Julie Livingston
New York University
What a surreal and yet deeply welcome experience to read The Spirit Ambulance in the midst of a pandemic rife with images of dying patients, tubes running every which way, tethered to respirators, cut off from kin. This small, intimate book, its kind disposition, and beautiful prose anchored me as I read it. This anchoring was a gift I savored amid the anxious temporal and social dislocations of the pandemic. My own father had died quite suddenly a few months before I began reading and I took deep comfort from Scott Stonington’s gentle, but firm insistence on rendering emotion and metaphysics in tight relationship. Then as I prepared to write this, the brilliant and singular medical anthropologist Sharon Kaufman followed suit, leaving me stunned all over again by the suddenness of loss. Scott Stonington was Sharon’s student and he shares her gift for rendering the most complex of dilemmas with tremendous clarity, as well as her careful attention to medical decision-making and the social and institutional dramaturgy of end of life care. He takes these concerns into new and fruitful territory, rendering an expansive and grounded bioethical orientation in the process. I know far too little about Thailand or Theravada Buddhism, but the book returned me to deep truths about dying that are determined by and at moments escape or even supersede the technological embrace. These meanings permeate our current moment, saturated as it is with death.
The Spirit Ambulance examines processes through which people attempt to orchestrate a good death in Thailand, undertaken with great effort and often considerable expense. They do this by drawing biomedical technologies into Buddhist processes of familial and community care. This effort entails choreographing the interplay between place and technology such that relatives bring patients into settings of intensive medicalization only to return them home to die. Stonington shows how this choreography hinges on a serial engagement with concepts that foreground the relational quality of the human body: the debt of life, in which children recognize themselves as embodying a debt they owe to their parents for the blood, breath, and flesh that gave them life; followed by kam lang chai (heart/mind energy), an animating vitality that helps to anchor the mind and spirit within the body. Death then, is a process in which children marshal resources to pay back the debt of life to their elders, even as a good death necessitates maintaining enough kam lang chai in the patient so that their final breath is taken at home, where their spirit can depart and be reborn without unfulfilled attachments. The spirit ambulance of Stonington’s title is the site of some of his most memorable ethnographic moments—a vehicle in which a patient is rushed home from the hospital amid a flurry of encouragement and activity meant to build enough kam lang chai to tether the spirit in the body until it reaches a safe site for its release.
Stonington is both doctor and anthropologist. He approaches this dual position with an openness and humility, and he writes in prose accessible to medical students and anthropologists alike. In this way he navigates medicine and bioethics as cultural forms themselves rather than fixed truths against which deviations in practice must be evaluated. The reader learns that suffering is an accepted part of dying in Thailand, rather than the central orienting phenomenon of ethical adjudication. Failed choreography of dying can turn the home into a “torture chamber” that threatens to turn a good death bad; yet a patient can live with their pain by studying rather than fighting it. Rather than frame the autonomous patient as the bioethical subject that matters, Stonington outlines with clarity a bioethical system in which caregiver and care receiver are relational participants in an ethical practice that is spatially distributed through home and hospital; this is among the greatest gifts of the book. In showing how ethical decisions are always contextual, social, and unfolding amid real contingencies, uncertainties, ambiguities, and tensions, Stonington’s point is not that Thailand offers a better, purer ethical system. Rather, this is how ethics must necessarily unfold across the twists and turns of dying. In doing so he dislodges the universal subject of biomedicine and grapples with the complex ways that relational personhood is embodied and enacted.
The book is tightly focused on the end of life, a process structured by an interplay of patience and urgency. But as I read, I wondered about the broader ambit of the ethical dispositions Stonington so carefully unpacks. What would happen if we took Stonington’s emphasis on location and ethical relations and applied them to a different moment in the circle of life—one requiring a similar interplay of patience and urgency—such as pregnancy and childbirth? Thailand’s system of universal health care enables poor and working class families to draw the hospital into the debt of life, to subordinate the hospital to Buddhist ethics at the end of life. How, if at all, might this form of ethical choreography be mirrored in the choreography of birth and reproduction? What would happen if the debt of life was not only reckoned through family, but also through community, society, nation, planet? Stonington’s book offers clear orientation for approaching such questions with care and insight.