By Arnav Sankaranthi, March 2020.
Due to the current coronavirus pandemic, many are dying and many fear that they will die. Can mindfulness of death help calm the American public during times of medical crises? Can it help us cope with loss? Most importantly, can it help doctors on-call to be more empathetic, compassionate, and humane during times of crises as well as times of serenity? These questions have been brought up and discussed by doctors, medical humanities researchers, and sati-practicing Buddhists. In their textbook, Medical Humanities: An Introduction, Cole, Carlin, and Carson introduce the reader to the field of medical humanities and its main goals. In his memoir, When Breath Becomes Air, neurosurgeon-scientist Dr. Paul Kalanithi shares his experience wrestling with the profoundly human question: “what makes life meaningful to live even in the face of death?” Mindfulness teachers and researchers like Nikki Mirghafori and Jon Kabat-Zinn show that mindfulness can be a way to explore these questions and turn our attention toward them. The perspectives of these sources, when put into conversation, reveal that integrating mindfulness of death in medical schools may result in more compassionate physicians.
In the medical field, there has been a sincere call for doctors to be more empathetic towards patients. In their textbook on medical humanities, Cole, Carlin, and Carson outlined the problem of physicians struggling with dehumanizing behaviors. These behaviors have resulted from the commercialization of the healthcare system, a focus on expensive technologies, and conflicts-of interest with pharmaceutical and biotech companies. Indeed, patients have indicated that they feel a lack of listening to their concerns, and instead, a keenness to interpret diagnostic data from machines (10). Dr. Paul Kalanithi, reflecting on his anatomy instruction in medical school, reveals that medical students often “objectified the dead, literally reducing them to organs, tissues, nerves, muscles” (Kalanithi 49). He later notes that, “seeing the body as matter and mechanism is the flip side to easing the most profound human suffering” (49). He himself feared he “was on the way to becoming Tolstoy’s stereotype of a doctor, preoccupied with empty formalism, focused on the rote treatment of disease—and utterly missing the larger human significance, … the singular importance of human relationships … between doctor and patient” (85, 86). Despite this, it is still possible to make sense of death and malady without medical reductionism, and Kalanithi affirms this ideal in his memoir. In response to the biomedical reductionism prominent in healthcare, Cole and colleagues also state that reducing medicine to a mere biological or pathophysiological approach is ineffective in addressing the holistic and human experiences physicians face day by day. In doing so, they note a conceptual shift in the field of medical humanities towards seeing patients in the full context of their experiences (Cole et. al. 8).
One sign of this shift is a growing awareness of the distinction between disease and illness, with disease being “what happens to the body” and illness being “what the person experiences” (Cole et. al. 9). In order to understand illness, the authors argue, the physician must ask the right questions to bring out patients’ stories and converse with them, so as to produce an “emotional and spiritual healing, whether or not physical curing … is possible” (Cole et. al. 10). Dr. Kalanithi realized that there will be points in his practice where a patient’s death cannot be deferred any longer, so he made it his ultimate goal to “[guide] a patient or family to an understanding of death or illness” and “work until they can stand back up and face, and make sense of, their own existence” (Kalanithi 86, 166). However, Dr. Kalanithi acknowledged that he had failed at empathy, recalling the many occasions where he “had pushed discharge over patient worries, ignored patients’ pain when other demands pressed” (85). Initially, he had thought that being in charge of life-and-death decisions as a physician would “grant [him] not merely a stage for compassionate action but an elevation of [his] own being … to the heart of the matter” (81). But he soon realized that “being so close to the fiery light of such moments only blinded [him] to their nature,” and he conceded that, “[he] was not yet with patients in their pivotal moments, [he] was merely at those pivotal moments” (81).
In reality, the only way to truly connect to the experiences of a patient is to feel those same pains. And Kalanithi did. Before the end of his medical residency, he was diagnosed with stage four lung cancer -- a terminal illness. Kalanithi proclaims this: “Like my own patients, I had to face my mortality and try to understand what made my life worth living” (139). Unlike Kalanithi, many physicians are not in the kind of position that allows them to view death and disease as both a doctor and a patient. Therefore, the closest alternative to experiencing the imminence of death firsthand is to be mindful of death rather than being passive to it.
Mindfulness of death practice, called maranasati in the Theravada tradition, is practiced by Buddhists worldwide. One Buddhist teacher, Nikki Mirghafori teaches on the mindfulness of death in a podcast episode called “The Profound Upsides of Mortality.” She describes disease and death as her teacher, sharing that it gives life meaning and shows people how precious life is. In her podcast episode on Ten Percent Happier with Dan Harris, Mirghafori counsels to “keep death on your shoulder as a wise advisor” (1:04:55-1:05:05). Most people, she says, don’t live their lives with an awareness that they are going to die. She cites the Terror Management Theory, which states that the human ego can’t understand its death, so it finds ways to avert our thoughts from this subject (48:30-49:30). Mirghafori recommends using discursive thought by repeating and internalizing the fact that “this could be my last breath” (42:00-43:00). Practicing daily mantras such as “I am subject to aging, illness, effects of actions, and death; I have not gone beyond these things,” “Everything that is loved and is dear to me will become separated from me,” and “our lives are for rent” can help one to comprehend death (58:20-59:30). A sense of terror will arise that will help one’s mortality to register. Ultimately, these mantras can help people to make peace of dying. Another approach to the mindfulness of death goes back to the time of the Buddha. In Buddha’s time, charnel grounds, where bodies of the dead lay to decompose, were commonly found. In those days, followers of Buddha would meditate and focus on the decomposition of the body to grasp the reality of death (54:30-57:00). Since charnel grounds are uncommon in modern day, medical students or physicians who wish to practice mindfulness of death could do something similar at a cadaver lab.
Mirghafori explains that these mindfulness of death methods have many benefits. First, this practice can help us align our life with our values, when we understand that our time on earth is finite and each moment is valuable. Additionally, when we feel more comfortable with our own mortality and don’t fear death, it’s helpful for our loved ones when we pass, and it can also help us to maintain composure when someone we know perishes. Furthermore, awareness of death can bring a feeling of gratitude for being alive (1:01-1:18).
These practices can bring physicians close to how it feels to be a patient who may face death soon. Consequently, it can enable doctors to better identify with and commiserate the reality that patients undergo. In their textbook, Cole, Carlin, and Carson state that medical humanities seeks to develop key values of medicine through the use of “reflective, interpretive, and reflexive practices” (Cole et. al. 10). Perhaps mindfulness of death can be one such practice implemented to produce “compassionate and humane caregivers operating realistically under the modern pressures of medicine” (10). Dr. Kalanithi states that after “cancer had changed the calculus,” he viewed his responsibility over patients as temporary, yet still having the effect to “ease the mind … [and] ease a disease of the brain” (Kalanithi 164,166). Being mindful of death allowed Kalanithi to understand that, as a physician, his words can be used to bring families assurance and make sense of death and sickness (166). Currently, mindfulness is getting integrated in many medical school programs. Dr. Ron Epstein of the University of Rochester School of Medicine emphasizes the need for physicians to “[self-reflect], … listen attentively to their patients distress, recognize their own errors, refine their technical skills, make evidence-based decisions, and clarify their values” (Kabat-Zinn 229). He and his colleagues created a mindful communication program for primary care physicians that was shown to “reduce physician burnout, … depersonalization ([treating] patients as objects), and low sense of accomplishment,” and “‘was associated with short-term and sustained improvements in well being and attitudes associated with patient-centered care’” (Kabat-Zinn 229, 230). Not only can mindfulness of death help patients make sense of their disorders, but it can also help physicians to cope with loss. For instance, Dr. Kalanithi had heard that his fellow neurosurgeon and friend Jeff had jumped off a building after his patient died due to a difficult complication. In his memoir, Kalanithi says that doctors “assume the onerous yoke … of mortal responsibility” (Kalanithi 114). If Jeff had been more mindful of death, perhaps he could have avoided trying to end his life.
Mindfulness of death practices have a great potential to help physicians become more altruistic, empathetic, compassionate, ethical, and accepting. If incorporated in medical humanities curricula in medical schools, it will be powerfully beneficial. The texts discussed above point to the need for a larger conversation about bringing mindful practices into medical schools to train aspiring physicians’ hearts as well as their minds. From simple informal practices to formal regimens, mindfulness shows promise as a tool that can benefit the entire medical community, extending beyond the physician-patient relationship to the families, nurses, specialists, and scientists contributing to healthcare.
Works Cited
Cole, Thomas R., et al. Medical Humanities: An Introduction. Cambridge University Press, 2019.
Harris, Dan, host. “The Profound Upsides of Mortality.” Ten Percent Happier with Dan Harris, Apple Podcasts, 28 December 2019.
Kabat-Zinn, Jon. Full Catastrophe Living: Using The Wisdom Of Your Body And Mind To Face Stress, Pain, And Illness. Bantam Dell, 2013.
Kalanithi, Paul, and A. Verghese. When Breath Becomes Air. Random House, 2016.