Mindfulness, Ethics and End-of-Life Care: The impact of Canada’s Supreme Court decision

Today, February 6, 2015, the Supreme Court of Canada allowed the appeal against the “blanket prohibition on assisted suicide.” An earlier appeal by Sue Rodriguez (Rodriguez v. British Columbia) in 1993 to have the Criminal Code ruling against assisted suicide declared unconstitutional was denied. The upholding of the current appeal (Carter v. Canada) is destined to be controversial for many reason, not the least of which is the ethical weight it will place on health care practitioners. The ruling is clear that while the Criminal Code is still valid for assisted suicide, it is over-reaching in its application in regards to persons who suffer from intractable medical conditions that compromise their ability to live well. It states that the Criminal Code infringes on the individual’s “right to life, liberty and security of the person and the right not to be deprived thereof except in accordance with the principles of fundamental justice.

“…and are of no force or effect to the extent that they prohibit physician‑assisted death for a competent adult person who (1) clearly consents to the termination of life and (2) has a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition.”

There will be many issues to clarify as this ruling enters the health care system. Parliament could enact a legislation should it “choose to do so” though whether it will be in favour is in some contention given the current government’s opposition to assisted suicide. Not only are there definitional issues, there will also be issues of a chain of decision-makers who can effectively guide and support individuals who wish to avail themselves of this right. Ultimately, one would hope this does not become a decision that is relegated to the hands of a few but one that will be made in community with compassionate support and wisdom of our past experiences. In order to meet these demands, we will be called upon to examine our own values and conscience with regard to a primary precept we hold, especially as mindfulness practitioners: What are the nuances of the ethic of respecting life in this context?

Can Mindfulness Practices Have an Ethical Role in Physician-Assisted End-of-Life Care? stump w flowersThe complex issues facing us will be challenging. More and more in the writings on mindfulness, an important point is being made that the practice of mindfulness must contain an ethical core. That means not doing harm, avoiding acts that encourage or precipitate harm, and respecting life in all its intricacies. Will we therefore wonder, as mindfulness teachers, if supporting requests for mindfulness training in cases of assisted suicide is ethically within our scope of practice? There are no easy answers however, as with all koans it invites us to examine how these questions play out in our life.

A common question asked of secular mindfulness teachers is – given the purported absence of ethics in a mindfulness program – whether one can therefore rob a bank mindfully or shoot and kill someone mindfully. This argument maintains that what we learn in a mindfulness program is how to pay attention to what is unfolding in the moment and letting it be. Thus, we can bring our attention to the gun, the bank, the person we are about to kill and let that be without engaging in any critical thinking that may have us wonder if this is the right thing to do. Similar arguments may end up being levelled against an involvement of mindfulness teachers in end-of-life care that involves assisted suicide. (I should note that end-of-life work by many conscientious and compassionate colleagues is a powerful part of health care.)

It’s important to ask these questions. It’s also important to use the right understanding of what mindfulness practice actually is. If paying attention is the sole characteristic of a “mindfulness” practice, then the practice is missing a crucial component. Attention by itself generates raw and unusable data. Heat, cold, tingling, blue, red, grey, snow, sun and so on are data points but have no intrinsic ability to change our life path. Remembering consequences of past experiences and recalling our intention for paying attention makes the data meaningful. Mindfulness practice is the opportunity to cultivate wisdom from information to which previously we were reactive but which we now can hold with equanimity to facilitate a better choice. So, there is no mindfulness involved in knowing one is in that bank with a gun pointed at the clients and employees. Mindfulness is in remembering that this action is about to bring harm and recalling a core value.

How might this play out in the potential future of end-of-life and assisted suicide? We have to ask which carries the greater potential to harm: teaching someone to “live well” with a grievous, intractable, unendurable illness or teaching them how to be truly mindful by opening to all the consequences of their wish to be free of pain and suffering. I believe, in this context, the former risks reducing our work to trite phrases like “be grateful for the life you have,” “be in the moment,” or any of the aphorisms we find in mindfulness memes these days. The later however may allow for a clarity of mind in our clients and therefore a range of decisions they can make in conjunction with family, faith communities, physicians, psychologists and all other health care support available to them.

We are entering interesting times.

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Edited at 16:43 for typing errors & paragraph spacing.

We are 10 Years Old!

Ten years ago, we (Frank Musten & Lynette Monteiro) were inspired by the development of Mindfulness-Based Cognitive Therapy (see Mindfulness-Based Cognitive Therapy for Depression: A new approach to preventing relapse by Zindel Segal, J. Mark Williams & John Teasdale; Guilford Press) and, after a brief correspondence with Dr. Segal, launched the Ottawa Mindfulness Clinic. It was a scary venture despite our experience as therapists and use of meditation in individual sessions as an adjunct to progressive muscular relaxation. We also were refining our experiences in the Buddhist community, learning more and more about the foundations of mindfulness, in particular the role of ethics in guiding lifestyle changes. The program took shape as a process of understanding the nature of “symptoms” which reflected our clinical training and interest in finding a way view psychological difficulties such as depression and anxiety as an interaction between internal and external sensation experiences.

OLYMPUS DIGITAL CAMERAThe concepts of mindfulness were still new and not always welcomed by the medical and psychological communities then. So much has changed since! The first class started in May 2003 and was held in a conference room at the Riverside Hospital. It was so crowded – not because of a large enrollment but because of a three-piece horseshoe conference table that took up most of the space. When we did the Body Scan, some participants had to lie down with their legs out the door or under the table itself; one even lay down on top of the table. Still, despite the random sounds of walls and doors being drilled during the Awareness of Breath meditations, transformations occurred.

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The next year the OMC moved to a little space that resembled a very short bowling alley. Here, courses in Mindfulness-Based Symptom Management (MBSM) unfolded over many years. Participants joined us to learn how to breathe through physical and emotional pain, with joy and woe, in sickness and health. It was a joining ceremony in each class, meeting ourselves for the first time and embracing this stranger we had become. It didn’t matter whether we spoke of teacher or participant; change happened.

In 2008, we began the Teacher Training Program at the request of many colleagues. The focus on an Ethics-Based Mindfulness Program was appealing for many professionals who understood intuitively that healthy choices could only come out of a set of principles that directed those choices. The Five Skillful Habits, as the core of the OMC program, was innovative and participants as well as teacher trainees welcomed the idea that skillful choices cannot be left to a process of “just paying attention.”

The OMC moved into new space five years ago and now is composed of several wonderful teachers who facilitate courses in Core Mindfulness, Burnout Resilience, Self-Compassion for Health Care Professionals, Pain & Chronic Illness Management and who coach the Teacher Training Retreat. The OMC is also a Practicuum training facility for PhD candidates in Clinical Psychology at the School of Psychology, University of Ottawa.

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We have been blessed with the generous involvement of the Ottawa community in creating this safe and quiet space where so much healing can happen.

Book-posterOur future is bright and exciting. Our book, Mindfulness Starts Here: An eight-week guide to skillful living, will be published soon and we look forward to continuing to offer our support and care to an ever-growing community of mindfulness practitioners.

Thank you for all you have done to make this a reality!

An Ethical Path to Compassionate Community: The fire in the heart of mindfulness

(This is a transcript of talk given at the inaugural meeting of Mindfulness Ottawa, Ottawa ON 2012 November 21.  The preliminary section on “laying down the path by walking” has been excluded.)

Let me share here what we have distilled out of 10 years of our path – what Zen teacher Suzuki Roshi calls “one continuous mistake.”

 

 

 

Mindfulness-Based Interventions are composed of three components:

1 – Contemplative practices, in particular sitting, walking, lying down meditations;

2 –Buddhist insight that experience can be perceived in this moment through our six senses, is knowable, and constructed or an emergent property of a myriad of sensations[1]; and

3 – Western psychological theories that propose experiential avoidance is the root of our psychological difficulties.

These three components underlie the various forms of Mindfulness-Based Interventions (MBIs).  Specific programming may hold one or the other of these components in the foreground but that’s a reflection of the individual intent of the program.  This model is not just about what we do in teaching mindfulness skills; it is also about who we are. Furthermore, it applies to us as individual teachers of mindfulness practices and – most important – as an evolving community of practitioners.  

First, to evolve from our complex history and emerge as beings open to intimate connections, we – as teachers of mindfulness – are called upon to cultivate a contemplative life, engaging in practices that steady us in the face of personal and professional challenges.

Second, to co-create a community that is supportive and compassionate, we need to examine our experience and relinquish our perceptions that we are separate from one another.  We need to begin to see ourselves as emergent properties of an innumerable set of interactions.  This, more than anything else, calls forth the practice of sila or ethics.  It is not a call for moral constraints or moral code but of a considered approach to what brings us mutual care and encouragement.  I’ll expand on that in a moment.

Third, we are not immune to our own tendencies to experiential avoidance.  As health care providers, we have both personal and professional agendas that set our intentions when we teach.  We have our fears of disappointing, not meeting expectations, feeling insecure. 

We slide into adaptations when we are uncertain of the impact of what we are doing.  And, this is our work: to face our own nature and be intimate with it.  To bring best practice to our work, we begin by reaching deep into our professional training – whatever that may be – and stepping out from there.  We remember – the meaning of sati or mindfulness – that our love for this mindful path arises from our passion for what we already do for others.

Now, let me return to ethics, the fire in the heart of mindfulness:

Laying down the path to community is a challenging one.  Laying down the path to a compassionate community can be both challenging and threatening to many who may see it as mushy tree-hugging. 

In Buddhist philosophy, ethics is made up of compassionate action, discerning livelihood, and compassionate communication.  However, in a market economy, it is a challenge to turn away from our survival-derived impulses to competitiveness, ownership, and exclusion. Continue reading

Fostering the Mind of Poverty

Is it unethical to bring awareness to certain life circumstances?

by Lynette Monteiro & Frank Musten

The Ottawa Mindfulness Clinic Teacher Training Retreat brings out the best in our participants and this session was no different.  One of the questions that arose from our examination of the impact of the various exercises we invite a class to do was particularly thought-provoking.  This question is also central to refining our intention as teachers of and participants in any Mindfulness-Based program.

“What are the ethics of an exercise that brings attention and awareness to a lack in their life?”

We take many levels of our comfort for granted; Cheri Maples, co-founder of the Center for Mindfulness and Justice, calls these assumptions “unearned assets”.  By virtue of our gender, race, creed, and access to education, certain avenues that get us what we need are available to us.  By virtue of our education, we enjoy a “value-added” level of credibility when we speak to people.  Our patients grant us, in our initial meeting, a trust and assumption that we likely are competent because of the title and degree.  We don’t have to work for these “credibility assets” because they come as a package along with the labels.

The specific question asked by one of our participants was about the ethics of asking someone to do the raisin exercise if this person may be in a financially tough situation and may not have enough food at home.  On the surface this may seem like a non sequitor however it raises a deeper question about the impact of our work as mindfulness teachers.  What are the unearned assets we bring to class?  What are the assumptions we operate from that could highlight a hardship or a lack in our participants’ lives that may not be helpful?

This is a tough and complex question.  Let’s look at the intention of mindfulness.  It is to bring not only awareness but also value to our life as it is.  Our tendency is to only see what is missing, to see the glass half full.  When we start from this stance our tendency is to continue down the path of probing for lack.  “What if my participants don’t even have a glass; what if they don’t even have potable water?”  This is where, we believe, the true work of practice happens.  The issue is absolutely about the glass and the water.  And it is neither about the glass nor the water. Continue reading

A Rationale for an Ethics-Based Mindfulness Program

This is a slide from Dr. Richard Davidson’s keynote speech at the 10th Annual Scientific Conference of The Center for Mindfulness in Medicine, Health Care, and Society, March 31, 2012.  The text in the second bullet reads: Basic research on “naturally occurring” virtuous qualities; Toward a scientific foundation for secular ethics.

The third bullet reads: Research on contemplative practices other than meditation; e.g., intentions and vows.

These are two issues very close to the heart of the programs at the Ottawa Mindfulness Clinic.  Beginning with the second point addressed by Dr. Davidson, the underpinnings of mindfulness are described (see research by Shauna Shapiro and colleagues) as intention, attention, and attitude.  Other writers, both from mindfulness and Buddhist Psychology, emphasize the need for creating an intention which directs the attention to cultivate a particular attitude to our experience.  Intention forms the foundation of the practice of mindfulness and it is a necessary component of practice.  It is, at the heart of practice, the means by which autopilot is interrupted and compassionate attentiveness is given to the moment.

Dr. Davidson’s reference to secular ethics is an important consideration.  It opens to a debate that has flowed in Buddhist circles for centuries and perhaps reflects more of a habit than any real schism of ideology.  One set of teachers views ethical behaviours as an emergent property of practice.  Another school of teachers suggest that while this is true, it cannot be left to happenstance and the ethical actions require conscious cultivation.

Regardless of the different points of view, the endpoint is the same: both perspectives require active, intentional practice of actions that are guided by ethics.  As we cultivate our meditative skills, we become aware of the impermanence of life, situations, and feelings, of our deep interconnections with each other, and of the universal nature of suffering.  We cannot help but feel compassion and empathy grow from this deep profound insight. We practice meditation in all forms, formal and informal, to cultivate this realization that we have choices in the actions we activate.  And in those moments, we practice intentionally choosing the actions that reflect respect for life, generosity, unexploitative relationships with each other and ourselves, mindful speech, and mindful consumption.  We are both motivated by compassion to practice these actions and these actions deepen our capacity for compassion.

Meditating without awareness of the intention to cultivate an ethical lifestyle is possible.  There has been much in the news recently about Norwegian Anders Breivik who killed 77 people including children in 2011 and claimed he practiced meditation to numb himself.  While it would be possible to argue about whether he was “meditating” or not, it is more important for teachers of mindfulness skills to understand that a practice of sustaining attention and cultivation of a particular attitude can result in a belief that the practitioner is “freeing themselves” of emotions.  Without the litmus test of ethical choices, this “detachment” is easily mistaken for acceptance or equanimity of the individual situation or feeling state.  In other words, intention while necessary is not sufficient and directionality of that intention must be included in practice.  Even Breivik referred to his meditation process as “de-humanizing” – an outcome in direct opposition to the intent of a mindfulness practice of becoming more open to our humanity.

In traditional practices, usually Buddhist but actually any contemplative practice, the guides of intention are a set of ethical values.  Typically there are universal virtues but these can also be spiritual or religious ones.

It will be interesting to see where Dr. Davidson’s call for a scientific study (and hopefully inclusion) of “secular ethics” in the mindfulness realm of interventions will take us.  Hopefully, it will be to a deeper understanding of our responsibility to each other and the world.

Dr. Richard Davidson’s research and papers are available at Center for Investigating Healthy Minds.

The critical role of ethics as process in an MB program – a gentle critique of Grabovac, Lau and Willet’s article

A recent article, Mechanisms of Mindfulness: a Buddhist Psychological Model by Grabovac, Lau and Willett in Mindfulness attempted to re-insert Buddhist Psychology into the foundations of Mindfulness-Based Stress Reduction. Grabovac and her colleagues did a good job of putting the Three Dharma Seals (impermanence, suffering and nonself) into the service of explaining the mechanisms involved in mindfulness-based interventions. Drawing partially from the Abdhidhamma (the texts that form the basis of Buddhist Psychology), they worked out a pretty good set of visuals that lead us through sense perceptions, attachment/aversion, and the generation of suffering and nonself. I found their explanations of the concept of nonself narrow, but that’s not as critical as what comes next.

About halfway through the article, they address the role of Ethics (sila) in the cultivation of mindfulness. After listing the Five Precepts (not killing, stealing, engaging in sexual misconduct, lying, or using intoxicants), Grabovac and colleagues make what is likely one of most faulty statements of the intent of a practice founded on sila.

(O)ne of the major purposes of the ethical guideline is to reduce the baseline amount of mental proliferation, thus aiding both concentration and mindfulness practices… Leading an ethical life, in the context of the (Buddhist Psychological Model),implies that the meditator experiences less guilt, doubts, worries, etc. that can often be a source of mental proliferation.

I don’t think one can get more off-track than this. In effect, Buddhist Ethics are reduced to a utilitarian process of feeling good. In terms of Kohlberg’s moral development that makes Buddhist and Mindfulness-Based Stress Reduction practitioners capable of not much more than the second level in which we choose the “right” thing to do because it gets us something in return. What Grabovac and friends have missed is that sila plays an equal role (if not more so) to Wisdom and Concentration in the triumvariate model of practice. (The Buddhist practice model is formulated by the Eightfold Path which is categorized into Wisdom, Ethics, and Concentration.)  It is more than just doing something to get something in return. And perhaps, this is where I find the teaching of Mindfulness-Based courses to be inherently limited if we stop, as most courses do, at symptom relief -and that includes “feeling good.”

The ethics of a Buddhist Psychological or Applied Model requires opening to our interconnectedness (non-self is the start point). The practice of the Five Precepts (or Five Mindfulness Trainings of Thich Nhat Hanh) is more than about avoiding a poor rebirth or ensuring some Thing for ourselves. To miss this, places their translation of Dharma into Psychology on very shaky ground. In fact, I think it just collapses.

It’s disappointing that researchers who put so much into developing a bridge between the two worlds would have missed something so critical and obvious. And in a journal of some repute, it concerns me that readers not well-versed in Buddhist thought will take the diminishing of Buddhist Ethics to a utilitarian role as a fact. I haven’t seen an open challenges to this part of the article. Perhaps it will come soon.