The Transformation of Tragedy

Epigram

The word tragedy is used not infrequently on the oncology ward. The word appears to be reserved for certain cases, particularly young ones, or poignant psycho-social circumstances. My sense is that the oncology ward uses the word “tragedy” loosely, emotionally, with unconscious sentiment.

Can We Characterize What Constitutes a Tragedy in Oncology?

Let us look at a couple of scenarios. Is the death of a young man defending his country during the War against the Enemy a tragedy? Is a dying 90-year-old great-grandmother surrounded by her generations a tragedy? Are all 25-year-olds dying of cancer tragic in equal measure?

Here is another question, facile maybe: Is everything about life tragic? “To have emerged from nothing, to have a name, consciousness of self, deep inner feelings, an excruciating inner yearning for life and self-expression—and with all this yet to die.” ²

I think “the word” is to be revered. That is, we should use language precisely, otherwise communication falters and problems ensue. Clinical medicine is dependent upon communication for diagnosis and therapy. An inaccurately taken history can have fatal consequences. In the general marketplace words like fascism, racism and apartheid are recklessly (or ruthlessly) thrown around. We should make an effort to be precise with words.

The dictionary defines tragedy as “a serious drama typically describing a conflict between the protagonist and a superior force (as destiny) and having a sorrowful or disastrous conclusion that elicits pity or terror.” ³ The Shakespearean or Greek literary tragedy is the formulaic prototype. Courage and heroism, frailty and faults fill the stage. At first glance this classic definition does not seem appropriate for the oncology setting, and it is unlikely that Shakespeare is whom the oncologists have foremost in mind at the bedside.

Can there be an objective definition of tragedy? Or is the definition necessarily subjective, based on whether the patients see themselves as tragic figures? How would I (or you the reader) feel if the doctors at the end of my bed labeled me a tragedy even though I did not consider myself a tragic figure? Nevertheless to define the parameters of “tragic” based on self-assessment would likely lead to an infinitely variable and equally unusable definition. It remains preferable to make an objective assessment, however limited, after taking a careful history.

Pity, as noted in the epigram, is one response to perceived tragedy. Zweig wrote of his hero: “But he was gradually to learn that pity, like morphia, is only a first solace to the invalid and unless one knows the exact dosage, and when to stop, it can become a virulent poison.” ¹

The first step of pity recognizes that another person is suffering, wretched or miserable. This is commendable. The point Zweig is making, however, is what is the better way to respond to suffering? To indulge patients emotionally may make them dependent upon misplaced “kindness” and make us ingratiatingly paternalistic. For example, health practitioners may experience pity or embarrassment in the presence of extreme suffering and be unable to hold empathically the gaze or hand of a dying patient; or be unable to ask difficult questions such as: “Do you want more chemotherapy?” “Is it time to contact your estranged son?” “Where would you prefer to die?” When meeting a blind person for the first time one does not presume to pity them and place their blindness before their personhood. Some people are ugly, crass, deformed—yet their self-esteem, their world view and their ability to find meaning in life may be as refined as the next person. Think of Quasimodo, Victor Hugo's The Hunchback of Notre Dame. We should not presume pity, nor indeed tragedy without first listening.

Another response to suffering is to observe that “there but for the grace of God go you and I.” Roy observed: “A model of dying with dignity would include…dying in the presence of people who know how to drop the professional role mask and relate to others simply and richly as a human being.” ⁴ The challenge is not to pity the patient as in feel sorry for them, rather to empathize and to visit daily; to challenge and question, whilst encouraging and supporting. But to always look them in the eye, and encourage resoluteness. Much as Zweig hinted at in the epigram.

Is tragedy simply the loss of potential life? The young person dying is tragic since the expected life trajectory is dramatically foreshortened or curtailed. However, some people can turn a tragedy of blindness in war to a rousing and inspiring story of success. ⁵ Stories like this suggest that by imbuing meaning or spirituality into life, tragedy is somehow negated or muted.

Tragedy can also be understood as an absence of justice. Where the normal life expectancy and/or pattern is not played out, a cry of injustice rings forth. It does not matter whether the injustice is inflicted through a random role of the die, or a whim of the gods. Injustice in this sense of course includes aborted life potential.

In Europe 500 years ago death in childbirth and infant mortality was very high. It was expected that many children would not reach adulthood. Was death tragic back then, in the same way such health outcomes would be viewed today? If there was an influenza pandemic today and millions died, would our criteria for defining tragedy be adjusted? Emotional tolerance and compassion fatigue might alter our perception of what is tragic. Tragedy, therefore, seems to include the idea that the event is unexpected or exceptional.

Dictators, notwithstanding their moral turpitude, possess certain psychological insights that enable them to dictate. Stalin was said to have cynically observed: “The death of one man is a tragedy. The death of millions is a statistic.” Millions of faceless nameless deaths preclude the empathic personal component that characterizes our perception of tragedy.

Finally, tragedy is applied to adverse outcomes that are self-inflicted. In general it is not used for people who have cancer, although it could be applied to self-destructive behaviors such as alcoholism and smoking. Rather, it is used to describe flawed characters who despite great potential bring about their own destruction. Again there is the loss of life potential.

There is no unitary definition of tragedy, which is more like a syndrome than a disease. My working description of tragedy is one of irredeemable suffering, with some or all of the following characteristics: a truncated life potential; an event outside societal norms; a death (or loss) without meaning; and a measure of injustice.

Can Tragedy Be Undone or Palliated?

Tragedy might be a discussion topic for after-theater drinks but there is no value in cloyingly focusing on tragedy at the bedside. Indeed there is little practical use in the cumbersome description I outlined above. The problem is that labeling the patient “a tragedy” tends to block further consideration by the health care team of psychological and spiritual growth. It is far better to talk of reframing the patients' hopes, losses, anger, fears and sadness. If one can learn to imbue meaning and or purpose into a “tragic” circumstance, the sharp edge of tragedy wears off.

And yet, facing death with cancer does have a heroic, pitying, tragic dimension much like the classic Greek or Shakespearean dramas. Patients die with courage or unrequited fear, neurotic or cowardly, angry or fulfilled. I have often wondered if this drama was a contributing factor that drew me to oncology in the first place.

Frankl: When we are no longer able to change a situation—just think of an incurable disease such as inoperable cancer—we are challenged to change ourselves…Everything can be taken from a man but one thing: the last of the human freedoms—to choose one's attitude in any given set of circumstances, to choose one's own way. ⁶

Frankl seems to be saying that notwithstanding the depths of despair and tragedy, life can become significant and meaningful, even tolerable.

As clinicians we are challenged to assist in transforming “tragedy” into spiritual growth. We should be neither sanctimonious nor sentimental and must avoid imprudent judgments, such as pity. Better is empathy and that we, the health care practitioners, are obligated to “patience and forbearance” in the service of the patient.