I have been staying with Hok, and his three siblings and mother. They are a Cambodian family who run a homestay in the South of Phnom Penh. I realise that my perspective on palliative care since I have been here has come with directly from the staff at DSF, or through translators who work full-time with the staff. I am curious to find out more about the end of life as perceived by Cambodian people, and also how and whether Buddhist practices and beliefs help people to prepare for death.
Hok and I go for a walk one humid evening, and sit down to a meal of lotus root stew and banana flower salad. Hok tells me that his brother died of throat cancer two years ago, at the age of thirty three. When I explain the work of DSF he is surprised – he had no idea that such a thing existed. Like many Cambodians who are able to pay, Hok’s brother went to Vietnam for treatment after losing faith in Cambodian doctors. However despite extensive disfiguring surgery which included resection of his vocal cords, the cancer continued to spread. He was admitted to the Calmette Hospital and died there, 6 months later, “in much pain”. When he was dying, only some members of the family talked about it, and they rarely if ever included his brother in these discussions in case he gave up hope and stopped eating and trying to live. But Hok thinks that this made it more difficult because his brother was not able to say what was important, and could not prepare for his future because he had not been able to discuss what this future might be. I ask Hok whether his faith helps him and his family with difficult times like this, and am surprised to learn that he is a Christian, although the rest of his family are Theravada Buddhists. He tells me the story of how this came to be.
When Hok was young, his family had very little money. They could not afford to send him to school but they were keen for him to learn English as they considered that this was a potential way to secure his future. A Catholic Charity were running a small English-speaking school in Phnom Penh, near to the Khmer Soviet Hospital, at that time. In exchange for lessons they wanted no recompense, other than for students to accept the Christian teachings during the time of their schooling. Hok’s parents were keen for his education to progress and they readily agreed to this. Bol himself agreed, although at that time he secretly wished to follow in his father’s footsteps and become a bhikku, or monk, and live at one of the Wats surrounding the city. Accordingly, Hok began his schooling and concurrently learned about the Christian teachings. One day, one of the priests baked him a cake for his birthday and the teachers and students sang to him. he can’t recall which birthday it was – maybe 11, maybe 12, he shrugs.
For many Cambodians, birthdays are not recognised. This was the first time Hok had celebrated a birthday. He tells me that something happened to him in that moment, that he was looking at the candles on the cake and at the faces of the monks and students and that he felt real love from them, a love that did not demand to be repaid, and a celebration of his life as holy. He decided in that moment that he would become a Christian and continues to pray at the Church where he was schooled.
During the Khmer Rouge regime, many respected Buddhist teachers and monks were killed. They were among those targeted as threats to the revolution, and the books and temples of Cambodia were very nearly all destroyed. Today, the main way for a child to learn Buddhism is to join a pagoda, often as a boy, to live as a monk. Many boys join the pagoda because their parents cannot afford to raise them. For women it is not so easy, as to be recognised as a Buddhist one must surrender all worldly goods to live in the pagoda. Yet with ongoing struggles against poverty and illness, it is rare for a woman under the age of fifty to be able to choose this life. There are no Buddhist teachings for younger women other than what they receive at school or from their parents. The Cambodian women that I meet tell me enthusiastically that they are Buddhists. They practices chanting scripts in Khmer and have shrines in their homes, but rarely meditate, having never been taught to do so, and in any case there is rarely time alongside other responsibilities such as working, preparing food, childcare and tending the sick. Even though Buddhism remains the faith of the majority of the country, active faith practices in the laity are increasingly less common. Women who do choose to become nuns in later life are often marginalised by Khmer society. Many Cambodians I meet are skeptical about the pagodas. The Wats are often elaborate buildings inlaid with intricate carvings and topped with gold spires. For some, Buddhism is a serious lifelong practice dedicated to caring for the suffering, but for many, it offers an alternative to the daily struggles faced by the laity. Suffering is a part of life here, this is rarely questioned. Indeed, almost all of the Cambodian people I have met so far are curiously calm and smiling. Unprompted, they tell me stories of their losses with an acceptance and an equanimity that humbles me. It certainly puts my own recent loss into great perspective.
Hok draws his strength from quiet contemplation. When he describes this practice to me it sounds remarkably similar to Buddhist meditation. Hok tells me that there is “pretend love” and “real love”. What he saw and felt on that birthday has affected him in such a deep way that it will stay in his heart for the rest of his days. Since my conversation with Hok I have been thinking about the Christian origins of the hospice movement, the close connection of nursing and monastic traditions, the place of suffering in both faiths and in the “scriptures” of palliative care. Both Christiantiy and Buddhism advocate compassion, or real love, as a way to challenge sin, or egotism. And both faiths are often associated with palliative care. Many increasing number of services inspired by Buddhism are diffusing into Western palliative care, as well as Buddhism-influenced practices such as mindfulness, acceptance and commitment therapy and mindfulness-based stress reduction, often interpreted through a Western lens and in a secularised way. The etymological origin of compassion is “to suffer with” somebody, so as a foundation for compassion it is necessary to be able to sense a person’s suffering. This requires that we open ourselves to feeling some difficult feelings – there is no avoiding this. It hurts to sense that another person is suffering if we open our hearts to that reality.
Love is rarely considered to be part of a nurses’ role – indeed, many continue to believe that you can become “too close” to a patient and that this opens you up to suffering, vicarious traumatisation and compassion fatigue. But one could easily substitute the word “love” for “compassion” in the literature. It is impossible to make someone love another person. But the word “love” is used in so many situations – we can love our children, chocolate, our partner, our friends, our gardens – and yet we understand this use of the term because we hear it talked about in context. The context of love for a patient is one further form of love that we may wish to consider. The priests felt real unsentimental, open-hearted love as they gave cake and sang songs for the young Cambodian boy who had come to learn in their school. Many of my heroes describe seminal moments in their lives when they felt unconditionally loved or cared for by another person. BJ Miller describes his response to the nurse who brought him a snowball from outside the hospital during his prolonged stay following a severe injury.
I am not a religious person but I do think of myself as spiritual. I would not advocate religion as a means of addressing the so-called “compassion deficit” – there is authenticity and goodness in people of all faiths and none, and the opposite is also true – adopting a religion or being an agnostic or atheist does not itself make a person good – compassion lies in one’s actions and their origins and motivations.
Talking to Hok today I learned an important thing about the nature of authentic love and the profound potential that it has to influence another person. Compassion does not refer to “idiot kindness” – a response to suffering in which saccharine niceness is considered part of the nurses role (which is more usually a performance, a form of emotion work). Compassion can only exist as a result of a real connection with a patient and an authentic wish to make life better for them, and to ease their suffering or to help them create meaning out of it. And this, I believe, can never be taught until one has experienced for oneself the feeling of receiving another person’s unconditional love.