mindfulness, silence, clinical encounter, cross-cultural
Kawabata, a Japanese writer, won the Nobel Prize for literature in 1968. Four years later, at age 72, words from his short story “Silence” were quoted in his obituary: “A silent death is an endless word” . That story and my travels to Japan inspired this commentary. Remarkably, the story, while written more than a decade before Kawabata’s protégé took his life in the traditional and dramatic samurai manner, foreshadowed the Nobel laurate’s death. To the chagrin of his readers and fellow citizens, the former suicide apparently triggered Kawabata’s.
Japanese attitudes towards death interested me as I was traveling to Japan to teach palliative care clinicians Mindful Medical Practice . I sought to understand how 21st century healthcare professionals who faced death daily integrated traditional values into their work. Thus, I read Japanese literature and articles on the topic. I was curious about their perspectives on sudden death (self-induced or illness-related) which is generally viewed positively. Studies showed differences in ideology across Asian physicians (Korean, Taiwanese, and Japanese) regarding the role of religion (low in Japan) and autonomy (patient informed first; high in Japan) . When I queried workshop attendees what they considered to be a “good death” they described their own (e.g. reconnecting with ancestors) rather than their patients’. “Dying on a tatami”  refers not only to taking one’s last breath at home (on a futon, stretched out on a traditional tatami mat); it implies being embedded in an extended family – those who are alive and dead. Thus, even though religion does not play a role in hospital care, ancient beliefs remain central.
The story “Silence”1; p. 153-173 relates an exchange between the narrator (a writer) and his 66-year-old mentor who had chosen to remain silent following a debilitating stroke. The narrator is disconcerted by the formerly prolific author refusing to write even a single kanji character. He is at loss regarding how to interact with his unresponsive old acquaintance. He wished to save the novelist from “verbal starvation” viewed as “something intolerable.” Awkwardly, the narrator fumbled with his own words as he said too much or as he put it, “babbled.” The narrator was able to reflect on his own behaviour and ask, “Wasn’t what I was doing… like violating the sanctuary of silence? … Perhaps he had chosen to remain silent, chosen to be wordless because of some deep sorrow, some regret. Hadn’t my own experience taught me that no word can say as much as silence?” Later, addressing his friend’s taciturnity with his own words, the narrator muses, “No. Silence is certainly not meaningless… I think that sometime before I die, I would like to get inside silence, at least for a while.” Finally, when it became clear the patient-novelist would not respond to any of his utterances the narrator states, “Here you’d gone to all the effort of achieving silence, and then I come along and disturb you.”
How does Kawabata’s story relate to medical encounters? When I teach Mindful Medical Practice  clinicians become more reflective and self-aware. They engage in “deep listening” during dyadic exercises and experience what it feels like to be heard without the other person interfering with the process. With meditation practice what silence has to offer is discovered. They become more perceptive, noticing body language and tacit forms of communication (e.g. tone of voice, pace of speech). This counters physicians’ inclinations to push through checklists or fall into the habit of interrupting patients. Such behaviours can be modified with regular meditation practices and acting with awareness during routine activities (e.g. washing hands prior to examining a patient).
While traveling via subway, buses, and trains in a completely different world, I was struck by how quiet people were. No one spoke on their mobile phones. There were pictograms instructing travelers to keep their thoughts and words to themselves. Smokers were directed to not walk and smoke simultaneously. Eating and drinking were restricted to sitting or standing still. Despite masses of people moving to various destinations, silence promoted calm. I realized that the Japanese social norm of restraint contributed to the wellbeing of the community. It reflects the importance of being considerate of others first. My inability to converse with Japanese people heightened my awareness of other forms of communication (e.g. smiles, hand signals).
These experiences led me to consider my ethnic background, one that encourages questioning, expressing views and sentiments openly, with little reserve. Japanese people tend to be subtle, even among themselves, expecting others to be insightful. Young children are instructed with regard to this type of social intelligence. For example, I observed a father teaching a 3-year-old to girl to bow wordlessly at a shrine after dropping coins in a donation box. In Kawabata’s novel, The Sound of the Mountain , the ageing patriarch, distressed by his adult children’s complicated lives, hesitates to contribute his thoughts and feelings despite the importance he attributes to the problems they face. Even though it is his traditional role to promote harmony in his family he held back. Kawabata wrote, “At night he heard only the sound of death in the distant rumble from the mountain” .
One of my Japanese hosts who had studied in Canada explained to me that because Japan was isolated for centuries and remains a homogenous society there is less needed to state directly what one thinks. He said that multiculturalism, common in Canada, renders it more difficult to understand “the other.” For that reason, Westerners need to speak openly and directly. During my early training in pain management I observed that some cultures allow and encourage overt expressions of suffering whereas others do not. My experiences in Japan mirrored that. Traveling from Tokyo to Osaka we barely missed a typhoon, one that stopped bullet trains in their tracks. When it struck, contingency plans were rapidly put into action and citizens helped one another through the natural disaster. Japanese people have endured hardships during their storied history for centuries with individual resilience and collective cooperation.
While visiting Kyoto, I strolled through the Nanzenji Temple gardens whose spacious grounds included the placement of rocks suggesting mountains and ocean waves represented by sand raked to perfection. Nothing more was needed. Understatement spoke volumes. The exquisite attention to detail, where everything has its place was astonishing. Standing motionless, I witnessed a grey heron with its wide-spread wings swoop down to land on a branch overlooking a lotus-filled pond. From there I followed the Philosopher’s Path, walking mindfully (as did Kitaro, one of Japan’s most famous philosophers on his way to Kyoto University) for two kilometers along the canal where leaves flowed upwards, north bound. The day was stifling hot, but the beauty manifest in ordinary places awakened in me a sense of joy and gratitude.
The author would like to thank Dr. Satoru Tsuneto for his invitation to teach in Japan and the Japan Hospice Palliative Care Foundation for their generosity.
- Kawabata Y (1999) Silence in First Snow on Fuji: 153-173. [Translated by Emmerich M. Counterpoint, Washington D.C.; 1959]
- Dobkin PL (2015) Mindful Medical Practice: Clinical Narratives and Therapeutic Insights. Springer International (Switzerland).
- Morita T, Oyama Y, Cheng SY, Suh SY, Koh SJ, et al. (2015) Palliative care physicians’ attitudes toward patient autonomy and a good death in East Asians countries. J Pain Symp Manage 50: 190-199. [Crossref]
- Long S (2004) Cultural scripts for a good death in Japan and the US: Similarities and differences. Soc Science and Med 58: 913-928; 2004.
- Kawabata Y (Reprint ebook) (1996) The Sound of the Mountain. Translated by Emmerich, M G Vintage International (Division of Random House) New York.