The Spirit Ambulance: Choreographing the End of Life in Thailand

By Scott Stonington

The Spirit Ambulance is a journey into decision-making at the end of life in Thailand, where families attempt to craft good deaths for their elders in the face of clashing ethical frameworks, from a rapidly developing universal medical system, to national and global human-rights politics, to contemporary movements in Buddhist metaphysics. Scott Stonington’s gripping ethnography documents how Thai families attempt to pay back a “debt of life” to their elders through intensive medical care, followed by a medically assisted rush from the hospital to home to ensure a spiritually advantageous last breath. The result is a powerful exploration of the nature of death and the complexities arising from the globalization of biomedical expertise and ethics around the world.
 

• Language: English
• Publisher: University of California Press
• Release date: Aug 25, 2020
• ISBN: 9780520975231

Scott Stonington

Scott Stonington, MD, PhD, is Assistant Professor of Anthropology, International Studies, and Internal Medicine at the University of Michigan.  

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CALIFORNIA SERIES IN PUBLIC ANTHROPOLOGY

The California Series in Public Anthropology emphasizes the anthropologist’s role as an engaged intellectual. It continues anthropology’s commitment to being an ethnographic witness, to describing, in human terms, how life is lived beyond the borders of many readers’ experiences. But it also adds a commitment, through ethnography, to reframing the terms of public debate—transforming received, accepted understandings of social issues with new insights, new framings.

Series Editor: Robert Borofsky (Hawaii Pacific University)

Contributing Editors: Philippe Bourgois (UCLA), Paul Farmer (Partners In Health), Alex Hinton (Rutgers University), Carolyn Nordstrom (University of Notre Dame), and Nancy Scheper-Hughes (UC Berkeley)

University of California Press Editor: Naomi Schneider

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The Spirit Ambulance

The Spirit Ambulance

Choreographing the End of Life in Thailand

Scott Stonington

UC Logo

UNIVERSITY OF CALIFORNIA PRESS

University of California Press

Oakland, California

© 2020 by Scott Stonington

Library of Congress Cataloging-in-Publication Data

Names: Stonington, Scott, author.

Title: The Spirit Ambulance : Choreographing the End of Life in Thailand / Scott Stonington.

Description: Oakland, California : University of California Press, [2020] | Includes bibliographical references and index.

ISBN 978-0-520-34389-4 (cloth : alk. paper)

ISBN 978-0-520-34390-0 (pbk. : alk. paper)

ISBN 978-0-520-97523-1 (ebook)

Manufactured in the United States of America

28  27  26  25  24  23  22  21  20

10  9  8  7  6  5  4  3  2  1

To my parents

I owe you a nī bun khun for a lifetime of inspiration and care.

Contents

Acknowledgments

Jandi: The Spirit Ambulance

Arirat: Facing the Karma Master

Introduction: Choreographing the End of Life

1. Paying the Debt of Life

2. The Spirit Ambulance

Buddhadasa: Problematizing Death

3. The New End of Life

4. Karma Masters

Coda

Notes

Bibliography

Index

Acknowledgments

Work on this book began a decade ago and has involved multiple phases of my life on two continents, making it impossible to acknowledge all of the kindnesses tucked into its pages. I am forever grateful to all who played a part, though I am able to mention only a few of them here.

I owe a great debt to my academic mentors, whose touches can be found everywhere in this work. Sharon Kaufman has always been an extraordinarily talented and devoted mentor, showing how to move heartfully into challenging domains of human experience with brilliance and bravery. Vincanne Adams believed in me from the start and then unfailingly lent her nimble and creative mind to my work at every stage. Philippe Bourgois taught me to make ethnography a way of life. Paul Rabinow provided much of the conceptual methodology that runs through my scholarship and medical practice. Steve Pantilat and Steve McPhee took me under their wings as they helped forge palliative care in the United States. Paul Farmer intervened pivotally at every step of my career path. Arthur Kleinman has been extraordinarily generous, from career advice to notes on my work. Mary-Jo Delvecchio Good and Byron Good provided an intellectual home during my residency, which has loomed large in my intellectual development.

I am also deeply indebted to my mentors in Thailand, for making my project manifest and helping me build a way of being that allowed me access to Thailand. Preeyanoot Surinkaew has long moved deftly between many roles, all with characteristic interpersonal genius, as friend, facilitator, collaborator, assistant, and teacher. Linchong Pothiban, of Chiang Mai University’s Faculty of Nursing, has been a guide, advocate and parent, in research and in life. Several leaders in Thailand’s public health system have invited me into their professional worlds and facilitated core components of my work. Suriya Wongkongkathep of the Ministry of Public Health has been a patron and ally, waving a wand to make aspects of my project materialize, from field sites to intellectual community to pathways through the political tangles of Thai academic medicine. He has also been a great role model for how to be heartfully effective in the world. At Chiang Mai University, Suwat Chariyalertsak (of the Research Institute for Health Sciences) and Wipada Kunaviktikul (dean of the Faculty of Nursing) were pivotal, setting up aspects of my project and acting as invaluable interlocutors. Komatra Chuengsatiansup, director of the Society and Health Institute at the Ministry of Public Health, a great charismatic leader, has helped show me a window into many parts of Thai social life.

I am indebted to those involved in pioneering palliative care in Thailand, especially Temsak Phungrassami, humble world-mover, responsible for a great deal of the compassionate gaze on the end of life in Thailand. I am also indebted to the palliative care team at Prince of Songkla University, including Sakon Singha, P’Fong and P’Yae, and to Phra Paisal Visalo, who has been key to much of my research. I deeply regret that for reasons of confidentiality, I am unable name the many people at Nakhon Ping and other hospitals who took me into their hearts and busy schedules to make all aspects of this project thrive. I would particularly like to thank the nurses whose brilliance and devotion to dying patients motivated me to pursue end-of-life care. I would also like to thank Nicole Ripley, Steve Epstein and Tanapong Sungkaew for companionship and for sharing their deep engagements with Thailand, invaluable to my habilitation into Thai life. I would like to thank as well a set of scholars of Thailand who have provided close friendship, wisdom, and contributions to many aspects and iterations of my work: Felicity Aulino, Julia Cassaniti, Joe Harris, and Claudio Sopranzetti. Thank you for being my siblings in this endeavor.

Many people not already mentioned above have read and advised on versions of this book or on phases of my research. Their contributions have been invaluable, and I hope I have done them justice. They include Zoe Boudart, Dominic Boyer, Mara Buchbinder, Diana Coffa, Tom Gething, Jon Goldman, Anita Hannig, Seth Holmes, Ieva Jussionyte, Jen Karlin, Rebecca Katz, Stephan Kloos, Charles Keyes, Olivia Para, Joe Stoller, Na’amah Razon, Beatriz Reyes-Cortez, Liz Roberts, China Scherz, Janelle Taylor, Megan Valentine, Katrina Whaley, Erick White, and the STS workshop at the University of Michigan. I would also like to extend particular thanks to Nathinee Chucherdwatanasak, whose editorial work and insights were pivotal to this entire book, and especially the archival portions.

Many sources of financial support have made this project possible. I am indebted to the Blakemore Freeman Foundation, which has taken the role of patron far beyond financial support—through intellectual engagement, logistical support, and the great breadth of its network. Other sources of funding that contributed to this book include the Fletcher-Jones Foundation, the Pacific Rim Research Program, and the U.S. Department of Education’s Foreign Language Area Studies Program. I am also indebted to the Medical Scientist Training Program, whose goal of crafting physician-scholars I hope to have manifested in this book. I am also grateful to those in the medical residency program at Brigham and Women’s Hospital and the Department of Global Health and Social Medicine at Harvard Medical School who facilitated my time as a physician-anthropologist, including Marshall Wolf, Joel Katz, Chuck Morris, Paul Farmer, and many others. I am also grateful to the Institute for Humanities at the University of Michigan for time to finish this project.

In the spirit of this book, I would like to thank my parents, who have supported every phase of its development, acting as incubators, editors and coaches. I owe them a debt of life and a nī bun khun, neither of which I will ever be able to repay. And I would like to thank my creative and brilliant brother for being a partner in this debt and in so many other life projects.

Finally, I would like to thank my wife Irene for embracing our journeys through Thai life-worlds, for devoting her genius, courage, and her ability to draw me deeper into feeling and living my work. And I would like to thank my daughters Leela and Paloma, for enthusiastically embracing life as anthropologists, and reminding me that curiosity is the core wisdom in a life of joy.

Jandi

The Spirit Ambulance

We have to make it home, said Jandi’s son, who sat across from me as I pumped oxygen into his mother’s lungs to keep her spirit attached to her body. We were seated in the cab of an old pickup truck outfitted as an ambulance. Jandi lay unconscious on a mattress, a blood-filled endotracheal tube emerging from her mouth, connected by a balloon pump in my hand to an oxygen tank at the front of the cab. We struggled to stabilize ourselves as the truck tossed from side to side, winding its way into northern Thailand’s mountain jungle. Rice fields passed us out of mist, punctuated by flames from fires set to prime the forest soil for mushroom growing in the coming monsoon season. The smoky air was interrupted periodically by scents of pine and mint. In a quiet stretch of road, I could hear the gurgling sound of blood in Jandi’s endotracheal tube.

I had met Jandi several days before, in the hot season of 2008, when she arrived at Nakhon Ping Hospital in Chiang Mai, the capital of northern Thailand, where I was engaged in fieldwork on end-of-life care. She was a rice farmer from a remote village, five hours by precipitous road from the city. She had been sick for a long time with a cough but had refused to go to the doctor despite her family’s pleas, claiming that the ride to the city and accommodations on arrival would be too expensive for them. They wanted to take her, even against her protests—in fact, this was part of their duty as her children—but every time she suspected plans were afoot to do so, she escaped into the village or the fields. Her family waited reluctantly. One day, when she was making lāp (ground pork with lime, chili, mint and cilantro) in her teak house, she began coughing blood. Then she collapsed onto the kitchen floor.

Her family heard the thump and found her unconscious. They called for help, and neighbors arrived. They quickly arranged to borrow gas money from friends for a trip to the city in a truck lent by the head of the village. The family lifted Jandi into the truck’s cab and drove to Chiang Mai city and the emergency room at Nakhon Ping Hospital.

Nakhon Ping was the public hospital for Chiang Mai province, available at very low cost to all citizens under Thailand’s universal health care system. It had a CT scanner, mechanical ventilation, dialysis capacity, and a surgical-anesthesia suite capable of most surgeries. The hospital served both poor and middle class people, with some open wards (beds pressed close together) and some private rooms (with extra nursing care available at extra cost). In the open wards, family members camped for much of the day on straw mats between patients’ beds, serving meals and helping with the care of their hospitalized loved ones. Hospital room walls boasted not only outlets for oxygen and electrical arrays on protected generator circuits but shrines adorned with flowers, amulets, and ribbons, at which families prostrated themselves and made offerings to appeal to the spirits that inhabited the place. Many languages could be heard in the halls: Hmong, Karen, and Tai-Yai (spoken by families in colorful outfits, setting them visually apart); kam mư̄ang, the Northern Thai language; Central Thai (spoken by younger northern Thais and migrants from Bangkok); and hybrids of Thai languages and medical English (spoken by doctors and nurses).

On arrival at the emergency room at Nakhon Ping, Jandi was breathing rapidly and oxygenating poorly. Doctors inserted an endotracheal tube into her lungs, and she was started on a mechanical ventilator. She was still unconscious. A chest X-ray showed widespread masses and fluid, likely with bleeding in her lungs from either cancer or tuberculosis. Her lung function was rapidly declining, and her doctor, Dr. Prani, felt that there was no hope of turning her around. The family took shifts sitting vigil, chanting and offering prayers, whispering kindnesses in her ear. When they were exhausted, family members took turns sleeping in the back of the pickup truck in the parking lot.

On her third day in the hospital, Dr. Prani told Jandi’s family that she was likely to die soon, even on life support. I was standing with them when they received this news. It was early in my fieldwork for my Ph.D. in anthropology, and I was still inexperienced. Despite the family’s open-heartedness, they hadn’t incorporated me into their experience yet. We had simply been sitting in worried silence together. But after hearing from the doctor, Jandi’s daughter turned to me suddenly and asked fiercely, Would you help us? We need to take mother home.

I felt a wave of sadness come over me: this family had just come all the way from the mountains, only to receive this devastating news and have to turn around again. I agreed to accompany them, of course, galvanized both by their sorrow and my own, and by being included in the situation. Simultaneously a medical student and a graduate student in anthropology, I was in Thailand as part of a joint MD/PhD training program, and although initially determined to remain an observer, I was often shunted into a combined practitioner-observer role, mostly answering questions for families about what was happening. With so many patients to attend to, physicians in Thailand were often too overwhelmed to communicate much with families. Initially, I worried that people might hope that I would be able to help treat or cure their loved ones, and I did not want to mislead them. But I soon learned that it was my presence itself that people wanted: physicians are seen by many to carry accumulated spiritual merit (bun),¹ because of a life spent caring for others, and this merit can bring benefit simply through their presence. So despite my insistence that I was only a student, families often wanted me to be there, without any expectation of intervention or skill.

I hadn’t traveled home with a patient like this before, but I knew that we would probably be attempting to have Jandi’s last breath take place in the right location. The hospital would be a bad place to die—impure, haunted by ghosts (phī), and disadvantageous for rebirth. Her home, on the other hand, would be full of familiar things, warmth and merit (bun) from a life lived ethically and with beneficial ceremony. Our task would be to keep Jandi’s spirit attached to her body until she could make it home.

When are we leaving? I asked Jandi’s daughter.

We’re waiting for the ambulance to be prepared, she said.

Ambulance? I thought, surprised. And then I realized that Jandi was on a mechanical ventilator, pumping oxygen into her blood-filled lungs. If we were going to get her home for her last breath, we would have to take over from the machine and pump her lungs the entire way.

The head nurse of the surgical ward pulled me aside, and asked me in a whisper, Have you ever removed an endotracheal tube before?

I said no, suspecting where this was going.

Here’s how, she said, and pulled a plastic tube out of the cupboard to show me how to deflate the balloon that held it in place. As the most medical person around, you’ll have to withdraw it. I was confused, since many nurses and physicians I had interviewed in the hospital considered withdrawal of life support unethical. This included Jandi’s physician, Dr. Prani. The breath, many explained, is the last element to separate from the body, and so pulling out an endotracheal tube feels like killing. In the heat of the moment, I had time for only one question. "Isn’t it unethical [phit čhariya tham]?"² I asked.

Well, yes, the nurse replied. Dr. Prani doesn’t withdraw tubes in the hospital, but it is okay at home. The patient [Jandi] will be at home when it is removed. Ethical at home but not in the hospital? I felt a wave of disorientation wash over me as I tried to make sense of this, but there was no time to clarify.

We were then swept into feverish activity. The nurses took Jandi off the mechanical ventilator and switched her to a balloon pump, and as we wheeled her down the hall to the parking lot, they showed me how to pump air into her lungs to keep her spirit attached to her body. The ambulance that had been waiting for us was a pickup truck owned by one of the hospital gate guards. He ran a small business on the side, taking people home to die. His truck was less expensive than a real ambulance, serving poor families like Jandi’s. It was equipped with a mattress, two tall green oxygen tanks, and a motorcycle tire pump that he had reconfigured to administer intravenous embalming fluid in case a patient were to die on the way home. If Jandi were to die in transit, the guard explained, the embalming fluid would help keep her spirit near her body, to make sure that she could follow us home even once disembodied. This system was the guard’s innovation, derived partly through study with monks about the metaphysics of death, and partly through years of experience transporting spirits and their bodies home. It was among the services he offered.

I helped lift Jandi into the truck, and then sat in back with her son and pumped air into her lungs. We pulled out, followed by the truck carrying her relatives. The truck whipped through Chiang Mai city traffic, swerving and dodging until we were outside of town, and then climbed into the burning mountain jungle.

We have to make it home, Jandi’s son shouted over the rush of wind and road noise. He sat across from me in clothes dirty from days of sleeping in the pickup truck. "If she dies on the way we have to change places so that I can talk her spirit [winyān] into following us, so she won’t get lost."

I nodded.

You take her pulse! he shouted. If she dies, tell me. We may have to go to a temple instead of home.

Why? I shouted back.

"There are ghosts [phī] all along the way! he replied. They might harm her or bring something bad along. At the temple, the monks will help. Bad spirits can’t enter."

I took Jandi’s pulse; I thought it was still there, though it was hard to tell over the shaking of the car. I looked at her endotracheal tube, full of blood. I couldn’t imagine I was oxygenating her lungs, instead probably just bubbling air into and out of the pool of blood in them. But the tube was connected to the oxygen tank in the guard’s truck, so I talked myself into hoping that I was getting some small amount of oxygen into her. I also decided to ignore the fact that the blood might be full of tuberculosis bacilli or some other pathogen, convincing myself that the open air of the road made contracting an infection unlikely. After a tortuous stretch of road, I retched off the end of