The Useless Tree

It's not Zen, it's Taoism

Atul Gawande has a beautiful piece in last week's New Yorker on hospice care and end of life issues.  Having had end of life experiences in recent years with my son, my mother and my aunt, it really hit home for me.  But I found myself pressing back when I read these sentences:

Like many people, I had believed that hospice care hastens death, because patients forgo hospital treatments and are allowed high-dose narcotics to combat pain. But studies suggest otherwise. In one, researchers followed 4,493 Medicare patients with either terminal cancer or congestive heart failure. They found no difference in survival time between hospice and non-hospice patients with breast cancer, prostate cancer, and colon cancer. Curiously, hospice care seemed to extend survival for some patients; those with pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months. The lesson seems almost Zen: you live longer only when you stop trying to live longer...

It is probably a small thing, I know: Zen is Likely a combination of Buddhist and Taoist ideas and practices, so Gawande is not far off the mark.  But there are some great Taoist references for the idea his is offering here.  Take, for instance, passage 50 of the Tao Te Ching:

People born into life enter death.

Constant companion in life and in death, this body is the kill-site animating their lives.  And isn't that because they think life is the fullness of life?

I've heard those who encompass the whole of life could walk on and on without meeting rhinoceros or tiger, could charge into armies without feeling shield or sword.  A rhinoceros would find nowhere to gore them, a tiger nowhere to claw them, a sword nowhere to slice them.

And isn't that because for them there's no kill-site?

This is Hinton's translation, and I know there will be those who take issue with it (where is the reference to "three in ten"? - see Chinese text and alternate translation here).  But he gets at the basic idea here, which is a bit complicated.

There is a bit of ambiguity here. At first the "kill-site" (i.e. the thing that we worry about and which can ultimately bring about our death) of our body is our constant companion because we "think life is the fullness of life."  That is, we worry about the distinction between life and death, the boundary between animation and non-being.  But toward the end of the passage we learn that if we simply focus on living in the present, "encompass the whole of life," we can get away from the anxieties of death, in effect have no "kill site."   The ambiguity arises in the contrast of "think life is the fullness of life" and "encompass the whole of life."  They seem rather similar.  The Legge translation, and others, draw a clearer line between "excessive endeavors to perpetuate life" and "he who is skillful in managing the life entrusted to him."  The classical Chinese is difficult, but Legge lets us see the main point, which is essentially Gawande's.

And that is: if we fight to hold on to life, we will lose it; but if we just give ourselves over to the natural unfolding of life then there is no "kill-site;" we will live serenely to the end of our days and melt back into Way without injury from rhinoceros or tiger or sword. 

Perhaps that is what hospice allows us to accomplish.

Growing old well

NPR's Barbara Bradley Hagerty writes (and speaks) a tribute to Fred Stocking, a man who taught at Williams College for over forty years.  Living and working here for the past twenty years, I came to know Fred mostly by reputation, and by sight: he was a common presence at College functions and around town.  He clearly inspired Hagerty, and many, many other students over the years.

This part of Hagerty's lovely piece resonated with me most:

As for me, Fred's letters became a road map for growing old well. He began painting at 80, taking lessons every Tuesday. At 91, he played Gonzalo in The Tempest at the community theater. When his body began to fail, he watched the process with a sort of bemused detachment. "I've had a lot of horizontal time," he quipped in one letter. At his 94th-birthday party, Fred demonstrated his new motorized stair chair lift by waving like the Queen as he purred up and down the stairs. Later, with far more gusto than any 94-year-old should have possessed — and with uncanny timing — Fred belted out his trademark song from Broadway, "Lulu's Back In Town."

That acceptance of aging, that "bemused detachment," has a Taoist ring to it, which becomes even more pronounced in the next paragraph:

As Fred's body shut down, he leaned all the more on his mind. It was a sort of tit for tat with age. You take away my driver's license; I'll read the new biography of Shakespeare. You dim my vision; I'll listen to books on tape. He was ecstatic when his wife gave him a new translation of War and Peace. He was 92 when I sent him an early draft of my book Fingerprints of God: The Search for the Science of Spirituality. A year later, he sent back a seven-page critique, musing on the limits of scientific inquiry, the flaws of religious doctrine and the nature of death.

The tit for tat response to changing circumstance, even in the face of demise and  ultimately death, brings Zhuangzi to mind.  When one character in that book is asked if he resented his own physical deterioration and impending death he replies:

"No, why should I resent it?" replied Adept Cart.  "If my left arm's transformed into a rooster, I'll just go looking for night's end.  If my right arm's transformed into a crossbow, I'll just go looking for owls to roast.  And if my butt's transformed into a pair of wheels and my spirit's transformed into a horse, I'll just ride away!  I'd never need a cart again. (92)

Sounds rather like Fred, and like a good approach to growing old well...

Assisted Suicide

    This past Sunday, the NYT Magazine ran a piece on assisted suicide.  As I started to read it, I thought it conjured up certain Confucian themes, but by the time I had finished it, I was definitely thinking more in Taoist terms.

    The Confucian resonances come from the basic outlines of a story: a father with Parkinson's disease works to create a law in Washington state, where he had served as governor, that will allow for assisted suicide.  He is inspired by his own gradual demise and by a broader vision that would allow people to have control over their end of life circumstances.  His son, a devout Christian, opposes him on religious grounds.  Their relationship is strained by the father's history of not spending much time with his children as they were growing up but now expecting the son to play a certain role in this his final campaign.

      The Confucian question to ask is: should the son's obligation to his father trump his religious beliefs in this case?  Should the son help the father die, even if it violates his more general moral code? 

     Personally, I think the Confucian expectation of filial duty is not automatic and all encompassing.  Sons are not expected to do anything at all that their fathers tell them to do.   Although sons might be expected to shield fathers from legal actions in some cases (i.e. sheep stealing), sons should not act inhumanely at the command of the father.  If a father told a son to kill someone, Confucius would not expect the son to automatically comply.

     Assisted suicide is a bit murkier, however, since the father might be understood to have a certain privilege in determining his own life's conditions.  But - and this is a very important but - the father is not wholly autonomous.  No one is wholly autonomous in a Confucian world. A father is embedded in a web of social relationships and vital members of that network not only determine the quality of a father's life but should also have a voice in any discussions about the voluntary death of the father.  Fathers may be due a certain respect, but they do not exist outside the practices that define Humanity.

     These Confucian issues fell by the wayside, however, as I read passages like this one:

Gardner [the father] wants death but won’t acquiesce to his disease. The drugs that are prescribed, like the electricity, to mitigate his symptoms are kept and meted out by his assistant. When Gardner kept them himself he took far more than was recommended. He couldn’t bear the shuffling, the stiffness “like the Tin Man in ‘The Wizard of Oz,’ ” the stumbling; “it does not fit with my concept of who I am.” He swallowed as many pills as he needed to fit his concept....

 He is driven by an idea of himself, an image in his mind of what he thinks he ought to be.  Instead of looking and embracing what he is, he drowns in frustrations over what he is not or what he is no longer.  The pursuit of an idealized self has become the rationale for the death of the actual self.  His self motto is: "My life, my death, my control."  As if any of us really controls the conditions of our own lives.

     My experience with Aidan floods back to me at moments like this.  He taught me about not having control, about relinquishing the idealized self, about embracing the actual conditions of the moment.  And he taught me that through my reflections on Taoism.

     The Tao Te Ching (22) comes to mind when thinking of the father who demand control over his own life and death:

In yielding is completion.
In bent is straight.
In hollow is full.
In exhaustion is renewal
In little is contentment.
In much is confusion.

This is how a sage embraces primal unity
As the measure of all beneath heaven.

Give up self-reflection
and you're soon enlightened.
Give up self-definition
and you're soon apparent.
Give up self-promotion
and you're soon proverbial.
Give up self-esteem
and you're soon perennial.
Simply give up contention
and soon nothing in all beneath heaven contends with you.

It was hardly empty talk
when the ancients declared in yielding is completion.
Once you have perfected completion
you've returned home to it all.

     Taoism could accept assisted suicide if it was the path of least resistance, the natural next move of "nothing's own doing" (wu wei) but not in the pursuit of "My life, my death, my control."

Euthanasia in China

     A sad story in the LA Times yesterday about a severely disabled woman in China who is asserting a right to die:

Confined to a rusty wheelchair and unable to control her muscles below her neck, Li Yan seemed destined for nothing more than a short life of pain and hopelessness.

Instead, the 29-year-old with muscular dystrophy has been catapulted into the center of an ethical debate. Li, fearing that her disease eventually will leave her in a helpless state, used her blog in March to ask the National People's Congress to legalize her right to die.

"I don't want to live with my brothers and sisters-in-law after my parents' death, let alone go to an orphanage or welfare institute," wrote Li, a rosy-cheeked woman with plump lips who can't keep from breaking into a smile even when discussing her most morbid wishes.

     The article points out that public opinion in China seems to be overwhelmingly in favor of euthanasia in this sort of case, where an individual is making a well-informed and rational decision about her own life.  What is interesting to me is the lack of philosophical support for the pro-euthanasia position in the classical texts of Confucianism and Taoism.

     Confucianism would tolerate euthanasia, but the decision-making process would be of the utmost importance.  For a Confucian, individual preference would not be sufficient grounds for such an action.  That is, the afflicted individual would not be recognized as fully autonomous and independent to decide whether to live or die.  Such a decision would have to include those people closest to the person wanting to die.  Thus, if the parents of the individual opposed euthanasia, then an active move to assist in the death of that individual would not be allowed.  Siblings, spouses, children and perhaps other close acquaintances might also have a certain moral standing in the decision-making process.  We are, in a Confucian perspective, social beings and thus determinations about the beginning or end of our lives must be made in social settings.

     Taoism would be less tolerant of the idea of euthanasia.  The distinction of "letting die" and "causing death" is key here.  Taoism, with its "do nothing" sensibility, would have no trouble refusing medical care and thus letting an individual who had a terminal illness succumb and die.  But a more active intervention that would cause death before it was "naturally" present would be resisted by Taoists: too much "doing".    Indeed, the very end of the Times story has a Taoist ring to it: although the disabled woman suffers in certain ways, there is a broader meaning and significance to her life:

Despite the outpouring of support, Li still says she'll dedicate what time she has left with her faculties intact to gaining the right to end her life.

On a recent afternoon, she signed on to her online instant messaging service linking her to 300 friends. A month ago, she had 15. Her sign-on name is a line from a Chinese poem:

"The fragrance of a plum flower is conceived in the bitter cold."

Its message: To suffer is to grow.

"I feel really close to this idea," Li said.

 That reminds me of a line from Confucius:

The Master said: "Only after the seasons turn cold can we truly know the resolve of pine and cypress." (9.28).

      That might not be sufficient solace for Li Yan, but it suggests that she has her place, as valuable as any other place, in Way.

Buddhism and Death

     I must preface this post by saying I do not know all that much about Buddhism.  In recent years, I have been spending time learning what I can about pre-Qin Chinese thought, a historical period well before Buddhism entered China.  So, I offer the ideas below in the hopes that any readers who understand or practice Buddhism might comment and correct me if I am wrong.

    This story was on the front page of today's Boston Globe:

After Buddhist dies, legal battle continues
Kin, hospital  split on when  death occurs

The family of 72-year-old Cho Fook Cheng of Brookline knew there was no chance that he would ever wake  up again.

Last week, doctors declared Cheng, a grandfather of seven who suffered cardiac arrest the day after Thanksgiving, brain-dead and said it was time to remove him from the ventilators and intravenous medicines keeping his organs functioning.

But the family refused to let doctors take Cheng off the life-support system because his heart was still beating. They said their belief as Buddhists was that Cheng's beating heart meant his spirit and consciousness was not ready to move on. Taking him off life support, they said, would be the same as killing him.

The Chengs hired a lawyer and obtained a restraining order against the hospital; Beth Israel Deaconness Medical Center Friday took Cho Cheng's wife, Joyce, and his son, Henry, to court to get an order allowing doctors to remove life-support systems.

    First, let me say that I have every sympathy with the Chengs.  I know well just how difficult it is to face the death of a loved one, and how agonizing end of life decisions can be.  Their desire to keep their father alive is completely understandable.  The story continues: ultimately the Chengs agreed to cut back his medications and he died.  The legal battle goes on, however, as the Chengs are bringing actions (not well specified in the article) against the hospital.

     What baffles me is the invocation of Buddhist principles here.  Further on in the story we have this:

One complication is that there are different Buddhist understandings of death, said John J. Makransky, a professor of Buddhism at Boston College.

"Tibetan Buddhism is the one that is the most renowned for the understanding of death," he said. "Within the Tibetan Buddhist system, there are different levels of consciousness, levels that may not be measured by scientific methods. Even if someone is brain-dead, there may be a level of consciousness communicated by the heart beating. Even if there is no measurable activity in the brain, there still could be consciousness."

While Buddhism is not a centralized religion, all Buddhists believe in rebirth, said Makransky, when consciousness becomes associated with another life after it leaves that body. For such a spiritual achievement, a peaceful state of mind in death is important to the Chengs in their Taiwanese form of Buddhism, Jing Tao Chung, Unitt said.

    As I suggested before, I have no good basis upon which to judge these assertions, though it is certainly reasonable to expect that there are diverse Buddhist positions on these kinds of questions.  And, again, I do not doubt the Chengs sincerity.  But, in this case, the "beating heart" and the "consciousness" of Mr. Cheng were the result of "artificial" means of life support.  It would seem, to me, that it was reasonable to turn off the ventilator and stop his medications, even in terms of Buddhist understandings.

    I would imagine that, for Buddhists (and here is where I could be getting onto thin ice), a "natural death" would be one that did not depend upon IVs and ventilators.  This, of course, would not preclude Buddhists from pursing "extraordinary" or "heroic" care.  Rather, it would presumably mean that withdrawing such measures would be acceptable under the kinds of circumstances the Chengs faced.  After all, discontinuing artificial means would bring an individual closer to his or her "natural" state and that is when a determination of consciousness would be possible.

    My own views are now colored by Taoism and Confucianism.  In this case, Taoists - or, I should say, Taoists who are influenced by Chuang Tzu's notions about the end of life - would accept the withdrawal of extraordinary measures.  Confucians might disagree, wanting to make sure, as the Cheng's were trying to do, that the honor and dignity of the family member were respected.  Again, in this case, given the imminent deterioration of Mr. Cheng's body, I think Confucians might also agree that the time was right to turn off the ventilator. 

      Of course, for any particular case, these sorts of general theoretical understandings might be very hard to apply.  The Chengs were trying to make sure their father was respected - and we all must respect that.

    But, I wonder if they were acting more on Confucian impulses than Buddhist tenets. 

    I look forward to comments from readers who might add to these considerations.

Do Not Resuscitate

    A long piece today in the NYT on end of life issues, specifically the questions that surround whether or not to establish "do not resuscitate" (DNR) orders for terminally ill patients. 

    These are difficult issues, with which I have had some experience.  There are no clear criteria for determining how far to push medical care or when to stop and accept palliation.  But I think we need to be more open, in general, to accepting death when it is near.  The article is helpful in pointing out the distorted view of "heroic" measures that people might get from TV:

Many doctors believe that their medical judgment about whether CPR will be effective in a given patient’s case, and their knowledge of the havoc it can wreak on a dying body, should prevail. But a patient’s representative, who is often a relative, may believe that every medical option should be exercised and that a miracle could be just a chest compression away. And patients’ families, spurred on by TV medical dramas, often mistakenly believe that CPR is almost always effective — a notion emphatically disproved by studies.

...

The widespread misunderstanding about CPR itself can make a family’s agony worse. The technique, which has been an accepted medical procedure for about 40 years, can be successful in patients who have a sudden, unexpected heart attack or severe respiratory distress. But it was not intended to be used routinely for very sick patients, for whom cardiac arrest is expected. Some studies show that the long-term survival for hospitalized patients given CPR is about 15 percent; some find even smaller percentages. But according to a 1996 article in The New England Journal of Medicine, the long-term survival rate on TV medical dramas for patients given CPR was 67 percent.

    This is important information.  CPR does not work most of the time.  Of course, we should know how the cited studies define "long-term."  It might be true that a week or two or a month more life is really quite valuable to some.  But we need to puncture the dominant myth that we can revive just about anyone.  We can't.  Indeed, when you factor in the broken ribs that an aggressive CPR assault can inflict on an elderly body, an attempted resuscitation could leave a person with more pain, rather than less.

     This is not to say that doctors are always right.  They have a certain perspective, which must be part of the deliberations, but family members must also be centrally involved.  What is needed is both an understanding of the medical possibilities and a sense of the person in his or her social context.  At the family end of things there has to be, at some point, an acceptance that a life has been fully lived and further medical intervention will not make that life better.

      Another point that emerges from the story is that law, which demands clear and precise definitions consistently applied, is not a good medium for working out agonizing end of life issues:

“The black and white of the law has significant limitations in the emotional gray area of decision making around serious illness and dying,” said William H. Colby, a lawyer who represented the family of Nancy Cruzan, a patient in a vegetative state whose parents won the right to refuse medical treatment for her.

  We don't have to agree with all of the implications of the Cruzan case to see the wisdom of Colby's point.  These are not each decisions and they cannot be dictated by ideology or legalisms.

     Rather, we must anticipate facing these kinds of quandaries and cultivate in ourselves a sensibility that weighs the impulse to save a life against the necessity of accepting the end of a life.  Chuang Tzu can help us toward that understanding:

Birth and death, living and dead, failure and success, poverty and wealth, honor and dishonor, slander and praise, hunger and thirst, hot and cold - such are the transformations of this world, the movements of its inevitable nature.  They keep vanishing into one another before our very eyes, day in and day out, but we'll never calibrate what drives them.  So how can they steal our serenity...?  If you let them move together, at ease and serene, you'll never lose your joy.  And if you do this without pause, day in and day out, you'll invest all things with spring.  Then, mingling it all together, you'll bring seasons alive in the mind.

     Maybe that is how we should think about end of life questions...

Baby MB: A Good Outcome

    Before Aidan got sick for the last time, I had blogged about the case of Baby MB, an 18-month-old boy in Britain with severe, and most likely fatal, disabilities.  The national health service wanted to discontinue his care, seeing his life as "intolerable," while his parents fought to keep him on a respirator and maintain his life for the months he had left before his affliction took his life.

    I had argued, on Confucian grounds, that the parent's view should prevail.  From this point of view, the loving context provided by the parents should be understood as a key element, perhaps the defining element, of Baby MB's "quality of life."   

    While we were in the hospital, it turns out that the parents have won the court case and will be able to keep Baby MB alive for some time longer.  The judge made recommendations that could amount to a "do not resuscitate" order, which sounds right to me.  But, more importantly, he recognized the importance of the parents' love and care.  I will post an excerpt from the judge's decision below, which echoes what Confucius might have said: "Cherish the young."

Baby MB and the Social Context of Human Life

    In Britain a difficult ethical case is unfolding, involving a profoundly disabled 17-month old child, Baby MB.  It seems the child was born prematurely with a terribly debilitating condition:

The boy, who can be named only as MB, suffers from spinal muscular atrophy - an incurable and progressively worsening condition that leads to complete paralysis.

The court heard that he cannot breathe for himself, cannot chew or swallow, is fed through a tube and, though he is not impaired mentally, can move only his eyebrows, feet and fingers, and these very slightly.

 His parents want to keep him alive, while doctors have gone to court to discontinue his care, turning off his respirator which will likely lead to his death very quickly.  The doctors contend that he is living an "intolerable life," and the parents argue that his life is "reasonable" and care should be continued.   They are due to give testimony in the case soon.

    The arguments seem to be focusing on how to define the "quality of life," and who should define it.  It is a question that a combination of Taoism and Confucianism can speak to, perhaps in ways that have not yet come up in this case.

   From Taoism we can take the notion that no one life is any more or any less valuable than any other.  Each thing, each person, whether disabled or abled, has a certain integrity (Te) in and of itself, and the integrities of all things together are equally a part of Tao: "all things move as one and the same."  If that is true, then there is no exogenous standard of "quality of life" that can be used as a universal measure in such cases.  Baby MB's quality of life will be the quality of the unfolding of his particular integrity.  That will be different than mine, but no worse or better than mine.

    Some might argue that physical pain might render the unfolding of some individual lives "intolerable."  That may be true, even for a philosophic Taoist - who would be quite willing to let go when a life is at an end - but it is not demonstrated in this case.  The doctor's agree that they cannot know what Baby MB is experiencing:

The doctor said it was impossible to say whether or not there were occasions when the boy was getting some enjoyment out of his life because there was no means of properly assessing it.

    If we add in here Taoism's general disdain for human-created "knowledge" that moves us away from an open-minded apprehension of Tao, then we should reject the expert assessment that the baby's life is somehow "intolerable."  It simply cannot be known.

    What is to be done, then?  Enter Confucianism, which would understand the value of the child's life within its social context.  A Confucian (and by this I mean a modern day Confucian embedded in an already-existing moral-legal universe of liberalism where individual rights are assumed and protected) would point out that if the parents are willing to do the loving daily work of care for the child, then that work invests both the child's life and the parents lives with a potential for Humanity that ought to be allowed.  "Quality of life," from this point of view is not a static state, it is something to be realized in the routine performance of our social duties.  By caring for their child, the parents are creating a loving and supportive and beautiful quality of life for him and themselves.  Why not let that happen?

    Confucians would reject cost as a criteria for making a decision, something that may be lurking in the margins of this case.  But it may be that allowing the parents to care for the child could also be cost effective.  If, as the parents want, a tracheotomy is done (a hole in the throat where a tube is inserted into the wind pipe to facilitate breathing) the respirator may be more manageable and the child may be able to be cared for in a home setting.  A trach is not that big a deal actually (my son, Aidan has one; I clean it twice a day).  Why not make that the goal?

    I will say, however, that I see a difference between continuing certain kinds of care, especially if the parents are committed to participating in it, and launching "heroic measures" should the child's heart stop.  Baby MB is obviously in a life-threatening condition, he is flirting with death.  If this is a degenerative condition, it is close to certain that he will die very young.  That is hard to take for the parents, but a line will need to be drawn.  A "do not resuscitate" (DNR) order would seem to be reasonable to me.  Such orders can be targeted very specifically such that cardiac arrest should not be treated but, perhaps, pneumonia should. 

    In short, the parents should decide, and be a part of, Baby MB's "quality of life," the medical establishment should facilitate his care, but a line should be drawn that recognizes death when it occurs with a DNR order.