Buddhist End of Life Care in Toronto: Ritual Practice to Social Engagement, by Helen Craigie

Buddhist End of Life Care in Toronto: Ritual Practice to Social Engagement,
by Helen Craigie
[Masters Student in Religion (Buddhist Studies)/Bioethics, University of Toronto]
April, 2008

(based in part on an interview with Sean Hillman; transcript of full interview coming soon; much appreciation to Helen Craigie for allowing me to post her excellent paper on a subject dear to my heart)

Buddhist end-of-life care is a unique form of socially engaged Buddhism that has made a home in Toronto’s health care institutions. The compassionate practice of caring for the terminally ill is distinctly ritualistic in that it was part of the Buddhist tradition well before Buddhism made its way to the West. On the other hand, in the Western world there are examples of Buddhist palliative care participating in social activism at the ground level. Palliative care in the West has even developed into group movements to create centres for care that exist outside social healthcare institutions. Considering that there are elements of engagement from both sides of the extreme, where does this place Buddhist palliative care in Toronto within socially engaged Buddhism as a whole?

In Ken Jones’ work “Emptiness and Form”, he outlines different forms of Buddhist social engagement: “Two kinds of engagement can be arranged along a continuum. At one end Buddhist compassion is expressed in public and organized forms of service and caring – therapy, healing and healthcare (especially with the terminally ill)... At the other end of the Engaged Buddhist spectrum is an activism directed towards radical social change” (p. 2). Jones’ description places Buddhist engagement in healthcare at one end of the Engaged Buddhist spectrum, while radical social change is found at the opposite end. Bearing this in mind, Jones categorizes Western Buddhist focused palliative care in this manner because of its roots in upholding Buddhist ritual practice. However, because there are examples of groups creating separate social models for care, it can be argued that it belongs at other end of the spectrum as radical social change. In Christopher Queen’s collection of studies in engaged Buddhism entitled Action Dharma, he makes a clear distinction between social action and ritual action: “social action (caring for the sick or joining a peace march, for example), which is typically undertaken to relieve other’s suffering, and ritual action (meditation and devotional rites, for example)” (p. 2). Buddhist end-of-life care is unlike other forms of Buddhist social engagement in that the line between social action and ritual action is blurred. Its social action aims to reproduce Buddhist ritual practice in a Western situation. Its ritual action is through its connection with Buddhist traditional methods. Essentially, what transfers to our healthcare guidelines in Toronto is that basic understanding of Buddhist rituals used at the time of death is to be recognized by healthcare professionals. The Ontario Multifaith Council and the Trillium Health Centre understand a Buddhist idea of death to be a time of transition from one life to another (p. 9). In her book, Caring for Dying People of Different Faiths, Julia Neuberger describes the Buddhist's acceptance of death as `striking', noting that it may be difficult for care givers to fully comprehend their attitude (p. 70). What Neuberger found strikingly different about caring for the dying Buddhist is the Buddhist's attitude at this time of transition. Buddhists hold that the way in which a dying man or woman is cared for is crucial to the spiritual process. They will accept their death, and may request to be drug free. At the time of death, a Buddhist will need a calm atmosphere, and may request spiritual guidance. Neuberger notes: “the only certainty when caring for a Buddhist who is dying is that he will require as much time and space for meditation as possible”(p. 67). She points out that, although it may be difficult to meet these needs in a care facility, that mental preparation for the period of transition is crucial and should be respected as much as possible. To create a more accurate understanding of how this practice plays out in palliative institutions in Toronto, further research for this essay is sourced predominantly from a revealing interview with a Tibetan Buddhist who works as a nurse’s aid in palliative care in Toronto.

Sean Hillman is a former Tibetan Buddhist monastic. Since leaving the order he has returned home to Toronto and is now working in as a nursing assistant in palliative care at St. Michael’s hospital. Hillman sees his work as a socially engaged Buddhist in Toronto as a natural choice as he wanted his livelihood to be able to support his practice (par. 2). Studying and becoming a monastic in [India], as well as working with the dying in Toronto makes Hillman an ideal authority on Buddhist social engagement in end-of-life care in Toronto. When Hillman was asked whether there are ritualistic or social aspects of engaged Buddhist practice in the area of palliative care, he responded by saying that there are elements of both. His experience in trying to meet the ritual needs of dying Buddhists has required that he take social action. He explained that because of obstacles when trying to fulfill the religious wishes of his patients he has been in situations where he had no choice but to get involved at some level (par. 4). He identified unfamiliarity as a main contributor to the resistance from his peers. In his experience, palliative care practitioners had no experience with the types of requests they received from the patients. Hillman provided examples of how this has played out in his time at St. Michaels hospital:

“If you try to make something happen that is unusual, like spending a day chanting around a body in hospital, through familiarization it is becoming less unusual. If my patient's family says that they want to spend, let's say, 10 hours with the body, I have no choice but to get involved with whoever can make that happen” (par. 4).

Considering Buddhist palliative care practice in Toronto’s institutions, Hillman was then asked whether in modern Western healthcare it is the ritual practice, the Buddhist philosophy or something different [that has] carried over from the East? Hillman’s response to this question came from his knowledge of Tibetan Buddhism:

“The only thing that I can think of is the personal liberation vows that come from the time of the Buddha, which can in some ways be seen as specific to that time, where there are things that exist now that didn’t exist at that time like vehicles and electronic communication and so on, yet the spirit is still there. I think that the principles in the Buddhist teaching and also in practice can easily be applied to a modern situation, even though some of the situations are new” (par. 18).

In Hillman’s perspective, it is the basic principles of Buddhist philosophy that are being brought forth. He maintained that how these principles play out in modern situations differ depending on the individual’s background, karma, environment and predispositions. Even though the situation in which these principles are applied is new, the essence of Buddhist teachings remain the same.

Examples of Buddhist end-of-life care in the West show that engaged practitioners are not typically planning peace marches or protests to make social change. Instead, compassionate practitioners are typically active in working with the terminally ill and dying. In the context of palliative care in Toronto, as a place that recognizes religious diversity, what type of activism is necessary? Working in the palliative care unit at St. Michael’s hospital, Hillman has experienced barriers that have lead to him become actively engaged. In upholding policy that recognizes multi-faith palliative care [delivery], his means of engagement have played out through appealing to higher levels of power. Hillman was asked, “What is your means for peaceful change?”

“Through dialogue and through talking to all the levels of power. I’d say in a hospital environment there were times when I had to, for example, go to the head of the spiritual care department because going to the head of the nurses of this particular area wasn’t working to make the situation change when there was an obstacle with palliative care delivery for a certain patient”(par. 8).

Hillman explained one example where he was compelled to become active. The circumstances involved a palliative patient who was not competent enough to express his wishes. According to his charts, the patient was a long standing Buddhist yet the [staff] were continuously taking him to Christian mass. Hillman saw this situation as “obviously a breach of the rights of the individual, particularly to a vulnerable patient who is palliative” (par. 8). To address this situation, Hillman had to go above the heads of his peers and appeal to a higher level of authority. Drawing from his Tibetan Buddhist background, Hillman rationalized this particular set of events: “There are these worldly attitudes that we as practitioners are supposed to reduce and one of them is caring whether we are liked or not . . . And if I cared more about being liked more than caring about making change happened, then I wouldn’t have done it” (par. 9). It is with this frame of mind that made up-keeping moral standards take priority over his concern for how his peers would react: “I was just so enthusiastic about making this change happen that it overrode any sort of concern about how people would perceive me. Because in the end the result was achieved. And it made me happy” (par. 10)

Ken Jones makes reference to further manifestations of engaged Buddhism that are far more radical then most types of socially engaged Buddhist movements (p. 3). Jones provides examples of socially engaged Buddhist movements that share the goal of creating Buddhist alternative social models. In other parts of the world, Buddhist end-of-life care fits into this model of social activism in that the common goal is the creation of centres for alternative care outside of the normal system of care. Examples are found in Buddhist hospices like Amitabha Hospice in Auckland New Zealand, or the Zen Hospice in San Francisco. By building alternative models of health care, such as hospices outside of the hospital institutions, these groups aim to ensure a certain level of Buddhist integrity in end-of-life care. Hillman commented on the situation in Toronto: “We don’t have a freestanding Buddhist hospice in Toronto. We have budding hospice movements or groups, there is a growing interest and a growing awareness. [As] part of that, we look at what other groups are doing for palliative care for Buddhists” (par. 16). In reference to his experience in Toronto, Hillman goes on to say that a natural extension of looking into other situations similar to ours in other parts of the world, is that we reflect on what works and what doesn’t in our own system. We then understand why in other parts of the world the logical extension of this thought is to have a freestanding Buddhist hospice that delivers Buddhist specific care. Since multi-faith sensitive end-of-life care is already part of our social healthcare system in Toronto, it seems that there would be less necessity for reform. Hillman maintains that multi-faith sensitive care is already in government policy and reform is necessary for governments to uphold what is already intended to exist within the system (par. 16). Considering we don’t have a freestanding Buddhist hospice in Toronto, as an alternative way to experience Buddhist palliative care, is what is already practiced in Toronto’s institutions enough? Do we need a separate social model? Although his experience has encountered some obstacles, Hillman’s faith in Toronto’s healthcare policies remains optimistic:

“Things have progressed so much in our healthcare institutions now. There are things that you will find in Buddhism in our hospital now. There are meditation groups, there are alternative practitioners that come in and engage in alternative therapies in our own hospitals. Some of these barriers that might have in the past have needed a completely alternative system for alternative therapy to even be considered, I don’t think that we need now, given that our system is more open minded and has more experience with non-allopathic, non-Western traditional medical approaches to health and illness in palliative care. I think that we need a place that has a different approach but I think that we can do this within our system” (par. 16).

In addition to seeing positive changes in his workplace, Hillman attributes his motivation to work within the current system to Tibetan Buddhist wisdom. He said that in the earliest Buddhist teachings monastics were instructed by the Buddha to follow the law of the land. Hillman argues that this philosophy applies today in that “[W]e need to work within the context of our culture within our socio-political systems” (par. 14). Following this view, if we find gaps in our system of palliative care, our approach should be to insist on the system following through with its intention to benefit everyone equally. Working as a Tibetan Buddhist in palliative care in Toronto has provided Sean Hillman with remarkable insight into real world models of engaged Buddhism. Throughout the interview, Hillman addressed contemporary concerns with a combination of timeless Buddhist doctrine and real life experience in one of Toronto’s palliative care departments.

Considering that there are examples from both ends of the Buddhist activism found in Western Buddhist palliative care, it would be impossible to place this form of engagement into one category over another. Sean Hillman’s experience supports the belief that social activism is intertwined in Buddhism at its root principles. Hillman brought to light that palliative care in Toronto’s healthcare system is a compassionate practice that emphasizes the importance of recognizing the different rituals and practices in various religions. It is faith in this system and its policies in multi-faith palliative care that deters Hillman from resorting to radical Buddhist activism. On the ground level, however, the system is not perfect. There is still resistance to what practitioners are not used to and might deem ‘unusual’. It is in these situations where activism and engagement become necessary to uphold the integrity of our multi-faith respecting policies.

References:

Amitabha Hospice Service. (n.d.). Amitabha Hospice Service. Retrieved March 28, 2008 from Amitabha Hospice Service: http://www.amitabhahospice.org/

Hillman, S. (2008, March 9). Engaged Buddhism and End-of-Life Care in Toronto. (H. Nuttall, Interviewer) Toronto, ON, Canada.

Jones, K. (Unlisted). Emptiness and Form. Retrieved February 12, 2008, from Buddhist Peace Fellowship: http://www.bpf.org/tsangha/jonesform.html

Neuberger, J. (204). Caring for Dying People of Different Faiths Third edition. London, England: Radcliffe Medical Press.

Ontario Multifaith Council on Spiritual and Religious Care and Trillium Health Centre. (2008, April). How Different Faiths Approach Death and Dying. Toronto, ON, Canada.

Queen, C. (2003). Action Dharma New Studies in Engaged Buddhism. (C. P. Christopher Queen, Ed.) New York, NY, USA: RoutledgeCurzon.

Zen Hospice Project. (n.d.). Zen Hospice Project. Retrieved March 28, 2008, from Zen Hospice Project: http://www.zenhospice.org/