The Natural Death Centre keeps track of research on the subject of death by fasting - see, for instance, the award-winning article 'Fasting to a comfortable death' by Chris Docker in Creative Endings (Natural Death Centre, 1996). The following article by Christopher Justice, entitled 'The natural death while not eating - A type of palliative care in Banaras, India' - is adapted from the Journal of Palliative Care (1005;11(1): 38-42; editorial address: David Roy, Centre for Bioethics, Clinical Research Institute of Montreal, 110 Pine Avenue West, Montreal, QC, Canada, tel 001 514 987 5617; fax 001 514 987 5695).
The necessity of feeding and hydrating gerontological and terminally ill patients is currently quite a controversial ethical and legal issue in North America (1). In the home environment, there is often pressure from family members for an old person to continue to sustain his or her self by eating and drinking. In the hospital, where the vast majority of people in North America die of old age and lingering terminal disease, nutrition and hydration are provided as a matter of course (2,3). When they are not, staff feel pressure from family members to provide nutrition and hydration, thereby 'unnaturally' extending the dying process as well as exacerbating certain physiological problems (2).
Food and the provision of nutrition are laden with cultural meaning. In the literature on the ethics of dying can be found statements such as "food and water are not the only good that preserve life and provide comfort, they are also symbols of care and compassion" (4) and "The feeding of the hungry ... is the most fundamental of all human relationships" (5). According to Callahan, while Karen Ann Quinlan's father was fighting to have his daughter taken off her respirator, he was amazed when asked if he wanted her intravenous feeding stopped too. "Oh no," he reportedly said, "that is her nourishment" (5). Taking her off the respirator would have been letting her die, but stopping her feeding would have been killing her.
This paper speaks to the issue of sustenance at the end of life through a cross-cultural example from a context where the meanings attached to eating and its relationship to dying are different from our own. [This paper deals primarily with death at the end of the natural life cycle as opposed to premature deaths from 'unnatural' causes. This distinction, while seldom made in thanatological literature, is stressed in Hindu eschatology and forms the basis of a dichotomy between good and bad deaths]. Here I describe the type of death which occurs in a palliative care institution in Banaras, India, where I conducted ethnographic research during 1990 and 1991. These deaths are those of old people who, as they feel their lives coming to an end, leave their friends and the familiar surroundings of their villages in order to die in their holy city.
Banaras, or Kashi as it is called by pious pilgrims, is situated on the river Ganges and is about halfway from Delhi to Calcutta. Banaras is a major destination of pilgrimages, and thousands of people stream into the city to take holy baths in the river and to accomplish any one of hundreds of possible spiritual objectives.
Banaras is famous in India for death. Death in Banaras is associated with the attainment of moksha, which for most people means liberation from the eternal cycle of birth, death, and rebirth. It is the ultimate spiritual goal of most Hindus. In order to secure moksha for dead relatives, bodies are brought from far and near to be burned in the city. Some people who live too far away from Banaras to bring a body cremate their relatives at home and mail the ashes and pieces of unburned bone to a Banarsi priest to be blessed and then immersed in the river. There are other people who believe that cremation in Banaras is not enough; they make a pilgrimage to Banaras while still alive in order that they might die there. For them it is the act of dying in the holy city that yields the great spiritual reward.
The people coming to die can be divided into two types. Many come at a stage in their lives when they are essentially retiring from their worldly duties. They come from all over India desiring to live the rest of their lives in Banaras and eventually die there. On the other hand, the people who end up in the palliative care institutions come from the poor farming villages of the region around Banaras. These people have no desire to live in Banaras, only to die there, and so wait until the last possible moment before setting off with their families.
Banaras has probably been attracting people to die for a very long time. The city developed at least 2000 years ago as one of the three places on or near the Ganges river and in the heart of orthodox Hinduism with some special relevance for death. Somewhere between the third and eleventh centuries AD, the composers of Puranic literature "fixed the major lineaments" of the sacred geography of India and secured for Banaras a reputation as an important centre for death (6).
It is rumoured that before the British arrived in India, pilgrims used to come to Banaras and commit religious suicide. What is more sure is that about 60 years ago, some Hindu industrialists saw that there were many old people coming into the city to die a natural death who had no place to stay. They set up the first of the cities muktibhavans literally houses of salvation - with the charitable intention of providing shelter for the dying pilgrims. Since that time another two have been set up, one of which was closed some years ago. Most of my research was conducted in the newest of the muktibhavans, which began operation about thirty years ago. This one is now attracting the majority of dying pilgrims as a result of providing, in addition to shelter, a religious atmosphere in which to die.
The new muktibhavan i a large building in the centre of the city. Inside, there are eight rooms where dying people and their families can stay, a simple office, and a room in which worship takes place. Around the building are small rooms for the staff and a garden lined with holy Tulsi plants. The leaves of these plants are infused in water from the Ganges to form a powerful substance; a few drops of this are given daily to dying patients. Compared to the surrounding buildings, and those of the villages from which the people come, this muktibhavan i luxurious. For the dying people and their families it is a place of wonder - a place such as they have probably never seen before, let alone had the opportunity to make their temporary home.
Having reached the muktibhavan, the dying person and his family are registered and given a simple room in which to stay. There is one wooden bed but it is generally not used because the dying person sleeps on the hard floor, with the rest of the family, where it is better to die. The muktibhavan sstaff consists of priest-workers who live there full-time. Their job is not the physical care of the dying person - which is solely the family's responsibility - but his or her spiritual well-being. The priest-workers chant the name of God 24 hours a day, read religious stories to the dying persons, and conduct rites of purification over them.
The priest-workers, as well as the families, expect that people will die very quickly once they have reached the muktibhavan. They give rooms, according to one priest-worker "only to people who look like they will live three to four days" and often the family will come thinking they will be away from home for just a short time.
For the one-year period between July 1990 and June 1991, 365 people registered at the muktibhavan. Approximately 90 per cent of these people died and the remaining 10 per cent were taken back to their villages. People die remarkably quickly after arriving at the muktibhavan. 129 people, representing fully 40 per cent of all those people who died there, died on the very day they arrived. Many of these people died only hours after being checked in. Those people who did not die immediately did not, for the most part, linger very long. Eighty-four per cent of muktibhavan aarrivals died within one week and virtually everybody had died by the 17th day. This corresponds with the muktibhavan's written, but unenforced, rule that dying people can stay there for a maximum of 15 days.
There are a number of possible explanations for the speed with which the patients tend to die after arriving at the muktibhavan. For instance, some people may be somehow holding on to life in order that they may reach their chosen place to die. Alternatively some deaths may be accelerated by the rigours of the journey or from the emotional trauma of having left all of their friends and the familiar surroundings of their homes and villages. I believe that both these processes occur to some extent. But I am here interested in another explanation: that some families are able accurately to recognise the signs that allow them to anticipate correctly when someone is dying and to wait until the very last possible moment before setting off from home. They are able to do this because the type of death they are witnessing is familiar and therefore predictable.
One of the characteristics of the type of death occurring at the muktibhavan i that the people who are dying are old. There is a rule, unwritten but enforced, that people must be over 60 years old to be eligible to stay in the muktibhavan. In fact, the average reported age is 80 years. [Many people do not know their ages and so estimate them, as evidenced by a preponderance of numbers ending in zeros and fives. In many cases, ages are exaggerated as well as estimated]. There is another rule which states that people with an infectious disease - a category which here includes cancer - may not stay. From the perspective of the muktibhavan staff, everybody must be dying a 'good' death, which in this case means they must be dying a death of old age and one which is natural in the sense of being free of disease.
However there is another characteristic of the deaths occurring at the muktibhavan. This is illustrated by one of the priest-workers who began in the following way a description of the people who die in the muktibhavan:
"The people who come to this place are those whose final stage has come and who have stopped eating and drinking."
It is an accepted and unremarkable fact to the priest-workers that, for the most part, those people coming to die at the muktibhavan aare no longer taking food and liquids and in general have given them up quite some time before arriving. The muktibhavan ddoes not have a rule that dying people cannot eat, but the priest-workers assume that a dying person who is eating is not close enough to death to be staying in the institution. Seventy-four of eighty-one families whom I questioned indicated that the dying person they had brought was at that time not eating. Many people told me that the dying person they had brought had not been taking food or drink for as long as several weeks or a month.
The people whom I got to know and whose dying experience I followed almost invariably had given up food. No one case is typical but here is a brief example:
"A man named Singh was brought to the muktibhavan. His son-in-law told me that Singh was 105 years old. He did look pretty old, but not particularly feeble compared to many of the other people who were there to die. The colour of his face and hair had converged, giving him a look of lifelessness, and his arms were strikingly thin and a little flattened. His son-in-law told me that he had recently stopped speaking. He could, however, still hear and understand what was going on around him.
"The family, themselves, recognised that Singh was dying. They never heard the opinion of a doctor and they didn't need to: Singh had stopped eating food. His son-in-law explained it like this:
" 'His soul or atman, is no longer demanding the food. Slowly the atman has given this answer, because he is very old.'
"The son-in-law insisted that he hadn't actively decided to stop eating, he had simply lost his desire for food. 'People automatically do not desire food and water as their death approaches. It is not a good thing, to eat just before dying.'
Four days after he stopped taking food, Singh asked his family to take him to Banaras to die. Two days later they set off for the holy city. Just before they left the village many people came to see Singh off. They touched his feet and said things like: "Now you are going to Banaras and nobody knows if you will come back to be with us." They also asked Singh to forgive any mistakes they had made and to give them his blessing.
"When Singh arrived in Banaras, he had been off food for six days. Gradually he became weaker and weaker and after being in the muktibhavan for 25 days, and off food for 31 days, he died quietly. The family agreed that it had been a very good death."
Mr Singh was an anomaly in the sense that he stayed at the muktibhavan for 25 days before he died. However the manner in which he died was not anomalous; he was simply brought 'early' in the dying process. Typically, the people coming to die are coming 'late' in the dying process - as close to the last moments as possible. Often the dying person has performed a gau dan ritual which involves the gifting of a cow before giving up food. As this ritual is done in preparation for death, this suggests that individuals understand that death is approaching before they give up eating. The family recognises the cessation of eating as a sign, not a cause, of dying; they classify an old person as dying at the time that they stop being interested in food. If plans are made to take the old person to Banaras to die, the family usually remains in the village until they estimate that death is imminent - a point usually signalled by the dying person ceasing to communicate.
It is likely that the close correspondence between the times of arrival and death is due, at least in part, to the fact that people give up food. Because the dying person gives up sustaining his or her self, the process of dying occurs in a more or less predictable manner. This allows people to arrive in Banaras just days or sometimes hours before death.
The question is: why are these people giving up food?
There is a small body of literature which focuses on appetite loss among elderly people. It is generally accepted that food intake decreases with age and that often elderly people report a decrease in appetite (7). The literature often assumes that these changes are problematic and it has been suggested that they may be a result of increased depression in old age (8). The literature generally assumes that it would be good to restore 'normal' eating behaviour and some of it (9) takes the restoration of appetite in the elderly as the primary focus.
Sensitivity of taste and smell decline progressively with age, but this has not been linked to appetite loss and elderly people seem to report no corresponding decrease in the appreciation of food (7). There is some evidence that natural regulatory changes with ageing may affect hunger and food intake, however. Older rats have been shown to have decreased opioid peptides in the hypothalamus, a factor which has been linked to the palatability of food (10). Elderly human subjects have shown reduced ability to experience the sensation of thirst after dehydration, due in part to changes to receptors in the central nervous system (11).
There seems to be general agreement that dying people, as distinct from elderly people, lose their appetites and do not eat much on their own (4). There are also anecdotes of animals, eg dogs and cats, who stop eating many days before their deaths, and it seems that the cessation of eating as part of a general withdrawal preceding death is common in domesticated animals. Though this is only suggestive, the implication is that the cessation of eating before dying is a 'natural' process because it occurs without cultural mediation.
Though it might in some respects seem an unmediated process, the cessation of eating among the people dying at the muktibhavan is also inherently cultural. Cessation of eating is connected to several things which the people coming to the muktibhavan regard as aspects of a spiritually good death. For instance, when food has been forsaken, life leaves without a struggle. A struggle at the end is a very bad sign in terms of judging the fate of the soul (atman) Giving up of food early in the dying process also has the effect of making the death predictable, and self-controlled - an ideal of death illustrated by such famous deaths as that of Bhishma in the religious epic Mahabharata.
Not eating and drinking for some time before death probably results in a lowered chance of incontinence at the time of death. No incontinence is evidence that the life's breath has escaped through one of the holes of the head which, in turn, indicates that the soul has achieved moksha. This is written in the Garuda Purana. Several people told me that this is the only indication of what had happened to the atman after death.] If there is incontinence at the time that the life's breath leaves the body, it indicates a bad fate. Turned around, the desire that the life's breath appear to exit through the upper region may be one of the reasons why people do not eat in anticipation of their deaths.
Not eating or drinking during the time of dying can also be considered an aspect of a general detachment from the material world, a spiritual goal of classical Hinduism and an idea that many people seem to share. From an outside perspective, many of the aspects of the pilgrimage to Banaras to die, such as leaving the familiar surroundings of home and village and leaving one's friends and relatives, can be seen as enabling detachment from the material world.
This line of thinking can be taken quite far. Focusing on God may be seen as a metaphor for complete detachment from the material world. Many of the things which are observable can be explained in terms of rejection of the body, including the more or less rough handling of the dying person's body by the relatives, the injunction that the person should die on the ground, and especially the fact that the person has not eaten for some time.
The causal relationship between behaviour and result are not necessarily understood by the individual. They may be following a custom or the prescription of particular scriptural texts. The connections are made, or have been made, at these social and historical levels. However, this does not mean an individual is either unaware or not party to the process him or herself. Death by not eating is not only good in the spiritual and moral (social) senses, it is also a death that is prepared for and dignified and is one of slow slipping away involving relatively little pain or suffering.
In addition to reasons why an individual might be motivated to stop eating, there are also broader cultural reasons why such an action is accepted by others. There is an obvious relationship between food and life, though it is one that is culturally mediated everywhere. The ancient Ayurvedic medical system is a pervading source of such mediation in India (12). Health, in Ayurveda, consists of maintaining a proper balance in the body of such things as the five elements, the three humours and heat and cold. Foods are infused with these properties and have the ability to throw off or restore the body's balance. The control of food intake is thus an important aspect of day-to-day body maintenance and the determination of longevity. For instance, some say that people who eat less live longer than those people who eat a lot, or that if one wants to live longer, one should maintain fasts. Fasting is familiar to everyone as both a religious discipline and a method of controlling physiological processes.
There is also a cultural relationship between eating and dying. In India, death by fasting has a particular meaning. Though suicide is considered to be a sin, leaving the body by such yogic practices as fasting may be considered to be a very great thing. This was explained to me in the following manner: "If somebody was going into battle and knew they would probably die, would you call that suicide? No. In the same way, we don't consider death from hunger strike suicide."
The question of the naturalness of not eating as death approaches is important because we often base our actions and policies on our understanding of what is or is not natural. From a North American perspective, not eating while dying must unnaturally accelerate the dying process. It is like suicide to stop eating, like killing someone to allow them to stop.
Considering the cessation of eating early in the dying process has some significant theoretical and practical implications. If it is 'natural' to stop eating, then it could be envisioned that the people dying at the muktibhavan aare not accelerating their deaths by not eating but are dying at the appropriate time. The cultural norms around which they are making decisions would be seen as allowing nature to take its course. On the other hand, we would have to see our cultural norms as non-conducive to dying a 'natural death'. That is to say that cultural norms which allow either force feeding or the gentle encouragement of a non-hungry, dying person to eat - and which encourage the dying person, him or herself, to always continue eating - may act 'unnaturally' to extend the dying process.
The question of the naturalness of not eating as death approaches is, however, a heuristic one. The value in the exercise is in the recognition that with human beings, nature is always mediated, if not overwhelmed, by culture. Our pre-disposition to continual sustenance to the very end, which underlies our policies of force-feeding or other less obvious methods of control, is cultural and arbitrary and thus amenable to being rethought.
(1) Sandstead HH. A point of view: nutrition and care of terminally ill patients. Am J Clin Nutr 1990; 52: 767-769.
(2) Zerwekh JV. The dehydration question. Nursing 83 1983: January 47-51.
(3) Michaelson E, Norberg A, Norberg B. Feeding methods for demented patients in the end stage of life. Geriatr Nurs 1987; March/April 69-73.
(4) Lynn J, Childress JF. Must patients always be given food and water? In: Weir RF (ed). Ethical Issues in Death and Dying. New York: Columbia University Press, 1986; pp 215-229.
(5) Callahan D. On feeding the dying. In: Weir RF (ed). Ethical Issues in Death and Dying. New York: Columbia University Press, 1986; pp 230-233.
(6) Bhardwaj SM. Hindu places of pilgrimage: a study in cultural geography. University of California Press, 1973.
(7) Rolls B. Ageing and appetite. Nutr Rev 1992; 50(12): 422-426.
(8) Olson-Noll C, Bosworth NF. Anorexia and weight loss in the elderly. Postgraduate Medicine 1989; 85(3):140-144.
(9) Winograd CH, Brown E. Aggressive oral refeeding in hospitalised patients. Am J Clin Nutr 1990; 52: 967-968
(10) Morly JE, SIlverman AJ. Anorexia in the elderly. Neurobiological Ageing 1988; 91: 9-16.
(11) Phillips PA, Bretherton M, Johnson C, Gray L. Reduced osmotic thirst in healthy elderly men. Am J Physiol 1991; 261: 166-171.
(12) Kakar S. Shamans, Mystics and Doctors: A Psychological Inquiry into India and its Healing Traditions. Delhi: Oxford University Press, 1982.
Christopher Justice, 979A Governors Road, RR#3, Dundas, Ontario, Canada L9H 5E3 (e-mail: <justice@interlynx.net>). His book Dying the Good Death - The pilgrimage to die in India's holy city is published by State University of New York Press (c/o CUP Services, PO Box 6525, Ithaca, NY 14851, tel 001 607 277 2211; $19.95; ISBN 0 7914 3262 9).
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