Contents>> Vol. 10, No. 3
The Spirit Ambulance: Choreographing the End of Life in Thailand
Oakland: University of California Press, 2020.
The Spirit Ambulance: Choreographing the End of Life in Thailand aims to understand how people achieve making death good within the increasingly common global coexistence of Western biomedicine with other ways of approaching death. Specifically, this book describes the “choreography of good death” in northern Thailand, that is, how people arrange actions and resources dynamically in the flow of time to make death (hopefully) good in a specific context (p. 18), based mainly on medical anthropological fieldwork of the mid-2000s carried out in provincial government hospitals.
One of important strengths of this book is Stonington’s inclusion of his own experiences in biomedicine. His fieldwork was implemented as part of his MD/PhD training while at medical school in the United States. He described experiencing a “whiplash” from his toggling between his medical training in the US and his ethnographic research in Thailand. By comparing these two worlds within the book, the author invites readers to focus both on the particularities and universalities of death (p. 19).
The phases of dying in northern Thailand are set out in The Spirit Ambulance. The “status quo” process of dying can be divided in two phases. Chapter 1 deals with the first phase involving aggressive medical care in the hospital. Here, there are two imperatives for family members of the dying. One involves paying back the “debt of life (nii chiiwit),” rooted in the relationship between body, spirit, and family—arising from the blood given by parents at the creation of a body. In present-day northern Thailand, high-tech medical care is the means used to repay this debt. Family members may try to get their dying elders to receive better and more aggressive medical treatments in hospital—regardless of the latter’s prognosis or chances of a cure, and even if they may wish to go home.
The second imperative is to give elders “heart-mind energy (hai kamlang cai)” that animate their thinking and feeling selves in order to calm their mind and keep their body healthy. Protecting dying elders’ kamlang cai can mean concealing the truth about their illness so as to mitigate the dangerous risk of shocking them (with the truth) and draining kamlang cai—the result of which might be their sudden decline and death. As such, most families in northern Thailand withhold the full extent of the elder’s diagnosis and prognosis from them. Stonington, who studied many patients during his research in northern Thailand, found that they were kept ignorant of their medical condition for the duration of their illness. This runs contrary to what is practiced in the US, where patients are told the truth about their state of health based on their right to know.
Governed by these two imperatives, people in northern Thailand embody and act out different roles in the choreography of death. For instance, family members perform the role of “children” whose duty is to repay the “debt of life” they owe their elders for their gift of birth. In turn, the dying elders acknowledge their duty to maintain their own kamlang cai, by remaining in a state of not-knowing (or partly knowing) about their own illness, and moving toward death without jeopardizing or shortening their lives.
Chapter 2 explores the second phase of dying, that is, “the last phase of life” that begins when medical staff and family members recognize that an elder’s death is imminent. The central issue then becomes about when and where the elder will take their last breath, because one’s place of death is partly responsible for the quality of their rebirth. In northern Thailand, people regard withdrawing life support in the home as ethical, and not so if in the hospital. This is because each place is a different ethical location inhabited by a different set of spirts and thus different ethical forces. Hospitals may be good for the purposes of saving lives and repaying the debt of life, but are not considered to be an ethical choice for a place to die—being amoral, dangerous, devoid of ceremonial history, and haunted by spirits. Rather, homes—imbued with ethical power from a history of beneficial ceremony and moral family life—are the ideal place of death to optimize an elder’s rebirth. Families can use the “spirit ambulance” to transport elders on the brink of death from hospitals back to their homes to take their final breath. This chapter also describes successful and failed cases of families who balance the dual desires to pay back the debt of life at the hospital as well as to ensure their dying elder can take their last breath at home.
The author next describes how the famous monk, Buddahadasa, had died after spending many weeks in an ICU, despite having clearly stated that he did not want hospital care. This is followed by Chapter 3, where Stonington examines the new phase of dying, commonly referred to in English as “end-of-life.” This phase emerged from public debates surrounding the problematizing of Buddahadasa’s death, and relating to the social ills in Thai society such as consumerism and technology-worship. End-of-life, as a locus for societal improvements, offered an alternative approach—one shaped by broader ideas ranging from palliative care to human rights discourse; from conflicts around self-determination to the role of religion in daily life (p. 130). Today, this new end-of-life phase has become an additional imperative in the choreography of death in northern Thailand.
In this new approach, the period before death is regarded as an important opportunity for an individual’s transformation and growth. This is modeled on the ethical figure of the “seeker of wisdom”; one who faces the truth and can therefore ascend the hierarchy of spiritual achievement. To achieve such self-transformation, the dying person must face the truth of their own illness and untie “pom (knot),” the heart of the specific problem to be solved. However, this approach is not applicable to everyone. Those who do not have a “high level of mind (cit radap suung)” risk the deadly consequences of truth-telling—the decline of kamlang cai. And only those who have a high degree of cit radap suung may be assured of their ability to face the truth and walk the path of spiritual advancement.
Chapter 4 discusses the choreography of severe illness, examining mainly how people in northern Thailand conceive of and relate to their tumors or failing organs. The author encountered many individuals who regarded their severe illness as a “karma master (cao kam naai ween),” a moral being from the past that enters the present to resolve an old grievance (p. 133). His informants described their karma master not only as a being to which they needed to relate, but also as one that had become part of them. They therefore thought of themselves as an assemblage of multiple beings that have formed a collective. The self, consisting of multiple components, can be treated as independent at times and as part of a unified whole at others. It is also interesting how Stonington’s informants related with their karma master as moral beings that were partly self and partly other. They did not fight against them or cut them out to save their body, but instead attempted to improve their relationship with them by treating them with loving-kindness and asking their forgiveness. The author considers such interactions with their karma master as their process to heal “ethical wounds”—fundamentally relational rather than individual interactions.
End-of-life discourse, which used to take place mainly in developed countries, has since the 1990s gradually increased in Southeast Asia. However, there are still few ethnographic studies that attempt to approach the lived experiences of the dying and their families based on intensive fieldwork (cf. Iwasa 2013). The Spirit Ambulance, describing vividly how northern Thai people struggle with choreographing different imperatives and resources in the precarious process of dying, is—as far as I am aware—the first monograph-length ethnography about end-of-life in Southeast Asia.
I especially appreciate the examination of the “new end-of-life” in this book. To date, many end-of-life discussions in the Asian region tend to be static and monolithic. They are often influenced by the Occidentalist gaze that portrays “Asian values” such as familism and Buddhism in opposition to “Western values” such as individualism and Christianity. Under such a tendency, the emergence of the “new end-of-life” in Thailand—which embraces truth-telling and self-determination—may be regarded as the “simple arrival” of biomedical expertise based on Western values. Stonington, however, succeeds in presenting “new end-of-life” through a different lens—as dynamically born out of a complex ecosystem overlapping global expertise, national politics, and religious practice. This fresh approach will be of great help in examining current situation end-of-life discussions and practices, not only in Thailand but also in other Southeast Asian countries.
There are some topics not covered in this book as well. One is concerning “cultural differences” of choreographing good death. The author does mention that diverse ethnic minorities including the Hmong, Karen, and Tai-Yai use provincial hospitals (p. 2), but there is little discussion of how they use hospitals in their dying process. If cases showing the differences of choreography of good death among ethnic minorities were presented, readers could have arrived at a more complex picture of end-of-life in northern Thailand.
However, in general, The Spirit Ambulance is undoubtedly an ethnography of fine quality, offering vivid descriptions of the realm of end-of-life in contemporary Thailand. I hope many people read this book and enjoy experiencing “whiplash” as I did.
Iwasa Mitsuhiro 岩佐光広
Faculty of Humanities and Social Sciences, Kochi University
Iwasa Mitsuhiro. 2013. Aging and Dying in a Rural Lowland Area of Laos: A Consideration of Creating a “Good Death” Together. In The Anthropology of Aging and Well-being Searching for the Space and Time to Cultivate Life Together (Senri Ethnological Studies 80), edited by Suzuki Nanami, pp. 123–142. Osaka: National Museum of Ethnology, Japan.