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Dying as a Spiritual Practice: An Interview with BJ Miller

BJ Miller is executive director at Zen Hospice Project in San Francisco and an attending specialist for the Symptom Management Service of the Helen Diller Comprehensive Cancer Center at the University of California, San Francisco. He will be a featured speaker at the annual Buddhist Contemplative Care Symposium, November 3- 6 at the Garrison Institute in New York.

Sam Mowe: You’re the executive director at Zen Hospice Project. Are you a Zen practitioner?

BJ Miller: No, ironically. I'm very drawn to Buddhism—and I can’t refute any of the teachings—but I just have an allergy to joining groups. I prefer to feel my own way forward. I'm not anti-Buddhist, but I love being agnostic.

But there must be something that you admire about the Zen approach to end-of-life care. What is it?

As physicians, we talk about existential distress. No one in the field has defined it very well, but we are aware that once you get beyond the treatable conditions of physical pain or depression, it’s not as though, all of a sudden, life is easy and happy. There’s still the real quagmire of being future-oriented beings who, at some point, run out of a future.

I have always been interested in how it is that we are given the facility to ask questions that we can’t answer. And how we can see our own death well in advance of it. It seems like a peculiar issue that is specific to our species.

Zen and Buddhism offer so much in response to this situation. Essentially Zen expresses the need for being with whatever is happening.

Awareness of death is a practice in many spiritual traditions. And it seems like many physicians, hospice workers, and others who work with people who are dying find spiritual insights. Can you talk about the connection between spirituality and dying?

In a way, I think it’s a shame to begin thinking about these things once you have a diagnosis. Because the truth of it is and this may seem paradoxical, but reflecting on mortality has the potential to be very life enhancing and help you appreciate what you have while you still have it.

It’s one thing to make peace with loss after you’ve lost something. But why do we wait until we’ve lost something to appreciate it? My hope is that we mature as a society and begin to sprinkle conversations about death throughout life. I think we’d be better off as a species and as a society.

Do you suggest strategies for doing that? Even though I agree with you, it’s not like it’s an easy thing to talk about.

That’s an important point. This is not something to be rammed into someone’s face. From an educational point of view, I think that touching on grief from a young age makes good sense. Then when loss happens in our daily life—whether it’s the loss of a pet or a parent or a wallet or whatever—we learn to lean into those moments rather than abandon people. We can begin to model, one loss at a time, how we can be a little kinder to each other.

With this quiet revolution happening around how we approach death and dying, I find myself getting excited about the progress we seem to be making as a culture and society. But, at the end of the day, the excitement doesn’t outweigh the sadness felt when someone you love is dying.

Yes, one of the hazards of doing this work is that we start getting happy feelings about all the progress we can make and then we encounter the pain and the sorrow that is always going be there, too. And confusion is going to be there, too.

I think the goal is not to get beyond feeling anxious or sad. The goal is to make space to let yourself feel those feelings and not hate yourself on top of it. To not be ashamed to be afraid, to not be ashamed to be confused. Just be confused. That would be a great success if we could just be afraid and anxious without moving on to guilt or shame. That’s really what I'm hoping for.

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