In the Chemotherapy Suite

December 28, 2022

Immunotherapy. The Irving Greenberg Cancer Centre, Ottawa ON

Ontario is deep in snow, and I am on a bed in a chemotherapy suite. A machine behind the bed slowly pumps pembrolizumab, my immunotherapy treatment, into a vein in my right arm. 

All cancer treatments have side effects. Pembrolizumab disables one of the mechanisms that hold my immune system in check. Unleashed, my T cells attack the tumour in my throat. The problem is that these cells may also attack other body parts.

My next few days will be tired and achy, like having mild flu. Since I started immunotherapy, my cheeks have turned bright red, and there are itchy, scaly patches of skin at various places on my body.

I have periods of pins and needles tingling in my hands and feet. The tingling occurs because my immune system is attacking my peripheral nervous system, which can cause severe problems if it worsens.

And I have mucositis, meaning sores have formed in my mouth and throat. They're painful, and to eat, I must first numb my mouth with a prescription mouthwash. 

---

A litany of problems, yes, but I have outlived the prognosis I received when my cancer recurred. I'll take the deal.

---

Moreover, I'm suffering less than my neighbours in the chemotherapy suite. The suite is an open space partitioned into several modules, each with a dozen patients connected to intravenous infusion pumps.

The clenched facial muscles of the woman across the way suggest that she is fighting nausea. And losing.

The man in the bed to my right repeatedly asks his nurse the same questions. Is this early dementia, or is he stupified by the medication?

The man to my left shivers uncontrollably, even though the suite is warm and they bring him warmed blankets. His nurse teaches him how to take one of his medications at home: he must inject it into his abdomen three times a day. He's distraught.

We are all lying in beds, connected to machines, patients, not agents. What can we do? Quietly, I begin the Buddhist meditation practice of tonglen.

The Bodhisattva Avalokiteshvara, the embodiment of the virtue of compassion.

 In tonglen, you focus on your breath, using it to connect with others. When you breathe in, you focus on someone you know and visualize yourself inhaling a dark cloud of their suffering. When you breathe out, you send them a cloud of well-being. My Buddhist teacher Ken McLeod presents it this way:

The crux of taking and sending [McLeod's name for tonglen] is that you use the coming and going of your breath to exchange the good you experience in your life for the struggles that others experience in theirs.

On the in-breath, you take in all the ills of the world, all the evil, all the pain, all the injustice, in the form of thick black smoke.

On the out-breath, you send out everything that is good in your life in the form of silvery moonlight.

You give it to everyone who struggles in life, and you feel that each can now rest in peace and joy, free from struggle. You make this exchange, again and again, synchronizing it with your breath.

The chemotherapy suite is ideal for practicing compassion meditation. You do not need to form mental images of suffering people; they're right there.

---

One of the obstacles to meditation is that you can get distracted from your breath, mantra, or prayer. One common distraction is asking why you are even doing this. There's an inner argument that goes something like this.

Hostile Inner Critic: "Sending thoughts and prayers" to your fellow patients? That has a familiar ring, doesn't it?

Me: I understand. Since the Sandy Hook Elementary School massacre, many people view "sending thoughts and prayers" as an expression of pious sentiment meant to absolve us from acting to prevent tragedy. But is that what's happening here? This is an excellent cancer centre. The care we receive won't necessarily have a good effect, but the clinicians and staff are doing their best. 

Critic: Is your meditation an action that prevents tragedy? Will your tonglen will shrink the tumour in that patient in the next bed?

I'm a medical school professor. We have views about the evidence needed to make causal statements. That's a polite way to say, "we loathe magical thinking about health." So, no: I cannot shrink my tumour through visualization, let alone anyone else's.

Critic: Then what's the point of tonglen, or any other form of prayer? What does it do for anyone?

Meditation and prayer are practices for spiritual formation. The Buddhist teacher Pema Chödron remarks, “[Practicing tonglen], we become liberated from age-old patterns of selfishness. We begin to feel love for both ourselves and others; we begin to take care of ourselves and others.” 

By actively seeking out and acknowledging suffering, rather than avoiding it, tonglen practitioners can learn to be more present with their own suffering and the suffering of others. 

Critic: So very pious. But looking at the history of religions, what's the evidence that these practices make any difference in our moral character? The ancient cults that interest you -- Zen, Tibetan Buddhism, Catholicism, and Anglo-Catholicism -- are racked with scandals of child and sexual abuse. 

Yes, it's all so sad. The church and the sangha (the Buddhist equivalent) are human institutions: many ordinary people, some monsters, and a few saints.

Nevertheless, religious practice helps me.

Critic: Finally, we get to it. Helps you in what way?

 Chödron says, “Tonglen awakens our compassion and introduces us to a far bigger view of reality.”

Critic: Bigger in what sense? 

I am distracted most of the time, sometimes by pain, more often by work, and most often by trivia. I am the guy who, when he encounters a friend, needs to remind himself, "Turn off the podcast. Stop stressing about the manuscript. Listen when she is speaking." Meditation strengthens my capacity for attention. 

Focusing my attention on another's suffering and attempting to take it in does what it says: you can get better access to another's experience. When we sincerely attend to others, we can pick up cues from their inner experience.

These cues are available to us because our emotions interpenetrate our thoughts. People unconsciously disclose visible and audible signals to their emotional states in trusted relationships. Being attentive, we can sometimes fall into a deep connection and mutual presence.

A suffering person benefits when someone else registers their pain and acknowledges it matters. And when you recognize another's suffering, your empathetic response in a compassionate relationship makes your world bigger. Your world now includes another being; you are connected to something bigger than yourself.

Critic: I didn't follow all that, but if meditation might improve your character, I'm for it. But prayer involves speaking to God, no? 

Correct, the point of Christian prayer is not just to cultivate a virtuous life but to engage with God. I doubt you'll agree, but that’s the main point.

However, Buddhists don't believe in God in the sense that Christians, Jews, or Muslims do. And yet they pray. Chödron says that “[Tonglen] introduces us to the unlimited spaciousness of shunyata (emptiness). By doing the practice, we begin to connect with the open dimension of our being.”

I suspect St John of the Cross (1542-1591) might agree

Anonymous, St John of the Cross (17th century)

During contemplative prayer, he reported that

I entered into unknowing,

yet when I saw myself there,

without knowing where I was,

I understood great things;

I will not say what I felt

for I remained in unknowing

transcending all knowledge.

---

If you're interested in learning about Buddhist compassion meditation, Chödron's books are excellent and accessible. If you want a traditional Tibetan text, try McLeod's renowned translation of Jamgon Kongtrül's The Great Path of Awakening.