Buddhist spiritualitya compassionate perspective on hospice care

·期刊原文

Buddhist spirituality--a compassionate perspective on hospice care

by Pam McGrath

Mortality

Vol. 3 No. 3 Nov.1998, Pp.251-264

Copyright by Mortality

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ABSTRACT The practical, everyday metaphysic of Buddhist philosophy, which
is based on notions of compassion and wisdom, a willingness to serve,
tolerance, a duty to do no harm, and the significance of death, shares a
commonality with hospice discourse. This discussion explores the connection
between these two compatible discourses by detailing some of the findings
of research recently completed on a Brisbane community-based, Buddhist
hospice service (the Karuna Hospice Service).

Karuna Hospice Service [KHS] [1] is a community-based, Buddhist
organization in Brisbane, which provides comprehensive home care services
for people with a life-threatening illness and their loved ones. It
provides full hospice-at-home service, with expert nursing, counselling and
respite care. Nursing care is provided on a 24-hour, seven-days-a-week
basis and specialist palliative care medical consultation is made available
if required. Individual and family counselling is provided, as well as
bereavement counselling and support, and pastoral care. The KHS team cares
for adults and children who have a life expectancy of under six months, who
have a caregiver available and a general practitioner willing to be
involved in home-based care. The service was established by a group of
'visionaries' in the community under the charismatic leadership of a
Buddhist monk. It is now five years old and presently receives some of its
funding from the Regional Health Authority. Although it has only been
established for five years, the organization has already earned an
excellent reputation in the local community for its innovative, committed
and compassionate work with the dying.

Reports I received about KHS, from both health professionals and clients,
were that it had a caring and genuine approach to working with the
terminally ill that was considered in someway 'unique'. These reports
stimulated and sustained a desire to explore and describe, through
research, the organization's 'uniqueness'. This exploration was developed
with two secondary questions in mind: how is this uniqueness (if
documented) sustained in relation to the biomedical model? What
constructive contribution could such an alternative model offer to our
approach to death and dying in our society? This discussion is not
concerned with the totality of these findings, but rather focuses on the
data that arose from the research which specifically addressed the Buddhist
influence within the organization.

Buddhist spirituality emerged as one significant factor in inscribing KHS's
'uniqueness'. This discussion will look closely at the findings on this
Buddhist factor, and in so doing will seek to demonstrate the value and
commensurability of this Eastern metaphysic with the hospice ideology and
practice of humane and compassionate care of the dying.

Methodology

This research was not concerned with the modernist notion of simulated
neutrality, supposedly attainable through methodological strictness, which
is expressed in beliefs about proof, objectivity or measurement (Powles,
1973; Fay, 1975; Chalmers, 1976; Oldroyd, 1986; Capra, 1990; Fox, 1991;
Lather, 1991). The interest was rather to capture and document the way in
which 'reality' (in this case the 'reality' of KHS's 'uniqueness') is
socially constructed through organizational 'talk'. The methodological
focus was on exploring Mumby & Stohl's (1991: 313) notion of how "social
collectives come to privilege certain articulations of reality over
others". A postmodern approach to research was used which focused on
Foucaultian notions of discourse (Foucault, 1972; 1973; 1980; Lyotard,
1984; Weedon, 1987; Best & Kellner, 1991; Valverde, 1991; Fairclough, 1992;
Davies, 1994). The research task was to record and explore the description
of KHS's 'uniqueness' articulated in the 'talk' of individuals both within
and outside the organization. Such descriptions were taken as examples of
discourse and analysed using the insights of writers on deconstruction
(Norris, 1982; Dear, 1988; Lemert, 1992; Smart, 1993; Elam, 1994). The
assumption that underpinned the analysis was that:

Language does not simply inform; it creates the very possibility for the
creation of meaning environments. (Mumby, 1988: 102)

The methodological issues surrounding this research are as important as the
findings. Consequently, care has been taken to publish the full details
separately so that understanding is not compromised by brevity in
discussions that are designed only to present aspects of the findings. For
those interested, a complete discussion is now available internationally as
several chapters in a book published on this research or in journal
articles focusing on specific epistemological concerns (McGrath, 1997a;
1997b; 1998a; 1998b).

In summary, the data, which comprised 15 participants' comments
(language/texts) about KHS, were collected through open-ended,
non-structured interviews. The participants were representative of a
diverse group of individuals associated with KHS. This selection included
those with roles within the organization, e.g. doctor, nurse,
administrator; those outside the organization e.g. health professionals and
patients; those with a past connection and those presently involved.
Participants included those with both positive and negative experiences
with the organization. Exact replication of the spoken texts was made
through audio recordings and then transcribed verbatim. Each interview when
transcribed varied from 6,000 to 10,000 words, producing an immense amount
of data. The texts were then developed using a thematic analysis of
significant statements. All ideas expressed were included, with one
interview at a time being used to create categories and with subsequent
interviews analysed in such a way as to build on these or to create new
categories. As this research was concerned with discursive practices, such
an analysis used the exact words of the participants, not abstract concepts
developed from such transcripts. It must be emphasized that the statements
that became categorized under headings associated with the Buddhist factor
in the organization, and which will consequently be used for this
discussion, were only part of the wider findings. These statements were
included under a specific category entitled 'Buddhist philosophy', which
included further subcategories such as 'contributing to the difference';
'Buddhist representation'; 'Buddhist principles'; 'public presentation of
Buddhism'; 'translation of principles to service provision' and 'the
problems of translating Buddhist philosophy'. Although the spirituality of
the organization is informed by Buddhism, it tolerantly embraces a wide
variety of philosophical/theological positions. Consequently, the
statements on Buddhism were also included under more generic headings such
as 'spirituality' and 'charismatic leadership'.

Findings

The findings which arose from the research suggested that the respect given
by members of this service to the transcendent notion of spirituality was
seen as the important factor inscribing KHS's stated 'uniqueness' (McGrath,
1997a; 1997b). A caveat to the discussion on this finding is that it is the
'talk' about spirituality and the valued discursive space inscribed by a
respect for this transcendent dimension in KHS's everyday existence, which
is presented in these findings. There is no attempt to engage in a
positivist discussion of the empirical proof or otherwise of spirituality
per se. It is acknowledged, however, that the challenge of making the
connection between empirical data and philosophy is presently an
interesting trend taken by leading scientific writers (Hawking, 1988;
Heisenberg, 1962; Koestler, 1967; Davies, 1983; Dyson, 1988; Capra, 1991;
Capra & Steindl-Rast, 1992; Davies, 1992; Smoot & Davidson, 1993; De Duve,
1995).

A significant part of KHS's generic, everyday 'talk' on spirituality was
informed by the primacy within this organization of a Buddhist discourse.
The discussion in this article will present the findings on this Buddhist
construction of reality and how it relates to both hospice ideology and
KHS's spiritual way of 'speaking the world'. By developing such a focus on
Buddhism this discussion will be presenting only part of the story of KHS's
spirituality. To balance such a discussion it must be emphasized that the
organization's discourse embraces a theological/metaphysical openness which
is respectful of a multiplicity of world views. As one participant stated,
it welcomed:

People of all different religious backgrounds but who have spiritual
yearning for some sort of satisfaction. (EQ:A.21.j) [2]

Introducing KHS's Buddhist discourse

As a Buddhist based organization the Karuna Hospice Service also acts as a
compassionate service model to the dying for the world Buddhist community.
Our vision springs from a Buddhist value base. (The Karuna Hospice Service
Vision and Values Statement, 1995)

Karuna Hospice Service is in the unique position of being the only
Buddhist-based community hospice service in Australia. Although it now
receives significant funding from the Queensland Government's Regional
Health Authority, KHS, a registered charity, is part of the Foundation for
the Preservation of the Mahayana Tradition (FPMT). The FPMT is a non-profit
network of Buddhist healing, meditation and publishing houses with over 70
centres in more than 17 countries.

This hospice service was established by a group of visionaries in the
community under the charismatic leadership of their founder, Ven. Pende
Hawter, a Buddhist monk. The initial idea for the hospice came from an
instruction from Ven. Pende Hawter's Buddhist teacher. During the initial
stages of the establishment of the service the members were labelled, 'Just
that bunch of Buddhists' and met a great deal of resistance from the health
establishment. They have now earned a reputation for excellence and are
seen as leaders in the provision of community-based hospice care.

Clearly, Buddhist philosophy is of considerable importance to the
organization. Throughout the language/texts, such a Buddhist influence was
seen to give a significant stamp of difference specific to KHS, setting it
apart from other local hospice, palliative care or nursing organizations
working with the dying. As participants stated the case:

What is different is our spiritual philosophy is Buddhist. [EQ:A.20.e]

Karuna is also unique partly because it is a Buddhist organisation.
[EQ:A.20.a]

In this research Mahayana practitioners (Dharma students) spoke in detail
of the Buddhist principles which guide their work. Although KHS is a meld
of theological-metaphysical traditions (including, for example Christian,
Zen, atheist) with an inscribed tolerance of a multiplicity of
perspectives, even non-Buddhist members of the organization spoke with
great respect for the influence of the Buddhist philosophy and about their
attraction to, and ability to be comfortable with, such ideas.

Ideas of particular significant which surfaced throughout such discussion
can be summarized as an understanding of, and commitment to, notions of
compassion and wisdom, the importance of a practical metaphysic, a
willingness to serve, tolerance, the duty to do no harm, and the
significance of death. These ideas will now be explored in detail.

The notion of compassion and wisdom

Compassion (the sanskrit word for which is Karuna) and wisdom (or prajna),
according to Florida (1994: 107) are the core values in the Buddhist
metaphysic, and are intricately linked as the essence of the Buddhist way:
compassion being the practical expression of wisdom (ibid). Metaphorically
described as the pillars of Buddhist teaching, wisdom and compassion are
seen as one (Humphreys, 1974: 109; Kornfield, 1977: 14), each one is
considered dangerous without the other.

The Buddhist principles articulated by the participants, although concise
and without full description, were reflective of these core Buddhist
principles, as stated in the literature, and exemplified by the following
language/text:

I guess compassion ... they call the two wings of enlightenment wisdom and
compassion ... and so I guess compassion and wisdom in trying to cut
through some of your own [problems], in trying to just be more open to
situations and less defensive and ego centred or more just open and not
always trying to do the best for me and protect me. (EQ:A.20.mm)

The Buddhist concept of universal compassion has traditionally been tied to
the care of the ill through the provision of a caring and loving service
(Ratanakul, 1988: 302). The desire to serve is seen in Buddhist literature
as the moral imperative of compassion (Florida, 1994:107): a self-giving,
self-denying act of generosity of spirit. Ratanakul stated that to
demonstrate by example, "when nurses or doctors stay with patients who need
them, night and day, foregoing rest and family, this is an act of
compassion, of self-denial" (1988: 312).

This aspiration to be of benefit to all living things is described in the
Mahayana Buddhist literature as a desire directing the central path to
Buddhahood (Dalai Lama, 1995:10). Such a desire is privileged throughout
the discourse of this organization. One example illustrates the point:

Buddhist principles of serving others the whole organization was based on
what the client needs, what do they and their family need, and how can we
meet it. [EQ:A.20.uu]

Understandably, compassion is also a central concept emphasized throughout
the literature on hospice care (Fulton & Owen, 1981; Koff, 1980; Manning,
1984; Munley, 1983; Saunders & Baines, 1983; Saunders et al., 1981).
Compassionate, caring hospice service is seen to provide the dying with a
sense of security and trust, and hence safety, which is only available when
a dependable plan of care is maintained by people who really do care (Mor
et al., 1988: 10).

A practical, everyday metaphysic

As can be seen by the above quotes, a Buddhist discourse is highly
compatible with hospice care as it creates the discursive space for a
caring day to day practice. Mahayana Buddhism is chiefly an altruistic
psychological metaphysic with implication for the everyday actions of
individuals. As Keown (1996: 60) explains "the highest ideal in the
Mahayana is a life dedicated to the well-being of the world ... the
Mahayana places great emphasis on working to save others". Throughout the
literature on Buddhism, and certainly as demonstrated by the language/texts
of this research, abstractness is not privileged as a virtue by itself, as
is often the case in Western philosophical theory. The Buddhist metaphysic
is guided by religious insight, rather than philosophically abstract and
rational argumentation. Buddhists speak of a 'religious path', a 'spiritual
journey'; their philosophical orientation is pre-eminently practical
(Florida, 1994:107). There is no dichotomous separation between intellect
and psychology. The first step to wisdom is self-domination: "he who
conquers himself is the greatest warrior" (Humphreys, 1974: 61). This idea
was clearly expressed by one of the participants, who stated that:

Everything about Buddhism is about how you see the world ... everything and
so it all comes back to you. (EQ.A.20.nn)

The inward discovery is not a journey into egoic consciousness, as in
Western psychology, which privileges the importance of a sense of self or a
personal identity to be protected, developed and self-actualized. Rather,
the Buddhist notion of the inward journey is to discover the non-self, 'the
original self', which is both pure and empty: in short, to discover our
buddha-nature (Humphreys, 1974: 43). Buddhism steps outside the dualism of
Western thought and posits the interconnectedness of all existence which is
integrated into a single, non-dual reality (Ryomin, 1990: 86). While
promoting ideas of self-awareness and responsibility for one's own actions,
such an idea silences the right to impose dogma and values on others, and
incorporates a respect and flexibility, honesty and humility in
relationships with others (Kornfield, 1977: 133). This is definitely seen
as a positive aspect of working in the KHS, as seen by the following
statement of a participant:

Working in a Buddhist organisation I feel more obligation or whatever to
own my own stuff and work through it, rather than trying to find ways of
externalising it ... it has an incredible influence. (EQ:A.20.c)

This is a flexible metaphysic with a central psychotherapeutic message
(Ross, 1993: 160), moral rather than intellectual purpose (Ward, 1947: 61),
and practical foundation (Florida, 1994: 107) which emphasizes the
importance of personal humility and self-awareness.

Although the palliative care/hospice literature is awash with sensitive
insights into the experiences of the dying and their caregivers, this
wisdom is not usually accompanied by an emphasis on the role of
self-awareness, or the need for 'pure motivation' in acting out this
understanding. Indeed, even in such an important document on hospice
spirituality as the 'Assumptions and principles of spiritual care' which
was developed by the Spiritual Care Working Group of the International Work
Group on Death, Dying and Bereavement (1990: 78-81), no direct reference is
made to self-awareness or to the need for purity of motivation, in spite of
the sensitivity of the document to the needs of the dying.

Tolerance

The basic thing ... I guess is tolerance, it is a religion or philosophy
which sees that there are many different paths ... it doesn't say this is
the right way as some religions do ... it can embrace all religious beliefs
that don't cause harm to people. (EQ:A.20.kk)

Buddhism is documented as a tradition of tolerance, which affirms freedom
in matters of belief, worship and religious practice (Florida, 1994: 105).
Simply stated, in the words of one interviewee:

a basic principle of Buddhism is ... that caring for others is a source of
happiness and that if you are self-centred and care only about yourself
that is a cause for sadness. So actually, the two things go hand in hand:
your own happiness, your own satisfaction and being of service to others.
It is what the Dalai Lama calls being wisely selfish. If you can generate
compassion and kindness towards others you will have your own happiness.
(EQ:A.20.rr)

Such a caring, compassionate tolerance of others in the discourse of KHS is
not just privileged in relation to the families they care for, but also in
relation to the members of the organization and the wider social network.
As with the previously mentioned notion of self-investigation, this virtue
of tolerance emerged as one of central importance in defining KHS's
difference.

An indication of KHS's practical application of the notion of tolerance can
be seen by the non-proselytizing, non-ritualistic approach taken to the
expression of their Buddhist philosophy. From the perspective of
deconstruction, the language texts demonstrated a silencing of the notion
that rituals (e.g. chants, meditations or ceremonies) are, or should be,
prioritized as the modus operandi or public face of this Buddhist
organization. There were also no references to the need to convert,
advertise or persuade. In short, at KHS the Buddhist philosophy is
expressed through the process of actively engaging in a strongly held
commitment to a tolerant Buddhist outlook. That outlook does not emphasize
difference, but rather affirms a shared compassionate commonality with all
other 'sentient beings'. The only overt signs of KHS are the small altar,
occasional Buddhist artifact, the brief meditations before the commencement
of meetings, and the robes worn by the leader of the organization. As most
of the work of the hospice is carried out in the community, even these
signs are not visible to most clients. However, members of KHS's staff will
perform ritualistic practices with clients, but only if specifically
requested by a patient with an understanding of Buddhist philosophy.

Equally, tolerance is seen as a cornerstone of hospice care. The very
notion is enshrined in clauses found in the Dying Patient's Bill of Rights,
such as, "I have the right to retain my individuality and not be judged for
my decisions which may be contrary to the beliefs of others" or "I have the
right to discuss and enlarge my religious and/or spiritual experiences,
whatever these may mean to others" (Koff, 1980: 26).

The duty to do no harm

Another Buddhist notion which surfaced in this research and is highly
compatible with the spiritual and holistic goals of hospice palliative care
(Manning, 1984; Martocchio, 1982; Munley, 1983; Seibold, 1992) is that of
ahimsa: the duty to do no harm. As one participant commented:

Dalai Lama says the basic foundation is if you can't do anything else,
don't do any harm to anybody. (EQ:A.20.jj)

The Buddhist duty not to harm is seen as important in human relationships
in general, but especially in medicine (in this case the care of the
dying), where one is dealing with the vulnerable, those already
experiencing the harm of pain and helplessness of disease and disability of
terminal illness. Indeed, the duty of ahimsa, when applied to those
suffering from illness that can not be cured, has a conceptual paralleled
with Western ideas on palliative care. The idea is to 'cloak', alleviate,
or lessen the distress. This Buddhist ethical notion was expressed by
Ratanakul (1986: 99) as, "if one cannot remove it [harm or disease], our
duty is to alleviate it, lessen it [i.e. relieve the suffering, care for
and comfort the dying and maintain as best we can those beyond our capacity
to cure] ".

Similarly, the philosophy of hospice/palliative care grew out of a response
to the distress caused to the dying by the invasive processes of highly
technologized, institutional, curative treatments (Munley, 1983; Ratcliff
et el., 1989: 264; Rinaldi & Kearl, 1990; Seibold, 1992). The aim of
hospice care, similar to ahimsa, was to provide a less harmful approach
which offered death with the dignity of caring designed to comfort, not to
cure aggressively (Saunders & Baines, 1983).

The significance of death

So far in this discussion central concepts in Buddhist discourse such as
karuna, prajna, and ahimsa, have been shown to have a similarity and
compatibility to ideas in hospice/palliative care. The resemblance between
these two discourses is further strengthened by the shared view of the
significance of the dignity and importance of death. Participants in this
research believed that Buddhist ideas could enrich hospice practice, as
seen by the following language/text:

Having studied the Tibetan literature on death and dying, I am totally
convinced of the amazing understanding that the Tibetan understanding of
dying can make. (EQ:A.20.qq)

Buddhism is a metaphysic which points to an understanding of the
significance of death as an essential ingredient in understanding the
meaning of life. The intense significance attributed to the time of dying
flows from the Buddhist idea of reincarnation. A calm and peaceful death
can positively improve the next rebirth (or samsara), despite negative
karma of past lives. According to Rinpoche (1992: 224), such a privileging
of the significance of the moment of death is predicated on the assumption
that the last thought and emotion individuals have before death has an
extremely powerful determining effect on their immediate future, their
rebirth into a new life.

A core Buddhist belief is that the whole of life is a preparation for
death: the mark of a spiritual practitioner is to have no regrets at the
time of death (Hawter, 1995: 3). As Pende Hawter, the Buddhist monk who
founded KHS, explains:

the basic aim is to avoid any objects or people that generate strong
attachment or anger in the mind of the dying person. From the spiritual
viewpoint it is desirable to avoid loud shows of emotion in the presence of
the dying person. We have to remind ourselves that the dying process is of
great spiritual importance and we don't want to disturb the mind of the
dying person, which is in an increasingly clear and subtle state. We have
to do whatever we can to allow the person to die in a calm/happy/peaceful
state of mind. (1995: 4)

Participation by all in the multi-disciplinary team is seen as making an
important contribution to achieving this calm and peaceful state.

Participants in this research made comments referring to the idea that
death is "extremely significant" [EQ], indeed, the "culmination of all
life" [EQ], and hence, that the moment of death is the "most important
moment in your life" [EQ]. The orientation in working with the dying was to
achieve a calm and peaceful death: a notion directly compatible with
hospice care.

It is important to note, however, that although the hospice practitioners
at KHS bring a deep respect for the process of dying, because of their
tradition of tolerance they in no way see it as their right to impose the
Buddhist philosophy of dying on their clients. There are specific rituals
for Buddhist practitioners (Goss & Klass, 1997: 381) but these are only
engaged in if requested by the client. The Buddhist tolerant and
non-judgemental commitment to supporting others in their individual journey
necessitates a flexible, compassionate approach to dying which affirms the
right of each person to die in the way they choose.

Participants made reference to the individual variability of the dying
experience, and KHS's non-judgmental support of individuals' choice of how
they die. Underpinning such supportive work was the stated fact that
members of this organization were comfortable with issues of death and
dying.

This acceptance of death as a spiritual event and ease with the dying
experience parallels the hospice notion of the 'normalization of death' in
which death is seen as a very human event, a legitimate and normal process,
an inevitable part of life (Hamilton & Reid, 1980: 48). Such an orientation
is a significant move away from the dominant attitudes in our death-denying
society, where the medical 'war' against death is maintained to the end
(Fuchs, 1968: 192; Short, 1985; Dutton 1988: 351-352; Jonsen, 1990: 51).

In hospice care, as with Buddhist philosophy, the final days and hours of
death are given particular attention, with opportunities provided for
patients to experience their final moments in a way meaningful to them (Mor
et al., 1988: 10).

Summarizing the connection between Buddhist spirituality and hospice care

This discussion has presented research findings on Karuna Hospice Service
which indicate that the organization's Buddhist discourse not only
contributes significantly to defining the 'uniqueness' of the organization,
but is also seen as a major ingredient in the service's success in
achieving an excellent reputation for compassionate work with the dying.

As Fairclough (1992: 55) states when pointing out the primacy of
interdiscursivity, "any discursive practice is defined by its relations
with others, and draws upon others in complex ways". The 'talk' of KHS, it
is suggested, draws on and combines both the hospice and Buddhist discourse
as an effective discursive space for working compassionately with the
dying. In particular, Buddhist notions of compassion and wisdom, the
importance of a practical metaphysic, a willingness to serve, tolerance,
the duty to do no harm, and the significance of death are seen as
commensurable with and supportive of hospice practice.

Situated at the crossroads of two compatible and complementary discourses
(Buddhism and hospice) the KHS 'talk' sanctions compassionate,
non-judgmental caring which translates into practical, humane care of the
dying. In doing so, KHS demonstrates the commensurability of Buddhist
philosophy with hospice practice. The spiritual ideology central to both
discourses embraces a commitment to Rinpoche's Buddhist vision for the care
of the dying, which is:

To inspire a quiet revolution in the whole way we look at death and care
for the dying, and so the whole way we look at life and care for the
living. (1992: 358)

Notes

[1] The postal address of this service is Karuna Hospice Service, PO Box
2020, Windsor, Queensland 4030, Australia. Tel: (07) 3857 8555.

[2] The reference (EQ) is used to signify a verbatim quotation from a
language/text of the research.

Correspondence to: Pam McGrath, Centre for Public Health Research,
Queensland University of Technology, Kelvin Grove Campus, Locked Bag No. 2,
Red Hill, Queensland 4059, Australia. Tel: + 61 (07) 3864 5916. Fax: + 61
(07) 3864 3369. E-mail: p.mcgrath@qut.edu.au

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Biographical note

Dr Pam McGrath, BSocWk, MA, PhD, is a postdoctoral Research Fellow at the
Centre for Public Health Research at the Queensland University of
Technology. Dr McGrath is presently directing a program in psychosocial
research in the area of oncology and palliative care.

~~~~~~~~

By Pam McGrath, Centre for Public Health Research, Queensland University of
Technology, Australia