Fear of Death

Excerpted from
Going On Being; Buddhism and the Way of Change
By Mark Epstein, M.D.

As a psychiatrist in training, I was expected to do a one-year medical internship. I chose a program in a chronic care facility where there were wards of people who were not expected to recover from their illnesses as well as a functioning intensive care unit and a locked prison ward serving the medical problems of the state's incarcerated population. It was a backwater hospital, for patients whom the medical establishment had little interest in, but it was also a place where friends of mine were establishing a short-lived "pain and stress" clinic with a natural foods kitchen and acupuncture in the outpatient clinic. The hospital was happy to have me: I was a doctor who spoke English and had gone to an American medical school, a rarity in that environment. The fact that I wanted to be a psychiatrist was not a liability.

My patients were not like Mary. I remember the first two people I ever cared for, both lying in their hospital beds suffering from illnesses that we could do nothing about. Mr. Fishman, a round and once overweight Jewish grocer, was gradually suffocating from emphysema, in which his lungs, made brittle from years of smoking, could no longer expand and contract to allow a flow of oxygen into his blood. He would gasp and call out to me, "Dr. Epstein, Dr. Epstein," whenever I was near, with the unquenched neediness of a hungry child. He was scared, and there was not much I could do for him. Mr. Houlihan, an alcoholic Irish shipyard worker, was shrivelling up from chronic cirrhosis. His liver was shutting down and was unable to clear his blood of impurities. His skin and eyes were yellowing, he itched unrelievedly, and his belly was swollen with ascites, fluid that could no longer pass through the liver. He was withdrawn, turned over in his bed away from visitors and turned into himself, hardly looking up at his grown daughter who sometimes attended his bedside.

With both people I eventually adopted the strategy of just sitting with them for a bit every day. There was not really room for this in my schedule, but I would try to find time. Luckily my internship was not as frantic as most. I would think of Mary, or of the Diamond Sutra, or of the vision that death is happening all the time, to each of us, that it is not an unnatural thing. I would remember the terror of dissolution in meditation and the equanimity that came from not fighting it. I could not talk about any of this to my patients-I am sure it would not have been well received if I had-but I could stop and hang out just a bit. This was not the usual modus operandi on the hospital floor.

In some ways I could see myself in both Mr. Fishman and Mr. Houlihan. When the Buddha taught, in his Second Noble Truth, that the cause of suffering was "thirst" or "craving," he suggested that this thirst was of three types: the craving for sensory pleasures, the craving for being, and the craving for nonbeing. The first one I understood, but the latter two categories took me some time to fully appreciate-they seemed so abstract. What did it mean to crave being, or nonbeing? How did this translate into real life? As I investigated these concepts, I started to understand them better.

Craving for being means the desire for more of what one already has. There were all kinds of ways in which I could see that desire at work. If only my wife could be more loving, if only the sunset could last longer, if only my best friend still lived around the corner. If only I felt as real as I was supposed to. The craving for nonbeing meant seeking after oblivion, the desire for nothingness, the wish for the peace of deepest sleep, the hope that a problem could be eliminated altogether or that there was somewhere to escape to. One recent patient of mine described it as a craving for amputation, the wish that an obstacle could be cut off and thrown away. I could also understand it as a reaction to frustration, in which my own tendency was to withdraw as far as possible into a cocoon of invisibility, shrinking down to nothing, if I could.

Mr. Fish man and Mr. Houlihan seemed to me to embody these cravings. In their symptoms they were expressing a deeper pattern of behavior that ran through the texture of their lives. In his gasping after the next breath, Mr. Fishman was grasping for more of what he already had-oxygen-but in his anxiety he was using up that which was so precious to him. He would become increasingly short of breath the more he struggled. Mr. Houlihan was seeking the oblivion that he thought death could be, much as he had sought it through alcohol in his drinking life. He was not open to the life that remained for him, embodied in the presence of his daughter at his side.

In sitting quietly with each of these men, I did not do therapy, nor did I meditate. I simply sat with them, aware of the continuity of their going on being. They were so caught up in their dying that they were no longer paying attention. I attempted to use my presence to give them something to focus on, without feeling sorry for them and without pushing them away. I wanted them to know themselves as spirit, as something more than their ailing minds and bodies. I do not have any real way of knowing how successful I was at communicating any of this, but I do know that they both liked me. Mr. Fishman calmed down a bit, and Mr. Houlihan opened up a little. There were moments when I felt that each was a bit less afraid, when my awareness touched the place in them that was beyond craving. Although I did not know it at the time, I can see now that these men were among my earliest teachers in psychotherapy. With each of them, unable to help them in more conventional ways, I had to become a fear seer.