Calling for a Buddhist Theology of Dementia

Abstract

Traditionally, religious discourses and practices have assumed cognitive abilities. This article argues for the need to reexamine our theologies in light of the prevalence of Alzheimer's disease and related dementias that cause severe cognitive impairment. Challenges posed by dementia for theological anthropology, ecclesiology, and soteriology are explored. Explaining responses to dementia found in the Christian theological literature, the essay then asks what a Buddhist version of theology-after-dementia might look like, suggesting in preliminary fashion some potential Buddhist resources. Overall, the piece begins, calls for, and hopes to stimulate Buddhist, and Buddhist-Christian comparative, work in this area.

Introduction

Ever since becoming a caregiver for a relative with Alzheimer's, the extent to which traditional theological discourses assume autonomy and cognitive competence has unsettled me. Most theology and religious practices assume a self capable of understanding, reasoning, deciding, remembering, keeping attention, and responding. Prayer, study, reflection, confessing, repenting, meditating, serving, devotion, ritual participation, adhering to precepts, and so forth all require intellectual abilities and yet Alzheimer's and other types of dementia destroy these abilities. As David Keck summarizes, "(T)he phenomena of Alzheimer's render the self-conscious subject as the ground of theological and religious life highly suspect" (Keck 1996: 121). Putting this in a broader context, Michelle Voss Roberts laments that we "have forgotten how to do theology from the bodies we actually have" (Roberts 2017: xx).

Up-close experience with dementia can alert us to the need to reexamine religious thought and experience from a new perspective—that is, from what Keck has called an "Alzheimer's hermeneutic" (1996: 227). We should ask ourselves whether theological ideas make sense in light of Alzheimer's and whether they are helpful when dealing with Alzheimer's. As Peter Kevern argues, if we "attempt to 'theologize' some insights from the world of dementia care," there can be much to learn from "re-membering the forgetful" (Kevern 2010a: 240–241, and 2010b: 175).

Alzheimer's has been called the "theological disease" because of the fundamental questions that it raises about the very nature of personhood, love, religious experience, community, soteriology, and more (Keck 1996: 15). The challenges posed, just to name a handful, include¹

• • In what sense are people able to be receptive to or to strive toward God or Ultimate Reality if they have forgotten who or what that is?

• • In what sense can people be religious, have spiritual lives, and seek salvation or ultimate ends if they cannot read scriptures, express assent, comprehend concepts and values, keep attention, develop insight, self-reflect, make choices, perform rituals, offer devotion and service, and so forth? What should we say about the soteriological prospects of such persons?

• • How should the realities of dementia impact our theological anthropologies and, for those traditions that have such concepts, notions such as the soul or being created in the image of God? Does dementia rob a person of what we think of as making them human or the person we once knew?

• • When people can no longer recognize themselves or others, communicate verbally, or behave with control or intention, how can they meaningfully be part of a religious community or shared tradition? What sort of community can accommodate such persons, and how?

• • What other options might there be for constructing our theologies besides the traditional ones that seem to assume autonomy and cognitive ability? What options provide hope for, and show better awareness of, the plight of those with dementia and thus discriminate against the demented less? Assuming that our religious systems do not intend to exclude a large and growing swath of the population, how might theology that does better justice to the demented also do better justice to the core values and meaning of our religions?²

Because the statistics pertaining to Alzheimer's and other forms of dementia are alarming and show the high and increasing prevalence of dementia, this issue would seem relevant and pressing not just to me and my family but to the broader society at large.³ The extensive, intensive, protracted care required for those afflicted with Alzheimer's and other dementias takes a huge toll on family and caregivers' lives as well as on social services and national budgets, meaning that dementia impacts not only individuals with neurological disease but wider systems and networks. In addition, dementia reminds us that none of us is autonomous and that we are all finite and dependent with limited abilities. We all experience disability at times. Therefore, dementia, as extreme case, shines a light on what is ultimately true of us all, which is yet another reason why we should think through the religious implications of Alzheimer's and related conditions.

However, despite the fact that dementia is so common and despite the devastation that the "dementia epidemic" is causing, and although there is a literature on pastoral care and chaplaincy for dementia, surprisingly, to this point, there has been little rigorous theological engagement with dementia and its implications. From my research and as noted by others, the Christian theology of dementia literature is still rather small.⁴ Furthermore, it is hard to find much Buddhist thought on the subject at all.

As a practicing Episcopalian and comparative theologian who has lived in a Buddhist country and has academic training in Buddhism, when studying the available Christian theology of dementia (especially work by Peter Kevern, David Keck, and John Swinton), I was struck by ways that some of the ideas called to mind Buddhist concepts and teachings.⁵ In other cases, however, the theological moves made were drawing on uniquely Christian resources. In those latter instances, I found myself wondering what resources Buddhists have within their systems that could speak to the challenges posed by Alzheimer's and related conditions. I asked myself, "What would a Buddhist version of theology-after-dementia look like? What Buddhist concepts and teachings could help respond to the various challenges? How might both the questions about and the responses to dementia differ between the two religions, and what might both traditions learn from exploring the similarities and differences?" This article developed from such reflection.

In what follows, I first explain some themes from Christian theological work on dementia and then briefly consider the issues from a Buddhist perspective. I gesture in a very tentative, preliminary way toward some initial possibilities for Buddhist resources as a way of calling for more in-depth work (and help from those more expert than I) to develop a Buddhist theology of dementia.

Theological anthropology

I begin with theological anthropology because Alzheimer's is often thought of as causing the dissolution or ebbing of the person, even a "de-souling,"⁶ and is considered a disease that takes away the abilities and traits that we consider distinctively human. Therefore, Alzheimer's challenges our typical assumptions about personhood and humanity. We have a tendency to equate our essences with our minds and to assume that the ability to think, and how we think, is especially constitutive of who we are, but of course dementia impedes our thinking and, according to Swinton, the word "dementia" means "deprived of mind" (2012: 63).

When I was commiserating recently with a friend whose mother has advanced Alzheimer's, my friend remarked that her mother "really isn't Mom anymore." As Swinton has said, dementia turns us into strangers (2012: 258). Despite my friend's remark, however, beautifully, she still felt obligated to care for and love this person known as "Mom." I am interested here in that tension; I am interested in the truth that my friend's actions speak or aspire toward, despite her words, while recognizing that her words also speak a truth. I want to find a way to talk about dementia that does justice to both parts, not glossing over the hard facts (medical, neurological) but fortifying a theological hope and moral obligation. As Swinton asks starkly, if memory is the seat of identity, and the memory goes so that afflicted persons are not the persons they were before, then who now are they? Further, "if we don't know who they are, then how and why might we desire to care for them?" (2012: 212).

People with severe Alzheimer's cannot recall their own past or recognize loved ones. They may not know their own names anymore or recognize themselves in a mirror. They undergo significant personality changes and can no longer play roles that once were constitutive of their identity. Less able to communicate or interact, they can become isolated, withdrawn, and "socially and politically invisible" (Kevern 2010a: 243). They become utterly dependent on others for toileting, feeding, hygiene, dressing, and other basic needs. Dan Brock has gone so far as to argue that they become more like animals than humans (Baldwin and Capstick 2007: 176). At the very end stage, it is not uncommon to hear those with advanced dementia described as the living dead or mere husks.

Theologians warn that we should be cautious about defining personhood according to intellectual or functional capacity, for, if we do, then diseases such as Alzheimer's are dehumanizing. Defining personhood according to intellectual or functional capacity has led to arguments that those who are cognitively disabled should be abandoned or even killed. For example, on the TV show The 700 Club, the famous televangelist Pat Robertson once caused a stir by suggesting that a man should divorce his wife who had ceased to recognize him because, despite marriage vows about "till death do us part," her dementia was a "kind of death" (Swinton 2012: 117–118). Australian ethicist Peter Singer has said that people with dementia should be killed because they are no longer persons (Swinton 2012: 126–130). Mary Warnock has advocated advanced directives for assisted suicide, saying, "I think why not, because the real person has gone already and all that's left is just the body … ." and "If you're demented, you're wasting people's lives—your family's lives—and you're wasting the resources of the National Health Service" (Swinton 2012: 121). Even Martin Luther suggested killing a mentally disabled boy, saying that the boy was a "mass of flesh without a soul" (Yong 2007: 34). Given all this, what should religions say on the matter of dementia in relation to personhood?

One strategy found in the Christian theological literature is to rely on a community of relationships in order to maintain or justify personhood. Maybe we are persons not due to our inner awareness or abilities but by virtue of our relationships, an idea emphasized in Tom Kitwood's work.⁷ The contention here is that identities and memories are not held by individual persons but within and by communities. Someone is a person if recognized as such by others, and supportive communities can take responsibility for maintaining identity and preserving memory. As Swinton characterizes this approach, "If human beings are persons-in-relation, then our personhood is not determined by anything within ourselves, but rather by that which lies between us." Personhood, he says, "is not defined by what someone has or does not have. Rather personhood relates to who someone is in relation to others" (2007:50–51). I will come back to this relational strategy again below while discussing the role of the church and ecclesiology.

One drawback of this approach, however, is that it suggests that those without relationships thereby lose their humanity or personhood, a danger even more likely because dementia impairs people's ability to be in relation. Swinton argues therefore that, although we want to take human relationships seriously, human relationships have limitations because they can be transient, flawed, or withheld; the less fortunate might be without the support of fellow humans. Thus, Swinton hesitates to place our personhood at the discretion of other people, especially given notions of our sinful imperfection (2007: 46–48, 51).

A second drawback of relying on relationships for personhood status is that doing so creates a further burden on caregivers and family, risking generating further guilt when, despite loved ones and caregivers doing what they can, the afflicted person still seems to decline and slip away. "(R)elational personhood may … shift blame … from the disease to those within that person's immediate environment" (Baldwin and Capstick 2007: 181, 184).

For such reasons, rather than depending exclusively on relationships, we need something more. Theologians have proposed a theological element to "anchor" personhood (Swinton 2007: 51–52). As Jill Harshaw observes, we should recognize and value afflicted persons' relationships not only with other humans but with God. Harshaw argues that, despite dementia, the capacity to enjoy a meaningful relationship with God is still there and is what counts (2016: 50). (I will return to the argument for this in the soteriology section ahead.) Swinton, drawing on the work of Martin Buber, concurs: "Even if human beings do not or cannot respond, they remain persons as God the absolute Person continues to relate with them. … (P)ersonhood has to do with God's desire to relate and … God's mode of relating is personal" (2012: 148).

In order to determine personhood, rather than employing secular values (often "hypercognitive" ones deriving from the Enlightenment, such as self-reliance, competence, self-consciousness, and rationality), theologians have suggested that instead we should employ Christian values. In contrast to Descartes' famous equating of thinking and therefore being, we should recognize that our human existence also centrally involves feeling, relating, loving, and being loved. Rather than a sole emphasis on the mind as central to what makes us, theologians have suggested instead that our hearts or our souls are primary and are not completely dependent on the mind. Although in some contexts, the essence of a person might be construed as the mind, in Christian reflection our essence is the soul as the site of God's work, love, or image in us. It is something God gifts to us and therefore not something that a brain disease can destroy or that a community can bestow.

The authors from whom I draw (especially Keck, Swinton, and Kevern) do not seek to dismiss medicine, science, or the body and brain but only to assert their limits and look at things from a theological perspective, not just a medical or scientific one. John Swinton writes, "Persons are not defined by what they do but by what they are, or perhaps better, as David Keck puts it, by whose they are." In short, Swinton argues "for a revised understanding centered in God's commitment to human beings" (2007: 38). From a Christian point of view, these theologians think, the power and love of God are what matters, not the afflicted individual's ability (or lack thereof).

Swinton thinks that we should be careful about allowing a diagnosis to dominate and determine the way that we treat the demented person rather than acting toward the person according to our theological culture and its values, which tell us that those with dementia are loved by God and created in God's image and that our role as Christians is to care for and love them, not "de-personalize" them (2007: 42). Ultimately, Swinton thinks, continuing to see the severely disabled person before us as still fully a person requires an act of faith. "Christians," he says, "can construct a different story around the experience of dementia" (58).

Theologians following this general strategy invoke the doctrine of the imago dei.To say that we are created conveys dependence and contingency. We are, we exist because of God. Dependence does not, Swinton says, "downgrade one's humanity or threaten one's personhood" but rather is part of being created (2012: 162–163). By virtue of being created by God in God's image, we have an "inherent holiness" (174). DeeAnn Klapp adds that the image of God and God-breathed life remains after personality and intellect are debilitated, because in the Christian view, the body is not the whole of a life. Furthermore, she argues that Jesus's care for the weak, sick, and marginalized attributes to them worth and dignity (Klapp 2003: 70–71, 75).

These are some of the key responses to issues about personhood in light of dementia that I have found in the Christian literature. Briefly, what, then, might Buddhists say? Because Buddhists understand persons differently than Christians, it is not clear that this issue poses the same theoretical challenges for Buddhists. Buddhists are famous for their teaching of no-self (anātman). According to Buddhist theory of the person, we are ever-changing, interrelated aggregates of mental and physical processes (form, or body and senses; sensations; perception; volition; and consciousness), with no enduring stable or autonomous essence. Reacting against the early Hindus who asserted a self or soul (ātman), Buddhists taught that any belief in a permanent, unchanging, independent self is a false delusion that leads to defilements such as selfish desire, attachment, craving, and so forth and thus to suffering. Therefore, because for Buddhists there is no separate, absolute, eternal self or person-essence in the first place, it would seem that they would not be worried to uphold a sense of a separate, enduring person-essence as dementia progresses.

Likewise, while some of the Christian questions stem from the radical change in the afflicted person as dementia worsens, Buddhists stress impermanence (anitya), so constant change, for them, is a given more than a problem and there is no notion of a stable, enduring essence to expect or defend. Buddhists may find in the Christian concern to defend and maintain an enduring essence of personhood a negative attachment to an illusory and harmful notion, the illusoriness of which dementia exposes and confirms. Of course, this is not to say that Buddhists are uncaring or are not deeply concerned and saddened by the effects of Alzheimer's and other kinds of dementia. It is just to say that their religious system may cause them to think about and identify the theoretical, theological issues differently, including reflecting on personhood differently.

On the other hand, the emphasis found in the Christian literature on the importance of relationships and support for those with dementia fits easily with Buddhists' emphases on interbeing and dependent origination as well as loving kindness, compassion, and the bodhisattva ideal. Thich Nhat Hahn is famous for his teachings on interbeing, contending that all phenomena, whether mental or physical, are interdependent and exist in relation to other phenomena. This is another way to speak of dependent origination, which means that nothing and no one has independent existence. Everything comes into being and persists within a changing nexus of causes, conditions, and relations. Identities form in relationship to other things according to the temporary confluences of multiple factors. As Swinton, drawing on Kitwood's work, argues that environment and relationships matter to individual neurology because of how conditions such as loneliness, poor treatment, and perceptions can cause malignant social positioning and contribute to functional decline, Buddhists would agree that what we do has an influence on persons and the environment around us and that memory and dementia, like everything else, arise dependently and exist only in relation, with no clear boundaries between one person and another or between a brain and the world beyond that brain.⁸

Recognizing our interconnection with the world around us and our responsibilities to one another in these ways, Buddhists stress loving kindness, which is a deep empathy with others and desire for others' well-being, as well as compassion, a feeling of sameness and non-separateness with others and a desire to remove the suffering of all. In the Mahāyāna traditions, these notions are conceived alongside the bodhisattva quest to put others first and live to help others.⁹ Thus, both the Christian and Buddhist systems encourage help, care, and deep regard for the demented, even if the Buddhist system does not attempt to define and prop up a personal essence.

When dementia might be thought to call into question the humanity or worth of the demented person, the second Christian tool discussed was the strategy of affirming God's commitment to and love for us. God's power suffices when our own powers are lost, the thinking goes. Although there is no Creator God or notion of imago dei for Buddhists, perhaps here Buddha Nature (Buddha-dhātu) and the closely related concept Buddha Embryo (tathāgata-garbha), applied to all sentient beings, might function similarly to retain worth and dignity in the face of devastating disease and debilitation. Although these terms are not without controversy in the Buddhist world and there are varying interpretations, the general idea is that, while care is taken to distinguish it from a soul or self, the Buddha Nature is something innate (not something we have but an essential nature or truth) that goes unrecognized or is obscured by defilements. It is the luminous mind of all sentient beings that, at least according to many Buddhists, eventually, when impurities are rooted out, becomes or reveals Buddha. The Buddha Embryo is the seed of or potential for this enlightenment. These concepts seem to provide, in Buddhists' own way, a sense of "inherent holiness" for all sentient beings, including the demented.¹⁰

Community and ecclesiology

The above topics of relationships and God's love for us flow easily into thinking further about Christian community and the church. Developing her theology of aging, Klapp writes about the centrality of community. The account of Creation, she observes, says that it is not good for a human to be alone (Gen 2:18) but rather that we are created for "interaction and interrelationship with God and with one another." Creation tells of the "ordination of community as an essential aspect of human existence" (Klapp 2003: 71). Aligning with this, Kevern, in his article "What Sort of a God is to be Found in Dementia?," writes that the inherently relational nature of humans arises from the nature of God as Trinitarian, in whose image we are created (2010b: 179).

Also sharing with Klapp an emphasis on community, Keck affirms that the Christian life is not something individual; rather, it is about lives lived together. Practicing Christianity is not something we do on our own but rather through a community (1996: 137, 83). In light of Alzheimer's, Keck thinks that we may come to recognize even more clearly our responsibility for others. Keck maintains that just as the church community accepts the responsibility of believing for baptized infants who have limited abilities at the beginning of a life, so also must we accept responsibility for those with dementia at the end of life (91). Because victims of neurological disease cannot confront their own deaths with dignity and faith, the church must "do the dying vicariously" for them (131). Keck explains that the way that we die should be "a profession of faith, trust, and love. But such options are not available to the end-stage Alzheimer's patient. … Consequently, the Christian communities … have to do the dying for them." As we are all united in the body of Christ, "we can die for others by vicariously helping them to die well" (138–139).

Elaborating further, Keck describes the church's functions from a number of angles. For example, liturgical traditions are crucial, he feels. Because the demented ideally have spent years participating in worship, the liturgy is very ingrained in them and familiar in an automatic or muscle-memory way. This enables the demented to retain recognition and respond during communal worship (at least affectively), even if they could not otherwise. Cautious about liturgical innovation for this reason, Keck says that the church's consistency over time benefits us later in life when we may have cognitive decline. Over years, the church supplies or instills a kind of liturgical memory that allows us to remain worshipers even as our minds may degenerate (1996: 96).

Related to this, in his "Community Without Memory? In Search of an Ecclesiology of Liberation in the Company of People with Dementia," Kevern points out that as superficial memories dissipate, our fundamental virtues remain because they are "carved through our souls by the early, meaningful, oft-repeated habits of our hearts." "It seems there are habits of the heart that persist even when we do not 'understand' them ourselves, even when we are no longer in conscious control of them" (2012: 48). This reminds us, Kevern says, that the power of the gospel is not entirely dependent on our conscious appropriation of it, and the effects of a tradition in our lives are "durable" (48, 51). This reminds me of the famous B. F. Skinner quotation that "education is what survives after what has been learned has been forgotten" (Skinner 1964: 483–484). It also relates to why many churches call their education programs "Christian formation," for they are acknowledging more holistic and long-lasting development and shaping.

Regarding other contributions of the church, Keck writes that the church performs the general function of addressing physical limitations and suffering, offering hope by bearing witness to things such as "the non-corporeal nature of our existence" and God's grace (1996: 98). When personhood may be in question, the church, as it does for the deceased, can affirm the demented person's continuity through prayer and remembrance (144). While Alzheimer's patients may lose the ability to maintain hope or anticipate eternal life for themselves, Keck says that the congregation can provide this for them "just as we feed them or pay their bills" (151).

The church fulfills responsibilities such as these not only for the demented, but also for the demented person's family and caregivers, too, for they are also very deeply affected by the tragic condition of dementia. For example, Keck writes that when we caregivers are discouraged because our care and love seem unrequited and unappreciated by the person with dementia, the church can sustain us, reminding us that at the beatific vision or resurrection, "no faithful loves will be unrequited" and we anticipate new, incorruptible bodies. The faces of those we care for at that time "will be radiant with knowledge and love" (Keck 1996: 136, 154). Additionally, part of the trials of caregiving include frequently feeling that we cannot do enough, experiencing burdens of guilt and remorse and a heavy sense of our own sinfulness. Here the church can help caregivers hear the promise of forgiveness when caregivers on their own may be overwhelmed and struggling (164–165).

In agreement with Keck, Swinton's writing also confirms the centrality of the church community in thinking about dementia. Because, according to the social model of Kitwood, dementia is relational and social and not just neurological, love and relationships are the appropriate place for theological consideration to begin, Swinton thinks (2012: 71–72). The church, he reminds us, is called to offer hospitality, including to strangers and those marginalized or weak, and to become an "attentive community," especially because sometimes people with dementia may lose their other social networks (276, 223, 103).

Kevern, however, in his "The Grace of Foolishness: What Christians with Dementia Can Bring to the Churches," addresses the concern that those with dementia may be unable to behave in conventional ways and therefore could disrupt the worship community. Although those with dementia can act in ways that seem unholy (such as being profane, violent, or promiscuous), Kevern asks whether we can imagine a community in which the troubled behavior of those with advanced dementia might be accepted as an enrichment rather than a disturbance. Kevern points to the "Holy Fool" tradition, and Leontius' Life of Symeon the Holy Fool, in particular, in answering this question affirmatively (2009: 207–211). Kevern describes "a distinct strand within the tradition of hagiography in which the apparent speaking of nonsense and aberrant behavior is recognized as a positive grace." "Holy Fools," he explains, are marginal, disruptive, sometimes even obscene "and in this respect may provide an echo of the presence of dementing members in our churches." However, he goes on to say that these figures were also "counted holy by the Church" (209). The tradition of the Holy Fool tells us that grace can operate "by interrupting the life of the church" rather than by business as usual and that "chaos and disruption may be part of that grace" and the way that the community learns and is transformed (211). Kevern argues that Holy Fools like Symeon can teach us that we must "treat persons as having meaning by virtue of their presence, prior to any abilities" (216).

Now, having considered the role of the church in Christian theology of dementia in these ways, what would this look like from a Buddhist perspective? Although the Buddhist term has been used variously, what typically comes to mind as a Buddhist counterpart to "church" is "sangha" (saṃgha). Although this term can refer more narrowly to monastic orders and institutions, "sangha" is also commonly used as Christians use "church" in that the term can refer to the broader community of practicing Buddhists, including laity. When Buddhists take the threefold refuge, taking refuge in the sangha is the third part, indicating the importance and centrality of the community alongside the Buddha and the teaching (Dharma).

As in Christianity, practicing within community is similarly important in Buddhism, especially given Buddhist emphasis on interdependence. The Buddhist life, like the Christian one, is usually envisioned as taking place communally with the support of others. In Buddhism, compassionate love for and generous service to others are central values just as they are in Christian teachings. Mindfulness practices in Buddhism, like prayer and remembrances in Christianity, can help Buddhists to keep the demented recognized and included. Furthermore, as in Christianity, Buddhist liturgy and ritual can create ingrained memory absorbed over time that helps preserve recognition and affective responses even when abilities deteriorate with dementia. Although Buddhists do not share the specific notions of the beatific vision or resurrection that can provide hope for a more perfect future and sustain Christians diagnosed with Alzheimer's and their caregivers, Buddhist sanghas do teach functionally similar concepts, such as pure lands or better rebirths that, with spiritual advancement, can lead to liberation from suffering and the bliss of nirvāṇa. Buddhists even have counterparts to the Holy Fool tradition in the sense that Zen koans and legends of shocking things said and done by masters can function to disrupt our normal habits and point to the limits of rationality and convention. Buddhism has its own famous "holy fool" figures or "wise fool" poets, such as Taigu Ryokan.

However, there are important differences between the church and the sangha. To my knowledge, notions of vicarious atonement and vicarious responsibility are not found in Buddhism in the same way or to the same degree as they are in Christianity. While the Buddha can help us and teach us, and we can compassionately help one another, it is frequently said that ultimately in Buddhism the Buddha is not a savior in the same sense as Jesus is, and one must realize enlightenment oneself. As Robert Thurman has said, "Freedom from suffering, … liberation, … Buddhahood all come from your own understanding, your insight into your own reality. It cannot come just from the blessing of another … or from membership in a group."¹¹

Differences become clear when considering how the Christian church is seen as the body of Christ and identified with Jesus. Christians speak of the church as the representative of Christ in the world and say that the life of Christ manifests through the ideal church. The church is seen as indwelt by the Spirit. The body of Christ is said to share in Jesus's death and resurrection. It could be argued that such ways of speaking in Christian thought give an elevated significance to the church and bestow more salvific or healing power to it, in comparison to the sangha.

On the other hand, one Buddhist notion that could be a potential resource is merit transfer or merit dedication (puṇyapariṇāmanā). Ideas of making and transferring merit relate to karma. To make positive karma or merit, one does things such as practice generosity, morality, meditation, and dharma study. Although questions have been raised about the origins of the concept of merit transfer (and the influence of indigenous practices) and about whether the concept contradicts other Buddhist beliefs concerning the individualism of karma, nevertheless merit sharing practices are very common throughout the Buddhist world. Buddhists frequently dedicate the merit of a virtuous act or gift to help deceased family, for instance. According to the ideals of the Mahāyāna, a key notion is that bodhisattvas are to dedicate and share their merit for others' good, to assist all sentient beings. Perhaps merit dedication, or merit sharing, may function to explain how the sangha may take vicarious responsibility for the demented who are unable to make merit themselves. One could imagine Buddhists expressly dedicating merit not only to the deceased or generally to all sentient beings, but merit could also be specifically dedicated to those with dementia.

Soteriology

The church's (or sangha's) help notwithstanding, dementia raises the question of the soteriological outlook of persons with severe cognitive decline. If, as Anselm wrote, faith is seeking understanding, then as Swinton points out, "it is clear that people with advanced dementia have no real way of finding God." Swinton continues, "The experience of seeking understanding is precisely what is being lost as one encounters the latter stages of the process of dementia. It would appear that people who are losing their sense of self … will struggle to access God" (2012: 12).

Beyond saying that others may help us when we cannot help ourselves, what else have theologians said? Similar to the worry expressed in the theological anthropology section above about the danger of relying exclusively on relationships, we may hesitate to place responsibility for our salvation solely at the mercy of others, so further reflection on the soteriological predicament of those with dementia is needed.

Harshaw in her God Beyond Words: Christian Theology and the Spiritual Experiences of People with Profound Intellectual Disabilities discusses reasons why the ability of Christians to have faith, experience God, and be saved is not dependent on their intellectual abilities.¹² Harshaw recognizes that Christianity is "hugely reliant" on verbal language and she acknowledges that if intellectual reflection and linguistic ability are necessary for encountering God, then this excludes people with dementia who then have little hope (2016: 86–88). Theologically, however, Harshaw argues that scripture tells us that God desires for us to have knowledge of God and accommodates our capacities (90–98). Given that all humans have limited abilities, why would God's accommodation not extend to the intellectually disabled? (103). Harshaw reasons that God is not constricted by linguistic communication, nor is language about God ever adequate anyway (114).

Harshaw points out that infants and young children have not developed sufficient understanding and language, but we do not condemn them or exclude them from hope for salvation, so we should not exclude the intellectually disabled, either (2016: 123). However, at the same time, Harshaw hesitates to compare the disabled to infants. A senior with dementia is not a child. Equating demented seniors with young children potentially questions the ability of those with intellectual disabilities to have meaningful experiences of God (126–127). Harshaw, in contrast, wants to uphold the possibility that the intellectually disabled could have a significant relationship with God, even one that grows and is not mediated by others (127–129). She says that it is the Spirit indwelling, rather than our own abilities, that enables us to be transformed and know God (131).¹³ She argues as well that accounts of perception of God in mystical experience show that in these experiences, awareness of God is not mediated by cognition and language and, finally, is mysterious (147). Lastly, the fact that we cannot know how God might choose to meet the intellectually disabled person does not prove that God cannot, Harshaw maintains (161).

Amos Yong's work concurs. The many tongues of Pentecost, Yong reminds us, show how God reveals Godself and reaches humans in all their variety (2011: 15). We must be, Yong writes, cognizant of the possibility of what the Spirit can do for those with disabilities (115). Salvation finally rests, he says, on the power of God (2007: 249). Swinton agrees, writing that "dementia cannot de-spiritualize people because God is Spirit, and unless God withdraws God's spirit from us, spirituality remains. … (S)pirituality may take a different form than it had before, but it does not disappear along with vanishing neurons" (2012: 173–174).

Addressing how the cognitively challenged might be included in the Eucharist or catechesis, Yong feels that we can customize practices to people's abilities and situations. For example, rather than propositions, we can use images, stories, ritual, music, and so forth, engaging people not just cognitively but affectively and imaginatively. The spoken word can be minimized and replaced with singing, gestures, stimulating senses, play, and so on (Yong 2007: 208–209, 213–214). Stephen G. Post agrees, pointing out aspects "that are equally important as cognition and even more so: symbolic, creative, emotional, relational, somatic, musical, rhythmic, aesthetic, olfactory (smell), spiritual, and tactile" (2016: 151).

In addition, Yong worries about idolatry toward the healthy or young body (2007: 243). There is a difference, he thinks, between physical curing and healing, between physically fixing and holistically saving. Perhaps we do not need to be medically cured so much as loved. Healing, Yong writes, may consist of adapting and existing with a condition and the experience of love. He explains that healing includes "a social dimension of reconciliation, inclusion, and solidarity" (245, 250). In the parable of the great banquet, Yong notes, the crippled, blind, and lame "are invited and included just as they are" (246).

In The Bible, Disability, and the Church, Yong writes that God chose the weak and disabled as his friends (2011: 116). God's solidarity with the marginalized and weak and his resurrected body that showed marks of injury show that weakness is God's form of revelation and the way of the cross. This teaches us that the damaged and impaired should receive honor, not be excluded (142). Similarly, Nancy Eiesland has written that the resurrected Jesus, when showing his scared friends the marks of his damaged body, reveals himself as the "disabled God" and calls for them to recognize in this their own connection with God and their own salvation. "Here is the resurrected Christ making good on the incarnational proclamation that God would be with us, embodied as we are, incorporating the fullness of human contingency and ordinary life into God. … In so doing, this disabled God is also the revealer of a new humanity," Eiesland writes (1994: 100).

Taking this line of thought even further, Kevern urges us to consider as well that Christ may have "demented" on the cross. "The unique message of the Crucified One," writes Kevern, "is that there is no sort of human suffering where God is not to be found" (2010c: 413). Kevern argues that, if we take seriously Jesus's humanity, Jesus on the cross must have at least become delirious. It is extremely unlikely, given the torture and agony that he endured, that in his last moments Jesus would have had full self-awareness (416). The accounts of what happened have been sanitized, theologized, and tidied, and it is unlikely that Jesus would have been able to give instructions and make pronouncements once he had been on the cross a long time, despite the depiction in the gospel of John. Rather, Jesus probably was only "slightly able to function mentally, dimly aware of his surroundings, his mission and his self-identity. There is a fair chance that Jesus did not know what was happening to him" at the very end, Kevern thinks. If Jesus's self-awareness was gone for a time before his breathing stopped, then "for that period he was brought into solidarity with the demented, the comatose, and the mentally disabled" (416). Kevern concludes, "The assertion that Christ … demented on the cross opens the way for an understanding of dementia as potentially grace-filled; as potentially an agent for union with God rather than estrangement from God" (419).

Connecting the "dementing Christ" to the earlier point about how we are shaped over the course of our lives in ways that persist even if cognitive abilities decline, Kevern holds that Jesus's humanity is salvific not because he was able to make a decision at the very last moment of his life (for, if dementing, he could not have), but instead "because of the dispositions and decisions he made throughout the whole of it: his 'identity' is rendered not by some form of self-awareness at a particular moment, but by the narrative of a whole life … ." (2010c: 420). "On the cross the work of redemption apparently goes forward without Jesus's conscious participation" (421). For those who would object that it is important to maintain that Jesus freely accepted his death at the very end, Kevern counters that what Jesus chose in Gethsemane was to obey God's will, regardless of the consequences. That, Kevern thinks, is the "groundwork for our salvation, not the details of his consciousness at the end." The important thing, Kevern insists, is that "Jesus did not shrink from or renege on his decision when he had the opportunity; it is irrelevant when he effectively ceased to have the opportunity" (419–420). If we apply such reasoning to the demented, then even if a dementing Christian in the late stages of disease "loses self-awareness to the point of losing any memory of having had a faith, the fact that they are a diachronic, causal extension of the person who, when they were self-aware did have a faith is enough to provide confidence in their status before God" (420).¹⁴

While Kevern writes about the possibility that Jesus suffered dementia on the cross and its implications, Keck points out themes about God's forgetfulness and memory in the Christian tradition generally. While Kevern focuses on the passion narratives, Keck discusses how memory is a motif throughout the Bible.

Keck explains that existence is equated in the Old Testament with being remembered by God. Keck writes,

God's very presence, grace, and mercy are expressed through the divine memory. The blinded Samson's strength is reborn when God answers his prayer to be remembered (Judg. 17:28), and Rachel is able to conceive because "God remembered Rachel" (Gen 30:22). By contrast, in Psalm 88, the person whom God has forgotten has no strength, is already in the grave, already in "the regions dark and deep." Although God's remembering of a person is crucial, the role of human memory is also underscored, especially in the case of the unrighteous. In Job 24:20, the names of the wicked are forgotten in the towns, and so "wickedness is broken like a tree."

(1996: 43)

The book of Deuteronomy expresses a "theology of remembering" because after the great deliverance of the Exodus, Israel is obligated to remember God's saving deeds and the law but is in constant danger of forgetting, and idolatry and other sins can be seen as forms of forgetfulness (Keck 1996: 45–46, 58). Hence Keck concludes that "the problem of Alzheimer's, the problem of memory loss, is no stranger to the Biblical and Christian traditions" (44). Because of the people's forgetting, "only God's memory prevents total destruction" (47).

In the New Testament, however, Keck observes that God's memory takes on different meaning. Because of Christ, "God forgives, and forgiveness is phrased as the forgetting of sins" (1996: 47). Whereas human forgetfulness shows our weakness or sin, God's forgetting in this case is a sign of God's power and love. Also, in Jesus, "God divinizes human memory" (48). When Jesus cries to God, asking why God had forsaken him, it is "the lament of a man who possesses the fullness of divine memory—yet who himself simultaneously experiences being forgotten" (48). "When God remembers us, then, he also remembers being forgotten himself." This experience, Keck surmises, facilitates God remembering us and those with Alzheimer's (48).

Exploring this multilayered biblical motif of memory, Keck contends that memory is at the center of Christian faith. The most important act of Christians is a ritual in which we remember Jesus's saving sacrifice. During the Eucharist, we say that our Lord commanded us, "Do this in remembrance of me" (1996: 48). However, Christians have more than memories of Jesus because the Spirit descends and remains present (50–51). Also, Keck notes that memory can be transformed, as happened when the Resurrection changed the memories of Jesus among the disciples (51).

Keck says that, despite humans' failure to remember as well as we should, God remembers, and therein lies our hope. This, he says, is the witness of both Testaments. Our cry, he says, "is the cry of the thief in Luke 23:42, 'Jesus, remember me when you come into your kingdom'" (1996: 45). Although as sinners we forget, which makes all of us akin to those with Alzheimer's, the declaration that "God never forgets" becomes the soteriological hope and slogan of much Christian theology of dementia. Further, God gives us ways to help us remember, such as tassels on garments to remember commandments, the sending of prophets and preachers, the Eucharist, and so on (59).

Reinforcing our reliance ultimately on God, Swinton recalls the hymn "According to Thy Gracious Word" from the English Hymnal. The verses throughout focus on our remembering Jesus, but the end is telling, for "the last verse lays the task of remembering back with God, on our behalf":

Yea, while a breath, a pulse remains,Will I remember Thee.And when these failing lips grow dumbAnd mind and memory flee,When Thou shalt in Thy kingdom come,Jesus, remember me.

(Swinton 2012: 195)

Swinton summarizes that the hymn "calls us to remember while we can, but to trust that God will remember for us when we cannot" (2012: 196). The "deep fear of forgetting," Swinton says, can be "overcome by the deeper promise of being remembered" (197).¹⁵

Now that I have discussed some Christian responses, how might reflection on dementia affect Buddhist soteriological thought? Are Buddhist practice and reaching enlightenment possible for a person with dementia? What might Buddhists say so that the demented have hope?

Like Harshaw's stance about the limits of language in the Christian context, Buddhists often recognize the limits of language and in fact worry about attachment to language and ways that language can distort our understanding. Buddhists strive instead for a more immediate and intuitive awareness than a language-mediated one. In Buddhist communities, language is often compared to a finger pointing at the moon or to a raft, something that is a tool or means, not valuable for its own sake but for how it guides us to something beyond words. Zen traditions speak of mind-to-mind transmission outside the scriptures and the famous Flower Sermon in which the Buddha simply held a flower wordlessly. These are just examples but they indicate views that language is not essential. Thus, the fact that dementia leads to impaired or lost linguistic ability per se may not be an insurmountable problem for Buddhists.

On the other hand, with dementia, problems with language are typically symptomatic of broader cognitive impairment, and this may be a thornier problem. Buddhists characterize "salvation" differently than Christians—as liberation or awakening. Buddhists discuss their ultimate end in terms of reaching full enlightenment or nirvāṇa, the cessation of suffering and rebirth. The process to reach that end involves ridding ourselves of harmful delusions and attachments, discovering Dharma. The Buddhist path centers around training the mind and purifying our cognitive and psychological processes. Thus, diseases that affect the mind would seem to pose a particularly pointed challenge in Buddhist traditions that seem to focus heavily on the mind.

A mitigating factor, however, and another important difference from Christianity, is that in Buddhism, the work of reaching the ultimate end may span countless lifetimes, such that failure to liberate oneself in this lifetime postpones awakening but does not prevent reaching the ultimate end in future lives. Dementia with its confusion and suffering may be understood in some fashion as a karmic consequence, but once that karma runs its course and this life ends, the next rebirth, propelled by other karmic seeds, may be dementia-free.

Another comparative point, when Christians describe modifying their approaches to worship and catechesis in order to make them more dementia-friendly, and when Harshaw and Yong maintain that God accommodates our capacities, the notion of skillful means (upāya-kauśalya) comes to mind as a Buddhist resource. This concept, especially important in the Mahāyāna, means that the Buddha and wise teachers adapt how they convey Dharma according to the needs, nature, and potential of their audience. According to this notion of skillful means, teachings and methods may vary while serving a common compassionate purpose to benefit sentient beings. As modifications have been proposed for Christian practice, this Buddhist concept could easily serve to justify a sangha and teachers reaching the intellectually disabled in ways modified to suit their abilities.

Also, although of course Buddhism lacks incarnational theology, nevertheless, as the Christian thinkers emphasized Jesus's humanity and embodiment, in Buddhism (although with extraordinary karmic history and virtue compared to average humans) Śākyamuni, too, was born human. In his old age he became feeble, his body decaying. The first of the four noble truths forthrightly acknowledges the suffering of life in saṃsāra, and the tale of the four sights includes a confrontation with old age, sickness, and mortality. The marks of existence taught in Buddhism emphasize that we are impermanent. Perhaps, inspired by Kevern's argument about the dementing Christ, one could, as a thought experiment, even imagine Siddhārtha beset with profound confusion and delirium as he practiced extreme fasting or underwent temptation by Māra during his religious quest.

However, while Christian theologians appeal to God's power and memory to confront the challenge posed by dementia, Buddhists do not affirm a Creator God. The closest thing in the Buddhist world might be the stress, in Pure Land Buddhism, on "other-power" (tariki) and the notion of shinjin, a letting go of a belief in one's own ability to liberate oneself and instead having faith and trust in Amida (Amitābha). In Pure Land traditions, it is an implication or extension of no-self teaching that we cannot rely on our imperfect, weak selves or deluded egos to reach enlightenment. This is the egoism from which we need to be delivered. Living in a period when the Dharma has declined, we must rely on help from Amida Buddha. Our liberation is then assured, because of Amida's perfect, flawless power and limitless compassion.

Rev. Mari Sengoku, a minister in the Jodo Shin Pure Land tradition and a hospital chaplain, has quoted Shinran as saying that "the Primal Vow of Amida makes no distinction between people young and old; … only shinjin (entrusting faith) is essential." The reverend remarks that, unlike sects that require strict practice to win enlightenment, Pure Land tradition teaches that Amida will ultimately save everyone, "including persons who are suffering or dying from dementia." This, the reverend says, can "bring peace and comfort."¹⁶

Conclusion

The discussion has made it clear, at least, that both Christian and Buddhist traditions have resources to be explored and developed, that comparative consideration is thought-provoking, that the religious questions raised by dementia are significant, and that more energy and expertise need to be devoted to thinking theologically in light of dementia. While this exploration of Christian and potential Buddhist responses to Alzheimer's and related conditions is just a preliminary beginning, I hope it stimulates further work and raises awareness. May the forgetful from both religious cultures, and all cultures, be "re-membered."