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If you have any friends or family members who are sick or dying, I know of no one who would tell you to treat them in a hardhearted way. Everyone would agree that you should be as compassionate as you can. The problem is that there's little agreement on how compassion translates into specific actions. For some people, compassion means extending life as long as possible; for others it means terminating life — through assisted suicide or euthanasia — when quality of life falls below a certain level. And neither of these two groups sees the other as compassionate at all. The first sees the second as criminal; the second sees the first as heartless and cruel.
For those of us trying to negotiate the murky territory between these two extremes, there's not much reliable guidance. Ours is a culture that doesn't like to think about illness and death, and as a result, when faced with someone who's sick or dying, we're at a loss as to what to do. Some people will advise you simply to do what feels right, but feelings have a way of turning slippery and devious. Some things feel right simply because they make you feel good, regardless of whether they're genuinely right for the other person. A desire to extend life may mask a deeper fear of your own death; a desire to terminate a miserable illness may rationalize your distress at having to witness suffering. Even if you're told to act from a place of mindful presence, you may find that what seem to be your spontaneous inspirations are actually conditioned by hidden, unexamined assumptions about what life and death are all about.
This is why the simple injunction to be compassionate or mindful in the presence of a sick or dying person isn't enough. We need help in educating our compassion: specific advice on how to think through the implications of our actions in the face of life and death, and specific examples of how people who have contemplated these issues thoroughly have actually acted in the past.
With this thought in mind, I searched through the Pali canon — the oldest extant record of the Buddha's teachings — to see what lessons could be drawn from the Buddha's example. After all, the Buddha often referred to himself as a doctor, and to his Dharma as medicine for the sufferings of the world. From his point of view, we're all sick and dying on a subtle level, so we all deserve continual compassion. But what sort of advice did this doctor give when face-to-face with the flesh and blood suffering of illness and death? How did he treat people who were physically sick or dying?
You probably know the story of how, together with Ven. Ananda, he once found an unattended sick monk lying in his own filth. After washing the monk, he assembled the other monks, chided them for abandoning their brother, and gave them strong incentive to follow his example: “Whoever would tend to me,” he said, “should tend to the sick.” He arranged that monks nursing their fellow monks should receive special allotments of food, to encourage them in their work and help lighten their burden. But he didn't subscribe to the notion that medical treatment should try to extend life at all costs. The Vinaya, his monastic discipline, imposes only a minor penalty on a monk who refuses to care for a fellow monk who is sick or dying, or who totally abandons a sick monk before the latter recovers or dies. And there's no penalty for withholding or discontinuing a specific medical treatment. So the rules convey no message that the failure to keep life going is an offense of any kind. At the same time, though, a monk who deliberately ends the life of a patient, even from compassionate motives, is expelled from the monkhood and can never reordain in this life, so there's no room for euthanasia or assisted suicide.
This means that the middle ground is where true compassion can be exercised. The Buddha sets out some guidelines for this area in his definition of the ideal nurse. You're qualified to tend to the sick if (1) you know how to prepare medicines; (2) you know what's amenable to the patient's cure, taking away whatever's unamenable and providing things that are amenable; (3) you're motivated by compassion and not by material gain; (4) you're not squeamish about cleaning up urine, excrement, saliva, or vomit; and (5) you're competent at encouraging the patient at the proper times with talk on Dharma.
Of these five qualifications, the one most discussed in the Pali canon is the fifth: What qualifies as a helpful and compassionate talk on Dharma to a person who is sick or dying? What doesn't?
Here again, the don'ts mark off the territory for the do's. The Vinaya cites cases where monks tell a sick person to focus his thoughts on dying, in the belief that death would be better than the miserable state of his life. The sick person does as they advise, he dies as a result, and the Buddha expels the monks from the monkhood. Thus, from the Buddha's perspective, encouraging a sick person to relax her grip on life or to give up the will to live would not count as an act of compassion. Instead of trying to ease the patient's transition to death, the Buddha focused on easing his or her insight into suffering and its end.
This is because he regarded every moment of life as an opportunity to practice and benefit from the Dharma. It's a well-known principle in all meditation traditions that a moment's insight into the pain of the present is far more beneficial than viewing the present moment with disgust and placing one's hopes on a better future. This principle applies as much at the end of life as it does anywhere in the middle. In fact, the Buddha encouraged his monks to reflect constantly on the potential imminence of death at every moment, even when in ordinary health, so that they could bring a sense of urgency to their practice and give the present moment their full attention. If you learn to treat all moments as potentially your last, then when your last moment does come you will face it prepared.
Most often, though, a sick or dying person hasn't been living with this sort of urgent alertness, so the first step in advising such a person is to aim at clearing away any emotional obstacles to learning from the present. The Pali texts note two such obstacles: worry over the responsibilities the person is leaving behind, and fear of death. In one poignant discourse, a man appears to be dying and his wife consoles him not to worry: She'll be able to provide for herself and their children in his absence; she won't go looking for another husband; and she'll continue in her practice of the Dharma. With each reassurance she repeats the refrain, “So don't be worried as you die. Death is painful for one who is worried. The Blessed One has warned against being worried at the time of death.” The man recovers unexpectedly and, while still frail, goes to visit the Buddha, telling him of his wife's reassurances. The Buddha comments on how fortunate the man is for having such a wise and sympathetic wife.
As for fear of death, the Buddha notes that one of the primary reasons for this fear is the remembrance of hurtful or cruel things you've done in the past. Thus the Vinaya shows that monks would often console a fellow monk on his deathbed by asking him to call to mind something more positive — his highest meditative attainment — and to focus his thoughts there. In a similar vein, a common practice in Asian Buddhist countries is to remind a dying person of the acts of generosity or virtue he or she has performed in this life. Even if the person is unable to muster the mindfulness and alertness needed to gain further insight into the present, any Dharma talk that helps allay worries and forestall fears is an act of true compassion.
The Buddha comments, however, that there are three additional reasons for fearing death: attachment to the body, attachment to sensual pleasures, and a lack of direct insight into the unconditioned Dharma of the Deathless. His more advanced instructions for sick and dying people thus focus on cutting these reasons for fear at the root. He once visited a sick ward and told the monks there to approach the moment of death mindful and alert. Instead of focusing on whether they would recover, they should observe the movements of the feelings they were experiencing: painful, pleasant, or neutral. Observing a sensation of pain, for instance, they should notice how inconstant it is and then focus on the repeated dissolution of all pains. They could then apply the same focused alertness to pleasant and neutral feelings as well. The steadiness of their focus would give rise to a sense of ease independent of sensory feelings, and from this point of independence they could develop dispassion and relinquishment, both for the body and for feelings of any sort. With relinquishment would come a genuine insight into the Dharma which, being Deathless, would end all fear of death.
On another occasion, Ven. Sariputta visited the famous supporter of the Buddha, Anathapindika, who was on his deathbed. After learning that Anathapindika's disease was worsening, he advised him to train himself: “I won't cling to the eye; my consciousness won't be dependent on the eye. I won't cling to the ear; my consciousness won't be dependent on the ear,” and so forth through all the six senses, their objects, and any mental events dependent on them. Although Anathapindika was unable to develop this independent consciousness in line with Sariputta's instructions, he asked that these instructions be given to other lay people as well, for there would be those who would understand and benefit from them.
Obviously, these recommendations are all shaped by the Buddha's teachings on how the state of one's mind influences the process of death and rebirth, but that doesn't mean that they're appropriate only for those who would call themselves Buddhist. Regardless of your religious beliefs, when you're faced with obvious pain you're bound to see the value of any instructions that show you how to reduce suffering by investigating the pain in and of itself. If you have the strength to follow through with the instructions, you're bound to want to give them a try. And if you encounter the Deathless in the course of your efforts, you're not going to quibble about whether to call it by a Buddhist or non-Buddhist name.
This point is illustrated by another story involving Ven. Sariputta. Visiting an aged brahman on his deathbed, Sariputta reflected that brahmans desire union with Brahma, so he taught the man to develop the four attitudes of a Brahma — infinite good will, compassion, appreciation, and equanimity. After following these instructions, the brahman was reborn as a Brahma after death. The Buddha, however, later chided Sariputta for not teaching the brahman to focus instead on investigating pain, for if he had, the brahman would have experienced nirvana and been freed from rebirth altogether.
What's striking about all these instructions is that, from the Buddha's point of view, deathbed Dharma is no different from Dharma taught to people in ordinary health. The cause of suffering is in every case the same, and the path to the end of suffering is the same as well: comprehend suffering, abandon its cause, realize its cessation, and develop the qualities of mind that lead to its cessation. The only difference is that the obvious proximity of death makes teaching the Dharma both easier and harder — easier in that the patient is freed from extraneous responsibilities and can see clearly the need to understand and gain release from pain; harder in that the patient may be too weakened physically or emotionally, through fear or worry, to put the instructions into practice. But whatever the case, it's worth noting that up to the moment of death the Buddha would have you focus less on the limitations of the situation than on the potential opportunities. Even one moment of insight in the midst of pain and suffering, he said, is worth more than one hundred years of good health.
From my own personal experience — both in watching my teachers implement these instructions and in trying to implement them myself — I've learned two major lessons. One is that the patients best suited for making the most of the Dharma when sick or dying are those who are not tormented with memories of cruel or hurtful things they did in the past, and who have already developed a meditative or contemplative practice prior to their illness. Even if that practice isn't Buddhist, they intuitively respond to the Buddha's message on pain and are able to use it to alleviate their own sufferings. The lesson here is that as long as you know you're going to die someday, it's a good idea to avoid cruel actions and to get started on a meditative practice of your own, so that you'll be prepared for illness and death when they come. As my teacher, Ajaan Fuang, once said, when you meditate you're gaining practice in how to die — how to be mindful and alert, how to endure pain, how to gain control over wayward thoughts and maybe even reach the Deathless — so that when the time comes to die, you'll do it with skill.
The second lesson is that if you want to help other people overcome their fear of death, you have to learn how to overcome your own fear of death as well, by abandoning attachment to the body, abandoning attachment to sensual pleasures, avoiding cruel actions, and gaining direct insight into the Deathless. With your fears overcome, you'll be much more effective in teaching the Dharma to those on their deathbed. You won't be disturbed by the physical horrors of death, you'll be able to communicate directly to the needs of the dying person, and your words will carry more weight, for they come from direct experience. Your compassion will be educated not by books or feelings, but by a clear insight into what dies and what doesn't.
Ultimately, these two lessons boil down to one: Meditate, as an act of compassion both for yourself and for others, even if death seems far away. When the time comes to die, you'll be less of a burden on those who are caring for you. In the meantime, if you're called on to comfort those who are sick or dying, your compassion will be more genuinely helpful, and you'll have a more effective message to teach.