I will never forget the time I have spent working in intensive care departments. As a counsellor and rehabilitation therapist this was never my chosen field but in my physiotherapy course I was trained to do respiratory work in ICU and could be called in to work there at night. This pattern of working rather enhanced my view of the place as a strange twilight zone. I would arrive often in something of a dreamy state and find myself somehow trying to empathise with the dreamy world of semi-conscious patients. There was a lot of pain and grief mixed up with the heavy sedation. Many of the procedures on the patients were very intrusive – needles, tubes, suction. 

Then there was always the rude awakening coming for me, putting on the gloves and working out the read-outs from the instruments before launching in. Here, on the whole, I needed to be focussed and scientific. I so much admired the permanent staff, their level of experience meant they were able to be so clear in this respect and at the same time so compassionate. For me it was always hard to concentrate, to keep my mind on a situation that was frequently also shocking, especially having come from my other work where I was training myself to be sensitive and empathic, to form a holistic view of the patient that put them in the centre of the picture. 

But there was always a moment, a moment that I did not understand so well then but understand much more clearly now, when I would establish my mindfulness. This was always when it came to the solid, physical lifting-and-handling part of the job. My mind would firm up along with the body somehow. When this happened I found myself both present, robust and still able to reflect and relate. I found myself where I needed to be as the carer.

Then, looking on, it seemed to me that most of the patients needed, in contrast, to be guided away from reality into their inner world to find a refuge. I kept remembering a time during my years as a psychologist when a very close friend of mine ended up a patient in ICU. I went to see him every day. My friend was an artist and endowed with the most exceptional imagination. He was able to picture himself as a cartoon character, able to be squished one moment and pop back up the next. He was full of humour and seemed to have found a place where he was aware of his body as an image in his mind and at the same time beyond concern for his body. In his own way he was still in there fighting for his life, he could still follow the guidance of the nurses and do what he needed to do, but he kept a light touch on the whole affair. To me this looks like a good place for the patient to find themselves in.

Overall then, remembering ICU, I am reminded how life can demand such fluidity of mind from us all. One moment we can need to be solid and firm, the next as light as air. If we can master all this we will truly be free of attachment.

​
​I offer this for your reflection

Ajahn Kalyāno
http://www.openthesky.co.uk

Two years ago my heart was effected by a flu virus. I don't think I will ever forget lying in the ambulance all wired up to the heart monitor. The paramedic kept talking to me all the way, “Any pain?” “What day is it today?”

I knew the situation; I was at risk of a heart attack or a stroke, that was the reason for the continuous checking. I just kept looking at the skin of my bare chest with all the ECG stickers all over it and surprisingly I felt completely unconcerned. This was so clearly a result of the practice but it still really surprised me that my contemplation of the body had gone as deep as that. I really felt quite happy. I was remembering how a few days ago I had been feeling stressed over monastery administrative stuff and wondering if my practice was starting to weaken with all my responsibilities. I was reassured that underneath I was still alright. I still had my refuge when it really mattered.

Here are some resources on the subject of illness and death from a Buddhist perspective.​ These will form the framework of Ajahn's teaching session at Oslo University this Winter.


​

• Sariputta's teachings to a dying Anathapindika: MN 143: A teaching of a gradual letting go through reflection and strength of mind https://www.accesstoinsight.org/tipitaka/mn/mn.143.than.html 
  
  
• The Buddha attends to a monk with dysentery: Mv 8.26.1-8: Practical nursing advice and the sense of duty looking after the sick https://www.accesstoinsight.org/tipitaka/vin/mv/mv.08.26.01-08.than.html
  
  
• One need not be sick in mind just because one is sick in body: SN 22.1: The presence of the Buddha as an inspiration for a sick man to train himself https://www.accesstoinsight.org/tipitaka/sn/sn22/sn22.001.than.html
  
  
• An encouragement to reflect on the goodness one has done in the past to raise up the mind: SN 55.21
  https://www.accesstoinsight.org/tipitaka/sn/sn55/sn55.021.than.html
  ​
  
• Ajahn Chah to a dying lady, on how to use meditation to help us let go https://www.accesstoinsight.org/lib/thai/chah/our_real_home.html

From Nurse to Chaplain 
– from care to prayer


there I was 
with the bandage and the crutch
listening ears 
tissues for tears
there I always was
for all those years

at the time 
and every time
it meant so much

I can still smell the savlon, the soap
and the desperate hope...

there I was 
with the pooh I always knew
and the blood, always a surprise
sharpening the eyes
there I was in the rolling tears 
of lost loves
and in the niggling fears

now it doesn’t mean so much
the world of touch

meaning more is a softness in the eye
which knows
a softness so sweet
and always new
like baby’s toes

a softness where 
a given prayer
giggles and wriggles itself free
free to simply be

such that a prayer
is always there 
in the air
a prayer that knows

‘there is life and death 
in every breath
as it flows’

as a bandage or a crutch
it doesn’t mean much
it is heavy to the touch

yet the prayer 
is there
where light meets the air

at the touch of light 
and the lightest touch

such is the suchness
pure and bright 
of the heart
where we can go
if we can let go
and where we need never part

I thought to offer something more personal along with the more formal articles on this same subject. For some reason death had been something that had been on my mind since a very early age. When I was six years old I walked into my Mum's bedroom in floods of tears saying,
'We're all going to die Mummy, we're all going to die,' I can remember it now. As I grew older, thinking about death became the root of my philosophical nature, and yet let me first of all be very honest about how clueless I was in the face of death – the reality – at the outset. This fact speaks a lot for itself. Let me tell you a story from my early encounters with death in the form of a letter to a friend of mine, long dead, a story that pictures my reaction and also introduces the kind of opening of heart that is always there, it seems to me, at the outset of every truly wise encounter with death.   

Dear Jane
It is very many years since we last met and you are long dead. I am writing to you now to say how much I loved you. I could never have said it back then, it would not have been right. We had met in an Old People's Home in Stepney where I was working, having just graduated in psychology and doing a fill in job as a nursing assistant. You lived in the Home and had lived in a Council flat in Stepney all your life. In fact, as you told me when you introduced yourself, you had only ever been to the seaside at Southend and had only ever done washing up as a job. You had never married. I knew you had been through the war in the docklands, the fire bombing and all the rest, but you never spoke about it like many of the other residents did. You never said much. Your breathing was not so good. You liked a nice cup of tea and smiled a lot. You would take my hand sometimes and give it a gentle squeeze when I talked too much.

You used to sit in your wheelchair by the main doors, wrapped in all your hand-knitted blankets so you could watch the cars go past on the road outside. You said it made you feel like you were still part of it all somehow. This all inspired me to take you out. After my shift was over I would push you around the streets and you would tell me when I asked a little bit about what it used to be like.  I even took you to see my parents in Kent in their posh old house. I remember you saying over and over, so simply, 'thank you kindly,' in a way that made me gradually realise that you were quite happy not to go out. I kept getting the feeling that you were looking after me rather than me looking after you even although you did not seem to be doing very much.

Then one day I heard you had been admitted to hospital. I went to see you there. This hospital had a reputation locally as the place the elderly went to and never came out of alive. We sat on the ward together and several times you told me, lightly, that you were afraid that you were going to die there too. There was a television in the ward and I found myself watching the football. Chelsea were playing. I never watched football. I truly could not understand why I was watching it. I cannot remember how I managed to excuse myself and go home. A week or so later I heard that you had died. I was completely stunned and dismayed. Somehow that possibility had not even entered my mind, my romantic mind. I had not at all realised either just how frail you were. You must have been so strong to get up and stay sitting all day the way you did but you were someone whose very nature, it seemed, was to face the world straight on. 

Looking back at our last moments together I realised that I had not known what to say. I realised that you had told me of your fears several times to give me the chance to say something. I don't think it would have mattered what I had said so much but to say something would have made me feel better. Yet the fact was that I did not even know that I did not know what to say, so empty had I been of any kind of response despite all that I had thought of you, all that I had thought about you, indeed all that I had thought about life. 

I am writing to you now not because I have an answer but because I realise that no answer is a way to become free. Not a way to go anywhere else, just a way to be freely alive and a way to freely die. There is something there in the silence of no answer which holds its own answer.
I offer you my silent love, just straight, without the romance, wherever you are. 
Be free, dear Jane.


Let me tell you another story where I found myself at the receiving end of this same kind of loving silence:
At times of great tragedy we can want so much to help, with answers or in other ways, when there is really not very much we can do to change things. I thought to recount a story of how doing nothing can actually achieve so much.

Just a few days after my father died suddenly, a family friend came to visit. I opened the door and he stood there and said, steadily,
‘I don’t know what to say but I thought I would come.’
I just replied,
‘That’s OK Ron. Come in if you like.’
Our friend was one of the naturally quietest people I have ever met. He entered slowly and sat down, saying nothing. Eventually he repeated the same phrase, steadily,
‘I don’t know what to say but I thought I would come.’
Naturally enough everyone else who had come had wanted to talk, but not Ron.  Neither did I feel any pressure from him to say anything. He seemed comfortable enough sitting there in silence without trying to say anything or do anything. He began looking around the room, as he always did. I did not feel the need to do anything. I felt tears welling up.

A pain I had been feeling inside seemed strangely to have disappeared.
I realised that the pressure I had been feeling to try to do something about my feelings and those of others had suddenly lifted. I got up and made him a cup of tea. Still he said nothing. Now it felt strangely like he was holding the grief for me somehow, although I knew he was not. We said nothing until someone else entered and broke the spell so to speak. 

Afterwards I felt so much respect for this man. After all, there was nothing to say, nothing that could be done. Not even at this seemingly critical time. In fact, perhaps, there is nothing that can be done most especially at these critical times. There was no answer to these feelings, just a truth about them. That is somehow such a central paradox, this kind of doing by not doing. But it takes a special kind of courage to do nothing, to just sit there.

So it was in this spirit that I entered into my professional life, working on hospitals, to reflect with a more open mind on death and dying and more generally on the whole matter of human suffering, with a wish to help others. What I discovered was something much more radical, even at the outset, than I ever thought I would. All the years I worked in hospitals as a psychologist and in rehabilitation research, there was the mystery of why some people had small problems and suffered a lot and others had huge problems and showed tremendous courage and fortitude. Over and over again I was astonished at the difference.

As a Buddhist this was the clearest evidence I could see of another dimension to the human mind, one that was beyond the suffering of life, a truly spiritual dimension. What was also clear throughout was that these truths held true for both patient and carer and that perhaps most interestingly there could be times when patient and carer came together very strongly through a shared, deep perception of a situation. I became curious to see how this could work. There was the possibility there of a deep learning happening between patient and carer. It was also revealing to see which kind of people had this kind of inner strength as well as the circumstances in which it would arise. In terms of my research, however, the best I have to offer are not the formal studies but examples from my own experience that effected me most deeply, not in an intellectual way but as a human being. For here I was shown this dimension for myself. Always the wisdom and the love came together and to talk about the wisdom separately is not my intention. So first of all I would want to express my love for the people in the examples that follow and hope this carries through the analytical aspect of the text. There was never any lack of love, quite the reverse. These are experiences, encounters I will never forget on my spiritual path.

Most obviously there were glowingly clear examples of the power of religious faith:
Glynis had been on the ward for many weeks. She was dying of cancer. She was well overdue to go. There was very little left of her body. However, as her body faded her spirit grew daily brighter. Staff started to come to the ward especially to see her. She looked so good despite her appalling physical state. To the Christian nurses she was especially inspiring. She never talked about herself. She was interested only in her visitors, and in God.

In some cases it was clear that the person concerned had developed fortitude through living a tough life and come through:
Bob, a farmer from Northumberland, had a heart attack at three a.m. He did not call the doctor until the surgery opened at 8.30 a.m. He said he did not want to get the doctor out of bed.

In other cases it was clear that people went beyond their limits through love:
Alan’s wife was dying of cancer in the hospice. He went every day. All his friends criticised him for not looking after himself. The house was a mess. He said nothing. After his wife died, he went to the doctor. He was in terrible pain and bleeding profusely from his anus. He had cancer. He had been hiding it from everyone so his wife would not worry.

He died in the same hospice a few weeks later.

Whatever our spiritual practise might be one of the great mistakes is to waver when life gets difficult and think that we need to change the way we practice. What holds us together through the difficult times is the faith to just keep going. This is equally true even if we are dying. If we are really practising then if we were to hear that we have only a short time to live there would be no change in our lives, it would be business as usual.

Furthermore, to a truly deep Dhamma practitioner, the art of living and the art of death and dying are the same. The mind of the practitioner is always looking for the way out of suffering whatever situation it finds itself in, but to the deep practitioner this goes all the way and includes suffering with mental or physical origin. So while being with a dying person we can find ourselves trying the same way to let go of the body as the person dying. Our advantage is that we do not have bodily pain to overcome.

So where do we look for our escape from the body? How do we let go? Our attachment to the body is a matter of perception. The power of perception was very clear in many different ways. A person's sense of who they were, was all dependent on their perception of their relationship to their own body or the perceived relationship between mind and body.

What we are looking for is the perception we need to be able to find release, at a given moment. This is the one that goes counter to our hindrances (anger, lust, doubt, restlessness or sleepiness). At each moment we need to counter the hindrance we have. If we are angry or averse to the body, we need to find love to let go. If we are greedy for more, we need to see the disadvantage of bodily life to let go.

In any case we need also to find somewhere for the mind to go. We find this place, when our mindfulness strengthens into samādhi, not somewhere else in time or space but somewhere in our minds. We find our minds beyond the body in the course of our experience of the body, to a perception beyond materiality, to a pure inner image. This is the place that is beyond suffering where it is only the suffering that is absent from the experience and nothing else. This is our path to freedom here and now.

We refine this image to take the mind deeper and deeper. There are different truths that can reveal themselves when the mind gets beyond the hindrances. Students of Dhamma will know these already as the three characteristics of impermanence, suffering and not-self. First and foremost is to simply see the suffering of the body in a clear, unambiguous, compassionate and accepting way – natural, impersonal. Then the perception of suffering can relieve us of the experience of suffering to one degree or another. This can be largely a measure of the level of meditative calm we can take with us in to a difficult situation. We are not rendered unfeeling, our feelings are transformed. 

The impermanence of the body in terms of its mortality is the most liberating perception, but a very difficult thing to grasp, especially for the patient in whom it can be most urgently needed. If the truth of suffering is seen as described, a window can open at least to the changing, unreliable nature of our physical experience. This points us in the direction of seeing deeper. To really see death and let go, all kinds of things have to come just right without us trying to make them so.

Then there are various ways in which we see that the body and mind are separate and free ourselves from being bound to the body by our perception – we see the body as not self. There were times when it was clear to see the fact that the body was beyond the control of the mind. This could be very liberating. It seemed that particularly powerful were occasions of death or dying when a touch of the absurd entered into a situation to throw the mind off its current perception in one way or another. There also needed to be a caring softness, compassion in the mind for the heart to let go and be at peace. Most importantly there could be no sense of looking for anything from the experience; this would make the heart merely into some kind of strange voyeur looking for a Dhamma experience, for a result. The heart must be simply giving itself to the moment in an open, peaceful way. We merely create the conditions for an experience to happen by putting ourselves in the right place with the right attitude. It must be emphasised that I am not talking about 'Dhamma method' or '-technique' but true 'Dhamma life'. We are not trying to construct a situation, but learn from the presently apparent situation in a direct way how the mind and heart work. Then the experience will be truly an experiential proof of the Dhamma – not an intellectual proof, a view or opinion.

We can have many different perceptions of death, all of which may be completely unknown to us or contrary to what we thought. We can discover that how ever much we may have thought about death, when we come close to the reality our reactions reveal very different perceptions to the one we thought we had.

We can have the perception that death is a terrible and traumatic experience yet sometimes it is the most peaceful thing you could imagine:
One time I was working my way routinely through a care of the elderly ward and noticed one of the patients had been lying in exactly the same position, on his back for many hours. I reached under him to turn him gently on his side. He sighed so deeply, so peacefully, melting. I could not believe it, he had died in my arms, just like that. I kept remembering him as I was meditating, letting out that long out breath...  

Even in cases of traumatic death there can be a moment when time seems to stand still giving us a space in which to see things in a new light:
His face went blue, heart attack. He went straight down, hitting the deck with the same sound that trousers with pockets full of coins make when they hit the floor.  I stepped back and sat down. I was reminded of an embarrassing moment, dropping my trousers in a public toilet. It felt so incongruous to feel that embarrassment again now as the crash team arrived it seemed to put me in another space, light and open to the frantic scene of that was unfolding in front of my eyes.

Humour and irony can also enable the mind to remain light. This goes beyond simply finding something funny – in the humour of letting go, there needs to be some kind of twist to the perception, seeing afresh to see beyond:
He was so sweet, so very camp. Every day he harmlessly attempted a little innuendo. It wasn't easy, he gasped for breath. He was a very sick man. One day he asked me if I was an angel. The next day he was in ITU, comatose. He died there. I never saw him again. If I had known he was so close to the edge, I thought to myself I could have said 'yes' or even better perhaps, 'maybe'. I think he knew he was dying but maybe this would have been a beautiful way of letting him know how close he really was.

Even deeper can be irony without word or thought. The peaceful mind lets go most deeply:
I had gone to see him to gather a sample of sputum for the lab. He was so freshly dead snot still hung suspended from one nostril, his head tilted to one side. There was a strange irony there that rooted me to the spot as the nurses laid out the body

Another occasion we may see afresh is when someone acts or speaks completely out of character:
A very upper class elderly cancer patient was referred to me with the idea of improving his mobility. He was already very weak. I had to explain to him there was nothing I could do. He said it was o.k. He understood. He was so sweet. I was there to visit him again at the last to check his lungs He writhed in agony at the last in a pool of blood and faeces. It was a tragic sight. He could not help but say, 'Shit! Shit! with the pain and then lose control of his bowels. The irony was so strong he smiled an embarrassed stiff-upper-lip smile.

I smiled back and there was a moment of mutual recognition, a shared space, that makes this possibly the most important example of all – there was a palpable lightening of the heaviest of situations. 

When there is something we see there that just does not make sense, a questioning, this opens the mind:
A patient of mine tragically had a second stroke. She lay so limp I knew she was a going to die soon. She was put in a single room for no medical reason I could fathom. As I looked in the door on passing, the room seemed like some strange attempt just to make death look more peaceful by giving it a peaceful surrounding. 

On very many occasions outside of death and dying, it was clear the power of perception for the patient, again not always in the obvious or seemingly deep way, and yet there could be a tremendous strength of mind there to tap into:
Tom was a big old East-ender, a retired builder. A stroke had left one side paralysed; he had lost his speech but managed to lightly tease everyone with playful mimicry. But he was struggling to recover.

The breakthrough came when the doctors said he would never walk again – he was a fighter. It took us four months to get him back on his feet. Every day he would haul himself up with his good arm and growl with determination. I have never forgotten that growl. But he could only stand and for weeks failed to take a single step forward.

Then one day we put a football in front of his paralysed leg and he kicked it. Everyone cheered like he had scored a goal. At the time it seemed like a miracle.

There are times too when we are taken off guard and the role of patient and carer is reversed. This is an especially interesting way in which our view of a patient is transformed, we see a human being suffering, not a job to do, perhaps:           
As a student on a General Medical ward, I took pity on a patient admitted with Korsakoff’s syndrome (alcoholic pre-senile dementia).  I offered to help him saying,
‘If there‘s anything you need let me know.’
 He replied,
‘If you want to help me, mate you can go out tonight after work and have a bloody good time!’

Always a mind that sees differently can share the perception or just the lightness of heart that comes from it. What is most often the obstacle to such a shift of perception is an established existing cultural norm or tradition. There is, for example, the hospital culture around the death process. When someone died on the hospital wards in England the body was always laid out quickly behind the curtain and, out of sight, usually with disdain, almost with aggression. When they came from the morgue all the curtains were drawn around all the beds so that nobody saw the body go. The bed was then restored to perfection. Death was made to disappear.

There was always silence yet everybody knew. The tea was passed out with extra care. Everyone tenderly took extra sugar. There were more biscuits than usual. Nothing was ever said. But to me the silence said it all. Often these things are pointed to as examples of a culture in denial of death, hiding and protecting us from it and yet in my experience the irony was that for the patients, such traditions became more a show of respect and a ritual that drew people's attention to the event rather than away from it.

But why would anyone want to think about death? When we are a carer, when we lose someone or when our own lives are under threat we come to the point where we cannot avoid the issue of course, but even before this time the contemplation of death if done in the right way can be hugely life enhancing rather than life denying. Ultimately for those in search of enlightenment it is the key that opens the door.

If we can find a good way to stay with the reality of death and dying we will grow in wisdom and compassion toward release, to freedom of heart. The tragedy of my father's death I would say has now been so transformed in my mind:

Reflections on death and dying

It may seem in poor taste but I thought to offer some reflections on death and dying in the shape of a few bullet points. I will not offer much explanation. The value of reflection lies often in the process of trying to accept or work something out for ourselves by repeated reflection on a given theme, here are some suggestions:

    • we do not even really know that we are going to die
    • dying and the fact of death are our ultimate test in life
    • to allow the fact of death to change our lives in a positive way is wisdom
    • to accept that we are going to die and to do nothing is the ultimate folly
      
    • getting used to the idea (by thinking about death on a sunny day when we are well and happy and joking about it to dispel our fear) is a good start
    • ultimately we must look for something beyond
    • belief is not enough
    • beliefs alone will let us down
    • we have to see beyond
    • seeing is believing, believing is not seeing     
      
    • it is the experience of the body as not-self, the seeing of this, that leads to the end of fear and anxiety and opens us up to a new vision of reality
    • if we see the body as not-self we realise the possibility that when the body dies something can continue, we will naturally have no fear of old age, sickness or death; we will furthermore see all other things as not-self and realise that death is not what it seems to be in terms of the mind
      
    • we can realise that we do not have to survive as a body or as a self to survive
    • all of us leave our karma behind us, in this way we survive 
      
    • if we see deeper we realise that when conditions are here we manifest, when conditions are no longer here we do not but then when conditions come around again we re-manifest
      
    • we are a manifestation of the greater Mind; we must not, however, confuse this greater Mind with the imagination, the personal mind or the abstract mathematical mind

    • we don't have to survive as an individual in order to survive, in fact group karma is stronger than individual karma
      
   • if we see deeper still we realise that the truths that underlie our existence are eternal
      
  • the relationship between personal truth and universal truth, whatever this is, is our personal relationship to the universal
  • the deepest truth is the truth of death – if we can see death, the mind will let go and we will see the deathless
     • ultimately, through truth we find a refuge in reality, the way out is in
   • we take refuge in reality not apart from it: heaven and the supernatural, and ultimately the transcendent – Nibbāna – is here, not somewhere else 
    • the intersection of the timeless with time is the timeless, the only timeless, because there is nothing other than the things of time – there is nowhere else to go
    • there is, however, no need to be anything, the spiritual 'man of light' is an image not a being
    • light reveals truth; this light is not a mystical energy but a purity, an emptiness of mind
    • our survival, our refuge, is in the truth that underlies the purest emptiness, not in the emptiness itself – the illusion of an eternal soul
  • during our lives this refuge can be found and strengthened as the non-dual knowingness of the mind – this is perception raised to the level of wisdom

In this way the process of reflection can find its own way beyond death and dying. A commitment to wisdom in itself providing a vehicle for the mind. Consider this as a statement of such commitment:

The Oath     

​
One day I shall lay down these bones, 
look up at the sky 
and be neither here nor there. 

One day I shall be in between 
and between-between, 
a whispering nowhere. 

In between the lines of life I will gently, humbly care.

I will serve the truth until the end of time, 
so I swear. 

​
I offer this for your reflection
​
Ajahn Kalyāno
http://www.openthesky.co.uk/



​

Background 

Over twenty years ago I was studying for a PhD in Psychology. My research was aimed at providing a model for the facilitation of medical case conferences by professional advocates, first of all for application in the field of palliative care. The intention was to promote a holistic model. At the time, patient led or centred care was becoming the ideal in interdisciplinary settings but from experience I could never see how a patient could be sufficiently well balanced or informed to take the lead in such difficult circumstances.

It seems to me that wider experience is showing us now that patient led palliative care is often a disaster. As Stephen Jenkinson puts it, we have just provided people with the right to die badly. There was after all no substitute presented for the dialogue between the patient, their carers and their medical and spiritual advisers; and yet what we have also discovered is that this dialogue is not at all easy. I believe that this dialogue, however, has immense potential as a modern forum for the development of wisdom within a culture. To thus keep a genuine spiritual presence in the modern world helps us to avoid mankind becoming hopelessly inflated by its technology and expertise, of letting these things take the place of the creator God, (when this God was misconceived in the first place.)

What I believe now is that a Buddhist practitioner can hold a unique position as a possible advocate. Buddhism in my eyes holds a special place in this dialogue or debate. As far as it is a tradition of contemplating the relevance of impermanence in the present, the Buddhist spiritual position is valid even in the absence of any belief in the supernatural, (while leaving room for such belief to form out of experience.)

We can widen this debate to include any kind of care or education where we are teaching people how to integrate the fact of impermanence into their lives. In our contemplation we can start with light and easier examples, such as for example the transience of the food or music we are enjoying. We train and practice with the lighter weights, which are no different in essence from the heavy ones.

Death is the most weighty and pressing example of impermanence for us personally. While the impermanence of the planet is possibly the heaviest example overall – which the ecological crisis presently is thrusting upon us. In relation to that, surely the ecological crisis is the most glaring example of the fact that it is not a solution to give people control over things that they do not understand.

Advocacy training is the way to give us all a wiser voice. Wise culture can help people towards making wiser choices for themselves; but after centuries of unwise culture and exploitation people lack faith in their culture. Yet to throw out any cultural influence is ultimately to isolate ourselves from support or from offering support to others. In life there is the model of personal independence and choice, which is so much the modern way; or on the other side the way of letting go and surrender. In fact the life where there is the most choice is the one that has both these possibilities to follow at any given moment. Let us examine the above proposition by considering different models of care.

The ‘surrender’ model

In modern consumer society the model of care is the 'patient led care model'. The opposite to this would be the 'body surrender model'. In this latter model the carers are trusted to offer the best care they can provide and the patient accepts whatever care is offered. Psychologically the latter suits a situation where the patient is stressed and needs to let go. The combination of the two models we can see as a ‘Partnership’ model.


The patient still gives feedback to the carers on how they feel their treatment or condition is going where this is necessary but the possibility of recording more information objectively to guide treatment also helps the process of surrender. The more the doctors can find out without having to bother the patient the better.

The doctors are empowered by this model rather than disempowered. In the case of major decision making, then an advocate may be used to make a decision on behalf of the patient and they would choose how much to involve the patient, how much information to provide. The advocate can be given authority as a check on the power of the doctor. The patient reserves the right to say enough is enough and to withdraw from the treatment or simply to withdraw from the body-surrender model and return to the conventional patient-led model.

This puts the patient in a position where they are able to let go of their body, surrendering their body to the care of others and concentrate on looking after their minds. Not knowing what all the medical options are or all the costs removes the burden of choice or of resentment. They can train themselves to be grateful for what they receive, to relate to the carers as human beings; and the carers can relate to them in their personal interactions with the body matters out of the way, the body matters that would otherwise become the dominant agenda. This way a patient can never become just a body in his or her relationship to the carers, a relationship which must be one of the patient simply trusting the carers to do their best. I believe that the enhanced personal contact that would ensue would in most cases ensure that best care was offered. The patient would not need to relate to the carers so much about their body, and may so remain a human being in his or her own eyes and in the eyes of the carers.

This model acknowledges the reality that often it is the situation that the carers have the knowledge and the power to act; or it becomes the appropriate model more and more where this is the case. The patient has very much more limited resources. This is not a consumer model but a giving model. All treatment is like an offering, not demanded, it is all a gift. This fits very well with national health service provision. And this model could be an explicitly available option for a particular patient or care situation, rather than an imposed model.

A holistic model of care can be used in either case, 'patient led' or 'body surrender', but is particularly useful in the latter to allow carers to take over more aspects of a patient's care. This model could apply equally to people taking part in their own care that they surrender to the advice of the professionals.

This removes the false sense of a person having a right to whatever care they might want in a situation of limited resources. It removes the false sense that they are in control of a situation that they are not in control of at all. It allows professionals to make difficult choices without the added stress of a patient's resistance, in fact knowing instead that the patient is willing to accept their judgement. The advocate will have the role of shielding the patient from the dominance of the doctor in this case.

This would be recommended as the model for a good Buddhist to follow, or for the good Buddhist to represent within a health care system both in terms of the patient and the professionals. So the professionals would be encouraging their patients to let go and yet at the same time making sure that they continue to offer the best care they can. The standard of care offered can of course be monitored as usual, but not by the patient wherever possible. So the patient is removed from the situation of trying to motivate the carer, and the professional is not pressured by the patient either but can come forward with their best effort.

At the least to simply portray this model acts as a balancing voice to the patient led model. It opens up the whole range of possibilities to choose from. In a sense the inclusion of this option gives more power to the patient. They have the power to lead, or the choice not to. Both options can be portrayed as positive moves – “I do it”, or “I trust you to do it for me”.

This model can also reserve the right to refuse treatment at any time as another gesture of letting go. You let go into the treatment, or you let go and refuse or turn away from the treatment – from the spiritual perspective these can be the same. What we do not do is to demand treatment. To fight in this way can merely become the fight to try to claim more resources than the next man or woman, to being compelled to fight for life like a soldier might but in the doctor's office rather than the battlefield.

We can assume that to fight is empowering but to trust and let go can also be truly empowering to the mind. We are empowering the spirit which in turn naturally empowers the body, rather than looking for power from our animal instinct and from the body which in the case of serious chronic illness ceases to give us reliable information or to react in appropriate ways: The body is adapted to react to acute trauma, not to chronic illness in which case its adaptation is dysfunctional. The body and its instincts do not know what to do in these situations.

In summary I would suggest that the body surrender model could be the option for the true Dhamma practitioner who finds him or herself in a situation they trust.





I offer this for your reflection

Ajahn Kalyāno 
http://www.openthesky.co.uk



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Recommended further reading:


We suggest Ajahn Chah’s classic talk, “Our Real Home” for more Dhamma in relation to illness and death.

Our human dignity is what can define our very humanity. It can be what raises us up and an expression of our spirituality. Our dignity or honour can be a source of tremendous strength and motivation. Dignified people can be the ones who find it most difficult, of course, to suffer from any indignity, but they can also be the ones whose dignity motivates them to carry on. In difficult circumstances, however, our dignity can still be hard to maintain. In a complex and grave medical situation, it is very important to be sure to make every attempt to obtain clear consent from a patient. Then the baseline in terms of standards of care is often the attempt to maintain a person's dignity for them, both in terms of the level of treatment offered and throughout any treatment procedure.

Human society has, of course, a moral obligation to try to provide a basic level of care to all its members as best it can. I would suggest that each individual can reply to this with an acceptance of what society is able to offer. But then the question asked is: “should we not demand our rights?” Within a prosperous, or indeed greedy, society we must. But when resources are limited it becomes a nonsense to be trying to demand our rights. We may then try to demand our share but when we have done all the demanding we can we still need to come to an acceptance for ourselves.

And then rather the attitude of the wise patient can be to try to maintain their dignity no matter what happens. How might this be done? Is there not something curiously beautiful about the upright stance of the human being? Standing raises us above many animals physically but also is linked to human dignity. We maintain our dignity by 'holding our heads high'. In this way a sense of dignity is linked to that of posture. Our postural or proprioceptive sense has been termed our sixth sense. when we become very aware of our posture and movement it can have an almost mystical effect on the mind for this reason. This sense is also a way in which our body image is formed in the mind, an image free of pain or pleasure – neutral and steady. The body and its pain can in this way be perceived as two different things. In times of pain this image can be a refuge. This is important. To find a mental refuge from pain within the body helps us to stay with it, not to want to get away or to resent the body.

This body image is one of the qualities and one of the fruits of a detached attitude toward the body. This sense of detachment can be well established or an ability to at least detach the mind momentarily or to some degree. Take the example of a situation in which someone is in need of of a gynaecological investigation. For the patient, so exposed, to look away whilst this examination takes place, or to look only when necessary may be a way they can keep their dignity. We can also relate to the body in an impersonal way to encourage detachment, even with a little healthy contempt, on occasion exclaiming, perhaps, with a smile:

“Oh, bodies! Can't rely on them, can we.”

or

“Sometimes bodies can be really disgusting, can't they.”

The mind that acknowledges these facts at the crucial moment can protect its own dignity and there need be no loss of love. At least there will be no loss if the love is real, if it is a giving love. 

Often the great human drama is played out most visibly and hence most powerfully in the life of the stars of film or music. We can see there how strongly certain events can effect our highest values or aspirations. I remember as a child how my father was a great lover of Elgar's music. He particularly loved Elgar's cello concerto. There was a particular cellist, the charismatic Jacqueline Du Pre and her genius husband, the conductor Daniel Barenboim whose rendering of this concerto was divine. My father loved it and I think was a little in love with Jacqueline. Then the tragedy: Jacqueline contracted the neurological disease multiple sclerosis. My father was very sad for her. As the story goes, the couple then separated. Whatever really happened, to my father it appeared as if the husband deserted his wife in her time of most need. My father was devastated. His dream was shattered. To some degree so was mine.

I have no idea what really happened to Daniel and Jacqueline but perhaps the great romance could not be sustained through the indignities of her disease. Perhaps the love if not the romance could have been maintained if her dignity could have been more properly cared for, who knows? This was anyway no small matter for my father, it was the beginning of a big breakdown. I found myself going on to specialise in the care of people with neurological disorders as though I was caring for Jacqueline.

It was in this crucible that I realised the importance of dignity, and the fact that holding it foremost in our minds through difficult times was how our true love and our spirituality could be protected.










I offer this for your reflection

Ajahn Kalyāno 
http://www.openthesky.co.uk


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