A Simplified Description of the Person
in
The Nature of Suffering
And The Goals of Medicine
by Eric J. Cassell
Oxford University Press
Unlike other objects of science, persons cannot be reduced to their parts
in
order to better understand them. But a simple topology of person may be
useful in understanding the relation between suffering and the goals of
medicine. The features identified should also apply to ourselves and thus
be
confirmable on the basis of our own life experiences. They should also
point
the way to further study and to the possibility of specific action by
individual
physicians. Persons have personality and character. All parents know that
personality traits appear within the first few weeks to months of life and
are
remarkably durable over time. Some personalities handle some illnesses
better
than others. What may be destructive for one person is easily tolerated by
another, but some stresses that may accompany illness, such as loss of
control, are universally difficult to bear. Individuals vary in character
as well as
personality. During the heyday of psychoanalysis in the 1950s, all
behavior
was attributed to unconscious determinants laid down early in life. No one
was
bad or good; they were merely sick or well. Fortunately, such a simplistic
view
of human character is passing from popularity. Some people do, in fact,
have
"stronger" character than others and bear adversity better. Some are good,
kind, and tolerant under the stress of terminal illness, while others
become
mean and strike out when even mildly ill.
A person has a past. Things done and places visited. Accomplishments
and
failures. The lived past is a story that has taken place over time, in
many
places, and involving countless others. The experiences gathered during
living
one's life are part of today as well as yesterday. Events of the present
can be
checked against the past, and events of the past contribute to the
meanings
assigned to present happenings. It would be an error to think that the
past is
simply memories stored in some old mental filing cabinet. Rather, the
constant
flow of happenings reinforces some past experiences and dilutes others.
Memory exists in the nostrils and the hands as well as in other body
parts. A
fragrance drifts by and an old memory is evoked. My feet have not
forgotten
how to roller skate and my hands remember skills I was hardly aware I had
learned. When these memories and past experiences involve sickness and
medical care. They can stimulate fear or confidence, bodily symptoms, and
even anguish. It damages people to rob them of their past, deny the truth
of
their memories, or mock their fears and worries. A person without a past
is
incomplete.
Life experiences-- previous illness, experiences with doctors, hospitals,
medications, deformities and disabilities, pleasures and successes, or
miseries and failures-- form the background for illness. The personal
meaning of the disease and its treatment arise from the past as well as
the present. If cancer occurs in a patient with self-confidence resulting
from many past achievements, it may give rise to optimism and a resurgence
of strength. Even if fatal, the disease may produce not the destruction
of the person, but rather reaffirm his or her indomitability. The outcome
would be different in a person for whom life had been a succession of
failures. Some time ago I reviewed an examination meant to test the
interpersonal skills of medical students by having them interview an
actress playing the part of a patient. The "patient" was a woman who had
just discovered a lump in her breast. Her past history is given. Her
father died when she was very young and her mother was an alcoholic. The
patient's first marriage ended in disaster, leaving her with a
brain-damaged child. She has been unable to hold a job. She has finally
made a liaison with a man and is about to go off with him when she
discovers the breast mass. The student's job is to convince her of the
need for surgery. The examination sheet that provides this history ends
with, "The patient was very optimistic about her future." That is not true
to life-- nobody with her history could be optimistic. She "knows" that
the mass will be cancer, and it does not matter whether it is or not.
Nothing good has ever happened to her, and this tumor is just another
piece of her that is rotten. Her suffering, one might postulate, would
start before her operation, when she became aware again of how much less
whole she is than other people. Like an old wound that aches when it
rains, one can suffer again the injuries of yesterday. The lived past
provides other occasions for suffering. It may simply be lost, as in the
case of amnesia, leaving the person less whole. Or its truth may be denied
by the events of today, as in "All my life I believed in..., and now, when
it is too late to change, it turns out not to be true."
A person has
a family. The intensity of family ties cannot be overemphasized; people
frequently behave as though they were physical extensions of their
parents. Things that might cause suffering in others may be borne without
complaint by someone who believes that the disease is part of the family
identity and thus inevitable. I remember a man with polycystic kidney
disease who was quite proud of his ultimately fatal disease because he was
finally "one of them," like his mother and sister. Many diseases where no
heritable basis is known are also acceptable to an individual because
others in the family have been similarly afflicted. What seems to count is
the connection of the individual to the family. One of my patients, dying
of cancer of the lung, literally shrugged his shoulders over his impending
death from the disease that killed his father and two brothers. His
children suffered at his bedside. He was fulfilling his destiny, while
they were losing a father. Just as a person's past experiences give
meaning to the present, so do the past experiences of the person's family.
They are part of the person.
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