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Cult Med Psychiatry (2011) 35:113-133 DOI 10.

1007/s11013-011-9210-6

Facing Death, Gazing Inward: End-of-Life and the Transformation of Clinical Subjectivity in Thailand
Scott Stonington

Published online: 15 May 2011 Springer Science+Business Media, LLC 2011

Abstract In this article, I describe a new form of clinical subjectivity in Thailand, emerging out of public debate over medical care at the end of life. Following the controversial high-tech death of the famous Buddhist monk Buddhadasa, many began to denounce modern death as falling prey to social ills in Thai society, such as consumerism, technology-worship, and the desire to escape the realities of existence. As a result, governmental and non-governmental organizations have begun to focus on the end-of-life as a locus for transforming Thai society. Moving beyond the classic outward focus of the medical gaze, they have begun teaching clinicians and patients to gaze inward instead, to use the suffering inherent in medicine and illness to face the nature of existence and attain inner wisdom. In this article, I describe the emergence of this new gaze and its major conceptual components, including a novel idea of what it means to be human, as well as a series of technologies used to craft this humanity: confession, facing suffering, and untying knots in the heart. I also describe how this new subjectivity has begun to change the long-stable Buddhist concept of death as taking place at a moment in time, giving way for a new concept of end-of-life, an elongated interval to be experienced, studied, and used for inner wisdom. I am happy to be a nurse because it is an opportunity to become the right kind of person. Nurses get to see suffering every day. We have more opportunity than any other profession to face suffering, to understand nature, and to receive merit. Ampha, a young nurse in a provincial hospital in Northern Thailand

S. Stonington (&) Anthropology, History and Social Medicine, University of California, San Francisco, San Francisco, CA, USA e-mail: scott.stonington@stanfordalumni.org

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Prelude: A Hospital Room in Northern Thailand Can we talk English? asks Jae, in English. We are in a provincial hospital in Northern Thailand, home to some of the best public medical care in Asia. We are sitting on a rolled-out straw mat on the oor, a hint of tradition in this very high-tech place. I am a student, both of medicine and of anthropology, and my eldwork on end-of-life care in Thailand has led me to this hospital, where Jaes mother, who is dying from lung cancer, is an arms length away, drifting in and out of consciousness. Her cousin had this [disease], before, explains Jae, If she hears us talk, she might guess. Jae has not told her mother that she has cancer, or that she is dying. Non-disclosure of cancer diagnosis and prognosis is the rule rather than the exception here in Northern Thailand. Instead of discussing medical matters, Jae and I spend many hours sitting on her mothers oor, simply being here to give her mother encouragement (kamlang hai). Periodically, I leave the room to give Jae time alone with her mother. I step out into the hall, where I run into Nurse Ampha, a poised, kind woman with scholarly round glasses. I feel like Nurse Ampha is a schoolteacher, and I treat her that way since I feel like an ignorant and eager young student in Thailand and especially here in the hospital. What do you think about this case? I ask her. It is not good, she says. I think at rst shes going to talk about the lung cancer quickly colonizing Jaes mothers body. But instead, she surprises me by talking about Jaes unwillingness to tell her mother her diagnosis. Most clinicians in Thailand do not disclose diagnoses, so I am surprised she considers this as a problem. The mother, Nurse Ampha explains, will have no chance to prepare her mind for the nal moment. How can she know she needs to meditate and chant if she doesnt know what is happening? This is not a real end-of-life case. She uses the English for the words end-of-life. When Nurse Ampha talks to Jae about her mother, she pushes gently on her, saying maybe if you talked with your mother, you could chant together, or is there anything your mother would want to do with this last period of life if she knew she was dying? Apparently, these are important components of a real end-of-life case. Nurse Ampha tells me about a lecture she heard at the Hospital Accreditation National Forum in Bangkok about using the end-of-life to wake people up to the nature of their minds. It was one of many lectures she has attended about preventing burnout in the workplace by nding spiritual meaning in medicine again. Nurse Ampha looks exhausted from a long work shift in the understaffed hospital, but her eyes light and her posture rights when she talks about Jaes mother and the coming nal moment. As she later explains to me, helping patients face the end of life is inspiring and energizing. And Jae, by denying her mother explicit knowledge about her pending death, is also denying Nurse Ampha the opportunity to play this role at the end of the dying womans life. Several months later, Nurse Ampha introduces me to another patient, Mali, a woman dying of pancreatic cancer. Mali not only knows her diagnosis and prognosis, she has also chosen not to take any opiate pain medications, to use mindfulness meditation to control her pain while she dies. She has a glow to her,

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both from her jaundiced skin and from her gentle smile. As long as she meditates around the clock, she feels no pain, or more precisely, her body has pain, but her mind does not suffer from it. But as soon as she loses her mindfulness (sati), usually while talking to me or to the doctors, her pain comes crashing back upon her. When I ask Nurse Ampha about this case, she says, nally, a true end-of-life patient. Later, she explains, I am happy to be a nurse because it is an opportunity to become the right kind of person. Nurses get to see suffering (khwm thuk) every day. We have more opportunity than any other profession to face suffering, to understand nature, and to receive merit. She imagines her role as a health care worker as that of a spiritual seeker who uses the experience of the end of life to attain wisdom. This gure, the seeker of wisdom, is not of a clinician with technical nursing skill or with astute powers of observation, but someone who can use experience of the human condition to transcend suffering. I have always been interested in meditation, Ampha explains to me one day in the hall. In Buddhism, we teach that life has suffering in itwe are all born, get old, have pain, and die. These are natural things. If we dont accept the truth of nature, we will suffer and be without peace when we die. I ask her, So have you always wanted your patients to know their prognosis? She thinks for a moment. No, she says. It is a new thing. I rst heard about it from a lecture by Phra Paisal Visalo. He is the expert on facing death. There are trainings, too. This is not the rst I have heard of the famous monk Paisal Visalo, a disciple of the great teacher Buddhadasa, and now a proponent of a Buddhism engaged with the social ills of modern Thai societyconsumerism, inequality, and social change. Somehow, being an expert on facing death has become part of this agenda.

Introduction: From Outward to Inward Gaze, from Death to End-of-Life In the past several years, Ampha has undergone a transformation. She has developed a new kind of clinical subjectivity in which the purpose of clinical practice is to face suffering in order to become the right kind of person. This is very different in concept and practice from her previous way of being. Prior to thisin nursing school, and in most of her life practicing nursingher career was solely about her patients, not about herself. She had an outward gaze. Now, she is hoping to use clinical practice to gaze inward, to become a moral being. Amphas transformation raises an epistemological question: what do we assume clinicians to know and how do they acquire this knowledge (Foucault 1963)? It also raises a hermeneutic question: what technologies do individuals use to build inner meaning and identity (Foucault 1984; Foucault et al. 2001)? For most scholars of clinical training and practice, the motive force between knowledge and meaning is in the direction of knowledge. The purpose of self-cultivating practices in clinicians is to produce an assumed incontrovertible knowledge derived from experience and observation, what Foucault termed the clinical gaze. In his own words, The

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clinical gaze is a gaze of concrete sensibility, a gaze that travels from body to body, and whose trajectory is situated in the space of sensible manifestation. For the clinic, all truth is sensible truth (120) (Foucault 1973). The gaze is the gaze precisely because it is outward, and because it is concrete and sensible. Clinicians only cultivate their inner selves in as much as it helps them observe, diagnose and cure the other. In this article, I describe the emergence of a form of clinical subjectivity in Thailand that turns the gaze inward instead of outward, in which the usually assumed relationship between knowledge and self-cultivation is inverted. Nurse Ampha gazes outward to craft her inner self. And as I hope to show, this inward clinical subjectivity applies not only to health care workers, but to patients as well. In fact, it unites them in a single identity, a single gaze. Ampha wants to face suffering in order to become the right kind of person, and she wants this for her patients as well. This new form of clinical subjectivity is coincident with a related transformation: the appearance of a category of time and experience, the end-of-life. Death and dying have long been core concerns of Buddhist philosophy and practice, but death, as an interval, has been cast as a moment in time more than as a period to be experienced and explored. The Pali Canon (the core Theravada Buddhist text) teaches that death serves several functions: as something to study, by meditating on corpses and decay, in order to understand the transience of all things (asuphaphwan) (Keyes 1987; Klima 2002; Vajiranana Mahathera 1975); as a looming and unpredictable threat that should motivate urgent spiritual practice before it is too late (maranasati) (Panyapatipo 2007); and as a critical moment in which ones mind-state partially determines ones future rebirth (Keyes 1987; Payutto 2003). Buddhism has long been focused on death as a concept to be contemplated or as an important event that takes place at a single moment in time. In the last 20 years, however, a new concept has been built in Thailand, a concept of a period of time known as the end-of-life, an elongated interval that is to be experienced, to be approached through a particular form of subjectivity. This term is sometimes used in English, highlighting a global component to its origins. Sometimes it appears as a relatively new phrase in Thai (raya sut thi kho ng chwit, lit: the last interval of life) (Komatra 2007). This new concept is the result of a series of social forces and political events that have placed death and dying at the heart of debates about modernity, consumerism, autonomy, and social change in Thailand. And as I hope to show in this article, these debates have given rise both to a new category of end-of-life and a new type of clinical subjectivity, an inward gaze. It is no coincidence that Ampha has chosen a dying patient as the site for her selftransformation. This is what leads her to look for a real end-of-life case. There is something about this new category end-of-life that provides the best opportunity to face suffering. The controversy about death in Thailand has generated a re-imagining of clinical practice as a path to spiritual salvation, a path to becoming a certain kind of human who faces the truths of suffering to understand ones own mind and access its true, liberated nature. In the rst portion of this article, I trace the historical and political roots of this novel form of clinical subjectivity. I begin with the history and politics of death and

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dying in Thailand, including a set of ethical frameworks that patients and clinicians have historically used to approach the end of life, as well as recent shifts in these frameworks due to events that have brought death and dying to the forefront of national debate. This contextual history is a brief summary of a more detailed study of the end-of-life experiences of thirty patients in Northern Thailand, with results published elsewhere (Stonington 2009). This summary is necessary for understanding the context from which new forms of clinical subjectivity are arising. In the second portion of the article, I describe the novel form of clinical subjectivity that is emerging in Thailand around end-of-life care, based on ethnographic data from clinical training seminars, policy documents, and government meetings. I describe its conceptual components, including a novel conception of what it means to be human, as well as a series of technologies of the self used to craft this humanity, including confession, facing suffering, and untying knots in the heart.

Dying in Northern Thailand Northern Thailand is home to great contradictions of medical modernity. It has remote villages with dirt roads and farming economies alongside ultra-high-tech urban hospitals with fully equipped intensive care, radiology and surgical capabilities. It has physicians and nurses highly skilled in scientic knowledge and experimental rationality as well as animistic and Buddhist spirituality. It has a well-renowned universal health care system, so that individuals who may have had little access to modern medicine out in rural villages may suddenly nd themselves receiving high-tech health care when they fall seriously ill, usually at the end of life. A common gure of this cohabitation of pre-modern and modern is the rural farmer who ends up in the intensive care unit at the end of life, strapped to cybernetic machines of articial life. Prior and concurrent to the emergence of the novel form of clinical subjectivity that I present in this article, dying in Northern Thailand has been governed by two ethical frameworks. First, family members have to pay back a debt of life (pen n chwit) to their elders, usually today by providing high-tech hospital care. But even more essentially, children must give their parents heart power or encouragement (kamlang hai), a form of emotional support that lls up the heart (hai kamlang hai) and prevents a worrying mind (khit mk) from harming the body. Since a worrying mind harms the body, diagnosis and prognosis are often kept from the patient, to protect them from the harmful effects of suddenly running out of heart power (mot kamlang hai), which can shock someone to death. For a fuller description and analysis of this ethical framework, see (Stonington and Ratanakul 2006; Stonington 2009). A second ethical framework takes over in the last hours of life, when it is important for a dying elder to take her last breath at home. The place where body and mind separate is vital to the spiritual outcome of the individual. Some feel that hospitals are bad places to die because they are haunted; thus hospital death risks creating an unhappy spirit or a ghost instead of a benecial rebirth. In contrast, the home is an ideal place to die because it is sacred and contains familiar items that put

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individuals at peace at the moment of death. For a more detailed description of this framework, see (Stonington 2009). The key to these two ethical frameworks is that death is conceived of as taking place in a moment (the last breath taken at home), and not as requiring particular knowledge or subjectivity (not knowing that one is dying or why). In fact, the purposes of the debt of life and heart power are to push life exchange until the last minute, to make death as short a part of existence as possible, and to avoid knowing that death is coming for fear of hastening death with that knowledge. This approach is not contradictory to that found in thousands of years of Buddhist doctrine, although the focus is very different. A prominent monk in a forest monastery in Thailand summarized the traditional focus on death in Buddhist doctrine to me as follows: Death serves two functions in Buddhism. It is a source of useful disgust and useful fear. The disgust is an antidote to lust; the fear is an antidote to laziness (Phra Dhammavidu, personal correspondence, Wat Suan Mokh). Death gives rise to repulsion that teaches us the impermanence of all things and thus liberates us from ego, lust and desire; and it is a source of fear about the brevity of our lifetime and thus as an incentive to diligently meditate with the time that remains. Each of these perspectives culminates in a particular form of meditation. Most Thais have been exposed to asuphaphwan, one of the ve major categories of Buddhist concentration meditationa meditation on foulnesses, focused on contemplating corpses at ten different stages of decay, described as bloated, livid, festering, split, gnawed, mangled, mutilated, blood-stained, worm-infested, and skeleton (Klima 2002; Payutto 2003; Vajiranana Mahathera 1975). But much larger in public consciousness is the mindfulness of death, maranasati, one of the ten core mindfulness meditations (anusati). One popular text explains that mindfulness of death is a cure for the curse of heedlessness. When people are young, it explains, they mistakenly believe they are young forever. They misunderstand the nature of human existence because death might come at any moment. Our bodies are impermanent and their nature is to fall apart. Thus we should practice meditation and acquire wisdom, almost as an emergency in the present moment (Panyapatipo 2007). A third major feature of death in the Buddhist canon is as a critical component of transition to rebirth. The content of ones consciousness (winyn) at the moment of death is a large part of the karma (kam) that is still stuck to a persons consciousness, and it is this karma that causes the consciousness to be reborn again into a new body. Because of this, the narrative biographies of many great spiritual leaders include analyses of their last moment of life, as a kind of window into their level of spiritual attainment (Keyes 1982). Prior to the emergence of the form of subjectivity I describe in this article, death has largely been emphasized as a concept to be contemplated by the living as a tool for spiritual practice and also as an object, a moment in time. The wisdom that could be attained from death had little to do with the actual process of dying itself. One could think about death to ght lust, or to become motivated to practice. But of the experience of dying, only the exact moment of death mattered.

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Politics, Death, and Subjectivity In the last 20 years, political events have destabilized this understanding of death and made room for new ways to think about dying. In 1993, the famous Buddhist monk Buddhadasa died of a stroke. For many great monks in Thailand, the manner of their death becomes an important component of the legacy and biography they leave behind, often leading to sainthood or mystication of their spiritual powers, sometimes reaching beyond spiritual issues to broader social debates (Keyes 1982). Similarly for Buddhadasa, a set of historical coincidences occurred around his death, pulling a host of political and social issues into the meaning of his death. Buddhadasas teachings focused on the concept of nature, of understanding the reality of life and death (Buddhadasa 1956; Santikaro 1993; Buddhadasa and Dhammavicayo 1994). He was highly critical of the Thai Buddhist clergy (sangha) and the increasing consumerism of Thai society. He had written an advance directive, formerly an unknown and unfamiliar concept in Thailand, stating that he wanted to die peacefully in his forest monastery. But upon his stroke, he was rushed by doctors and disciples to a large academic hospital in Bangkok, where he spent several weeks in the intensive care unit (Jackson 2003). Meanwhile, controversy raged in the Thai press about autonomy, knowledge, and self-determination, using death and dying as the focal point. Many argued that the choice to ignore the great teachers wishes to die a natural death unveiled misguided forces in Thai society: the use of spiritualism and social hierarchy to trump individual choice, and the worship of high-tech materialism over the nature that Buddhadasa had emphasized throughout his life (Prawase 1993; Anothai 2002). His death was also coincident with a complex and important political crisis in Thailand. In 1992, a series of pro-democracy protests and subsequent massacres by the Thai military led to an outpouring of debate about democracy, human rights, autonomy, religion, and modernization. Buddhadasa died shortly after this, in the midst of political and social theoretical controversy. As a result, reformists latched on to Buddhadasas death as a site for critiquing Thai society as a whole. Death and dying were taken up as key examples of the breakdown of democratic imagination in Thailand, of the inability of Thais to determine their own destinies. Although Buddhadasas death alone likely would have raised complex political issues because of his teachings and important social role, the timing of his death amplied its political and social implications. Death and politics became inseparably mixed [for analysis of this political history, see (Stonington 2009)]. Part of this political crisis involved the health care workforce. Doctors and nurses had long been seen as powerful holders of moral authority in Thai society. But health care workers had come under the same re for consumerism and materialism as monks. Because of this, and because of challenges in training, development, and paying salaries, public hospitals had long struggled to ll the ranks of health care workers. Long hours, low pay, and the new attractions of the private sector were luring good students away from health care (Komatra 2005; Suriya et al. 2005). A small minority of clinicians, public-service rural doctors and nurses, had been intimately involved in the politics of protest that led to the overthrow of military

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rule. These activist clinicians emphasized health care as a key sector of Thai society requiring reform in the atmosphere of social transformation occurring at the time. Buddhadasas death spurred a critique of biomedicine and the notion of good death. And because of other events at the timehealth care workforce crisis, criticism of the Buddhist clergy, and democratic reform politicsa broad set of other political issues became wrapped into Buddhadasas death. As I argue in this article, the avenue that reformists envisioned out of the crisis was by constructing a new form of clinical subjectivity, a way to get both health workers and patients to turn away from their outward gazes and look inward instead. Part of this transformation included the introduction of a new conceptual category, the end-oflife, an interval of time expanded beyond the momentary nature of death, a period of time that should be experienced, studied and used to attain wisdom.

Facing Death In order to understand the nature of existence and be free from suffering, explained Phra Paisal, the most important thing is to face reality. This is true in all things. Therefore, the rst requisite for having a peaceful death is to accept death, to know and accept that one is going to die. It was early morning, before the opening activities on the third day of a 4-day training entitled Facing Death Peacefully (phachen khwm ti yng sangop), hosted by Phra Paisals Buddhist organization, the Buddhika Network (Paisal and Bridaa 2006, Paisal 2006, Kanajariyaa 2006). Phra Paisal and I were sitting out on a veranda overlooking a lush garden at a conference center outside of Bangkok. I had come to the training looking for the source of Nurse Amphas desire to use end-of-life care to become the right kind of person. Though I was a participant in the training, I asked for an audience to clarify some of the history and agenda of the movement. Phra Paisal was one of Buddhadasas foremost disciples. After Buddhadasas death, Phra Paisal has spent his career attempting to transform Thai society toward Buddhadasas spiritual vision. He balances a desire for a low-prole, humble monastic existence with the public face required for addressing broad social problems. His programs are far reaching, including teaching and writing on peace and non-violence, ecological preservation, religious reform, and volunteerism. Perhaps the most popular of his programs is this one on facing death, largely brought into public awareness because of his translation into Thai of the Tibetan Book of Living and Dying. The training, as well as the broad social agenda of his organization Buddhika, can all be understood via the word pachen, to face or confront. Buddhika was formed in 2001 by Phra Paisal explicitly to ll a vacuum that was being left by the wane of traditional religious authority in Thailand. People had begun to lose faith in the conservative Thai sangha. According to Phra Paisal, this was because the clergy remained locked in a ritualistic spirituality based on distant and inconceivable enlightenment, divorced from the real problems of modern life. Swept up by globalization and social change, people were quickly leaving the clergy behind and turning to alternative forms of spirituality. Phra Paisal felt that many of these forms of spirituality were thinly masked forms of consumerism (Trungpa and Baker 1973),

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expanding a general trend in Thai society toward consumerism as a solution to the challenges of modern life. Particularly, the growing Thai middle class, increasingly seduced by materialist values, had begun to deny the reality of existence by buying themselves comfort instead of working hard to understand the fundamental nature of being human. Why death, then? I asked Phra Paisal. Buddhadasas death, he answered, was the rst time that we understood that consumerism is epidemic in modern Thai medicine, the rst time that we realized how much people want to buy their way out of death, out of the truths of nature. Because of the issues that arose around Buddhadasas death, Phra Paisals organization realized that death could become a focal point for addressing materialism in Thai society. Paisal saw the organization as an incarnation of Buddhadasas social vision, with death as its focus. In the hands of Buddhika, the word facing (pachen) performs a transformation on death. Death as a single moment is no longer adequate, nor is death without knowledge or subjectivity. Death instead must become an experience and a process that can be faced, studied, and understood. By transforming death in this way, Paisal hopes to transform Thai people from passive consumers of religious wisdom into active explorers who use the challenges inherent in life and death to understand the nature of human existence. The organizations trainings are a technology, designed to craft a new kind of spiritual individual. Out of the trainings, a gure emerges, a gure of the kind of person that Nurse Ampha wants to become and that she wants her patient to becomesomeone who faces reality, and by so doing understands the nature of existence. This gure hovers in Jaes mothers room and it hovers in the hall where Nurse Ampha is quietly critical of her patients dying. The Human (Manut) as an Ethical Figure As discussed previously, when disapproving of the approach to her patients death, Ampha looks exhaustedas well she might be from a long work shift in the understaffed hospital. Nonetheless, discussing the coming nal moment re-energizes her. As she continually explains to me in the interviews, she wants to talk about it. She would rather spend her day preparing her patients mind than writing in a chart and checking vital signs. She has a vision for herselfshe wants to be a certain kind of healer, one whose job is primarily to help patients through the dark-butinspiring journey of fear and death. She explains that she rst learned this approach at a conference of the Institute of Hospital Quality Improvement and Accreditation (HA) in Bangkok. HA was established initially to ensure adherence to a common standard for hospitals in Thailand, focusing on sterile procedure, infection control and prescription protocols. It is in charge of every hospital in the country. This year, HA dedicated half of its yearly session to a broad social change program entitled humanized healthcare (rapop sukaphp th m huahai khwmpen manut). When I asked Ampha what this word humanized meant, she replied, it is about nding true value (khunkh the)

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in being a nurse and interacting with patients. When she told me this, I was unable to contain my surprise about such a broad social program coming from a public health bureaucracy. Why is HA interested in this? I asked. We are in a crisis in healthcare in Thailand, she explained. Everyone is afraid of being sued. We are understaffed and overworked. No one wants to be nurses and doctors anymore. They want to be business people. We need a way to make healthcare attractive again. Seeing my interest, Ampha gave me the small book on the philosophy of humanized health care produced by the HA organization (Piyasagol 2005). The introduction contained the following explanation: Being human (manut), at its profoundest level, is the state of entering truth (khwm hing), goodness (khwm d) and beauty (khwm ngm). Other animals (sat) cannot enter this state. Even angels (thwad) cannot enter this state. The ability to enter truth, goodness and beauty is a characteristic only of humans. And when a human enters truth, it gives rise to freedom (isaraphp), supreme health (sukhaphp lonlu a), and love for humanity (phan manut) and all existence (thamacht thang man). If health workers enter into being human, it will have several effects. First, health workers themselves will have abundant happiness (khwm suk yng lonlm). Now they are all stressed, work is hard, and they cannot take it. Everyone is afraid of being sued. If they can enter into the heart of humanity, they can reduce and eliminate their stress and be truly happy. [] Second, patients and families will be happy because they will have contact with health workers who have entered into truth, goodness and beauty. [] This has been shown scientically to help cure disease. [] What is the best way to enter truth? To encounter suffering (prasop khwm thuk). Healthcare workers have a great opportunity to encounter suffering every day. This document is a manifesto for the reform of medicine, beyond the modern, into the heart of humanity (khwm pen manut). The word manut is difcult to translate, and human is a complicated choice. It calls to mind the rich conceptualization of anthropos, explored most extensively by Paul Rabinow (Rabinow 2003). In English, human has contradictory undertones. If one appeals to a common humanity, human is infused with ethical goodness that transcends the animal existence of man. But other uses, like: Oh, well, you are only human! imply the aws inherent in being the creatures that we are. In all, human stands in for a prole of what we are, our condition as moral beings. Manut is slightly different. In daily speech, it is often used interchangeably with khonperson. But in philosophy and religion, manut is opposed to khon, and is used precisely to differentiate ordinary people from those individuals who have engaged in enough introspective spiritual practice to encounter and embrace wisdom. In fact, many of my interview participants felt that the daily usage of manut as similar to khon was actually a slippage into Thai language from the English use of the word human, and that the more authentic meaning was the

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way that manut appears in religious texts. In Buddhism, humans have a telosa potential state of perfection, and thus an ultimate goal of livingin the form of the enlightened being (uttarimanutsatam)which translates literally as a human (manut) who has become so aligned with the wisdom of Buddhist teaching (thamma) to be freed from the cycle of suffering. Manut, then, is a person (khon) walking the path to humans telos, interested in gaining the wisdom that will take her there. Already, out of this basic explanation of humanity, a kind of ethical gure begins to emerge, a new imaginary of a clinical subject. Humanized health care proposes to reform medicine by creating an idealized image of the health care worker who pursues wisdom through the practice of medicine. Wisdom is further detailed as consisting of truth (khwm hing), goodness (khwm d) and beauty (khwm ngm), which in turn have complex denitions. Humanized health care contains a complete ethical framework, the center of which is manut, the human, whose purpose is primarily to face and understand the truth. This gure of the health care worker as seeker of wisdom proposes a ip in the clinical gaze. Instead of crafting oneself to gaze outward, to condently know concrete facts about anothers body in order to treat it, the gaze is inverted. One gazes outward to face truths that will craft an appropriate inner self. The reward for practicing this kind of medicine, according to the manifesto on humanized health care, is abundant happiness. Or in the words of Nurse Ampha, it is nding true value in ones occupation. The result is a new kind of clinical subjectivity. These philosophies have found their way into the mechanics of medical care, particularly into the rapidly growing eld of palliative care. In the 1970s, this new international medical eld emerged in Western countriesa modied version of hospice, emphasizing hospital-based and doctor-dominated expertise in care of the dying. This movement accelerated with the AIDS epidemic and a need for expertise to deal with the medical, spiritual and administrative consequences of a dramatic increase in the death of young patients in hospitals. Also core to the disciplines development were cancer care and the increasingly complex decisions required with evolving cancer therapies (Clark 2007). The eld arrived in Thailand in 1992 in the hands of Dr. Temsak Phungrassami, a radiation-oncologist from Songkhla who trained in Palliative Care in Australia and returned to teach the discipline in Thailand. He began by translating his Australian mentors handbook on Palliative Care (Maddocks 1992) into Thai. After Buddhadasas death in 1993, Dr. Temsak began to include a book about the teachers death in his courses (Prawase 1993). Over the following 10 years, the discipline took off dramatically in Thailand (Wright et al. 2010). Those hoping to design palliative care programs looked to Dr. Temsak as the source of wisdom and practical experience. Buddhadasas death, and the social issues surrounding it, became central in the teaching agenda of the evolving discipline. In the mid 1990s, a set of philosophically minded doctors at the Ministry of Public Health started a network of people interested in caring for patients at the end of life. The motivation for those involved in the network was similar for allfrom doctors, nurses, and alternative medicine practitioners to monks and individual meditators.

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Why did you get involved in this eld? I asked Dr. Sakon Singha, President of the palliative care network at the time of interview in 2009. Originally I trained as a surgeon, he explained. But I was not happy. I was just putting people back together, like a mechanic. I thought that maybe I wanted to be a scientist, so I went to study a PhD in transplant immunology in the UK. But I was still not happy. When I returned from England, I saw Dr. Temsak, who had started working in end of life care. He was so happy. And I thought to myself, I want what he has. I dropped everything and started studying end of life care with Temsak. Since then, I have been happy. I am lucky to spend every day thinking about the truths of nature. Thus two gures emerge from these movements, from Buddhika and Humanized Health Care and the new medical discipline of Palliative Care. One is the patient who faces reality, and by so doing understands the nature of existence. The other is the health care provider who encounters suffering as an opportunity to acquire wisdom. These two gures push on one another. They co-create. As nurses and doctors embrace the gure of the healer with true value, they begin to push patients to know about their deaths, to bring medical realities into the open so that their spiritual correlates become available for discussion. As patients embrace the gure of the patient who seeks wisdom through experience, they begin to push on their doctors and nurses to become the kind of practitioners who can discuss death openly and with spiritual wisdom. The dialectic interaction between these two new and idealized ways of being creates a healer-patient relationship that is full of persuasion and motion.

A Knot in the Heart This motion can be seen in one of Buddhikas central conceptual technologies for facing death: the knot, or pom. In general Thai, pom can be used to refer to a literal knot, but it appears more often in idioms for social or psychological complexity. Pom panh, literally knot-problem, means the heart of a situation, the part of something that must be loosened or untied for a problem to be solved. In psychology, pom means a psychological complex. In Buddhikas lexicon, pom is imported as a specic technical term to describe something that prevents peaceful death, a knot of mental worries that ties up a persons mind, preventing her from letting go and moving through death with an empty heart. The term was invented by Nurse Fong, a core teacher in the Facing Death workshops and the senior nurse in Dr. Temsaks department of radiation oncology in Songkhla. Nurse Fong developed the term over dozens of years caring for terminal patients to describe the obstacles she observed in peoples lives and minds that prevent them from letting go of life peacefully. I started using this word maybe twenty years ago, Nurse Fong explains to those who come to learn about death from her. I almost died myself. I didnt want to die because I was worried (hang), I still had something [in my heart]. I was unconscious, but I could hear everything. And I made a contract with the Messenger of Death (yomatt) that I would return and understand what was in my heart. And so

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I started working with dying patients. She made a commitment with Death to come back and understand pom, the obstacle that sits in ones heart at the edge of death, blocking peace. Nurse Fong has built the concept of pom out of so many peoples stories that by now she thinks only in stories. The word itself is an accumulation of a thousand intimate moments trying to push through the wall at the edge of patients deaths. Each time someone asks for a denition of pom, she reveals one of these moments. She never forgets anyone, a Buddhika training leader told me, she thinks with stories, and she never tells the same one twice. She must have hundreds I recorded dozens of these hundreds, myself. Here is one: One patient I remember fell from a truck while at work and lost 97% of his brain function. The patient cried when I said the right thing I gured out his pom and went straight to the right point, and he cried tears even though he was unconscious. But before I could talk about his pom, I had to nd out what it was from his relatives. I asked his wife what he was like before he was unconscious. One day, before the accident, he had said to his relatives that he wanted to make merit (tham bun) by making an offering to monks (sangkhathn), and that he missed his son, who was paralyzed. I was called to a palliative care consult because his wife wanted to remove the endotrachial tube [respiratory life-support]. But we could not remove the tube, because it is unethical. So I went to the patients room to ask his wife why she wanted to remove the tube. I asked the wife, and she said that she could not care for her husband because she had to take care of the paralyzed son as well. She wanted to sacrice her husbands life for her sons. I didnt think that he could live much longer, because of the brain damage. So I told the wife: you must be prepared, your husband may die soon. I told her to make an offering to monks in her husbands stead. When she was done, I told her to go to her husband and tell him that she did this and that he need not worry about it anymore. And I told her to tell the husband that he does not need to worry about his son anymore because she is taking good care of him. And then we arranged for her to bring the paralyzed son to the hospital to tell his father in person that he is okay, to say I am healthy and strong. You dont have to worry. All of these things were to untie the patients pom. And when all of this was done, the patient cried, even though he was unconscious. [] I told the patient that he had nothing left to worry about, so he should think about the yellow edge of the monks robes, to hold on tight to the robe. [The monk will lead him to heaven]. I told him: if your physical body (sangkhn conditioned thing) cant hold on, just let it go, and your mind will follow it. [] And the patient cried again, and died in peace very quickly. We were surprised because a few days earlier he was completely unconscious and would not react to anything. And now, he cried tears in response to what I said, and died peacefully. Pom is the knot of worries and fears that ties a person to this life and that causes the mind to hold on. It resides within a persons consciousness and radiates outward

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into their attachments in the external world. It is a mystery, both seen from the outside and from the inside, and it must be investigated, understood and then released. Nurse Fongs stories all involve similar elements. Patients shed tears once their pom is uncovered and untied. There is often a performance by those who love the dying patient, a performance that goes straight to the right point to release the knot. The pom is specic more than it is generalit is about the particulars of a persons mind and situation. The pom is like a tense muscle, wrapped around the mind of the dying patient. One must simply nd the right trigger point, press it, and then watch a wave of relaxation open into the patients mind. Buddhika uses this concept to help train people to face the truth of human existence at the end of life. It combines the knot (pom) and the concept of facing (pachen) to stretch the moment of death out until it includes an experience that can be faced. These technologies are designed to transform death into an experience that can be engaged practically. The pom is the name given to the aspect of inner identity that must be transformed with this new form of clinical subjectivity. We turn outward to the truths of suffering, to the nature of existence, in order to then turn inward to untie the knots in our own hearts.

Confessional Technology On the rst day of Buddhikas training, I am still disoriented. My Thai is inadequate. Standing in the hall before the afternoons activities, I ask a participant to tell me what is happening next. She is a nurse from an intensive care unit outside of Bangkok. Thai people are not used to sharing about themselves with strangers, she says. This is a big problem. How can we care for people at the end of life if were afraid to ask about intimate things? How can we know what to ask if we dont know how to share ourselves? We need to learn to break this habit in Thai culture. The next exercise is about this, about listening and telling. One way to release a pom is to talk about it. If we tell our story to others, we cannot trick ourselves into hiding from aspects of reality. Thus, Buddhika employs a series of confessional technologies. In the conference room, we break up into pairs, and engage in deep listening, staring into our partners eyes for long uninterrupted minutes, and then listening to them tell a story without breaking eye contact. Following this we sit in a larger sharing circle to tell stories about mistakes and sorrows from our past. As I sit down in the circle, I think of the myth that foreigners learn about Thai culture that they should not expect ever to get close enough to someone to hear their emotions. And I think that I have never seen anyone cry in public in Thailand. I have sat in open patient wards and watched families swallow unbearable tragedy and keep face for the people around them. But in our sharing circle, as people begin to tell their stories, the sorrow becomes thicker and thicker in the room. A woman in her thirties tells about her alienation from a schizophrenic father. A politician tells about relentless pressure from her parents to succeed, with the stress of their judgment weighing on her every hour and every failure. A doctor tells about losing

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his little brother to cancer, about holding him by the shoulders in his hospital bed as he died. At points, there is uncontrollable crying. At the end of our sharing, Phra Paisal summarizes the process we have just been through: When we talk about our selves (tua ton), it is difcult because we slam up against the reality of the self that we are in this moment and the selves that we have been before. Often our suffering is not from ghting with others, but because we ght with ourselves, because we cannot accept an aspect of who we are or used to be. We have all made mistakes and suffered losses in the past. If we look deeply at our mistakes, we will see that they are not our self in the present moment, they are part of past selves. We misunderstand them to be part of us. Talking about ourselves shows us this aspect of reality, and if we can accept this reality as it is, we can reconcile (khun d) or make a truce with (sangop sk) or befriend (pen mit) our former selves. This will increase our happiness, our steadiness and harmony in life. When we arrive at the end of life, if our present self can get along with our past selves, it will help heal us, help sustain us until we pass the end of life moment. But if we cant get along with our past selves, they may return to demand payment for moral debts (thuan bn khn) or haunt us (lk ln) and avenge us (ke khen) in our last moments. This is a terrifying idea. We need to befriend our selves, before we get to the last moment, or it will come and do us violence (ruk rn) in our weakest moments, especially at the moment when our breath stops. We must have the bravery to open and look deeply into our selves, to accept (ym rap) and face (pachen) this truth. As Phra Paisal explains, the moment of death, though important, is not enough. There is work to do in the period of life that precedes death, in the content of the fears and challenges to character that arise during the process of dying. During this period, we must have the bravery to face the truth and investigate it as material for understanding nature and acquiring wisdom. Confession is one of the technologies of the inward gaze. We must look outward to encounter the truth of nature, the truth of suffering. We must then use this experience to turn inward and craft our inner self so as to become free of suffering. And again, this process is dialectic between clinician and patient. We not only must become clinicians who gaze inward, but we need to elicit other peoples knots, other peoples obstacles, and help them to gaze inward. And in turn, by revealing their stories, we will face the truths of nature more intimately, and in turn gaze inward more deeply.

Imagination as Partial Experience Confession as a tool for revealing the disconnections between our past and present selves does little, however, to prepare us for the actual experience of our end of life. How can we prepare in advance for an experience we have never had? To do so, the Buddhika trainings use imagination, enactment, and encounterstools designed to use the important period of the end-of-life as an experience that contains the truths of nature.

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On the second day of the training, we gather into groups of three for a role-play. My two scene-mates are Songchai, a young pharmacist man with tightly cropped hair and preened clothes, and Noo, a middle-aged woman doctor with dark curly hair. In our confessional session, I had already learned about each of their lives. Songchai told the story of his sister who died from cancer 8 years ago. Noo told the story of her own battle with cancer 10 years before, still in remission now, but with some lasting side effects like back pain. We reach into a bag and withdraw our roles in the play. My role reads: You are the HUSBAND. Your wife has end-stage cancer. Yesterday, her condition worsened so much that you had to bring her to the hospital. The doctor tells you that your wifes bile duct has become obstructed from the cancer. She will need surgery, or she will not live longer than seven days. The surgery will not cure her cancer, but might make her live longer. But it could also have complications. You know that your wife would rather spend her last days at home with your two children (both younger than ten) than risk dying in the hospital. You want her to live as long as possible, but you understand her wishes and will support her in refusing treatment. I ask the others what their roles are. Noo has been assigned to play the patient with cancer and obstructed bile duct, and the Songchai is meant to play her brother. They look at each other and at me with wet, heavy eyes. The similarity to their real lives is uncanny. In real life, Songchai lost his sister to cancer, and now he will play an almost identical rolethe brother of an imaginary dying sister. His role in the role-play is to sit over her as she lies on the conference room oor, just as he sat aside his dying sisters bedside. In real life, Noo is a breast-cancer survivor, and she has drawn the role of an imaginary woman dying of cancer. So as she lies down on the training room oor, she is lying into her own memory of a nearly missed-death. I quickly realize that this role-play is close to home for them. Is this okay? I ask them. Can you do it? The young man smiles sorrowfully at me, already crying lightly, something I have rarely seen in Thailand. It is good. We need to face reality. The closer this is to the real thing, the better. In our role-play, Songchai has come to the hospital to convince Noo to accept treatment for her cancer. Sinking into the role, sinking into his past, Songchai argues with Noo, who is playing the role of his dying sister. Dont you remember, he says, how we used to play in the elds? And how our parents did everything to be with us? Dont you want more time, just a little more time with me, with your children? And the material, of course, is from his own life. He explains later that this role makes him suddenly remember wanting to yell at his sister, to make her live longer. The knot that was in his heart then, and still sits in his heart now, has come out into the room. And Noo, who in real life lived through her cancer, lies on the oor remembering what it was like at one time to think she was dying. In the exercise, we have imagined ourselves in the period of life before death. We do not imagine the moment of death, but the emotions and experiences of the period before death, when we need to negotiate our relationships, our fears and attachments, our many selves that must be reconciled to one another. What kind

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of gaze is this? We are imagining ourselves in the midst of the suffering that is inherent in the nature of human existence, and we are using the vivid experience of this suffering to understand our own minds and to free ourselves from illusion and pain. These clinicians are not training in empathy to better understand patients and treat them more effectively; they are using their patients suffering to experience a simulation of their own suffering, and then facing that suffering to craft an inner self. They are using patient experience to turn themselves into humans (manut), or as Nurse Ampha says, into the right kind of person.

Finding Reality to Face Thot and I walk through the crowded halls of Nakhon Pathoms Provincial Hospital, the central public hospital for a province neighboring Bangkok. We have come here on a eld trip from the Confronting Your Death Peacefully training to practice our new-found skills on real patients. Thot is walking slower and talking faster than usual, and from this, I know that he is nervous. He has also reverted to teaching me about Buddhadasa, a familiar and comforting topic for him. Thot is my roommate at Buddhikas training. I know from long evening chats that his goal here has little to do with learning to care for dying patients. His impoverished childhood was fraught with suffering and his family was full of mental illness. Thot threw himself into studies, became a dentist and devoted his life to making money. But the sorrows and insecurities from his childhood plagued him, and the more money he made, the less stable and happy he felt, until he nally turned to religious teachings to learn how to free himself from suffering. In his meditation practice, he discovered mostly fear, a fear of death and of connecting with other people. He came to the Buddhika training to learn to face and release his fear, and he hopes that after the training, he will be able to use his work as a path to spiritual freedom. Now we are walking through the hospital, with its throngs of patients and families and its open-air gardens, and I can feel the fear mounting in Thot as he walks next to me. Since my medical Thai is still awkward, we have agreed that today I will just accompany and watch. This makes Thot feel more comfortable, because he is worried I will accidentally open a Pandoras Box. But as he later explains, it is also terrifying, because he needs to run the show. The head nurse of the neurological ward greets us and tells us sparse details about the patient we were going to visit: She is hopeless, with a degenerative neuromuscular disorder, but no one knows how long she has to live. Also, the patient does not know that she is dying, so dont talk about dying. After this description, the nurse tells us the room number and turns back to her work. The patients door is open. We look in on a short hall that leads to a hospital bed and a mat rolled out on the oor beside it. A middle-aged woman, with a girlish face and a pear-shaped body steps up expectantly from the oor to greet us. Thot steps in ahead of me, his nervousness exploding out of him, and begins speaking rapidly. He says various iterations of: We are volunteers. Were here to give moral support (hai kamlang hai). The patient is connected to a respirator, but not through the mouth, through a tracheotomy. The middle-aged woman introduces herself as the

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patients daughter, and says that her mother can understand things, but cannot talk because of the respirator. We sit and say hello to the patient, who is lying still, strapped into the machines of modern medicine. She smiles broadly back at us. Over our shoulder, the daughter tells us that they want to cure her mothers disease and go home. Thot, clearly ustered by the patients inability to talk, tentatively reaches into touch the patients hand. The daughter smiles at this and tells Thot that her mother is unable to feel her body below the neck. At this piece of information, Thots legs begin to shake. For 2 days, we have roleplayed about how to talk to patients and how to touch patients, and here is a woman who cannot talk and cannot feel. Nothing about what is happening ts the image in Thots mind of how this interaction should go. Clearly, there is a knot (pom) in the room preventing the family from talking about death, but suddenly the way to unlocking it is opaque. Thot stands up quickly, fumbling: Im sorry, we have to leave. I am not good at talking, not good at talking. We are just here to give moral support (hai gamlang hai). Nothing more. Good luck, get well. And we shufe out of the room. Outside in the hall, Thot is visibly upset, perhaps even angry. They did not prepare us enough to do that. We have not been trained to deal with situations like that. How are we supposed to nd out the patients pom in there? I just dont know what to do But later, at dinner, his perspective has shifted. Thoughts about the experience overow: Being in the actual room, it was not about dying. It was about the family, and about talking. I didnt know what to say. I didnt know them and there was no time. I am not used to talking to people like that, about things that matter so much. How can I know what to say? I dont know how to just be in a place like that. This is so good for me. This last phrase, this is so good for me, strikes me. As he has explained several times, Thots purpose for being at the training has little to do with learning to take care of dying patients, about walking into a room of strangers and asking them intimate and dangerous things. How, then, is it good for him? There is something in me that keeps me from facing suffering, he explains. I dont want to talk about it with people. It is uncomfortable. If I can understand why, then I will understand myself. Thot has an image of himself, of the kind of person he wants to be. This is an ethical gure, a new kind of clinical subjectivity. He wants to be the kind of person who faces suffering, and uses the emotions that he nds there to understand the nature of his own mind. He wants to face the truth, and reveal that truth to others. When he arrives at his own end-of-life, he wants to encounter the difculties there and study them. And now, while he is not yet dying, he wants to practice health care in a way that brings him face-to-face with those realities. He wants to use health care practice, normally an outward gaze, to force himself to gaze inward instead.

Conclusion: Clinical Subjectivity, Clinical Practice In July 2007, the movements around the end-of-life in Thailand coalesced into a conference in Bangkok with over ve hundred participants, entitled Culture, Death

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and the End-of-Life (Komatra 2007). Participants were largely hospital administrators and medical educators, coming to learn palliative care to teach in their schools and wards. The keynote talk, by the famous physician Prawase Wasi, was about Buddhadasas death, about the rifts in Thai society that it laid bare, and the kind of humanized medicine that it called for. Phra Paisal gave a talk about death before death, about experiencing the end of life as a tool for honing the mind. Few emotions were shared. The conference was not about grief, or about counseling. It was about the mind, and using the experience of the end of life as a tool for understanding it. The centerpiece of the day was a documentary about the work of palliative care clinician Dr. Temsaks experience caring for a cancer patient named Supaporn at the end of her life. Supaporn had been a meditator her whole life, and when her breast cancer came, she talked her doctors into not treating it. She decided that she wanted to use the experience to study suffering. The tumor became necrotic, opening her chest up into a giant black hole of putrid dead tissue. She removed the bandages frequently to study it. She studied the pain and the nausea. She did not want opiate medications, until the end when the pain became so intense that it overwhelmed her ability to focus on it. She had to talk her doctors at various points into the merits of her approach. They were so used to ghting disease that they felt powerless in the face of letting it be. When I asked Dr. Temsak about the documentary, he said: We wanted to create a legend (tamnn), an ideal (tua bep) of the way that someones end of life could be. We hope that the legend will spread so that people know what is possible. This legend, of the patient and clinician who use the end of life to attain inner wisdom, is what haunts Nurse Ampha as she stands outside her patients room, wishing she could talk about death with the dying woman, wishing she could go into her room and directly face the reality of suffering. The legend is also what causes Ampha to gently push on her patients daughter, saying, maybe if you talked with your mother, you could chant together, or is there anything your mother would want to do with her last time if she knew she was dying? A new kind of clinical subjectivity has emerged, a shift of the clinical gaze from outward concrete sensibility, to inward ethical self-formation. It is a common subjectivity that unites both patient and practitioner. And so patient and practitioner push on one another, nudging the new subjectivity into existence. Supaporn talked her physicians into facing suffering and looking inward; Ampha gently persuades her patients daughter toward the same. This new gaze is inward instead of outward, but it crafts the concrete realities of dying in Thailand. Patients are beginning to know about their diagnosis and prognosis and make their own decisions. Clinicians, like Nurse Ampha and the thousands of clinicians who have attended the clinical training sessions, are shifting their care at the end of life to reect the need to experience suffering with a clear mind. Doses of opiates, palliative radiation and surgery, radiographs and labsall of these concrete technical practices are shifting their purpose toward crafting a particular form of inner self. Or according to Nurse Ampha, they are turning toward becoming the right kind of person, toward facing suffering and understanding nature.

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Acknowledgments I would like to thank Preeyanoot Surinkaew, Vincanne Adams, Sharon Kaufman, Temsak Phungrassami, Charles Keyes, Komatra Chuengsatiansup, Felicity Aulino and Phra Paisal Visalo for comments on this manuscript. I would like to thank the Pacic Rim Research Program, the Blakemore Foundation, the Fletcher-Jones Foundation and the National Institutes of Health for nancial support.

References

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English Language
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