University of California-Irvine
Scott Stonington’s titular spirit ambulance is a different kind of emergency vehicle than the one we are used to. The direction of the spirit ambulance is away from the hope of biomedical salvation, not toward it. And although it can move with the same sense of urgency as its medical counterpart, the purpose of the spirit ambulance is not to save a life, but to let one go. The urgency lies in staging the precise moment of death, so as to optimize conditions for the spirit’s journey from life to the afterlife.
This is the world Stonington recreates for us as he delves into what “a good death” means in northern Thailand, a place increasingly entangled in medicine’s biotechnical embrace, but not (yet) fully shaped by it. Stonington is interested in how Thai people recruit biomedical resources and interventions in their tasks of preparing for a good death. In the process, Stonington—as anthropologist, medical student, future physician, storyteller, and foreigner in Thailand—introduces us to a cast of fascinating characters and occasionally offers glimpses behind the stage that reveal his own work in crafting the ethnography. Luckily for him (and us), his interlocutors like to have doctors or healers around without the expectation that they can treat or cure patients, because of the “spiritual bonus” provided by their presence (p. 3).
The preface starts out in media res, on a bumpy truck ride with Stonington the anthropologist/doctor-in-training manually pumping oxygen into Jandi’s lungs. Jandi’s death is imminent, and Stonington and Jandi’s family are racing against time to make it home from the hospital for Jandi’s soul to depart. The family members’ coordination and orchestration of the spirit’s journey—what Scott calls “choreographing death”—holds high stakes. Without a proper transition, Jandi’s spirit could head in the wrong direction, or her journey could be intercepted by bad spirits. Jandi’s family spends limited resources to rent the hospital guard’s truck, which is a cheaper version of a medical transport vehicle. The objective of this urgent medical transportation is not to prolong her life, or even to have a “good” or “comfortable” death—for Jandi could have done so without leaving the hospital. Jandi’s relatives’ goal is to “repay the debt of life” by ensuring her successful journey into the spirit world.
Stonington puzzles through some of the language that surrounds him. Jandi’s attending doctor refused to pull out her breathing tube in the public hospital, because that would be “unethical”; yet he instructs Stonington on how to do so in Jandi’s home (p. 6). Why would it be “unethical” in the hospital but non-objectionable at home? Stonington also ponders how expertise is meted out; he is only a medical student with no degree or clinical experience, so how is he entrusted in withdrawing the tube? Both of these puzzles highlight how ethics are often bound up with questions about accountability, legality, and professional responsibility. But Stonington is there to end Jandi’s life (not to help it), so one could reasonably assume there is no more “medical harm” that could possibly be done. Thus Stonington’s quandaries open up further questions about assumptions regarding the uses of medical interventions, and how they are applied when death is already a foregone conclusion.
Throughout his ethnography, I was enthralled with the scenes Stonington sets up, which prompted me to consider new questions about the uses of biomedicine at the end of life. Rather than take on the role of health advocate on behalf of his interlocutors—for example, drawing from his biomedical background to argue for greater access to care or against improper medicalization—Stonington takes a distinct path. His interests are in palliative care and dying, and in his case there is neither too much nor too little of biomedicine; there is simply a different use of it and these uses are rapidly changing as biomedicine extends its reach.
Thus Stonington provides us with an altogether different physician-anthropologist role, for he is concerned with debates about the end of life, where the social determinants of health and proper use of life-saving treatments are less salient. This sets up a unique encounter for the medically trained anthropologist: biomedicine does not concern itself with questions of the spirit or soul, and his interlocutors’ primary goal is to ensure the spirits’ peaceful release. Thus, even if Stonington did have clinical experience before his fieldwork, it would not have been relevant anyway to helping these spiritual journeys.
The scene of rushing Jandi and her family home from the hospital is one Stonington returns to throughout the book, and it is noteworthy how he depicts himself within it: neither volunteering his medical services, nor shying away from carrying them out when asked. He goes along with the decisions being made, learning from and puzzling through them. Interesting questions emerge, such as how to anthropologically portray someone who is unconscious, and the positive meanings people can attribute to pain, such as when a cancer patient refuses morphine despite significant distress, so she can “learn from” her tumor. In contrast to the biomedical imperative to disclose all medical information to the patient and to enhance their autonomy, Stonington demonstrates the burdens patients feel in having to make autonomous decisions, and the heaviness of carrying the knowledge of one’s prognosis that can be lifted when family members shield them.
At other times, Stonington’s committed non-interventionism raised still more questions for me. For example, Stonington described moments when “repaying the debt of life” involved what seemed to be a mis-use of medical resources. In one instance, a young man attempted to “repay his debt” to his uncle via blood donation, even though this was not medically efficacious for the uncle’s condition. Why does the “symbolic meaning” of the blood transfer eclipse its medical futility (when, presumably, there might be other ways to symbolically repay the debt of life)? People are, after all, improvising all along to changing circumstances.
Elsewhere, Stonington describes stressed out nurses trying to help orchestrate the moments of death, and chaotic CPR attempts on dying patients to ensure they die at home. While these descriptions illustrate the profound meaning attached to the spirit’s journey, they also raise questions about the mismatch of expectations between what patients’ family members want and what the biomedical system is equipped to do. I wondered whether family members could benefit from having better access to information about what biomedical services are provided in order to prevent misuse of biomedicine. Perhaps health care practitioners could offer alternative interventions to assist with spirit journeys, such as home visits that help prepare for death, or other forms of services that could assist family members with paying their “debts of life.” These were just some of the questions that Stonington’s provocative book raised for me.
In the Coda, Stonington describes an encounter in which he assertively makes an intervention. Notably, it is no longer in the fieldsite, but in his medical training back in a U.S. hospital, when he employs what he learned in the field to help a family “let go” of a dying loved one. What he learned in Thailand about spiritual journeys, he discovered, could help encourage American family members to face and acknowledge death, and he comes up with an impromptu ritual or sorts, modeled on those of the Thai families he lived with. This moment of “anthropology as cultural critique” happens spontaneously; Stonington did not embark on his fieldwork with the express purpose of learning techniques that would facilitate his future medical work in the US. But fieldwork transforms selves, and we learn from our experiences. Expertly shying away from any claim to a universal truth, Stonington does allow that “some components of contemporary death may transcend geography,” and we see how with every slice of life, we glean an enriched capacity to understand meaning-making everywhere.