by Sudhir Kakar
‘Death by Sallekhana (santhara) according to spiritual rules,’ writes Justice T.K. Tukol, ‘is the victory of the soul over karmas and consequential infirmities of the mind and body, which worldly existence might have brought into being. It is an act of fulfilment.’72 Or, as Sanjay Metha remarks: ‘The only similarity between sallekhana (santhara) and suicide is death.’73
Kirin’s Case of Escaping the Power of a Ghost through Santhara
Laukik and Lokottar
As we have seen, predominantly elderly people with incurable diseases are taking the vow of santhara. A healthy person or a person that can be cured of its illness is not permitted to take the vow of santhara and thus, very rarely is santhara taken by young people. But how can a decision be taken if it concerns mental health? In the following I will summarize the case of a young woman Kirin who took the vow of santhara to escape a ghost (bhut) she was possessed by. Being possessed by ghosts is a fairly common phenomena in rural India and, interestingly, also very common among Jain nuns.74 The terms laukik, referring to the worldly, and lokottar, to the transcendent realms of the universe, are two realities highly interdependent in the Jain construction of reality. Bhuts—like people—are part of the worldly realm (laukik), while the ascetic, who renounces the world, represents the spiritual realm (lokottar). I am mentioning this here, because it allows us to acknowledge that ghosts (bhut) are considered a ‘true’ reality, highly feared and treated as ‘real beings’ that can ‘do’ things and, in the case of attacking a Jain ascetic, threaten to weaken the boundaries between laukik and lokottar. When a bhut attacks a Jain nun, it can also be interpreted as a symbolic form of experiencing highly conflicting emotions (such as sexual desire), while the nun, at the same time, preserves her moral status since she is not made responsible for the experienced emotions and attacks.75 In other words, even though an attack by a bhut is shameful and highly distressing for the nun, it might be the only way—unconsciously—of channelling desire. This has to be kept in mind when listening to Kirin’s story of possession that tragically ended in death.
Kirin’s Story
Shortly after Kirin joined the order of the Terapanthis as a trainee to become a nun, she began to be tormented by a bhut who claimed to be her lover from a past life. He said Kirin had accidently killed him and he now wanted to be reunited with her, because he still loved her. Thus, he attacked her violently with the aim to kill her before she could be initiated as a nun, because once she is a nun, he claimed, she would be lost to him. He set fire, threw stones and hurt Kirin in different ways, tormenting her for months. The only weapon Kirin had was sadhana (spiritual practice). When she did her spiritual practice, such as meditation or pratikraman (a ritualized confessional prayer), he left her at peace. Kirin anxiously wanted to be initiated as a proper nun, insisting that the bhut will not be able to kill her afterwards. But her urgency was met with apprehension, and she was asked by her superiors to wait to take her diksha (initiation). Kirin, too troubled to wait and convinced that the bhut would soon kill her, started to fast. Once she began her fast, the bhut was unable to reach out to her. Thus, Kirin decided to take santhara in order to escape the powers of the bhut. When she asked her guru for consent, he severely challenged her, but gave his blessings at the end of the meeting. Kirin fasted for forty-five days, only taking a little water. When she was becoming very weak, the order decided to give her the initiation she longed for so much, so she would die as a nun. When Kirin died four days later, cheering crowds accompanied her body to the cremation ground. She became a legend in her locality, representing the victory of asceticism over worldliness, of dispassion over passion.76
Kirin’s battle, which can be interpreted as a discourse of laukik (sexual desires, which Kirin did not even allow herself to feel) and lokottar (her spiritual vow) is a tragic example where the threat to be pulled back into ‘the world’ (samsara) is met by voluntary death. However, Kirin emerged out of a situation with highly conflicting emotions in victory: discipline reigned over desire, detachment over attachment.
When I asked monks and laypeople I interviewed, how a guru (any guru) can take such a huge responsibility on himself to give permission for santhara to any person asking for it, I got repeatedly the rather vague answer that the guru knows and will only give permission to those who are truly ready. As the monk Vimal Sagarji remarks in another context, ‘Whether santhara is a suicide or a holy practice to attain moksha, I feel, is for the person embracing santhara to answer for himself.’77 But how can santhara be justified in a case such as Kirin’s? It is a story, which leaves many questions unanswered.
Concluding Remarks
Jain laypeople, nuns and monks who are taking the vow of santhara are treated with the uttermost respect. They are admired, and often worshipped, such as the nun Vicakshan Shriji (191–280) from Rajasthan, who embraced her suffering of cancer actively by taking the vow of santhara—thus, redefining her involuntary pain as voluntary asceticism.78 In her case shrines and statues of her were established after her death.79 Despite its scope and meaning for the Jain community, legal as well as moral questions have been raised regarding santhara. A debate whether santhara is against Indian law80 was triggered in 2006, when several Jain laywomen in Rajasthan starved themselves publicly to death. Social activists in India criticized santhara as a cruel practice which has no place in modern society. The controversies around the legality of santhara erupted when the lawyers Nikhil Soni and Madhav Mishra filed a Public Interest Ligitation (PIL) in the high court of Rajasthan, claiming that santhara is a form of suicide and thus illegal under Indian law.81 For the Jain community such a claim is regarded as a violation of the Indian Constitution’s guarantee of religious freedom (Article 25 and 2982). This led to a nationwide debate on euthanasia and bioethics, a debate that is still going on.
The moral concerns of social activists regarding the death of Kela Devi Hiravat, a ninety-three-year-old lady, and Vimla Devi, a sixty-one-year-old lady, who took santhara in 2006 and sparked the debate on the legality of santhara, did not find any sympathy among the Jain community. Says Acharya Maha Pragyaji: ‘When millions of people are dying of starvation and require immediate help, no one seemed to be bothered,’ and adds that society is only concerned about the fate of the affluent.83
‘This fasting is not to die, but a festival to face death,’84 says Sudhir Hiravat, the grandson of Kela Devi, who regards his grandmother’s santhara as a victory over death. People participating in the cremation of Kela Devi, wore the most colourful and beautiful dresses, instead of (the white) mourning clothes. The fact that laypeople in Jainism are not only permitted but even summoned to practise santhara is astonishing,85 and shows the importance of santhara as a major concept in Jain soteriology—even if practised only in rare cases by its laity and ascetics.86 The importance of the ritual is reflected in the sheer masses that turn up to celebrate a santhara. Up to 20,000 people came, for example, to the publicly announced santhara,87 of sixty-year-old Sadhvi Charan Pragyaji, a Jain nun who died on 11 September 2009, after an eighty-seven-day fast.88
From an anthropological point of view, taking into consideration the Jain perception of life and death, santhara can be regarded as a rite of passage of birth and death.
It is a ritual that allows us to get a glimpse of a time long past, a cultural heritage and ascetic radicalism that goes back to the times of the Upanishads, and which unfolded over the centuries into different religious traditions such as Jainism, Buddhism and Hinduism. In its radical asceticism, Jainism has survived against all odds. Jain monks and nuns may, at times, use a mobile phone or have an email account, but almost all of them still refuse to use vehicles and instead walk nine months a year around the subcontinent (barefoot, of course). They might live in a parallel world, far removed from our modern reality, but their heritage, reaching back more than 2500 years, is very much a reality of our times. Celebrating death, as they do, might feel disconcerting for many of us who are shaped by the cultural idiom of the moder
n West89 that centres around the individual; a culture that fears and denies the issue of death and has few rituals left to deal with it. Perhaps we should engage ourselves more open-mindedly with other cultural models of death and dying to make it more visible and less distressing in our own lives.
Adding Life to the Dying:
Palliative Care and Psycho-Oncology
Pia Heußner and Almuth Sellschopp
When recovery cannot be achieved any more one of the central medical objectives is to provide care services for people in palliative life-situations. Establishing Palliative Care as a distinct discipline is not novel and hitherto unheard of. In fact it is something that many professionals across disciplines see as a centrepiece of their work. However, critical debate over definitions and priorities has spurred intense public discussion and interpersonal reflection of those working in the field.
Looking at the definitions of Palliative Medicine (see box 1 and 2) we find many important clues on the subject and guiding ethical principles that we have to deal with in a palliative setting.
World Health Organization (WHO): Definition of Palliative Medicine Palliative Care is an approach to improve quality of life of patients (and their familiy members) facing a life-threatening illness. This is done by prevention and mitigation of suffering by early detection and correct assessment and treatment of pain and other bodily, psychosocial and spiritual grievances.1,2
Palliative Care sets in where quality of life is given more importance than the sheer extension of lifespan at all costs. According to the definitions, Palliative Medicine is increasingly substituted by Palliative Care in order to take into account the holistic approach of care. A shared component of all definitions is the derivative form the latin word pallium (coat), that covers the person, protecting it:3
European Association for Palliative Care (EAPC): Definition Palliative care is the active, total care of the patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of social, psychological and spiritual problems is paramount.
Palliative care is interdisciplinary in its approach and encompasses the patient, the family and the community in its scope. In a sense, palliative care is to offer the most basic concept of care—that of providing for the needs of the patient wherever he or she is cared for, either at home or in the hospital.
Palliative care affirms life and regards dying as a normal process; it neither hastens nor postpones death. It sets out to preserve the best possible quality of life until death.4
In that sense, the objectives of Palliative Care could be summarized in the words of Cicely Saunders (1918–2005), founder of modern hospice practices and of the St Christopher’s Hospice in London in 1967: ‘Hospice is not a place to go to die, but rather a concept of care based on the promise that when medical science can no longer add days to life, more life will be added to each day.’5
The various definitions of Palliative Medicine make clear that the implementation of a holistic care system does not only require competence in the field of somatic medicine, but includes especially knowledge and integration of the psychosocial setting and the support of relatives.
Thus, it is understandable that Palliative Medicine opts for the inter-professional way (often wrongly oversimplified as interdisciplinary) in order to implement the concept. A palliative team naturally and always consists of experts belonging to several disciplines: medical doctors in different fields, nurses, social workers, spiritual counsellors, honorary helpers in the hospice process, psychologists and creative therapists. At the same time, the latter profession is frequently subject to dubious cost-cutting decisions or arguments if they are essentially necessary or not. The psychosocial field, so critics say, could be adequately covered by a social worker and a music therapist, and besides, also, doctors and nurses could talk, because ‘communication skills’ would indeed be one of the training modules of palliative doctors and nurses. Now the critical question has to be raised at what time patients or their relatives need profound psychotherapeutic support. The membership statistics of the German Association for Palliative Medicine confirm the impression that psychological competences are still a project in progress: Less than 10 per cent of the members are psychologists or psychotherapists by profession, and the statistics do not offer any information about the quality of their psychotherapeutic and psycho-oncologic training. Currently, a mission statement for Psychologists in Palliative Care is under development, pointing out the importance of self-awareness, the ability to critically reflect, and a specific therapeutic competence, which is a vital ingredient for the many different tasks therapists have to perform in the framework of Palliative Medicine.6
From a psycho-oncological perspective we might ask: Where should our place be in the context of Palliative Care, and, more importantly, is there a demand for psycho-oncological competence within Palliative Care teams at all?
Modern concepts of Palliative Medicine state that the main caretaking is continuously increasing during the course of an incurable disease. At the same time, it is desirable to make Palliative Care available at the very onset of the incurable disease (e.g., when symptoms occur that reduce the quality of life), and not just a few days before the expected end. Psycho-oncology defines its task as giving support in a dynamic process, ideally starting out as prevention, before the onset of a stress-related psychological disorder. The aim is to focus on psychological symptoms and to establish a care system for relatives. This makes clear that psycho-oncology and Palliative Medicine are not two separate entities, mutually exclusive disciplines, but rather should be available simultaneously to the patient.
When it is important to find out which care is appropriate for what kind of patient, we have to integrate the patients’ perspective as well. This is especially of importance when patients enter the palliative treatment phase, which is often coupled with the change of the treatment team. Then it is essential to decide which treatment is desirable at what point in time and when can a patient ask for Palliative Care and really immerse in it? In the beginning, patients and their relatives have to consider and find out where they see themselves in the course of the disease. Is the assessment of the future trajectory congruent with what the experts and relatives say, or do all involved people see the patient at a different point of an either anticipated or repressed trajectory? In order to make Palliative Care work, the task of psycho-oncology is to sensitively support the patients in their subjective perception of the chronic and progressive disease as well as helping them to process and cope with it. To illustrate this we present an example:
Mrs P is diagnosed with breast cancer when she is forty-four years old. She undergoes the primary therapy including breast preserving surgery, radiation and chemotherapy, as well as a five-year-long anti-hormone therapy. Six years later, liver metastases develop and another round of chemotherapy, antibody therapy and anti-hormone therapy begins. Another year later, metastases are found in her lungs, pleura and her abdominal membrane, which launch different chemotherapies and another adjustment of the anti-hormone therapy.
The patient is married, and has three children in the ages of seventeen, fifteen and thirteen. Her husband is a self-employed biologist in leading position, who travels on work a lot and works overtime to keep his company from bankruptcy. Her parents live in the same city and, regardless of their advanced age, try to help the family with household matters and support the children with their care, attention and stability-granting attitude. The sister, who is three years younger than the patient and who has two little children herself, is also supporting Mrs P. However, the sister is also concerned about her own six-year-old son, who has been diagnosed with a metabolic disorder one year ago.
In the seventh year of the course of the disease the oncological treatment team motivates the patient to see the psycho-oncologist. At that time, Mrs P undergoes chemotherapy and anti-hormone therapy, as well as punctures of the ascites (caused by the metastases in the abdominal membrane) seve
ral times per week. The patient is very sick, suffers from nausea, vomiting, cachexia, asthenia, depressive mood, and stays in bed most of the time. She oscillates between the clinic and home, where she also receives parenteral nutrition intravenously. Walks and excursions into the nature would be a resource for her, but she is too weak and cannot actively pursue them any more.
Mrs P hovers between the two statements of ‘I will get healthy again’ on the one hand and ‘I cannot live like this any more’ on the other hand. She retreats socially and does not allow visits from friends and family. She wants to hide her physical symptoms from the family, especially the children, and thus, stays in her bedroom on the second floor most of the time. She also refuses ambulant home care.
Mrs P rarely talks about her fears and worries, but she says that talking to her sister relieves her. She refuses to talk to doctors or nurses, but demands more visits from the psycho-oncologist to receive more information about how to deal with the children and further treatment options. She does not want to talk to her children about her state because she does not want to burden them. Thus, she refuses visits from her children in the clinic.
Her husband has one appointment with the psycho-oncologist; after that, he talks to her twice on the phone. Mr P wants to find a good time to speak with his children and talk about the short life-expectancy of their mother. He attempted such a talk once in the past, but is afraid to speak about it again. He saves up his yearly holidays to be there when the time comes, to be able to take care of his wife and children. He wants to personally take care of his wife when she enters the terminal phase of her life, and is prepared to reorganize the house to make room for a special nursing bed. This, however, is refused by the patient. Also, the sister gets advice from the psycho-oncologist on how to support the children.