This story highlights the potential emotional and spiritual fallout that can result when the care of patients is religiously or culturally incompetent—or both.

A Cambodian Buddhist man named Khin Tep lay dying. His family began the traditional rituals that would ease the transition to his next life form—rebirth, they hoped, as a human being in better circumstances than he would leave behind in this lifetime. These rituals were to extend several days beyond Khin Tep's clinical death. Then the body would be cremated in a specified way so that the bones could be washed and gilded as a part of the ceremonial activities.

Although this case is an extreme example, it shows how much culturally and religiously sensitive care can matter. Although the news report does not implicate anyone else, we can be certain that everyone involved in Khin Tep's care—nurses, physicians, social workers, and others in addition to the funeral home staff—could have provided better care during his transition from life to death/rebirth if they knew even minimal details about Cambodian Buddhist beliefs and practices (see resources below). But would that knowledge help in the case of the next Buddhist patient who came through the door? Perhaps—if he or she were another Cambodian Buddhist. But Buddhists from other ethnic groups and other branches of Buddhism might not hold the same beliefs or follow the same practices as Cambodians. That's why it is important to learn what kind of Buddhism a particular patient practices.

Buddhists in America can be grouped under two large categories. In one category we find Asian Americans whose Buddhism is an expression of their cultural heritage from Asian homelands. Two of these groups, Chinese and Japanese Buddhists, have been in America for more than a century, while several other groups, such as Vietnamese, Korean, Thai, and Cambodian Buddhists, have immigrated in large numbers only recently. The specific beliefs and practices of these Buddhist populations vary from group to group.

In the other category of American Buddhists we find non-Asian converts who have chosen Buddhism as their new religious worldview, most having been raised as Christians or Jews. These Buddhists receive much of today's public attention even though ethnic-Asian Buddhists outnumber them. Converts typically understand and practice their Buddhism differently from ethnic-Asian Buddhists. A follower of Zen Buddhism or a member of one of the many insight meditation groups around the country would probably face death very differently from the Cambodian Khin Tep. For one thing, anxiety over an inauspicious rebirth into another life form would likely be a nonissue. Moreover, preparation for death would probably not involve a large contingent of extended family, as was the case with Khin Tep.

Of course, Buddhists of all kinds share certain things in common. For instance, they view life as ever-changing and impermanent, they see human suffering as often caused by our own unenlightened desires, and they strive for both wisdom and compassion in living a moral life. Even so, it is important to be attentive to the distinctiveness of each Buddhist group, as well as to each Buddhist patient within those groups. Buddhists are not all alike, just as adherents of other religions differ in their personal beliefs and practices.

Attitudes on Terminal Illness Common among Cambodian Buddhist Patients:

• Cambodians start very early in life to prepare for death and, as Buddhists, believe that death is another change in an endless round of ceaseless change, which includes successive cycles of birth, sickness, old age, and death, followed by rebirth.
• Terminal illness is a time to reflect upon what it means to be human.
• At the time of illness the family is very supportive and they attempt to make the sick person comfortable. They invite the monks to come to the home to offer prayer in order to pacify the soul and earn merit in the afterlife.
• Medicinal herbal remedies are common and are based on traditions that have been handed down for thousands of years. Most Cambodians try both the medicine prescribed by the physician and other traditional methods.²

Selected Resources on Buddhism and Buddhist groups

• Buddhist Council of the Midwest, (http://www.bcmw.org). Accessed February 22, 2002.
• E. R. Canda and T. Phaobtong, "Buddhism as a Support System for Southeast Asian Refugees," Social Work 37, no. 1 (1992): 61–67.
• DharmaNet International, (http://jbe.la.psu.edu). Accessed February 22, 2002.
• D. Keown, Buddhism and Bioethics (New York: St. Martin's Press, 1995).
• E. Lee, ed., Working with Asian Americans: A Guide for Clinicians (New York: Guilford Press, 1997).
• M. A. Muecke, "Caring for Southeast Asian Refugee Patients in the USA," American Journal of Public Health 73, no. 4 (1983): 431–438.
• P. D. Numrich, The Buddhist Tradition: Religious Beliefs and Healthcare Decisions (Chicago: Park Ridge Center, 2001).
• P. Ratanakul, "Buddhist Health Care Ethics," in H. Coward and P. Ratanakul, ed., A Cross-Cultural Dialogue on Health Care Ethics (Waterloo, Ontario, Canada: Wilfrid Laurier University Press, 1999), 119–127.
• R. H. Seager, Buddhism in America (New York: Columbia University Press, 1999).
• Tricycle: The Buddhist Review, (http://www.tricycle.com). Accessed February 22, 2002.