Author’s Response to Reviewers

Scott Stonington
University of Michigan, Ann Arbor

What a gift to read these powerful resonances with The Spirit Ambulance by a few of my greatest heroes! I am grateful to SMA for recognizing The Spirit Ambulance with the New Millennium Award and precipitating this engagement.  

I am most heartened to see that the reviewers connected with the “warm tone” of The Spirit Ambulance. This has been one of the most difficult paradoxes for me to convey about caring for people at the end of life: one might imagine that spending time with dying people would be grim or bleak, but there is often an extraordinary warmth to it. This is all the truer in Thailand, where warmth has an ethical and metaphysical support structure beneath it. It is a joy to hear that the text allowed these readers to sink into it. 

The reason I name warmth a paradox is partly because when I arrived in Thailand for fieldwork, it was clear that death’s nature and stakes had become uncertain and contested. This contrast compelled my fieldwork. I wanted to know how such a fundamental part of human life could become unstable, not just at a policy level, but down to moment-to-moment decisions made by dying individuals, their families, and their clinicians. In Northern Thailand, the rapid development of ICU medicine had become enfolded into a prior ethical imperative for children to pay their elders a “debt of life.” This debt, previously paid through medications, rituals and nursing at home, had moved to the intensive care units of hospitals, the most supercharged places to transfer life. But the concentration of bad deaths in hospitals also made them terrifying and dangerous places to die, haunted by spirits with unresolved business with the living. This tension between hospital and home generated the “spirit ambulance,” a wild and unstable journey through an inspirited landscape to achieve death in the right place. When I arrived in the field, choreographing technology and metaphysics had become a focal point for Thai politics, for debates about individual versus collective autonomy, modernity versus tradition, and global versus local.  

Nonetheless, in the midst of this problematization, death and dying seemed to maintain a full-hearted tone. Some of this was due to what Julie Livingston noted, that The Spirit Ambulance “foregrounds the relational quality of the human body,” and I might add the relational quality of Buddhism, whose spiritual practices are often misdiagnosed as ascetic individualism. The Spirit Ambulance tells of bodies that fail because of their entanglements with others, and it is those entanglements with others that make for the paradox of warmth and problematization. For many in Northern Thailand, severe disease is a manifestation of other beings that one harmed in the past, with whom one has a chance to reconcile. The deathbed is thus inevitably a noisy place, full of presences (both alive and otherwise) with stakes in the dying process. The work of dying, then, is to untangle those entanglements, to heal old “ethical wounds,” through forgiveness, peacemaking and letting go. As Daena Funahashi summarized “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.”  

Despite this relationality and its tone of kindness and forgiveness, there are ethical problems that arise from the profound disruption of the individual. The commentators on the Spirit Ambulance noted many of these perils. Daena Funahashi noted that “the more you indebt others to your generosity, the more they push to stave off death,” often at your peril. When everyone at the deathbed, both living and dying, are entangled in the outcome, then it is difficult to sort out the balance of altruism and selfishness that govern people’s actions. Sherine Hamdy wondered why the “symbolic meaning” of a medical intervention should so profoundly “eclipse its medical futility.” Surely one could find interventions that are both medically effective and symbolically rich? And if a choice must be made between the two, shouldn’t life-saving ultimately win? And Julie Livingston wondered “what would happen if the debt of life was not only reckoned through family, but also through community, society, nation, planet?” If a haunted personhood profoundly disrupts the individual autonomy we are accustomed to when thinking about medicine, what bounds should be placed on this porosity?  

A facile response to the binaries embedded in these questions – selfishness versus altruism, symbol versus efficacy, individual versus family/community/society/nation/planet – would be that the ethical world of those in Northern Thailand collapses these distinctions. But that would be empirically simplistic. The Spirit Ambulance is instead animated by them. The contrasts generate plot. Just as families must coordinate both hospital and home as part of dying, they must also coordinate ethical frames. They not only need to pay the debt of life (maybe mostly symbolic?) but also want to save the life of their loved ones (maybe mostly physical?). They need to optimize the ethical outcomes for all involved (measured as the mount of “merit” accrued), including their own and that of the dying individual, and others around, making altruism and selfishness a constant dance. And they need to balance respect for individual, family, community, and beyond, since those things all show up in the assemblage of elements haunting the deathbed room. The attempt to collapse seeming contradictions is what makes the spirit ambulance suspenseful. Thus the concept of choreography, as characters work quickly in the face of pending death to assemble the most optimal elements and actions into the space of the last moment. Unlike Julie Livingston’s interlocutors in Botswana – whose improvisation was an attempt to patch holes in a sinking ship, or close the distance between their reality and Western-created biomedical protocols – choreography was always already complete, plot-filled because of its stakes but not because of its lacks.  

Sherine Hamdy described the Northern Thailand that I portrayed in The Spirit Ambulance as “a place increasingly entangled in medicine’s biotechnical embrace, but not (yet) fully shaped by it,” cleverly noting the book’s problem of how to write about something while it is changing before one’s eyes. The Spirit Ambulance is ultimately a story about globalization and social change, a kind of rolling transformation. I intended to capture death in a freeze-frame of change, neither synchrony nor diachrony – a body in motion with speed but without knowable trajectory or acceleration. This is how those I witnessed at the edge of death in Thailand experienced it. They and I attended workshops on how to use our and others’ ends of life to study the nature of our minds (apparently, we did not know how to die before); and on how to use healthcare to force Thai society to recognize our autonomy as individual decision-makers (apparently, we weren’t fierce enough individuals before).  

Unsurprisingly, this rolling change did not stop with the fieldwork for the book, which spanned 2007-2011. I am now writing this review response from Thailand, where I am amid fieldwork for a new project that wonders whether and how physical pain is crafted by the categories to which we subject it. The question of how to manage pain has become as political in Thailand as death was previously, spurred in part by the spirit ambulance itself, which created a new kind of pain, as persons that had been kept alive beyond death were suddenly thrust back into their mostly dead bodies with sudden, excruciating sensory vividness. One thing leads to another, and so medicalization has rolled onward to include more medicine to deal with the problems created by medicine. Globalization, but as always also extraordinarily local. 

While here, I have coincidentally found myself in spaces where death is being choreographed, and of course death itself has changed as well. According to a doctor at the inpatient palliative care ward in Chiang Mai, only about 50% of patients now request to go home to die. The other 50% have found a new home for death in the hospital, in a cozy ward with plenty of pain medication available, apparently un-haunted enough that patients do not discuss ghosts with their doctors, unless the patients “come from very far out in the mountains, ” a code for hilltribe ethnicity as much as geography. A key concept from The Spirit Ambulance was “ethical location,” the dependence of the ethics of an act not only on the actors present, but also on the physical location, within a landscape haunted by the remnants of prior “ethical wounds.” Over the last ten years, has Northern Thailand shifted from sharing a collective ethical geography of death (at least among the elderly) to one attached to particular people and their “beliefs?” I asked a prominent academic monk about this change, and he said: “Urbanization, materialism, middle-class values, smaller families, a new generation, loss of a generation… everything that was changing when you were doing your fieldwork has kept changing.” I could feel the countryside of Thailand shifting in my mind, from populated by spirits with karmic histories, to instead populated by those who define themselves by whether they identify with that version of karma.  

I was heartened that commentators connected with the coda of The Spirit Ambulance, wherein hopefully the book’s longevity lies. Why would any reader be interested in the world of elder Thais who died in the now distant 2000s? To this, I can say that imagining their world steers how I care for dying elders in the contemporary U.S. Someday I hope it will also steer my own death. It seems a worthwhile goal for a book to teach one possible set of tools for assembling beneficial elements into one’s deathbed. I hope that future readers go to The Spirit Ambulance for that. And this same aspiration guides my current project: to tap a world with ways of relating to pain currently unavailable to me and those I care for. Death and pain both seem like domains of life for which an expanded toolkit could do us all some good. 

Many thanks to these three brilliant authors for lending their hearts and minds to this endeavor.