The term ‘end of life’ in biomedical contexts would seem to have a stable and universal meaning. But as this fine ethnography demonstrates, this is not the case. Scott Stonington's research among contemporary hospital patients and their families in northern Thailand reveals a fascinating mixture of medical technology, combined with traditional-yet-flexible Thai views of bodies, spirits, families, powers and places. The practices that bring these all together constitute choreography, Stonington's word for a work performed by many persons trying to meet complicated and sometimes incompatible expectations. While it is accepted by medical practitioners that medicalised dying requires tinkering, timing and following a script once someone is ready for ‘end-of-life care’, the ways this can happen are dependent on factors and forces far beyond the simply medical. This book reveals how several particular choreographies now are danced in one geographical, cultural and religious setting. The importance of this choreography is his central theme.
Stonington is an expert observer and vivid storyteller. In chapter 1, ‘Paying the debt of life’, he introduces readers to patients and their families where certain principles dominate actions. Chai nī, ‘the debt of life’, is what all offspring owe their parents, and this requires maximum effort to sustain and prolong the lives of those to whom one owes life. This debt brings the very sick a trip to the hospital, where the ICU and its machines await. The purpose is not cure, but to repay familial debt. The family must help to keep up the sick person's life-energy, kamlang čhai. This goal also requires that patients never learn their diagnosis or prognosis; this knowledge would depress and weaken them. Then, when the family decides this phase is over, it is time to rush the patient home to die.
In chapter 2, the ‘spirit ambulance’ of the title can be the back of a truck, but the patient must still be breathing and so have their spirit present as they ride back home. Thai understandings of body, spirit and what constitutes personhood are introduced, yet what matters too is place. Home is the ideal peaceful death-place. This sounds familiar, but not because the patient wanted to return home and their wishes are now honoured; that would be a Western and particularly American understanding based on an ideal of autonomy. Home is best because of the sacred power of one's own things, one's own family, and the good thoughts and mental peace these bring. A good state of mind is what matters most in dying there.
A short account of the tragic and unhappy dying of the famous monk Buddhadasa precedes chapter 3. Buddhadasa had wished no mechanical interventions or prolonged treatments, but received both at the final weeks of his life. The impact of this important person's dying-gone-awry turned many Thais toward a close questioning of their own traditional practices. Maybe the days before one's death had a radically transformative purpose for a wise individual, a difference that required knowledge of one's disease and terminal prognosis. For the persons who chose this path, even medications for pain would be an obstacle to facing reality and embracing the fullness of the present moment. Thus, a pattern labelled ‘the new end-of-life’ emerged. Stonington's next chapter amplifies the meaning of this phrase which significantly enough is often kept in English when used by Thais. This new way bears a superficial resemblance to Western ideals of ‘conscious dying’, and both can claim some relationship with Buddhism. But the new end-of-life is basically for those with a ‘high level of mind’ (p. 114) who are advanced in meditation and wisdom. These are individuals who can not only face the truth of their own dying, but can face and befriend their tumours, failed organs, and especially their physical pain. While Western-based ideas of ‘patient's rights’ are posted on the walls of hospital rooms, inspiration for this changed approach to dying came from a spiritual and elitist understanding of ‘becoming human’ (pp. 116ff.).
The picture of human personhood is even more complex and choreographed than this, as Stonington discusses the concept of ‘karma masters’ in the final chapter. A disease, an injury, is not an arbitrary misfortune; it is connected to a person's actions in this and past lives. One must befriend and forgive this entity, for example, a tumour. It is both you and not-you, a view that draws on a flexible and fuzzy-bordered sense of self. Stonington, who is both a medical doctor and a trained anthropologist, tries to present this enigmatic portrayal of persons whose bodies are both their own, and inclusive of alien residents.
To summarise, Stonington has succeeded in writing a fine ethnographic description of Thai people's practices with regard to dying. His discussion reveals the inadequacy of any simple contrast between supposedly traditional vs modern practices, and he is just as skilled in questioning the language and assumptions of biomedicine and its conventional ethical framework. Concepts that appear secular and Enlightenment-based, such as the idea of patients’ rights, are neither universal nor necessary in order to choreograph a person's dying ethically. This process works within an enmeshed landscape of relationships, objects and persons. With his image of ‘choreography’, Stonington shows humans actively at work creating and negotiating a coherent medical, social and spiritual world.
