Palliative Care...and care of the dying in particular, the practice of Hospice,  reminds us we are not alone in this life.  We are connected to all being that has ever lived upon the earth, and to all that ever will - Indeed, we are all a part of the life of the planet itself.  In spite of our seeming perennial conflict, our propensity to marginalize and often dehumanize one another, the pain and suffering we experience as individuals and as communities, we experience as a whole.  Rwandans say, 'Turi Kumwe' ~ 'We are together'.  And it's true. 

 

Care of the dying and its ability to break our hearts open to the realization of oneness - to unity beyond division, has the potential to meaningfully contribute to community based peacebuilding.   This is small 'p' peacebuidling, working from the grass roots, one person at a time, is reflected by the way in which we meet one another on the path and assert, 'N'amahoro ~ It's peace.    

 

In palliative care, we intentionally focus upon celebrating the value of us all, right to the moment of our final breath,  just because we are - as Dr. Cicely Saunders reminded us.   In these moments, together we gather to  bear witness to one another's journey, and in so doing foster a shared sense of common purpose and a community culture of empathic concern for the well being and enduring happiness of all.  This is what is meant by the Rwandan concept of Ubumuntu.    Ubumuntu buoys our courage and calls us to the practice of consistent and principled altruism, which is the realization of universal compassion, and compassionate action in ever widening circles - always beginning by coming back to our own good hearts.   That is where we begin to build peace. 

 

The emergent qualities of Ubumuntu and Compassion may be cultivated and grown within and amongst human beings, as has been demonstrated in the contemplative neuroscience and peace literature with such tools as  functional MRI, and various validated metrics.  This literature supports the premise that the tender shoots of ubumuntu  can be watered and grown to reflect a  'peace-oriented mindset.'   

 

Such findings in the literature may be particularly supportive of  peacebuilding efforts in communities where the population has been traumatized by conflict.  Post-genocidal societies represent particularly poignant examples of the principle, because in such circumstances, sacred reciprocity, vis a vis the culture’s relationship with the sanctity of living and dying, has been fractured.  This injury makes it difficult to trust one another and people often develop as a result, a modus operandi that author Jean Hatzfield refers to as the "Antelope Strategy,"  a strategy of hiding one's feelings, including anger, and righteous indignation, and pain - all to avoid being exposed and made vulnerable.  While it is surely adaptive in the moment, where one's actual survival is at stake, in the long term it separates us from our own good hearts and from one another. 

 

In a small town south of Kigali lives Ms. Sylvie U., a former social worker and survivor of the Rwandan genocide, who once heartbreakingly asserted that, “The genocide destroyed the sanctity of dying in Rwanda.”   

 

While the perspective expressed by Ms. U., that the harm of genocide is irreparable, while understandable and perhaps more prevalent that we know may exist,  we also have witnessed countless examples of the heartfelt and sustained aspiration to rebuild an infrastructure of just peace, where people in community are working tirelessly and often quietly to reclaim the sanctity of living and dying, fostering ever greater spheres of peace, peace that is equally a possibility in each new moment as it unfolds.  Peace that Etty Hillesum reminded us prior to her death at Auschwitz, is our  moral obligation to build in this life.   

 

By addressing physical, psychosocial, and spiritual needs, of dying human beings, their immediate circle, and the community writ large, palliative care practice can create sacred spaces of trust, empathy, community and shared understanding, potentially mitigating the effects of conflict and division and trauma.  We premise that this transformation can permeate and penetrate one's being to such a degree that it can even decrease the  likelihood of future calls to dehumanize our neighbors, and instead recollect that we are all in the same boat, that we all are one another's keepers, and in so doing integrate what we like to refer to as a ‘logic of reciprocity' as opposed to a 'logic of atrocity' which is pathologic in nature.   It is the logic of reciprocity that allows to maintain connection with, and as required reclaim our basic goodness.  

 

When presented in a structured and thoughtful manner where this concept of a 'consistent principled altruism' is modeled and practiced, we have shown in our bereavement retreats known as "Life After Loss Rwanda," that it is possible to transform and empower people to take up the role of empathetic and compassionate witness in the world.  These practices we undertake in palliative care, where our hearts are broken open, allow us to again glimpse the truth that no being can ever exist outside the web of mutual care and concern.   The poet Mary Oliver invited us to this realization in her famous and beautifully heart breaking poem Lead.

 

Here is a story
to break your heart.
Are you willing?
This winter
the loons came to our harbor
and died, one by one,
of nothing we could see.
A friend told me
of one on the shore
that lifted its head and opened
the elegant beak and cried out
in the long, sweet savoring of its life
which, if you have heard it,
you know is a sacred thing,
and for which, if you have not heard it,
you had better hurry to where
they still sing.
And, believe me, tell no one
just where that is.
The next morning
this loon, speckled
and iridescent and with a plan
to fly home
to some hidden lake,
was dead on the shore.
I tell you this
to break your heart,
by which I mean only
that it break open and never close again
to the rest of the world.

 

The web of mutual care and concern is that of inter-being, a concept elucidated by Zen teacher, Thich Nhat Hanh.   The idea is also conceptualized as Indra’s Net, the metaphor for an infinite number of linked nodal points, where each point is an infinitely faceted gem, interpenetrating all of being.  This web and these facets, which are the totality of all sentient beings, do literally extend to the entire biosphere: the reality of our birth and also our dying and death makes this abundantly clear.  

 

HWB asserts that palliative care contributes to peacebuilding as follows:

 

1. Addressing Universal Suffering:

Palliative care recognizes that suffering from illness and dying is a shared human experience, transcending cultural and political boundaries.

 

By providing compassionate care to the seriously ill and dying as well as to their entourage and to all those who we meet on the path (twahuriye mu'nzira), palliative care can create space for dialogue and understanding, even in the midst of conflict and division. 

 

2. Promoting Compassion and Empathy:

Palliative care focuses on alleviating suffering, which can be a powerful tool for building empathy and compassion within and across communities.

 

When people witness the care and support provided to the dying, it can foster a sense of shared humanity and encourage a more compassionate response to the suffering they meet along their own path, conceivably independent of the context of care of the dying.   Empathic concern does not stop at the doors of the hospice.  We take that commitment to bearing witness, humility, and compassionate action out into the world. 

 

3. Supporting Mental Health and Emotional Well-being:

Palliative care addresses psychosocial and spiritual needs, such as anxiety, depression, and grief, which are so often exacerbated by conflict, whether within the individual, the family, the community, the nation, or internationally - regardless the scale and nature of conflict.   By providing mental health support and spiritual guidance, and bereavement care to promote adaptive adjustment in the face of loss, palliative care can help individuals and families cope with the emotional and psychological impact of violence and displacement. 

 

4. Creating Spaces for Healing and Reconciliation & Conflict Transformation:

Palliative care can create safe and supportive environments where individuals can process their experiences, express their emotions, and find meaning in the face of adversity and suffering.   

 

This emergent capacity for individual, family and community transformation can be particularly important in post-conflict settings, where reconciliation and healing are essential for rebuilding trust and social cohesion. 

 

5. Advocating for Human Rights:

Palliative care advocates for the rights of the dying and their families, including the right to dignity, respect, and access to quality care including the right to be free of suffering and to be happy.   Equity for all, in particular for the most vulnerable.

 

By raising awareness of the mission and vision and scope of palliative care practice, it has the potential to contribute to broader efforts to promote human rights and social justice in conflict-affected areas. 

 

6. Building a Foundation for Community Resilience:

Palliative care can empower communities to address the needs of the most vulnerable, including those facing life-limiting illnesses, death, and displacement.

 

By building capacity and strengthening local community resources and resourcefulness, palliative care can contribute to community resilience and preparedness to avert future crises.   Perhaps not all, but some.  Why?  Because we are cultivating that Peace Orientation.  

 

In summary, palliative care's focus upon compassionate care, empathic concern, and psychosocial and spiritual support can provide a powerful tool for peacebuilding by addressing the root causes of conflict such as ‘fear of the other’ thus promoting healing, hope, a recollection of our shared humanity, and in so doing contribute to fostering a more just and compassionate world. 

 

David Slack MD