The philosophical and cultural situatedness of spirituality at the end of life in India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/IJPC.IJPC_61_17
Source of Support: None, Conflict of Interest: None
Keywords: Spirituality, philosophy, culture, end of life
The sustained interest in exploring the spiritual domain at the end of life in the Indian context reflects the recognition of its significance as an aspect of palliative care. Several studies have sought to explore this critical end-of-life zone. There have been quantitative studies aimed at the effectiveness of attention to spirituality and spiritual care at the end of life and qualitative studies that explored the features of spirituality based on the experiences of patients and perceptions of professionals.,,,
A key aspect of the findings from studies so far is the recognition and identification of challenges, inadequacies, limitations, and ethical dilemmas in relation to spirituality at the end of life. These are also often reflected in commentaries and are part of presentations at scientific meetings. There has been a genuine sense of inadequacy that we do not know what spirituality at the end of life means. The existence of many religions and the fact that health-care professionals and care receivers can have different religious affiliations has been perceived as a challenging context in India. In a country where access to basic palliative care and pain medicines are scarce, the sense of inadequacy of personal and financial resources is overwhelming. In addition, a recent systematic review of studies on spirituality at the end of life in India highlighted fundamental ethical challenges in providing spiritual care in the Indian palliative care setting. Many of these have identified features that are culturally characteristic of the Indian way of life, particularly making reference to the significance of religious faith for most of the Indian population and the importance of family and community. However, an in-depth exposition of religious, philosophical, and cultural tenets to inform our understanding of spirituality and spiritual care is lacking.
India is known for its rich spiritual heritage and has unique ways of understanding, experiencing, and expressing spirituality. The philosophical and cultural frames of reference, with which communities in India make sense of life, death and dying, determine the characteristics of Indian spirituality at the end of life. In international literature, spirituality is often characterized as the “essence of the human person” and the “meaning and purpose of life.”, These are philosophical concepts that shape our perceptions of our identity and our experience of living in human communities in particular contexts. Similarly, “death” is not only an event of life but also carries with it considerable philosophical and cultural concepts that give meaning to death and the experience of dying.
Communities around the world have been responding to end-of-life issues in different ways, and some have focused their efforts on “intangible” aspects of care provided at the end of life such as spiritual care. Drawing ideas and methods from different parts of the world to address end-of-life issues is an increasingly common phenomenon in the contemporary world. While this can potentially facilitate mutual learning, it also accounts for the lack of attention to the particularities of the local context. Drawing ideas and concepts from elsewhere may provide some guidance; however, it undermines the possibility of creating a knowledge base informed by philosophical, theological, and sociological concepts, which are critical to the understanding of spirituality.
Critical differences between Indian philosophical approaches and others, particularly those of the Western world have been well established. Indian philosophy engages with metaphysical questions arising from the experiences of life where the divine and the human share in the formation of understanding, with direct implications to practical everyday life (Sādhanās)., Exploring the concepts of the human person, the purpose of human life, the meaning of death, and caring for the dying using Indian philosophical and cultural resources, therefore, offers the opportunity to understand the unique ways, in which they shape the Indian understanding and experience of spirituality at the end of life.
The concept of the human person is based on the understanding that the human soul is from the divine and is of the same substance as its divine source. It is not the individual's capacity as a “thinking being” or a “rational being” that gives the human person his/her existence. It is an extension of the divine, a gift of God. The purpose of life is the ultimate liberation from the māya of this world and to be united with the divine. Following the right way of life, discerning the will of God and following it is central to the understanding of the purpose of life., It is significant to recognize that purpose of life in the Indian conscience is not individually thought out and self-determined. Following on from the two former concepts, death is understood as a process, a passage, rather than a termination of existence. In the words of Rabindranath Tagore, “Death is not extinguishing the light; it is only putting out the lamp because the dawn has come.”
A study exploring a historical-cultural understanding of spirituality in India, identified “union with the divine,” “being at peace,” and “preserving dignity” as the three core principles of spirituality at the end of life in India. These principles were found to be at the heart of the practices and beliefs in the context of the care of the dying. For example, “A daughter's wedding” is a common cause of worry for many palliative care patients. It sounds reasonable that this can be understood as “unfinished business” and classified as a “social” aspect of the total pain the person is experiencing. However, viewed through the Indian philosophical and cultural lens, it can be understood in a deep spiritual way. A daughter's marriage is not merely “unfinished business” - a special occasion in the family and an important event in the life of the daughter, which the parent likes to witness before s/he dies; the worry stems from a deep sense of responsibility as a parent, an identity which has embedded in itself the moral duty to make sure his/her daughter is settled in life. Deliverance from this bondage to the sense of duty leads to the opportunity of dying in peace; and in dignity, with the realization of the divine within oneself; and with only “God-thought” at the time of death, leading to union with the divine.
Cultural aspects are particularly important while considering models of spiritual care. Other than the few Christian mission hospitals in India, the idea of a chaplain is an unfamiliar concept. Professional spiritual care providers are not part of India's health-care fabric. It is widely held, particularly among palliative care communities, that “being with” and “listening” are essential skills, all palliative care professionals should exercise to provide spiritual care for their patients and families. While there is no doubt that patients greatly benefit from the presence and the listening of health-care providers, which can lead to spiritual healing, it cannot be ignored that emphasis on these skills assumes that the patient is able to think through, rationalize, and articulate their spiritual experiences. The words they say and the observations of the professional become the basis for assessing spiritual needs. This may be in conflict with the Indian sense of spirituality, where people often find practices and experiences deeply meaningful but are not always are able to describe or explain it. Spirituality, therefore, remains something people experience as being someone, being part of something significant, and doing something that is meaningful for them though they may never find the words to describe their experience.
Spirituality at the end of life can be conceptually seen as the area of common overlap of three domains. The life experience of people and organized religion or belief system form the first two domains. In ordinary circumstances of life, people constantly draw, experience, and interpret spiritual meanings from their affiliation to religion or a belief system. In the context of end-of-life care, the domain of medicine and health care gets to be an influential factor. Much of the search for understanding spirituality seems to remain within the narrow triangle of the area of common overlap of the three domains, often drawing tools and methods used in medicine and health sciences. There is little engagement with the domain of religion and belief systems that accounts for spiritual meanings and experiences for the rest of people's lives.
”How to recognize spiritual distress at the end of life” is a question frequently voiced in palliative care meetings. How do we recognize spiritual distress in ordinary circumstances in non-end-of-life situations? Responses to this question might have implications for how we recognize and respond to spiritual distress in palliative care, and more importantly, such answers cannot be found if we keep looking inside the little triangle using tools from the medical domain. We need other approaches, such as theology and philosophy that have expertise in the domain of religion and belief systems and sociology and psychology with their resources to make sense of the life experiences, to help us see the whole picture.
A cross-disciplinary approach, drawing together expertise from clinical palliative care, philosophy, theology, and sociology, will enrich the understanding of spirituality at the end of life and can contribute effective means of providing spiritual care in palliative care in specific contexts around the world.
The author would like to thank Cairdeas International Palliative Care Trust and the Glasgow End of Life Studies Group, University of Glasgow for their support. The author is currently supported by a Wellcome Trust Investigator Award (Grant number: 103319/Z/13/Z).
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Conflicts of interest
There are no conflicts of interest.