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Journal of Cancer Research and Therapeutics, Vol. 7, No. 2, April-June, 2011, pp. 112-114 Invited Editorial The paradox of attending to the self in brain tumor Varsha Dutta Clinical Neuropsychologist, ACRO-Department of Radiation Oncology,Dr. Balabhai Nanavati Hospital, S.V. Road, Vile Parle (W), Mumbai 400 056, India, Code Number: cr11028 PMID: 21768694 Cancer care practitioners are better equipped now than before in alleviating symptomatic suffering. What remains a problem however is the skill required to comprehend, assess, and empathetically address the "being in self." Competent assessment tools have often come to the rescue and bettered our penchant toward defining the self more rigorously, but the basic problem of "the self in pain," which has often been claimed as a problem of language and grammar in philosophy mired in so many layers, has but scientifically remained elusive. Even though the philosophy of care has matured over the years, when confronted with challenges like a brain tumor it becomes exceedingly difficult to tell the difference between the somatic expression of pain and the personal angst associated with it. Self-autonomy is at stake here, so preserving it under such circumstances becomes exhaustive. We have been able to generalize a conceptual model of the self in pain and have made it a useful substitute for individual concerns of pain, trauma, anxiety, and uncertainty that normally plagues a person battling with brain tumor. [1],[2],[3] This option helps deliver if not anything an objective way of approaching the self, a self in question that encourages us to develop more ways of assessing it during pain. With newer decision-making strategies, more information is accrued, but what should concern us really is the way to connect the two polarized realities, one outward (clinical assessment, clinician′s own ratings, decision making and external control) and the other a more subjective version accessible only by the patient. The relation between self and pain is unique, inseparable so to speak, so subjective feelings of hopelessness, the overriding guilt of being a burden and a growing lack of confidence along with the loss of will to live cannot be treated as empirical cohorts. Such diffuse boundaries should compel palliation and such empirical cohorts that determine the precincts of care into becoming more sublime, more sensitive when dealing with the other. The role of care shrinks and it becomes shoddy particularly so when it stretches its corners and pushes it into an outwardly existing psycho-social realm. By arrogating different names for care (cancer, Neurocognitive and palliative) we are confining it to meaning set by boundaries. This affirms the subjugation of thought by language, because after having named something it inadvertently becomes a noun, a reality that accedes to nothing but its own symbolic closure. This common notion of the self is indefensible when tried under objective assessments alone. The idea here is not to merely satiate some quasi-intellectual curiosity but take into consideration the very "subjective reality" of one′s own existence in the face of such objective ambiguity. It needs to borrow from philosophy, particularly the existentialist stance if it wants to redeem its practical efficacy. How does one come to terms with the self when one is pushed to the corners of his own limitations? The problem of self in question becomes a reality only then. While the technical tools help us maneuver around the tumor site from where we draw our inferences from it does not help us in any way of knowing the exact location of where one′s own subjective experience rests. So far all we know is that cognitive deficits secondary to a brain tumor vary depending on the lesion site. From what we know, frontal tumors are cognitively silent, and draw attention because of the way in which psychiatric and personality changes reveal themselves. [4] Dominant temporal lobe tumors on the anterior side cause expressive aphasia, but it is usually the episodic memory loss that points toward a dominant temporal lobe lesion. Parietal lobe tumors on the other hand, especially if it is located in the right hemisphere, causes visuospatial dysfunction, whereas tumors adjacent to the motor strip and its descending fibers can cause focal paralysis or increased tone, and sensory strip lesions cause pain, temperature and proprioceptive loss as well high-order sensory deficits such as graphesthesias. Finally, tumors in the occipital lobe or anywhere along the occipital tract will cause a visual disturbance. Agnosias often result from lesions in the secondary and tertiary visual cortex. [4] In the case of primary brain tumors, there are no typical neuropsychological batteries in use. Patient issues concern cognitive problems that are associated with the tumor site, coupled with depressive changes, and a deleterious quality of life. This is what determines test selection from a battery which is again influenced by the histological grade, diagnosis time (recent vs. remote), surgical intervention, and adjuvant RT and CT. [4] Very little time or consideration is given to the subjective reality in which the patient finds himself. Usually, when a patient is considered for a rehabilitation program, he is subjected to an evaluation that becomes more comprehensive, whereas in an evaluation for cognitive deterioration secondary to a plausible recurrence the neurocognitive assessment demands become more focused, more severe. Like in the case of a patient with a newly diagnosed low grade glioma (LGG), after a thorough neuropsychological evaluation, rehabilitation strategies will be directed to focus on functional deficits secondary to the tumor, particularly if the lesion is in the predominant temporal lobe. Some studies have shown that dominant hemisphere primary brain tumor patients experience more problems related to memory, verbal fluency, verbal learning, and mood than their nondominant counterparts. [5] The left hemispheric tumor will always raise a greater concern for antidepressant therapy. [5],[6] So one way of resolving the need for a more robust care is by assessing mood and the quality of life, particularly in biopsy confirmed LGG patients. [4] The FACT-Br, an extended brain subscale for the Functional Assessment of Cancer Therapy Scale-General (FACT-G), [7] is one such set used specifically for brain tumor patients. It garners responses that are specific to the concerns and the experiences patients go through. LGG patients who live for a longer period after the initial diagnosis are often considered here. In high grade glioma (HGG) patients pertinent issues that rake the self demands equal attention, more so because of the limited survival expectancies in patients with glioblastoma multiforme (GBM). Individualized arrangements are gaining popularity and neurotoxicity owing to the regimen of aggressive chemotherapy is monitored across a serial battery of tests. [4] Yet, we need to do more while dealing with the personal issues of physical, existential, and spiritual angst related to the dying experience. The clinical process of examination needs to transform itself to help the patient re-examine his own subjective reality and in the process guide the clinician with it. While most theories of the self continue to resuscitate itself with assertive psychological declarations alone it is only the "no-self" theory that lets the self be where it is. The self can be seen as an idea only, an idea that is in constant flux, a phenomenological view that goes back to the nature of things themselves. [8] The Buddhist view of the ′non-self′ begins therefore from the examination of the very experience of the self itself and remains there. [8] There is no affliction here, no weakness of naming this thought conceived experience as a permanent part of one′s identity. Among the first Western philosophers to question this moral lack of self was Hume, who scoffed off at the idea of attending to and remaining trapped to a fixed personal identity. [9] The aspect of accommodating the other in the scheme of things is unavoidably profound, but what is bleak is the equality of the human condition which is so difficult to correspond to, cautioning that care can only be realized through responsibility of both the one being cared for and the one who is giving the care, because without this it delimits itself to pure rhetoric. This dichotomy of the self, one that is being examined and the other a more subjective, accessible part of the self concealed from the clinical aspect needs to change. Equality is not something that can be attained; dignity becomes a different counter when separated from ethical consideration. Care can be meted out only as a familiar way of knowing. We cannot structure a spiritual interview in this case or develop an empirically based model of dignity [2],[3],[4] and have different groups of clinicians adhering to the norms set by such objective limits. Care giving becomes an execution then without any real concern and a monopoly of the select few, with patchy, focal interests. Human affairs are not certain, merely plausible; the only kind of certainty that can be relatively assured is the kind of moral conviction that is less demonstrative than the one that is being taken for granted in the exact sciences. The moral proclivity toward the self and the self in relation to the other comes crumbling down when treated with the exactitude of such demonstrative certainty. An oughtness that is unobtrusive and non-intervening needs to be embraced if we are to strike the right cord, set the right tone of empathy when we tread into the patient′s turf, his boundaries. References
Copyright 2011 - Journal of Cancer Research and Therapeutics The following images related to this document are available:Photo images[cr11028f1.jpg] |
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