders on the U.S.-Mexico Border, by Ieva Jusionyte 42. Lives in Transit: Violence and Intimacy on the Migrant Journey, by Wendy A. Vogt 43. The Myth of International Protection: War and Survival in Congo, by Claudia Seymour 44. Dispossessed: How Predatory Bureaucracy Foreclosed on the American Middle Class, by Noelle Stout 45. Deported to Death: How Drug Violence Is Changing Migration on the US–Mexico Border, by Jeremy Slack

46. Getting Wrecked: Women, Incarceration, and the American Opioid Crisis, by Kimberly Sue 47. Making Global MBAs: The Culture of Business and the Business of Culture, by Andrew Orta 48. The United States of War: A Global History of America’s Endless Conflicts, from Columbus to the Islamic State, by David Vine 49. The Spirit Ambulance: Choreographing the End of Life in Thailand, by Scott Stonington

The Spirit Ambulance

The Spirit Ambulance Choreographing the End of Life in Thailand

Scott Stonington

university of california press

University of California Press Oakland, California © 2020 by Scott Stonington Library of Congress Cataloging-in-Publication Data Names: Stonington, Scott, author. Title: The Spirit Ambulance : Choreographing the End of Life in Thailand / Scott Stonington. Description: Oakland, California : University of California Press, [2020] | Includes bibliographical references and index. isbn 978-0-520-34389-4 (cloth : alk. paper) isbn 978-0-520-34390-0 (pbk. : alk. paper)

Manufactured in the United States of America 28 10

27 26 25 24 23 22 21 9 8 7 6 5 4 3 2 1

20

To my parents I owe you a nī bun khun for a lifetime of inspiration and care.

Contents

Acknowledgments

1. 2. 3. 4.

Jandi: The Spirit Ambulance Arirat: Facing the Karma Master Introduction: Choreographing the End of Life Paying the Debt of Life The Spirit Ambulance Buddhadasa: Problematizing Death The New End of Life Karma Masters Coda

Notes Bibliography Index

xiii

1 9 17 27 65 102 113 132 145

151 167 183

Acknowledgments

Work on this book began a decade ago and has involved multiple phases of my life on two continents, making it impossible to acknowledge all of the kindnesses tucked into its pages. I am forever grateful to all who played a part, though I am able to mention only a few of them here. I owe a great debt to my academic mentors, whose touches can be found everywhere in this work. Sharon Kaufman has always been an extraordinarily talented and devoted mentor, showing how to move heartfully into challenging domains of human experience with brilliance and bravery. Vincanne Adams believed in me from the start and then unfailingly lent her nimble and creative mind to my work at every stage. Philippe Bourgois taught me to make ethnography a way of life. Paul Rabinow provided much of the conceptual methodology that runs through my scholarship and medical practice. Steve Pantilat and Steve McPhee took me under their wings as they helped forge palliative care in the United States. Paul Farmer intervened pivotally at every step of my career path. Arthur Kleinman has been extraordinarily generous, from career advice to notes on my work. Mary-Jo Delvecchio Good and Byron Good provided an intellectual home during my residency, which has loomed large in my intellectual development. I am also deeply indebted to my mentors in Thailand, for making my project manifest and helping me build a way of being that allowed me access to Thailand. Preeyanoot Surinkaew has long moved deftly between many roles, all with characteristic interpersonal genius, as xiii

xiv

|

Acknowledgments

friend, facilitator, collaborator, assistant, and teacher. Linchong Pothiban, of Chiang Mai University’s Faculty of Nursing, has been a guide, advocate and parent, in research and in life. Several leaders in Thailand’s public health system have invited me into their professional worlds and facilitated core components of my work. Suriya Wongkongkathep of the Ministry of Public Health has been a patron and ally, waving a wand to make aspects of my project materialize, from field sites to intellectual community to pathways through the political tangles of Thai academic medicine. He has also been a great role model for how to be heartfully effective in the world. At Chiang Mai University, Suwat Chariyalertsak (of the Research Institute for Health Sciences) and Wipada Kunaviktikul (dean of the Faculty of Nursing) were pivotal, setting up aspects of my project and acting as invaluable interlocutors. Komatra Chuengsatiansup, director of the Society and Health Institute at the Ministry of Public Health, a great charismatic leader, has helped show me a window into many parts of Thai social life. I am indebted to those involved in pioneering palliative care in Thailand, especially Temsak Phungrassami, humble world-mover, responsible for a great deal of the compassionate gaze on the end of life in Thailand. I am also indebted to the palliative care team at Prince of Songkla University, including Sakon Singha, P’Fong and P’Yae, and to Phra Paisal Visalo, who has been key to much of my research. I deeply regret that for reasons of confidentiality, I am unable name the many people at Nakhon Ping and other hospitals who took me into their hearts and busy schedules to make all aspects of this project thrive. I would particularly like to thank the nurses whose brilliance and devotion to dying patients motivated me to pursue end-of-life care. I would also like to thank Nicole Ripley, Steve Epstein and Tanapong Sungkaew for companionship and for sharing their deep engagements with Thailand, invaluable to my habilitation into Thai life. I would like to thank as well a set of scholars of Thailand who have provided close friendship, wisdom, and contributions to many aspects and iterations of my work: Felicity Aulino, Julia Cassaniti, Joe Harris, and Claudio Sopranzetti. Thank you for being my siblings in this endeavor. Many people not already mentioned above have read and advised on versions of this book or on phases of my research. Their contributions have been invaluable, and I hope I have done them justice. They include Zoe Boudart, Dominic Boyer, Mara Buchbinder, Diana Coffa, Tom Gething, Jon Goldman, Anita Hannig, Seth Holmes, Ieva Jussionyte, Jen Karlin, Rebecca Katz, Stephan Kloos, Charles Keyes, Olivia Para,

Acknowledgments

|

xv

Joe Stoller, Na’amah Razon, Beatriz Reyes-Cortez, Liz Roberts, China Scherz, Janelle Taylor, Megan Valentine, Katrina Whaley, Erick White, and the STS workshop at the University of Michigan. I would also like to extend particular thanks to Nathinee Chucherdwatanasak, whose editorial work and insights were pivotal to this entire book, and especially the archival portions. Many sources of financial support have made this project possible. I am indebted to the Blakemore Freeman Foundation, which has taken the role of patron far beyond financial support—through intellectual engagement, logistical support, and the great breadth of its network. Other sources of funding that contributed to this book include the FletcherJones Foundation, the Pacific Rim Research Program, and the U.S. Department of Education’s Foreign Language Area Studies Program. I am also indebted to the Medical Scientist Training Program, whose goal of crafting physician-scholars I hope to have manifested in this book. I am also grateful to those in the medical residency program at Brigham and Women’s Hospital and the Department of Global Health and Social Medicine at Harvard Medical School who facilitated my time as a physiciananthropologist, including Marshall Wolf, Joel Katz, Chuck Morris, Paul Farmer, and many others. I am also grateful to the Institute for Humanities at the University of Michigan for time to finish this project. In the spirit of this book, I would like to thank my parents, who have supported every phase of its development, acting as incubators, editors and coaches. I owe them a debt of life and a nī bun khun, neither of which I will ever be able to repay. And I would like to thank my creative and brilliant brother for being a partner in this debt and in so many other life projects. Finally, I would like to thank my wife Irene for embracing our journeys through Thai life-worlds, for devoting her genius, courage, and her ability to draw me deeper into feeling and living my work. And I would like to thank my daughters Leela and Paloma, for enthusiastically embracing life as anthropologists, and reminding me that curiosity is the core wisdom in a life of joy.

Jandi The Spirit Ambulance

“We have to make it home,” said Jandi’s son, who sat across from me as I pumped oxygen into his mother’s lungs to keep her spirit attached to her body. We were seated in the cab of an old pickup truck outfitted as an ambulance. Jandi lay unconscious on a mattress, a blood-filled endotracheal tube emerging from her mouth, connected by a balloon pump in my hand to an oxygen tank at the front of the cab. We struggled to stabilize ourselves as the truck tossed from side to side, winding its way into northern Thailand’s mountain jungle. Rice fields passed us out of mist, punctuated by flames from fires set to prime the forest soil for mushroom growing in the coming monsoon season. The smoky air was interrupted periodically by scents of pine and mint. In a quiet stretch of road, I could hear the gurgling sound of blood in Jandi’s endotracheal tube. I had met Jandi several days before, in the hot season of 2008, when she arrived at Nakhon Ping Hospital in Chiang Mai, the capital of northern Thailand, where I was engaged in fieldwork on end-of-life care. She was a rice farmer from a remote village, five hours by precipitous road from the city. She had been sick for a long time with a cough but had refused to go to the doctor despite her family’s pleas, claiming that the ride to the city and accommodations on arrival would be too expensive for them. They wanted to take her, even against her protests—in fact, this was part of their duty as her children—but every time she suspected plans were afoot to do so, she escaped into the 1

2

|

Jandi

village or the fields. Her family waited reluctantly. One day, when she was making lāp (ground pork with lime, chili, mint and cilantro) in her teak house, she began coughing blood. Then she collapsed onto the kitchen floor. Her family heard the thump and found her unconscious. They called for help, and neighbors arrived. They quickly arranged to borrow gas money from friends for a trip to the city in a truck lent by the head of the village. The family lifted Jandi into the truck’s cab and drove to Chiang Mai city and the emergency room at Nakhon Ping Hospital. Nakhon Ping was the public hospital for Chiang Mai province, available at very low cost to all citizens under Thailand’s universal health care system. It had a CT scanner, mechanical ventilation, dialysis capacity, and a surgical-anesthesia suite capable of most surgeries. The hospital served both poor and middle class people, with some open wards (beds pressed close together) and some private rooms (with extra nursing care available at extra cost). In the open wards, family members camped for much of the day on straw mats between patients’ beds, serving meals and helping with the care of their hospitalized loved ones. Hospital room walls boasted not only outlets for oxygen and electrical arrays on protected generator circuits but shrines adorned with flowers, amulets, and ribbons, at which families prostrated themselves and made offerings to appeal to the spirits that inhabited the place. Many languages could be heard in the halls: Hmong, Karen, and Tai-Yai (spoken by families in colorful outfits, setting them visually apart); kam mư– ang, the Northern Thai language; Central Thai (spoken by younger northern Thais and migrants from Bangkok); and hybrids of Thai languages and medical English (spoken by doctors and nurses). On arrival at the emergency room at Nakhon Ping, Jandi was breathing rapidly and oxygenating poorly. Doctors inserted an endotracheal tube into her lungs, and she was started on a mechanical ventilator. She was still unconscious. A chest X-ray showed widespread masses and fluid, likely with bleeding in her lungs from either cancer or tuberculosis. Her lung function was rapidly declining, and her doctor, Dr. Prani, felt that there was no hope of turning her around. The family took shifts sitting vigil, chanting and offering prayers, whispering kindnesses in her ear. When they were exhausted, family members took turns sleeping in the back of the pickup truck in the parking lot. On her third day in the hospital, Dr. Prani told Jandi’s family that she was likely to die soon, even on life support. I was standing with them

Jandi

|

3

when they received this news. It was early in my fieldwork for my Ph.D. in anthropology, and I was still inexperienced. Despite the family’s open-heartedness, they hadn’t incorporated me into their experience yet. We had simply been sitting in worried silence together. But after hearing from the doctor, Jandi’s daughter turned to me suddenly and asked fiercely, “Would you help us? We need to take mother home.” I felt a wave of sadness come over me: this family had just come all the way from the mountains, only to receive this devastating news and have to turn around again. I agreed to accompany them, of course, galvanized both by their sorrow and my own, and by being included in the situation. Simultaneously a medical student and a graduate student in anthropology, I was in Thailand as part of a joint MD/PhD training program, and although initially determined to remain an observer, I was often shunted into a combined practitioner-observer role, mostly answering questions for families about what was happening. With so many patients to attend to, physicians in Thailand were often too overwhelmed to communicate much with families. Initially, I worried that people might hope that I would be able to help treat or cure their loved ones, and I did not want to mislead them. But I soon learned that it was my presence itself that people wanted: physicians are seen by many to carry accumulated spiritual merit (bun),1 because of a life spent caring for others, and this merit can bring benefit simply through their presence. So despite my insistence that I was only a student, families often wanted me to be there, without any expectation of intervention or skill. I hadn’t traveled home with a patient like this before, but I knew that we would probably be attempting to have Jandi’s last breath take place in the right location. The hospital would be a bad place to die—impure, haunted by ghosts (phī), and disadvantageous for rebirth. Her home, on the other hand, would be full of familiar things, warmth and merit (bun) from a life lived ethically and with beneficial ceremony. Our task would be to keep Jandi’s spirit attached to her body until she could make it home. “When are we leaving?” I asked Jandi’s daughter. “We’re waiting for the ambulance to be prepared,” she said. Ambulance? I thought, surprised. And then I realized that Jandi was on a mechanical ventilator, pumping oxygen into her blood-filled lungs. If we were going to get her home for her last breath, we would have to take over from the machine and pump her lungs the entire way. The head nurse of the surgical ward pulled me aside, and asked me in a whisper, “Have you ever removed an endotracheal tube before?”

4

|

Jandi

I said no, suspecting where this was going. “Here’s how,” she said, and pulled a plastic tube out of the cupboard to show me how to deflate the balloon that held it in place. “As the most medical person around, you’ll have to withdraw it.” I was confused, since many nurses and physicians I had interviewed in the hospital considered withdrawal of life support unethical. This included Jandi’s physician, Dr. Prani. The breath, many explained, is the last element to separate from the body, and so pulling out an endotracheal tube feels like killing. In the heat of the moment, I had time for only one question. “Isn’t it unethical [phit čhariya tham]?”2 I asked. “Well, yes,” the nurse replied. “Dr. Prani doesn’t withdraw tubes in the hospital, but it is okay at home. The patient [Jandi] will be at home when it is removed.” Ethical at home but not in the hospital? I felt a wave of disorientation wash over me as I tried to make sense of this, but there was no time to clarify. We were then swept into feverish activity. The nurses took Jandi off the mechanical ventilator and switched her to a balloon pump, and as we wheeled her down the hall to the parking lot, they showed me how to pump air into her lungs to keep her spirit attached to her body. The “ambulance” that had been waiting for us was a pickup truck owned by one of the hospital gate guards. He ran a small business on the side, taking people home to die. His truck was less expensive than a real ambulance, serving poor families like Jandi’s. It was equipped with a mattress, two tall green oxygen tanks, and a motorcycle tire pump that he had reconfigured to administer intravenous embalming fluid in case a patient were to die on the way home. If Jandi were to die in transit, the guard explained, the embalming fluid would help keep her spirit near her body, to make sure that she could follow us home even once disembodied. This system was the guard’s innovation, derived partly through study with monks about the metaphysics of death, and partly through years of experience transporting spirits and their bodies home. It was among the services he offered. I helped lift Jandi into the truck, and then sat in back with her son and pumped air into her lungs. We pulled out, followed by the truck carrying her relatives. The truck whipped through Chiang Mai city traffic, swerving and dodging until we were outside of town, and then climbed into the burning mountain jungle. “We have to make it home,” Jandi’s son shouted over the rush of wind and road noise. He sat across from me in clothes dirty from days of sleeping in the pickup truck. “If she dies on the way we have to

Jandi

|

5

change places so that I can talk her spirit [winyān] into following us, so she won’t get lost.” I nodded. “You take her pulse!” he shouted. “If she dies, tell me. We may have to go to a temple instead of home.” “Why?” I shouted back. “There are ghosts [phī] all along the way!” he replied. “They might harm her or bring something bad along. At the temple, the monks will help. Bad spirits can’t enter.” I took Jandi’s pulse; I thought it was still there, though it was hard to tell over the shaking of the car. I looked at her endotracheal tube, full of blood. I couldn’t imagine I was oxygenating her lungs, instead probably just bubbling air into and out of the pool of blood in them. But the tube was connected to the oxygen tank in the guard’s truck, so I talked myself into hoping that I was getting some small amount of oxygen into her. I also decided to ignore the fact that the blood might be full of tuberculosis bacilli or some other pathogen, convincing myself that the open air of the road made contracting an infection unlikely. After a tortuous stretch of road, I retched off the end of the truck from motion sickness, and then returned to my job of keeping Jandi’s spirit attached to her body. The son shouted again over the hum, “The guard said that he can make it there in three hours. It normally takes five and a half. I think we’ll make it!” I nodded my support. As the sun set, I could see the forest fires glowing more fiercely around us and the silhouettes of villagers in sun hats working the rice fields, iconic rural images contrasting starkly with the high-tech intensive care unit (ICU) we had left just hours before. As we approached the village, the road changed from paved to dirt, and the smell shifted as the landscape opened from jungle into terraced fields. The guard slowed down, and Jandi’s son looked up and said, “We’re close. She should know we’re here.” Shaking her arm, he said, “Mother, smell the air!” For the first time in three days, Jandi woke up. She looked at me and at her son, seeming surprised but not afraid. We pumped a breath into her lungs, and she coughed up a splash of blood onto her shirt and then closed her eyes again. “See!” said her son, “I knew she would make it! She has so much heart-mind energy [kamlang čhai]!” I had learned a bit about this concept, kamlang čhai, the thing that animates one’s thinking and feeling self, that keeps the heart-mind calm

6

|

Jandi

and the body healthy. It was apparently what had kept Jandi alive so that she could see and smell her village once again. We pulled up outside Jandi’s house, greeted by a crowd of villagers alerted to our arrival by cell phone. They lifted Jandi’s mattress and carried her up to the second floor of her house, while I continued to pump air into her lungs. As soon as we set Jandi down, the people who nearly filled the house began lovingly to squeeze and pat her arms and legs. The guard, who had followed us up, said to me, “It’s time to take out the tube now.” So soon! I thought. Why the rush? Jandi’s daughter intervened, “Can we wait until the second car arrives?” The village head’s truck, filled with relatives, had been behind us. “If they aren’t here, she’ll miss them.” The villagers and family members nodded what looked like reluctant assent. How precarious choreographing the moment of death was! Such an emergency, even getting relatives there. Our ride from the hospital had been more harrowing than an ambulance ride to the hospital would have been, much closer to the moment of death, suspended only by the technology of artificial ventilation. And our “ambulance” had really been more for Jandi’s spirit than for her body, a spirit ready at any moment to tumble out of her into a terrifying world infested with ghosts, with forces poised to trap her and do her spiritual harm. Now that we had arrived and her spirit was in the right place, why such urgency to withdraw the tube? Some minutes later, the second truck arrived, and the house suddenly overflowed with even more people. In preparation for Jandi’s arrival, her relatives had laid her possessions—bags full of clothes and keepsakes—around the head of her mattress. The purpose of these objects, as with the house full of loved ones, was to make sure that she did not miss anything at the moment of death. Otherwise she would cling (‘upāthān) to them, and this clinging would stick (tit) to her and negatively influence her rebirth. All eyes turned to me for a moment, and the guard again said: “Now it’s time to take out the tube.” I hesitated, still confused about the ethics of this act (Ethical at home but not in the hospital?), and about my dual practitioner-observer role. Seeing my hesitation, and the guard stepped forward urgently, drained the balloon of air, and pulled out the tube. Apparently, withdrawing it was ethical enough here in Jandi’s home to be part of the driver’s services to the family, and urgent enough that they couldn’t wait for my hesitation. I was also struck by the fluidity of medical expertise in this spirit ambulance process, with a guard in

Jandi

|

7

charge of life support and family members pumping oxygen into Jandi’s lungs until her spirit and body arrived home. Again as if on cue, Jandi woke up. They propped her up on pillows, and she looked around at everyone gathered together to see her off. People in the room shouted out to her: “We love you grandmother!” and “You’re home!” Jandi’s daughter held up a spoonful of boiled rice porridge to her mother’s mouth. Jandi took a bite, tasted it, looked at her daughter, and smiled. Everyone reached out and held her legs and arms. She locked eyes concertedly and in turn with a few people in the crowd. And then she took a deep gurgling gasp, coughed up a splash of blood, closed her eyes, and died. I held back a wave of tears, a combination of sorrow and catharsis. In that moment, Jandi’s death felt replete with beauty and meaning, though I was only barely beginning to make sense of everything that had happened. After a time, people began to file out. One of the guests invited me to leave, and I realized that the family needed to clean the body in private, to prepare her for cremation, and so I followed. Jandi’s younger brother was outside, and stood talking with a small group of relatives. “That was good,” he said, and, turning to explain to me, “They took her to the hospital to pay back their debt [chai nī], and then they got her home.” I had heard from others about the “debt of life,” a duty to provide care for one’s family members at the end of their lives. I had many questions about the particular way the family had repaid this debt to Jandi, but it was an emotionally charged moment, so I did not probe further, simply saying: “That’s important, isn’t it?” “Yes,” he replied. “She had her things around her. Everyone was there. She wasn’t worried about anything. It was very good.” We all stood in silence. Eventually, someone told me I should go and get some sleep and leave the family to take care of the corpse. I had been offered a bed in the village head’s home. The guard excused himself, and I walked with him back to his truck, which he would drive all night to get back to his guard duties the next morning. “How do you feel that went?” I asked him. “It was good,” he answered. “The family made it to the hospital, and then they made it back home. It worked out. They borrowed money to pay for all of this, but it was worth it.” Three days earlier, Jandi had been in her house, in the very place where she just died. Viewed through a biomedical lens, with success measured in prolongation of life, the trip to the city had achieved

8

|

Jandi

nothing, and in fact may have been an undue burden for Jandi’s very poor family, for whom a ride to the city was an expense whose effects I imagined would linger for some time. But those three days—going to the hospital to pay back the “debt of life,” followed by rushing home to allow Jandi’s spirit to separate from her body in the right place—these things were well worth the cost to Jandi’s family. Hers was deemed an unequivocally good death. And though I somehow felt this myself, the specifics of what made it good were still mysterious to me. It would take me a year of fieldwork to make sense of them. And that fieldwork would end up taking me into some surprising places, into parts of Thai society seemingly far removed from Jandi’s spirit ambulance: into the ways that modern biomedical technology had begun unsettling Thai law, ethics, and perceptions about health and the body; into electoral politics and religious reform; into global flows of capital and expertise; into a fierce rural/urban divide; all ultimately synthesized into a shifting experience of dying, which Jandi and her family had somehow managed to navigate masterfully. Choreographing her death in the right place, at the right time, safe from dangerous spirits, surrounded by good people and things, all intended to steer her rebirth in the right direction, had been precarious. There were many moments when this process could have gone wrong. But despite all of it, Jandi’s family had managed to make her death a success.

Arirat Facing the Karma Master

I stood above Arirat’s bed in her private room in Nakhon Ping Hospital, holding her down as she convulsed with pain. A moment before, we had been talking calmly—about her pancreatic cancer, about her choice to practice mindfulness (sati) through her dying process, to not receive any aggressive interventions or take any pain medications, which she felt would disrupt her ability to study the tumor. Her tumor was part of nature, and it therefore needed to be understood and loved. I had been sitting at her bedside, listening to her explain this process. She had been calm with the gentle look on her face that I had come to expect from her, only occasionally wincing from pain due to interrupting her meditation practice to talk with me. And then, in the middle of a sentence, she moaned, arched her back, and clenched her fists and her face, seemingly in the throes of a sudden full-body episode of pain, as though her tumor had ruptured and released something awful into her blood. I ran to the door and called down the hall for Arirat’s nurse, Ampha, and then returned to Arirat’s bedside. “Hold me down!” she gasped, urgent, breathless. “Press on my muscles!” I leaned my weight into her and squeezed her arms with my hands. I could feel her trembling. “Please let us give you some morphine,” I pleaded. “It will help with this. There is no need to suffer.” 9

10

|

Arirat

She opened her eyes momentarily, and gave me a stern look. “I need to focus. You are having a problem with this. For me, it is an opportunity. Now hold me down, I need to study [phičhāranā]!” Nurse Ampha arrived into the room, and seeing the scene, repeated my appeal for morphine, but Arirat was deep in concentration and gasping for air and did not respond, and so Nurse Ampha joined me at her bedside, applying her own weight to Arirat’s arms and chest. We stood in this configuration for only a few moments, though they felt interminable. Arirat’s pain filled the room. I agreed with her charge that I lacked the emotional strength to peacefully witness something like this, never mind to endure it myself. After a few long moments, the shaking subsided, and Arirat slowly relaxed. As suddenly as the pain had come, it left. She opened her eyes and beamed her joyful smile. “That was so interesting,” she said. “I have been trying to understand the connection between heart-mind [čhit čhai] and body. I thought I understood, but that was so intense, I couldn’t control my body at all. Very interesting.” The next day, I had a chance to see her again, this time accompanied by Tom Taem, my research assistant and collaborator, a scholar of Buddhism and Thai society, who had become part of my research team to help me understand the concepts emerging in my research. Tom Taem had grown up in northern Thailand, and accompanied me occasionally to translate from Northern Thai into Central Thai, and to smooth out my often-awkward questions and ensure that I understood the answers. She had become particularly interested in Arirat, both professionally and personally, because the dying woman seemed to offer the possibility of a radical freedom from suffering, something that we all might achieve with proper study. Arirat explained that her episode of pain from the day before had led to a great leap forward in her meditation practice. “Until that moment,” she said, “I don’t think I truly understood the relationship between heart-mind and body, and now I’m almost getting there.” She left unsaid what she meant by “getting there,” but it implied access to a kind of joy no longer dependent on conditions in the material world, including the body. She would never have used the word “enlightenment,” reserved only for the Buddha, for total cessation of the cycle of rebirth. But as Tom Taem remarked later, “I think she means something in that vein, not cessation of existence altogether but at least of suffering in this lifetime.” Freedom from suffering was one way of formulating the ultimate destination of Buddhist practice. Until that point in my

Arirat

|

11

life and research, the concept had been an abstraction, a distant spiritual ideal, not something to be lived and attained by individuals in ordinary life. Tom Taem and I had first met Arirat six months before, just a few months after her cancer diagnosis. Arirat had noticed her skin turning yellow, and a CT scan at the University Hospital had revealed a pancreatic tumor that had already expanded to encase her abdominal blood vessels. The physicians had offered her a surgery, but only to de-bulk the mass, since it could not be safely removed from the blood vessels. They had also offered chemotherapy to extend her life, but the results would have been modest at best. She had declined these interventions, as well as any pain medications, deciding instead to “accept” and “face” the tumor, to use it as an object of study during the remaining days of her life. It was around that time that Tom Taem and I met her. Nurse Ampha, a poised, kind woman with scholarly round glasses who had become my main point person for patient recruitment in the private ward of Nakhon Ping Hospital, introduced her to us. Nurse Ampha had the energy and appearance of a teacher, and she had adopted me as a disciple. She pulled me and Tom Taem aside, and then ushered us down the hall, saying: “I have someone for you to meet. She’s a real ‘end-of-life case’ [said in English]. Ms. Arirat knows what [disease] she has, and wants to face it peacefully with meditation [patibat]. She already has a high level of mind [čhit radap sūng] and wants to develop it further before she dies.” By that point in my fieldwork, I knew enough to be shocked by this description, particularly the phrase “she knows what she has.” None of the approximately fifteen northern Thais that I had followed though their terminal illnesses by that point had been told their diagnosis or prognosis, although a sign on the wall in every room of Nakhon Ping Hospital proclaimed: “Things you have a right and responsibility to know during your stay in this hospital: (1) your disease; (2) treatment you are receiving for your disease; and (3) self-care appropriate for your disease.” Hospital staff had explained the sign as emerging out of a patients’ rights movement, rapidly gaining traction. But in the cases I had seen, it seemed to be ignored, or actively resisted. As one patient’s daughter explained about this “right to know”: “A right to what? A right to know a disease that can’t be cured, can’t do any good? A right to worry in her last days? That is not a right I want for my mother.” Now I was about to meet a patient who not only “knew what she had” but also was using that knowledge to meditate and develop her “level of mind.”

12

|

Arirat

I only had time for one question as we walked toward Arirat’s room. I asked Nurse Ampha why she had said “end of life” in English, thinking that it was for my benefit, but she shook her head and explained that she had attended a required nationwide training about using the “end of life” to teach people the nature of their minds. The word “end of life” was in English at the trainings, which were led in part by physicians who had trained abroad in the medical specialty of palliative care. The training had been spurred, in part, by the death of a famous monk, Buddhadasa, who had died after many weeks in an ICU despite having clearly stated that he did not want hospital care. After the event, monks, nurses, and physicians began to draw on Buddhadasa’s teachings to support reforms for perceived flaws in the Thai medical system, religious clergy, and overall approach to healthcare. “In Thailand,” Ampha explained, “we have started to think about death in a new way, as the ‘end of life.’” The point of introducing us to Arirat was apparently to show us a patient whose “end of life” was going the right way. Nurse Ampha warned that a group of Arirat’s friends had come to visit her, so there would be a crowd in her room. “But you will know who she is, she is very peaceful [čhai yen]. Let’s go, I’ll introduce you.” We knocked gently on the door, and entered a private room full of welldressed older women, drinking tea and talking animatedly. At the center sat Arirat, yellow-skinned and yellow-eyed, in her sixties, smiling, with calm, energetic eyes. The scene was distinctly middle-class, at least compared to the understaffed and crowded open ward where Jandi’s family had needed to squeeze into the tiny spaces between closely packed hospital beds. Here, there was enough space for a tea party and conversation, and there was a small enough patient-to-nurse ratio that Nurse Ampha could take the time to worry about whether or not her patient represented a “real end-of-life case.” I felt a wave of judgment about this class connection, that a set of economic structures might have been part of what made Arirat’s approach to dying more “real” than another’s. “Welcome!” Arirat said upon seeing me and Tom Taem. “Nurse Ampha said you might come. Please have a seat.” Because of the crowd in the room, and because I was unsure of whether to trust Ampha’s claim that Arirat knew her diagnosis, I began with a few cautious phrases: “You are lucky to have so many visitors here to give you support [hai kamlang čhai]!” and “Is everyone from this area?” Arirat responded politely and then smiled and said, “We’re all here talking about my cancer. Do you have any questions about it?”

Arirat

|

13

This was the first time that I had heard a patient use this word, and I was taken aback. I asked: “How long have you known your diagnosis?” “From the beginning!” she said. “They told my husband first, but he knew I could take the news, that I would want to practice [patibat] on it, so he made the doctor tell me right then.” Nurse Ampha, who was still standing quietly next to me as my broker into the room, told me about another patient on the ward, whose family had insisted that his cancer diagnosis be concealed from him. He then accidentally overheard his diagnosis, and it had upset him so much that he had suddenly worsened and died shortly thereafter. His family ultimately accused the medical staff of killing their father with the truth. “This is how almost all families operate,” Ampha said, and turned to me to explain, “It’s how we’ve done things in Thailand.” Arirat responded, “That is so sad! If the patient doesn’t know his disease, how can he take care of himself? How can he eat the right foods and take the right medicines? How can he meditate and prepare himself, and resolve his karma?”1 “Some patients can’t take the news—it’s too big a shock,” Nurse Ampha replied. Arirat nodded. “I suppose it depends on the patient’s level of mind [radap čhit],” she said. Here again was this concept of “level of mind,” one’s place in a hierarchy of mental and spiritual evolution, which seemed vital to communication about critical illness. Nurse Ampha had described Arirat as having a “high” level of mind, so that she could not only “take the news,” but also do something useful with it. And now Arirat herself was implying that another patient had had an insufficient level of mind, making him vulnerable to death by truth. Seeing my confusion, she continued: “Cancer is a very strong word. Death is a very strong word. There is something about death that goes straight to the heart-mind [čhai] and makes people despair. Death is fine as a concept, but when it is your own death, it is not a concept anymore, it is real. It takes great strength to face it.” Again, I recalled Arirat’s affluent background. The connection between wealth and spiritual attainment is considered to be very direct by many in Thailand. A middle-class life is seen as a beneficial product of past karma, and thus class and “level of mind” are connected.2 I couldn’t help but wonder about how this hierarchical setup had primed Arirat to be able to “take the news.” Arirat then explained her daily practice, which consisted of around-theclock meditation, focused largely on being present to the experience of pain. She had discovered that, as long as she focused on and fully embraced

14

|

Arirat

the pain, she did not suffer from it. “This is an important distinction,” she said. “Pain [čhep] and suffering [thuk thō˛ramān] are not the same thing. Mindfulness [sati]3 sometimes actually increases my pain, because I’m so aware of it, but it always decreases my suffering from it.” She gave a similar explanation about her decision about pain medications: whenever she took short-acting opioids such as morphine, they made her “just confused enough” to disrupt her ability to meditate. “Even though the morphine decreases my pain,” she said, “it increases my suffering.” It would take me many months of study—much of it with Arirat, following her wherever her practice took her, to her home or to the forest monastery outside of town where she consulted teachers about her meditation technique—to begin to understand this distinction between pain and suffering, a distinction core to Arirat’s transcendence, to her indefatigable bright mood, something I had never really imagined possible.4 Arirat went on to explain to the group gathered in her hospital room that there was another important part of her practice: sending lovingkindness (mēttā) to her tumor. Her tumor needed to be treated well because it was a being from her past that had come to work out an old grievance with her. She explained that, although she could not recall her past lives in much detail, she knew without doubt that she had harmed another being in the past, and that this being had returned, manifesting within her pancreas as a way of exacting vengeance for past injustice. She named her tumor a “karma master” (čhao kam nāi wēn). Karma is the concept that all actions have consequences: good actions have good consequences and bad actions have bad consequences. These consequences carry forward in time and “stick” (tit) to those involved, binding them to the world and to one another, regenerating the cycle of rebirth and suffering.5 A “karma master” (čhao kam nāi wēn), she explained, is a being to which one is still stuck by past actions, and who has come forward in time to resolve this stickiness. “Resolving karma” (wēn kam) is one of many ways of formulating Buddhist practice, whose promise is liberation from this cycle, and thus from suffering. For Arirat, the way to achieve this was to love her tumor, to treat it kindly. Both when I first met her that day and later when I held her body down as she convulsed in pain, Arirat was engaged in a process of selfimprovement that required her to experience dying in a particular way. This process was dependent on her “level of mind,” her ability “to take the news,” and then to work with it to a positive end, to “face the truth” and thereby come to an understanding of the “nature of things”

Arirat

|

15

and liberate herself from suffering despite immense pain. This process seemed to involve a kind of independence and access to spiritual practice that elided the difference between spiritual and material hierarchy. And despite the long history of many of the techniques she was using, she and Nurse Ampha encapsulated her process with an English phrase, the “end of life,” linking it to a newly arriving medical expertise in palliative care, which seemed to advocate approaching the end of life as an opportunity for growth, for meaning-making. In my medical school training, I had taken many courses in the subspecialty of palliative care, and had trained to become an “end-of-life doula,”6 accompanying patients through their dying process, partly to help them find meaning in their last phase of life. But the similarity between my training and the “end of life” that Arirat and Ampha invoked seemed to end there, because the details of their process were foreign to me: a sentient tumor that needed to be loved and forgiven, a hierarchy of truth-telling based on one’s “level of mind,” and the suggestion that treating one’s pain might cause suffering. Just as it would take me a year of fieldwork to unravel the web of criteria that had made Jandi’s death “good,” it took time to unravel the very different criteria that had made Arirat’s “good” as well. And because of the connection between the things I was seeing and the death of the famous monk, Buddhadasa, this journey would take me to an unexpected breadth of places: to the Thai political landscape, to a web of global forces interlaced into daily life, and into debates about the interlocking roles of religion and biomedicine in death.

Introduction Choreographing the End of Life

Death is a universal component of the human condition, and one might argue that people everywhere attempt to die well, to achieve “good deaths” for themselves and their loved ones. However, definitions of what constitutes a good death differ greatly.1 Over the past century, death has become increasingly medicalized in many parts of the world—both in wealthy countries and more broadly, either through the ascendance of high-tech biomedical interventions,2 or through their assumed lack.3 The medicalization of death has, for the most part, been imagined as a universal good. After all, who doesn’t want to live longer or better, to stave off death as long as possible? But over the past few decades, there has been increasing attention to problems with medicalizing death. Many people around the world have debated the possible harms of prolonging dying.4 And medical technologies, like the mechanical ventilator that pumped Jandi’s lungs, have unsettled the definition of death itself.5 When does death occur? Is it when the heart and lungs stop working, or when the brain stops showing electrical activity? If one slows or pauses the deterioration of the human body, what happens to human experience? Is life improved, or is there simply more unnecessary suffering? How, moreover, should one relate to the dying, and how are we to relate to others as we die? Despite increasing medicalization, medical technologies and expertise exist alongside other resources for navigating the dying process. I use the term “resources” to include conceptual and material possibilities: ideas 17

18

|

Introduction

and things available when attempting to make death good. The goal of this book is to use Jandi’s, Arirat’s, and others’ stories to understand how people attempt to achieve good deaths, particularly within the increasingly common global coexistence of Western biomedicine with other ways of approaching death. To understand how Jandi and Arirat and their families attempted to achieve good deaths, I draw on the concept of social “choreography,” arranging actions in the flow of time to make things (hopefully) go well. The concept of choreography evokes a dance that is partly planned, partly improvised, coordinating multiple different roles. Choreography is ubiquitous in human social life, which frequently involves irreversible actions that are dependent on one another.6 More specifically to medicine, in what is called “ontological choreography,” therapeutic technology is woven into life as a tool for making meaning and rearranging social relationships.7 In her book And a Time to Die, Sharon Kaufman argues that death in modern American hospitals has become structured by bureaucratic dependence on timing, so that both providers’ and patients’ conceptions of the “good death” have become linked to manipulating when death occurs.8 Following Kaufman, many have used concepts about practice— strategy, coordination, improvisation—as complements or alternatives to the more classic bioethical approach of treating values as abstracted from context.9 I use the term “choreography” partly because it captures many of these components of practice. As Jandi’s and Arirat’s stories indicate, choreographing death is complicated and context specific. Their deaths were situated—unique not only to northern Thailand in the mid-2000s but also down to divisions between hospital and home, temple and street. Their deaths were also complex, requiring satisfaction of multiple, sometimes contradictory imperatives: the need both to pay back the debt of life in the hospital and also to allow body and spirit to separate at home; the need to respect one’s elders but also protect their heart-minds, possibly by concealing the truth from them. And their deaths were shifting, occurring in a stream of transforming social factors, spurred by political events, changes in religion and medical expertise, and a host of global forces. Mapping Jandi’s and Arirat’s situated, complex, and shifting deaths requires a journey into many things, from biology to religion to politics. One task of this book, then, will be to step into the particulars of Jandi’s and Arirat’s deaths, for it is out of the particulars that they come into relief: out of Jandi’s family’s “debt of life” and Arirat’s “level of mind” and “karma master”; out of the collection of possessions at the

Introduction

|

19

head of Jandi’s bed; out of the ghosts, the monks, the nurses; out of the hospital and the home; out of the roles of the family and the individual. A second parallel task of this book will be to help the reader sort through these details to understand more broadly the problems and possibilities that come from needing to choreograph death amid an array of shifting forces, especially the increasing medicalization of death in many places. How did choreographing death become so complicated in northern Thailand, with components like the harrowing spirit ambulance and the ideological tug-of-war about truth-telling and about what one should do with one’s own “end of life?” And what can one learn from this particular context about death and dying everywhere? To help with this task in this book, I use some of my own encounters with dying patients in the United States as a comparison. I conducted research for this book as part of a joint MD/PhD training program in San Francisco, California: two years of medical school, followed by a PhD program in medical anthropology (beginning with coursework, followed by two years of research and writing in northern Thailand from 2007 to 2009); followed by two remaining years of clinical clerkships to finish medical school, and eventually by an internship and residency in internal medicine. My training involved frequent tacking back and forth between medical training in the United States and research in Thailand. The result was a whiplash between worlds. It is this whiplash that I hope to share in this book, to help bring readers close to both the particulars and universals of death. In my initial two years in medical school, before going to Thailand, I took electives in the medical specialty of “palliative care,” a field focused on managing the dying process. I also trained as an “end-of-life doula,” accompanying patients as an advocate and counselor through their dying processes. Palliative care was presented to me both as a medical specialty (with expert knowledge about medications and techniques) but also as a view of things somehow alternative to mainstream medicine: a way of paying more attention to meaning-making, to patient and family experience, to relieving suffering rather than just curing disease. In my electives, palliative care professors talked about most medical practice as involving too much “noise”—paperwork, time-pressure, routine—that seemed to melt away when the end of life was concerned, leaving only raw experience. I attended workshops on the “art of medicine” and “meaning in medicine,” designed to inoculate me against the corrupting effects of reductionism and inhumanity in my medical training, to unearth and preserve my natural impulses as a holistic healer.

20

|

Introduction

In retrospect, the tension between palliative care and other medical fields was exposing me to two strains of thinking within Western biomedicine: one was a reductionist, materialist, mechanistic, combatoriented approach to diagnosis and treatment; the other was a largely Judeo-Christian notion of physicians and nurses as healers who accompany patients through the meaning-disrupting effects of illness, guiding them back into wholeness and dignity of spirit, even when the body might be beyond fixing.10 Managing the dying process somehow seemed to induce dialogue and tension between these modes. My central question going into my PhD fieldwork was how this complex set of ideas might be affecting other parts of the world, presumably with their own complex ways of approaching dying. For fieldwork, I settled on Thailand, a place with several features that promised to highlight encounters between biomedicine and “other” worldviews. The first feature was Thailand’s roots in Buddhism and Hinduism, distant from the Judeo-Christian and Enlightenment roots of Western biomedicine. Second was Thailand’s impressive universal healthcare system, allowing all citizens access to high-tech hospital medicine. Third was a feature of Thailand’s self-narrative, appearing everywhere from national health policy to soap operas and novels, as full of contrasts between “modernity” and “tradition”: remote villages with dirt roads and farming economies alongside urban hospitals with fully equipped intensive care units, radiology, and surgical capabilities.11 I chose Thailand to explore this imagined contrast, to understand how people made sense of it, and whether it was a part of the strategies that they deployed to navigate the end of life. From 2007 through 2009, I enrolled thirty-five terminally ill patients from a provincial government hospital, Nakhon Ping, just outside of Chiang Mai in northern Thailand, and then followed them through their journeys in and out of medical settings. My goal was to write participants’ end-of-life histories in as fine-grained detail as possible. I thus spent time with them at home and in hospitals and clinics, and interviewed them and their family members, often in multiple contexts and locations. I used their trajectories to determine whom else to interview: the nurses and doctors who cared for them, the monks who performed rituals at their bedsides. Following the threads of the things that showed up in individual deaths occasionally took me as far afield as to Bangkok and Southern Thailand to understand the trainings in palliative care and the national political landscape that had generated Arirat’s and Nurse Ampha’s claims about the “new end of life.”

Introduction

|

21

My research design was based on several assumptions, and as is often the case with ethnography, these assumptions began crumbling upon entering the field. The first was that people would frame their understanding of the dying process in terms of a tension between biomedical and other forms of intervention. Instead, as Jandi’s story makes clear, choreographing a good death required a mix of biomedical and other solutions, from mechanical ventilator to spirit ambulance. Biomedicine was one of many resources, repurposed into a complex strategy. The second assumption was somewhat subtler, and was based on what my U.S. palliative care professors had claimed: that dying is an experience that needs to be managed, one that universally leads to a confrontation of deep philosophical questions. It is worth a brief anecdote from the beginning of my fieldwork to illustrate this assumption and its dissolution. When I initially presented my work to the directors of Nakhon Ping Hospital, I faced the seemingly small challenge of how to explain my study topic. I settled on the phrase “the care of patients in the last stage of life.”12 If asked further, I could have explained my target study population: patients with terminal diagnoses who had a less than 50 percent expected six-month prospect of survival. But at first no one asked, and we seemed to be on the same page. When I arrived for my first day at the hospital, the head nurse at the ICU told me that she had already identified three patients for my study, but that I would have to choose one because I wouldn’t have time to study all three. Confused, I suggested introducing myself to them all and then working with them in an ongoing manner. “But they are in the last stage of life,” she said, confused, “they’re going to die today.” When I detailed my study population further, she looked disappointed, and said, “Oh, you’re just interested in regular patients.” Over the subsequent eight months, this same confusion arose many times. Often, when I explained my patient population, a nurse or a doctor seemed to think my study unremarkable. Shouldn’t I be studying “the last stage of life” instead? It seemed that my translation was incorrect, and that I would need to find a better word. I was trying to point to an interval of time that I imagined to be most important and relevant to an individual’s death: a time when one knows that one will die but prior to the final physiological breakdown of the body. I began asking nurses and doctors how to translate this term. Some claimed that there was no phrase that would encapsulate my study

22

|

Introduction

population effectively. Others seemed familiar with my conception but framed it as a new idea arriving in Thailand. They would say, “Ah, you are studying ‘palliative’ [care],” or “You are studying [the] ‘end of life,’” with “palliative” and “end of life” said in English. Or they might even say, in Thai, “You are studying this new way of thinking about the last phase of life.” These comments often came with a reference to something that they had recently read or heard. This was the “new” way of approaching the end of life that Arirat and Nurse Ampha tried to teach me. This phenomenon was much more complex than the “arrival” of a global field of palliative care in Thailand. Certainly, there seemed to be a status quo that was being disrupted by a “new” way of approaching things, linked enough to outside forces to have acquired an English title, “end of life.” But this “end of life” did not particularly resemble the way of approaching death that I had learned in my training in U.S. palliative care, or any global palliative care movements that I had encountered. In fact, both the status quo and the new approach to dying seemed to be inextricable mixtures of “local” and “global” elements, of biomedicine and other resources. Because of this, in this book, I follow recent analytic insights that the division between local and global obscures more than it reveals.13 Instead, I think of deaths as situated, as specific to time and place due to particular combinations of social forces, some of which connect to a broader world.14 Jandi’s and Arirat’s stories provide a first pass at delineating the different ways of dying in northern Thailand. In a way, Jandi’s death represented the status quo, given that it did not incorporate the “new endof-life” logic. As her family explained to me, and as I seek to show below, her death was divided into two phases. These phases were not precise, and often bled into each other, but they are nonetheless useful for sorting out the different ethical imperatives driving the choreography of death. The first of these phases involved aggressive medical care. In some ways, for Jandi’s children, it began when she fell ill, long before they managed to get her to the hospital. It was governed by an imperative to maximize, honor, and preserve life regardless of prognosis or chance for cure, to pay back the “debt of life” that they owed her for having been given life themselves at birth. They paid their debt through medical intervention and by “giving her heart-mind energy” (hai kamlang čhai) to keep her from worrying and thus from harming her own body. This phase involved an important tension between the family and Jandi herself. Jandi resisted every time her family tried to take her to the hospital, because she did not want to be a burden on them, to let them

Introduction

|

23

pay back their debt of life. They, on the other hand, were tenacious in their insistence on paying it, on taking her to the hospital. Even though it didn’t prolong her life, this was all perceived as a success. The second phase of Jandi’s death was what the ICU nurse on my first day of fieldwork called “the last stage of life.” It began when Jandi’s physicians told her family that she would die in a matter of days or hours. When this happened, the framework governing Jandi’s family’s behavior shifted to facilitating the movement of her spirit to an optimal rebirth. This was dominated by a logic of place, because dying at home was essential to ensuring an effective and safe rebirth. Her death would occur when the elements of her body—earth as flesh, water as blood, fire as warmth, and air as breath—separated from her spirit. Her location at the completion of this separation would be partly responsible for the direction and quality of her rebirth. For Jandi, the hospital would have been a bad place to die, because it would have risked getting her stuck to polluted metaphysical forces. In contrast, her home was an ideal place to die, full of familiar people and possessions, and blessed by a history of moral family life. After Jandi’s death, in a way, this phase continued, through ceremonies controlled by officiating Buddhist monks, designed to further optimize Jandi’s rebirth. These ceremonies transferred merit (bun)—spiritual benefit—to her disembodied spirit, largely to direct her into a beneficial rebirth, and also to keep her spirit from haunting the living. The concept of merit (bun) is based on the law of karma (kam)—that all actions have consequences: good actions produce good consequences, known as merit (bun), a substance-like force that can be generated, stored, spent, wasted, transferred, and used.15 Jandi’s rebirth, like all events (or more accurately, all consequences), was shaped by the balance of past actions attached to her. The function of her funeral ceremonies was to ritually add goodness to this balance, to positively affect her rebirth. These “status quo” phases of dying required complex choreography, most dramatically manifesting as the spirit ambulance. They were also inextricable mixes of diverse resources: hospitals and ventilators and motorcycle tire pump embalmers; monks and rituals of merit-transfer; favorite possessions and components of the body. Importantly, in these phases of Jandi’s dying, death was conceived as taking place in a moment (the last breath taken at home), with a short logistical phase (the “last stage of life”) meant to get her into the proper environment. Her death did not require her to know that she was dying or why.

24

|

Introduction

The concept of “end of life” emerging in Nakhon Ping Hospital was different from these two phases of dying. It showed up as an activist agenda, intended to change the way that people perceived and performed the process of dying. Advocates for what Nurse Ampha called the “new end of life” proposed adding a phase, structurally different from the two phases of Jandi’s death. Arirat explained that because patients like Jandi did not know their diagnosis or prognosis, they would “have no chance to prepare their minds for the final moment.” Arirat was imagining an ideal type of person, an imagined figure,16 who wanted to confront the difficult and suffering-laden reality of the end of life and use it to attain spiritual liberation. This process would take time, and thus required a new phase in the dying process, a time she called the “end of life,” when one should “meditate and chant,” “know what was happening,” and “prepare one’s mind.” The sign on the wall also had an opinion about how patients should relate to illness: they had “a right and responsibility to know their disease, self-care for their disease, and treatment they were receiving for their disease.” The sign proposed a figure of its own—an ideal type of person who knew the truth and exerted her right to advocate self-determination in medical care. The sign also pushed the idea of an interval of time when one should know that one is dying, a time when one can actively engage and struggle with life-threatening illness. Into the phases of dying encapsulated by Jandi’s spirit ambulance, the “end of life” had emerged as an imagined new phase—a period of time pried into the existing phases of dying, requiring a different way of being in the world. In the chapters that follow, I present portraits of the life-worlds of those choreographing death in northern Thailand. This journey requires some conceptual tools, designed to help show how the particulars of specific deaths in one place relate to a broader world where death is changing for everyone. I draw these from various sources: from globalization theory, ethical theory, practice theory, and religious studies, among other fields. For example: how does globalization work—do outside forces flatten local experience, or do they form mixtures, like chimeras or creoles? Another example: how do people choreograph situations—do they follow well-defined scores, fumble their way blindly through, or not really have enough freedom of choice to choreograph at all? Yet another: do people use principles or other constructs to make decisions, and do they act as individuals or groups or something else? And if we take Arirat’s claim that her tumor was another being seri-

Introduction

|

25

ously, how could she make medical decisions about a body that was not wholly her own? Rather than answer these questions in the abstract, I use them throughout the book to understand how individual stories reflect on the choreography of death in a broader globalizing world. One piece of vocabulary worth building at the outset is the conceptual world of ethical theory. This is partly because throughout this book, I draw comparisons from my experiences in U.S. biomedicine, where end-of-life decision-making is overwhelmingly framed in bioethical terms. Many of the terms that I use in this book are self-evident: frameworks, imperatives, improvisation, persuasion, justification. But one problem with ethical terms is that many of them assume that people rely only on mental constructs to decide how to move through the world, ignoring the fact that real life is constricted by material conditions, and that people use different ideas in different situations. To account for this, I use the term “resources,” and the related term from ethics, “affordances,” to refer to the combinations of elements—mental constructs, material possibilities, and the vagaries of situations—available to those attempting to choreograph good deaths for themselves and those around them.17 Understanding Jandi’s and Arirat’s deaths will also require some conceptual tools particular to Thailand. It will require enough of an understanding of Thai Buddhism to explain the metaphysical mechanics of the spirit ambulance and karma masters. It will require enough of an understanding of Thai politics to make sense of why the death of a monk could lead to a new national movement around death and dying. It will require enough of an understanding of Thailand’s universal health scheme to make sense of why the deaths in this book were not plagued by material lack as much as they might have been elsewhere in the world. And it will require enough of an understanding of the connections between class, power, and spiritual hierarchy in Thailand to explain why Arirat’s “end of life” might be considered superior to other ways of approaching death. In this book, I weave these concepts together throughout on an as-needed basis. This book follows the phases of dying in northern Thailand. Chapter 1 explores the “debt of life,” and how the biomedical hospital has become woven into the choreography of death. Chapter 2 explores the “last phase of life,” including using the spirit ambulance to ensure death’s proper location. Chapter 3 presents the phase of “the new end of life,” built out of a complex swirl of global expertise, national politics and religious practice. Chapter 4 explores the complexities of choreographing a good

26

|

Introduction

death when one might be composed of multiple beings, such as Arirat and the tumor that she experienced as a karma master. Overall, the purpose of this journey into dying in Thailand is to understand the contemporary global phenomenon of the increasing medicalization of death, and the resulting complex world that people must navigate as they attempt to choreograph good deaths for themselves and others.

chapter 1

Paying the Debt of Life

Jandi’s family declared that the process of getting her to the hospital and then home again was a great success, despite the fact that it did not prolong her life. Her brother said, “It was good . . . they took her to the hospital to pay back their debt [chai nī], and then they got her home.” With this sentence, he invoked a concept with enough assumed commonality among his listeners that it only needed a single phrase: “pay back their debt.” And the phrase pointed to a compelling enough imperative to drive an extraordinary process: the expensive and arduous journey to the city, high-tech intervention in the intensive care unit (ICU), and then the metaphysically precarious journey home. This process required a kind of choreography, a series of actions arranged in time, that needed to be performed well. The concept of a “debt” (nī) emerged early in my fieldwork, and continued to thread through every death that I accompanied. One of my first fieldwork locations at Nakhon Ping Hospital was the ICU—an unassuming room with eight ventilator-supported beds at the end of an outdoor hallway. The hallway was lined with concrete benches, usually full of family members waiting in tense silence for the arrival of limited patient visiting hours. I had not explicitly requested the ICU as my starting point, but given that I was to be studying “the last phase of life,” I was taken by the head nurse of the ICU to this hallway, where death hovered ominously over the living. After several days shadowing the clinical staff, I met my first research participant, Peng, a man in his 27

28

|

Paying the Debt of Life

seventies dying of multiple organ failure. He had been admitted to the ICU with liver failure, which led to kidney failure, then pneumonia and sepsis, requiring him to be intubated and placed on life support: a mechanical respirator for his lungs, medications to support his blood pressure, dialysis for his newly inoperative kidneys, and a feeding tube for nutrition. Despite all of this, he awoke occasionally, alert enough to interact. One day, I was at his bedside when he awoke for one of these moments, and he mouthed a few words to me, though I could not make them out. The nurse at my side explained that he was asking to go home, which in his condition implied wanting to die. I stepped out to fetch his family from the waiting area—his daughter Bua and his niece Phai—so that they could talk with him while he was awake. They came in and spent a few moments delivering news of family and home, to which he smiled against the endotracheal tube, and mouthed a few words, which may again have been about going home. Bua and Phai and I then stepped out into the hall so that Peng’s nurse could suction secretions from his endotracheal tube. We sat for a moment on the benches. Bua and Phai mentioned that Peng’s doctor had told the family that morning that he had little hope of recovery given the deteriorating function of his organs. “Does this mean that you will be stopping ICU treatment?” I asked. Peng’s daughter Bua shook her head. “We can’t think of stopping!” she exclaimed. “Why not?” I asked. “We have to give him as much life [hai chīwit] as possible,” she answered. I must have had an inquisitive look on my face—we had just been discussing Peng’s decline in spite of ICU care. In response, Peng’s niece elaborated, “Our father gave us flesh [nư– a], gave us blood [lư– at], and gave us breath [lom hāičhai]. He gave us birth [kamn oēt], and now we have a debt of life [pen nī chīwit]. We have to pay down this debt [chai nī].” It was early in my fieldwork, and I was nervous that I was out of my linguistic and cultural depth. I had not yet engaged Tom Taem as a collaborator to make sure I understood, and my emotional range in Thai also did not include the subtlety or tact required to tread lightly through sensitive emotions. But I fumbled ahead: “So life is what matters . . . suppose your father was not good to you, and did not take care of you, or if you did not know him . . . would it be different?”

Paying the Debt of Life table 1

|

29

bua and phai’s “debt of life” to peng

Life Component

Ways to Pay Debt

Flesh Blood Breath

Nasogastric tube-feeding, surgery Dialysis, blood draws, IV medications, pulse oximeter Endotracheal tube, mechanical respirator, inhaled medications

“It wouldn’t matter,” said Bua without missing a beat, “even if father were a dog, a swine, a buffalo, even if he beat us or abandoned us. Life is a debt and we have to pay it back.” I asked how they were paying this debt, and they explained that they were giving “flesh, blood, and breath” to Peng through concrete care: his feeding tube a gift of flesh, his dialysis a gift of blood, and his respirator a gift of breath. I pulled out a piece of paper and asked them to list other treatments, making a small table; they helped categorize healthcare interventions into the scheme by nodding and saying “Yes, something like that,” smiling kindly at my doctor-like need to make a table (see table 1). Others that I worked with later often added the category “warmth” (khwām ‘op’un), making four categories of body that correspond to the elements of matter: earth (flesh), water (blood), air (breath), and fire (warmth). I would later learn that these four elements make up the body (kāi), which contacts with the spirit (winyān). At the interface of body and spirit, the self arises.1 Young relatives of other patients did not express the “debt of life” (nī chīwit) theory as formally as Bua and Phai, but they expressed a desire to repay (tō˛p thæˉn) their parent by giving life. One family that I befriended was so adamantly aggressive with medical care for their father, Tawo, that the old man underwent three rounds of cardiopulmonary resuscitation despite his pleas to go home. Later, at the man’s funeral, I asked his youngest son about the decision to keep fighting for so long. “In Thailand,” he explained, “our parents are our holy trees, our gods.2 We have to give them everything, to the very end.” “What do you mean by ‘everything’?” I asked, thinking to myself: you didn’t give him what he was asking for most, which was to go home! I was surprised by the intensity of this internal reaction, and flagged it as a moment of cultural disconnect to explore later, clearly a marker of concepts of autonomy and self-determination that I was bringing with me as both an American and a trainee in biomedicine, where individual rights dominate decision-making.

30

|

Paying the Debt of Life

He thought for a moment, and then said, “We have to give them life. Life is everything.” Here, early in my fieldwork, it was clear that this imperative, of lifeas-everything, was a vital framework, one that subsequently played a role to some degree in the decisions of every family that I accompanied. If the “debt of life” had simply represented a desire to aggressively treat illness, it would have been familiar to me: I had accompanied families in the United States who wanted to continue treatment despite being told of improbable odds of survival. Families often said that they were “holding out for a miracle,” or “not ready to let go, and wanting more time.”3 But there were also very unfamiliar things in Bua’s, Phai’s, and others’ explanations about this “debt of life,” and from those unfamiliar things, its contours as a framework began to emerge. The first of these was the insistence on continuing treatment while simultaneously accepting that it would be ineffective. Bua and Phai did not seem to argue with Peng’s prognosis: that he would likely die despite everything they were doing, and might even not live any longer. But there was a value to paying the debt of life in the present moment regardless of its ability to extend life. In my biomedical training, I had been socialized to think of medical interventions as valuable only for life-extension or symptom improvement. This was obviously not the case for Bua and Phai, just as it was not the case for Jandi’s family, who insisted that hers was a good death because of her trip to the hospital, regardless of whether or not it extended her life. Second, there was something unfamiliar to me about the way that Bua and Phai used the concept of “life.” At first, I assumed that “giving life” was synonymous with keeping someone alive. Though this was certainly part of it, there was also a way in which life was an object that could be transferred to an individual, in the form of concrete things (flesh, blood, breath, and warmth), manifest as the material technologies of modern biomedicine (mechanical ventilation, blood transfusions, dialysis). Life, for Bua and Phai, was not just an abstract property of human consciousness; it was also a thing. The definition of life I had come to expect in the West seemed somehow less material than this, perhaps more like an emergent property of complex biological systems.4 But Bua and Phai seemed to be talking about something material enough to be transferred.5 I first had a chance to understand this materiality through a serendipitous encounter early in my research. When I arrived in Chiang Mai to settle down for fieldwork, I set out on a bicycle to find an apartment

Paying the Debt of Life

|

31

in the back streets behind Chiang Mai University. In a small blind alleyway lined with banana trees, I came upon three young men running a food stall, selling grilled pork and green papaya salad. They invited me to sit with them. I ate one of their dishes, and then we juggled a football, and made small talk, saying nothing about my research. When I got ready to leave, they refused to let me pay, which I interpreted as a desire to strike up a friendship outside of a business interaction. We exchanged phone numbers. Later that evening, I received a phone call asking me to return to their food stall. I rode out to meet them, and was greeted by the youngest of the three, named Yai. He again asked if I would sit down at one of the tables. He was clearly nervous. He had mentioned on the phone being worried about putting me out by calling me across town on a bicycle, saying that he felt krēng čhai, literally, an “irritated heart,” a sensation of feeling like a burden to another.6 Not yet knowing why he had called, I realized I was likely about to get a request, and that treating me to a meal earlier had been an attempt to create a bond or a debt, to help overcome this feeling of krēng čhai. “We are brothers, from northeast Thailand [‘īsān],” he began. “Our uncle is very sick. They say that he needs a lot of blood transfusions.” “What is he sick with?” I asked. “The doctor says he has end-stage liver cirrhosis. He has been sick for a long time, but now he needs a lot of blood.” “I’m so sorry,” I said, “it must be hard to be so far away from him.” There was another long silence as I waited for him to continue, wondering where he was taking me. “Is there anything I can do to help?” I asked. He replied, “There is a problem. My uncle is blood type B-negative. B-negative blood is very rare in Asia. They say that they can’t keep transfusing him so much because they don’t have enough blood.” Another pause. He continued, “I looked on the internet and they say that B-negative blood is more common among Westerners [farang]. Do you know what blood type you have?” I told him that I was O-positive, which was incompatible with their uncle’s blood type but that I could help him contact other Westerners in Chiang Mai if he needed me to. But I was still confused about Yai’s plan: ‘īsān was twelve hours’ drive away. From my time in medical school, I had some sense that matching blood is not a simple process of one-to-one transfer; it requires a blood bank and careful testing and

32

|

Paying the Debt of Life

storage. It was confusing to think of this plan as coming from Yai’s uncle’s doctors, and I suspected it was an invention of Yai’s own, or a hybrid of parts of his uncle’s story. Maybe he was grasping at straws, trying to save his uncle. When I asked about the details of the plan, he said, “I don’t know, maybe someone could give blood here, and we could transport it there?” He used the Thai particle mang at the end of his sentence, to indicate not being certain of anything he had just said. It was clear that he had not thought his plan through but was still fumbling his way forward, driven perhaps by a desperate need to do something. I felt suddenly that I understood what was going on. Such a common reaction, I thought, so human! But then Yai said, “my uncle raised us after my father died. He is my closest blood relative [yāt]. And he fed me when I was little and sent me to school. Now he is dying and I have to pay him back for the life he gave me.” Here was this idea again, the debt of life, and I felt my understanding slip. We used Yai’s cell phone to call his aunt in ‘īsān, where she was sitting by her husband’s bedside in the hospital. She handed the phone to Yai’s uncle’s nurse. I asked about the man’s status and about the problem of transfusions. The nurse said that he did indeed have B-negative blood, but that he was already in liver failure and that they could not keep up with transfusions, not for lack of blood, but for lack of a longterm cure strategy. Other organ systems were failing, too, including his kidneys. When I explained Yai’s scheme, the nurse sounded affectionate but dismissive. “He has a debt to his uncle,” she said, “and he is trying to pay it back. He is just being grateful.” For “grateful,” she used the word katanyū: dutiful kindness, deference, and reciprocation to one’s elders. Yai wanted to help, and according to the nurse, this took the form of an attempt to pay back the debt of life—specifically to find a piece of life, a transferable living object, and mail it to his uncle. Yai, like Bua and Phai, was participating in an economy, replete with debt accrual, payments, and objects of value. The currency of the economy was life, a type of object that runs in families, coalescing both in birth and again near death in the failing bodies of one’s elders. Some of this economy of life was material—medications, life-support machines, surgeries; some of it was emotional—the expression of care and love through the need to do something. And some of it was material in a different way, through this material substance called life. I tried to ask Yai about this, but all I could think to ask was, “Why did you pick blood as the solution?” I was expecting an unhelpful

Paying the Debt of Life

|

33

response to my clunky question, like I just told you he needed blood, or something else pointing to the logistics of the clinical situation. But instead, he replied, “Blood is powerful. One lineage, one blood.”7 At the time, I did not understand this very specific set of phrases, but they became clear to me from later experiences, and particularly clearly through an event during the political turmoil of 2010: a group of protesters in Bangkok had their blood drawn by doctors in a refrigerated tent in the middle of a conflict zone, and then dumped buckets of their own blood on the gates of the Government House, shouting, “We will curse you with our blood, flesh and spirit!”8 When I asked people about this ritual, they said it had no equivalent in northern Thailand, but that the principles of it made sense: human life is contained at the interface between the spirit and the components of the body; life is powerful and can be used to curse (sāp chæˉng); so it makes sense that blood and flesh could curse as well. “Blood is powerful,” Yai claimed, meaning not only for saving life, but also as a container of the metaphysical power of life itself: for him, blood was life, blood was power. This is reminiscent of Alan Klima’s work on what he calls “the funeral casino” in Thailand, where life and death are part of an economy of karma (kam), of an attempt to maximize one’s merit (bun) and placement in the afterlife, exemplified by gambling at funerals to optimize the transfer of merit between the living and the dead.9 But in Yai’s case, life was not only an abstract metaphysical force affected by material things, it was also a concrete material thing in itself, something that could be transferred. Importantly, Yai added family to the network of meanings that formed the understanding of blood: “One lineage, one blood.” Several months later, a nursing professor at Chiang Mai University explained to me that a term of endearment for children in northern Thailand is kō˛n lư– at, literally “blood nugget” (also used as the technical term for a blood clot), implying that a child starts life as a small piece of his mother’s and father’s blood. This is an additional source of blood’s power, not just because it is a component of the interface between spirit and body but because it is the mechanism by which family becomes life. In many places around the world, blood is imbued with meaning, both physical and metaphysical, much of it tied to kinship and exchange. In the nineteenth and twentieth centuries, Europeans conceptualized race as generated by mixing blood, from the “one drop” definition of blackness in the United States to more graded concepts like “limpieza de sangre” (blood purity) in Spain and its colonies.10 In many places outside of Europe, blood mixing is perceived as generating many of

34

|

Paying the Debt of Life

people’s attributes, including during one’s life, rather than simply being present at birth. In parts of Melanesia, for example, persons are seen as made up of initial substances, such as father’s bone and mother’s blood, as well as ongoing contributions of food, ceremonial wealth, and bodily fluids.11 In some parts of India, ethnographers have noted that blood and other bodily components are regarded as material “substances,” or “codes,” that transfer characteristics of one person into another.12 And even in the supposedly individualistic West, ethnographies of organ donation and reproductive technologies reveal that many transplant recipients talk about receiving attributes of donors via their organs.13 Certainly, for Yai, sending blood was more than a practical treatment; it was also a complex physical and metaphysical exchange, simultaneously concrete and symbolic. He wanted to send life in the form of blood, which contained the metaphysical power to generate merit (bun) for his uncle and himself, to pay back his debt of life. And as outlined by Bua and Phai, blood was only one of four elemental components of human bodies with this power. In the ICU, they had been attempting to pay back their debt via all four components. Yai and his brothers found themselves in the terrible position of not being near their uncle. Unable to participate directly in his medical care, they needed to find another way. Of all of the elements, blood seemed like one that could be sent over a distance. They had learned that their own blood was medically incompatible with their uncle’s, and so they had flagged me down in an alley to see if they could acquire a compatible life object to send. Yai was engaged in a complicated choreography to get the necessary substances into his uncle’s body in time to ensure the optimal metaphysical transformation prior to his death. In this precarious, complicated choreography involving me and my blood, biomedical and metaphysical elements were inextricably interwoven. In these conversations—with Bua and Phai in the hospital, and with Yai about his uncle’s blood—I was struck by the technology that they deemed important to paying their debts of life. They described the debt itself as timeless, rooted in the relationship between body, spirit, and family, arising from the blood given by mother and father at the creation of a body. But paying of the debt of life now relied on what MaryJo DelVecchio Good calls a “biotechnical embrace.”14 At the time when Yai’s uncle was in the hospital, Thailand had adopted a “30 baht” regime, allowing all citizens access to any level of medical care for only thirty baht (~$1 USD) per encounter with the health system. The Thai medical establishment has long been able to

Paying the Debt of Life

|

35

operate relatively independently as an “autonomous political network” in the interstices between the more explicit political networks of monarchy, military, and elected officials.15 Relying on this role, in 2001, a small group of activist physicians pushed through the dramatic policy experiment of near-universal health coverage.16 Because of this policy’s relative political neutrality, it has remained remarkably stable despite the extreme shifts in other aspects of Thai government and policy.17 Although there are certainly class-based and citizenship-based differences in healthcare access in Thailand, there is a much more equitable landscape for healthcare utilization than in most low- and middleincome countries, and even than in many high-income countries.18 Some striking features of the contemporary end of life in Thailand can only be understood in this context. Even at a public hospital, families are able to choreograph death biomedically, rather than resorting to the kinds of brutal triage required of families in low-resource health systems.19 This explains some of the Thai political economy of hope at the end of life. People can confidently use healthcare resources for ethical logics like paying the debt of life only in a reasonably equitable, abundant system. Even in other contexts in Thailand in which patients and families bear significant long-term costs, such as chronic dialysis for kidney failure, the demands of the debt of life are mixed with harsh economic trade-offs, care rationing, and a more skeptical relationship to the medical establishment.20 But beyond the costs of transportation and time involved in using the spirit ambulance, the “last phase of life” as it was presented to me seemed relatively free of such concerns. This is not to say that economic factors were not central to the phases of dying in other ways, due to the connections between “level of mind” and social class. Later in my fieldwork, I sat at a funeral in the countryside next to an older man, and asked about the embrace of high-tech hospital medicine in paying the debt of life. He explained: In the old days, we used to care for our elders in the village. Someone would get sick, and they would go to the local doctor [mō˛ klāng bān], who would give them medication, or massage, or herbs. And their children would stay at home and care for them, feeding them, praying for them [athitthān hai]. And monks would come and chant. But now, the hospital is so modern! We revere [nap thư– ] the hospital. We think doctors can do anything. They are powerful because they have high technology and great knowledge.

Others emphasized that not everyone pays the debt of life with technology. Some felt that staying at home through severe illness was what

36

|

Paying the Debt of Life

their particular elder needed. But they were a clear minority. One physician explained: “As Thailand has developed economically, and particularly with the universal healthcare policies of the 1990s and 2000s, people increasingly revere the hospital. This is part of a trend in Thailand toward consumerism and technological solutions to problems.” Even prior to the new concept of the “end of life” that Arirat and Ampha emphasized was causing Thais to “think in a new way” about dying, death in Thailand had already become the province of high-tech biomedicine. The modern hospital, now so “revered,” had had the effect of shifting the ethical imperative of paying the debt of life from home to hospital. And for Bua and Phai, the ideal was to be at the locus of the highest technology of all, the ICU, where machines provided powerful flesh, blood, breath, and warmth. Yai, a young man, Bua and Phai, middle-aged women, and the older man at the funeral all described a unified “Thai culture,” as though everyone everywhere lived in a single social world, governed by a single set of resources, of ideas about right action combined with material realities to navigate.21 Some of this uniformity was a result of the concept of Thai culture concertedly enforced through Thailand’s “selfcolonization” process in the nineteenth century: the propagation of a national identity as part of a strategy to avoid colonization by convincing European powers that Thailand was already a nation-state.22 Unsurprisingly, this unifying culture concept was something that seemed to appear and then dissolve based on context. Differences in the concept of the debt of life (and in many other concepts presented here) often showed up—based on generation, class, and rural-urban divides—but this did not impede the tendency to return to a common narrative.

obligation and gratitude With Bua, Phai, and Yai, the debt of life was presented as a coherent, strong, commonly held understanding of what made a death good, tied to a phase of dying in which death was not the focus, though its reality was all too evident. But it would be an oversimplification to separate the “debt of life” too cleanly from other forms of care and other forms of debt that individuals owed one another. In fact, the debt of life was often imbricated with other types of care for dying individuals, and these types of care moved fluidly together in a complex framework. I learned of this from a woman named Hawm and her daughter Bet. Tom Taem and I met the two of them in the medical ward at Nakhon

Paying the Debt of Life

|

37

Ping Hospital. Hawm had recently been diagnosed with pancreatic cancer, already advanced enough to have turned her skin yellow, and to haze her consciousness. Her daughter Bet was on vigil at her mother’s bedside. Hawm had abandoned Bet at an early age, and Bet had been raised instead by her father. She had spent most of her life angry at her mother for leaving. She saw Hawm every few years, but it was always a painful and awkward encounter. Hawm had remarried. Bet had heard that the man was kind, but she had never met him. When I met Bet, she was in her twenties, and described herself as energetic, running an export sales business and teaching art to kindergarteners on weekends, always staying busy. She said that busyness was a way to keep her mind off of things. In the silence of inactivity, she encountered doubt and fear. She described herself as still always a little anxious, nervous, and lonely notwithstanding her active life. When Hawm was diagnosed with pancreatic cancer, Hawm’s new husband tracked down Bet’s phone number and called her, even though they had never met. Bet rushed to the hospital that same evening to sit by her mother’s bed. For the following days, she cancelled work for a half-day each day and came to care for her mother. It took me some time to get to know Bet. We discussed many intimate things about her life and her sorrow about her mother. It was only after all of this that I felt comfortable asking the real question on my mind: “Why are you spending so much time caring for your mother when you never knew her?” I left hanging what I really meant, but felt I could not say directly: why would you care for someone who abandoned you? She smiled, and said, “I know . . . it’s strange isn’t it? When I first heard the news, I thought: I don’t even know her. But then I thought: she’s my mother! She gave me existence, she gave me life. I have to pay her back [chai nī].” She paused for a moment. “It is hard, though. I have never had any phūkphan with my mother.23 I look at her and feel nothing, not angry, not sad, just nothing. I only feel like I have to pay back my debt.” The word phūkphan is translated as both “obligation” and “relationship” by most Thai-English dictionaries, but it needs unpacking: phūk means to tie or to fasten, and phan means to wrap around. Together they mean a kind of tie of affection, something that would link Bet to her mother, make her sad to lose this person, who had grown in her heart. Bet explained to me that it is the kind of obligation that

38

|

Paying the Debt of Life

comes from loving someone, from owing them part of oneself, and from needing to show that love to the world. Several months later, with a different family, one patient’s daughter explained to me why she was so aggressive with medical care for her father: “If we didn’t do all of this, people would say that we don’t care for him, that we have no phūkphan with him.” Most people who pay back their debts of life to a loved one also have phūkphan with them, or at least want to show the world that they do. The two sentiments mix together into a dutiful and loving kind of care. And those who do not owe a person a debt of life, such as spouses or siblings or friends, may have a great deal of phūkphan with them and be quite involved in caregiving. That day, when we left the hospital ward, Bet checked as she walked by to see if her mother was awake. Her mother was sleeping, so she turned and walked out without saying goodbye or touching her. Later, Tom Taem and I discussed this. We had seen similar moments with other families, and we both shared our expectation that Bet might show her mother a little intimate affection—a loving smile or a gentle touch. The absence of this connection seemed somehow related to her explanation that she had only a debt of life, without any phūkphan. One week later, the next time I saw Bet, this time without Tom Taem, she and I sat out on the balcony of the hospital ward, and she started to cry. “I was angry at her my whole life,” she said, “for abandoning me when I was only one year old. I barely know her. She never kissed me or hugged me or gave me anything. But yesterday when I came she kissed me on the forehead. It was the first time.” We walked back into the room. Bet’s mother was unconscious, but this time Bet walked over and put her hand on her mother’s arm and sat there, holding her affectionately and gently. Many weeks later, after Hawm had died, Bet and I drove up to the temple on the mountain overlooking the city, to donate money to make merit (bun) that would transfer to her mother’s spirit wherever it was. In the ritual aspects of Thai Buddhism, the results of karma—the consequences that arise from actions—are often conceived of as a kind of moldable and transferable metaphysical substance (bun). Following the rules set out in Buddhist texts, Thai clergy, a male ascetic monastic order (sangha), are tasked with maintaining the original scriptures and generating bun. In rituals, monks chant and meditate, and the resultant bun is carried through white threads to be infused into people or objects (including the famous amulets of power worn by many Thais).24 Laypeo-

Paying the Debt of Life

|

39

ple can make merit as well, through meditation or chanting or through acts of selflessness and generosity, such as by giving to good causes or helping others in need. The most common form of making merit for most Thais is the presentation of offerings or donations to temples (wat). Since bun is transferrable and social, those engaged in such activities accumulate power. Monks are thus not just respected, but revered as sources of spiritual power.25 This is also one of the mechanisms through which wealth is connected to spiritual hierarchies: making more merit means greater spiritual benefit, both now and in the future. Given that we were on our way to the temple precisely so that we could contribute to Hawm’s ongoing well-being in whatever form she took after death, conversations about her death flowed easily. I found myself thinking back to the difference between the two moments when Bet stood at Hawm’s bedside, separated by only a week, but with such a different affect and touch between them. I said, “It seemed like you developed some phūkphan with your mother in the few days before she died.” “Yes,” she said, and teared up. “It was a great gift.” Bet had always already owed her mother a debt of life. This duty brought her, despite estrangement and anger, to her mother’s bedside to give her mother the life that had been given to Bet at birth. At first, she had no affection for her mother, and thus had none of the particular intimate duty that came with it. She needed to be physically at the hospital, to be part of the process of using technology to give her life; but the process was cold and technical. Along the way, though, Bet built a new phūkphan with her mother and described that she would carry it for the rest of her life. This was surprising to Bet because most people describe phūkphan as developing over time, accumulated out of the moments of kindness and help that people show one another throughout their lives together. For most families, the two concepts, the debt of life (nī chīwit) and affectionate duty (phūkphan) coexisted. People often use words that combined them, such as nī bun khun, literally a debt owed (nī) for a prior merit accrued (bun khun), or simply katanyū, a term often translated as “gratitude,” but usually specifically referring to the debt-like gratitude one has to one’s elders. But most people that I spoke with made sure I knew that the stronger of the two debts was the debt of life. One helpful expression of this occurred during an otherwise unrelated casual conversation I had with a friend, a nursing professor at Chiang Mai University. She had asked what I had done that day:

40

|

Paying the Debt of Life

Scott: I just saw a TV show about a woman whose father abused her and her mother. The father was a friend of the police chief, so they couldn’t use the police to protect them. The father threatened to find the daughter and mother wherever they went, so they had no escape. The father said that he was going to kill them. So the daughter locked her father in the house and set it on fire. Nurse: No! Impossible! That is not even a thinkable thing here. That would be the worst sin [bāp]26 possible. It makes me cringe to even hear about it. Scott: What if the bad man had been her stepfather, not her father? Nurse: [Laughing] We would cheer her on! No, I’m joking a bit. It would be a sin to kill, the same as killing anyone else. But given the circumstances, we might understand. Scott: But because it was her father, it would be unthinkable. Nurse: Yes! One’s elder, one’s blood relative, holds a special status, because he or she provided the raw material, the nugget of blood, that became one’s body and thus one’s self. One thus shares the essence of life itself with one’s elder. And since blood is life and power, there is great potential for good or for harm contained in this shared substance. The most important debt that one has in life is to one’s parents, to repay them the debt of flesh, blood, breath, and warmth that they have given. Violating this debt is the worst conceivable action. Honoring it outweighs all others. All of this illuminates why Bua and Phai, sitting outside the ICU where their father was dying, would say, “We can’t think of stopping!” For them, ICU care was as much about paying back their debt of life as it was about cure. In my medical training, I had been taught a deep dependence on certain outcomes as the only criteria by which to evaluate medical decisions—mortality benefit, days of life lived, quality of life. For families, these things were not unimportant but co-existed with another outcome, the paying of the debt of life, that motivated them even once the chance for cure seemed to have passed. Bua and Phai wanted to continue ICU care even once Peng had reached a point of no return. Yai had been told that giving his uncle more transfusions could not cure his cirrhosis. Yai may have been hoping against hope, disagreeing with the nurse’s explanation of his uncle’s condition, or refusing to let it into his heart. But his language was conspicuously absent of this kind of biomedically legible outcome—such as wanting to have one last conversation with his uncle,

Paying the Debt of Life

|

41

or bridge his uncle’s life to some procedure that could cure his illness. He talked instead about the need to give his uncle a living substance, blood. This had the power to treat but not to cure; it had the ability to transfer metaphysical debt and restore a family imbalance in meritorious action and its consequences. The concept of the “debt of life” emerging from Peng’s and Yai’s stories required them to juggle many things: the cure-orientation of the hospital and paying the debt of life; combining the debt of life with other forms of care, like attachment and love; a reverence for the hospital’s metaphysically and physically powerful tools, contrasted to an imagined simpler, warmer village past, in which the debt of life was paid with food and personal care. These ethical demands made the first phase of dying, what might otherwise have been simply a process of seeking treatment, difficult to choreograph. Yai and his brothers flagged me down on the road to recruit my blood into a plan, an improvisation in the flow of time winding their uncle toward death, designed to satisfy the complex criteria that needed to be achieved before the final moment. Jandi’s family needed to wait for her to collapse so that they could deploy their prearranged plan to rush her to the hospital that she had been resisting. And beyond the doctors’ recommendations, Bua and Phai needed to figure out how to extend their father’s time in the ICU so that it was enough to pay down the debt of life. This choreography required skillful navigation of biomedical technologies (mechanical ventilators, blood draws, transfusions) and metaphysical principles (karma, bodily debt) to satisfy a complex set of criteria for a good death.

heart-mind energy As I came to understand the contours of the debt of life, I noticed an additional component of it that was unfamiliar to me and needed to be explored: it seemed to operate independently of elders’ own expressed wishes. Bua and Phai had no thought of ending treatment for Peng, despite the fact that when he awoke, he asked to go home. In my medical training in the United States, autonomy had reigned supreme among ethical principles, and I had internalized its importance to the point where hearing Peng plead to go home upset me, and I felt that his wishes were being violated. Initially, I thought that perhaps autonomy simply did not carry much weight for the people I accompanied, that the sign on Arirat’s wall about her right to refuse treatment was a heavy-handed, irrelevant foreign imposition. I would later learn that a different and

42

|

Paying the Debt of Life

more complex concept of autonomy operated for those choreographing the deaths that I witnessed, one that yet again combined a complex mixture of biomedical and other logics. This framework was based on yet another term, “heart-mind energy” (kamlang čhai). And unlike the “debt of life,” this term brought the wishes of dying individuals themselves into the ethical landscape. I first heard of this concept early, sitting with Bua and Phai. After they drafted me their table of technological interventions that were paying their debt of life, I was curious if anything on the list was more important than the others, or if all of the interventions were the same. I asked, “What do you think Peng needs most right now?” Bua answered without missing a beat, but she named something that was not on the list we had just made. She said “heart-mind energy” (kamlang čhai), a term that I did not yet know. We were then swept into other activities, because Peng’s nurse requested Bua’s and Phai’s presence at Peng’s bedside, and I had no chance to clarify its meaning. This turned out not to be a missed opportunity because the concept of kamlang čhai resurfaced in nearly every conversation that I had in my fieldwork. In the midst of discussions with patients about an extraordinary array of topics—surgery, finances, memories—family members would interrupt me and say: “You know, none of this is important . . . the most important thing is kamlang čhai.” The term kamlang čhai is difficult to translate, as is true with many terms that incorporate the word čhai, which means both “heart” and “mind” and is used to express a vast array of emotions and mind-states in the Thai language.27 In my fieldwork, some people described čhai as having a physical location, just below the diaphragm or in the lower chest, although they were quick to emphasize that the čhai was not a physical organ. One could simply feel its presence in that place. When people said, “I was thinking about . . . ,” they generally placed their hand on their chest or their abdomen, not on their head, always making me think of the mind-body division that I had inherited from Descartes, for whom the head thought and the body felt.28 The word kamlang means “energy,” or possibly “power” or “force.” At first, I took kamlang čhai as its dictionary translation: morale, or spirits (as in: “He is in good spirits”). I began logging phrases that incorporated the word: hai (“to give”) kamlang čhai, meaning to encourage or boost morale; mot (“to run out of”) kamlang čhai, meaning to despair or lose spirit; “to be kamlang čhai for someone” (pen kamlang čhai hai), meaning to inspire or support. But knowing how

Paying the Debt of Life

|

43

different the concepts of čhai and heart and mind were in English and Thai, I had a lurking suspicion that the term was the tip of a complex understanding of health and the body that would require some exploration to understand. My first chance to clarify this came through my encounters with a man named Mahu, and his daughter Pheuak. Prior to first meeting Mahu, I learned from the nurses at the hospital that he was dying of rectal cancer. He was there briefly for a CT scan, and I had only a moment with him and his daughter Pheuak before they were discharged home. They suggested that I find them at home for an initial interview. Pheuak said that this was a great idea, but briefly pulled me aside to say that we could come to their home as long as we did not tell Mahu his diagnosis or that he was dying. The next day, Tom Taem and I drove through rice fields, past temples and food stalls, to Mahu’s house, thirty kilometers from town. When we arrived, Pheuak greeted us warmly, but said that Mahu was taking a much-needed nap. She invited us to sit down with her on a cement table in the shade of a tree at the front of the house. It was the beginning of the hot season, and even in the shade, the breeze sweltered. After a few exchanges, we talked about the results of Mahu’s CT scan, which had shown extensive local invasion of his cancer. Harking back to my question to Bua and Phai that had first elicited the importance of kamlang čhai, I asked, “What does Mahu need most now?” I imagined from the flow of conversation that Pheuak might talk about the possibility of upcoming surgery or chemotherapy. But she responded just as Bua and Phai had: “He needs kamlang čhai.” As she said this, she moved her hand to a spot on her abdomen and turned it slowly like a turbine, simultaneously tilting her head to the side and half-closing her eyes, her face peaceful. “What are you doing?” I asked, imitating the movement and facial expression myself. “When you have kamlang čhai,” she said, rotating her fist as she spoke, “it makes you have mindfulness [sati] and concentration [samāthi] and be with your heart-mind [yū kap čhai], down here, so that the heart-mind is calm and quiet.” “And why is that the most important thing?” I asked. “We were just talking about surgery . . . isn’t surgery important?” “Without kamlang čhai, the surgery won’t work,” she said. “If grandfather runs out of kamlang čhai, he will think too much [khit māk], and thinking too much harms the body. We have to give him

44

|

Paying the Debt of Life

kamlang čhai, so he will be in his heart-mind and not think too much, and this will cure him.” This concept, “thinking too much [khit māk],” often translated as “anxiety,” is a powerfully negative mind state, and can lead to selfharm, both physical and psychological. Its opposite, “having kamlang čhai,” can have the opposite effect, the ability to cure, to confer vitality and life. This concept is at the center of an understanding of humans as having intimately connected mind and body, to the point where they cannot be separated. When I asked Pheuak about this connection, she said: “In the West, you use research to convince yourselves that heart-mind [čhit čhai]29 and body [kāi] are one. I read an article about Western scientists’ surprise about a study that showed that depressed people have worse results from surgery. Of course they do! That is a basic concept for us.” I had heard this argument before, often spun as a critique of Western society in general, as a civilization trapped in an age of anxiety, generated by an ever-worsening disconnect between heart-mind and body. Many Thais that I knew claimed that, unlike Westerners, Thai people know how to keep their hearts cool (čhai yen), to keep them from filling with hot and harmful worry.30 Pheuak was explaining that one major way to do this was to keep one’s heart-mind full of energy. When describing the concept of kamlang čhai, many people I worked with fused it with a second term: khwan, which translates roughly as “animating spirit.” Most living things are infused with an animating spirit. A rice field is vibrant and productive because it is infused with the khwan khāo, the animating spirit of rice. In humans, each organ is infused with a khwan, and there is a chief khwan that resides in the swirl of hair at the back of the head and is responsible for personality and vitality.31 If a khwan becomes frightened or disrespected, it may flee and leave the organ or person that it animates anemic and lifeless. A fled khwan leads to illness, and the khwan must return for vitality to be restored. There are sets of rituals designed to invite a khwan back into an abandoned body. Many scholars describe the history of Thai metaphysics as a baseline of pre-Vedic religious ideas (sometimes lumped into the category of “animisms”), punctuated by inflows of Hinduism and Buddhism from South Asia.32 The theory of mind encapsulated by the words khwan and kamlang čhai also reflects this history. Khwan is a deeply animistic concept, and it exists alongside the concept of winyān, or consciousness, putatively from the Vedic religions. Winyān, possible to translate as

Paying the Debt of Life

|

45

“soul,” is the consciousness of a person—the thing that remembers and decides and contains morality and its consequences. It is the entity that is reborn. Khwan, on the other hand, provide energy and vitality. When a person dies, the many khwan that animated that person and her organs disperse off and animate other things, and some talk about each khwan as having its own moral trajectory (we revisit this idea in chapter 4). This animation of organs recalls research on organ transplantation in other places, where receiving an organ from another person is sometimes felt to bring characteristics of another’s body into one’s own self.33 There are similar effects with organ transplantation in Thailand, supported by the concept of khwan.34 Often, when I talked with people about their sense of self, they referred to winyān and khwan as static, bounded entities. It was only later, when attempting to understand some of the new practices around the “end of life,” that people introduced me to the fact that each of these metaphysical objects is constantly changing, subject to the vagaries of karmic cause and effect, interconnected with other entities and people, a complex form of personhood that is difficult to account for with an individualist ethical theory. But when I was attempting to understand the “debt of life,” no one mentioned this complex, unstable personhood; apparently the debt of life was easier to think about if one regarded individuals as self-contained. When talking about how to pay back their debt of life, most people simply referred to kamlang čhai. But to help me understand how kamlang čhai worked, about half of these people used a fused term: khwan kamlang čhai. Heart-mind energy, they explained, is the animating spirit of the heart-mind, and just like any other khwan, it can suddenly flee and leave the heart-mind weak. Pheuak was in the phase of caring for her grandfather Mahu, a phase during which she both wanted to cure him, and to pay back her debt of life. She was worried that his “thinking too much” (khit māk) would make the cancer grow and weaken his body. Giving him kamlang čhai would suppress this thinking and fill him with vitality by allowing him to be with his heart-mind, represented by the twisting fist beneath the diaphragm. This would cure his body, paying back the debt of life she owed him for the life he had once given her. Notably, Pheuak did not say that Mahu needed to be “happy” (mī khwām suk), which was an emotion (‘ārom) and thus a superficial thing, almost like weather moving through the heart-mind, arising and dissipating according to its own whims. Nor did she discuss him

46

|

Paying the Debt of Life

needing to be free from pain, which was simply a feeling of the body (khwām rū sưk). Instead, he needed something much more substantial and real—khwan kamlang čhai, an actual thing unlike pain or emotion, capable of filling up and animating his heart-mind.

kamlang čhai and truth Pheuak’s explanation was a first step in clarifying an ethical framework, a framework clearly as important to the first phase of dying as the “debt of life.” But at the time, it still felt incomplete. It was missing an answer to the question about a dying individual’s own wishes. Pheuak’s explanation centered on her own need to fill Mahu with kamlang čhai, or sometimes on his need for it, but never on his requesting it. This was similar to Bua’s and Phai’s explanation that their choices for their father’s ICU care revolved around their need to pay their debt of life, or to Tawo’s son, who said that he needed to give his father “everything,” without explaining why “everything” did not include fulfilling his father’s request to go home. In fact, the theory of kamlang čhai seemed at first to evacuate ethical criteria of patients’ wishes. Pheuak was so concerned with Mahu’s kamlang čhai that she insisted that we could visit Mahu as long as we did not tell him his diagnosis or prognosis. Since “thinking too much” was the source of harm, a patient discovering his diagnosis risked making him suddenly “run out of kamlang čhai” and “shocking” him to death. Of the several dozen patients that I followed closely during my research, all but three were kept ignorant of their prognosis and their diagnosis for the duration of their illness. One of those who knew was Arirat, whose case was presented as exceptional, as depending on her engagement in a “new” way of approaching the end of life, and on her “level of mind,” which made her capable of using the information in a particular way, to further her progress along a spiritual path. On my first day recruiting patients to my study, I went around to every medical and surgical ward and introduced myself to the nursing staff. At one ward, the nurses eagerly descended upon me. “We have a patient for you now, we are so glad you’ve come, maybe you can help give him kamlang čhai.” They explained that his name was Nanban, and he had come in coughing blood. A CT scan just the day before had shown advanced lung cancer. They asked if I would like to meet him, and of course I agreed, a bit apprehensive about diving into interacting with an elder and his family so soon after such a grim diagnosis. But their positive tone, combined with the sense that I might be able to help

Paying the Debt of Life

|

47

give the patient some kamlang čhai, spurred me forward. I later learned that, because lay merit-generating activity leads to personal spiritual and charismatic power, physicians have long been revered in Thailand. One survey asked respondents to place people on a hierarchy of spiritual power, and physicians landed a notch below royalty and clergy, but above military leaders and politicians.35 No one refused to participate in my research during my fieldwork, and people emphasized that this had nothing to do with my ability to cure or treat, but simply to the desire to have me present, for its effects on patients’ merit. Standing outside Nanban’s room, the nurse said off-handedly, “They’re expecting you, but be careful when we go meet him, because he doesn’t know what disease he has or how bad it is.” From her intonation and my own experience with lung cancer, I assumed that by “how bad it is,” she really meant he doesn’t know that he’s dying. I felt another moment of nervousness. I was going in to introduce my research to a patient who knows nothing about his condition? But she opened the door and walked into the room, and I followed. Upon seeing a foreigner, Mr. Nanban’s son and daughter leapt up from their straw mat on the floor to intercept us. The nurse said, “This is Scott. He has come to do research. I want to introduce you to him.” I watched what I interpreted as panic run over Nanban’s daughter’s face, and I later learned from her that she was thinking in that moment: research, meaning research on cancer, he’s going to say the word cancer now . . . There was a palpable tension in the room. I presented myself in the most neutral way I could in the heat of the moment: “I am here to study the experience of very ill patients in the hospital,” I said, and presented my consent form, which fortunately I had written to address severe illness rather than cancer or dying. “I just wanted to leave some information with you and meet you. I’ll leave this form for you to read and think about, and I will be back on Monday.” The daughter looked instantly relieved, and I interpreted this relief coming from my benign choice of words. But she quickly added, seemingly regretful that she could not be more welcoming, “I don’t think we will want to participate. I’m so sorry.” Given that it was my first day, I left the hospital thinking to myself this is going to be very hard. After the weekend, I arrived to the same ward, and the nurse pulled me aside, “Scott, where have you been!? Mr. Nanban’s family has been asking for you all weekend! They want to participate in your research.”

48

|

Paying the Debt of Life

I was shocked. Had I misread the interaction from the Friday before—the daughter’s reluctance to have me involved, the nervousness in the room that I interpreted to be fear of me saying too much? “Why?” I asked. The nurse lowered her voice and pulled me aside. “The doctor accidentally told the patient he has cancer, and now Nanban has run out of kamlang čhai, and he is worsening fast. The family needs you to help give him kamlang čhai.” Later, I had the chance to interview Nanban’s doctor, who explained that he had been whispering in the room, discussing Nanban’s case with his nurse. He had assumed that Nanban was asleep and had thus spoken too loudly. Hearing the word “cancer,” Nanban opened his eyes and asked, “Do I have cancer?” And feeling unable to lie in response to a direct question, the doctor replied, “Yes.” The physician’s sudden need to say something later became a keystone in my understanding of the choreography of the good death, or in this case, of its failure. Nanban’s physician made a misstep in choreography, revealing something that he did not intend to reveal, and competing ethical frameworks came into conflict. In some ways, one might think of this as a moment of what Jarret Zigon has called “moral breakdown,” a situation when available ethical criteria contradict, propelling individuals out of their unexamined “being in the world” into explicitly choosing among competing ethical criteria.36 This breakdown was due to a complex relationship to truth, embodied by the sign on the wall declaring Nanban’s right to know his diagnosis, and by the whispered concealment of it expected of the physician. I spent the next three days with Nanban in the hospital, sitting with his daughter Buaphan and son Sak, talking in whispers about their father’s condition. Nanban was in pain, distracted, periodically in and out of consciousness. When he was awake, he was clearly distraught, and his family interpreted this as a kind of despair, literally a “rotten heart-mind” (tam čhai). It was not just the truth that had hurt him: Buaphan explained that there is something terrible about the word “cancer” itself, almost like a curse (kham sāp chæˉng), with the power to suddenly “shock” someone’s heart-mind and drain it of kamlang čhai. Many people were terrified of the word itself. It kills; it is rotten, evil, full of suffering, and leads to a bad death. I thought of the subtle and dark cloud of meaning surrounding cancer in the West through a long history,37 and the fact that here, in Buaphan’s explanation, there seemed to be a much clearer framework giving cancer’s harmful effects a mechanism of action on a person’s heart-mind.

Paying the Debt of Life

|

49

I found it particularly challenging to know how to communicate with Nanban during those days. I was accustomed to the truth of medical conditions as a basic premise in interacting with patients. Buaphan and Sak did not seem to want me to discuss Nanban’s illness with him, even simply to talk about how his doctors could relieve his symptoms in the coming days. I asked him open-ended questions about his experience, but this only caused him to loudly lament his fate, to describe his pain and anxiety. Buaphan and Sak tried to lead the conversation toward stories about relatives and home, to try to give him kamlang čhai, but he did not seem to register. I felt a pressure to find the right thing to say, but it seemed that nothing short of reversing the truth could help. And it did not seem possible to tell a convincing lie, such as, “the doctor was wrong, you do not actually have cancer, everything is okay.” The truth had been let loose, and there was no way to put it back. Nanban declined very quickly, over several days, and his physician said that he was at risk of dying in the hospital if he stayed longer, and so his family took him home, where Tom Taem and I sat vigil with them all in their mountain village. At home, he was clearly in pain, and continued to moan and writhe, and he died several days later. Afterward, at the time of the funeral, I drove through the mountains with Buaphan. For the first hour of our drive, we sat in silence. I had asked a question or two at the outset, but she seemed not in a mood to share. Then, suddenly, she volunteered: “The doctor killed my father, by telling him what he had. My father ran out of kamlang čhai. The words the doctor used made my father think too much, and so he died. Too fast! There wasn’t even any time to say goodbye.” This monologue expressed not only a devastating emotional loss but also a damning judgment of the cause of her father’s death. Cancer had not caused it, the truth had caused it. And the doctor, who delivered this fatal truth, was to blame. The choreography of death, with its order of actions in time, in this case had not only failed to produce a good death, it had actively made for a bad one. These experiences with Nanban, as with Pheuak and her grandfather Mahu, began to show the fact that it was not only important to repay the debt of life with life itself but also with kamlang čhai, to preserve a person’s vitality. Nanban’s daughter and son were attempting to navigate many imperatives: the hope of curing their father, the desire to pay back their debt of life, their affectionate duty—and in the midst of this, the truth lurked as a great danger. When it arrived suddenly, it killed Nanban by shocking his heart-mind and draining it of energy, leading

50

|

Paying the Debt of Life

to sudden decline and death. Meanwhile, there were further complexities I had not yet had time to explore, including the sign on the wall (just as on Arirat’s) that wanted Nanban to know his diagnosis, and the doctor who felt that he could not lie in response to a direct question. And I, too, had no idea how to relate to Nanban amid this complex hybrid of truth and avoidance of that truth. Nanban’s daughter had said that the doctor had “killed her father.” His was not a failure to understand and respect the relationship between kamlang čhai, “thinking too much,” and the body but a failure of choreography, of skillful execution. But with most dying elders that I came to know, the truth did not come tumbling out in this damaging way. Concealment seemed to function well. Watching Mahu and Pheuak interact provided great insight into the complex relationship to truth necessitated by kamlang čhai. Sitting under the tree outside Mahu’s house, Pheuak described some of the care that she provided for him. He had a colostomy bag draining his bowels through an opening in his abdomen, since his rectum was completely obstructed. Pheuak had to change and clean the bag for him every day. She slept in the room with him every night, next to his bed, so he could fall asleep holding her hand. And when he awoke in the night, she adjusted his pillows or gave him water or changed his bag. She said that these forms of care were a great joy for her, because she cared so much about him, and was so grateful (katanyū) to him for everything he had been to her throughout her life. Some of this positive spin on caregiving was certainly discursive: over time I would see that in reality caregiving in northern Thailand was as fraught with frustration and suffering as elsewhere in the world. In fact, Felicity Aulino has used data about caregiving in Thailand to illustrate the gritty, brutal aspects of caregiving at the end of life, partly to propose an action-oriented habit-forming model of ethics as an alternative to the mentalist models that elsewhere dominate Buddhist ethical theory,38 but also more broadly to challenge idealized presentations of caregiving as balm to the moral wound.39 After some time sitting beneath the tree, Mahu emerged from his nap and ambled with his cane across the yard to sit with us. He brushed aside my polite bow (wai) with a laugh and big smile and launched without introduction into a narrative about what a wonderful caregiver Pheuak had been for him. In our many conversations that followed, he spent most of his time talking about two topics: her care for him and his own positive state of heart-mind. “I am in pain, and sometimes I am dizzy

Paying the Debt of Life

|

51

dizzy!” he said in thick Northern Thai, and I was thankful that Tom Taem was there to translate into central Thai. “But I have so much kamlang čhai because of my granddaughter, she takes such good care of me!” On a visit several days later, when Pheuak stepped away to bring food, hoping to elicit some explanatory model of what was happening, I asked Mahu a more direct question: “What do you know about your disease?” But he simply answered, “I have so much kamlang čhai. I am so happy!” Tom Taem tried my question again several ways, asking about potential surgery, about his medications and what they were doing. He answered all of these questions in the same way, smiling and proclaiming his impenetrable kamlang čhai. At first, I thought that he did not understand, but after a while, it was clear that his responses were a willful avoidance of where we were trying to take him. When Pheuak returned, we talked of a host of other things, all of them about the kamlang čhai that he received from doing his favorite activities. He had a group of old friends that rode bicycles together from village to village, visiting with neighbors and heckling old rivals. He also liked to feed the chickens and trim the trees around the house, including the one under which we sat, of which he was particularly proud. Lately, however, he had had to stop many of these activities due to his illness. Pheuak was the enforcer, determining what was safe. “But it doesn’t matter,” Mahu said, “I can sweep the yard, that is enough for me to keep my kamlang čhai up.” After some time, Pheuak said, “Well, grandfather, we would like to go see the village temple, so I think we will go for a walk. Do you mind if we leave you here?” Mahu looked suddenly suspicious. He pointed at me: “He’s already seen the temple! You just want to get away so you can talk without me!” There was a brief awkward pause, and then he burst into his usual unbridled laugh, “Ha ha, I’m just joking! Go and have fun! I need another nap anyway.” And he ambled back into the house. This scene was repeated the next time I saw Mahu, this time at a doctor’s visit at the hospital. The doctor greeted Mahu and Pheuak, chatted with Mahu briefly about his symptoms, during which Mahu said again that Pheuak was a fabulous nurse, and that he himself was full of kamlang čhai. The doctor then asked Mahu if he would leave the room so that he could speak directly to Pheuak. Mahu stood up with his cane and went to the door. At the threshold, he turned around, looking feisty more than concerned, and asked, “Why do you want to talk without me? Is it bad?”

52

|

Paying the Debt of Life

“Don’t worry, no!” said the doctor. “You’ll get rid of this disease, don’t worry. We don’t want to bother you with the details of care and medications and such.” Mahu burst into his disarming smile and said, “Good! Because you know I don’t like details! Ha ha ha!” And he went outside.

choreographing the dangerous truth Pheuak’s desire and duty as a granddaughter was to pay back a debt of life to Mahu for the life given to her. In order to do this, she spent her days infusing him with kamlang čhai. Partly this involved concealing the truth about his diagnosis and prognosis from him. Mahu’s role as loving and appreciative grandfather was to perform both life and kamlang čhai for everyone to see. We were made to understand in everything he said that his spirits were high, he was fighting for life, and he was thankful for the care he was receiving. It was also vital that he collude with Pheuak in maintaining his own ignorance. Inasmuch as the truth was dangerous to his kamlang čhai, he was as much responsible for not knowing his diagnosis and prognosis as Pheuak was for not telling him. Temsak Phungrassami has used the term “collusion” to describe truth-telling in medicine in Thailand, to emphasize that forms of nontruth are co-constructed, with both parties responsible for maintaining them. This is distinct from the concepts of “deception” and “concealment” used to describe non-truth-telling in many Western biomedical settings, terms that imply one-sided abusive or paternalistic acts.40 Although Mahu occasionally asked directly about his illness, it was always jokingly, and Pheuak insisted that he was just being “feisty” and did not really want to know. Her explanation was supported by the fact that whenever I tried to talk him into discussing the details of his illness, he dodged the question by discussing his excellent kamlang čhai. As I continued to have experiences with patients in various forms of truth and non-truth about their illnesses, it became clear that I had come into my research with preconceived notions of truth and knowledge—that something was either true or false and that one had a moral duty to communicate solid, if difficult, facts. I quickly found myself very confused about how to move through truth and communication. A culmination of this for me came with a visit to the only official “hospice” in Thailand at the time, at the National Cancer Center outside of Bangkok. The hospice ward consisted of twenty beds, cordoned

Paying the Debt of Life

|

53

off in a separate section of the hospital. It was run by two interns, recent medical graduates who had been randomly assigned there for government service to pay back their medical school education. They both wanted to be radiologists, and were clearly unhappy at being stuck for a year having to talk to dying patients. Walking around their ward, I asked one quietly, “So everyone here knows that they are dying . . . ?” My experiences with Mahu and Nanban had made me curious about truth in clinical settings that might differ from those I was seeing in northern Thailand. I imagined that things might be different here in this very formal institutional setting in the nation’s capital. The intern responded, “It depends. Actually, most of them don’t know.” I looked baffled. This was the only “hospice” in Thailand at the time.41 I had expected hospice and palliative care to be mostly aligned with the discourses of social change whose beginnings I had observed at Nakhon Ping Hospital. Hospice, I imagined, was based fundamentally on the acceptance that someone was dying. The emotional and symptom-relief therapies at the heart of hospice and palliative care, at least in the United States, where I had trained, required that death itself be out in the open. Somehow, I was more surprised to find collusion here, at the nation’s official hospice, than I would have been in the provincial hospital where I had been working. “Do they know that they have cancer?” I asked. She thought for a minute, and said, “I think about 50 percent know.” This time, I was openly incredulous. “But we’re at the National Cancer Institute . . . the word ‘cancer’ is written in big letters on the side of the hospital, and on the wall of this room!” She paused for a moment and then said, “Well . . . you ask: ‘Do they know?’ What is it to know? They know and they don’t know. They know and they don’t want to know. We don’t tell them. They don’t ask. We give them kamlang čhai.” Seemingly without intending any particular depth, this intern had dispensed with a pillar of Western thought, a pillar that I had not known ran so deep in my own assumptions about the body, illness, and healing: that knowledge is black-and-white, something that one either has or does not have. Instead, she said, knowledge was simultaneously present and not present: “They know and don’t know.” And knowledge was less important than what was really going on, which was the provision of kamlang čhai.

54

|

Paying the Debt of Life

This subtlety will be no news to social theorists. Religious studies scholars had long before tossed out the word “belief” in a similar operation. Rodney Needham and Malcom Ruel have argued that belief is not a useful concept for explaining human behavior and decisionmaking, since, in the words of Galina Lindquist and Simon Coleman, it fallaciously assumes that: people’s ideas are necessarily formulated as coherent orthodoxies; that people are committed to them and hold them unquestioningly; that these ideas are experienced as inner states; that they form grounds of personal commitment or group identity and can be cited as explanations of personal and group behavior; that the referents of people’s words and behavior are imaginative projections rather than substantive “reality.”42

Scholars have shifted instead to more practice-oriented models of belief.43 Science studies scholars have performed a similar intervention around the term “knowledge”—from Bruno Latour’s illustration of the highly contingent, unstable, social process by which scientific “truths” become constructed,44 to Annemarie Mol’s illustration of the complex, fractal-like multiplicity and “enactment” of what appear to be stable disease categories.45 The hospice intern deconstructed both “knowledge” and “truth” in a similar way, saying that they were both things and not things, but, more important, that they did not really matter, because what mattered was the action, the practice of giving someone kamlang čhai, which existed in a plane orthogonal to truth and lie, to knowing and not-knowing.46 Later that evening, I told this story to a group of American friends. When I finished, a friend chimed in: “That’s ridiculous! They either know or they don’t. Maybe they’re faking, pretending they don’t know. But they probably really know.” I had been mulling over the intern’s claim, and played devil’s advocate to my friend: “Have you ever half-known something? And not let it into your heart?” And then, knowing a bit about this friend’s life, I continued, “When did you first know that you wanted to leave your boyfriend?” She thought for a moment, and said, “Ha! You’re right, I sort of knew, and then I waited because I didn’t want to know, and that was bad, because I really needed to leave, but I was still in it. I was carrying it around with me like a weight, but I couldn’t look at it. Then one day I really knew, and so I left.” Somehow, as regards love, my friend had no problem thinking about half-knowledge. But when it came to some-

Paying the Debt of Life

|

55

thing concrete and material like cancer, which seemed to be either physically in the body or not, half-knowing was much harder to grasp. Spurred by this experience, the next time Tom Taem and I saw Pheuak, I took the opportunity to see how this concept worked for her. “Do you think your grandfather knows what he has?” I asked. “Well . . . I don’t know,” she said. “Maybe. He knows. He doesn’t know. I’m not sure. He . . . he has kamlang čhai.” The important thing about knowledge was not knowledge itself but its effect on the heartmind. Mahu had kamlang čhai, and so whatever combination of knowing and not-knowing he currently had was working for him. This may have been why Mahu always dodged my questions about his disease, and diverted me to his kamlang čhai. It was partly because it was his job to show how much kamlang čhai he had, but also because kamlang čhai was the more relevant category. This felt in great contrast to the Western biomedical term used to describe similar situations: “denial,” a necessarily pathological form of not-knowing that prevents cognitive insight and understanding about one’s disease and situation, which are essential to a healthy emotional processing of illness. It also seemed in contrast with the trends of “positive thinking” that I had seen among patients in hospitals in the United States, which did not seem to rely on ignorance so much as on attitude about the truth, staying positive in the face of difficult circumstances. Instead, for Mahu, it was partly his duty to not know, in whatever amount of not knowing or partly knowing that kept his own kamlang čhai most intact. Later in my fieldwork, as I began to synthesize these frameworks regarding truth, I ran them by nurses, doctors, and family members. In that formal context, many of them referred to a scriptural Buddhist perspective on truth-telling, which involves opting for “right-speech” (sammā wāčhā) rather than “truth” (khwām čhing). Right-speech, they explained, is true, but it also needs to be beneficial, endearing, and appropriately timed.47 If there were a truth whose utterance would not aid another, it should not be spoken. Elizabeth Bennett, writing about cancer diagnosis disclosure in Thailand, has proposed that this produces a “soft truth,” as opposed to the cold, hard truth envisaged by the biomedical West.48 Others have shown that perhaps the hard biomedical truth is unique to U.S. biomedicine, based in a fierce individualism and legalistic rights-orientation, given that many places in Europe take a more fluid view of disclosure.49 But Pheuak pointed to something even more fundamental than a “soft truth”: the place of truth and knowledge in a hierarchy of values, where

56

|

Paying the Debt of Life

the manner and intention of communication is in some ways more important than the content, where the truth is more than an analytic fact, and cannot be averaged out of its interpersonal, social, and political context.50 This complex, ambivalent relationship to truth in both Nanban’s and Mahu’s worlds created a complex choreography. Both Mahu and his granddaughter spent a great deal of energy crafting his environment to contain the right information, in order to maintain and replenish his kamlang čhai. On the other hand, Nanban’s death, blamed on the physician who told him the truth, was not so successful, hinting at how precarious death could become if not properly choreographed, with the danger of truth lurking everywhere during the phase of paying the debt of life. And as I will describe later, landing into this environment, already complex, were the new visions of the patient as a seeker of wisdom or a rights-wielding citizen, like those in Arirat’s “new end of life,” pushing (sometimes gently, sometimes harshly) on the precarious balance of truth and kamlang čhai. The doctor’s choosing to tell the truth at a crucial moment was a hint of this. In the words of the medical intern, a patient’s job was to “know and not-know.” In some ways, this was a performance for all to see. In other ways, it was more like cultivation, an active process like meditating, a way of maintaining mindfulness and concentration, in order to “be with the heart-mind,” to keep the heart-mind calm and quiet. But it was not only a personal practice, it was also highly social, and so it required a choreography that included the internal experience of the world and the outward arrangement of relationships and communication. I learned more about this social choreography of kamlang čhai later in my fieldwork, with a patient named Meuandak. Meuandak was being discharged that day, his gastric cancer advancing but not yet causing enough harm to warrant ongoing inpatient care. I only had a brief moment to meet him and his wife, and we agreed to have our first meeting at their home outside of Chiang Mai. I met Tom Taem and we rode out to their home through a hybrid suburban-rural landscape, passing both shopping malls and rice fields. When we arrived, Meuandak and his wife invited us in and gave us tea. The atmosphere was unmistakably tense. By that point in my fieldwork, I had become more comfortable with Northern Thai and with comporting myself among people with illnesses in various stages of intensity, and I thus noted the tension as an anomaly. Silence sat in the room like a substance. Meuandak and his wife were overly polite about our presence. I had made a mistake and come from the hospital in my nice business-

Paying the Debt of Life

|

57

casual outfit. I sat in tailored pants on their teak-slat floor, in what was clearly a very small impoverished home. Tom Taem was dressed more appropriately, for which I was very grateful. She was also from a similar class background to Mueandak, which I hoped would help. But although she was usually excellent at making everyone feel comfortable, this time even her charming initial comments seemed to fall flat. Everything seemed to be going wrong. Meuandak also looked physically pained and was straining to pay attention to my presence, through what seemed to be a haze of suffering from his quickly evolving gastric cancer. The phone rang, and his wife answered. “Allo?” she said in Northern Thai, “we are meeting with a foreign medical student doing research at the hospital.” Meuandak’s wife reached out and handed me the phone, “It’s our daughter, she would like to speak with you,” she said. Tom Taem took the phone initially, but after exchanging a few words, she handed it to me, and it was clear that the daughter wanted to talk to me directly. I took the phone and introduced myself. “Thank you for coming,” said the daughter over the phone in Central Thai, “I just wanted to make sure you don’t tell my father what he has. If he knows, he will lose all his kamlang čhai and get worse. My mother doesn’t know either.” “Ok, thank you,” I said, trying to think of how to respond in a way that would not reveal what the daughter had said. “I am glad to help. I’m here to give kamlang čhai to everyone.” When I hung up, the tension was still in the room, and both Meuandak and his wife looked at me expectantly for my first question. I took a medical tack first, directing my question to Meundak: “I don’t know much about your case. Can you explain a little about your illness to me?” I was expecting him to talk about symptoms, and the first time he went to the hospital. If he mentioned anything about the disease, I expected him to say “I have a stomach obstruction,” a way of avoiding the word “mass,” which might hint at cancer. Most patients that I worked with had been told something partly true about what they had, usually something about the organ involved, describing a process or mechanism but leaving diagnosis and prognosis unstated. Instead, Mr. Meuandak shocked me by saying, “I have stomach cancer, stage four.” His wife jumped in quickly, “Please don’t tell our daughter that we know what he has! She will lose kamlang čhai, and we want her to have as much kamlang čhai as she can right now. She lives so far away, and her life in Bangkok is hard.”

58

|

Paying the Debt of Life

I sat stunned for a moment. Then I asked, “Who told you what disease you have?” “The first doctor,” Meuandak said. “I wanted to know because we live here all alone. We have to make decisions.” He paused, and looked at his wife, “What if she were the only one who knew and we were all alone? It would be too hard on her.” His wife shook her head, clearly upset at this decision. “It is too much for him, I worry that it is harming him.” They fell into a tense silence. It was clear that they did not want to discuss this further. Tom Taem and I returned to their home several times, and each time the same tension remained. Once, when Meuandak went to another room to use the toilet, his wife quickly whispered a rapid flood of words in Northern Thai to Tom Taem. I did not catch the meaning at the time, but I knew something important had happened. Soon, Meuandak returned, and we continued on in our usual awkward silence. On our ride home, Tom Taem explained, “She said so much in that moment! She said that Meuandak is out of kamlang čhai, and has talked about wanting to die. She is worried that his despair might kill him.” I could feel what she meant: when we were there, Meuandak did not seem to be doing well. He was always distracted, maybe partly by pain, but also by a dark cloud that seemed to hang over him, a nervous anxiety. His wife’s diagnosis of this was that he was “out of kamlang čhai.” For her, telling him his diagnosis and prognosis had been a mistake. Meanwhile, the two of them were concealing from Meuandak’s daughter the fact that they knew his diagnosis. This was to protect her from the worry that would come from knowing about her father’s lack of kamlang čhai, his “thinking too much.” Knowing about it might drain her kamlang čhai, too. The family was caught in a tense struggle, trying desperately to hold on to the remaining energy animating their heart-minds. Again, here was a clear example of choreography, of trying to coordinate actions and perceptions in the right configuration, in the flow of time, but in this case, it was failing. Everyone in Meuandak’s family knew that he had cancer, but they could not discuss it because such explicitness would endanger all of them. Temsak Phungrassami, as part of a survey on disclosure of diagnosis among radiotherapy patients in Thailand, asked two simple questions. First: “If you had cancer, would you want to know your diagnosis?” A large majority of his respondents said yes. Second: “If a relative of yours had cancer, would you tell them?” A large majority said no.51 This was a tension similar to the tension in Meuandak’s room: everyone

Paying the Debt of Life

|

59

wanted to know the difficult information, but wanted to conceal it from their loved ones. Temsak’s article did not speculate about the reasons behind this, but Meuandak’s story provided a possible answer: if a harsh truth were dangerous to the heart-mind, and if families loved one another, then each member of a family would want to assume the burden of knowing, to protect others from having to carry the knowledge, or at least to carry it alone. This generated a complex choreography, where each family member attempted to protect others from the dangerous truth, and at the same time performed his or her own well-being for the others. Knowing his diagnosis was “killing” Meuandak. And in their desperation to prevent this, to stay afloat, everyone in his family choreographed a kind of ignorance: Meuandak’s wife by lying to their daughter and whispering to us when he was in the toilet; Meuandak’s daughter by seeking to keep the diagnosis from her father; and Meuandak, by trying his hardest to keep his spirits up while we were there, despite his cloud of pain and anxiety.

autonomy and roles The first phase of Meuandak’s dying was fraught with ethical criteria: his daughter needed to pay back her debt of life; his wife and daughter both needed to pay their debts of affection; and everyone needed to play ignorant to preserve the family’s kamlang čhai. The asymmetry of some of these roles resulted in a theater of deception or collusion. This was the first hint I had at an explanation for why the wishes of dying elders might not be an important or explicit part of choreographing a good death in Thailand. If knowledge was harmful, and it was required for decision-making, then perhaps making decisions was harmful as well, and dying elders were thus just not incorporated in them. Later in my fieldwork a set of experiences began to unsettle my conception of patient autonomy even further. The clearest moment of this happened in a conversation with a friend, a nurse at the University Hospital in Chiang Mai. We sat one afternoon at a café, talking about our days. She described a case she was working on. An elderly man with colorectal cancer had developed abdominal pain at home. He did not want to come into the hospital, instead saying, “I am fine. Don’t worry about me. I have had a good life and am at peace with my illness.” But his son said, “No way. We’re taking you to the hospital, and we’ll do everything that medicine has to offer.” At the hospital, the old man said

60

|

Paying the Debt of Life

often, “I want to go home. I don’t need any of this treatment.” But his son always told the physicians, “We are treating him until the very end.” One day, the old man’s heart faltered, and the medical staff gave him cardiopulmonary resuscitation (CPR). He regained consciousness and asked to go home. They decided instead to continue with the plan to take him to surgery to debulk his tumor in preparation for chemotherapy. After surgery, his heart arrested again, and he received another round of CPR. He spent several days on mechanical ventilation in the ICU. His physicians then informed the son that his father had little chance of recovery, that it was time to take him home to die. After my friend relayed this story, I felt a sudden uncontrollable upset about the violation of this man’s autonomy. “He clearly expressed his wishes,” I said, “and everyone went against what he wanted!” She rolled her eyes. “You think so like a foreigner! The role [sūan] of a father is to say: ‘Don’t worry about me, I am fine, I am ready for whatever comes.’ And the role of a son is to say: ‘We’re doing everything until the end.’ They both do the right thing, and they both get merit [bun].” My nurse friend had again turned my conception of patient autonomy on its head with the word sūan, which can be translated as “role” or “part.” Here, it invoked a choreography, or a play—not to imply falseness, but to imply instead that there was a script, with each family member following his or her part. This was a vivid addition to my understanding that people seemed to be choreographing death, here with explicit and different roles. Even though there was conflict, each individual was playing his part well, thus accruing merit (bun). In other words, the old man and son in my friend’s case were each “doing the right thing.” If, in contrast, the father had said, “Yes, please take me to the hospital,” it would have shown that he was clinging to life, willing to burden his family with his own selfish interests. Likewise, if the son had said, “Okay, father, we’ll stay at home,” it would have shown a lack of caring, an unwillingness to pay back the debt that he owed his father for parentage and a life of caregiving. They would both have suffered, losing the opportunity to generate the optimal amount of bun at the end of the old man’s life. This was similar to the choreography of collusion around knowledge, with each person maintaining some combination of knowing and not-knowing, but practicing kamlang čhai so as to create and maintain more of it for everyone. Western bioethics, and particularly U.S. bioethics—partly from its need to find an ethical system able to appear universal enough to deal with a diversity of beliefs and cultures, partly from its highly legalistic

Paying the Debt of Life

|

61

rights-based environment, and partly from a material world that allows for emphasis on individual decision-making through the life course— has relied ever-increasingly on individual rights and autonomy.52 But the idea of patient autonomy is often divorced from this historical context and taken to be a universal principle. Edmund Pellegrino, after years of research on cultural differences in bioethics, was still driven to claim: Autonomy is still a valid and universal principle because it is based on what it is to be human. The patient must decide how much autonomy he or she wishes to exercise, and this amount can vary from culture to culture. It seems probable that the democratic ideals that lie behind the contemporary North American concept of autonomy will spread and that something close to it will be the choice of many individuals in other countries.53

Other scholars have tempered this with the idea that some families operate on a principle of “family determination,” with “family harmony” allowing distribution of decision-making between patients and their family members.54 But my friend’s story, and her analysis that families must act out appropriate roles in a play, unsettled the idea of autonomy even more deeply than this. For the characters in her story, disagreement, rather than harmony, was part of their ideal family script. By concealing diagnosis and prognosis from one another, and by insisting on paying the debt of life despite the protests of dying patients, everyone was “doing the right thing,” optimizing the merit that could be gained by all.55 In this choreography, the role of the dying person was to receive the life given, to craft and perform ignorance, and to accept suffering as an opportunity to eliminate the residual effects of past actions. In this framework, everyone’s actions and knowledge were linked, so that decisions and their consequences affected a family web, all engaged in a theater or choreography of exchange, in paying back debts of life. The Western bioethical solution to situations where families wish to conceal a truth from a loved one usually involves asking the patient how much she would like to know, or something like “To whom would you like us to tell the details of your results?” This had been my own experience in U.S. hospitals in my training up to that point, and it seemed like a sophisticated way of dealing with the difficult question of when to be less than fully truthful. But in Pellegrino’s words, this is actually the ultimate vindication of and reliance on autonomy, because “the patient must decide how much autonomy he or she wishes to exercise.”

62

|

Paying the Debt of Life

In Mahu and Pheuak’s case, it was clear that this strategy would precisely fail. In the choreography of the good death, each person wanted to assume the burden of knowledge in order to protect those around them. And so, if one were truly to protect one’s dying elder, one must protect her even from her own autonomy. Moreover, the question “What do you want to know?” might already contain information that there might be something dangerous worth knowing, and so the question itself could be dangerous. This recalls Joseph Carrese and Lorna Rhodes’s classic article on the failure of policies requiring discussing advance directives in the Navajo nation’s Indian National Health Service clinics. For many Navajo elders, words had the power to create reality, so discussing death and dying, even in the hypothetical, was a harmful thing to force someone to do.56 Later, once I began to put together all of the criteria layered together in choreographing deaths in northern Thailand, I came to see role requirements as one of the greatest contrasts to the arriving concept of patient rights, represented by the sign on Arirat’s wall. Arirat’s sign addressed itself to a generic (i.e., universal) patient, willfully flouting any family role and proclaiming the “right and responsibility” of every individual to know her or his diagnosis and prognosis. This impulse ran counter to the core of what families were trying to achieve in choreographing good deaths. Children of dying elders could not ask how much their elders wanted to know, because their elders would have certainly invited the truth, given that their own role was to protect those they loved from having to shoulder the truth alone.

choreographing the debt of life Frameworks for what constitutes a good death—imperatives like paying back the debt of life and giving elders kamlang čhai—reveal how complex and precarious it can be to choreograph a good death in northern Thailand. What people presented as the first phase of death was governed by the children’s imperative to give life, regardless of chance of cure—to give their elders flesh, blood, breath, and warmth, and to preserve their kamlang čhai, all to pay back a debt incurred for a body received at birth. Elders, in turn, had a duty to maintain their own kamlang čhai, by remaining in a state of not-knowing, or partly knowing, moving toward death without thinking too much, without jeopardizing or shortening their lives. This required a complex choreography, a dance in the flow of time, in which many things needed to be balanced—caregiving, often in

Paying the Debt of Life

|

63

the high-tech biomedical ICU, as well as the flow of potentially dangerous information. Different criteria applied to different individuals within a dying person’s social world due to the roles that each needed to play. These criteria were in a tense balance with one another, and individuals navigating them needed to improvise their way through them in precarious and complex situations, seemingly always on the verge of collapse: the elaborate techniques of truth-concealment in Mahu’s doctor’s office; the incomplete collusion keeping Muandak’s family in tension and fear; the push and pull between elders wanting to go home and their children wanting to pay their debt of life in the hospital. The people involved in the stories in this chapter presented the criteria for good deaths for their elders as a kind of status quo, as timeless and universally “Thai.” The “debt of life,” they explained, was something that all children owe their elders, a fact that Thais happen to understand and respect. Likewise, all people must maintain kamlang čhai in the face of adversity, although one must pay attention to the particulars of an individual’s psychological and spiritual makeup, to their “level of mind,” in order to effectively achieve this, leaving room for variations in what makes people strong or fragile.57 Part of the motivation for this book is an effort to understand how the choreography of death is changing in our contemporary world, particularly in the face of spreading medical technologies and expertise. And even though the “debt of life” and the maintenance of kamlang čhai were presented by the characters in this chapter as the status quo “Thai” way of approaching this phase of death, they were intimately interwoven with things that readers may recognize from all over the world. Debates about the normative approach to truth-telling are widespread in biomedical literature and in the experiences of patients and families in many places.58 Dilemmas and complications arising from the roles of family members in reaching medical decisions are equally widespread.59 What is clear from the first phase of dying in northern Thailand, however, is that even this “status quo” phase of dying was a complex combination of elements that dissolved a clear distinction between biomedical and other ways of managing death. The ICU and the home, the biomedical and the spirit world, all were seamlessly interwoven and intermixed. And another set of elements had now arrived in this mix: the sign on Arirat’s wall, and the English-language name for the “new end of life.” Globalization theorists have proposed tools for modeling how social forces move around the globe. Many of these ideas evolved in the 1990s and 2000s, when there was a strong sense in academic circles that

64

|

Paying the Debt of Life

globalization was a newly accelerating force.60 For example, Ulf Hannerz likened globalization to the formation of creole languages, arguing that social forms get assembled from pre-existing and arriving elements into a coherent grammar despite their eclectic origins.61 In another prominent model, Anna Tsing proposed that globalization involves flows of ideas reaching into local places, pulling everyone into a global current, causing friction whenever that current clashes with incompatible local worlds.62 Paying the debt of life has features of both of these frameworks: the hybrids of medical technologies and metaphysical logics in the use of the ICU look like a creole language; but patient-rights signs on the walls of Nakhon Ping Hospital may function more like a global current, clashing with the elaborate dance of collusion required to maintain kamlang čhai. Regardless, what is undeniable is that biomedical elements were an integral part of the status quo way of approaching the choreography of death as described to me in northern Thailand. Rather than point to a particular model of globalization, the stories in this chapter show that the first phase of dying was governed by a multiplicity of criteria for a good death, and that some of these criteria were connected to a broader world outside of hospitals and homes in northern Thailand. Dying was situated, specific to time and place due to a combination of social forces, some of them wide-ranging, and others very context-specific. And these forces made it very complicated for families to choreograph good deaths for their loved ones. It is perhaps this complexity of choreographing death, manifesting differently everywhere, that one could say characterizes contemporary death. In the next chapter, I show how an additional set of criteria for good deaths in northern Thailand overlaid the first phase of dying, leading to the phenomenon of the spirit ambulance, an arrangement that balanced the needs of hospital and home, of spirit and body, all in a dance designed to achieve good deaths for elders. Through this second phase of dying, a portrait emerges of how the mixture of biomedical and other resources have shaped the choreography of death.

chapter 2

The Spirit Ambulance

When I met Jandi’s family, they were assembled in the Nakhon Ping medical ward, waiting in tense silence. Medical interventions had already been set in motion, proceeding on their own rhythms—mechanical ventilation, inhaled medications, blood draws, daily vital signs, chest X-rays. The family’s process of paying back their debt of life had begun days before, with their journey to the hospital, to deliver Jandi into the stream of power that was technology and knowledge. And now they mostly sat waiting. Surprisingly, as her family would later explain to me, the pivotal turn in Jandi’s death had yet to come: it was not her collapse at home after coughing up blood, not her terrifying ride to the hospital, not her arrival at the hospital’s life-saving technologies. Instead, choreographing a good death for Jandi pivoted on a seemingly technical moment, three days after arrival at the hospital, amid seemingly interminable waiting. Jandi’s physician, reviewing her oxygenation numbers, blood pressure, and daily chest X-ray, told the family: “Her illness is too severe. She may die here in the hospital, even with full treatment. It’s time.” The family erupted into action. There was no doubt about the meaning of “It’s time”—everyone understood: it was time to get Jandi home. There was also no confusion about the importance of “time” in the doctor’s phrase. The family’s energy instantly shifted from tense waiting to action-packed emergency status. That news, delivered by the attending physician, suddenly shifted the perceived right way to care for her. 65

66

|

The Spirit Ambulance

Paying the debt of life was over; now it was time to do everything possible to ensure that her death happened in the right place, within a very narrow window of time remaining. This was the beginning of Jandi’s second phase of dying, in her case a short, precipitous one, clearly demarcated from paying the debt of life. For her, it stretched from the moment when her pending death was revealed to the moment when she would ideally take her last breath at home. And because the family had pushed the debt of life as long as they could, first into the hospital and then into the ICU, there was now a panicked atmosphere, a rush that would ultimately take us careening along mountain roads in the spirit ambulance, desperate to make it home before her last breath. In Jandi’s case, pivoting between the phases of dying occurred cleanly and clearly, largely because she was unconscious. But this was not always the case with the elders I followed. “I want to go home,” Peng whispered through his endotracheal tube to Bua and Phai. In some cases, the second phase of dying blended into the first, starting in some ways prior to leaving the hospital, creating an even more complex choreography of hospital care than just the first phase had alone. Components of the first phase, such as giving kamlang čhai, remained important, but shifted to a different kind of logic, one of crafting the contents of the mind at the moment of death, something that became fraught as the imminence of death loomed. Potential criteria for a good death, layered upon one another, robbed situations of clarity and required creative improvisation, not always successful. I learned a great deal about the potential messiness of this transition from Tawo, whom I met midway through my fieldwork. Tawo seemed to know that he was dying. No one spoke of this fact around him, not the nurses caring for him in the ICU, not his sons, not his daughter-inlaw Nai who was a nurse in the internal medicine ward next door. And especially not his youngest son, Loek, who was the most eager to give him kamlang čhai by telling him that he would live. But Tawo’s organs were failing. He was seventy-three, and his liver had begun to fail years ago, despite his never having drunk much alcohol, which is the most common cause of liver failure in his generation in northern Thailand. Throughout his middle-age years, he had bought medications from his local pharmacy whenever he experienced insomnia or a general sense of ill health. His favorite medication was bird’s nest, an originally Chinese medication popular in northern Thailand,1 which increased his overall vitality and cured many little problems. But among the other village medications that he took were steroids and

The Spirit Ambulance

|

67

mixed concoctions of antibiotics and pain-killers,2 and his physicians suspected that something among these may have destroyed his liver. Other organs had begun to fail, too. He had congestive heart failure and atrial fibrillation. His kidneys had been on a slow decline, and for several years he had been on twice-weekly hemodialysis.3 Eventually, he developed fluid overload that was increasingly difficult to manage with dialysis, and he ended up in the ICU, intubated for a time, and then was eventually extubated and moved to a medical ward, still dependent on relatively high-flow oxygen, despite now getting nearly daily dialysis in the hospital. His physicians felt that he was unlikely to regain good enough respiratory health to be free from hospital care. Through the years on dialysis, Tawo’s youngest son Loek had cared for his father, taking time off of work to stay home and tend to his father’s complex medical needs. Nai, Loek’s wife, said that Loek had a lot of phūkphan, affectionate duty, toward his father. Nai, a nurse in the hospital, had been to recent trainings in caring for patients at the “end of life,” which made her think that it might have been best to let Tawo “go peacefully.” But Loek did not want this, and was adamant that they treat his father as long as possible. “My father gave me life,” he said, “I need to give it back.” It was clear from my conversations with them that there was some tension at home and in the hospital over this disagreement, but Nai deferred to her husband. Nonetheless, when Nai sat with Tawo, instead of simply propping up his kamlang čhai with encouraging words, she gently asked him why he was so afraid, what attachments he might have that were making him cling to a particular vision of how his illness should go. She described this later to me as gently seeing if he was ready for the “new end of life.” But because Loek felt that talking about death itself would have destroyed Tawo’s kamlang čhai, Nai kept her words in the most generic of terms. The first time I met the family, I initially stood alone next to Tawo’s bed in the ICU. He mouthed toothless words to me and smiled a kind, grandfatherly smile. After a moment, his son Loek came into the room. At his father’s side, Loek fed Tawo gently out of a jar of bird’s nest extract, leaning over to listen to his father’s requests, responding in a way that would give his father kamlang čhai. But as I would later learn from Tawo, he felt that he was dying, and he was terrified. In fact, his terror was easy for all to see. When his son was not there, he had a wild-eyed look. One nurse told me that she would see from his monitor that he was hyperventilating and his heart rate was high, and she would hold his hand until his breathing and

68

|

The Spirit Ambulance

heart rate slowed and he started smiling again. I was curious that this nurse formulated his vital sign changes as fear rather than critical illness, especially given his atrial fibrillation, and so I asked her: “What do you think he’s afraid of?” She replied without hesitation, He is afraid of dying. Well, actually, I don’t think he’s afraid of dying, just of dying in the hospital. The hospital is a bad place to die. At night, he won’t let us turn out the lights. At first, we thought he might be scared of ghosts. But I think he doesn’t want to fall asleep because he’s afraid he will die if he does.

With this explanation, she invoked the core logic of the emerging second phase of Tawo’s dying, in which the place of death was paramount. Above all else, Tawo did not want to die in the hospital. And so he needed to keep himself alive. Keeping the lights on served to keep him awake, and thus alive. Throughout my time visiting Tawo, it seemed that he took every possible opportunity to let those around him know the precariousness of this arrangement. At one point in the ICU, he pulled out his endotracheal tube and moaned. Nurses came rushing in, and he said, “I want to go home.” The nurses were happy that he was well enough to continue breathing without the tube, and they considered this a success. After that day’s dialysis, they moved him to the regular ward next door, where his daughter-in-law Nai was working as a nurse and could watch over him more closely. I went to visit him there. When we made eye contact, he grabbed my hand and held it to his flank, which felt hard enough that I looked underneath to see if there was a piece of plastic or something surgical, but it was just his ribs with no body fat, and his hardened skin from kidney disease. He pulled me close so that I could hear his voice, still hoarse from the damage to his vocal chords caused by the tube during his ICU stay. “I need bird’s nest,” he said with urgency. I nodded, though I was not sure quite what I was affirming. He shook his head as though I did not understand at all. Now his voice was shaking with panic, and his eyes were wide. “Almost dead, almost dead!” he said. “I need bird’s nest. I’m dying.” The nurses had told me that he did not want to die in the hospital, but I was still shocked to hear him use the word “dying” so directly, so urgently, since I had always heard death discussed elliptically with phrases like “departing” (čhāk pai) or going home.

The Spirit Ambulance

|

69

“Are you afraid?” I asked, holding his hand again. He shook his head, “No, no, no. I want to go home. Please get me some bird’s nest!” I was still unsure of what was going on. What did bird’s next have to do with going home? “Do you want bird’s nest because you’re hungry,” I asked, “or because it’s medicine?” I was confused and overcome with a wave of sadness, seeing the fear in his eyes, feeling the tension in his hand. “Almost dead!” he whisper-shouted, urgent, pulling on my hand, pointing to a patient in the bed next to his, who was strapped into a mechanical ventilator, unconscious, his body rising and twisting with the artificial life support.4 “I’m going to die! I need to get better enough to make it home.” “Okay,” I said, thinking quickly, swept up into his panic. Doesn’t a person know when he’s dying? Who else could know better? “I’ll go across the street to the 7–11,” I said, “and get you some bird’s nest.” “No!” he whisper-shouted, and grabbed my arm. “I’ll die! Don’t go! There’s no time!” Then he began to cry, sobs wracking his frail, hardened body. I held his hand again—the only thing I could think to do in this strange crisis, whose nature I could barely grasp. After a moment, I said, “I want to stay with you, but I also want to go get some bird’s nest. What do you think is more important?” He stopped crying, thought for a moment, and then looked at me, nodding bravely: “Go!” I told the nurses about his state of panic, and one of them went to sit with him while I rushed across the street to buy a bottle of bird’s nest from the 7–11. When I returned, Tawo’s son Loek was standing by his father’s bed, feeding Tawo bites of stewed pork leg on rice, his favorite food. The panic of the moment before seemed to have lessened with his son’s presence, and Tawo simply nodded thanks when I put the bottle of bird’s nest onto his bedside table. Loek’s body, though, communicated some residual tension: his face was taut, and I interpreted this as him holding his father’s fear as well, and trying hard to keep everyone’s kamlang čhai intact. A few moments later, Tawo nodded off while eating, and his son slapped his face lightly, waking him back up to the world of the living. On waking, Tawo’s eyes filled with sudden fear, and he nodded vigorously, as if to say, “I’m still alive, I’m still alive,” convincing himself and his son. Then he paused, looked at his son and said, “I want to go home.”

70

|

The Spirit Ambulance

His son looked despondent. Later, I had a chance to speak with Loek, and asked him again about the phrase “I want to go home,” which for others that I had followed had clearly been a metaphor for dying. “Dying,” he replied, “has to take place at home. So when someone says ‘I want to go home,’ they mean two things, mixed together. They mean ‘I want to go home,’ but they also mean ‘I want to die, I am ready to die.’” When he explained this, I was struck by how much the phrase not only stood in for death but also declared how vitally emplaced death must be. Tawo’s current struggle was not just about death and its prevention, but about its location. Loek was still engaged in the process of giving his father life in the hospital, but his father had stopped playing his part in that particular drama, had stopped performing kamlang čhai and participating as a dutiful recipient of life. And so Tawo’s care had become full of struggle: the two phases of dying, paying the debt of life and dying at home, had begun to bleed together. The pivotal moment of Jandi’s death, a physician’s declaration of the futility of medical care, had yet to arrive. And so the criteria available for how to choreograph Tawo’s death had begun to overlap messily, with no clear pathway forward. That night, an event occurred that I was later able to reconstruct with help from Tawo and several of his nurses. Tawo felt particularly like he was going to die in the middle of the night, mostly because he had not slept in over a week, and he was beginning to nod off despite his efforts to stay awake. He was in the open-air medical ward, with machines ticking and breathing, with lights on and people bustling around. Nai was not there because she had gone home to sleep, though she often stayed beyond her work shift to spend nights there to look after Tawo, alternating with Loek. Despite the lights, Tawo kept falling asleep, and would then wake with a start and scream. When the nurses arrived to check on him, he would mouth, “I want to go home,” using his hands to act out the things he wanted to do there: washing dishes, making food, tying loops of sacred thread (sāisin) around his grandchildren’s wrists to bless them. He asked the nurses for his wallet, so that he could hold money in his hand to take with him into his next life, in case he died accidentally in the middle of the night. Once the nurses realized that he was not in physical crisis, they continued to go about their work, and increasingly ignored his pleas as they fulfilled their very demanding duties, delivering medications and drawing blood. Tawo explained later that he suddenly realized that night that the project of getting better to go home was not working. He guessed that if he were to get worse, they might take him home to die. The problem

The Spirit Ambulance

|

71

was that he needed to get worse but not die, so that they would decide to take him home while he was still alive. This was a challenge, but seemed preferable to continuing to fight to stay awake, since falling asleep held the risk of dying without knowing it. So he removed his oxygen cannula from his nose and wrapped the cord around his neck, pulling tight, trying to cut off his air. But the cord was weak and had no effect. Eventually a nurse saw him and rushed to stop him, and restored the oxygen to its right configuration. As Tawo explained the next day, he could think of no other strategy, so he went on waiting, trying to stay awake to stay alive, until the morning, when his family and I arrived and heard this story from him and his nurses. I sat with Nai, Tawo’s daughter-in-law, at the nursing station while we heard about these events. I could feel that there was much under the surface, since she had been advocating for days that they let Tawo “die peacefully,” and I also imagined that my presence may have led to some scrutiny on the situation, either simply as an outside gaze, or even more strongly as a foreign doctor clearly curious about the new vision of the “end of life” at the hospital. “We’re all realizing,” said Nai, and I knew by ‘we’ she meant Loek, whose affectionate duty (phūkphan) and debt of life were the strongest, “that grandfather is almost in the last phase of life. We need to take him home, so he can die at home. Maybe we’ll take him home tomorrow after his dialysis.” That night, Tawo went into cardiac arrest and lost consciousness. The doctor on call was nearby and initiated CPR. It took ten minutes to restart Tawo’s heart, after which he was intubated and placed on mechanical ventilation. He remained unconscious, his ribs broken and his chest bruised from the CPR. The nursing team called Nai and Loek, who rushed to the hospital. I was not present for what ensued, but Nai and Loek helped me reconstruct the details later. That night, after this crisis, it was clear that Tawo was on the edge of death, so they called for a hospital ambulance. They did not use the services of the guard that Jandi had used, because Nai was a nurse and they could afford to hire a fully equipped ambulance. They removed Tawo from his respirator and attached a hand-pumped bag to his endotracheal tube. Nai did the pumping, and she later explained how fortunate it was for him to have a family member who was a nurse, so that his care could continue along the way home. At that point, his cardiac function was dependent on pressors—medications to maintain blood pressure and organ perfusion—and these medications

72

|

The Spirit Ambulance

were continued, hung from an IV pole in the ambulance. All of this, as with Jandi’s spirit ambulance return home, was calculated to ensure that he would make it home before taking his last breath. In the ambulance, they folded money in his hand, meant to provide wealth in the next life. They wanted him to have it on the way home, in case the mobile equipment failed to keep him alive. They whispered in his ear: “namō, namō, namō,” the first word of the Homage to the Buddha. And they told him about landmarks they were passing so that he would know the way home in case his spirit had already begun to separate from his body. When they reached the house, his heart was still beating, and Nai was still pumping air into his lungs. They sat with him for a time, and family members took turns using a small silver platter for a ceremony to ask Tawo for forgiveness, telling him to let go of any worries he might have about them, telling him to clear his mind and think of the Buddha. Then Nai withdrew the endotracheal tube, and Tawo took his last breath and died. Later, at the funeral, I asked Loek about how he thought everything went with his father. That was when he said, “In Thailand, our parents are our holy trees, our Gods. We have to give them everything, to the very end.” My cultural disorientation revived and unexpected anger welled up in me. “What do you mean by ‘everything’?” I asked, since it seemed to me that they had not given him what he had asked for most, which was to go home and die days before. Loek thought for a moment and then brilliantly encapsulated the ethical imperatives behind the first phase of dying. “We have to give them life,” he said. Even though Tawo had said that he wanted to go home, Loek had interpreted his request simply as having lost kamlang čhai, and thus rather than bringing Tawo home, he redoubled his efforts to bolster his father’s courage, to restore the animating spirit of his heart-mind. It only became clear after things turned medically catastrophic—with Tawo unconscious after CPR, teetering on the precipice of death—that the phase of giving life had come to an end. Later, without prompting from me, Nai said: “We are so glad that he was able to be at home when he died.” “Was he conscious?” I asked, still confused and trying as gently as possible to push on this idea of dying at home. What did it mean to die at home, I thought, if he was not awake to know it? “He took his last breath there,” said Nai.

The Spirit Ambulance

|

73

This simple conversation summarized the conception of death as a thing and as a human experience that was key to the second phase of dying, to “the last phase of life.” Tawo’s death was good because it had occurred at home, regardless of what preceded it. Tawo’s death had taken place at a moment, describable physically (the last breath that had kept his spirit and body linked), and also somewhat ephemerally (like a thin dividing line between two states of being). The chaotic and suffering-filled days leading up to Tawo’s death were much less important than the simple fact of where death itself occurred, and those days were important for paying back the debt of life, regardless of the suffering that it caused. And then death itself was simply when his spirit separated from his body; if this occurred in the right place, and with good contents in his mind right at that moment, then a good death had been achieved. A Thai Buddhist scriptural understanding of death teaches that the moment of death is important partly because the contents of the heartmind at the moment of its separation from the body affect the status of the spirit as it moves onward to rebirth. A heart-mind full only of peace and acceptance makes for a spirit free from clinging to worldly things— a kind of clinging that could “stick” (tit) to the spirit and negatively direct its rebirth.5 However, Loek and Nai did not seem to think that the suffering-filled events leading up to Tawo’s death were particularly relevant to the contents of his heart-mind at the moment of death. The place where he died seemed much more important, and besides, by the time he got home, he was unconscious and thus not suffering. Scripture also teaches that after the moment of Tawo’s death, after the irrevocable separation of his spirit from his body, a process of slower, less physical separation begins. Tawo’s spirit would not suddenly be gone forever, but necessarily needed to remain partly nearby, hovering around the body, though also precariously able to separate and go elsewhere. This state was similar to the state outlined by Robert Hertz in his classic study of the Dayak of Borneo, expanded to a broad theory about the dying process in many places: an “intermediary period” between two deaths, when the spirit has separated from the body, but has not yet reached its final destination, remaining partly in the world of the living until funerary rituals are complete.6 In northern Thailand, the body is cremated at the end of a funeral process lasting an odd number of days, usually 3, 5, 7 or 9 depending on auspicious dates and the financial means of the family, their ability to maintain supporting rituals for that length of time. But the cremation is usually not hot enough to destroy the bones, and this physical remnant is enough to keep the spirit in this

74

|

The Spirit Ambulance

world for another hundred days until the bones are destroyed, and a final transition ceremony is performed. The period between death and cremation, and then between cremation and the destruction of bones, form two distinct “intermediary periods” between life and rebirth.7 Thus the spirit of Tawo, in a newly vulnerable state, would remain until ultimately reborn many days later. Because of this, the state of mind of the dying individual at the moment of death was not the only way to affect rebirth; since his spirit would remain around and connected to events and people, rituals could then be used to transfer positive karmic power to it. This is why it was paramount for Tawo to die at home, because there was something about home that would facilitate that process. At the funeral, a four-minute history of Tawo and his illness was read aloud for a large crowd dressed in black, sitting in bleachers. It listed his family members, and then said: Father Tawo was a farmer, and when he was not farming, he sold umbrellas and fans. He worked with honesty, diligence, and perseverance to care for his family. His children have all raised families and become good people, some government workers and some in private business. Father Tawo passed away peacefully at home from kidney failure on May 13th at 8:51 a.m. His wife and children made merit up until the moment [of death]. Father’s goodness and love will be wrapped up in our hearts forever.

According to this eulogy, and according to Loek and Nai, Tawo had died “peacefully, at home.” In my foreigner’s mind, there seemed to be absolutely nothing peaceful about Tawo’s death. Everything seemed to have gone wrong: he was terrified and upset for many days before dying; then his body was pummeled and pumped full of medications to keep his heart beating until he arrived home and was taken somewhat precipitously off of life support. But like Jandi’s family, those around Tawo insisted that all was well. The chaotic activities leading up to Tawo’s unconsciousness were modeled as a process of “giving life”—not really related to death at all, just consisting of “ordinary patient” existence, as clinicians had insisted upon hearing about my research. This giving life was done in the choreography of the “biotechnical embrace,”8 the care provided through powerful high-tech equipment, supercharging the payment of the debt of life. And then the chaotic, rushed process of getting him home was modeled as “the last phase of life,” mostly logistical in its valuation, focused on ensuring the right place for the last breath. This choreography, relying on a complex combination of biomedical elements woven together with other imperatives, was deemed a success.

The Spirit Ambulance

|

75

But despite the insistence that everything had gone well, there were obviously tensions, and the eulogy was clearly as much an after-the-fact justification as it was a description of the frameworks used to choreograph Tawo’s death. Loek and Nai had disagreed about how to proceed with the phase of “giving life,” and Tawo himself had certainly not been part of the plan. One might say that that his adamant pleas had simply been playing out his “role” in an appropriate family drama, but this would be difficult to stomach, since he seemed so deeply disturbed by being in the hospital. Choreographing Tawo’s death was highly fraught, and this was largely because his ethical world had become so complex that it was difficult for those involved to move forward cleanly. The phases of dying, with their attendant criteria, had bled into one another. Loek’s need to pay the debt of life, only achievable in the hospital, was incompatible with keeping his father’s kamlang čhai up, which would have required going home and accepting death. This bleeding-together of phases of dying was largely due to the fact that the debt of life had been relocated from the home to the hospital. And so Tawo’s end of life was partly fraught due to the ambiguity of medical technology, which could potentially have kept Tawo alive indefinitely, bouncing back and forth to dialysis. This ambiguity manifested in Tawo’s physician, who had been unwilling to make the paternalistic decision to help the family accept that a death was imminent and inevitable and shift from one ethical framework to another. This was partly due to the medical details of end-stage kidney failure, which is characterized by a kind of waiting that blurs the transition between the debt of life and the last phase.9 The criteria for choreographing death thus blurred, and everything became chaotic. Tawo’s story introduces in sharp relief many of the criteria that undergird the choreography of the second phase of dying, governed by a conception of death as taking place in a moment. The hospital, to Tawo, was a terrifying place, full of unsacred and dangerous things. And he contrasted this to home, which he imagined to be a far better place. He enacted this with heartbreaking vividness: making food, a sign of life and vitality, and tying loops of sacred thread (sāisin) around his grandchildren’s wrists to bless them, a sign of the kind of moral and sacred power of the place. Everyone clearly agreed that Tawo’s debt of life needed to be paid in the hospital, but that he also needed to die at home, so much so that they restarted his heart and placed him on lifesupport, largely to make sure that his last breath was taken at home.

76

|

The Spirit Ambulance

To fully understand this tension and why it became so complex for Tawo requires a journey into the imaginaries of place that made up Tawo’s local moral world: the imaginaries of hospital and home, as figures and realities.

the hospital: power and danger From the beginning of my fieldwork, it was clear that the hospital was a powerful but ambivalent place for dying individuals and their families. The first person I asked about the hospital as a place was Bet, the young woman who had come to care for her mother Hawm despite their lifetime of estrangement. Motivated to care for her mother primarily by the debt of life, she focused on concrete forms of care. “I feel better when I’m doing something, because otherwise I don’t know how to be around her,” she said. So instead of affection, she provided things. When her mother was hot, Bet went out and bought ground ice at the market across from the hospital. She wiped her mother’s forehead and helped clean her bedpans. Later on, as she developed some sense of affectionate duty (phūkphan) toward her mother as well, she started to focus on her mother’s own requests, even though they contrasted somewhat with the debt of life that Bet was paying in the hospital. When she looked Bet in the eyes, kissed her for the first time, and said, “I love you,” Hawm also said, “I want to go home.” Bet quickly latched onto this and prepared things in advance, waiting for the physicians to say that it was time to go home. “Why is it so important for her to die at home?” I asked Bet. “The hospital is not a sacred [saksit] place,” she explained. “The home is. It would be bad for her to die here. Her spirit would not be happy.” Her word “sacred” (saksit) made me think of Tawo’s imagined activities at home, about the closeness of family, and some of the things that Nai had described happening urgently after Tawo arrived home, and before he drew his last breath, such as using the silver platter used to ask for forgiveness. I asked Bet if this was what she meant, and she nodded, “Exactly!” “If your mother died here in the hospital, couldn’t you do those same things here?” I asked. “Couldn’t the family come and be here for the final moments? Couldn’t you do the forgiveness ceremony here?” She nodded, but without enthusiasm. “The hospital is not sacred. We would make merit and we would put money in her hand and ask for forgiveness [khō˛ khamā], but the merit would not get to her as well.” “You mean the same ceremonies have no effect here?” I asked.

The Spirit Ambulance

|

77

“Well, they would work,” she said and sat quiet for a moment before adding, “but probably only 60 percent.” Then she paused, and looked around. “This place, the hospital, wouldn’t help the ceremonies work.” We sat together for a moment, looking out over the medical ward. It was an open ward, with some of the patients on mechanical ventilators due to overflow from the ICU. Nurses scuffled around wearing gloves, wheeling blood-pressure check units to the beds of almost corpse-like patients, strapped into the machines of biomedicine. I asked her to describe what she saw. She said that the atmosphere to her looked “cold,” and the noises were “mechanical and inhuman.” “The nurses are very kind,” she said, “and the doctors. But they are scientists. It is a powerful place [mī amnāt] here, but the power is from technology and knowledge. There is nothing of warmth or sacredness.” Bet did manage to get her mother home to die, but I was not there. Tom Taem and I arrived several days later at the funeral. During a quiet moment, I asked a group of relatives about the ceremonies they had performed at Hawm’s bedside before she died. They had placed money in her hand and asked for forgiveness, and they made merit at the temple that day. “Would those things have worked if you had done them at the hospital?” I asked. “No!” the group responded. When I looked confused, Hawm’s husband leaned over and said, “Making merit has to be done at the home or at the temple. Otherwise, it’s just not 100 percent.” The hospital, ideal for paying the debt of life, was not ideal for dying, and this complicated the choreography of death for nearly everyone I encountered. One woman, named Janpeng, whose mother Kiang was in the hospital with lung cancer, initially told me that she wanted her mother to be at the hospital until the very end, including her death. This was a great surprise to me because I had yet to meet someone who did not place a premium on dying at home. But the next time I interviewed her in the hospital, outside her mother’s room, Janpeng looked even more strained. She fidgeted with brochures and books of Buddhist sermons that were laid out on the hall table between plastic couches. I asked what was on her mind. “I can’t decide whether to take mother home or not,” she said. “I think she should be here, but I just can’t stop thinking that I’m making the wrong decision. What do you think?” I asked Janpeng why she wanted her mother at the hospital. “The hospital has a lot of power [mī amnāt],” she said. “It has equipment, it

78

|

The Spirit Ambulance

has knowledge, it has doctors. My mother gave me life, and I want her to be close to the doctor so that he can take care of her.” “So why are you confused . . . why do you want to take her home?” I asked. “The hospital is missing so many important things for the last phase of life,” she said. “There are no monks here. They come to visit, but their prayers don’t work well. A monk came to visit mother last week, and he said he would chant, but that it wouldn’t help much. She needs to go home or to the temple. And all of mother’s things are at home. It is where she grew up, it is familiar and comfortable. It is safe at home.” She formulated the hospital as both containing and lacking power. It had the power of modern technology, but it lacked the power of sacredness, of ceremony. Part of Janpeng’s duty at the end of life was to ensure that her mother’s spirit separated from her body in a beneficial place, to optimize the ritual transfer of merit—of positive karma—to her mother’s spirit. This process would be less effective in the hospital, and so dying there would be a kind of failure. But there was more than lack in individuals’ imaginaries of the hospital. Lack certainly did not seem enough to explain the visceral terror that Tawo felt at the thought of dying in the hospital. The nurse describing Tawo’s fear did not say, “The hospital would not be a good place to die;” she said: “The hospital would be a bad place to die,” using the word rāi for bad—a strong and damning diagnosis, translated in ThaiEnglish dictionaries variously as “fierce,” “cruel,” “harmful,” or “evil.” And even Janpeng’s description of the hospital and home, formulated much less dramatically, contained hints of something other than simple lack. She said, “It’s safe at home,” and at first, I did not pick up the implication that this meant it was somehow therefore unsafe in the hospital. And although Janpeng wanted her mother near the doctor because it was “safe,” she also wanted her at home because it was “safe.” These were not the same kind of safety. This difference became clear a bit later in my fieldwork in the case of a patient I followed in the same medical ward where Tawo had tried to strangle himself with his oxygen tube. This man, Kan, was likewise on a mechanical ventilator and receiving dialysis. He was in pain from the tube in his throat, but when his family came to visit he was visibly happy, and when they asked how he was doing he seemed full of kamlang čhai. He was getting better, too. One evening they withdrew the breathing tube, and he was able to keep his breathing up without it. The next morning, however, when I came into the room, the family was

The Spirit Ambulance

|

79

clearly upset, huddled in a tight knot, and there was tension in the air between them and the nurse who came to take his blood pressure. Back at the nurses’ station, I asked what was going on. “The patient thinks his bed is haunted by a constricting ghost [phī am],” the nurse explained. “Last night, a ghost sat on his chest and he couldn’t breathe, and so now they want a new bed, but there are no free beds. We can’t move someone else into his bed either.” A string of biomedical diagnoses leapt into my mind at hearing about Kan’s sudden chest pressure and shortness of breath: myocardial ischemia, flash pulmonary edema, pulmonary embolism. But I set these aside for a moment to focus on what the nurse had said instead. “Is his bed haunted by a ghost?” I asked. She laughed at my question, and then shook her head. But then she paused to think and said, “Well, I don’t know, maybe. I’ve never seen a ghost in this hospital, but maybe.” She seemed not inclined to claim the existence of ghosts, but also not inclined to deny it either. “Could a monk come purify the bed?” I asked. She shook her head, “I mentioned that, and they didn’t think so. They said, ‘So many people have died here, how could the monk succeed?’ Monks have so little power here.” Apparently, the hospital was so full of ghosts that it repelled the moral power of a monk. This was my first inkling that there were different kinds of “power” at work in people’s understandings of the hospital and the home. Janpeng had talked about the power of the hospital, consisting of technology and knowledge. But the hospital was weak in another kind of power, that of ritual and sacredness. This felt vaguely familiar, even in the history of Western social theory, in which modernism was modeled in part on a division between sacred and secular power, as Talal Asad contends.10 But here there was clearly some complex interaction between them, both because the hospital’s secular technologies were core to paying the debt of life, whose ultimate function was simultaneously physical and metaphysical, but also because there was something about the hospital that contained an obstructing force, a kind of evil power generated by so many people having died there. There was something about death itself that this second kind of power impeded. This made me think of a conversation I had had several months before on the way to a rural province in northern Thailand to rotate as a medical student in a small community hospital. I was one of four medical students in the rotation, a rare foreigner in the Thai medical system. The three other medical students, two from northern Thailand

80

|

The Spirit Ambulance

and one from Bangkok, picked me up to join them on the three-hour drive to the rural hospital. It was the rainy season, and beautiful clouds marched across the mountainous landscape as we drove. Along the way, in a pause between pop songs on the radio, one of the medical students turned to me and asked, “Are you afraid?” “Afraid of what?” I asked, thinking he must be referring to my incomplete medical training, or to trying to understand patient cases in Thai, both of which made me afraid indeed. “Afraid of ghosts [phī]!” he said. “These hospitals are full of ghosts, especially out in the countryside. They like to haunt new people who come, too. It’s unsafe.” I looked around to the other medical students and they nodded in confirmation: the medical student was not pulling my leg, he was genuinely afraid that there might be ghosts. Their stance again seemed to reflect a kind of ambivalence about ghosts, just as the nurse declined to claim either the existence or non-existence of ghosts. But this ambivalence certainly did not stop the medical students from taking precautions to protect themselves.11 Later, when we were sitting in our beds in the hospital dormitory, the medical student showed me a photograph on his computer of a hospital room. The overall tone of the photograph was green sepia and dimly lit. In the center was a young woman in a hospital bed. Beneath her bed was a wight-like sickly version of herself, terrifyingly distorted. The medical student smiled knowingly when I saw the photograph, as though it was proof of the existence of ghosts. He added that most photos of ghosts are taken in hospitals, because that is where ghosts are often closest at hand. “Is this real?” I asked, wondering what kind of argument he was making. We were sitting on a rickety bed in a dilapidated old dormitory outside of our rural hospital where the word “resident” still held its original meaning of resident doctors—recent medical school graduates both living at and running a hospital for a large community. The hospital was surrounded by mountain jungle, and for a moment I had an eerie ethnographic dizziness thinking of the poor resident staff, living in a place haunted by ghosts, part of a larger imaginary of rural places as lonely and dangerous. The walls of the emergency room were covered with charts of the various species of poisonous snakes that regularly bit villagers walking in the jungle, for which only a few anti-venom treatments existed, and many people had told me that such snakebites were forms of moral retribution, either from ghosts themselves or as karmic payback from prior transgressions.

The Spirit Ambulance

|

81

“I don’t know if it’s real or where it comes from,” my student friend answered, but he did not seem concerned. To me, his admission that it might not be a real photograph seemed good proof that he was not teasing. And by this point, I had had conversations about ghosts with nearly everyone I knew in Thailand, so I knew that this medical school friend was no outlier. “Some people believe in ghosts, and others aren’t sure,” he explained and then smiled a mischievous, knowing smile, “but everyone is afraid of them. I have seen them twice. First, when I was a kid, I saw one in the woods. And then I saw one in the hospital in the pharmaceutical dispensary at night.” An internet search for the words “hospital” and “ghost” in Thai brought up the same photograph that the medical student showed me. It was a blown-up and cleaned-up portion of a poster for the 2003 Thai horror film Hīan (released in English as The Unborn), a movie about a pregnant woman who is brought to the hospital after being beaten. At the hospital, she is haunted by a ghost child, which she thinks is the spirit of her unborn fetus, but turns out to be the spirit of a child who was wrongly murdered and has come back seeking justice. Thailand is legendary for ghost movies, and most ghost movies have scenes at hospitals. Hospitals are where people die. It is where they die inauspicious deaths that make them hungry and insatiable souls that wander about and harm the living. In Thai horror films, doctors and nurses often represent Western rationalism, just as Bet explained the power of the hospital as coming from “scientists,” who are powerful, but whose “power is from technology and knowledge,” with “nothing of warmth or sacredness.” The doctors and nurses in most films initially do not believe that the ghosts exist, and the ghosts hide or flee when they are around. But eventually the doctor or nurse becomes the most dramatic victim of the ghost. Their scientific power ultimately holds no sway over whatever generated the unhappy existence of the spirit, obliged by a bad death to haunt the living. Like animating spirits (khwan), ghosts (phī) are ubiquitous in Thai religious conceptions of the nature of beings. Organs of the body are physical, but their life force comes from an animating spirit, from a khwan; similarly, the human body is a physical entity, composed of the four elements of earth, air, fire, and water, making up flesh, breath, warmth, and blood; selfhood is both physical and ephemeral, generated at the interface between body and the winyān, the spirit or soul. This winyān is the part of the self that endures after death, returning eventually in a different physical form,

82

|

The Spirit Ambulance

since in rebirth it will interface with another body and form a new self. But for some who die, death does not initially produce a freed, disembodied consciousness (winyān) that moves onward to the process of rebirth into a new body. Instead, it produces a ghost (phī)—an intermediate, polluting, and dangerous entity. This entity persists for an unknown amount of time before being reborn—possibly until the body of the deceased is disposed of permanently by cremation, or possibly longer if the spirit has some unresolved issue or attachment. A ghost (phī) is a winyān that is unable to move on, either due to a logistical problem, like a body that has been destroyed and cannot be cremated, or lost at sea or in the forest; or it may be due to a spiritual residue still “stuck” (tit) to the spirit, from some unfinished business with the living. The ghost child in the movie Hīan returned to exact justice for its wrongful murder, because it could not let go of its need for revenge. This is why bad deaths produce ghosts, because they leave the spirit full of suffering or anger or unresolved love—emotions that stick to the spirit and prevent its moving onward in the cycle of lives. But beyond this, ghosts may be generated by a spiritual stickiness that has nothing to do with the life lived prior to death or the social world of the deceased—an individual may simply die in the wrong place, a place full of other dangerous, polluting, or evil spirits. This is ultimately an ecological theory of disease and harm, not fixed necessarily to the internal physiology of individual people, but about context, place, and time. The hospital is the prime example of such a place, even more than a charnel ground, which is a site where spirits are liberated from this world. Hospitals, rather, are storehouses of evil spirits, generated by the many bad deaths that have taken place there. And as I came to understand later as I learned more about the mechanics of karma, metaphysical parts of one’s being can stick to another; khwan and all winyān are unstable objects, changing constantly due to the effects of ethical actions on karmic consequences that transfer between beings. And so dying in the hospital would put one’s own winyān at risk of contracting karmic contagion from another spirit, or even of becoming trapped in the hospital among hungry ghosts (prēt). It was because of ghosts (phī) that my medical student friend claimed that hospitals were “unsafe.” They were good for saving lives, but unsafe for dying. And so, even though people claimed that the hospital was a “powerful” place, full of equipment and knowledge, this power was cold, technical, rational. On a metaphysical level, the hospital was dangerous, potentially infested with the polluting spirits of those who had suffered inauspicious deaths.

The Spirit Ambulance

|

83

The choreography of death as it had come to manifest in the complex practice of the spirit ambulance in northern Thailand was deeply tied to elements both biomedical and non-biomedical. The hospital was clearly a space not only of biomedical technology and rationality but also of a terrifying metaphysical landscape that it had helped to generate. For everyone I interviewed, the counterpoint to the imaginary of the hospital was the home, and it was only when I began spending time at home with dying individuals that the different kinds of “power” invoked by Janpeng and Bet began to become clear.

the home: morality, comfort, ceremony Fawng was a patient that I accompanied through death at home. I had met her briefly in the hospital: she had been diagnosed months before with metastatic lung cancer (though not told her diagnosis), and she had been in and out of the hospital for oxygen, IV fluids, and pain medications. When I met her, her doctor had already told the family that this hospital stay would be the last. The family was in the middle of preparations to take her home, in less of an emergency than Jandi’s spirit ambulance, since she was less close to dying. When I asked the family about their debt of life, they said that all of the visits to the hospital had been enough, and it was time to be at home instead. I spent many hours with the family at home over the subsequent days, including during Fawng’s death three days later, followed by days of funerary ritual. My time at their home, striking on so many levels, was most vivid for the inklings it gave me of the ethical depth of home, and thus why it was so important to die there. When they arrived home, Fawng was placed on a mattress on the floor, protected from the cool mountain weather by a pile of pink blankets. After this, Fawng’s daughter Nin never left her mother’s side, except to go to the bathroom and prepare food. Nin had been chosen among her many siblings to provide care, since she had been the one most often at home before the illness struck, and because she was the best cook and knew all of her mother’s favorite dishes. The other siblings gave money to support her. Nin took small naps next to her mother, holding her mother’s hand or embracing her as they slept. Fawng was awake only briefly after arriving home, but then drifted into a deep semi-consciousness, responding only with facial expressions and an occasional head turn, but not with words. Nin sponged water into her mother’s dry mouth every few minutes. She boiled rice and divided it into small cups, adding a bit of each of her mother’s favorite foods: chili paste, spicy pork with mint, tamarind

84

|

The Spirit Ambulance

curry; and she fed these flavors to her mother in small sips, enough to give her a taste of the food without interfering with her breathing. Fawng smiled minutely in response to each of these gifts. Nin massaged her mother’s legs and arms. She told her about goings-on at home and in the neighborhood. “Mother,” she said, “Niece Boo is studying for her entrance exams. She wants to study close to home so that she can take care of her mother. She says that if I am good, she’ll take care of me, too. But she’s still a rascal child, and goes out with that friend of hers . . .” and so on, filling her mother with stories of the family around her. The house was full of people. Nin’s two brothers and three sisters came through frequently, talking loudly and playing games. They all held her arms and her hands, and watched as Nin fed her, and made jokes. There were grandchildren and nieces and nephews, and unrelated villagers. “The home is good because of its atmosphere,” Nin explained. “It is so warm. There is family everywhere. It is familiar.” She used the same word, “warm” (‘op’un), that she had used when talking about paying her debt of life in the hospital, the word for the fire element of the body. This warmth was similar to the imaginary of the past invoked by others, of a time when the debt of life was paid almost exclusively like this, in the home, in the village, with care provided by family instead of by modern technology. Although I wondered whether this was not perhaps a romanticized rural present projected into the past, rather than an accurate description of historical practice,12 it was nonetheless a compelling vision, and I could feel the warmth that Nin was evoking. Fawng’s bed was surrounded by objects: a bag full of clothes, a pile of photographs, some in frames, others stacked in a loose pile. “These are all of grandmother’s possessions,” Nin explained. “Are they to take with her into the next life?” I asked. “No!” she exclaimed. “When we die, we can’t take anything, not this body, not these things. Except this . . . ” she said, smiling sheepishly, and pointed to a small wad of bills folded up in her mother’s hand, “but she doesn’t take the money with her, just the luck.” She seemed embarrassed by this custom, which she later explained was derived from Chinese-style luck worship, illustrating the hierarchy of acceptability of practices, some sanctioned by doctrinal Buddhism, and others more “popular.”13 She smiled to show that she knew the difference. “Are the bags of clothes for luck, too?” I asked. “No. They are so that when mother goes, she will have everything here, and she will not miss things, and so she will not hold anything in

The Spirit Ambulance

|

85

her heart [khāng khā čhai]. If her heart is stuck [yưt tit] to anything at the moment that she goes, she will be reborn with that karma.” As Fawng drew nearer to death, her breath became audible in the room, and her throat progressively dried and filled with secretions. Despite this, the atmosphere in the house became more and more festive. Eventually, at midday on the day of her death, there was a full party. For lunch, Nin’s sister had cooked an eight-course meal from local vegetables and meat—stringy bitter herbs in curry, sour spicy ground bird, and her specialty: fragrant sausage stuffed with lemon grass and lime. A steady, devoted stream of neighbors came through the house all day. “All of this,” explained Nin, “is to have grandmother let go of everything [plō˛i thuk yāng]. Her things are here, all of the people are here. And the most important thing is that she is at home, where she spent her whole life. She won’t miss [hūang] anything when she goes. Her mind will be empty [plō˛i wāng], and she will go without being hooked by anything here [mot hūang]. She will go peacefully.” “Does she hear the things that people say to her?” I asked, wondering about the spiritual mechanics of the empty mind that was being crafted. I thought of Tawo, who simply drew his last breath at home, long unconscious after rounds of CPR. “Does she see these things all around her?” “She is unconscious, but her spirit [winyān] receives everything. When we make merit for her, the spirit receives it, and her rebirth is better.” The ceremonies that did not work well in the hospital worked beautifully in Fawng’s home. Ceremonies would have failed her in the hospital both because of a lack of spiritual potency and a presence of evil forces. But her home was both a spiritually potent place and the site of an accumulation of positive forces. Across from her bed, in the open-air living room, was the family shrine, adorned with a bronze statue of the Buddha, a framed photograph of the abbot of the local forest monastery, several hanging amulets with Buddha and monk imagery. For all of Fawng’s life in that home, purchased nearly fifty years before, the shrine had been dressed daily with fresh-cut flowers, incense, candles, and small porcelain bowls of rice and sweets. All of the offerings had generated positive spiritual forces, glossed as merit (bun), accumulating over time in the place. “It is not just ritual,” explained Nin to me during one long session sitting with her mother. “All of her children were born in this house. She spent thousands of hours cooking meals for her children, taking care of them, helping them with schoolwork, protecting them from harm. Her marriage was here. And my father died peacefully here, so many years ago.”

86

|

The Spirit Ambulance

The home represented motherhood, care, protection, love, duty. This is the feminine side of Buddhism, often underrepresented in accounts of Buddhism, which tend to be male- and clergy-centric.14 And this list was more than a set of associations, it was a list of actions. The actions had generated something, had left a residue in the place, as well as accumulated stuff, which partly contained the residue of goodness. “All of those things make merit,” explained Nin, “they are part of what makes rituals so effective here. And the ceremonies that accompanied those events took place here, too.” The home, as a place, was full of power, a kind of power that had been generated through moral action over time. And this process, of merit transfer and accumulation, was nowhere more pronounced than around death. The events taking place at Fawng’s home after she died helped make this clear. After her last breath, her spirit separated from her body but had not yet moved on to be reborn again. This was the time of vulnerability and danger for the spirit that made dying at the hospital so fearsome. But the language concerning haunting at home was entirely different. Nin and her family did not use the word ghost (phī) to refer to Fawng, they used the word for spirit or consciousness (winyān). Their confidence about their mother was tied inextricably to the place: Nin knew that Fawng’s death was good because she was at home. She was also confident because of the ongoing process of merit transfer to her mother. At Fawng’s house, for the five days of waiting until the funeral, the house was full of things designed to generate goodness or merit. Monks chanted for long hours in Pali, the language of the Buddha’s original scriptures, a language imbued with strong powers to generate goodness. When not chanting, they sat in concentration meditation (samāthi), a practice of the mind that generates goodness that can be transferred to others. Villagers, and especially family members, brought gifts for the monks (sangkha thān). Gift-giving is a form of generous moral action and thus generates merit, even more so if the recipient is worthy and likely to do good things with the gifts received. Some of the monks’ prayers focused on calling on angels to help (būchā thēwadā), drawing another source of power that could be poured into Fawng’s spirit. Through all of this, Fawng’s corpse lay in an open viewing casket with a transparent plastic window above her face, her wooden abode adorned with flowers and incense. The merit being generated was transferred to her corpse via white sacred thread (sāisin), strung between monks, shrine, offerings, and casket in a chaotic web, a conduit for spiritual power, or as Nin said, “like electric wires for merit.” Monks

The Spirit Ambulance

|

87

had brought holy water from the temple, and sprinkled it on the visitors and the casket. All of this was summed up as “making merit.” Stanley Tambiah, in his classic work on the concept of spiritual power in northern Thai Buddhism, described the process by which objects and places become infused with power. Amulets and Buddha statues begin as simple physical objects, and then through meditation, chanting, and gift exchange, monks generate and pour power or sacredness into them. By this process, the images develop a kind of force, a portion of the Buddha’s existence and power, and it is this power that in turn generates goodness when people worship those images. Tambiah detailed the creation of a particularly powerful gold Buddha statue, one that required such purity of sacredness to craft that it needed a special ceremonial structure to be built within the temple. Temples, massive sites of ceremonial generation of merit, are already imbued with great sacredness.15 Thus there is an intimate connection between location and spiritual power. One can imagine the physical landscape of the world overlain with a landscape of immaterial power, with some places as hot spots of goodness (bun), and other places haunted by its opposite, evil, or sin (bāp). The home, in this formulation, emerges as a site of moral power, and the ceremonies that occur there around death are meant both to add to this and to draw on it. There is a quantitative aspect to this merit generation. The number of days for the funerary rituals is chosen partly based on astrology but also partly on the family’s finances. Fawng’s family was middle-class, with one of her sons working for the military in Bangkok, and other children working in office jobs in Chiang Mai. This partly explained the elaborate cooking and festivities in her home in the days leading up to her death, with enough resources to feed the village many times over, and to support Nin to be at home for full-time caregiving. But finances also meant a longer delay until the funeral, more days spent in meritmaking, more generation of positive spiritual power, and thus more benefit to Fawng’s spirit. The same was true of the number of monks who attended to add their voices to the chanting and their minds to the meditating. And the same was true of the amount of gift-giving, and the number of attendees at Fawng’s eventual cremation. There is a connection between merit and wealth. Throughout Thai history, kings’ funerals have been extravagant, drawn-out affairs, with many thousands of monks in attendance. In his book The Funeral Casino, Alan Klima describes games involving betting and wealth played out at Thai funerals to help move spiritual power to and from the spirit world.16 In a

88

|

The Spirit Ambulance

karmic framework of rebirth, wealth is connected to a meritorious past, because only good action can lead to good fortune, and thus hierarchies of wealth in Thailand map onto hierarchies of spirituality, though not unproblematically in a system where monastic spiritual power is the ultimate form of power, and renunciation and wealth thus form a strange non-binary tension.17 This vision of the physical location of immaterial power also confers extraordinarily fine-grained specificity to place. In the descriptions here, I have made ideal types out of home and hospital. But in fact, each home and each hospital is a unique place with its own spiritual history. I asked Nin about this and she said: Oh, yes! There was a house in our neighborhood haunted by ghosts. A teenage boy had committed suicide there, and the family had to move out because they all became depressed. Everyone who tried to live there had horrible things happen to them: car accidents, money stolen. Terrible. No one will live there now, it’s just empty and the owner can’t get any rent.

“But what about the people who died in your house before?” I asked. “They were peaceful deaths,” she explained. “Plus, we have the spirit house [sānphraphūm] outside, where we leave offerings and talk to them. They are an important part of this place.” Andrew Alan Johnson, in Ghosts of the New City, describes the complex and ambivalent moral history attributed to particular places in Chiang Mai. The city itself has an accumulated character (bāramī), infused with the moral activity of its inhabitants. And apartment buildings built during the excesses leading up to the economic crisis of the 1990s have become particularly porous to haunting forces because of the residue of human folly contained within their walls.18 And so the nature of a place is not just about the presence or absence of spirits, but about the moral landscape to which those spirits belong. Good deeds, and good deaths, leave a residue of goodness behind, and this residue becomes incorporated into the place, in layer after layer, with a kind of positive feedback loop, amplifying over time. The positive nature of the home, and particularly of a specific home, makes ceremonies and positive moral actions more effective there, which in turn make the place fuller of goodness, and so on. This understanding of place helps clarify the difference between homes and hospitals. When I asked Nin why one could not just make a hospital sacred, she said, “Maybe that’s possible? There are shrines and

The Spirit Ambulance

|

89

spirit houses at the hospital, I suppose.” And then she paused and thought for a moment. “But the balance is just in the other direction— too many bad things happen there. The nurses and doctors do good works, for sure, and that helps, but there are just so many bad deaths . . . ” It was not that she had abandoned hospitals to scientific rationality exactly, because part of what made them bad was the polluted metaphysical world that they had helped create, and part of what made them sacred was the moral action of nurses and doctors. But it was certainly necessary to turn one’s focus away from sacralizing the hospital and toward getting individuals home to die. This is reminiscent of Niels Mulder’s interpretation of different forms of “power” in Thai Buddhism: a “moral” power, generated by good actions and the ceremonial activity of monks; and an “amoral” power, composed of strategies meant to achieve success in a practical realm, both spiritual and material.19 Perhaps the technology of the hospital could be placed in this latter realm, irrelevant to the concerns of morality and ceremony. But Nin hinted at a critique of Mulder’s vision: that these forms of power are so interlinked as to be inseparable. “Doctors and nurses do good work,” thereby generating moral power, Nin said. And she might well have added that children pay their debts of life to their parents in the hospital, certainly a meritorious act. Instead of dividing power into types, Nin suggested that the way to think about power was about place: each place had a set of elements, some of them moral and some impure, some of them biomedical and some not, and the “balance” of forces determined the nature of the place. This balance tended to tip away from neutral in one direction or another because power amplified itself over time, and so it tended to polarize hospitals toward metaphysical impurity and homes toward moral goodness, pushing places into ideal types. The theme of getting home from the hospital is ubiquitous in the management of dying patients in many parts in the world.20 Part of my training as an “end of life doula” in the United States had been a lecture on how important home is to many people, proposing that part of the role of a palliative care provider might be to ascertain when a patient wants to stop intensive medical care and instead return home. One could imagine describing the division between hospital and home as a universal effect of medicalizing death, of moving care from the home into the hospital. But it was precisely the details of the ways in which biomedicine and other frames combined in each particular place in northern Thailand that determined how deaths must be choreographed.

90

|

The Spirit Ambulance

Hospitals had a complex and specific mixture of metaphysical and physical, of safety and terror, of different kinds of power; and homes had a different mix of these same things. It is perhaps at this point redundant to point out that this vision of place, just like the payment of the debt of life, was a hybrid of biomedical and non-biomedical elements. But the key to understanding the way that these specific components of death in northern Thailand relate to contemporary death more broadly is that it was precisely the mixture of physical and metaphysical, of biomedical and non-biomedical, that made death so complicated to choreograph.

place rupture: the dangerous moment of death The interconnections between types of power in hospital and home are part of what made phases of dying blur together for some and confuse the choreography of their deaths. Tawo’s death was complicated because the “last phase of life” had begun to infiltrate the paying of the debt of life, and the two had become mixed together in the hospital. Similar complexity and confusion were capable of occurring at home, as well. When Janpeng debated so ambivalently about whether or not to take her mother Kiang home, there was a strong pull to stay in the hospital, even to die there and forgo the importance of home as a place. She said that the hospital “has equipment, it has knowledge, it has doctors,” and she wanted her mother to be “close to the doctor,” possibly even up to the moment of death. This phrase, “close to the doctor” (klai mō˛) is extremely common in healthcare in Thailand, and has overtones of both logistical proximity, emotional accessibility, and access to resources. There are many private hospitals in Thailand named klai mō˛, implying both rapid service, and also more accessibility and communication than in the public system, where physicians are extremely overburdened and thus accessible only for brief decision-making moments. When talking with Janpeng about her temptation to keep her mother at the hospital, the question that I did not yet know to ask her was: “What are you afraid will go wrong at home?” At this point, I had come to think of the home as a purely positive place, full of nothing but sacred power and familiar warmth. I learned the answer to this question later in my fieldwork, from a heart-breaking experience with a dying elder woman named Nok. When I met her, she was already in the last phase of life, on what turned out to be the day of her death. She had bile duct cancer with extensive

The Spirit Ambulance

|

91

invasion in her abdomen. She was in the ICU, crashing quickly from sepsis, in severe kidney and liver failure, with the ICU team having difficulty maintaining her blood pressure. Her children were gathered together outside in the hall. The nurse explained the situation to them, because the physician was caught in an emergency elsewhere, and the family decided that it was time to take Nok home and forgo talking with the doctor. Their decision was complicated, and I would later learn that they were critical of the care that Nok had received in the ICU, because she seemed to be in pain and suffering on the ventilator. At the time that they made the decision to go home, Nok was sedated by both opiates and a benzodiazepine, essentially general anesthesia, to keep her from fighting against the ventilator. I was only partly aware of these dynamics at the time, since I had just arrived on the scene and had no time to ask about the medical or communication details. I simply assumed that the family had decided to move on from giving her life to arrange instead the optimal place for her death. The family was able to hire an actual hospital ambulance for the onehour ride home. It was a short ride, and thus relatively inexpensive. We loaded Nok into the vehicle, and I then followed on my motorcycle. I arrived at their house after Nok had been extubated and the ambulance was gone. She was laid out on a mattress in the main room of the family home, with her children and several grandchildren assembled around her. Her son Krit was clearly in charge of the scene. Some of the elements from other deaths I had witnessed were there—the silver platter for the forgiveness ceremony, her possessions assembled around her. I imagined that her family’s expectations of what would come next were similar to mine: that the family would perform a few necessary ceremonies, and then Nok would die peacefully in the comfort and spiritual purity of her home, just as Jandi and Fawng had. But upon arrival, things immediately began to go wrong. Nok had been in the hospital for several weeks, and on life support for at least a week, and she had been progressively sedated to manage increasing pain and distress as her illness worsened. But as was common practice for the return home, Nok had been taken off of life support, and off of the medications that go along with it. She was sent home with no medications at all. And so, rather than drifting gently into death, about a half-hour after I arrived, Nok awoke when her sedation lifted. Her waking was sudden and devastating: she began screaming—a loud, unmistakable, tortured wail of pain, and she kept screaming without letting up, wail after wail.

92

|

The Spirit Ambulance

Elaine Scarry, in her famous work on the phenomenology of pain, claimed that pain is the human experience that most isolates individuals from one another, by destroying their ability to communicate. “To have great pain,” she wrote, “is to have certainty; to hear that another person has pain is to have doubt.”21 As I sat with Nok’s family, I had never been so certain that Scarry’s claim was wrong. None of us in that room had any doubt about Nok’s pain. Krit, Nok’s son, was panicked and distraught: he could not sit still, breathing heavily and quickly, his face red, his eyes darting around. He was clearly feeling his mother’s pain, along with an impossible anxiety and need to do something about it. I felt the pain, too—I could feel it in the room, I could feel it with every moan, obviously not in the same way she did, but her pain was nonetheless certainly a social object, pulling us all into its gravity. I had a moment of understanding about the hospital and the kind of “safety” it would have provided that we did not have here at home. What if she were to die in horrible pain like this? And as the most medical person around, all eyes turned to me. “What can we do?” asked Krit, suddenly calm and determined. “This is very bad, it will be bad for her to go this way.” “She needs morphine,” I said, “both for the pain and for the breathing. Did they send her home with any medicines?” I had just arrived, quickly trying to piece together the details of the situation. “No!” several people in the room shouted in despair. Krit explained: “Morphine isn’t allowed out of the hospital. We should have stayed there, so she could be near the doctor.” “Maybe we should go back to the hospital, then,” I said. “They will be able to control her pain there.” This was late in my fieldwork, but surprisingly it was my first encounter with the kind of dilemma that pain management could present to the model of the good death at home. I had a vague sense that this dilemma, based on brutally restrictive opiate control policies in Thailand, was due to histories of political violence, to the global war on drugs, to Buddhist conceptions of suffering, and to the roles of the Thai public health system in both defending and resisting certain drug politics in Thailand.22 But at the time, this kind of dilemma was new to me, and I knew little of the broader context. I was swept with Nok’s family into the spiritual consequences of her situation, and into its dependence on place. As Krit later explained: “The contents of the mind at the moment of death are very important. So that is why we were so worried that she

The Spirit Ambulance

|

93

would die in pain.” If the purpose of being at home at the moment of death was to transfer merit to Nok’s spirit, the contents of her mind at the moment of death were part of this. She was supposed to have a positive mind-state: full of peace, not clinging and grasping onto things of this world. But instead, Nok lay there screaming in pain while her children and I pinned her body to the mattress to keep her from harming herself further as she thrashed. When I asked Krit later about that moment, about being at home, he said: “It didn’t feel like home. It felt like a torture chamber.” Pain was not only disallowing the positive process of Nok’s dying at home, it was also generating its opposite, making for a bad death. And the effects of such a death could reach far beyond that moment and that room—they could turn Nok into an unhappy spirit who would haunt the home, infuse the place with evil clinging and grasping, and redirect Nok’s rebirth and everyone’s merit-making in a bad direction. I asked again about returning to the hospital, but Krit said, “What if she dies on the way, and she’s still in pain?” Everyone nodded in response to this. The choreography of this moment had suddenly become terrifyingly time-sensitive. Three interventions happened simultaneously. One of Nok’s granddaughters called the hospital to ask them what to do, though ultimately she could not get a helpful answer from the emergency line. Nok’s youngest son went to ask a neighbor to lend a truck for the ride to the hospital, with instructions to prep for the journey in case Nok continued as she was. Meanwhile, everyone who remained—Krit, Nok’s two daughters, three grandchildren—gathered all of the sacred objects in the house around her—books of scripture, images of the Buddha, portraits of monks—and began to expatiate loudly in Nok’s ear on the things surrounding her: the love and guidance of her family, the power stored in her objects, the familiarity of home. And then they began to coach her: “Let go, grandmother!” “You can do it!” “Look for the corner of the monk’s robe, look in your heart-mind, you can see it, grab hold and follow the monk!” This lasted for nearly a half-hour, while Nok continued to scream in pain and fear, all of us shouting encouragement back at her. And then she suddenly passed into unconsciousness, and lay limp. Krit looked to me: “What just happened? Is she ok now?” I nodded and crafted what I said carefully, because in truth I could not be sure that she would not wake up again in pain. “I think she was distressed,” I said, “just because of the medications leaving her body.”

94

|

The Spirit Ambulance

Huge sighs of relief came from around the room. “It was because of the medications,” said Krit, nodding, “her heart-mind is at peace.” My comment had implied that things were likely to go better now, but also that her suffering had not been due to anything disadvantageous about Nok’s heart-mind, to excessive clinging or stress. If pain was a manifestation of karma, as are all things, then perhaps the pain was her own fault: the result of an imperfect mind, filled with greed or loathing or dissatisfaction. My comment relieved her of this, blaming the anesthesia in her system instead. The family quickly assembled around her to perform their forgiveness ceremony, and start some of the chanting that would prepare Nok for death. Fortunately, she did not reawaken, and the remainder of her experience went as planned. She died a few hours later, and her family described the death as peaceful and good. Nok’s death, or more accurately the suffering just prior to her death that might have slid into death itself, taught me the depth of meaning to Janpeng’s words “safe” and “unsafe” as they applied both to hospital and home. The home was safe because it was full of moral goodness and warmth and free of the evil forces generated by bad deaths. But it was also unsafe because it lacked the power of the doctors and their technology. In this case, it lacked morphine, making death a precarious and potentially painful experience, perhaps leading to a bad death at home. This was counterposed to the safety of the hospital, replete with modern medicine and “near to the doctor,” but itself polluted with metaphysical danger.

choreography and ethical locations The goal for the families that I followed was to choreograph good deaths and optimize their loved ones’ rebirth by having them die in the right place. But the complexities of the places available to them made this choreography difficult. This was partly logistical, with a journey to and from the hospital. But beneath the logistics lay a powerful ethical tension—between the imperative desire to pay back the debt of life (in the hospital) and the imperative need to have spirit and body separate in a beneficial place (at home). Families described this tension as a function of history: they imagined a past when both care and death occurred at home, and so they described the present by invoking the hospital as pulling the debt of life into a new, metaphysically different place. The desire to satisfy these imperatives led to an elaborate strategy—to the

The Spirit Ambulance

|

95

spirit ambulance, to the precarious decisions about when to go to the hospital and when and where to withdraw life support. Medicalization had generated ethical complexity by adding criteria that must be satisfied to achieve a good death, and individuals and families developed strategies to satisfy those criteria. Part of this strategy was the repurposing of medical technology itself. As we have seen, merging biomedical and other ways of approaching death in Thailand requires a complex choreography. The first phase of dying required balancing the debt of life and maintaining elders’ kamlang čhai. In the second phase, each hospital and home was inhabited by a different set of spirits, and thus by different ethical forces, requiring the choreography of death to be highly specific to the places and people involved. And the blurring of the two phases added even more complexity, with criteria piling on one another. This calls to mind Pierre Bourdieu’s notion that conducting the details of social life, glossed as “practice,” is too complex to follow a rule book, and so individuals must improvise based on the novelties of context, using a “sense” of the right thing to do, rather than a structure for it.23 Or perhaps it points to John Dewey’s understanding of social life as consisting of improvisation, where “conceptions, systems of conceptions, endsin-view and plans are constantly making and remaking, as fast as those already in use reveal their weaknesses, defects and positive values.”24 The result of this is that the nature of death itself is more like a fractal, with infinitely finely grained detail, variations on a theme rather than a clear script.25 This is part of what Charis Thompson means by “ontological choreography,” the dance that individuals do with medical technologies, weaving them into their life trajectories,26 and in this case using them to affect their relationships with the living, the dying, and the dead. This elaborate choreography in the face of complexity was driven home by the death of Peng, whose daughters Bua and Phai first explained the concept of the debt of life to me. Several days after our conversation in the hall about Bua’s and Phai’s inability to conceive of stopping treatment for their father, Peng died at the hospital. He was on a mechanical ventilator, and his physician had told Bua and Phai that there was very little chance of him recovering but had not yet told them that he was dying despite the life support, and so they were still engaged in their process of repaying the debt of life. Peng then took a sudden turn for the worse, likely from sepsis from pneumonia, and his blood pressure dropped and would no longer respond to pressors. Soon his heart stopped, and he could not be resuscitated.

96

|

The Spirit Ambulance

In a way, Peng’s death represented a failure of the paternalistic system of determining when patients enter the “last phase of life.” In the absence of a slow march toward death allowing for a decision to discharge him to the care of his family, the doctor misjudged his prognosis, and thus Peng’s ability to make it home. As a result, neither Bua nor Phai was there when Peng died. It was early in the morning, long before visiting hours. They both came rushing to the hospital when the nurses called them, fortunately getting there in a matter of minutes because of their home’s proximity to the hospital. When they got to his bedside, Phai began to whisper in his ear. “Grandfather, we’re here,” she said. “Stay with us, you need to stay nearby.” When they loaded Peng in a truck to take him home, with Phai’s husband at the wheel, Phai sat in back with her father’s corpse, which was still warm but pale and stiff. She continued to talk to him, explaining where they were going. “Grandfather, we’re passing the Tesco Lotus on the big road, do you remember? Do you see the Tesco Lotus? Stay with us, we love you, we are right here. Now we’re turning right at the motorcycle repair shop, do you remember?” Her narration was meant to coax the newly freed spirit from detaching from the body, from getting lost in the urban jungle. There was a route that they normally took to get home, but Phai instructed her husband to avoid it, and he nodded in agreement. There had been a grisly motorcycle accident on that stretch of road, and although there were placating shrines erected on the roadside where the driver had died, these had not prevented him from haunting nearby residents, and so it was common knowledge that this was a metaphysically sticky spot, that passing this place could pollute one’s spirit. Phai and her husband took the stretch of road on ordinary days, but avoided it whenever they felt spiritually vulnerable—when they were sick, or on days when they needed particular luck with a job or social event. And so they steered clear during the journey with Peng. Phai explained this strategy to her father’s corpse so that he would know which route they had taken, and know that he was safe from that particular harm. When they arrived home, Peng’s corpse was still warm, and Phai thought that she could feel his spirit’s presence. They counted themselves lucky to live so close to the hospital. That Peng’s death succeeded to the extent it did was not due to its simple alignment with criteria governing a good death. It was successful due to its subtle and skillful navigation of the array of complexities inherent in his particular situation. It was a success due to skillful cho-

The Spirit Ambulance

|

97

reography. Even though he had died in the hospital, his spirit made it home due to his family’s intimate knowledge of many things: of the area and of his personality, thus of what geographic features would help guide him home and of what metaphysical pitfalls would be particularly dangerous for him. They had the right kinds of embodied knowledge, enabling them to improvise a perfectly specific dance in the midst of complex criteria for a good death. Notably, this choreography had not only patients and families as performers, it was also deeply dependent on health care practitioners. One elderly woman named Euai was on a mechanical ventilator, and I assumed that, like Jandi, we would bag-mask ventilate her on the way home and then withdraw the endotracheal tube there. Euai’s doctor was Prani, who normally did not withdraw ventilators from patients. I was thus surprised when the nurses began to prepare Ms. Euai for transport home, and her nurse said that they were going to withdraw her ventilator before she left. “Why?” I asked quickly during the rush of activity. The nurse, named Nupa, answered, “Because she can breathe a bit on her own.” I looked confused, and she added, “We think she can make it home before she dies. The ambulance would be so expensive, we want to save this family the expense if we can.” And by “this family,” it was clear that she meant they were very poor, poorer even than Jandi’s family who could afford to hire the hospital guard and had sufficient social capital to borrow money and a car. Nupa excused herself to go and prepare Euai for the journey. The family asked if I would help them home. We loaded Euai, breathing shallowly and arrhythmically, onto a mattress in the back of a pickup and set off. It was rush hour in Chiang Mai, and we sped dangerously through traffic, passing cars on the wrong side, driving up on medians to get around the congestion. When the traffic cleared, the driver pushed the car into a frenzy. Euai could breathe on her own for a time, but if we were delayed in traffic she might die on the way. We made it home, lifted her out of the truck and took her into her room, where her grandchildren had gathered all of her possessions. When she arrived, she calmed down and her breathing became rhythmic and she opened her eyes. She smiled and looked around, clearly glad to be home. “See,” her daughter said to me, “she just needed to get out of the hospital. It is a bad place.” Euai lived for another three hours before dying. The next day I went to the hospital, and Nurse Nupa pulled me aside, asking, “Did that patient make it home?”

98

|

The Spirit Ambulance

I told her that we made it, and that she lived another three hours. Nupa looked relieved. “Oh, good,” she said. “We thought she could make it home.” Checking in with me was a vindication of the particular strategy, of the precarious choice to extubate before transport. “What would have happened if she didn’t make it?” I asked and then instantly regretted my direct question on an issue involving such an ethically fraught act as choreographing a person’s last breath. “It would have been a bad outcome,” she said generously. “We love our patients, and we want them to do well. That’s why we don’t withdraw ventilators in the hospital. We want them to make it home.” Everyone was implicated in the vagaries of strategy created by the tension between the debt of life and the separation of spirit from body. Mixes and tensions between the strategies of patient, family and provider formed much of the plot of individual deaths. Tawo, for example, knew that if his condition worsened without killing him, it would be undeniable that he had entered the last phase of life, and that this would prompt his doctor to declare the need to go home. So he tried to strangle himself with the oxygen hose, which turned out mostly to be an ineffective way to achieve the controlled, worsened condition that he hoped for. Then, when his heart stopped in the middle of the night, the nursing staff resuscitated him twice, putting him on a mechanical ventilator and blood-pressure support medications. And the next day, they kept the breathing tube in and continued his blood-pressure medications. All of this was so that he could make it home to draw his last breath there. Both Tawo and his medical care team manipulated medical intervention largely to choreograph the optimal location of his death. Sharon Kaufman has argued that death in modern U.S. hospitals focuses on controlling the timing of death.27 For families like Jandi’s and Peng’s, the strategies deployed in choreographing death involved both time and place. A healthcare provider needed to predict and manipulate the timing of death so that the last breath could be ensured to take place at home, not at the hospital. If death was coming too quickly, it needed to be slowed with equipment and medications until the patient’s spirit could make it home. How sick was the patient? How far was the home? These factors informed decisions about medical care. The body was manipulated, drugs were administered, a patient’s heart was restarted with CPR, ventilators were withdrawn, all to optimize the arrival at home with breaths left to take. The managing of such deaths extends beyond mental models of right action. Given that the dominant framework for discussing end-of-life

The Spirit Ambulance

|

99

decision-making in biomedicine uses Western ethical theory, it is worth taking a moment to understand how ethics are traditionally understood in both Western philosophy and in biomedical practice. Ethical arguments are often presented in thought experiments—scenarios involving actors, a situation, and a decision. For example, imagine a world in which you could know with great certainty the effects of a decision, and you knew that by killing an innocent person in front of you, you could prevent a thousand innocent deaths in the near future. Would you do it? In this scenario, individuals are abstracted out of their lives into an imagined (clean, clear) world, partly to help cut through the chaos of the real world, to think clearly about motivations and principles and find a just way forward.28 But it is precisely the fact that such an imagined world does not exist that invalidates it as a strategy. Almost everything that matters for making a real good death depends on the details of the context and place where it is occurring. The ethics of the good death are “situated ethics.”29 Examining a classic medical decision in Western bioethics helps unpack this concept. Take, for example, my confusion as I stood above Jandi, laid out on the hospital guard’s spirit ambulance mattress, now in her teak mountain home, as everyone looked to me to remove her endotracheal tube. If we took this act in the abstracted way that Western bioethics would have us take it—as an action involving actors (me, Jandi) and a medical decision (withdrawal of the endotracheal tube), then it could not have mattered that we were in her home, and that her home was inhabited by a particular set of things—of people, of possessions, of spirits, of ceremonial history, of memory. All of those things were necessarily wrapped up with the decision, so that a single act could have wildly different implications based on where and when it occurred. In Henri LeFebvre’s vision, places have untranslatable particularities that are both socially produced and socially productive.30 And recalling Dewey and Bourdieu, time and situation are similarly particular.31 In a way, if one were to discuss ethical criteria, it was almost as though Jandi’s home was inhabited by an ethical concept that had not accompanied us on our journey to that point: the properness of withdrawing her endotracheal tube. I have elsewhere called this the ethical location of an act.32 “Our view of things, including matters of health care, would be quite different if we thought of them as belonging to a place-world: a world composed primarily of places rather than of fixed and finite stretches of infinite space and time,” Edward Casey writes.33 This suggestion is

100 |

The Spirit Ambulance

somewhat mundane relative to concrete issues such as health risks or the mechanics of healthcare delivery: few would refute that different clinics deliver different kinds of care based on where they are, who staffs them, and what equipment they have available; that health risk factors vary by physical location; or that movement of people between places can affect their health. But less concrete components of health care may also vary in microscopic particulars. Sharon Kaufman, for example, has described long-term mechanical ventilator facilities where basic medical facts are interpreted in terms of an assumed vegetative state of consciousness for all patients. Medical decisions are influenced by this particular concept of personhood, and occur differently than in other medical settings. The nature of personhood is a deeply held concept in biomedicine, and it is somewhat unsettling to imagine it varying by location within a single hospital.34 Chapter 4 explores how karmic logic also creates an unsettling variability in forms of personhood found in particular places. The reason for this detour into ethical locations is to bring into relief the world that structures deaths like Jandi’s. Jandi’s death was precarious and complex, and ultimately it was beautifully choreographed, so much so that it was declared unequivocally good by all involved. This success required resolving a tension between the two phases of dying, paying the debt of life and separating spirit from body, as well as navigating a metaphysical geography that made certain actions good in some places but not in others, and at certain times more than others. And so the nature of death for Jandi—her postponement of hospitalization, her brief but highly aggressive time in the embrace of medical technology, her dramatic spirit ambulance ride home, and her death surrounded by all of her possessions and loved-ones—was a product of the strategies evolved to satisfy a mix of biomedical and nonbiomedical criteria. Jandi’s case provides a relatively complete portrait of the forces involved in choreographing death in Thailand. But for many others, such as for Arirat and Tawo, there was an added complication: a “new” force, a conception of the “end of life,” arriving as an activist agenda to change the definition of what makes a death good. A key component of the first two phases of dying as I came to understand them through patients like Jandi is that they did not require dying individuals to be active, knowing subjects. In the phase of children repaying the debt of life, ignorance was valuable because of its relationship to maintaining kamlang čhai. Likewise, the “last phase of life” was intended to be very short, determined by the minimum time required to get home for the last breath. Jandi was presented as having the ideal

The Spirit Ambulance |

101

death, because she maintained her kamlang čhai until she was unconscious, at which point her family took her to the hospital to pay back their debt of life, and then rushed her home for the final breath. Death was conceived of as taking place instantly; if experienced, it should last only long enough to ensure a peaceful mind at the last moment. In contrast to this, Arirat and many others had embarked on a new way of dying, the “end of life”—an interval of time during which an individual should know that she is dying and use that knowledge for spiritual growth and self-determination. This “new end of life” was the result of tendrils of changes in Thai society reaching into Nakhon Ping Hospital, changes that were themselves a complex hybrid of global and local forces. These forces added to the already complex criteria for choreographing good deaths for those that I followed. Understanding them requires a journey into the politics of identity in Thai society and how they came to ripple into the daily lives and the experiences of dying in Nakhon Ping Hospital.

Buddhadasa Problematizing Death

On the morning of May 25th, 1993, the famous monk Buddhadasa awoke as usual at 4 a.m. in his austere room at his forest monastery in Surat Thani, a province of southern Thailand.1 He began his morning writings, the daily routine that had led to tens of thousands of pages of doctrinal analysis spanning the prior fifty years. But on that morning, some time into writing, he suddenly felt unwell, unable to focus on the page in front of him. He took some herbal medications (yā hō˛m) at his bedside and laid down for a brief nap. Upon waking, he felt worse and rang his bell to call a fellow monk, Ajarn Pho, and Dr. Prayul, a retired doctor residing at the monastery as a lay meditator and caregiver for Buddhadasa. Dr. Prayul took Buddhadasa’s blood pressure, which was 170/100, which although elevated, was not unusual for him. Buddhadasa told them that he was worried his “previous illness” had returned.2 A year earlier,3 Buddhadasa had been giving a long sermon late into the night when his speech suddenly became slurred and nonsensical. He had been rushed by ambulance to Surat Thani hospital, where he was diagnosed with an embolic stroke. His symptoms improved quickly, leaving him with only mild trouble finding words. His physicians did not propose any major interventions, and he returned to his monastery to continue teaching and writing.4 Now, a year later, in his room with Ajarn Pho and Dr. Prayul, Buddhadasa wondered aloud whether he was having another stroke. Over the next few hours, his symptoms worsened. He told Dr. Prayul that his tongue felt heavy and would not move as he wanted, and then later his 102

Buddhadasa |

103

voice became soft and difficult to understand. Ajarn Pho and Dr. Prayul were able to catch a few phrases amid his soft whispers: “I do not feel that this is mine,” “no negative no positive,” and “peace brings happiness.”5 Buddhadasa also said: “I do not want to die under lock and key,” possibly meaning that he wanted no preoccupations in his mind at the moment of death.6 Shortly afterward, he became increasingly confused and his body stiffened with contractions, his legs extending and his arms tucking forcefully up against his chest. The monastery had contacted Dr. Nibhon Phoungwarin, a neurologist at Siriraj Hospital in Bangkok who had followed Buddhadasa since his previous stroke. Dr. Nibhon rushed to the airport and caught the first flight down from Bangkok. When he arrived, he diagnosed Buddhadasa with a likely hemorrhagic stroke. The group present, including a set of senior monks and the two physicians, discussed what to do. Dr. Nibhon advocated taking the teacher to Bangkok, saying that Buddhadasa might need serious intervention including brain surgery. But Buddhadasa refused, saying that he wanted to stay in the monastery regardless of what came next. After much discussion, he agreed to be taken to the local provincial hospital in Surat Thani for a CT scan of the head to confirm the diagnosis. An ambulance arrived, and they loaded him in, stiff and only partly responsive, and raced him to the hospital.7 When they arrived at 2 p.m., Buddhadasa was immediately taken to the ICU, although he was breathing well on his own, opening his eyes when spoken to, and able to nod yes and no. He also seemed to be protecting his airway, and thus did not need to be intubated or placed on life support. A CT scan of his head showed hemorrhaging in the brain from a ruptured blood vessel, and though it was a small quantity of blood, it was deep in the brain in a location that had paralyzed him on the right side. The hospital physicians worked closely with the neurologist Dr. Nibhon, who told Buddhadasa’s disciples that because the location of the bleed was not in an area affecting cognition, the teacher could recover his cognitive abilities enough to teach and write again.8 But the next day—just past midnight on May 27th—Buddhadasa developed a high fever and became difficult to arouse. To see if the bleeding in his brain had worsened, his physicians wanted to send him for another scan. Worried that his worsened mental status would keep him from protecting his airway, they inserted an endotracheal tube. Immediately afterward, his condition worsened. Concerned that he had inhaled secretions into his lungs during the tube placement, they were unable to take him for the repeat CT scan.9

104 |

Buddhadasa

It is worth pausing to note how familiar much of this, both at the monastery and in the hospital, would have been to ordinary Thais. A monk like Buddhadasa waking early in his austere room to analyze Buddhist texts would have been a scene recognizable by many. In a generic sense, this was a deeply familiar trope in Thai society. The Buddhist clergy is ubiquitous, one of the major pillars of power in Thailand, often encapsulated after the establishment of constitutional monarchy in 1932 as “nation, religion, and king”—the secular parliamentary government, the Buddhist clergy, and the extended monarchy.10 Before the early twentieth century, Thailand was an absolute monarchy, justified by the concept of dhammaraja, that the king possessed such spiritual greatness that his wisdom should guide all.11 The king was an extreme example of a more general principle—that individuals can be categorized by their level of spiritual attainment, with those at the top having bāramī, a term that combines spiritual perfection with charismatic influence over others.12 The spiritual and political orders have thus long been linked and mutually reinforcing in Thailand, in a dyad of king and religion.13 Unlike in many other Buddhist traditions, ordaining as a monk is not a permanent decision, and most Thai men spend some time as monks at some point in their lives, ranging anywhere from a few days (to contribute bun to one’s family or to oneself during a precarious life transition) to months or years. Monasteries are ubiquitous, and monks, in their striking orange robes, are a part of daily life nearly everywhere. But more specifically, Buddhadasa was also a public figure, to some a benevolent revolutionary, to others profoundly destabilizing of the religious order in Thailand. Many were familiar not only with his teachings but with his biography: his rise from a Chinese merchant’s son to a master of Buddhist texts; that as a child he was already engaged in debating minutiae of doctrine with government officials who patronized his father’s shop-house.14 Buddhadasa’s ultimate fame had come from his insistence that the interpretation of Buddhism should be rational, conforming to modern standards of logic and scientific reason, and that it should be relevant to contemporary life in the face of rapid urbanization and development.15 In order to perform this transformation at a deep enough level to also interface with the highly conservative religious institutions of Thailand, Buddhadasa devoted his life to reinterpreting the full body of the original texts of the Pali canon, the discourses of early Buddhism. This was a revolutionary project by all accounts, because Theravada Buddhism had always been purist, with reinterpretation of texts almost never sanctioned. Buddhadasa’s reinter-

Buddhadasa |

105

pretation was the first allowed since Buddhagosa’s in the fifth century c.e.,16 which gives some sense of the ambitious scope of the project, as well as of Buddhadasa’s skilled navigation of the Thai Buddhist clergy to embark on such a task without being rejected or punished.17 Part of what allowed this revolution was Buddhadasa’s “radical conservativism,” a reorientation of Buddhist teachings toward the central goal of the cessation of suffering. He argued that many of the structures of Thai Buddhism—temples, reverence for monks, reincarnation, the use of power amulets, fortune tellers, spirit mediums—were obscurations leading individuals away from the core teachings, away from the pursuit of Enlightenment. This argument was part of a century-old conflict over what constituted legitimate Thai Buddhism: monastic renunciation, focused on attaining ultimate liberation; versus lay life, focused on ritual and/or pursuit of worldly gain. Buddhadasa’s reinterpretation of the canon centered on the premise that those living in ordinary modern life could and should pursue Enlightenment as well. This was simultaneously a conservative call for the domination of religion over all other aspects of life and a radical undermining of the privileged monopoly of the clergy on spiritual wisdom. Buddhadasa ultimately advocated for what he called “dhammic socialism,” or “dhammocracy,” governance built from the ground up by individuals with pure states of mind (čhit wāng, lit., empty mind), liberated from the greed and self-interest that structures modern political life. He was thus critical of both capitalism and communism, which for him were simply different ways of managing greed for material wealth and thus generating greater cycles of suffering, rather than renouncing that greed to build society aimed at mutual liberation. Despite the professed anti-political stance of his teachings, however, Buddhadasa’s ideas were deployed increasingly throughout his life for political purposes. Thai political history in the twentieth century can be modeled as cycling between weakly representative democracy and strong military autocracy.18 This process has been punctuated by a few violent crises, events that loom large in most Thai’s senses of personal and national history.19 The first of these crises was in the early 1970s, when prodemocracy protests against a military coup were violently suppressed by the military. An international outcry helped usher in a brief period of democracy, with a free press and academic discourse, before the military staged another coup a few years later.20 Afterward, during the 1980s, democratic discourse continued but was driven underground by oppressive military rule. Buddhadasa’s “radical conservativism” provided an avenue for middle-class intellectuals to continue the debate about politics under

106 |

Buddhadasa

the guise of spiritual study. “Dhammic socialism,” originally proposed as a kind of spiritual utopia based on the Enlightenment of the masses, was used by both sides of the political spectrum to justify proposed forms of government. For many Thais, linking political power to wisdom justified a benevolent dictatorship by someone with great spiritual attainment (such as the king). Others argued for democratic politics based on the egalitarian ethic of spiritual potential for all, not just the elite. Among the transformations that Buddhadasa performed on Theravada Buddhist doctrine was to reinterpret it with a focus on the present. He revised much of the explanation of reincarnation, seen as happening through what is called “dependent origination,” pitching it as a metaphor for the process by which thought arises in the human mind and ultimately leads to suffering. Another core component of Buddhadasa’s teachings revolved around the word “dharma” (thamma), usually referring to the teachings of the Buddha, but reconfigured by Buddhadasa to return to its Sanskrit root, meaning “nature.” Nature is the truth of existence, the way-things-are. The job of humans (manut), according to Buddhadasa, was to face this nature, not to run away from it. Buddhadasa insisted that obsession with technology and material wealth had driven modern Thais away from contact with the true nature of existence, leading them into suffering, oppression, and injustice.21 Following this idea, Buddhadasa stated in public sermons and in several informal written documents that death is an important part of nature, and he did not want to deny it. He wanted to die at his forest monastery, without trying to prolong his life with technology in the unnatural environment of a hospital. Over the years before his strokes, Buddhadasa had begun speaking more frequently of his own coming death, that he was not afraid of it.22 In a famous observation, later disseminated in a book to lay followers, Buddhadasa said: “The Buddha attained enlightenment when he was eighty years old, and I am already eighty-seven. I don’t know why I’m still alive. It’s not good to live longer than the Buddha.”23 He had often talked about modern medicine, seeing the desire to live forever as a core delusion of the modern era. The image of Buddhadasa, lying attached to life support in the hospital, would thus have been striking and ironic to many Thais. This had not initially been the intention of Buddhadasa’s disciples. He had been taken to the hospital simply to diagnose his problem. But then, in a precipitous moment, he had been intubated and placed on life support. This threw his disciples into turmoil, and they met with Buddhadasa’s physicians. His fever, intubation, and the aspiration of secretions into his

Buddhadasa |

107

lungs suggested that he might be dying, and they did not want him to die attached to so much life-support technology and away from his monastery, Suan Mok, where he wanted to die. Transport was arranged to take him back to the temple, and prior to moving him, they removed a few invasive tubes (such as his nasogastric tube for feeding and his urinary catheter). But he remained with an endotracheal tube, oxygen tanks, IV fluids, and pressor medications to maintain his blood pressure.24 After a night of vigil and ongoing medical care at the monastery, Buddhadasa awoke the next morning, able to nod and squeeze a hand in response to basic questions.25 Another meeting was held with the neurologist Dr. Nibhon, who said that since Buddhadasa was responsive, he could almost certainly recover.26 A representative from the royal palace had also been in touch with the physicians, and communicated that the king had taken a personal interest in Buddhadasa’s recovery, and wanted him flown on an Air Force plane to Siriraj Hospital in Bangkok as a “special supportive patient of the palace.”27 A statement was issued to the press by the palace that the king was a student of Buddhadasa’s teachings and hoped that he could save the revered monk “to teach the Thai people a while longer.”28 This was also certainly a political move by the palace, whose power rested on affiliation with the spiritual authority of famous monks. Turmoil erupted among Buddhadasa’s disciples over the king’s offer and the neurologist’s recommendation. Buddhadasa had left a will detailing his desires for his funeral arrangements,29 but he had left no official written advance directive, and even if he had, at that time there was no legal or conceptual backing for the validity of such a document in Thailand. The argument, then, rested on disciples’ various interpretations of Buddhadasa’s teachings, and the teacher’s vague prescription that his treatment at the end of life should “be in accord with the principles by which he lived.”30 The teacher’s disciples found themselves quickly polarized along lines following Buddhadasa’s long-standing love-hate struggle with Thai “culture.” He had spent much of his career fighting against the “superstitions” in Thai Buddhism that obstruct people from seeing the “truths of nature.” Those who argued against the trip to Bangkok accused their peers of clinging to a misguided form of consumerism, to an idea that only high-tech medical care could give life and accrue merit. Those who argued for the journey cited the promise of recovery, their love for Buddhadasa, and their hope that he would live longer to expand on his teachings. They also said that they could not bear to make a choice that would lead to his death.31

108 |

Buddhadasa

Buddhadasa was flown to Bangkok the night of May 28th by Royal Thai Air Force jet, and admitted to Siriraj Hospital. On arrival, he was taken directly to the ICU, where he was maintained on mechanical ventilation, nasogastric feeding, renal replacement therapy, and had an internal jugular catheter placed.32 Six of his disciples had also traveled to be with him, intending to hold vigil over their teacher and act as his family in the absence of kin.33 But the disciples, even though they slept next to his bed and were involved in basic nursing care for him (suctioning, turning, cleaning), found themselves increasingly excluded from medical decision-making, and soon felt that Buddhadasa’s perspective of wanting a death in line with “nature” was increasingly ignored.34 On June 8th, Buddhadasa developed pneumonia and then sepsis, requiring pressors to stay alive.35 The next day, the controversy over his care, to that point only vague in the public eye, began to leak to the mainstream media, both from physicians on his care team, and from his disciples.36 One talk show, Rāikān mō˛ng tang mum, hosted particularly famous figures opining on the controversy. Parliament’s vice chairman Thawil Phraison declared: “We should treat him to the full extent because he is so valuable to society.” The chairman of the Medical Council of Thailand Dr. Withul Eungpraphan, countered: “Since Buddhadasa made an advance directive [sang sīa, literally, to direct his own death] we need to respect that, as they do in other countries, since it is his word.”37 The terms of these comments would have been both familiar and hotly controversial to Thais watching this program. The comments were about self-determination versus rule by the enlightened few, the same core tension pulling apart Thai politics at the time. Buddhadasa’s stroke had occurred in mid-1993, just one year after a second major violent political crisis, equal in significance to the massacres of the 1970s. In 1992, pro-democracy protests against a military coup had been violently suppressed by the military, and an international outcry had again helped usher in a brief period of democracy, free press, and academic discourse.38 For the first time since the early 1970s, Thailand was in open debate over the nature of politics, and the role of individual Thai political identities in it. Over the following week, prominent public intellectuals debated Buddhadasa’s fate in the editorial sections of newspapers.39 In doing so, they were debating the future of Thai politics and religion. This set of meanings would come to profoundly determine the repercussions of Buddhadasa’s “end of life” and ultimate death. As a great teacher who had won the hearts of the king and of many elite and middle-class Thais, many

Buddhadasa |

109

thought of him as a paradigmatic example of a wise teacher, one whose “level of mind” had reached or nearly reached perfection.40 At the same time, others had long drawn on his philosophy of “dhammic socialism” and his battle against the power hierarchies of the Thai clergy to fuel their campaigns for representative democracy in Thailand.41 The debates in mainstream media about Buddhadasa’s health were thus largely about grand political concepts, thinly veiled in terms of patient autonomy. The term “the right to die” was interpreted to mean a person’s ultimate inalienable right, something violated by selfish or paternalistic impulses. One early editorialist wrote: “We let the person whom we love and respect suffer just so that we can feel that he is still with us. We don’t care about how much he has to suffer, even when he is in the state of ‘unable to die, and unable to live.’ Such a demand is very self-serving.”42 The secretary of the Medical Council of Thailand wrote: “If the faculty of medicine [of Siriraj Hospital, Mahidol University] treats Buddhadasa by bringing him to the hospital, they should take into account his right to refuse treatment. I believe it was a patient’s right: Buddhadasa made very clear that he wanted to die at Suan Mok, that he did not want technology to prolong his life.43 Before diagnosing and treating someone, doctors should find out a patient’s wishes and use them to guide their decisions, even if it goes against their belief that they should always treat to the full extent.” Other famous figures weighed in with more lengthy discourses, including Dr. Prawet Wasi and Sulak Sivaraksa, both beloved public intellectuals long engaged in the debate over democracy and individual rights.44 These editorials all explicitly used the language of “rights,” either human rights or the closely related medical term “patients’ rights,” both of which had been cultivated in Thailand as part of a discourse of universal political representation. Others structured the debate in terms of concepts related to “level of mind,” claiming that the most important feature of Buddhadasa was the level of wisdom that he had attained through his very advanced Buddhist practice and study. If the word “death” was used for Buddhadasa, it was often dapkhan, meaning the ceasing of all existence, rather than an ordinary death leading to rebirth.45 In Thailand’s conservative Theravada Buddhist atmosphere, no one would directly claim that Buddhadasa had attained enlightenment (nipphān), a designation reserved for the Buddha. In fact, some writers faulted newspapers for using the word dapkhan, saying that it placed Buddhadasa on equal footing to the Buddha.46 This slippage, and the argument about the appropriate-

110 |

Buddhadasa

ness of dapkhan, were both flags for the implication that Buddhadasa had attained some level of wisdom above ordinary people, and that his medical decisions needed to follow accordingly. Some argued, like the king, that this meant that Buddhadasa should be kept alive, “to teach the Thai people a while longer.”47 Others countered that Buddhadasa’s exceptional wisdom (panyā or rūčhæˉng) made him better equipped than ordinary people to make his own medical decisions, to understand the full spiritual consequences of what he was requesting. As these arguments circulated in the popular press, controversy and confusion intensified at Siriraj Hospital. Buddhadasa’s disciples felt increasingly cut out of decision-making, and suspected that they were partly being punished for leaks to the press that were damaging Siriraj’s image. They also developed the impression that the motive for bringing the venerable teacher to receive medical care was largely political. Siriraj had been waning in prestige rankings, and some felt that Buddhadasa was being kept in the ICU to keep Siriraj’s valiant efforts at the forefront of media coverage. When confronted by Buddhadasa’s disciples about specific medical information, several doctors caring for Buddhadasa said that they had never been questioned about their medical decisions before and were accustomed to treating patients and their caretakers paternalistically in this way, and so they refused to answer.48 The minister of graduate education, who oversaw all universities in Thailand, wrote a letter to the dean of the Faculty of Medicine, Siriraj Hospital, declaring: “No member of any faculty or governing body may legally move Buddhadasa’s body from the hospital in his present state, because they are neither his parents nor other blood relations. If anyone disobeys this law in a way that is dangerous to Buddhadasa, they may have criminal charges brought against them.”49 Buddhadasa’s disciples eventually felt so embattled that they considered asking the king to intervene and allow them to return Buddhadasa to his monastery, but instead settled on writing a public letter to Buddhadasa’s doctors on July 1st, 1993, explaining why he would not want the invasive interventions he was receiving.50 By July 6th, six weeks since Buddhadasa had been admitted to the ICU at Siriraj Hospital, newspapers claimed that he had developed complications in his pulmonary, alimentary, renal, and circulatory systems.51 The dean of Mahidol University was quoted the same day as saying that there was nonetheless a chance he might recover, and that they would continue aggressive treatment.52 On July 7th, it was leaked to the press that a week before, Buddhadasa had received a tracheos-

Buddhadasa |

111

tomy (a surgical hole placed through the neck into the trachea to allow direct management of his airway on life support), in direct contravention of the expressed wishes of Buddhadasa’s disciples.53 A storm of negative press about Siriraj Hospital and Mahidol University followed, and Buddhadasa’s disciples’ letter started to circulate more widely.54 The next day, on July 8th, Buddhadasa’s medical team declared that Buddhadasa was beyond hope of recovery, and that they would allow his disciples to take him back to the temple.55 At 7:15 a.m., Buddhadasa traveled by ambulance to an Air Force medical plane, which flew him to Surat Thani airport, where he was received by Dr. Weera Kananurak, the provincial hospital director, and taken directly by ambulance to his temple.56 His endotracheal tube and life-support machinery were withdrawn by the medical team that had accompanied him on his journey, and he was pronounced dead at 11:20 a.m.57 In accordance with his will, which he had prepared in March of the same year, his funeral was attended only by his large team of disciples in robes.58 The will was unconventional in that it demanded only a very simple ceremony, forbade embalming and viewing of his body (which is common for powerful figures in order for individuals to acquire power and merit from worshipping the corpse), and forbade expansion into any royal-scale fanfare with attendance by lay followers.59 Thai public consciousness viewed the royal ambulance jet that conveyed Buddhadasa to the Bangkok hospital and back again as a spirit ambulance with epic overtones, conferred by Buddhadasa’s own fame and perceived Enlightened status, by the high drama of treatment in Thailand’s ultimate high-tech, high-prestige hospital, and by the direct involvement of the palace. But due to the political moment when Buddhadasa died, and to his own political identity, his death had further implications. The concepts that emerged as salient in his death were not primarily about paying the debt of life or optimizing the location of the separation of spirit from body, though these were present to some degree. Instead, the focus was on the period of time before death, the moments from critical illness to passing away, and their relevance to personal development, rights, and experience. Who had the right to decide how to care for Buddhadasa in critical health? And was this different for him, a nearly Enlightened being with true wisdom, than for an ordinary person still trapped in the ignorance and illusion of life? In the subsequent months and then years, Buddhadasa’s death became an increasing focus of debate—what Michel Foucault would have called a “problematization,” moving death out of the domain of

112 |

Buddhadasa

unquestioned reality and into “the play of the true and false, constituting it as an object for thought (whether under the form of moral reflection, scientific knowledge, political analysis, etc.).”60 This questioning, and the politics orbiting it, ultimately contributed to a growing movement to change the nature and experience of dying itself, so much so that by the mid-2000s, Arirat’s cancer bore a new name, “end of life,” with expectations about how she should behave toward it and experience it. As the sign on the wall of her hospital room declared, it was her “right and responsibility” to know her disease. The elements of Arirat’s story—“facing” the “nature of things,” the hierarchies of “level of mind,” the push and pull about what to know and when—were a complex mix of Thai politics and global forces, all woven into the complexity of choreographing good deaths for the critically ill. Though not caused by Buddhadasa’s death, all of these things were intimately connected to it. It would take me much fieldwork to understand how something so distant and political had made its way into the hospital rooms and homes of those that I followed through the choreography of their deaths.

chapter 3

The New End of Life

Buddhadasa’s death, both as I have recounted it and in the memories and retellings of many Thais, might be thought of as a kind of legend. It follows on a lineage of stories of hundreds of other famous monks’ deaths that circulate throughout Thailand. Most of these legends focus on events of exceptional holiness at the eve of now deceased teachers’ deaths, signaling their deserving posthumous status as saints.1 But Buddhadasa’s story is quite different from these others, and the key to understanding this difference lies in Ampha’s hyperbolic statement that his death made Thais “begin to think about the end of life in a new way.” Whether or not the famous monk’s death was so directly responsible for the change, for individuals like Ampha and Arirat, or like Nai as she cared for Tawo, the Buddhadasa legend organized a host of complex forces, pushing their visions of themselves and their approach to death in a new direction. Charles Hallisey and Anne Hansen have argued that, particularly in Theravada Buddhism, collective narratives (and specifically “morality tales”) act as “sub-ethics”—ideas that structure understandings of right action,2 forming part of a collective ethical unconscious. It is interesting to consider Buddhadasa’s story in this light, although in a less causal way. It was not that Buddhadasa’s death was the sole cause of the changes leading to Arirat’s “end of life,” but it had come to stand in for it as an organizing narrative: hovering, like a haunting spirit in homes and hospitals, inserting itself into notions of the right way to approach 113

114 |

The New End of Life

the dying process. For Ampha and Arirat and many others, the story had force beyond the medical decisions that they made—it had also become an instruction manual for becoming the right kind of person. The “end of life,” as they saw it, was an opportunity to craft themselves. One might think of the “sub-ethics” woven through Buddhadasa’s story and its influence on individual identities taking the shape of an idealized person, what one might call an ethical figure, an imagined mode of being to which one aspires. This ethical figure was not just an additional criterion to add to the already complex and situated set of criteria available in the ethical location of hospital rooms and homes. It was a force for change, evidence that the stream of political and social movements that had come to bear on death and dying was affecting the choreographing of a good death. The ethical figure connected to Buddhadasa’s death was that of an individual who accepts and faces the truth. But this figure took on slightly different forms. On the one hand, many providers at Nakhon Ping Hospital wanted their patients to know their diagnoses so that they could face the truth and elevate their “level of mind.” The figure that they imagined was a seeker of wisdom, someone on an ascending path in a hierarchy of spiritual achievement. On the other hand, the sign on the wall in each room of Nakhon Ping Hospital informed patients that they had the “right and responsibility” to know their diagnosis. This was an unalienable right, and relied on the notion that all people were the same, not different based on a spiritual hierarchy. This figure was that of a rights-wielding citizen. Charles Hallisey and Anne Hansen have also argued that morality stories function as a way to “imagine oneself in the place of another.”3 But this claim is not straightforward with respect to the public spin emerging out of Buddhadasa’s death. Was the lesson learned from it that all people have the same universal humanity, and should thus have the same “end of life?” Or was it that people are actually very different beings based on their “level of mind,” that there are superior and inferior ways of being at the end of life? And are some people just not able to handle the truth? One could imagine that, for ordinary Thais, hearing Buddhadasa’s story may not have led to their imagining themselves in his place, since it may be impossible to imagine being a nearly enlightened being. Arirat’s knowing and facing the truth of her illness were tailored precisely to her “level of mind.” She was told her diagnosis and prognosis because “she could take it,” and because she would do the right thing with the information—she would be a “real end-of-life case.” And this

The New End of Life

|

115

approach to the end of life was connected to class roles. Arirat occupied a particular place on a hierarchical spectrum of spiritual and material attainment, and ethical action needed to take that into account. As Sherry Ortner famously pointed out, subjectivity—one’s identity and self-formation—are tied to hierarchy and power.4 Moreover, if access to a spiritual path was the product of class and ethnicity and education, which were in turn products of the karmic forces set going in past lives, Arirat’s hierarchy of spirituality mapped onto social hierarchies as well. The sign on the walls of Nakhon Ping Hospital clearly clashed with this vision. Those advocating for democratic politics in Thailand had fought directly against medicine’s involvement in a hierarchical view of human nature. They felt that the hierarchical approach to truth-telling in medicine was among the conceptual injustices that had led autocratic despotism to dominate the Thai political landscape. And it was the political movement of such activist physicians that ultimately produced the sign on Arirat’s wall. Despite their differences, one clear agreement between these figures was that there was a vitally “new” phase of life, the “end of life,” that could not be ignored as an arena for the transformation of Thais. The “end of life” might be used to create rights-wielding citizens or seekers of wisdom, or both—but regardless, the old configuration of the spirit ambulance, of ignorance until the final breath, now had a competitor, an additional imperative to further complicate choreographing death. The English-language title for this new phase was a flag that it was not only emerging from Thai politics but also drawing on a set of broader discourses about dying. In my courses in palliative care in medical school in the United States, patients’ rights, self-determination, and death with dignity were presented as core tenets of the field’s resistance to the combat-oriented obsessions of mainstream medicine. But the field also presented itself as a way of paying more attention to meaningmaking, to patients’ experiences, to the possibility of death as the “final stage of growth.” In the years after Buddhadasa’s death, the movement to change the nature of dying interacted with both of these aspects of global palliative-care discourse. The emergence of these new ethical figures, and the new “end of life” during which one could become one of them, entailed a process, both on a political scale, and also in the lives of individuals. The Nakhon Ping nurses’ paths of transformation, for example, were the product of training, a set of activities undertaken to transform health providers and their understandings of the end of life. Like Nanban’s doctor’s

116 |

The New End of Life

decision to tell him the truth, the signs on the walls of hospital rooms, and the decisions that they informed, were the product of another bureaucratic process, one of patients’ rights policies and lawsuits. I set out in my fieldwork to follow the emergence of these figures. In particular, I followed Nurse Ampha’s claim that “before, in medicine, we never got involved; we are not monks, after all,” indicating that her path hinted at a larger shift in the role of health providers relative to their patients. Ampha insisted that something about Buddhadasa’s death had moved a certain kind of spiritual experience out of the monastery and into the hospital. And it had also moved political debates about rights and power into hospital rooms. These movements, in turn, had begun to change individuals’ understandings of who they were and their process for becoming who they wanted to be. This chapter traces the reverberations of Buddhadasa’s death in medicine and in Thai subjectivity through processes of self-transformation. I begin this journey where those at Nakhon Ping Hospital pointed me: the required national training where they had learned their new approach to the “end of life,” as well as several more in-depth courses for health professionals and patients led by one of Buddhadasa’s disciples, Phra Paisal Visalo. At these courses, I met people using the “end of life” to transform themselves, either as an end in itself, or as a step toward helping others engage in a similar process. These characters were in many ways prototypes, portraits of the imagined figures that haunted the hospital rooms of those dying in northern Thailand. Like the debt of life and the spirit ambulance, they were hybrids of biomedical and other ways of approaching the world.

a legend to make humans In 2007, I attended a workshop with several hundred participants entitled “The Culture of Death and the Last Interval of Life.”5 The first keynote address for the conference was by Dr. Prawet Wasi, a famous physician and public intellectual who exemplified the prestige conferred on physicians and its translation into political influence. It was this prestige that allowed healthcare to act as an “autonomous political network,” affecting Thai politics despite its apparent neutrality.6 Dr. Prawet had been involved in politics throughout his career, and was a public intellectual with great sway over Thai public opinion. At the conference, he spoke about his experiences in the public debates over Buddhadasa’s

The New End of Life

|

117

medical care, claiming that Buddhadasa’s death reflected deep ills of consumerism and technology-worship plaguing Thai society.7 After his presentation, the conference organizers played a video created by a group of physicians and nurses. The story was of a woman named Suphaphorn, who had had breast cancer for six years, initially locally invasive and then metastatic. Suphaphorn had decided to learn from her tumor, and she rejected chemotherapy, surgery, and pain medication. She was grateful to the tumor as a daily reminder that life was uncertain, that everything was transient, and that she ought to be fully present in every moment. Knowing this every day, her heart-mind became steadier and steadier (man khong), and ultimately fully equanimous (‘ubēkkhā). Images played of Suphaphorn smiling and laughing, over which the narrator said: “Suphaphorn has clear joy and delight that make it difficult to believe that she is a cancer patient.” The images then shifted to direct shots of her blackened necrotic invasive chest wall tumor, being cleaned by an attendant, with Suphaphorn looking on unflinchingly, her arm lifted above her head to allow for the cleaning. The camera then returned to an interview with her saying: “Many people know that they will die. Many even study the idea of death. What I am doing isn’t the same. It is a slow process of experiencing, leading to gradual acceptance of nature. If I were to die suddenly, I wouldn’t have this opportunity.” After the video ended, one of its producers, Temsak Phungrassami, a prominent physician from southern Thailand trained in palliative care in Australia, mounted the podium. He had become the leader of a movement to bring palliative care to Thailand, with modifications for Thai culture.8 “With this video,” he said, “we wanted to create a legend [tamnān], a model [tūa bæˉp] of the way that someone’s ‘end of life’ [said in English] could be, to show people what is possible. We hope that the legend will spread and become part of Thai culture, and help to correct the problems revealed to us by Buddhadasa’s death.” He later explained that this was partly inspired by the “countercultural” role that palliative care has played in Western medicine, returning physicians to their natural roles as healers shepherding patients through the meaning and experience of dying, which made being a health practitioner much more rewarding. The rest of the day’s program was focused on how to make this happen. This was not a small-scale or isolated project. It was announced that the following year’s training courses by the Hospital Accreditation Bureau (HAB) of Thailand, each expected to be attended by thousands of practicing nurses and physicians, were to be dedicated to this transformation,

118 |

The New End of Life

with the goal of reaching all of Thailand’s health practitioners. Ampha’s and Nai’s and other providers’ efforts to achieve “real end-of-life cases” at Nakhon Ping Hospital were the product of attendance at these courses. The HAB had originally been established to ensure adherence to a common standard for hospitals in Thailand, focusing on sterile procedure, infection control, and prescription protocols. The switch to a less traditional topic like palliative care represented a dramatic shift in tone. When I asked a set of nurses at Nakhon Ping Hospital about their training, and what had led a health-care bureaucracy to teach about something so untraditional, they explained that it was aimed at “finding true value [khunnakhā thæˉ] in practicing medicine,” partly motivated by a crisis in the health-care workforce,9 but more specifically precipitated by the politics ensuing from Buddhadasa’s death. HAB courses were organized around the concept of “humanized healthcare.” At the first session, the organizers handed out a manual (which later I noticed that Ampha and several others had on their desks) explaining this concept.10 The introduction began: Prince Father Mahidol Adulyadej [the father of King Bhumibol Adulyadej (Rama IX)], the father of modern medicine [in Thailand], respected throughout the country, admonished medical students: “I want you not only to be doctors, I also want you to be human [manut].” Being human, at its profoundest level, is the state of entering truth, goodness and beauty. [ . . . ] And when one enters this state, it gives rise to freedom, health, and love for humanity [phư– an manut] and all existence. [ . . . ] What is the best way to enter truth? To encounter suffering. Healthcare workers have a great opportunity to encounter suffering every day.

Legend has it that after seeing the abhorrent condition of Siriraj Hospital in Bangkok, Prince Mahidol left his military career to study public health and then medicine at Harvard, and returned to launch the modernization of medicine in Thailand with funds from the Rockefeller Foundation.11 “I want you to be human [manut],” Prince Mahidol told Thai medical students. The word manut is difficult to translate, and “human” is a complicated choice. There is a rich conceptualization of “the human” in European social thought, explicated by Paul Rabinow’s meditations on the Greek word anthropos.12 In English, “human” has contradictory undertones. It stands for everything we are. If one “appeals to a common humanity,” “human” is infused with ethical goodness that transcends animality. But other uses, such as, “Oh, well, you are only human!” evoke the flaws inherent in being the creatures we are.

The New End of Life

|

119

But the word manut used in the “humanized healthcare” movement was very different. In Thai philosophy and interpretation of scripture, manut is often opposed to the word khon—person. Khon are ordinary people. Manut are those who have engaged in enough introspective spiritual practice to encounter and embrace wisdom. In Buddhism, humans have a telos—a potential state of perfection and goal of living—becoming an enlightened being, a person who has become one with the Buddhist teachings (thamma), freed from the cycle of suffering.13 Manut, then, is a person walking the path to his or her ultimate nature, interested in gaining the wisdom to get there. Prince Mahidol was not saying, “I want you to be ordinary people,” but “I want you to be wise and on your path to enlightenment.” In Ampha’s and Arirat’s terms, this meant to heighten patients’ “level of mind.” The explicit link between the “end of life” movement and the Thai monarchy was no accident: it emphasized the class positions involved. All of the participants in the training were middle-class professionals. There was a sense in the air that those present could use their training and their privilege as a launch pad to move even closer to enlightenment, and to bring their patients along with them. A more particular version of the English word “human” was circulating in Thailand in the early 2000s: “human rights” (sitthi manutsayachon) discourse and policy, also deeply tied to Buddhadasa, both before and after his death. Those in the medical profession advocating for democratic ideals after the political violence of the 1970s began to use the concept of human rights to argue against the role of “physicians as gods” in Thailand.14 After Buddhadasa’s death and the political opening of the early 1990s, a particularly democracy-oriented group took over the Medical Council of Thailand and enacted a patients’ bill of rights to be deployed in all hospitals and clinics in Thailand. Largely because of the controversy after Buddhadasa’s death, the most explicitly advocated of these rights was autonomy, formulated in the bill as the right to “adequate information and clear understanding.” This was the “right to know your disease, treatment you are receiving for your disease, and self-care appropriate for your disease” at Nakhon Ping Hospital. Behind this movement there was an understanding of “humans,” in this case “patients,” as universally equivalent, and thus deserving identical rights.15 These two definitions of the “human”—as a seeker of wisdom or as a rights-wielding citizen—circulated in the movements emerging out of Buddhadasa’s death, just as the different uses of Buddhadasa’s teachings had danced across the political spectrum during his lifetime. These

120 |

The New End of Life

movements concurred that Thais needed to change their way of being in the world, and that one phase in which to accomplish this transformation was the “end of life.” The particular experience that would most effect this was “encountering suffering,” which would lead to “facing truth.” Buddhadasa’s death made it clear that the form of suffering most distorted by social ills in Thai society was death itself, and the video about Suphaphorn illustrated how to confront this by treating the end of life as “a slow process of experiencing, leading to gradual acceptance of nature.” As I sat in the audience watching the video, I could feel myself getting swept up in the “legend.” Was it truly possible to relate to one’s tumor— to experience the painful and disgusting decay of one’s own body right before one’s eyes—as an opportunity for inspiration and growth? Despite my skepticism about the class position of this movement, I had been drawn to Arirat, and continued to follow her intently through her dying process, partly to understand the social worlds that I was tracking in my research, but also to try to glean some of the wisdom that seemed available in the approach. Tom Taem felt the same way, personally driven to glean some of Arirat’s techniques for living and dying. I thought back to my training as an “end of life” doula in the United States, where something of this same quest for depth and meaning had led me to patients’ deathbeds. But here it had a different form; it was somehow about putting the dying person in the driver’s seat of his or her own death, which hovered as both opportunity and pressure. In addition to lectures on humanized healthcare, HAB offered short workshops on how to move from theory to practice through introspection aimed at facing “the truth of nature.” For those interested in going further, one of Buddhadasa’s disciples, Phra Paisal Visalo, also offered two-day retreats on how to attain wisdom through the process of dying.16 To study this new end-of-life strategy and perhaps become one of the ethical figures adverted to by the Suphaphorn legend, I attended several of these workshops.

from obstacle to opportunity Phra Paisal Visalo and I sat on a bench overlooking a field, just outside of the hotel conference center hosting his retreat, “Facing Death Peacefully.”17 I asked him to summarize the transformation process that he was guiding. “Much of Buddhist practice,” he answered, “can be summarized as: ‘from obstacle to opportunity.’ The obstacle here is death, the ultimate loss, and thus the place of people’s strongest attachments.”

The New End of Life

|

121

Along with some thirty other trainees, I was being taught how to turn death into an opportunity to transform myself. This was a process of self-formation, a kind of virtue ethics, though not exactly in the Greek conception of crafting a virtuous disposition that would aid in right action as the situation arose.18 It was more about attaining a kind of liberation, an increasing arrival at an unobscured existence. The first obstacle to surmount was fear of death itself. On the first day of the training, we traveled by minivan to the local community hospital, and toured the autopsy suite. Filing in, we faced a low metal table with a raised platform in its center and a trough encircling it. The platform was covered with a layer of bright red blood, reflecting overhead fluorescent lights like an infinity pool, slowly dripping from the platform and draining by pipe to a grill on the floor. On the platform was a man, recently dead, his chest and abdomen flayed open, organs set aside, his skull sawed in half, with the brain removed, the overturned cup of skull dripping its contents onto the table. The man appeared to be about forty years old, with a long face, dark skin, and a short beard. In front of his flayed body stood a pathologist with a surgical mask and blood-covered gloves, using a knife to slice the man’s liver into segments, then slowly dropping them into a jar full of fixation liquid. The man was so recently dead that his face looked almost alive, as though we could have asked him a question and he might have answered. Even without the monk Phra Paisal there, the autopsy suite was not a particularly secular place. We had passed a large Buddha statue on our way in, with participants from our group taking deep, heartfelt bows to the Buddha to prepare themselves for what they were about to see. In the antechamber, the wall was adorned with a small shrine of fresh offerings—flowers and rice and water—to placate spirits emerging from freshly dead bodies. When we entered the suite, through smoked glass doors, we passed two post-autopsy corpses, a man and woman in their sixties, arranged on a table, side-by-side, hands clutching lotus flowers to their chests like temple-goers, their spiritless state betrayed only by small tufts of cotton emerging from their noses. After allowing a moment to let us watch the liver be sliced, the pathologist paused in his work to give us a brief lecture about the process of decay after death. He then picked up his work again, and there was only silence punctuated by the slushy sound of knife cutting tissue. We then followed Phra Paisal out of the suite, down the hall and into a conference room that had been prepared for us. We took a moment of silence for a brief prayer, thanking the dead and their family members. Then Phra

122 |

The New End of Life

Paisal spoke briefly about letting death—the truth of the nature of existence—into our hearts and our minds. He described the death contemplation practices outlined in the Pali cannon, the original texts of Theravada Buddhism: mō˛ranānusati, mindfulness of the inevitability of death; and ‘asuphaphāwanā, contemplation of the foulness of corpses in different stages of decay. “The purpose of mō˛ranānusati is to make sure that we know that life could end at any moment. It is a reminder of the urgency of spiritual practice. Conversely, ‘asuphaphāwanā helps us get used to disgusting things.” He paused for a moment before continuing. “The purpose of this weekend’s training is different from both of these tasks. What we have just done is not to shock us or disgust us, it is the opposite: to see how close to life corpses are, how thin the barrier between life and death is. Death is not just an idea. It is a real thing. It happens to real people. We need to see that to prepare us for transformation at the end of life.” After this, we returned from the hospital for the two days of training. The leaders explained that the remainder of the training would focus on the obstacle—more core and more profound than fear of death itself— of the attachments and emotions that lead us to try to escape death, that lead us to do things to oneself and to others like what was done to Buddhadasa at the end of his life. The training was a kind of “technology of the self,”19 a set of tools of experiential self-formation, designed to turn us into the imagined figures emerging out of Buddhadasa’s death. The training had a particular conceptual tool for achieving this: a “knot” (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 panhā, 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 Thai psychology, pom means a “psychological complex.” The training relied on the term as a lay encapsulation of the concept of attachment or clinging (‘upāthān), which can seem esoteric, like something that only ascetic monks can truly release. The point of pom in the training was that either one’s own or another’s end of life was a particular time when one’s deepest attachments would make themselves clear, making people unable to let go and face the nature of existence. One’s task as a health provider at the end of life was quickly to identify this knot and help a patient untie it. And then at the end of one’s own life, one would be prepared to do the same for oneself. Pom are difficult to identify, because they are unique to each individual, to their “level of mind,” to their particular life story and circum-

The New End of Life

|

123

stance. Unlike death, which is a universal, the end of life is irrevocably particular. At the training center, one of our first tasks was to identify our own “knots,” and to help one another identify them. For this, explained Phra Paisal, we needed tools from outside of Thai culture—we needed to share our stories, to allow others to help us identify and unlock our pom. “Thai people are not used to sharing about themselves with strangers,” one of the organizers said when we returned to the training center, introducing our next activity. “This is a big problem. How can we care for people at the end of life if we’re afraid to ask about intimate things? How can we know what to ask if we don’t 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.” Another one of the organizers expanded: “As you know, there is a patient rights movement in Thailand. As patients have an increasing right to know things about their health, we need to learn how to tell them, in a kind way, in a way that they can hear. To do this, we ourselves must be comfortable with the end of life.” This new “end of life” phase was presented as a site for transforming Thai culture by teaching individuals to be different kinds of people who would resist the social ills that led to Buddhadasa’s problematic death. Phra Paisal’s comment that this required reaching “outside of Thai culture” called to mind the history of confessional technologies in Catholicism, one of the core “techniques of the self” explored by Foucault in his treatise on ethics as self-formation.20 The fact that several of the conference organizers were physicians who had trained in the West in palliative care was no coincidence. I could feel the specter in the room of a Judeo-Christian healer, accompanying patients through suffering back to wholeness of spirit. This is part of what Temsak Phungrassami had pointed to in his talk as one of the leaders of the “The Culture of Death and the Last Interval of Life” training. The vision of the legendary “new end of life” was a hybrid of political movements emerging out of Buddhadasa’s death and global palliative care discourses, themselves rooted in Western concepts of the physician healer. We broke up into pairs, to engage in “deep listening,” beginning by staring into our partner’s eyes for an uninterrupted minute, and then listening to him or her tell a story without breaking eye contact. After this, we sat in a large circle to share stories about this experience. This type of sharing is very unusual in Thailand. Most foreigners who do fieldwork in Thailand learn early that they should not expect to get close enough to someone to hear their emotions. Seeing people cry in

124 |

The New End of Life

public settings is almost unheard of. Even on open patient wards in hospitals, families swallow unbearable tragedy to keep face for the people around them. Felicity Aulino describes this as a collective duty to care for the “social body”: expression of negative emotions, or strong emotions of any kind, risks pulling others into a disadvantageous mental state, doing everyone harm.21 But in our training, as people began to tell their stories, many began to cry. A woman in her thirties told about her alienation from a schizophrenic father. Another woman told about relentless pressure from her parents to succeed, with the stress of their judgment weighing on her every hour of her life. Another participant told about losing his little brother to cancer, about holding him by the shoulders in his hospital bed as he died. At the end of our sharing, Phra Paisal summarized the process we had just been through: When we talk about our selves [tua ton], it is difficult because we slam up against the reality of the self that we are in this moment and the selves that we have been before. If we look deeply at our mistakes and losses, we will see that they are not our self in the present moment, they are part of past selves. When we arrive at the end of life, if we cannot get along with our past selves, they may return to demand payment for moral debts [thuang būn khūn] or haunt us [lō˛k lō˛n] and avenge themselves on us in our last moments. We need to befriend our selves, before we get to the last moment. We must have the bravery to open and look deeply into our selves, to accept and face the truth.

The key to this process is that it must happen “before we get to the last moment.” There is a period of time, the “end of life,” when we must dissolve prior attachments and release our pom. In order to do so, we must face the truth, know that we are dying, and face ourselves as we really are.

finding reality to face But recognition, and even confession, are not enough. Seeing a “knot” does not lead to untying it. In Phra Paisal’s terms, if the goal of selfformation is to turn obstacles into opportunities, then seeing an obstacle is only the first step. The only way to effect true change is through actual experience, through the process, not the fact, of dying. As one organizer explained: “The monks caring for Buddhadasa had plenty of knowledge about death, but they were still unprepared for the attachments that they would face when the moment came along.” Even

The New End of Life

|

125

monks, who had devoted their lives to spiritual ascension, had not fully enacted the difference between static knowledge and lived experience in the case of dying. There was thus something essential about the experience of the time before death, of the “end of life,” both one’s own and others’, that needed to be used to understand the nature of existence and achieve true spiritual perfection. This transformative process structured our second day of the training, organized into successive waves of increasing experiential “reality,” beginning with imagination through role-playing and then with actual encounters with others’ end-of-life “knots,” by talking with patients in a hospital. For the imagination portion, we began by gathering into groups of three for role-playing, helping us to imagine a real deathbed. My two scene-mates were Songchai, a young man fashionably dressed in formal wear, who worked as a pharmacist in a province outside Bangkok; and Noo, a middle-aged woman with curly hair, who had worked for years at a hospital near our training center. In our sharing session, I had already learned about each of their lives. Songchai had told the story of his sister who died from cancer eight years earlier. Noo had told the story of her own battle with cancer ten years before; she was in remission now, but with some lasting side effects like back pain. The purpose of our roleplaying was to move beyond simple thinking about difficult realities and move into experiencing them. My fellow actors and I reached into a bag to discover our roles. Noo had been assigned to play a patient with endstage liver cancer whose bile duct had recently become obstructed, and who was trying to decide whether to undergo risky surgery that might prolong her life. Her card read, “You would rather spend your last days at home with your two young children than die in the hospital, but you are nonetheless unsure of what to do.” I was assigned to be Noo’s husband, who was trying to help her decide. Songchai had been assigned to be her brother, who had come to the hospital to convince her to get surgery because he wanted her to live longer. The similarity to Noo’s and Songchai’s real lives was uncanny. In real life, Songchai had lost his own sister to cancer, and now he would play the brother of a dying patient, sitting over her on the conference room floor, just as he had sat at his own dying sister’s bedside. And Noo, lying on the floor, could have been lying in her own hospital bed years before, where she had hovered on the brink of her own death from cancer. “Is this okay?” I asked them. “Can you do it?” Songchai smiled sorrowfully at me, already tearing up. “It is good,” he said. “We need to face reality. The closer to real life, the better.”

126 |

The New End of Life

Later, Songchai told me that he sank fully into his role by sinking into his own past. He began arguing with his sister, played by Noo, lying on the conference room floor. “Don’t you remember,” he said, “how we used to play in the fields? And how our parents did everything to be with us? Don’t you want more time, just a little more time with me, with your children?” And the material itself, he explained later, was not improvised but was drawn from his own life: he remembered wanting to yell at his sister, to make her live longer. The knot that was in his heart then, and that still sat in his heart now, had been exposed and was there for him and for all to see. And Noo, who in real life had lived through cancer, lay on the floor remembering what it was like at one time to think that she herself might die. She later explained remembering her own fear of disappointing those who loved her by leaving them too soon, and so Songchai’s words “struck her heart” (sāpčhai) and she began to cry. I was also moved by this scene, though I had not managed to project my own present and past selves into the reality of the simulation, given that I needed to work so hard to follow these complex narratives in Thai. But I could feel, nonetheless, that we were all getting swept into a different orientation, one that could not be known cognitively, but that needed to be experienced to be felt. In the exercise, we imagined ourselves in the period of life before death, the “end of life.” We did not imagine the moment of death or the process of paying back the debt of life, but the emotions and experiences of the period before death, when we would need to negotiate our relationships, our fears and attachments, our many selves that must be reconciled to one another. Through this exercise, we learned to think of the “end of life” as a thing, as a developmental phase of life where our greatest “knots” would reveal themselves, and provide us with an opportunity to untie them. The role-playing was meant to bring us one step closer to actual end-of-life experience. This would not achieve the desired end in itself but would allow us to practice, so that when our own end of life arrived, we would know how to use it to transform ourselves. In the meantime, we would achieve some of the transformative effects of releasing our “knots,” thereby raising our levels of mind, and ultimately contributing to a corrective to Thai society by freeing ourselves of our addiction to consumerism and obsession with technology, the ills that had led to the problematic treatment of Buddhadasa at the end of his life. In our group debriefing after this exercise, participants talked about how different it felt to experience their “knots” rather than to simply talk about them. One participant said, “I think the key is to ‘face’ something. It is so different from just thinking about it.” In response, one of

The New End of Life

|

127

the course leaders said, “Yes, that is it! The key is that to face reality, it must be real. Even this exercise was only practice. It is not a substitute for the real ‘end of life.’” That afternoon, we set out on another field trip to get even closer to reality. We piled again into vans to take us to the local government hospital. This time, our task was to talk to dying patients. We were paired in teams of two with our partners from the “deep listening” exercise of the day before. My partner’s name was Thot. I had learned a great deal about him already. He worked as a dentist in a private hospital, but he had been clear that he was not at the training in order to help care for patients, but for his own transformation. All his life, he had had a great fear of losing people. He had grown up very poor, and had been raised by an abusive father, who was then killed in a motorcycle accident when Thot was a teenager. Ever since, Thot had been afraid that each new friendship or love relationship would end in trauma or loss. He had spent his whole life “trying to run away from things,” either through video games, alcohol, school, or making money. He explained to me, “I came to this training to figure out how to stop running and face the reality of my life.” In the car on the way to the hospital, Thot talked faster than usual, and I could sense that he was nervous. When we got out, and began walking through the hospital to find our assigned patient room, I could feel his fear mounting. Since my medical Thai was awkward, we had agreed that I would accompany him and watch. We were greeted by the head nurse of the neurological ward, who shared a few details about the patient we were going to visit: “She is ‘hopeless’ [said in English], with a degenerative neuro-muscular [said in English] disorder, but no one knows how long she has to live. Also, the patient does not know that she is dying, so don’t talk about dying.” That said, the nurse told us the room number and turned back to her work. The door to the patient’s room was open. At the far end of the room was a hospital bed, with the body of an emaciated woman, lying on her side, connected to a respirator, with its rhythmic “hoh-purr” delivering breaths through a tracheotomy hole in her neck. On the floor, next to the hospital bed, sat a middle-aged woman with her long hair in a braid. Thot stepped in ahead of me, his nervousness exploding out of him. He began speaking rapidly: “We are volunteers, we’re here to give kamlang čhai,” repeating iterations of the same phrase. The middle-aged woman introduced herself as the patient’s daughter and said that her mother could understand things but could not talk because of the respirator. We sat and greeted the dying woman, who smiled at us. Over our shoulder,

128 |

The New End of Life

the daughter said that she wanted to cure her mother’s disease and go home. Thot, clearly flustered by the patient’s inability to talk, tentatively reached to touch the patient’s hand. The daughter smiled and said that her mother was unable to feel her body below the neck. At this information, Thot’s legs began to shake. For two days, we had been role-playing about how to talk to patients, but here was a woman who could neither talk nor feel. Thot later explained that nothing about what was happening fit the image in his mind of how the interaction should go. Clearly, there was a “knot” in the room preventing the family from talking about death, but suddenly the way to unlocking it was opaque. Thot stood up quickly, fumbling: “I’m sorry, we have to leave. I am not good at talking. We are just here to give kamlang čhai. Good luck, get well.” And he shuffled out of the room with me trailing behind him. Outside in the hall, Thot was visibly upset. “They did not prepare us enough to do that,” he said. “How are we supposed to find out the patient’s story in there? I just didn’t know what to do . . . ” But later, at dinner, his perspective had shifted. Thoughts about the experience overflowed: “Being in the actual room, it was not about dying. It was about the family, and about talking. I didn’t know what to say. I didn’t 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 don’t know how to just be in a place like that. This is so good for me.” I said that his words “This is so good for me” had struck me forcibly. He explained further: “There is something in me that keeps me from facing suffering. I don’t want to talk about it with people. It is uncomfortable. If I can understand why, then I will understand myself. Plus,” he said, “more and more patients have a right to know these things, to talk about it, and so I need to be able to talk about it with them.” Thot had developed the goal to be someone who faces suffering and uses it to understand the nature of his own mind. He wanted to face the truth, and reveal that truth to others. And when he arrived one day at his own “end of life,” he wanted to confront the difficulties there and study them. For now, he wanted to practice healthcare in a way that would bring him face to face with those realities.

self-making and choreography Thot’s self-transformation represents a shift in the choreography of death, even for those far away at Nakhon Ping Hospital in northern

The New End of Life

|

129

Thailand, a kind of pressure to use death to become different kinds of people. The clearest example, of course, was Nurse Ampha, who was using techniques of “finding reality to face” to bring a “new end of life” into being as she interacted with patients, so that she and her patients could make spiritual progress and become more “human” (manut). The sign on the wall represented a similar force, if less penetrating. It was not simply a recommendation as to how to act but pushed (gently) on each person in the room to become a rights-wielding citizen, to use the “end of life” to exert self-determination. A swirl of forces—rights-based politics, critique of the role of consumerism in modern life, global expertise in palliative care—had brought social critique to people’s deathbeds. The resulting imperative to teach Thais “techniques of the self,” to have them transform themselves, was in tension with other criteria for the good death. When Tawo was in the hospital, pleading to go home because of his fear of dying in the hospital, his daughter-in-law Nai, who had been exposed to training on the end of life, sat with him to try to get him to let go of his fear. But she had to defer to Tawo’s son Loek, who felt that talking about diagnosis and prognosis directly would worsen Tawo’s loss of kamlang čhai. And so Nai only talked to Tawo in the most general terms about spiritual practice, unable to help him confront reality the way that Suphaphorn and Arirat had faced their tumors. The seeker of wisdom and the rights-wielding citizen conflicted with the need to collude with patients to maintain their kamlang čhai. The factor used to decide whom to engage in the new process of self-transformation was each individual’s “level of mind,” his or her ability to face the truth and walk the path of spiritual advancement. Only patients’ families could judge what they were capable of. And so, choreographing good deaths in northern Thailand had become interwoven with a fresh set of criteria. Not only was each hospital room a different ethical location, but choreographing a good death depended fundamentally on the characteristics of the individuals involved: their level of mind and the effects that knowledge was likely to have on them. Nurse Ampha and Arirat therefore spoke somewhat ambivalently about cases that seemed not to fit their ideal “real end of life,” trusting families to make the ultimate decision about their loved ones’ levels of mind. Although they lamented Nanban’s ignorance of his cancer and his inability to prepare himself for the final moment, they were mostly resigned to watch his death unfold, given the family’s insistence on collusion. Even with this passiveness, however, there seemed to

130 |

The New End of Life

be a gentle push, a sense that each person should want to engage with the end of life, even if perhaps unable to do so. It was difficult for me to see this not just as a kind of class superiority, a gentle insistence that an approach to Buddhism based in independence and liberation was superior to family enmeshment. But at the same time, I must confess that as I went through the training, I could feel myself persuaded by this as well: sinking into the experience of dying seemed to hold potential for so much discovery, for such depth of feeling and understanding. And so Ampha looked among the cases that presented to her hospital for people and situations into which a wedge might be inserted, so that she might create a death with an “end of life,” a death better than the good death that families were already choreographing for their loved ones via the debt of life and the spirit ambulance. Choreographing a good death in the face of the new end-of-life approach was more complicated than the simple arrival of biomedicine or biomedical expertise in a local context. Just as the spirit ambulance process relied on inseparable mixtures of biomedical technology and metaphysical landscapes both at home and in the hospital, the new endof-life strategy relied on a complex of ideas connected to broader forces, from palliative care to human rights discourse, and from conflicts around self-determination to the role of religion in daily life. This conception of how to use the new end-of-life approach had become an imperative in the choreography of death in Nakhon Ping Hospital. But ultimately, as everyone in the “Facing Death Peacefully” training emphasized, the details of that choreography would be deeply unique to each individual. The training was designed to give a taste of this. The experiences of Thot, Songchai, and Noo seemed like the tips of icebergs, hints of the depths of experience that would emerge when it came time for them to face the real ends of their own lives. As for myself, my only ethnographic entrée into those depths was through Arirat, whom I accompanied as she worked her way through the knots that she encountered as she died. Many of the things that she worked through involved details of meditation practice, ways of understanding the connection between consciousness, the body, and suffering. The dramatic moment of holding her down as she convulsed with pain, of that particular form of suffering that I was unable to endure watching, was only one of thousands of moments in her much longer process, much of it undertaken when no one was there to witness or document it. Even more than other dying patients discussed in this book, Arirat needed to choreograph her own death. This is largely what was meant

The New End of Life

|

131

by the “end of life,” a time when a dying person should self-appoint as director of her or his own choreography. A full exposition of Arirat’s journey is beyond the scope of this book, partly because it was specific to her in so many ways.22 Instead, in the next chapter, I pull out a component of the experience of dying in northern Thailand, initially introduced to me by Arirat, but one that was central for everyone that I encountered: how important it was to relate to one’s tumors or failing organs as beings, as players in one’s choreography. Attempting to understand this feature of the choreography of death required me to embark on a journey of questioning some of my deepest assumptions about how people are put together. The organizing logic for it was one of karma, of beings wrapped up in one another’s fates, entangled at the end of life, all trying to choreograph death together.

chapter 4

Karma Masters

Mahu was not engaged in the “new end of life” as Arirat and Nurse Ampha would have described it, but something was eating away at his insides. A surgeon had cut out a portion of his intestines, leaving him with a colostomy, draining stool into a bag attached to his abdominal wall. And he had a gnawing pain in his abdomen, relieved only in brief bouts when he fell asleep each night. Eventually, I became comfortable enough with him, and with how to ask him the things I needed to know for my research without disrupting his kamlang čhai, to ask the question that had been plaguing me: how was he not overwhelmed by his pain? I expected his answer to be a lesson in meditation technique, perhaps the separation of mind and body, or embracing the pain and thus not suffering from it. But instead, he explained: It is because my disease is a karma master [čhao kam nāi wēn]. My whole life, I was a buffalo farmer. I leashed buffaloes with rings through their noses. Then, last week, when I went into the hospital, I had an oxygen tube, and they put it in my nose just like a yoke ring. When they put it in, it made me sneeze and cough just like the buffaloes used to sneeze and cough. And when they took it out, there was still a tube through my nose into my stomach [a nasogastric tube], and when I turned my head, it pulled on me just like I pulled on buffaloes. Also, I used to ride the buffaloes. And now, my legs are bowed outward.

We were sitting at the small cement table outside his home, and he stood up from the table to show that his knees were pointed out to the sides 132

Karma Masters |

133

and his legs were curved like closed parentheses, as though he were permanently astride a buffalo. “Because of this, my knees and hips hurt,” he said. “The buffalo is still my karma master [čhao kam nāi wēn], first in my legs, and then in my abdomen.” The term “karma master” is a compound term, mixing the words for “owner” (čhao nāi), for “paying back” (wēn), and for “karma” (kam). It also contains and implies the term “resolving karma” (wēn kam). The word encapsulated Mahu’s illness as a living entity from the past that had come forward into the present to work out an old grievance, a taskmaster of ethical consequence. In this life, and likely in past lives, too, Mahu had treated buffaloes in a way that left a residue of unfinished business, and now the buffaloes had returned to exact a toll, either actively as spirits, or passively as residual forces rippling down through time. These forces had become a part of his body (in the form of his legs and the gnawing pain in his abdomen) and the material world around him (in the form of nasal cannulas and nasogastric tubes). Everyone that I came to know in my fieldwork identified their disease as a karma master, and pointed to this understanding as a key element of coping with it. This seemed to function beyond just the bounds of choreographing death alone, and so it was not limited to people who selfidentified as engaging with the “new end of life.” It was more like a choreography of severe illness, since it did not seem to require the radical “facing” prescribed by the “new end of life.” What Mahu needed to face was the buffaloes, via the pain and the nasal cannula that the buffaloes used to interact with him. Arirat, on the other hand, was adamant that she could not fully confront and resolve her karma master without facing its “true nature,” including the fact of her pending death. Regardless of this difference, managing relationships with karma masters was a major task that governed the choreography of death for nearly everyone that I followed. Mahu described his karma master not just as a being to which he needed to relate but also as one that had become part of him, though I was not clear when he spoke about it whether this was a metaphor or a (meta)physical reality. This fact, of beings co-constituting one another, was ubiquitous among those that I followed though their ends of lives, and was a key component of the choreography of death. People were, in some sense, choreographing their deaths not just as individuals but as entangled combinations of multiple entities. If Mahu’s disease was partly a being to which he was beholden, if it was partly buffalo in nature, did he and his family need to incorporate the buffalo in their choreography of death?

134 |

Karma Masters

This is difficult conceptual terrain. To explain it will require a set of tools for thinking about how people are put together—or, in the jargon of social theory, about personhood. It will also require ideas from the realm of ethical theory about how people determine the right way to behave toward themselves and others. Before presenting these tools, it will help to understand how karma masters functioned for those I followed. The phenomenon was not limited to dying. It also occurred among people with non-terminal chronic illness. For me, the most striking education that I received on the nature of karma masters came from a young man named Chonawat, whom I met during a later project on pain management in Thailand.1 I first spoke with Chonawat in the summer of 2015 at his cluttered house in a suburban subdivision outside of Chiang Mai. He served me and Tom Taem water using only his right hand, because his left arm hung lifeless at his side. The limp arm ached (tư– tư– ), he said, and at times sparks traveled down it (plæˉp plæˉp), or it felt like rāo, the cracks that form in glass before it breaks. I asked him about the accident that had led to his paralysis, and he tellingly started his story in the much more distant past than the night of the accident. As a teenager, Chonawat was handsome and wild, and became the leader of a group of brash boys. He felt invincible, that he could achieve great things through talent and charm. The girls of his village, just outside of Chiang Mai, showered him with attention. But mostly he spent time with his gang, who challenged one another each evening to feats of daring risk. One day, for sport, Chonawat took a street dog onto his motorcycle, and while it whined and struggled, he sped it in circles around the neighborhood, making his friends collapse with laughter. The trick became a favorite, until one evening he took a dog onto his motorcycle and then, when he was leaning into a fast turn, he accidentally let the dog slip off. It skidded along the pavement and collapsed into a heap, its leg broken, its fur matted with blood. The image of the bloodied dog stayed with him after that, and he wondered from time to time about it, especially since it disappeared from the neighborhood shortly after the accident, to an unknown fate. Years later, in his mid-twenties, Chonawat’s wild energy settled down. He began working fields, either picking the family orchards or working for other villagers. Then, one night he was riding his motorcycle through the mountains when a thick fog settled on his path, obscuring his view of the forest on either side of the road. He was able to see well enough to continue at a good pace. But suddenly, a dog bolted out

Karma Masters |

135

of the woods, no more than a dark shadow against the fog, a line of movement coming toward his front tire. He swerved, felt the thump of the dog’s body on his leg, and then his tire hooked the edge of the road, pulling the motorcycle down under him, throwing him hard onto his left shoulder. He skidded along the pavement, and the drag of his body tore the skin and flesh between his head and shoulder. He slid first along the pavement and then into the woods, where he came to rest against a tree. Pain seared through his mangled neck, and then he noticed that there was no sensation in his arm. He tried moving his hand, and it did not obey. He lay all night in the dark in pain, surrounded by the sounds of the forest, including the barking of dogs in the distance. It was a year after the accident when we met him at his home, where he now lived with his mother. He had begun to compensate for his disability to some degree, but had been without work and was thus dependent on others. After recounting his accident, he paused and switched to a different kind of explanation. “The dog,” he said, was a karma master [čhao kam nāi wēn]. I hurt the dog so much that time when I carried it on my motorcycle. And so the dog came back to punish me, to resolve the karma [wēn kam]. Now the dog is in my arm. Sometimes it comes to me in my dreams and chews on my arm from the outside. But mostly it chews from the inside, like my arm is part dog.

Like Mahu, Chonawat took great consolation from the presence of the dog. Although the dog continually hurt him, it was a being to which he was beholden, and it gave him an opportunity to make amends for his past sins. When his arm hurt particularly badly, he would pause in his day and send loving-kindness (phæˉ mēttā) to his dog-arm, to ask its forgiveness and request that it be gentler in its treatment of him. He also made merit (tham bun) often at the temple, some of it on behalf of the dog. Beyond this remarkable loving approach, there was a part of the relationship between Chonawat and his arm that was very foreign to me, just as Mahu’s relationship to his tumor was. For Chonawat, consequences and actions existed in a space not cleanly bounded by individuals. Chonawat’s abused dog had now become part of his arm, although again it was unclear whether this was metaphor or mechanical reality. And it was difficult to sort out who was whom in this configuration. Chonawat remembered harming a dog, which then returned later in dog form, though certainly not the same dog, and certainly not exclusively bound by the consequences of that single interaction so long ago. This dog then stuck around as a gnawing pain in his arm, and as a figure

136 |

Karma Masters

haunting his dreams. Could one draw a boundary between Chonawat and the dog? What was Chonawat’s arm? Did it consist of Chonawat or of dog? And which Chonawat and which dog? And what about the dreams? Were they simply Chonawat dreaming about a dog, or are we to take seriously the claim that the dog was there inside him? The same was true for Mahu. When Mahu sent love to the buffaloes that were torturing him, with whom was he interacting? With buffaloes? Not exactly. His own legs were now part buffalo, a part of himself that was angry with him. And some buffalo-nature also found its way into the nasal cannula that tugged on his nose in the hospital, an inanimate object that now contained a bit of buffalo anger. These things were also not likely the long-dead buffaloes’ only manifestations—their being was likely distributed in the world in many places and contexts, all ripples of past conditions. Action and consequence were separated by time, in the elapsing of which the relevant moral beings (including both animate and inanimate objects, humans and non-humans) had changed. Thot, my roommate and activity partner at the “Facing Death Peacefully” training, explained this to me. Thot had struggled with “mild schizophrenia” all of his life. He initially presented this to me in purely biomedical language, talking about the hallucinations as “mild positive symptoms” alleviated by “low-dose antipsychotics” (the quoted phrases said in English). But later he explained that the disturbing thoughts he experienced were a karma master from having killed a man in a past life. The man had come back to punish him for his crime. Thot and I had developed an intellectual rapport from our work in the training, and I was able to ask him a question that struck at the heart of my confusion about čhao kam nāi wēn. “Are the thoughts in your heart-mind [čhit čhai] your thoughts or his?” I asked. He considered for a moment, then answered: They are sort of my thoughts, but if you look at it deeply, my heart-mind [čhit čhai] is not really my own, anyway. That man, and killing him, are part of my mind [čhit] now. You know—non-self [‘anattā], impermanence [‘anitčhang]—that sort of thing. It doesn’t really matter, because now I just need to act well and forgive myself and the ideas in my head, regardless of whose ideas they are.2

He added later that the main function of forgiveness was to counteract the “stickiness” (tit) that had combined the two of them into a single being, echoing Mahu’s claim that the buffaloes were now “stuck” (tit) to him. He went on to explain that he was not a particularly religious

Karma Masters |

137

person, but that it was impossible to make sense of what was happening in his own mind without confronting the fact that his self was just as impermanent as all other things in the world. And that self was also an illusion—thoughts were just things happening in the space of his mind. And, more important, those thoughts were a combination, built out of parts with different origins, including components of the mind of a man who had died by murder in another lifetime. Despite Thot’s citing the doctrinal principle of impermanence, his explanation of his karma master was more complex than what usually appears in scholarship on the nature of personhood in most contexts in Thailand, which usually relies on a model of people having discrete, contained selves that change over time. Non-self (‘anattā) is the idea that the self assembles continuously out of conditions; impermanence (‘anitčhang) is the closely related idea that the self is constantly changing.3 But these concepts still largely assume a continuity (if not permanence) of the self— such that one may be held accountable for past actions, as demonstrated by the canonical stories of the many lives of the Buddha through successive animal incarnations, during which acts of selflessness and generosity accumulated over time into an ideally positioned mind that could attain ultimate wisdom.4 But like Mahu and Chonawat, Thot’s self was not only constantly changing, his mind was also merged with another mind. He was, in some ways, a combined being. His version of this was largely immaterial. Mahu and Chonawat, on the other hand, also explained themselves as interacting with their čhao kam nāi wēn through objects like nasal cannulas and tumors and motorcycles. Chonawat described his čhao kam nāi wēn as having become part of his body, so that his arm was part dog. This vision of the self was more complex than that of a singular, coherent mind, contained in the vessel of an individual bounded body. Instead, there seemed to be combinations of beings (like people and buffaloes) and things (like nasogastric tubes) at work in Mahu’s, Chonawat’s, and Thot’s worlds. The components that people described as coming together to make their selves were manifold. Recalling Yai, who pulled me into his scheme to send blood to his uncle, there was a way in which the blood that he wanted to transfer, clearly not just a biological object, was part of his own being: his body had been created as a clot of blood from his mother and father. Sending blood to his uncle would have returned some of that constitution of his own self to his uncle. In a way, it would then have become part of his uncle.

138 |

Karma Masters

And when people talked about their bodies being made up of khwan, the animating spirits that gave their organs vitality, they talked about each of those spirits potentially having its own moral history, its own set of events that might have gotten it “stuck” to other beings or things through time. These concepts fall into the study of “complex” personhood, a set of conceptual tools that address forms of personhood beyond the Western Enlightenment notion of bounded individuals. Perhaps the most applicable of these tools to Mahu and others are the terms “partible” and “distributed” personhood.5 These terms initially emerged from ethnographies of South Asia, in which persons seemed to be modeled as temporary composites in ongoing flows of food and bodily fluids, just like Yai’s.6 This was echoed in other world areas. In parts of Melanesia, for example, Mark Mosko writes, people were seen as “composed of gendered substances, such as father’s bone and mother’s blood, plus lifetimes of donations of embodied and non-substantial labor by other kin and relatives such as food, magical knowledge, ceremonial wealth, land, and so on.”7 The term “distributed” implies that people are connected to and originate in other beings;8 and the term “partible” implies that they consist of multiple components that can, at times, be treated as independent, and at other times as part of a unified whole.9 This set of ideas helps conceptualize Mahu’s and Chonawat’s descriptions of their severe illnesses: Mahu’s tumor, though part of his body, consisted partly of vengeful buffalo nature, and Chonawat was clear that his arm was “part dog.” Living in a world in which persons are made of up multiple beings is profoundly disturbing from a bioethical perspective. If bioethics is deeply dependent on autonomy as a concept, it is even more dependent on the idea that people consist only of themselves. Biomedicine is, in many ways, the enterprise of trying to fix broken people, people that are above all else bounded.10 Scholars have pushed against this assumption in Western biomedicine, mostly in situations in which certain people are deemed by those around them to be “partial” persons, such as in phases of the life-course: in utero,11 infancy,12 death,13 disability,14 or in states created by medical technologies, such as vegetative states15 or brain death.16 But none of this scholarship touches on the complexity of not just being partial, or ever-changing, but consisting of a combination of multiple beings, each with its own past and its own demands. Like the phases of dying in northern Thailand, the partible personhood of Mahu and Chonawat was a complex combination of biomedical and other elements.17 And for Mahu and others, this personhood

Karma Masters |

139

was not simply a fact, but something to be choreographed. How can one navigate death when one is always already partly the other? In other words, what kind of choreography ensues when one is managing not just the process of death, but also who dies? Mahu’s and others’ strategies for their end-of-life processes required strategies for assembling the right elements into their own personhood, including characters that might fuse with and possibly co-constitute their own body and spirit. They did this either by improving relationships with existing components of themselves, such as befriending their karma masters, or by trying to get more benevolent beings to join in. Lisa Stevenson opens her book Life beside Itself with a conversation with a young man in the Canadian Arctic who was unsure whether a raven who lived behind his house was his dead uncle returned in a new form. She related this to naming practices, where all community members were given the names of deceased relatives at birth, and thereby partly became those relatives. Stevenson’s interlocutors embody what Jacques Derrida terms “hauntology,”18 an approach to social life that examines how ideas or things appear at different times and in different places in slightly different form, leaving a true nature that is ultimately empty or ambiguous, in some ways similar to the Buddhist notion of self.19 And so perhaps the deathbed scenes I witnessed in northern Thailand were, above all else, haunted. This haunting was not just a notion of the presence of spirits but a model of the composition of persons. And the haunting was equally comprised of spirits and material objects. Each dying person was full of a multitude of things—dogs, nasal cannula, khwan animating each of the organs of their bodies, blood carrying debt-incurring essences of mother and father. Each of these things had its own background of cause and effect, its own ethical history that had made it stick to the collective. And so, just as many things assembled to bring a person into existence, many things need to be addressed in the choreography of a good death. If the blood of mother and father built the body of the new child, and were such deeply moral gifts that they accrued a massive debt of life that must be repaid, then one must attend to those objects in choreographing a good death. The mechanical ventilators, IV lines, and nasogastric and endotracheal tubes in the ICU also formed a constellation of objects, some infused with the force of sticky spirits, that played a part in choreographing death. At the deathbeds of Jandi and Fawng and Kiang, family members placed objects in their hands—statues of spiritual teachers or amulets

140 |

Karma Masters

infused with power or folded wads of cash. These were not objects to be taken into the next life—they were moral objects, infused with the actions of prior users, able to transfer the consequences of those actions to the spirit of the dying person. A good rebirth was anticipated for Fawng, whose bed was surrounded by bags full of her possessions, partly because she did not miss anything at the moment of death but also because she was in contact with good things—objects that had accrued to her during a life of ethical use and could confer a residue of that goodness on her. The result of all of this was a choreography of death, and ultimately a theory of ethics, whose chief concern was what is in the room: all the parts of oneself (including one’s partially incorporated others); all the parts of others; and all objects that might be infused with ethical force or parts of other beings. A major task for achieving the good death, then, was to try to get the optimal set of characters on the scene. If the hospital was full of polluted, hungry ghosts, one must escape them, find a less polluted place to be at the moment of death. One such place was most homes, which contained better characters: objects infused with merit, benevolent spirits produced by good deaths. And one could fill such places with additional good elements: assemble objects at the head of the bed, fill the room with good people, make sure not to chase away the dying person’s kamlang čhai by spilling dark and shocking news. But one cannot control all components of an ethical location, and so the choreography of death also entails trying to transform dark and harmful components into more benevolent ones. On the first day that Tom Taem and I met Arirat, she explained: I have always taken care of myself, eaten healthy food, never smoked. So I know that this tumor must be some old karma [kam]. It is my karma master [čhao kam nāi wēn]. The tumor is here because it is suffering, and it thinks that this suffering is because of something I have done. So I cannot be angry at the tumor. If I am angry, then I will harm it more, and it will grow and gnaw at me like an angry little dog. So instead, I meditate and send lovingkindness to the tumor and ask its forgiveness.

This was similar to Thot’s claim that it “didn’t really matter” whether the thoughts in his head were his own or someone else’s, because he simply needed to “act well and forgive himself and the ideas in his head, regardless of whose ideas they were.” And so Arirat and others did not fight against the parts of unhappy wronged spirits (buffalo, dog, human) that were part of their heart-minds, bodies, or the material objects around them. Instead, they endeavored to treat them with loving-kindness, ask

Karma Masters |

141

their forgiveness, and make merit on their behalf. This was a choreography of death in which unseen characters formed part of the dance. Achieving the good death necessarily involved ethical treatment of these others, which were also oneself. Ethical locations, then, were generated through a kind of recruitment, an ongoing active coordination to transform one’s constantly changing constellations of elements. Alan Klima observes in regard to ethnography in northern Thailand that in an ethical theory without bounded personhood, “what one is ultimately left with is the acts themselves.”20 Thot made this very clear: he did not care much about the multiplicity of his own mind because he knew exactly what to do. He, meaning all of the components of his multiple self, needed to love and forgive and ask for forgiveness from one another—both his “own” thoughts and those of the man he had killed in a past life. He was not concerned with sorting out whose thoughts were whose, only that his mind (with all of its component parts) be filled with the opposite kind of action from his prior act of murder: forgiveness, kindness, and humility. Despite complex personhood, right action was clear. Arirat spent much of her time sitting in meditation, not only trying to understand the connection between mind and body so that she could release her consciousness from the suffering-laden bounds of the physical world but also embracing and loving the tumor inside her. When I first met her, she had described her tumor as an “angry little dog.” Then, months later, when I held her down, convulsing with pain, teeth clenched, I felt as though I could feel the dog’s vicious teeth tearing at her flesh from the inside. She was briefly stern with me when I spoke because my voice distracted her from the near-impossible internal work that she needed to perform: not to fight the pain, and not only to “study” the tumor and to remember that it was only bodily and need not cause her suffering but also to love the angry little dog that was ripping apart her insides. How could I disagree when Arirat explained that her episode of pain was so brief because she asked the tumor for forgiveness and forgave it for the pain it was causing, and that as a result, the tumor, stuck to Arirat by the bitterness of past injustice, received that loving-kindness, relaxed into it, and let go? I came to think of this process as healing the ethical wound. I do not mean by this phrase to make a separation between mind and body and spirit. In fact, I mean it as a way of thinking about wounding as fundamentally relational rather than individual, and requiring interaction to resolve. If a non-relational model of healing would dictate that one cut out a tumor to save an individual’s body,

142 |

Karma Masters

then a relational model opens up the possibility of the experiential and physical benefit of doing the opposite, of thinking of oneself as not fully separate from anyone or anything, not even one’s tumor. For many, the choreography of what was in the room was less dramatically about partible personhood than it was for Arirat and Thot, and focused simply on the assembly of positive elements and transformation of negative ones. A good example for me was Fawng. One of the objects assembled at the head of her deathbed was an ornate silver platter, adorned with short-stem yellow and white flowers and a small silver cup filled with red liquid. The platter was for the forgiveness ceremony (ahōsikam or khō˛khamā). Throughout the day, each of Fawng’s children and grandchildren came through and took the platter in their hands, bowed their head over her chest, and quietly asked her for forgiveness for any wrongs that they had done to her during her life. If they could think of specific wrongs, then they spoke about those, like one of Fawng’s sons, who went away to work in Bangkok for too long, leaving her at home to worry; or like one of her daughters, who fought with her siblings throughout childhood. But the general atmosphere in the house was loving and kind, and it seemed as though this had built up over many years. Nin, Fawng’s daughter, explained that “many families have a lot to forgive, which is fine, but we are lucky because there isn’t much.” And so mostly they asked forgiveness for generic failings: not calling often enough, causing her grief as teenagers, not being devout enough in attending temples and making merit in her honor. They also each put a hand on her, or bowed their heads, and told her they loved her, and that she should let go of everything, and that she had done so much for them during her life. I was present for this forgiveness ceremony, and I, too, put my hands on her and asked forgiveness for intruding on her and her family’s experience at the end of life, for taking more than I felt like I was giving. The requests needed to be genuine rather than formal; they needed to make it as easy as possible for Fawng to forgive. If she was unable to forgive something, to let it go, then it would stick to her, and some part of her might become a čhao kam nāi wēn, might stick to her family members and bring them harm. And this would not be a good rebirth for her. And so her family, wanting her to move onward free of the stickiness of actions and their consequences, systematically went through everything that they could imagine might stick and tried to release it. Most of this process functioned as though Fawng and her children were each coherent, bounded persons. This coherence only came apart

Karma Masters |

143

bit by bit later, and only subtly. After Fawng’s death, Nin said that she could feel her mother’s presence in the house. “At night, when it is quiet,” she explained, “I hear hints of her. Last night, a door moved on its own, and then later, a cup dropped from the cupboard without anyone in the kitchen.” “Were you afraid?” I asked. “No!” she said. “Mother’s death was good, and she was at home. I think she was just trying to tell me that she was here, so that I would feel warm and close.” Nin confessed that she knew she was supposed to hope that her mother would cling to nothing in this world and thus have a burden-free rebirth, but she secretly hoped that her mother would remain for at least a little while after cremation, so that she could stay connected to her a bit longer. Fawng was clearly haunting Nin, but it was a lovely, warm kind of haunting. I asked Nin about all of the different components of her mother—her soul (winyān), the various khwan that animated her body, all of the things that we had tried to transfer to her before her death—but she simply shrugged and said that she didn’t know which of those things was haunting her house now. It didn’t seem to matter. She could feel something of her mother. Perhaps she was unconcerned by the ambiguity because of “the evidence of the senses,”21 because she could feel her, just as Chonawat could feel the dog in his arm in the form of a gnawing pain. Several months later, I asked Nin whether she still felt her mother’s presence. She said, No . . . At first, I was so happy to have her around. It gave me a cozy feeling to know that she was still there. But then I realized thinking this way was wrong [phit sīn]. She is not my mother, because she has changed. And wanting her around will stick [tit] to her, and stick to me too. It will harm us both.

At first, thinking of her mother and herself as discrete individuals, she had been glad for the ongoing interaction, but when she reframed the relationship in ethical terms, she could suddenly no longer separate her own thoughts and actions from those of her mother. Wanting Fawng to stay was not only a mistreatment of her mother, it could change her mother into a different being, and change herself into a different being as well—both with residual karmic commitments, with darkness that would stick (tit) to them and change their selves. And so, reminded of the transience of the self, and its sticky nature, always at risk of acquiring negative components, she forgave herself for her sadness and for clinging to her mother, sent her mother loving-kindness, and let go.

Coda

When I set out to do fieldwork in northern Thailand, my goal was to use one particular place to understand contemporary transformations in the experience of dying more broadly. I expected that northern Thailand might be deeply affected by medicalization, by flows of capital, technology, and expertise, things that seemed to be touching everywhere in the world. I had not expected, however, to find biomedical and other resources woven together into such a coherent way of dying, one in which the physical and metaphysical, biomedical and religious, practical and lofty, all fit into an ethical strategy of choreographing what was in the room leading up to the moment of death. I had not expected that this choreography would make things that at first seemed so foreign—like the transfer of bodily objects as bearers of karmic and familial debt, or talking spirits into following their bodies home through ghost-infested landscapes, or sending loving-kindness to one’s tumor and embracing pain as a karmic gift—feel like an intuitive part of a coherent whole. I also had not expected that the world of those in northern Thailand, so far from the training I had received in the United States, would provide action points for what to do at the deathbed in my own practice of medicine. This final discovery merits a bit of explanation. Ethnography requires deep immersion in a place. This can be transformative, both intellectually and on other registers. For me there were many different moments of this, from trying to craft myself into the 145

146 |

Coda

seeker of wisdom advocated by the “Facing Your Death Peacefully” training, to sitting in meditation with Arirat as she separated pain and suffering, to being with families at their elders’ deathbeds as we performed forgiveness ceremonies. This is not to say that I got fully swept up into those worlds—in fact, during my fieldwork, I intentionally held myself apart in some ways, hoping to maintain a partially objective gaze. After returning from the field, and after a brief period writing my dissertation, I had the jarring experience of returning to medical school in San Francisco, followed by medical residency at an academic hospital in Boston. At first, my strategy was to code-switch into this new context, like shedding a piece of clothing for one more suited to the weather. I returned to Western concepts of autonomy and the boundedness of individuals, setting aside any notion that my patients’ tumors might be beings that needed to be treated lovingly, or that deception and truth might be shades of grey rather than stark legal delineations, or that one could relate productively to one’s illness without knowing its biomedical name. I also found myself in medical contexts that felt very far from hospitals and homes in northern Thailand, contexts that have since become topics of subsequent anthropological writings, such as improvisation in decision-making in the high-data cardiac ICU,1 or pain management in the U.S. opioid epidemic.2 But it was medical training itself that allowed some of northern Thailand to creep back into my consciousness. Clinician educators describe part of residency training as learning to develop one’s own “style” of practice. It was quite late in my residency that I realized how much my “style” had begun to borrow from the spirit ambulance. An anecdote may help explain this. One evening, I was coming onto a night shift in the ICU of the hospital where I was doing my residency. I was the senior resident, and working with an intern. We had just taken over from the day team, who had passed off the care of a patient who had come in with cardiac arrest. After resuscitation, he had had signs of a systemic infection, and his organs began failing one by one, until he was intubated, admitted to the ICU, and placed on mechanical ventilation, continuous dialysis, and blood pressure support. This had all happened quickly, and he was clearly dying despite these interventions. The day team told us that the patient’s family had finally arrived after traveling from afar, and “seemed very resistant to withdrawing life support.” The intern and I faced the difficult task of meeting the family for the first time and then asking for permission to let the man die.

Coda

|

147

The intern asked if I would run the family meeting, and said, “I would very much like to see how you persuade them.” Persuade? Was that what we would be doing? I wasn’t sure that the intern was wrong, exactly, but something about her word choice made me feel contrarian. I could feel a legalistic biomedical model of autonomy hovering behind her words, as though our task was to get the family to sign a form to authorize the death of their loved one. Regardless, I realized suddenly that however we approached it, we would be choreographing the man’s end of life, and I wished for the first time that I had a score for that choreography as clear as the ones I had witnessed in Thailand. But on a moment’s reflection, I realized that I did have a kind of score: I had developed a “style” of my own, and knew at least how I wanted to start the process. Certainly, my style was a product of my training in a U.S. hospital, but from what followed I also realized that it had components that had come from years spent in Thailand, with Arirat and Jandi and many others. Upon entering a “family meeting room,” a small office-like space reserved for discussions just like these, we sat down, and I asked everyone to tell us their name and their relationship to the patient. After they had each taken a turn, I said, “The next thing that we need from you, if you’re able, is for you to tell us about your father. About who he was as a person. What was the meaning of his life? What made him happiest?” They told us of a man who loved the outdoors, who was fiercely devoted to hunting and fishing and exploring, who took each of his grandchildren out yearly to expose them to the harshest and most beautiful environments, telling them that God could be heard loudest out there. There was a pause after they recounted this, and I imagined everyone letting this version of him settle into the room. Momentarily, I could hear Phra Paisal’s voice in my head, arguing that untying the knots that bind us at the end of life requires making peace with our past selves, so that we can face the reality of who we are at the moment of death. I could also feel the uncomfortable claims about “level of mind,” that decisions and truths must be taken in the context of how someone will use them and know them. And I could feel my discomfort at seeing the paternalism of physicians in Thailand, who were accustomed to deciding things for patients, like how much and which truth to tell them. I could feel the possibly unavoidable arrogance of being a clinician in the position of helping choreograph a family’s experience of death. I also noted how much the family had invoked a logic of place, one in which there was a difference in how loud God might be in one place

148 |

Coda

compared to another. This was close to invoking an ethical world centered on attending to what was in the room.3 There we sat, in a cramped, windowless office, separated by a fluorescent half-lit hall from the room where the man in question was strapped to machines—lines and tubes sticking from his veins and arteries, urethra and throat. This seemed a far cry from the kinds of places his family described as close to God. Sitting with this family, I found that it was not the usual terms of debate around end-of-life care in the West that came to my mind, not “suffering-free,” “death with dignity,” “futile care,” or “prolongation of death,” although these terms certainly might have applied. Instead, ideas from the spirit ambulance came to mind. My intern colleague told the family that although predicting survival in itself was very difficult, we could say with certainty that their father would never again be the person that they described. This seemed to strike right at the heart of the matter, and the family began crying. After a moment, one of the daughters said, “Thank you, that is just what we needed to hear, and how we needed to hear it.” I thought for a moment about the discussions about truth that I had had in northern Thailand, where the way a truth was told was more important than the facts involved. I felt a wave of appreciation of the intern, who clearly had an instinct for how to choreograph death. After a discussion among themselves, the family decided that they wanted to let their father die. We offered to do our best to craft his death into a good one. I repeated a version of the phrase that they had used from their description of him: perhaps we could do whatever was possible to ensure that God was heard as loudly as he could be in his hospital room? I was thinking of the goal in Thailand of assembling positive elements and converting bad elements into good ones. This was, of course, a mixture of resources: biomedical and spiritual, material and metaphysical. The scene that followed was a hybrid of their suggestions and ours, including playing wilderness sounds in his room and having family members take turns recounting tales of adventure to him. With northern Thailand in mind, I suggested a forgiveness ceremony and walked them through the components of it. I am not so naïve as to think that this death had any specific relation to dying in northern Thailand, beyond perhaps distant echoes of global palliative-care movements that had reached into both places. In fact, perhaps our process at this man’s deathbed was just a modification of Judeo-Christian practices, reaching back to the late medieval imperative to resolve one’s struggles with darkness at the deathbed and exchange

Coda

|

149

words of absolution to pave the way to a peaceful entry into heaven.4 But my ability to use the elements that I encountered in northern Thailand to participate in this Boston death made me realize that some components of contemporary death may transcend geography. The first of these components was the need for choreography, the fact that achieving a good death required putting things in the proper time and place. There also seemed to be something important about the hospitals in both Boston and Thailand: each was a space with gravity, one that people needed to orient toward or away from, a place that had inserted itself into every facet of dying. To make death good, we needed to manage the hospital and everything it entailed. The second common component was closely related: the fact that medicalization had created mixtures of biomedical and other elements in the good death. As one patient that I cared for in an ICU during my training in Boston described it to me: “I feel like a cyborg. I’m not sure where I end and the machines begin anymore, but I’m not sure it matters at this point, I can’t do without them.”5 Contemporary death in both Boston and northern Thailand seemed to require a coordinated choreography of biomedical and non-biomedical resources, woven together into a fabric that spilled out of the bounds of biomedicine itself.6 This mixture of biomedicine with other resources, and the importance of choreography, has been documented in many contemporary world areas and many domains of life, from birth to disability to death.7 If there is a broad lesson to be learned from contemporary forms of dying, perhaps this is it. A third commonality between the Boston and northern Thai deaths was the fact that the ethical wound, as I have called it, seemed in both places to be more relational than individual. Although in Boston we did not have a model of karma to guide us, of the stickiness of moral action binding people to one another, the family that night in the ICU nonetheless needed to negotiate the transformation of their father’s social body— to grapple with their relationships to his past self, his current state on the brink of death, and his future self, whatever form that might take.8 After that night in the ICU, I began to use my work on Thailand in a different way, to unsettle my own assumptions about how I (and possibly others) might practice medicine in the United States.9 Learning of the distinction between pain and suffering has since grown into a large project on pain management, traversing Thailand and the United States, leading to a major shift in my own clinical approach to pain medicine. The details of that project are perhaps best left for another book.

150 |

Coda

Suffice to say that, in as much as contemporary dying is a situated phenomenon connected to broad social forces, ways of dying in northern Thailand offer the possibility of informing what we know about death everywhere. For me, this has been intimate and concrete, changing my own way of choreographing death. I hope that the journey of reading this book has provided readers with a window into this, and perhaps even an opportunity to unsettle their own understandings of death, to come to know some of the contours of choreographing death in an increasingly medicalized world.

Notes

Jandi 1. Two kinds of Thai words and phrases are transliterated in this book: (1) core concepts that form working vocabulary throughout the book, and (2) terms with multiple or potentially contested translations. I also occasionally add more detailed transliteration in the notes for terms that may be of interest to scholars. With the exception of those of proper names chosen by their owners, all transliterations follow the American Library Association–Library of Congress system. 2. Since the English word “ethics” is thoroughly bound up with the history of analytic philosophy in the West, translating the concept into and out of Thai is problematic. A full treatment of available terms in Thai and their conceptual origins is beyond the scope of this book. Here, I used the Thai term common in medical settings for accepted professional conduct.

arirat 1. This time she used the related phrase mot kam mot wēn, literally, to “end karma, end debt.” 2. See, e.g., Keyes, “Merit-Transference in the Kammic Theory of Popular Theravada Buddhism”; Ishii, Sangha, State, and Society; Jackson, Buddhism, Legitimation, and Conflict; Keown, Prebish, and Husted, Buddhism and Human Rights; Trungpa and Baker, Cutting through Spiritual Materialism; Cassaniti, Living Buddhism; Esterik, Materializing Thailand; Engel and Engel, Tort, Custom, and Karma. 3. A detailed account of different meditation techniques is beyond the scope of this book, but a basic working vocabulary may aid in understanding the stories that follow. Concentration (samāthi) is the practice of honing the mind’s ability to focus on a single mental object. Practitioners use an array of objects, 151

152 |

Notes to Pages 14–18

from chanting to mental images to positive mind states. Mindfulness (sati) is the practice of continually returning one’s focus to the present moment, and can use a concentration-style emphasis on a single object (such as the breath), but may alternatively emphasize attending to whatever objects present themselves to the mind. A related practice is insight (wipasanā), a progressive process of expanding one’s ability to attend simultaneously to multiple objects that present themselves to the mind at any given time (such as sounds, bodily sensations, thoughts, etc.) and to study the operation of cause and effect in the processes of the mind. Beyond these basic tools, there are transformative practices aimed at crafting positive mind-states. These function as combinations of concentration, mindfulness, and insight. The practice of loving-kindness (mēttā) meditation is often considered to be in this category. In this book, I present these techniques as they arise in the flow of narratives. For some contemporary expositions on these categories, see Payutto, Dictionary of Buddhism; Buddhaghosa, The Path of Purification; Cook, Meditation in Modern Buddhism; Cassaniti, Remembering the Present; Vajiranana Mahathera, Buddhist Meditation in Theory and Practice; Heim, Forerunner of All Things. 4. Stonington, “On the (F)Utility of Pain.” 5. This way of describing karma is generic and general, and there are many variations on it that are relevant to the stories in this book. For example, many Thai modernist Buddhists (such as Buddhadasa) reformulate the cycle of karma and its detailed mechanism, dependent origination, as describing not only the cycles of rebirth between lifetimes, but the way that the suffering self is regenerated in every moment (Payutto, Dependent Origination; Jackson, Buddhadasa: Theravada Buddhism and Modernist Reform in Thailand.). The question of “cessation of existence” can thus be formulated either as stopping the cycle of rebirth between lifetimes, or the rebirth of the suffering self in the present moment, or both. I present these distinctions as they emerge in the stories in this book. 6. The term “end-of-life doula” is derived by analogy from “birth doulas,” lay birth experts who accompany delivering mothers through the birth process. This role emerged out of patient movements of the 1960s critical of the overmedicalization of birth. Analogous “end-of-life doulas,” lay accompanists for the dying, emerged in the 1990s, born of a similar critique of the overmedicalization of death. See Rawlings et al., “What Role Do Death Doulas Play in Endof-Life Care?”

introduction 1. See Hertz, Death and the Right Hand; Ariès, Western Attitudes toward Death; Seale and van der Geest, “Good and Bad Death: Introduction.” 2. Kaufman, And a Time to Die; Lock, “Death in Technological Time.” 3. Seale and van der Geest, “Good and Bad Death: Introduction”; Livingston, Improvising Medicine. 4. For a thorough review of these trends, see Kaufman and Morgan, “Anthropology of the Beginnings and Ends of Life.” 5. Lock, “Death in Technological Time.” 6. Dewey, Quest for Certainty; Bourdieu, Outline of a Theory of Practice.

Notes to Pages 18–25

|

153

7. See, e.g., Thompson, “Ontological Choreography.” 8. Kaufman, And a Time to Die. 9. Kaufman and Morgan, “The Anthropology of the Beginnings and Ends of Life”; Das and Han, Living and Dying in the Contemporary World; Buchbinder, “Choreographing Death.” 10. See Langford, “Medical Eschatologies.” 11. For a sample of perspectives on this narrative of tradition and modernity in Thailand, see Keyes, Thailand, Buddhist Kingdom as Modern Nation-State; Jackson, Buddhadasa: A Buddhist Thinker for the Modern World; Rhum, “‘Modernity’ and ‘Tradition’ in ‘Thailand’”; Morris, “Crises of the Modern in Northern Thailand”; Morris, In the Place of Origins; Klima, Funeral Casino; Sopranzetti, Owners of the Map. 12. The Thai for this was kān dūlæˉ phūpuai raya sutthāi khāwng chīwit. 13. Latour, We Have Never Been Modern; Latour, Down to Earth; Ullrich, “Beyond the ‘Global–Local Divide’”; Johnson, “Narrating Entanglements.” 14. Haraway, “Situated Knowledges”; Lock, “Situated Ethics, Culture and the Brain Death ‘Problem’ in Japan.” 15. Spiro, Buddhism and Society; Tambiah, Buddhism and the Spirit Cults in North-East Thailand; Ishii, Sangha, State, and Society. 16. I use the term “figure” as a kind of ideal type, not so much in a Weberian fashion (i.e., “the synthesis of a great many diffuse, discrete, more or less present and occasionally absent concrete individual phenomena . . . into a unified analytical construct,” quoted in Coser, Masters of Sociological Thought), but more as something imagined by the people themselves in Jandi’s and Arirat’s worlds. A similar use of this conceptual tool can be found in Paul Rabinow’s use of the figure of the human (Rabinow, Anthropos Today.). 17. I owe the term “affordances,” or “perceived action possibilities” (Norman, Psychology of Everyday Things), to Webb Keane, who has recently repurposed “affordances” from a variety of fields (it was originally used by J. J. Gibson in his 1979 book Ecological Approach to Visual Perception) in an attempt to unify the disparate conceptual toolkit of ethical theory—such as virtue ethics, principalism, and practice theory—into a holistic framework (Keane, Ethical Life). I also occasionally draw on other recent synthetic approaches, such as Jarrett Zigon’s exploration of how situations can lead to “moral breakdown,” requiring people to come out of their unexamined “being in the world” (drawing on Heidegger) to address mental constructs directly, what Zigon calls the “ethical demand” (Zigon, “Moral Breakdown and the Ethical Demand”). I also draw on a few other terms in the stories that follow, such as Foucault’s concept of “problematization”—how previously unexamined assumptions can become destabilized at certain moments in history (Foucault, “Polemics, Politics, and Problematizations”). I also draw on what Arthur Kleinman and others have called “local moral worlds”—particular configurations of ethical imperatives that make individual decisions complex and situation-specific (Kleinman, “Experience and Its Moral Modes”; Haraway, “Situated Knowledges”; Cohen, “Where It Hurts”). And finally, to understand Arirat’s project of self-improvement, I draw on mid-century sociology and philosophy that use Greek virtue ethics to understand how individuals craft themselves as ethical beings (Foucault,

154 |

Notes to Pages 29–35

Government of Self and Others; Foucault, Care of the Self; Bourdieu, Outline of a Theory of Practice; MacIntyre, After Virtue). I follow the recent consensus in the field that the distinction between “ethics” and “morality” as terms has been largely arbitrary and has caused more confusion than clarity (Stonington, “On Ethical Locations”). In this book, I use the terms interchangeably.

chapter 1. paying the debt of life 1. Later in my fieldwork, I would come to learn that although people usually talked about themselves as having coherent (although impermanent) single selves, at other times they described the self as much more complex, incorporating other components, such as the animating spirits of their organs (khwan), as well as parts or wholes of other beings, such as Arirat’s karma master. This complex personhood is the topic of chapter 4 of this book. 2. The Thai for this phrase was: rom phō rom sai læ phra čhao. 3. Stonington, “Debt of Life.” 4. See, e.g., Gregersen, From Complexity to Life. 5. For a framework for modeling the materiality of the ephemeral, I rely on the work of Webb Keane; see Keane “Semiotics” and “Evidence of the Senses.” 6. The term krēng čhai is a complex one, relevant to many aspects of Thai social life. It refers to an embodied sensation of social discomfort, connected to hierarchy and power, to politeness and decorum. I think of it as part of what Felicity Aulino has termed a “phenomenology of the social body” (Aulino, “Perceiving the Social Body”). 7. For “powerful,” he used the phrase mī amnāt. What I translate as “one lineage, one blood” was chư– a dīeo kan lư– at dīeo kan. 8. Thai: rao khō˛ sāp chæˉng man duai lư– at nư– a læ chit winyān khō˛ng rao. See Fuller, “Protesters.” 9. Klima, Funeral Casino. 10. See, e.g., Torres, Martinez, and Nirenberg, Race and Blood; Romano, Race Mixing; Guterl, Color of Race in America. 11. Strathern, Gender of the Gift; Mosko, “Partible Penitents.” 12. Marriott, “Hindu Transactions”; Marriott and Inden, “Toward an Ethnosociology of South Asian Caste Systems.” 13. Lock, Twice Dead; Sharp, Strange Harvest. 14. Good, “Biotechnical Embrace.” 15. Harris, “Who Governs?” 16. Harris, “Uneven Inclusion.” 17. The political landscape in Thailand is complex, as will emerge later. For now, it is a reasonable operating summary to say that since the institution of constitutional monarchy in 1932, Thailand has gone through a frequent “wheel of crisis,” moving between the poles of representative democracy and rule by an elite oligarchy of military and extended network monarchy. See Kamolthip Chaemkrachang, Development of Human Rights in Thailand; Aulino et al., “Introduction: The Wheel of Crisis.” 18. Harris, “Uneven Inclusion”; Harris, “‘Developmental Capture’ of the State”; Harris, Achieving Access.

Notes to Pages 35–52

|

155

19. Wendland, Heart for the Work; Hamdy, Our Bodies Belong to God; Livingston, Improvising Medicine; Street, Biomedicine in an Unstable Place. 20. Seo, “Patient Waiting.” 21. Keane, Ethical Life. 22. Winichakul, Siam Mapped. 23. Note that phūkphan is a verb, meaning “to bind.” I use “to have phūkphan with” in translations here, given the narrative awkwardness of saying “to phūkphan” someone. 24. Tambiah, Buddhist Saints; Kitiarsa, Mediums, Monks, and Amulets. 25. Tambiah, World Conqueror and World Renouncer; Ishii, Sangha, State, and Society; Jackson, Buddhism, Legitimation, and Conflict. 26. Sin (bāp) is an action that generates negative consequences; it is the opposite of merit (bun). Here, the nurse connected a karmic logic to family via a debt. If one does not pay one’s debt, if one does harm to one’s elder, it will generate negative consequences to oneself. 27. For a sense of this breadth, see Moore, Heart Talk. 28. Descartes, Passions of the Soul. 29. Note that although the heart-mind was presented to me as a single entity, there was differentiating language used to refer to its thinking functions (čhit) and feeling functions (čhai). Often these two meanings were conflated in a single term, either just čhai alone or the combined term čhit čhai. People often talked about concentration (samāthi), mindfulness (sati), and insight (wipasanā) meditation techniques as training the čhit, and loving-kindness (mēttā) meditations as training the čhai, but the terms were often combined or switched and did not separate cleanly, certainly nowhere near as cleanly as Western notions of the distinction between thinking and feeling. 30. Cassaniti, Living Buddhism. 31. In the areas where I studied in Chiang Mai Province, most people said that a total of thirty-two khwan animate the human body. This detail seemed to vary by place in Thailand. 32. Tanabe and Keyes, Cultural Crisis and Social Memory. 33. Lock, Twice Dead; Sharp, Strange Harvest. 34. Lai, “‘It Was My Daughter’s Greatest Merit.’” 35. Ockey, Making Democracy. 36. Zigon, “Moral Breakdown and the Ethical Demand.” 37. Sontag, Illness as Metaphor. 38. Aulino, Rituals of Care. 39. For an illustration of this morally healing view of caregiving, see Kleinman, “Caregiving.” Note that although I am very compelled by Aulino’s critique of Kleinman’s approach, the view of caregiving that I present in this book is similar to Kleinman’s, and arises out of my fieldwork data in the context of managing relatively rapid deaths. Aulino’s critique of the mentalist assumptions beneath much of the analysis of Thai Buddhism arises very powerfully out of the context of her research on care for the chronically disabled, which is messy and interminable. I address the nature of care that appeared in my research in more detail in chapter 4. 40. Phungrassami et al., “Disclosure.”

156 |

Notes to Pages 53–58

41. The structure of hospices (both as physical settings where people can go to die and as home services) and palliative care (as a medical subspecialty) have changed rapidly in Thailand over the past twenty years. Thus far, this has not led to a significant number of physical locations denoted as hospices. There has been resistance to the concept of physical hospice facilities, both because home is seen as an optimal ethical location for death (see chapter 2) and due to general public opinion that placing an elder in a hospice facility would constitute abandonment of children’s duty to care for elders at home. Despite global trends, because of the lack of funding, few providers have been trained in palliative care. Given that the Thai health system needs many more cardiologists and oncologists, training physicians in palliative care has been a low priority for it. The focus has instead been on workshops for existing physicians and nurses, such as those discussed in chapter 3. See Wright et al., Hospice and Palliative Care in Southeast Asia. 42. Lindquist and Coleman, “Against Belief?” 8. See also Needham, Belief, Language, and Experience; Ruel, “Christians as Believers”; Ruel, Belief, Ritual and the Securing of Life. 43. Favret-Saada, Deadly Words; Good, Medicine Rationality and Experience; Pigg, “The Credible and the Credulous.” 44. Latour, Pandora’s Hope. 45. Mol, Body Multiple. 46. For a more thorough exposition on this notion of knowledge as a form of practice in medicine, see Stonington, “‘Making Moves’ in a Cardiac ICU.” 47. Many point to the Abhaya Sutta, Majjhima Nikaya of the Pali Cannon: “In the case of words that the Tathagata (Buddha) knows to be unfactual, untrue, unbeneficial (or: not connected with the goal), unendearing and disagreeable to others, he does not say them. In the case of words that the Tathagata knows to be factual, true, unbeneficial, unendearing and disagreeable to others, he does not say them. In the case of words that the Tathagata knows to be factual, true, beneficial, but unendearing and disagreeable to others, he has a sense of the proper time for saying them. In the case of words that the Tathagata knows to be unfactual, untrue, unbeneficial, but endearing and agreeable to others, he does not say them. In the case of words that the Tathagata knows to be factual, true, unbeneficial, but endearing and agreeable to others, he does not say them. In the case of words that the Tathagata knows to be factual, true, beneficial, and endearing and agreeable to others, he has a sense of the proper time for saying them. Why is that? Because the Tathagata has sympathy for living beings” (trans. Phungrassami et al., “Disclosure,” 1675). 48. Bennett, “Soft Truth.” 49. Pellegrino, “Is Truth Telling to the Patient a Cultural Artifact?”; Estape et al., “Cancer Diagnosis Disclosure”; Thomsen et al., “What Do Gastroenterologists in Europe Tell Cancer Patients?”; Gordon and Paci, “Disclosure Practices.” 50. For analyses of the inseparability of truth from a social landscape in informed consent practices and in global health research, see Pigg, “The Credible and the Credulous”; Adams, “Randomized Controlled Crime”; Adams, “Saving Tibet?.” 51. Phungrassami et al., “Disclosure,” 1678.

Notes to Pages 61–67

|

157

52. There are many sources for delving deeper into the social history of bioethics’ dependence on Western individualism. For a few examples, see Fox, “Evolution of American Bioethics”; DeVries and Subedi, Bioethics and Society; Rose, Inventing Our Selves; Hoffmaster, Bioethics in Social Context. 53. Pellegrino, “Is Truth Telling to the Patient a Cultural Artifact?” 1735. 54. Fan, “Self-Determination vs. Family-Determination.” 55. The critique of autonomy as a bioethical frame has a long and robust history in the social sciences, coming from scholars working in many world areas. There are many places to find overviews of this literature. For a few examples, see Das, “Public Good”; Drought and Koenig, “‘Choice’ in End-of-Life Decision Making”; Sargent and Smith-Morris, “Questioning Our Principles.” 56. Carrese and Rhodes, “Western Bioethics on the Navajo Reservation.” 57. I address “level of mind” in greater depth in chapter 3. It is a conceptual resource that brings broader social landscapes into what in this chapter may seem like family-specific or individual psychological processes. In chapter 3, I explore how social differences interface with this: how class, gender, generational effects, urban and rural, are used to describe the social world, and are related structurally to individual psychologies. 58. For a sampling of some of these debates, incomplete and intended only to give a sense of the breadth of world areas where this is an issue, see Hamadeh and Adib, “Cancer Truth Disclosure”; Butow, Tattersall, and Goldstein, “Communication with Cancer Patients”; Torrecillas, “Communication of the Cancer Diagnosis”; Harris, Shao, and Sugarman, “Disclosure of Cancer Diagnosis”; Gordon and Paci, “Disclosure Practices”; Elwyn et al., “Responsibility and Cancer Disclosure”; Harrison et al., “Should Doctors Inform Terminally Ill Patients?”; Brada, “How to Do Things to Children with Words”; Good et al., “American Oncology”; Van Hollen, “Handle with Care.” 59. The literature on family roles in decision-making is also immense. For a few reviews, see Hardwig, “What about the Family?”; Breslin, “Autonomy and the Role of the Family”; Ho, “Relational Autonomy or Undue Pressure?” Also see Lulu Wang’s 2019 film The Farewell. 60. Hannerz, “World”; Appadurai, “Disjuncture and Difference”; Tsing, “Global Situation”; Ong and Collier, Global Assemblages. 61. Hannerz, “World.” 62. Tsing, Friction.

chapter 2. the spirit ambulance 1. Bird’s nest is a Chinese herbal medicine and cuisine delicacy, composed of the inner linings of the nests of cave swiftlets found originally in Malaysian Borneo and Southern Thailand (genera Aerodramus, Hydrochous, Schoutedenapus, and Collocalia). The swiftlets form the nests by secreting a layer of modified saliva, which hardens into a protective lining for the nest. Bird’s nest is very expensive, but is nonetheless widely consumed and available in Thailand, usually in the form of tinctures made from small quantities of nest. 2. For an ethnographic exploration of the causes and effects of unregulated pharmaceuticals globally, see McDowell, “Mohit’s Pharmakon.”

158 |

Notes to Pages 67–102

3. Despite universal health care, outpatient dialysis is not universally available in Thailand. Tawo was able to get it because his daughter was a government employee, and he thus had more comprehensive health insurance. Dialysis is a fascinating side story to this more general study of death and dying in Thailand. See Seo, “Patient Waiting.” 4. The hospital had relatively mobile mechanical ventilators, and occasionally a patient on the general medical ward could be temporarily ventilated. 5. Komatra Chuengsatiansup, Culture, Death and the End-of-Life. 6. Hertz, Death and the Right Hand. 7. Nopanat Anupongpat, History of Death. 8. Good, “Biotechnical Embrace.” 9. Seo, “Patient waiting.” 10. Asad, Formations of the Secular. 11. Keane, “Sincerity”; Favret-Saada, Deadly Words. 12. See Williams, Keywords; Sopranzetti, Owners of the Map. 13. Kitiarsa, Mediums, Monks, and Amulets; White, “Rethinking Anthropological Models”; Tambiah, Buddhism and the Spirit Cults. 14. Ueki, Gender Equality in Buddhism; Murcott, First Buddhist Women; Paul and Wilson, Women in Buddhism; Gross, Buddhism after Patriarchy. 15. Tambiah, Buddhism and the Spirit Cults, 247–49. 16. Klima, Funeral Casino. 17. Tambiah, World Conqueror and World Renouncer. 18. Johnson, Ghosts of the New City 19. Mulder, Inside Thai Society: Religion, Everyday Life, Change. 20. Seale and van der Geest, “Good and Bad Death.” 21. Scarry, Body In Pain, 7. 22. Stonington, “On the (F)Utility of Pain.” 23. Bourdieu, Outline of a Theory of Practice. 24. Dewey, Quest for Certainty, 133–34. 25. Mol, Body Multiple. 26. Thompson, “Ontological Choreography.” 27. Kaufman, And a Time to Die. 28. Beauchamp and Childress, Principles of Biomedical Ethics. 29. Haraway, “Situated Knowledges”; Lock, “Situated Ethics.” 30. Lefebvre, Production of Space. 31. Dewey, Quest for Certainty; Bourdieu, Outline of a Theory of Practice. 32. Stonington, “On Ethical Locations.” 33. Casey, “From Space to Place,” 2245. 34. Kaufman, “Hidden Places, Uncommon Persons.”

buddhadasa 1. The following history is derived from primary Thai-language sources, most drawn from the online archive at http://archives.bia.or.th. These consist of newspaper articles and primary archival resources, such as handwritten notes or letters by those involved in the events described. Note that the bibliographic citations for these include transliterated name and date (to allow parenthetical

Notes to Pages 102–105 |

159

citation in text), followed by the Thai-language citation for the source. Following each citation is the decimal location for the online database (in the form BIAx.x/xx) at the time of publication of this book. 2. See Thairath, “Urgent Flight,” 16. This is also taken from two unpublished documents in the records of Buddhadasa’s monastery sūan mōk: “Record of Medical Treatment during Buddhadasa’s Illness,” 5 (BIA1.3/27, p. 5), and “Daily Health Record,” 146 (BIA1.3/16 p. 146). 3. On February 28, 1992. 4. Thai: mai rūsưk pen tūa kū, mai mī pwok mai mī lop, santiphāp sū santisuk (Prawet Wasi, “Report on Buddhadasa’s Illness”). 5. Matichon, “Buddhadasa Turns Over.” 6. Thai: mai yāk tāi khā kunčhæˉ (Jackson, Buddhadasa: Theravada Buddhism and Modernist Reform). 7. Matichon, “Paralyzed Buddhadasa Enters ICU.” 8. Phra Phonthep Thitpanyo and Sermsap Damrongrat. “Summary.” 9. Buddhadasa’s Disciples, “Clarifying Concerns among Buddhadasa’s Disciples.” 10. Ishii, Sangha, State, and Society; Keyes, Thailand, Buddhist Kingdom as Modern Nation-State; Jackson, Buddhism, Legitimation, and Conflict. 11. Tambiah, World Conqueror and World Renouncer. 12. Sopranzetti, Owners of the Map. 13. Ishii, Sangha, State, and Society. 14. Tiyavanich, Sons of the Buddha. 15. Jackson, Buddhadasa: Theravada Buddhism and Modernist Reform in Thailand. 16. Heim, The Forerunner of All Things. 17. Jackson, Buddhadasa: Theravada Buddhism and Modernist Reform in Thailand. 18. For further reading on this wheel of crisis in English, see Aulino et al., “Introduction: The Wheel of Crisis in Thailand”; Haberkorn and Winichakul, Revolution Interrupted; Ferrara, The Political Development of Modern Thailand; Baker and Pasuk, A History of Thailand; Murray, Angels and Devils; Wright, The Balancing Act. In Thai, see Kamolthip Chaemkrachang, The Development of Human Rights in Thailand. Note that both the monarchy and clergy have played powerful but ambivalent roles in this pendulum, sometimes appearing to support political representation for the masses, at other times advocating for rule by an elite oligarchy. 19. Sopranzetti, Owners of the Map; Aulino et al., “Introduction: The Wheel of Crisis in Thailand.” 20. In 1971, Field Marshall Thanom Kittikachorn, then prime minister and military dictator, staged a military coup against his own government in order to dissolve parliament, nullify the constitution and consolidate power into a smaller number of hands. In response, in 1973, 500,000 people took to the streets of Bangkok to protest. The military cracked down violently on the protests, killing hundreds and wounding thousands. National and international outcry erupted in response to this crackdown. To escape this global scrutiny, and also the threat of civil war, the king (Rama IX) intervened and asked the

160 |

Notes to Pages 106–108

military dictator to step down and go into exile. The result was a brief but powerful period of pro-democracy scholarship and debate in Thailand. But it was short-lived. Strong-state activists began a propaganda campaign equating student activism and reform politics with violent communist revolution. In 1976, the former dictator Thanom returned from exile amid rumors that he would protect Thailand from dangerous communist rebels. Student gatherings at Thammasat University grew in response to these rumors, and public debate intensified. The military surrounded Thammasat University, fired rockets and bullets into the central courtyard, and killed students who tried to flee. The military seized control of the government, suspending democratic processes. For more on this history, see Missingham, Assembly of the Poor in Thailand; Ockey, Making Democracy; Baker and Pasuk, History of Thailand; Wyatt, Thailand: A Short History; Wright, Balancing Act; Ferrara, Political Development of Modern Thailand; Haberkorn and Winichakul, Revolution Interrupted; Winichakul, Moments of Silence. 21. Buddhadasa, Handbook for Mankind. 22. See, e.g., “Buddhadasa Is Dead Leaving Priceless Inheritance Behind”; Krungthep Thurakit, “Buddhadasa Is Not Dead Yet”; Buddhadasa’s Disciples, “Notes.” 23. Jackson, Buddhadasa: Theravada Buddhism and Modernist Reform, 276. 24. “Buddhadasa Passed Away at Suan Mok.” 25. This is drawn from an unpublished document in the records of Buddhadasa’s monastery Suan Mok: “A Chronology of 42 Days Prior to Buddhadasa’s Death” (BIA1.4/1, p. 23). 26. Santikaro Bhikkhu, personal correspondence. Santikaro was a prominent and vocal disciple of Buddhadasa’s, perhaps the most involved in negotiations about his care throughout his dying process. A white American by birth and cultural background, he was willing to question and engage with Buddhadasa’s physicians more than his Thai peers. As Buddhadasa’s medical care later progressed, Santikaro became one of the public faces for Buddhadasa, and wrote a famous public letter on behalf of Buddhadasa’s disciples, as I discuss later. I had a chance to interview Santikaro Bikkhu in 2006 about his experiences during Buddhadasa’s end of life. 27. Thai: khonkhai nai phrabō˛ramarāchānukhro˛. See “Revered Monk Flown to City for Treatment”; “Buddhadasa Flown for Treatment at Siriraj.” 28. Jackson, Buddhadasa: Theravada Buddhism and Modernist Reform, 278. 29. See the text of Buddhadasa’s will, available in the files of Buddhadasa’s monastery, Suan Mok (BIA1.3/34, p. 45). 30. Jackson, Buddhadasa: Theravada Buddhism and Modernist Reform, 278. 31. Santikaro Bhikkhu, personal correspondence.. 32. Buddhadasa’s Attendants, “Summary”; Buddhadasa’s Physicians, “Announcement,” 7–14; see also untitled document, BIA1.3/27, 31, 35, 37, 67, 65, 80, 82, 83. 33. “Untitled document,” 17 (BIA 1.3/27); “Buddhadasa Is Stable.”

Notes to Pages 108–111 |

161

34. Santikaro Bhikkhu, personal correspondence. 35. Buddhadasa’s Attendants, “Summary.” 36. “Physicians Are Concerned That Buddhadasa Might Need Surgery”; “Complications Start to Appear—Doctors and Disciples Argue over Buddhadasa’s Brain Surgery”; Buddhadasa’s Attendants, “Summary.” 37. “Buddhadasa Would Regain Consciousness in Seven Days.” 38. After the massacre of 1976, pro-democracy political activity went underground. But by the 1980s, power had begun to shift again from the military to elected officials. In February 1991, Army Commander Suchinda Kraprayoon overthrew the democratically elected government, and in May, 1992, 200,000 pro-democracy protesters took over the central field in old Bangkok and then marched toward the Government House. At a bottleneck bridge near the Democracy Monument, troops blocked the protesters’ path, fired on the crowd with machine guns, and clubbed those trying to surmount the barricade, arresting thousands and killing hundreds. Vivid images of the brutal military crackdown hit the domestic and international media, largely via Bangkok’s black market in bootleg video (Klima, Funeral Casino). This international pressure led Suchinda to resign and restore democracy, leading to another period of open debate regarding the nature of Thai politics. For more on this history, see Klima, Funeral Casino; Haberkorn, In Plain Sight; Haberkorn and Winichakul, Revolution Interrupted; Keyes, Democracy Thwarted; Winichakul, Moments of Silence. 39. Khanit Amphraphak, “Let Us Talk about Buddhadasa”; Withun Lairungrueang, “Letter”; Phimphan Sinsuwan, “Right to Die”; Matithat, “Moral Case and Political Case”; Prayani, “Recollection of Death.” 40. Buddhadasa’s Disciples, Clarifying Concerns; Prasok, “Physical Death— Spiritual Death”; Kukrit Pramoj, “Remark.” 41. Jackson, Buddhadasa: Theravada Buddhism and Modernist Reform. 42. San Hatthirat, “For Buddhadasa.” 43. The phrase employed translates as “prolong life,” but uses the verb yư– , which means to “forcibly wrangle something away from someone,” hinting at the violence of this process. 44. Prayani, “Recollection of Death.” 45. Buddhadasa’s Disciples, Clarifying Concerns. 46. Prasok, “Physical Death—Spiritual Death”; Kukrit Pramoj, “Remark.” 47. Jackson, Buddhadasa: Theravada Buddhism and Modernist Reform, 278. 48. These perspectives from Buddhadasa’s disciples were summarized to me in a personal interview with Santikaro Bhikkhu. 49. Suthep Atthakon, “Letter.” 50. Santikaro Bhikkhu, “Letter.” 51. “Buddhadasa’s Condition Has Deteriorated.” 52. “Buddhadasa Suffers Severe Complications.” 53. “Buddhadasa Needs Intubation, Kidneys Not Functioning Properly.” 54. “Disciples Clarifying Buddhadasa’s Request.” 55. “Buddhadasa Is Dead, Leaving Priceless Inheritance Behind.” 56. Ibid.; “Thais Weep.”

162 |

Notes to Pages 111–122

57. “Buddhadasa Is Dead”; “Thais Weep.” 58. “Buddhadasa Buried in Simplicity.” 59. Aphaphon Kosonkun, “Buddhadasa’s Will.” 60. Foucault, “Polemics, Politics, and Problematizations,” quoted in Rabinow, Anthropos Today, 18.

chapter 3. the new end of life 1. Keyes, “Death of Two Buddhist Saints in Thailand” and “From Death to Birth.” 2. Hallisey and Hansen, “Narrative, Sub-Ethics, and the Moral Life.” 3. Ibid., 314. 4. Ortner, “Subjectivity and Cultural Critique.” 5. The Thai for this was: watthanatham kwāmtāi kap wāra sutthāi khō˛ng chīwit. For a related publication, an academic version of some of the contents of the conference, see: Komatra Chuengsatiansup, Culture, Death and the Endof-Life. 6. See, e.g., Harris, “Who Governs?” 7. For more of his perspective, see Dr. Prawet’s book about Buddhadasa’s death: Prawet Wasi, The Death of the Great Buddhadasa. 8. For a broader view of this movement, see: Nopanat Anupongpat, The History of Death and Changes in Outlook on Life in Thai Society; Komatra Chuengsatiansup, Culture, Death and the End-of-Life; Wright et al., Hospice and Palliative Care in Southeast Asia. 9. Komatra Chuengsatiansup and Yongsak Tantipidok, Thai Health, Thai Culture. 10. Phanubet Maharueankhwan, Mahidol Day and Powering the Health Care System with Humanized Healthcare. 11. Fernquest, “Prince Mahidol and Medical Education in Thailand.” 12. Rabinow, Anthropos Today. 13. Note that the word for an enlightened being, uttarimanutsatamma, which translates as “an ultimately wisdom-aligned person,” equates and combines the words for “human” (manut) and the true nature of the Buddhist teachings (thamma). 14. Wichai Chokwiwat, interview. 15. This brief conceptual history is from a series of interviews with Wichai Chokwiwat, Secretary General of the Medical Council of Thailand. See also Tatsanee Naenudon, Patient Rights; Kamolthip Chaemkrachang, The Development of Human Rights in Thailand; Vitoon Eungpraphan, Seminar on Patients’ Rights; Hewison, Political Change in Thailand; Selby, Human Rights in Thailand. 16. Paisal Visalo, Above Death: from Crisis to Opportunity; Paisal Visalo and Bridaa Reungwichaton, Facing Death Peacefully; Kanajariyaa Sukkharung, Happy at the End of the Path: Facing death Peacefully. 17. The Thai for this was: phachōen khwāmtāi yāng sangop. 18. See, e.g. Aquinas, Summa Theologica; Aristotle, Nicomachean Ethics. 19. Foucault and Davidson, The Government of Self and Others; Rose, Inventing Our Selves.

Notes to Pages 123–138 |

163

20. Foucault, The Care of the Self. For a history of present manifestations of confessional technologies of the self, see Rose, Governing the Soul; Rose, Inventing Our Selves. 21. Aulino, “Perceiving the Social Body”; Cassaniti, Living Buddhism. 22. Of note, one of Arirat’s dying requests was that the full transcripts of our interviews together—which contained a detailed exploration of her meditation techniques, her theories of karma and her discoveries about how to manage her family while she died—be published as a guide to the “new end of life” for others who might face similar issues to her in their dying processes. I produced a book version of these materials, which was distributed at her funeral.

chapter 4. karma masters 1. Stonington, “On the (F)Utility of Pain.” 2. I translate this monologue into English using the subjects “I” and “mine” for understandability, but Thot actually used the common Thai inflection of referring to himself as “we” (rao), and also dropped subjects before verbs. This was not, I do not believe, a deep semiotic intervention claiming multiple personhood, but simply a convention of speech. However, it did leave his monologue productively ambiguous about who was whom. 3. Cassaniti, Living Buddhism; McMahan and Braun, Meditation, Buddhism, and Science; Klima, Funeral Casino. 4. For these lives of the Buddha, see Ñanamoli, Life of the Buddha; Cozort and Shields, Oxford Handbook of Buddhist Ethics; Harvey, Introduction to Buddhist Ethics; Keown, Nature of Buddhist Ethics. In his work on gift exchange with the dead in Thailand, Alan Klima ultimately concluded that Buddhist ethical theory relies on a concept of personhood dependent on the transience of the self: “Generosity brings a return for someone else, a stranger, some other person in the future (even in the next moment), to whom you might habitually refer as ‘yourself’” (Klima, Funeral Casino, 272). This is part of what Phra Paisal summarized in his teaching on crafting a good death by making peace with one’s past selves. 5. Note that I have left out the related term “dividual” for clarity in this brief analysis. For more on this, see Vilaça, “Dividualism and Individualism.” 6. Marriott and Inden, “Toward an Ethnosociology of South Asian Caste Systems.” 7. Mosko, “Partible Penitents,” 218, but also note a prior canonical body of work on this by Strathern, Gender of the Gift. Another useful phrase for understanding partible personhood is the idea that persons are “multi-authored entities”(Finlay, “Personhood and Social Relations”). 8. Gell, Art and Agency. 9. Mosko, “Unbecoming Individuals”; Mosko, “Partible Penitents”; Vilaça, “Dividualism and Individualism.” 10. Note that in many ways the same is true of Western ethical theory. Summing up his argument for ethics as a universal aspect of human societies in “The Continuous and Discontinuous Person,” Michael Lambek asks whether ethics requires the concept of a consistent self and concludes that most cultures contain (but weight

164 |

Notes to Pages 138–148

variably) two ideal-type conceptions of the self. The first, particularly dominant in the post-Enlightenment West, is of the self as “unique, self-continuous, bounded, forensic and ‘possessive’” (p. 846) allowing one to claim that someone either “is or is not” an ethical person. Lambek contrasts this to a second ideal type, that of the self as discontinuous, allowing people to “move through a relatively fixed set of distinct, socially recognized positions that [they] successively come to inhabit, or through which they may alternate,” which he calls “personnages” (p. 846). But although this concept of personhood is much more complex than the simple Enlightenment individualism found in autonomy-dominated bioethics, it is still about roles played in different contexts, rather than any true notion of composite beings. Lambek presents spirit possession as a paradigmatic example of this, arguing that it is the exception that proves the rule of individual persons, since “the host and the spirit are clearly distinguished from one another” (p. 839), and so an individual simply alternates between discrete persons, allowing ethical action and consequence to be attributed cleanly to each of them. 11. LaFleur, Liquid Life. 12. Gottlieb, Afterlife; Scheper-Hughes, Death without Weeping. 13. Hertz, Death and the Right Hand. 14. Gammeltoft, “Childhood Disability and Parental Moral Responsibility in Northern Vietnam.” 15. Kaufman, “Hidden Places, Uncommon Persons.” 16. Lock, Twice Dead. 17. Cf. the conceptualization of “cyborgs” in Haraway, Simians, Cyborgs and Women. 18. Derrida’s “hauntology” was a response to the declared “death of communism” in the aftermath of the fall of the Soviet Union. Playing on Marx’s opening to the Communist Manifesto, “a specter is haunting Europe—the specter of communism,” Derrida wondered how something that had been a haunting force long before it took on a material reality could ever really be “dead,” but might instead arise over and again in slightly different form in different contexts (Derrida, Specters of Marx). His method is useful for tracing objects with a “deferred non-origin” (Buse and Stott, Ghosts), an ever-changing nature, and an inherent slipperiness and emptiness. For overviews of Derrida’s method, see Blanco and Peeren, Spectralities Reader; Davis, “Hauntology, Spectres and Phantoms”; Gordon, Ghostly Matters. 19. Klima, Funeral Casino; Morris, In the Place of Origins. 20. Klima, Funeral Casino, 272. 21. Keane, “Evidence of the Senses.”

coda 1. Stonington, “‘Making Moves.’” 2. Stonington and Coffa, “Structural Iatrogenesis”; Stonington, “‘Acute-onChronic.’” 3. For an exploration of considering God with a “flat ontology,” taken seriously as a character among others in ethical contexts, see Luhrmann, When God Talks Back; Scherz, “Enduring the Awkward Embrace.”

Notes to Page 149

|

165

4. See Ariès, Hour of Our Death. 5. Note that this feature of death is a small part of a broader phenomenon in contemporary life, compellingly outlined in Haraway, Simians, Cyborgs and Women. 6. Thompson, “Ontological Choreography.” 7. The sources for examining this phenomenon are very extensive. For a small sampling, see Thompson; Lock, Encounters with Aging; Lock, Twice Dead; Good, “Biotechnical Embrace”; Béhague, “Beyond the Simple Economics of Cesarean Section”; Pigg, “Languages of Sex and AIDS in Nepal”; Farquhar and Lock, Beyond the Body Proper; Roberts, God’s Laboratory; Roberts, “Gods, Germs, and Petri Dishes”; Livingston, Improvising Medicine; Street, Biomedicine in an Unstable Place. 8. For a classic exposition on the social body in the dying process, see Hertz, Death and the Right Hand. 9. Several of these questions about practice in the United States have made their way into medical journal articles. See Stonington, “Debt of Life—Thai Lessons on a Process-Oriented Ethical Logic”; Stonington, “Whose Autonomy?”; Stonington, “On the (F)Utility of Pain”; Stonington, “‘Acute-on-Chronic.’”

Bibliography

Thai-language listings in this bibliography begin with an English translation, followed by the Thai in brackets. Transliterated Thai names follow the convention for Thai: author’s full name, not separated by a comma. Many of the sources related to Buddhadasa’s death were drawn from an online historical archive, available at http://archives.bia.or.th (in Thai). Listings accessed through this database include the decimal location for the online database (in the form BIAx.x/xx) at the time of publication of this book. Adams, Vincanne. “Randomized Controlled Crime: Post-Colonial Sciences in Alternative Medicine Research.” Social Studies of Science 32, no. 5–6 (2002): 659–90. ———. “Saving Tibet? An Inquiry into Modernity, Lies, Truths and Beliefs.” Medical Anthropology 24 (2005): 71–110. Aphaphon Kosonkun. “Buddhadasa’s Will: Valuable Bequest.” Thairath, July 10, 1993. [อาภาภรณ์ โกศลกุล. “พินัยกรรมพุทธทาส มรดกอันล้ำาค่า.” ไทยรัฐ, 10 กรกฎาคม 2536.] (BIA1. 4/1, pp. 43–44). Appadurai, Arjun. “Disjuncture and Difference in the Global Cultural Economy.” Theory, Culture and Society 7, no. 2 (1990): 295–310. Aquinas, Saint Thomas. Summa Theologica. 1265–74 c.e. Translated by Fathers of the English Dominican Province. newadvent.org/summa. Ariès, Philippe. The Hour of Our Death. Translated by Helen Weaver. New York: Knopf, 1981. ———. Western Attitudes toward Death: From the Middle Ages to the Present. Translated by Patricia Ranum. Baltimore: Johns Hopkins University Press, 1974. Aristotle. The Nicomachean Ethics. Translated by J. A. K. Thomson. London: Penguin Books, 2004. 167

168 |

Bibliography

Asad, Talal. Formations of the Secular: Christianity, Islam, Modernity. Stanford, CA: Stanford University Press, 2003. Aulino, Felicity. “Perceiving the Social Body.” Journal of Religious Ethics 42, no. 3 (2014): 415–41. ———. Rituals of Care: Karmic Politics in an Aging Thailand. Ithaca, NY: Cornell University Press, 2019. Aulino, Felicity, Eli Elinoff, Claudio Sopranzetti, and Ben Tausig. “Introduction: The Wheel of Crisis in Thailand.” Hot Spots, Cultural Anthropology Website, September 2014. https://culanth.org/fieldsights/series/the-wheel-ofcrisis-in-thailand. Baker, Christopher J., and Phongpaichit Pasuk. A History of Thailand. New York: Cambridge University Press, 2005. Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 5th ed. New York: Oxford University Press, 2001. Béhague, Dominique P. “Beyond the Simple Economics of Cesarean Section Birthing: Women’s Resistance to Social Inequality.” Culture, Medicine and Psychiatry 26, no. 4 (December 1, 2002): 473–507. Bennett, Elizabeth S. “Soft Truth: Ethics and Cancer in Northeast Thailand.” Anthropology & Medicine 6, no. 3 (December 1, 1999): 395–404. Blanco, Maria del Pilar, and Esther Peeren, eds. The Spectralities Reader: Ghosts and Haunting in Contemporary Cultural Theory. New York: Bloomsbury Academic, 2013. Bourdieu, Pierre. Outline of a Theory of Practice. Translated by Richard Nice. Cambridge: Cambridge University Press, 1972. Brada, Betsey B. “How to Do Things to Children with Words: Language, Ritual, and Apocalypse in Pediatric HIV Treatment in Botswana.” American Ethnologist 40, no. 3 (2013): 437–51. Breslin, Jonathan M. “Autonomy and the Role of the Family in Making Decisions at the End of Life.” Journal of Clinical Ethics 16, no. 1 (2005): 11–19. Buchbinder, Mara. “Choreographing Death: A Social Phenomenology of Medical Aid-in-Dying in the United States.” Medical Anthropology Quarterly 32, no. 4 (2018): 481–97. Buddhadasa. Handbook for Mankind. Buddha Dharma Education Association, 1956. “Buddhadasa Buried in Simplicity According to His Will.” Thairath, July 10, 1993. [ฝังแล้ว ‘พุทธทาส’ เรียบ-ง่าย! ตาม ‘พินัยกรรม.” ไทยรัฐ 10 กรกฎาคม 2536.] (BIA1.4/1 p. 29). “Buddhadasa Flown for Treatment at Siriraj.” Khao Sod, May 29, 1993. [“รับ’พุทธทาส’บินรักษา’ศิริราช.’” ข่าวสด, 29 พฤษภาคม 2536.] (BIA1.3/36, p. 21). “Buddhadasa Is Dead.” Manager Daily, July 9, 1993. [“ท่านพุทธทาสมรณภาพ.” ผู้จัดการรายวัน, 9 กรกฎาคม 2536.] (BIA1.4/1, pp. 15–16). “Buddhadasa Is Dead, Leaving Priceless Inheritance Behind.” Daily News, July 9, 1993. [“พระพุทธทาส ดับขันธ์ เปิดพินัยกรรมทิ้งมรดกล้า ำ ค่า.” เดลินิวส์, 9 กรกฎาคม 2536.] (BIA1.4/1, p. 2). “Buddhadasa Is Not Dead Yet.” Krungthep Thurakit, July 9, 1993. [“ท่านพุทธ ทาสไม่ดับขันธ์.” กรุงเทพธุรกิจ, 9 กรกฎาคม 2536.] (BIA1.4/1, p. 10).

Bibliography |

169

“Buddhadasa Is Stable—Disciples Use Suan Mok’s Soundscape to Wake His Brain.” Matichon, June 1, 1993. [“‘พุทธทาส’อาการปลอดภัย ใช้เสียงสวน โมกข์ฟื้นสมอง.” มติชน, 1 มิถุนายน 2536.] (BIA1.3/37, p. 65). “Buddhadasa Needs Intubation, Kidneys Not Functioning Properly, Physicians Worry about Heart Failure.” Matichon, July 7, 1993. [“เจาะคอพุทธทาสไตผิด ปกติ แพทย์หวั่น ‘หัวใจล้มเหลว’.” มติชน, 7 กรกฎาคม 2536.] (BIA1. 3/41, p. 31). “Buddhadasa Passed Away at Suan Mok.” Khao Sod, May 28, 1993. [“พุทธ ทาสละสังขารที่สวนโมกข์.” ข่าวสด, 28 พฤษภาคม 2536] (BIA1.3/36, p. 9). Buddhadasa’s Attendants. “Summary of Buddhadasa’s Illness and Care during May 27–30, 1993.” In 3. Notes of the Event by Buddhadasa’s Attendant. Surat Thani: Suan Mok. [“สรุปเล่าเกี่ยวกับอาการอาพาธและการถวายการรักษา ท่านเจ้าคุณอาจารย์พุทธทาสภิกขุ ระหว่างวันที่ 27–30 พฤษภาคม พ.ศ. 2536.” 3. บันทึกเล่าเหตุการณ์ บันทึกพระอุปัฏฐาก.] (BIA1.3/34, p. 50). ———. “Summary of Buddhadasa’s Illness and Care during May 31–June 2, 1993.” In 3. Notes of the Event by Buddhadasa’s Attendant. Surat Thani: Suan Mok. [“บันทึกสรุปอาการอาพาธและการถวายการรักษาท่านเจ้าคุณอาจารย์ พุทธทาสภิกขุ ระหว่างวันที่ 31 พฤษภาคม—2 มิถุนายน 2536.” 3. บันทึกเล่า เหตุการณ์ บันทึกพระอุปัฏฐาก.] (BIA1.3/34, p. 52–53). “Buddhadasa’s Condition Has Deteriorated.” Thairath, July 6, 1993. [“พุทธ ทาสทรุดหนัก.” ไทยรัฐ, 6 กรกฎาคม 2536.] (BIA1.3/41, p. 22). Buddhadasa’s Disciples. 1993. “Notes on the Disciples’ Opinions and Meetings’ Resolutions on Buddhadasa’s Illness” In 2. Official Statement by Buddhadasa’s Disciples. Surat Thani: Suan Mok. [“บันทึกความเห็นและมติของการ ประชุมเกี่ยวกับการอาพาธของพระเดชพระคุณพระธรรมโกศาจารย์ (พุทธทาสมหา เถระ).” 2. แถลงการณ์ แถลงข่าว (คณะศิษย์).] (BIA1.3/34, p. 34). ———. Clarifying Concerns among Buddhadasa’s Disciples. Bangkok: Ruenkaew Printing, 1993. [ไขข้อข้องใจในชาวสวนโมกข์. กรุงเทพ: โรงพิมพ์ เรือนแก้ว, 2536.] (BIA1.3/35, p. 20–22). Buddhadasa’s Physicians. “Announcement by Siriraj’s Medical Team on the Progress of Buddhadasa’s Illness.” In 1. Statement on Buddhadasa’s Illness. Surat Thani: Suan Mok. [“ประกาศคณะแพทยศาสตร์ศิริราชพยาบาล เรื่อง ความคืบหน้าการรักษาอาการอาพาธของพระธรรมโกศาจารย์ (พุทธทาส อิน ทปัญโญ).” 1. แถลงอาการอาพาธ (คณะแพทย์)] (BIA1.3/34, p. 7–14). “Buddhadasa Suffers Severe Complications.” Matichon, July 6, 1993. [“‘พุทธ ทาส’อาการแทรกซ้อนทุกระบบ.” มติชน, 6 กรกฎาคม 2536.] (BIA1.3/41, p. 24). “Buddhadasa Turns Over and Says ‘Peace’ and ‘Nirvana’ in His Sleep.” Matichon, June 1, 1993. [“‘พุทธทาส’พลิกตัวได้แล้ว ละเมอ ‘สันติภาพนิพพาน’.” มติ ชน, 1 มิถุนายน พ.ศ. 2536.] (BIA1.3/37, p. 64). “Buddhadasa Would Regain Consciousness in Seven Days.” Khao Sod, May 30, 1993. [“แรงบุญ ‘พุทธทาส’ อีก 7 วันฟื้นสติ,” ข่าวสด, 30 พฤษภาคม 2536.] (BIA1.3/37, p. 6). Buddhaghosa, Bhadantācariya. The Path of Purification: Visuddhimagga. Translated by Nanamoli. Singapore: Buddha Educational Foundation, 1997. Buse, Peter, and Andrew Stott, eds. Ghosts: Deconstruction, Psychoanalysis, History. New York: Palgrave Macmillan, 1999.

170 |

Bibliography

Butow, P.  N., M. H. Tattersall, and D. Goldstein. “Communication with Cancer Patients in Culturally Diverse Societies.” Annals of the New York Academy of Medicine 809 (February 20, 1997): 317–29. Carrese, Joseph A., and Lorna A. Rhodes. “Western Bioethics on the Navajo Reservation: Benefit or Harm?” JAMA 274, no. 10 (September 13, 1995): 826–29. Casey, Edward S. “From Space to Place in Contemporary Health Care.” Social Science & Medicine 56, no. 11 (June 2003): 2245–47. Cassaniti, Julia. Living Buddhism: Mind, Self, and Emotion in a Thai Community. Ithaca, NY: Cornell University Press, 2015. ———. Remembering the Present: Mindfulness in Buddhist Asia. Ithaca, NY: Cornell University Press, 2018. Cohen, L. “Where It Hurts: Indian Material for an Ethics of Organ Transplantation.” Dædalus 128, no. 4 (Fall 1999): 135–65. “Complications Start to Appear—Doctors and Disciples Argue over Buddhadasa’s Brain Surgery.” Siam Post, June 8, 1993. [“โรคเริ่มแทรก ‘ศิษย์-หมอ’วิ วาทะ ‘พุทธทาส’วิกฤติต้องผ่าตัดสมอง,” 8 มิถุนายน 2536.] (BIA1.3/39, p. 85–86). Cook, Joanna. Meditation in Modern Buddhism: Renunciation and Change in Thai Monastic Life. Cambridge: Cambridge University Press, 2010. Coser, Lewis A. Masters of Sociological Thought: Ideas in Historical and Social Context. 2nd ed. Long Grove, IL: Waveland Press, 2003. Cozort, Daniel, and James M. Shields, eds. The Oxford Handbook of Buddhist Ethics. Oxford: Oxford University Press, 2018. Das, Veena. “Public Good, Ethics, and Everyday Life: Beyond the Boundaries of Bioethics.” Dædalus 128, no. 4 (1999): 99–133. Das, Veena, and Clara Han, eds. Living and Dying in the Contemporary World: A Compendium. Berkeley: University of California Press, 2015. Davis, Colin. “Hauntology, Spectres and Phantoms.” French Studies 59, no. 3 (July 1, 2005): 373–79. Derrida, Jacques. Specters of Marx: The State of the Debt, The Work of Mourning & the New International. London: Routledge, 2006. Descartes, René. The Passions of the Soul. Translated by Stephen Voss. Indianapolis: Hackett, 1989. DeVries, Raymond, and Janardan Subedi. Bioethics and Society: Constructing the Ethical Enterprise. Upper Saddle River, NJ: Prentice Hall, 1998. Dewey, John. The Quest for Certainty: A Study of the Relation of Knowledge and Action. Gifford Lectures 1929. New York: Minton, Balch & Company, 1929. “Disciples Clarifying Buddhadasa’s Request to Return to Suan Mok.” Siam Post, July 8, 1993. [“ศิษย์ไขข่าวพุทธทาสวอนขอกลับสวนโมกข์.” สยามโพสต์, 8 กรฎาคม 2536.] (BIA1.3/41, p. 35). Drought, Theresa S., and Barbara A. Koenig. “‘Choice’ in End-of-Life Decision Making: Researching Fact or Fiction?” Gerontologist 42, special no. 3 (October 2002): 114–28. Elwyn, T.  S., M. D. Fetters, H. Sasaki, and T. Tsuda. “Responsibility and Cancer Disclosure in Japan.” Soc Sci Med 54, no. 2 (January 2002): 281–93.

Bibliography |

171

Engel, David M., and Jaruwan S. Engel. Tort, Custom, and Karma: Globalization and Legal Consciousness in Thailand. Stanford CA: Stanford Law Books, 2010. Estape, J., H. Palombo, E. Hernandez, M. Daniels, T. Estape, J. J. Grau, N. Vinolas, and J. M. Mane. “Cancer Diagnosis Disclosure in a Spanish Hospital.” Ann Oncol 3, no. 6 (June 1992): 451–54. Esterik, Penny Van. Materializing Thailand. Oxford: Bloomsbury Academic, 2000. Fan, R. “Self-Determination vs. Family-Determination: Two Incommensurable Principles of Autonomy: A Report from East Asia.” Bioethics 11, no. 3–4 (July 1997): 309–22. Farquhar, Judith, and Margaret Lock, eds. Beyond the Body Proper: Reading the Anthropology of Material Life. Durham, NC: Duke University Press, 2007. Favret-Saada, Jeanne. Deadly Words: Witchcraft in the Bocage. New York: Cambridge University Press, 1977. Fernquest, Jon. “Prince Mahidol and Medical Education in Thailand.” Bangkok Post, January 31, 2014. Ferrara, Federico. The Political Development of Modern Thailand. Cambridge: Cambridge University Press, 2017. Finlay, Nyree. “Personhood and Social Relations.” In The Oxford Handbook of the Archaeology and Anthropology of Hunter-Gatherers, edited by Vicki Cummings, Peter Jordan, and Marek Zvelebil. Oxford: Oxford University Press, 2018. Foucault, Michel. The Care of the Self. New York: Vintage Books, 1988. ———. The Government of Self and Others: Lectures at the Collège de France, 1982–1983. Edited by Frédéric Gros, Alessandro Fontana, François Ewald, and Arnold I. Davidson. Translated by Graham Burchell. New York: Picador, 2011. ———. “Polemics, Politics, and Problematizations.” In Foucault, Ethics: Subjectivity and Truth, edited by Paul Rabinow and Robert Hurley. New York: New Press, 1997. Fox, Renée C. “The Evolution of American Bioethics: A Sociological Perspective.” In Social Science Perspectives on Medical Ethics, edited by George Weisz. Boston: Kluwer Academic Publishers, 1990. Fuller, Thomas. “Protesters Dump Blood at Thai Government Site.” New York Times. March 16, 2010. Gammeltoft, Tine M. “Childhood Disability and Parental Moral Responsibility in Northern Vietnam: Towards Ethnographies of Intercorporeality.” Journal of the Royal Anthropological Institute 14, no. 4 (2008): 825–42. Gell, Alfred. Art and Agency: An Anthropological Theory. Oxford: Oxford University Press, 1998. Gibson, James J. The Ecological Approach to Visual Perception. Boston: Houghton Mifflin, 1979. Good, Byron. Medicine Rationality and Experience. Cambridge: Cambridge University Press, 1994. Good, Mary-Jo DelVecchio. “The Biotechnical Embrace.” Culture, Medicine and Psychiatry 25, no. 4 (December 1, 2001): 395–410.

172 |

Bibliography

Good, Mary-Jo DelVecchio, Byron Good, C. Schaffer, and S. E. Lind. “American Oncology and the Discourse on Hope.” Culture, Medicine and Psychiatry 14, no. 1 (March 1990): 59–79. Gordon, Avery F. Ghostly Matters: Haunting and the Sociological Imagination. Minneapolis: University of Minnesota Press, 2008. Gordon, Deborah R., and Eugenio Paci. “Disclosure Practices and Cultural Narratives: Understanding Concealment and Silence around Cancer in Tuscany, Italy.” Social Science and Medicine 44, no. 10 (1997): 1433–52. Gottlieb, Alma. The Afterlife Is Where We Come From. Chicago: University of Chicago Press, 2004. Gregersen, Niels H., ed. From Complexity to Life: On the Emergence of Life and Meaning. Oxford: Oxford University Press, 2002. Gross, Rita M. Buddhism after Patriarchy: A Feminist History, Analysis, and Reconstruction of Buddhism. Albany: State University of New York Press, 1992. Guterl, Matthew P. The Color of Race in America, 1900–1940. Cambridge, MA: Harvard University Press, 2001. Haberkorn, Tyrell. In Plain Sight: Impunity and Human Rights in Thailand. Madison: University of Wisconsin Press, 2018. Haberkorn, Tyrell, and Thongchai Winichakul. Revolution Interrupted: Farmers, Students, Law, and Violence in Northern Thailand. Madison: University of Wisconsin Press, 2011. Hallisey, Charles, and Anne Hansen. “Narrative, Sub-Ethics, and the Moral Life: Some Evidence from Theravāda Buddhism.” Journal of Religious Ethics 24, no. 2 (1996): 305–27. Hamadeh, G. N., and S. M. Adib. “Cancer Truth Disclosure by Lebanese Doctors.” Social Science & Medicine 47, no. 9 (November 1998): 1289–94. Hamdy, Sherine. Our Bodies Belong to God: Organ Transplants, Islam, and the Struggle for Human Dignity in Egypt. Oakland: University of California Press, 2012. Hannerz, Ulf. “The World in Creolisation.” Africa: Journal of the International African Institute 57, no. 4 (1987): 546–59. Haraway, Donna J. Simians, Cyborgs and Women: The Reinvention of Nature. New York: Routledge; London: Free Association Books, 1991. ———. “Situated Knowledges: The Science Question in Feminism and the Privilege of Partial Perspective.” Feminist Studies 14, no. 3 (1988): 575–99. Hardwig, John. “What about the Family?” Hastings Center Report 20, no. 2 (1990): 5–10. Harris, J.  J., J. Shao, and J. Sugarman. “Disclosure of Cancer Diagnosis and Prognosis in Northern Tanzania.” Social Science & Medicine 56, no. 5 (March 2003): 905–13. Harris, Joseph. Achieving Access: Professional Movements and the Politics of Health Universalism. Ithaca, NY: ILR Press, 2017. ———. “‘Developmental Capture’ of the State: Explaining Thailand’s Universal Coverage Policy.” Journal of Health Politics, Policy and Law 40, no. 1 (February 1, 2015): 165–93.

Bibliography |

173

———. “Uneven Inclusion: Consequences of Universal Healthcare in Thailand.” Citizenship Studies 17, no. 1 (February 1, 2013): 111–27. ———. “Who Governs? Autonomous Political Networks as a Challenge to Power in Thailand.” Journal of Contemporary Asia 45, no. 1 (January 2, 2015): 3–25. Harrison, A., A. M. al-Saadi, A. S. al-Kaabi, M. R. al-Kaabi, S. S. al-Bedwawi, S. O. al-Kaabi, and S. B. al-Neaimi. “Should Doctors Inform Terminally Ill Patients? The Opinions of Nationals and Doctors in the United Arab Emirates.” Journal of Medical Ethics 23, no. 2 (April 1997): 101–7. Harvey, Peter. An Introduction to Buddhist Ethics: Foundations, Values and Issues. Cambridge: Cambridge University Press, 2000. Heim, Maria. The Forerunner of All Things: Buddhaghosa on Mind, Intention, And Agency. New York: Oxford University Press, 2013. Hertz, Robert. Death and the Right Hand. Translated by Rodney Needham. Glencoe, IL: Free Press, 1907. Hewison, Kevin. Political Change in Thailand: Democracy and Participation. Routledge, 2002. Ho, Anita. “Relational Autonomy or Undue Pressure? Family’s Role in Medical Decision-Making.” Scandinavian Journal of Caring Sciences 22, no. 1 (2008): 128–35. Hoffmaster, C. Barry. Bioethics in Social Context. Philadelphia: Temple University Press, 2001. Ishii, Yoneo. Sangha, State, and Society: Thai Buddhism in History. Honolulu: University of Hawai’i Press, 1986. Jackson, Peter A. Buddhadasa: A Buddhist Thinker for the Modern World. Bangkok: Siam Society, 1988. ———. Buddhadasa: Theravada Buddhism and Modernist Reform in Thailand. Chiang Mai, Thailand: Silkworm Books, 2003. ———. Buddhism, Legitimation, and Conflict: The Political Functions of Urban Thai Buddhism. Singapore: Institute of Southeast Asian Studies, 1989. Johnson, Andrew A. Ghosts of the New City: Spirits, Urbanity, and the Ruins of Progress in Chiang Mai. Honolulu: University of Hawai’i Press, 2014. Johnson, Heather L. “Narrating Entanglements: Rethinking the Local/Global Divide in Ethnographic Migration Research.” International Political Sociology 10, no. 4 (December 1, 2016): 383–97. Kamolthip Chaemkrachang. 2002. The Development of Human Rights in Thailand. [กมลทิพย์ แจ่มกระจ่าง. พัฒนาการของสิทธิมนุษยชนในประเทศไทย. กรุงเทพ: ศูนย์ศึกษาการพัฒนาประชาธิปไตยมหาวิทยาลัยธรรมศาสตร์.] Bangkok: Center for Development of Democracy, Thammasat University. Kanajariyaa Sukkharung. 2006. Happy at the End of the Path: Facing Death Peacefully. Bangkok: Putigaa Network. [กรรณจริยา สุขรุ่ง. สุขสุดท้ายที่ปลาย ทาง: เผชิญความตายอย่างสงบ. กรุงเทพ: เครือข่ายพุทธิกา] Kaufman, Sharon R. And a Time to Die: How American Hospitals Shape the End of Life. New York: Scribner, 2005. ———. “Hidden Places, Uncommon Persons.” Social Science & Medicine 56, no. 11 (June 2003): 2249–61.

174 |

Bibliography

Kaufman, Sharon R., and Lynn M. Morgan. “The Anthropology of the Beginnings and Ends of Life.” Annual Review of Anthropology 34 (2005): 317–41. Keane, Webb. Ethical Life: Its Natural and Social Histories. Princeton, NJ: Princeton University Press, 2017. ———. “The Evidence of the Senses and the Materiality of Religion.” Journal of the Royal Anthropological Institute 14 (2008): S110–27. ———. “Semiotics and the Social Analysis of Material Things.” Language & Communication 23, no. 3 (July 1, 2003): 409–25. ———. “Sincerity, ‘Modernity,’ and the Protestants.” Cultural Anthropology 17, no. 1 (April 9, 2013): 65–92. Keown, Damien. The Nature of Buddhist Ethics. Basingstoke, England: Palgrave Macmillan, 1992. Keown, Damien, Charles S. Prebish, and Wayne Rollen Husted. Buddhism and Human Rights. Richmond, England: Curzon, 1998. Keyes, Charles F. “Death of Two Buddhist Saints in Thailand.” In Charisma and Sacred Biography, edited by Michael A. Williams, 149–80. [New York]: American Academy of Religion, 1982. ———. Democracy Thwarted: The Crisis of Political Authority in Thailand. Pasir Panjang, Singapore: ISEAS Publishing, 2015. ———. “From Death to Birth: Ritual Process and Buddhist Meanings in Northern Thailand.” Folk 29 (1987): 181–206. ———. “Merit-Transference in the Kammic Theory of Popular Theravada Buddhism.” In Karma: An Anthropological Inquiry, edited by Charles F. Keyes and Valentine Daniel, 261–86. Berkeley: University of California Press, 1983. ———. Thailand, Buddhist Kingdom as Modern Nation-State. Boulder, CO: Westview Press, 1987. Khanit Amphraphak. “Let Us Talk about Buddhadasa Once More.” In Clarifying Concerns during Buddhadasa’s Illness. [พล.ต.ต.คณิต อัมพรภักดิ์. “ขอพูด ถึงท่านพุทธทาสอีกสักครั้ง.” ไขข้อข้องใจในยามอาพาธ.] (BIA1.3/35, p. 15). Kitiarsa, Pattana. Mediums, Monks, and Amulets: Thai Popular Buddhism Today. Chiang Mai, Thailand: University of Washington Press, 2012. Kleinman, Arthur. “Caregiving: The Odyssey of Becoming More Human.” Lancet 373, no. 9660 (January 24, 2009): 292–93. ———. “Experience and Its Moral Modes: Culture, Human Conditions and Disorder.” Delivered at Stanford University, April 13–16, 1998. In The Tanner Lectures on Human Values. https://tannerlectures.utah.edu/_documents /a-to-z/k/Kleinman99.pdf. Klima, Alan. The Funeral Casino: Meditation, Massacre, and Exchange with the Dead in Thailand. Princeton, NJ: Princeton University Press, 2002. Komatra Chuengsatiansup. 2007. Culture, Death and the End of Life. Bangkok: Society and Health Institute. [โกมาตร จึงเสถียรทรัพย์. วัฒนธรรม ความ ตาย กับวาระสุดท้ายของชีวิต. กรุงเทพ: สำานักวิจัยสังคมและสุขภาพ]. Komatra Chuengsatiansup and Yongsak Tantipidok. 2007. Thai Health, Thai Culture. Bangkok: Society and Health Institute. [โกมาตร จึงเสถียรทรัพย์ และ ภก.ยงศักดิ์ ตันติปิฎก. สุขภาพไทย วัฒนธรรมไทย. กรุงเทพ: สำานักวิจัยสังคมและ สุขภาพ]

Bibliography |

175

Kukrit Pramoj. “Remark from Suan Mok On Dapkhan.” Khao Sod, July 12, 1993. [คึกฤทธิ์ ปราโมช, “หมายเหตุจาก ‘สวนโมกข์’ ปริศนาศัพท์ ‘ดับขันธ์’ พุทธ ทาส,” ข่าวสด, 12 กรกฎาคม 2536.] (BIA1.4/2, p. 36). LaFleur, William. Liquid Life. Princeton, NJ: Princeton University Press, 1992. Lai, Lucinda. “‘It Was My Daughter’s Greatest Merit’: Reframing Barriers to Organ Donation in Thailand.” Stanford Journal of Public Health (blog), June 1, 2011. Lambek, Michael. “The Continuous and Discontinuous Person: Two Dimensions of Ethical Life.” Journal of the Royal Anthropological Institute 19, no. 4 (2013): 837–58. Langford, Jean M. “Medical Eschatologies: The Christian Spirit of Hospital Protocol.” Medical Anthropology 35, no. 3 (May 3, 2016): 236–46. Latour, Bruno. Down to Earth: Politics in the New Climatic Regime. Cambridge: Polity, 2018. ———. Pandora’s Hope: Essays on the Reality of Science Studies. Cambridge, MA: Harvard University Press, 1999. ———. We Have Never Been Modern. Translated by Catherine Porter. Cambridge, MA: Harvard University Press, 1993. Lefebvre, Henri. The Production of Space. Oxford: Blackwell, 1991. Lindquist, Galina, and Simon Coleman. “Against Belief?” Social Analysis 52, no. 1 (March 31, 2008): 1–18. Livingston, Julie. Improvising Medicine: An African Oncology Ward in an Emerging Cancer Epidemic. Durham, NC: Duke University Press, 2012. Lock, Margaret. “Death in Technological Time: Locating the End of Meaningful Life.” Medical Anthropology Quarterly 10, no. 4 (1996): 575–600. ———. Encounters with Aging: Mythologies of Menopause in Japan and North America. Berkeley: University of California Press, 1995. ———. “Situated Ethics, Culture and the Brain Death ‘Problem’ in Japan.” In Bioethics in Social Context, edited by C. Barry Hoffmaster, 39–68. Philadelphia: Temple University Press, 2001. ———. Twice Dead: Organ Transplants and the Reinvention of Death. Berkeley: University of California Press, 2001. Luhrmann, Tanya M. When God Talks Back: Understanding the American Evangelical Relationship with God. New York: Knopf, 2012. MacIntyre, Alasdair C. After Virtue: A Study in Moral Theory. London: Duckworth, 1981. Marriott, McKim. “Hindu Transactions: Diversity without Dualism.” In Transaction and Meaning: Directions in the Anthropology of Exchange and Symbolic Behavior, edited by Bruce Kapferer. Philadelphia: Institute for the Study of Human Issues, 1979. Marriott, McKim, and Ronald B. Inden. “Toward an Ethnosociology of South Asian Caste Systems.” In The New Wind: Changing Identities in South Asia, edited by Kenneth H. David, 227–38. The Hague: Mouton, 1977. Matithat. “Moral Case and Political Case.” Matichon, June 20, 1993. [มติทัศน์. “ธรรมคดีและการเมืองคดี.” มติชน, 20 มิถุนายน 2536.] (BIA1.3/41, p. 13).

176 |

Bibliography

McDowell, Andrew. “Mohit’s Pharmakon: Symptom, Rotational Bodies, and Pharmaceuticals in Rural Rajasthan.” Medical Anthropology Quarterly 31, no. 3 (2017): 332–48. McMahan, David, and Erik Braun, eds. Meditation, Buddhism, and Science. New York: Oxford University Press, 2017. Missingham, Bruce D. The Assembly of the Poor in Thailand: From Local Struggles to National Protest Movement. Chiang Mai, Thailand: Silkworm Books, 2003. Mol, Annemarie. The Body Multiple: Ontology in Medical Practice. Durham, NC: Duke University Press, 2002. Moore, Christopher G. Heart Talk. Bangkok: Heaven Lake Press, 2006. Morris, Rosalind C. “Crises of the Modern in Northern Thailand: Ritual, Tradition and the New Value of Pastness.” In Cultural Crisis and Social Memory: Modernity and Identity in Thailand and Laos, edited by Shigeharu Tanabe and Charles F. Keyes. Honolulu: University of Hawai’i Press, 2002. ———. In the Place of Origins: Modernity and Its Mediums in Northern Thailand. Durham, NC: Duke University Press, 2000. Mosko, Mark S. “Partible Penitents: Dividual Personhood and Christian Practice in Melanesia and the West.” Journal of the Royal Anthropological Institute 16, no. 2 (2010): 215–40. ———. “Unbecoming Individuals: The Partible Character of the Christian Person.” HAU: Journal of Ethnographic Theory 5, no. 1 (June 17, 2015): 361–93. Mulder, Niels. Inside Thai Society: Religion, Everyday Life, Change. Chiang Mai, Thailand: Silkworm Books, 2000. Murcott, Susan. The First Buddhist Women: Translations and Commentaries on the Therigatha. Berkeley, CA: Parallax Press, 1991. Murray, David. Angels and Devils: Thai Politics from February 1991 to September 1992, a Struggle for Democracy? Bangkok: White Orchid Press, 1996. Ñanamoli, Bhikkhu. The Life of the Buddha: According to the Pali Canon. Seattle: BPS Pariyatti Editions, 2003. Needham, Rodney. Belief, Language, and Experience. Oxford: Blackwell, 1972. Nopanat Anupongpat. 2007. The History of Death and Changes in Outlook on Life in Thai Society. Bangkok: Society and Health Institute. [นภนาท อนุพงศ์ พัฒน์. ประวัติศาสตร์ความตายและความเปลี่ยนแปลงของโลกทัศน์ต่อชีวิตในสังคม ไทย. กรุงเทพ: สำานักวิจัยสังคมและสุขภาพ]. Norman, Donald A. The Psychology of Everyday Things. New York: Basic Books, 1988. Ockey, James. Making Democracy: Leadership, Class, Gender, and Political Participation in Thailand. Honolulu: University of Hawai’i Press, 2004. Ong, Aihwa, and Stephen J. Collier. Global Assemblages: Technology, Politics, and Ethics as Anthropological Problems. Malden, MA: Blackwell Publishing, 2005. Ortner, Sherry B. “Subjectivity and Cultural Critique.” Anthropological Theory 5, no. 1 (March 1, 2005): 31–52.

Bibliography |

177

Paisal Visalo and Preeda Ruangwichatorn. 2006. Facing Death Peacefully. Bangkok: Putigaa Network. [พระไพศาล วิสาโล และ ปรีดา เรืองวิชาธร. เผชิญ ความตายอย่างสงบ: สาระและกระบวนการเรียนรู้. กรุงเทพ เครือข่ายพุทธิกา]. Paisal Visalo. 2006. Beyond Death: From Crisis to Opportunity. Bangkok: Putigaa Network. [พระไพศาล วิสาโล. เหนือความตาย: จากวิกฤตสู่โอกาส. กรุงเทพ เครือข่ายพุทธิกา]. “Paralyzed Buddhadasa Admitted to the ICU.” Matichon, May 26, 1993. [“‘พุทธ ทาส’อัมพาตเข้าไอซียู.” มติชน, 26 พฤษภาคม พ.ศ. 2536.] (BIA1.3/36, p. 3). Paul, Diana Y., and Frances Wilson. Women in Buddhism: Images of the Feminine in Mahayana Tradition. Berkeley, CA: Asian Humanities Press, 1979. Payutto, P. A. Dependent Origination: Buddhist Law of Conditionality. Translated by Bruce Evans. Bangkok: Buddhadhamma Foundation, 1995. ———. Dictionary of Buddhism. Bangkok: Mahachulalongkornwitayalai University, 2003. Pellegrino, Edmund D. “Is Truth Telling to the Patient a Cultural Artifact?” JAMA 268, no. 13 (October 7, 1992): 1734–35. Phanubet Maharueankhwan. 2006. Mahidol Day and Powering the Health Care System with Humanized Healthcare. Bangkok: Work Project for Mind and Health Development. [ภาณุเบศร์ มหาเรือนขวัญ, บรรณาธิการ. วันมหิดลกับ การขับเคลื่อนระบบสุขภาพที่มีหัวใจความเป็นมนุษย์. กรุงเทพ: แผนงานพัฒนาจิต เพื่อสุขภาพ มูลนิธิสดศรี-สฤษดิ์วงศ์]. Phimphan Sinsuwan. “The Right to Die: A Case Study on Buddhadasa’s Illness.” Matichon, June 19, 1993. [พิมพ์พรรณ ศิลป์สุวรรณ. “สิทธิในการเลือก ความตาย ทรรศนะกรณีอาพาธของ ‘ท่านพุทธทาส’.” มติชน, 19 มิถุนายน 2536.] (BIA1.3/41, p. 4–5). “Physicians Are Concerned that Buddhadasa Might Need Surgery; the Disciples Relentlessly Reject the Decision.” Matichon, June 8, 1993. [“แพทย์หนักใจ พุทธทาสถึงผ่าตัด พระลูกศิษย์เสียงแข็งยอมไม่ได้,” มติชน, 8 มิถุนายน 2536.] (BIA1.3/39, p. 83). Phra Phonthep Thitpanyo and Sermsap Damrongrat. “Summary of Buddhadasa’s Illness and Caring during May 27–30, 1993.” [พระพรเทพ ฐิตปัญโญ และ พ.ญ.เสริมทรัพย์ ดำารงรัตน์. “สรุปเล่าเกี่ยวกับอาการอาพาธและการถวายการ รักษาท่านเจ้าคุณอาจารย์พุทธทาสภิกขุ ระหว่างวันที่ 27–30 พฤษภาคม พ.ศ. 2536.” 30 พฤษภาคม พ.ศ. 2536.] (BIA1.3/34, p. 48). Phungrassami, T., H. Sriplung, A. Roka, E. Mintrasak, T. Peerawong, and U. Aegem. “Disclosure of a Cancer Diagnosis in Thai Patients Treated with Radiotherapy.” Social Science & Medicine 57, no. 9 (November 2003): 1675–82. Pigg, Stacy L. “The Credible and the Credulous: The Question of ‘Villagers’ Beliefs’ in Nepal.” Cultural Anthropology 11, no. 2 (1996): 160–201. ———. “Languages of Sex and AIDS in Nepal: Notes on the Social Production of Commensurability.” Cultural Anthropology 16, no. 4 (2001): 481–541. Prasok. “Physical Death—Spiritual Death.” Siam Rath, July 13, 1993. [ประสก. “ข้างวัด: ละสังขาร-ดับสังขาร,” สยามรัฐ, 13 กรกฎาคม 2536.] (BIA1.4/2, p. 65) Prawet Wasi. The Death of the Great Buddhadasa. Bangkok: Rural Doctors’ Press, 1993. [ประเวศ วะสี. ปัจฉิมอาพาธท่านพุทธทาสมหาเถระ. กรุงเทพ: สำานัก พิมพ์หมอบ้านเรา].

178 |

Bibliography

———. “Report on Buddhadasa’s Illness.” [นพ.ประเวศ วะสี. “รายงานการอาพาธ ของ พระธรรมโกศาจารย์ (พุทธทาสภิกขุ).” 2 มีนาคม พ.ศ. 2535.] (BIA1.3/31, p. 44). Prayani. “The Recollection of Death: A Case Study on Buddhadasa.” Bangkok Biz News, June 20, 1993. [ประยาณี. “อนุสติความตาย กรณีท่านพุทธทาส,” กรุงเทพธุรกิจ, 20 มิถุนายน 2536.] (BIA1.3/41, p. 10–11). Rabinow, Paul. Anthropos Today: Reflections on Modern Equipment. Princeton, NJ: Princeton University Press, 2003. Rawlings, Deb, Jennifer Tieman, Lauren Miller-Lewis, and Kate Swetenham. “What Role Do Death Doulas Play in End-of-Life Care? A Systematic Review.” Health and Social Care in the Community 27, no. 3 (2019): 82–94. “Revered Monk Flown to City for Treatment.” Bangkok Post, May 29, 1993 (BIA1.3/36, p. 9). Rhum, Michael R. “‘Modernity’ and ‘Tradition’ in ‘Thailand.’” Modern Asian Studies 30, no. 2 (1996): 325–55. Roberts, Elizabeth F. S. “Gods, Germs, and Petri Dishes: Toward a Nonsecular Medical Anthropology.” Medical Anthropology 35, no. 3 (June 2016): 209– 19. ———. God’s Laboratory: Assisted Reproduction in the Andes. Berkeley: University of California Press, 2012. Romano, Renee C. Race Mixing: Black-White Marriage in Postwar America. Gainesville: University Press of Florida, 2006. Rose, Nikolas. Governing the Soul: The Shaping of the Private Self. London: Routledge, 1990. ———. Inventing Our Selves: Psychology, Power, and Personhood. Cambridge: Cambridge University Press, 1998. Ruel, Malcolm. Belief, Ritual and the Securing of Life: Reflexive Essays on a Bantu Religion. Leiden: Brill Academic Pub, 1997. ———. “Christians as Believers.” In Religious Organization and Religious Experience, edited by John H. R. Davis, 9–31. London: Academic Press, 1982. San Hatthirat. “For Buddhadasa.” Matichon, June 12, 1993. [สันต์ หัตถีรัตน์. “เพื่อท่านพุทธทาส.” มติชน, 12 มิถุนายน 2536.] (BIA1.3/40 p. 58). Santikaro Bhikkhu. “Letter to Siriraj Doctors,” August 15, 2006. www.liberationpark.org/arts/other/siriraj.htm. Sargent, Carolyn, and Carolyn Smith-Morris. “Questioning Our Principles: Anthropological Contributions to Ethical Dilemmas in Clinical Practice.” Cambridge Quarterly of Healthcare Ethics: CQ: The International Journal of Healthcare Ethics Committees 15, no. 2 (2006): 123–34. Scarry, Elaine. The Body in Pain: The Making and Unmaking of the World. Oxford: Oxford University Press, 1987. Scheper-Hughes, Nancy. Death without Weeping: The Violence of Everyday Life in Brazil. Berkeley, CA: University of California Press, 1992. Scherz, China. “Enduring the Awkward Embrace: Ontology and Ethical Work in a Ugandan Convent.” American Anthropologist, 2017. Seale, C., and S. van der Geest. “Good and Bad Death: Introduction.” Social Science & Medicine 58, no. 5 (March 2004): 883–85.

Bibliography |

179

Selby, Don F. Human Rights in Thailand. Philadelphia: University of Pennsylvania Press, 2018. Seo, Bo Kyeong. “Patient Waiting: Care as a Gift and Debt in the Thai Healthcare System.” Journal of the Royal Anthropological Institute 22, no. 2 (June 1, 2016): 279–95. Sharp, Lesley A. Strange Harvest: Organ Transplants, Denatured Bodies, and the Transformed Self. Berkeley: University of California Press, 2006. Sontag, Susan. Illness as Metaphor. New York: Vintage Books, 1979. Sopranzetti, Claudio. Owners of the Map: Motorcycle Taxi Drivers, Mobility, and Politics in Bangkok. Oakland: University of California Press, 2017. Spiro, Melford E. Buddhism and Society: A Great Tradition and Its Burmese Vicissitudes. Berkeley: University of California Press, 1982. Stevenson, Lisa. Life beside Itself. Berkeley: University of California Press, 2014. Stonington, Scott D. “‘Acute-on-Chronic’: States of Emergency, the Social Pain Body and the One-Way ‘Staircase’ of Pharmaceutical Escalation.” Medical Anthropology, under review. ———. “The Debt of Life—Thai Lessons on a Process-Oriented Ethical Logic.” New England Journal of Medicine 369, no. 17 (October 24, 2013): 1583–85. ———. “‘Making Moves’ in a Cardiac ICU: An Epistemology of Rhythm, Data Richness and Process Certainty.” Medical Anthropology Quarterly, forthcoming. ———. “On Ethical Locations: The Good Death in Thailand, Where Ethics Sit in Places.” Social Science & Medicine 75, no. 5 (September 2012): 836–44. ———. “On the (F)Utility of Pain.” Lancet 385, no. 9976 (2015): 1388–89. ———. “Whose Autonomy?” JAMA 312, no. 11 (September 17, 2014): 1099– 1100. Stonington, Scott D., and Diana Coffa. “Structural Iatrogenesis—A 43-YearOld Man with ‘Opioid Misuse.’” New England Journal of Medicine 380, no. 8 (February 21, 2019): 701–4. Strathern, Marilyn. The Gender of the Gift: Problems with Women and Problems with Society in Melanesia. Berkeley: University of California Press, 1988. Street, Alice. Biomedicine in an Unstable Place: Infrastructure and Personhood in a Papua New Guinean Hospital. Durham, NC: Duke University Press, 2014. Suthep Atthakon. “Letter to the Dean of Faculty of Medicine.” Siriraj Hospital, June 11, 1993. [สุเทพ อัตถากร. จดหมายถึงคณบดีคณะแพทย์ศาสตร์ ศิริราช พยาบาล. 11 มิถุนายน 2536.] (BIA1.3/34, p. 79). Tambiah, Stanley J. Buddhism and the Spirit Cults in North-East Thailand. Cambridge: Cambridge University Press, 1970. ———. The Buddhist Saints of the Forest and the Cult of Amulets: A Study in Charisma, Hagiography, Sectarianism, and Millennial Buddhism. Cambridge: Cambridge University Press, 1984. ———. World Conqueror and World Renouncer: A Study of Buddhism and Polity in Thailand against a Historical Background. Cambridge: Cambridge University Press, 1976. Tanabe, Shigeharu, and Charles F. Keyes. Cultural Crisis and Social Memory: Modernity and Identity in Thailand and Laos. Honolulu: University of Hawai’i Press, 2002.

180 |

Bibliography

Tatsanee Naenudon. 1999. Patient Rights. Bangkok: Foundation for Consumers. [ทัศนีย์ แน่นอุดร. สิทธิผู้ป่วย. กรุงเทพ: มูลนิธิเพื่อผู้บริโภค]. “Thais Weep over Buddhadasa’s Death.” Baanmuang, July 9, 1993. [“ไทยสะอื้น อาลัยพุทธทาส.” บ้านเมือง, 9 กรกฎาคม 2536.] (BIA1.4/1, p. 5–6). Thompson, Charis. “Ontological Choreography: Agency through Objectification in Infertility Clinics.” Social Studies of Science 26, no. 3 (August 1, 1996): 575–610. Thomsen, O. O., H. R. Wulff, A. Martin, and P. A. Singer. “What Do Gastroenterologists in Europe Tell Cancer Patients?” Lancet 341, no. 8843 (February 20, 1993): 473–76. Tiyavanich, Kamala. Sons of the Buddha: The Early Lives of Three Extraordinary Thai Masters. Boston: Wisdom Publications, 2007. Torrecillas, L. “Communication of the Cancer Diagnosis to Mexican Patients. Attitudes of Physicians and Patients.” Annals of the New York Academy of Science 809 (February 20, 1997): 188–96. Torres, Max S. Hering, Maria Elena Martinez, and David Nirenberg, eds. Race and Blood in the Iberian World. Berlin: LIT, 2012. Trungpa, Chögyam, and John Baker. Cutting through Spiritual Materialism. Berkeley: Shambhala, 1973. Tsing, Anna. Friction: An Ethnography of Global Connection. Princeton, NJ: Princeton University Press, 2005. ———. “The Global Situation.” Cultural Anthropology 15, no. 3 (2000): 327– 60. Ueki, Masatoshi. Gender Equality in Buddhism. New York: Peter Lang, 2001. Ullrich, Leila. “Beyond the ‘Global–Local Divide’: Local Intermediaries, Victims and the Justice Contestations of the International Criminal Court.” Journal of International Criminal Justice 14, no. 3 (July 1, 2016): 543–68. “Urgent Flight to Take Buddhadasa to Bangkok for Surgery.” Thairath, May 30, 1993. [“บินด่วนรับ’พุทธทาส’เข้ากรุง’ผ่า’กลางดึก.” ไทยรัฐ, 30 พฤษภาคม พ.ศ. 2536.] (BIA1.3/37, p. 16). Vajiranana Mahathera, Paravahera. Buddhist Meditation in Theory and Practice: General Exposition According to the Pali Cannon of the Theravada School. Kuala Lampur, Malaysia: Buddhist Missionary School, 1975. Van Hollen, Cecilia Coale. “Handle with Care: Rethinking the Rights versus Culture Dichotomy in Cancer Disclosure in India.” Medical Anthropology Quarterly 32, no. 1 (2018): 59–84. Vilaça, Aparecida. “Dividualism and Individualism in Indigenous Christianity: A Debate Seen from Amazonia.” HAU: Journal of Ethnographic Theory 5, no. 1 (June 17, 2015): 197–225. Vitoon Eungpraphan. 1993. Seminar on Patients’ Rights. Bangkok: Mahidol University Press. [วิฑูรย์ อึ้งประพันธ์. สัมมนาเรื่องสิทธิของผู้ป่วย. กรุงเทพ: สำานัก พิมพ์มหาวิทยาลัยมหิดล]. Wang, Lulu. The Farewell. DVD. Santa Monica, CA: Lionsgate, 2019. Wendland, Claire. A Heart for the Work: Journeys through an African Medical School. Chicago: University of Chicago Press, 2010.

Bibliography |

181

White, Erick. “Rethinking Anthropological Models of Spirit Possession and Theravada Buddhism.” Religion and Society 8, no. 1 (September 1, 2017): 189–202. Williams, Raymond. Keywords: A Vocabulary of Culture and Society. New York: Oxford University Press, 1976. Winichakul, Thongchai. Moments of Silence: The Unforgetting of the October 6, 1976, Massacre in Bangkok. Honolulu: University of Hawai’i Press, 2020. ———. Siam Mapped: A History of the Geo-Body of a Nation. Honolulu: University of Hawai’i Press, 1994. Withun Lairungrueang. “A Letter to the Editor.” Matichon, June 19, 1993. [น.พ.วิฑูรย์ ไหลรุ่งเรือง, “จดหมายถึงบรรณาธิการ.” มติชน, 19 มิถุนายน 2536.] (BIA1.3/41, p. 8). Wright, Joseph J. The Balancing Act: A History of Modern Thailand. Bangkok: Asia Books, 1991. Wright, Michael, Hamzah Ednin, Phungrassami Temsak, and Agnes BausaClaudio. Hospice and Palliative Care in Southeast Asia: A Review of Developments and Challenges in Malaysia, Thailand and the Philippines. Oxford: Oxford University Press, 2010. Wyatt, David K. Thailand: A Short History. Chiang Mai, Thailand: Silkworm Books, 2003. Zigon, Jarrett. “Moral Breakdown and the Ethical Demand: A Theoretical Framework for an Anthropology of Moralities.” Anthropological Theory 7, no. 2 (June 1, 2007): 131–50.

Index

advance directive (sang sīa), 108 ̔ amnāt. See power/authority anattā. See non-self animating spirit (khwan), 44, 45, 81, 82, 138, 139, 143, 154n1, 155n31. See also heart-mind energy ̔ anitčhang. See impermanence ̔ ārom. See emotion astrology, 87 attachment/clinging (̔ upāthān), 122 Aulino, Felicity, 50, 124, 155n39 autonomy, 41, 42, 46, 59–62, 119, 129, 138; critique of, 157n55; legalistic model of, 147. See also ethics; rights Bangkok, 2, 20, 52, 80, 87, 108, 111, 142; protests in, 33. See also Thailand bāp. See sin bāramī. See prestige/charisma bioethics. See ethics biomedicine, 8, 17, 20–22, 30, 130, 138; high-tech, 35, 41, 95; personhood in, 100; truth-telling in, 52, 55, 115, 116. See also healthcare; hospital; palliative care; physicians blood, 33, 40, 41; mixing of, 33, 34; sending of, 34. See also life body (kāi), 29, 44 Bourdieu, Pierre, 95, 99

Buddhadasa, 12, 15, 102–24, 126, 152n5, 160n26 Buddhagosa, 105 Buddhism, 10, 14, 20, 23, 25, 38, 39, 44, 84, 87, 104–6, 121–22, 130, 137; clergy of, 104, 105, 109; ethical theory of, 50, 119; in the family, 85; feminine side of, 86; modernist, 152n5; power in, 89, 140; practice of, 120; reincarnation in, 106; ritual of, 38, 39, 72, 85; saints of, 113; sermons of, 77, 106; “superstitions” of, 107; texts of, 104; on truth-telling, 55; understanding of death in, 73. See also karma; Nirvana; Pali; spiritual merit; temple bun. See spiritual merit caregiving, 50, 60, 62, 76, 87, 155n39 Casey, Edward, 99 čhai. See heart-mind čhao kam nāi wēn. See karma master čhep. See hurt Chiang Mai, 1–4, 20, 21, 30, 31, 59, 87, 88, 97, 134 Chiang Mai University, 33, 39 čhit čhai. See heart-mind choreography: of death, 18–25, 35, 41, 42, 48, 49, 56–66, 70, 74–77, 83, 89, 90, 94–101, 112–15, 129–33, 139–41, 145–50; of the debt of life, 62–64, 70;

183

184 |

Index

choreography (continued) and ethical locations, 94–101, 142; failure of, 50; ontological, 18, 95; of personhood, 139; self-making and, 128–31; social, 18, 56. See also death; ethics concentration (samāthi), 43, 86, 151n3, 155n29. See also meditation consumerism, 36, 117, 126 dapkhan. See death of senior monk death: bad, 81, 82, 89, 93; complexity of, 18, 19, 95, 96; as a concept, 13; good, 1–8, 15–18, 21, 25, 36, 41, 48, 49, 59, 62–66, 73, 88, 92–96, 99, 100, 112, 114, 129, 130, 139–40, 143, 149; medicalization of, 17, 19, 26, 95, 149, 150; moment of, 6, 75, 90–94, 101, 124, 126, 140, 147; as part of nature, 106; power of, 79; problematizing of, 102–12; process of, 73, 74; reality of, 122. See also choreography; death of senior monk; end of life; ethics; home; spirit, separation from the body of the death of senior monk (dapkhan), 109, 110. See also death debt (nī), 27, 39 debt of life (nī chīwit), 7, 8, 18, 22, 23, 29–30, 39. See also debt of life, payment of the debt of life, payment of the, 27–64, 29tab., 74–79, 83, 84, 89, 90, 94, 95, 100, 101, 111, 126, 130. See also debt of life Derrida, Jacques, 139, 164n18 Dewey, John, 95, 99 dhammaraja. See spiritual greatness of the king dhammic socialism, 105, 106, 109 dharma (thamma), 106, 119, 162n13 dialysis, 67, 68, 71, 75, 78, 158n3 emotion (̔ ārom), 45, 123–26 end of life, 12, 15, 22, 24, 45, 67, 100, 108, 112, 123–31, 148; contemporary, 35; decision-making of the, 98, 99; new, 20, 36, 46, 56, 67, 71, 101, 113–32, 163n22. See also death; end-of-life doulas end-of-life doulas, 15, 19, 89, 120, 152n6. See also end of life ethical location, 6, 99, 100, 114, 141. See also ethics ethics, 4, 6, 151n2; complexity in, 95; of dying, 59–62, 94–101; healing the ethical wound in, 141, 149; models of,

50, 61, 99; situated, 99; theory of, 134, 141, 153n17, 163n4; vocabulary of, 25; Western, 60, 61, 99, 163n10. See also autonomy; death; ethical location; rights family: decision-making of the, 61; paying the debt of life in the, 27–64, 66, 71 forgiveness: asking of, 135, 140–42; ceremony of, 72, 76, 77, 91, 94, 142, 148; function of, 136 Foucault, Michel, 111, 123, 153n17 gambling, 33 ghosts (phī), 3, 5, 79–82, 86 globalization, 24, 25, 63, 64 Good, Mary-Jo DelVecchio, 34 grateful (katanyū), 32, 39, 50 Hallisey, Charles, 113, 114 Hansen, Anne, 113, 114 healthcare: approach to, 12, 90; humanized, 118, 119; politics and, 116; provider of, 98; settings of, 100; universal, 2, 20, 25, 35, 36. See also biomedicine; hospital; physicians heart-mind (čhai), 10–13, 31, 42–44, 48, 136, 155n29. See also animating spirit; heart-mind energy; rotten heart-mind heart-mind energy (kamlang čhai), 5, 6, 22, 41–52, 55–70, 72, 75, 78, 94, 95, 101, 127–29, 132, 140; and ignorance, 100; and truth, 46–52. See also animating spirit; heart-mind Hertz, Robert, 73 Hīan (The Unborn), 81, 82 Hinduism, 20, 44 home, 6, 83–90, 96–99, 143. See also death hospital: autonomy and, 60, 61; autopsy in the, 121; dying in the, 68, 76–83, 86, 96, 129, 149; ghosts in the, 80, 81; modern, 35, 36; public, 2, 35; reverence for, 35, 36, 41; rural, 80; standard for, 118; technologies of the, 65, 75–83, 89, 106. See also biomedicine; healthcare; physicians Hospital Accreditation Bureau (HAB), 117, 120 human (manut), 106, 118, 119, 129, 162n13 human nature, 115 hurt (čhep), 14. See also pain impermanence (̔ anitčhang), 136, 137, 154n1 India, 34

Index |

185

insight (wipasanā), 152n3, 155n29. See also meditation irritated heart (krēng čhai), 31, 154n6

Mol, Annemarie, 54 Mosko, Mark, 138 Mulder, Niels, 89

Johnson, Andrew Alan: Ghosts of the New City of, 88

Nakhon Ping Hospital, 1–3, 9, 11, 20, 21, 24, 27, 37, 53, 64, 101, 114–19, 128, 130 National Cancer Center, 52, 53 Navajo, 62 nī. See debt nī chīwit. See debt of life nipphān. See Nirvana Nirvana (nipphān), 109 non-self (anattā), 136, 137 northern Thailand, 10, 21–25, 33, 53, 62–64, 66, 79, 116, 145–48; funeral customs of, 73, 74; haunting in, 139. See also Thailand

kāi. See body kam. See karma kamlang čhai. See heart-mind energy karma (kam), 13–14, 23, 33, 85, 94, 131, 133, 135, 140, 152n5; mechanics of, 82; model of, 149; positive, 78; power of, 74; results of, 38. See also karma master karma master (čhao kam nāi wēn), 9–15, 25, 132–43. See also karma katanyū. See grateful Kaufman, Sharon, 98, 100; And a Time to Die of, 18 Keane, Webb, 153n17, 154n5 khit māk. See thinking too much khon. See person khwan. See animating spirit Kleinman, Arthur, 153n17, 155n39 Klima, Alan, 33, 87, 141, 163n4 knot (pom), 122–26, 128 knowledge, 54, 55; burden of, 62; about death, 124, 125; effects of, 129. See also truth krēng čhai. See irritated heart Lambek, Michael, 163n10 language: creole, 64; in hospitals, 2; of Thailand, 2, 10, 42, 51, 56 level of mind (radap čhit), 11, 13, 35, 46, 63, 109, 112, 114, 119, 122, 129, 147 life, 30–33; materiality of, 30–32. See also blood loving-kindness (mēttā), 14, 135, 152n3, 155n29 Mahidol University, 109–11 mainstream media, 108–10 male ascetic monastic order (sangha), 38, 86 manut. See human Medical Council of Thailand, 119 meditation, 9–11, 13–14, 151n3; lovingkindness, 152n3. See also concentration; insight; mindfulness Melanesia, 34, 138 merit. See spiritual merit mēttā. See loving-kindness mindfulness (sati), 9, 14, 43, 151n3, 155n29. See also meditation

obligated to, to be/in relationship, to be (phūkphan), 37–39, 67, 71, 76, 155n23 organ transplantation, 34, 45 pain, 9–10, 14–15, 50, 58, 130, 132, 141; lament of, 49, 91–93; management of, 91, 92, 134, 146, 148; medications for, 11, 14, 91–93; phenomenology of, 92. See also hurt; suffering Pali, 86, 104, 122, 156n47. See also Buddhism palliative care, 11, 15, 19–22, 53, 89, 115–18, 123, 130, 148; hospices in, 156n41. See also biomedicine panyā. See wisdom patibat. See practice Pellegrino, Edmund, 61 person (khon), 119 phī. See ghosts phūkphan. See obligated to, to be/in relationship, to be Phungrassami, Temsak, 52, 58, 59, 117, 123 physicians, 12, 47, 116; activist, 35, 115; decisions of, 75, 90; as healers, 123. See also healthcare; hospital politics, 25, 105–9, 112, 154n17, 159n20; democratic, 105, 106, 115, 119, 160n20, 161n38; and healthcare, 116. See also Thailand pom. See knot positive thinking, 55 power/authority (̔ amnāt): hierarchy and, 109, 115, 154n6; rights and, 116; of technology, 77

186 |

Index

practice (patibat), 11, 13 prestige/charisma (bāramī), 88, 104 radap čhit. See level of mind religion, 130. See also Buddhism rights, 61, 109, 111, 129; democracy and, 109; human, 119, 130; patient, 62–64, 109, 114–16, 119, 123. See also autonomy; ethics right speech (sammā wāčhā), 55 role/part (sūan), 60, 75 Roman Catholicism, 123 rotten heart-mind (tam čhai), 48. See also heart-mind sacred (saksit), 76 sacred thread (sāisin), 70, 75, 86 sāisin. See sacred thread saksit. See sacred samāthi. See concentration sammā wāčhā. See right speech sangha. See male ascetic monastic order sang sīa. See advance directive sānphraphūm. See spirit house sati. See mindfulness Scarry, Elaine, 92 schizophrenia, 136 sin (bāp), 40, 87, 155n26 Siriraj Hospital, 102, 107–11, 118 Sivaraksa, Sulak, 109 spirit (winyān), 5, 29, 44, 45, 81, 82, 85, 86, 143 spirit ambulance, 1–6, 8, 21, 23, 24, 35, 65–101, 111, 130, 146 spirit house (sānphraphūm), 88 spirit, separation from the body of the, 23, 73, 74, 82, 100, 111. See also death spiritual greatness of the king (dhammaraja), 104 spiritual merit (bun), 3, 23, 33, 34, 38, 39, 60, 61, 76, 77, 85–87, 104, 111, 135, 142, 155n26 Stevenson, Lisa: Life beside Itself of, 139 sūan. See role/part

Suan Mok, 107, 109. See also Buddhism suffer (thuk thōramān), 14. See also suffering suffering, 9–10, 15, 57, 73, 130; acceptance of, 61; Buddhist conceptions of, 92, 105; embrace of, 13; encounter with, 118, 119, 128; freedom from, 10, 15, 141; of spirits, 82; thought and, 106. See also pain; suffer Surat Thani, 102, 111. See also Thailand Tambiah, Stanley, 87 tam čhai. See rotten heart-mind temple (wat), 5, 38, 39, 51, 77, 78, 87, 111. See also Buddhism Thailand: central, 10; constitutional monarchy of, 104; health care system of, 2, 12, 20, 25, 34–36, 92, 156n41; national identity of, 36; physicians in, 3; southern, 20, 102. See also Bangkok; northern Thailand; politics thamma. See dharma Theravada Buddhism. See Buddhism thinking too much (khit māk), 43–46, 50, 58 Thompson, Charis, 95 thuk thōramān. See suffer truth: choreography of, 52–59; complexity of, 50, 114; deception and, 146; facing the, 120, 124, 128, 148; kamlang čhai and, 46–52; nature of, 52–59. See also knowledge United States, 19, 33; hospitals in the, 55 University Hospital, 59 ̔ upāthān. See attachment/clinging Visalo, Phra Paisal, 116, 120–24 Wasi, Dr. Prawet, 109, 116 wat. See temple winyān. See spirit wipasanā. See insight wisdom (panyā), 110

Founded in 1893,

University of California Press publishes bold, progressive books and journals on topics in the arts, humanities, social sciences, and natural sciences—with a focus on social justice issues—that inspire thought and action among readers worldwide. The UC Press Foundation raises funds to uphold the press’s vital role as an independent, nonprofit publisher, and receives philanthropic support from a wide range of individuals and institutions—and from committed readers like you. To learn more, visit ucpress.edu/supportus.