Daena Aki Funahashi
University of California-Berkeley
In The Spirit Ambulance, Scott Stonington explores the ethics and politics of end-of-life procedures in Thailand. The book takes us through the difficult decisions patients and their families must make as they consider, together with physicians, when life should (or should not) be prolonged. Biomedical technology, as Stonington illustrates, gives individuals this choice, and with it, the complexities of deciding when and how a terminally ill person should take their last breath. Through moving ethnographic detail, Stonington shows us how this question of whether or not to defer the inevitability of death challenges the medical authority of the physician. Just because we can prolong life does not mean that we should.
Stonington throws readers into the conundrum of death, as the question of how and when to die opens up broader religious, financial, and politico-ethical concerns. Thinking about dying here quickly slides into a question about living. In a Buddhist context where the nature of one’s death has implications for reincarnation, dying well also means living well. Living well, or having lived a good moral life translates into merit and placement in the afterlife. Thus, this book about death and dying brings life into sharp relief.
According to Stonington, the emergent certainty of death reveals aspects of life ordinarily covered over in everyday life. For the terminally ill, what matters—our attachments, our “knots” (122), what haunts us—whatever it is that we conceal in our day-to-day life comes to the fore. It is thus that death must be “choreographed.” Patients must live long enough to resolve and be freed of what holds them captive, of what knots them in place. It is not fear of death that affect patients, writes Stonington, but the fear of not having a “good death.”
Prolonging life requires not only biomedical technology—such as ventilators, endotracheal tubes, etc.— but also that the patient keeps up a sense of perseverance, or kamlang čhai, what Stonington translates as “heart-mind energy” (5). Patients must not be told about their ailments lest they lose their will to keep on living. Stonington demonstrates how this conflict over telling or not telling a patient what ails them becomes a point of friction where bioethical concerns with patient autonomy come into direct conflict with local ideas about what constitutes a good death.
What is ethical? What is good? Following Lock, Stonington argues the answers are “situated” (99) within the context in which such questions gain articulation. What is ethical here emerges per case, each case being a singular event. Here, another aspect of what Stonington calls “choreography” comes to the fore. Each death, each life, comes with unique spiritual, financial, and political concerns which demand coordination between the patient, family, physician, and disease progress so that the patient may have a good death that is true to the patient’s political and ethical leanings as well as within the family’s economic means.
Yet it is not always clear whether what constitutes a “good death” is good for the patient or the family. For example, the family of one patient, Tawo, insists on resuscitating Tawo back to life despite his repeated requests to be allowed to die. According to Stonington, children of dying parents often turn to biomedical technology to prolong life so that they may properly pay back their debt, a debt they incurred by receiving the gift of life. This debt must be repaid even if it means going against a parent’s wish to be spared further medical intervention. In Tawo’s case, he is allowed to die without further mechanical interruption only after the family feels their debt to him has been sufficiently repaid. The end of the exchange signals the “proper” time to be allowed to die.
As Stonington puts it, the end of life is “scripted” (61). Both patient and family must play their respective roles so that everyone accrues merit, debts are repaid, and nothing holds the patient back to life. The balancing of accounts emerges as an important aspect of the choreography of death. Life is conceptualized as a vital economy, one that must leave no remainder. How to die thus reflects how one enters into an exchange with others. The more you indebt others to your generosity, the more they push to stave off death.
Another approach to the end-of-life centers on the importance of knowing one’s condition. Rather than perseverance through secrecy, patients are encouraged to come to terms with their terminal condition and even to experience the pain of their cancer. This approach, based upon the principals of Buddhism as taught by the famous monk, Buddhadasa, posits biomedical capacities to prolong life as having distorted a natural relationship to death. Death is a natural end to life, and our attachments to life and desire to do anything possible to prolong it go against the laws of dharma [thamma]. Here, patients take no pain medication, and instead, treat pain and disease as “karma masters,” or teachers.
Stonington’s telling of Chonawat’s story is particularly poignant. In his youth, Chonawat, a self-proclaimed “wild” child, would do motorcycle tricks while holding the neighborhood stray dog in displays of cruel whimsy. Once, he let the dog slip, and it skidded down the road until it became a pile of blood and fur. This account is part of Chonawat’s story of his own arm injury, where the dog has become a “karma master,” returning to “resolve the karma” and teach Chonawat through the pain what he had done to another life. There is payback for every act, and one must learn to grow, not hide from it.
The dog becomes part of Chonawat’s story and his life. The story is ethnographically illuminating and highlights important questions to explore further. Stonington sees this story as one where Chonawat comes together, or “combines” (137) with the dog to become a “multiple being” (138). Yet I also wondered about what this story reveals about ideas about exchange that extend beyond life. In light of Stonington’s preceding discussions on debt, the gift, and the need to pay back what one owes, what might this story contribute to theories of exchange?
In sum, The Spirit Ambulance beautifully explains the current conflicts and conundrums concerning end-of-life processes in Thailand. I would recommend it to students interested in medical anthropology, Southeast Asia studies, and topics concerning bioethics. Stonington does a marvelous job highlighting the stakes of dying well and of living well in order to achieve such a death.