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Stigma, Oncological Terrain, and Single Patient Based Medicine.
- Sergio Stagnaro (17 June 2004)
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Stigmatisation benefits even smokers who develop a Cancer
- Santhanam Sundar (19 June 2004)
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Stigma beyond the grave
- Keith A Walters (21 June 2004)
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Re: Stigmatisation benefits even smokers who develop a Cancer
- Ruth McManus (21 June 2004)
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Patient blame, depression & anxiety: The role of health promotion and support groups
- Rory Coughlan (23 June 2004)
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Sergio Stagnaro, Specialist in Blood, Gastrointestinal, and Metabolic Diseases. Researcher in Biophysical Semeiotics. Via Erasmo Piaggio 23/8 16037 Riva Trigoso (Genova) Italy
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Sirs, Apart from the intriguing considerations summarized properly in the interesting paper (1), as well as the difficulty I encounter in understanding that patients, who never smoked, “felt particularly stigmatised because the disease is so strongly associated with smoking”, I’d like to invite my dear colleagues to remember that now-a-days we can either prevent or cure both diseases, like cancer, and their consequences, as stigma (2) (See website HONCode 233736, www.semeioticabiofisica.it). In fact, all over the world, authors ignore or overlook, unfortunately, the existence of both Oncological Terrain and other numerous biophysical-semeiotic constitutions (3, 4), as well as biophysical-semeiotic bed-side recognizing cancer “real” risk, in a quantitative way, e.g. in the lung, and cancer since its early stage (2,3,4). Consequently, all authors think wrongly that “all” individuals can be affected by malignancy, suggesting, e.g., mammography and other screening measures, aiming to efficacious prevention, therefore spending uselessly NHS money, and physician’s energy and time. In addition, a woman as well as a man, of course, can be affected by Oncological Terrain, even with or without precise real risk location in a well defined biological system, as lung (“ab posse ad esse non licet illatio”, Kant, Kritik der reinigen Vernunft). Finally, educational interventions should certainly be presented with care so as not to add to the stigma experienced by patients with lung cancer and other smoking related diseases; however, only in individuals involved by Oncological Terrain, according to my theory of Single Patient Based Medicine (See website www.semeioticabiofisica.it/microangiologia.it). 1)Chapple A., Ziebland S., McPhersonA. Stigma, shame, and blame experienced by patients with lung cancer: qualitative study. BMJ 2004;328:1470 (19 June), doi:10.1136/bmj.38111.639734.7C (published 11 June 2004) 2) Stagnaro-Neri Marina, Stagnaro Sergio. Introduzione alla Semeiotica Biofisica. Il Terreno oncologico”. Travel Factory SRL., Roma, 2004. http://www.travelfactory.it/semeiotica_biofisica.htm 3) Stagnaro S. Terreno Oncologico e Oncogenesi http://digilander.libero.it/piazzettamedici/professione/professione.htm 4) Stagnaro-Neri M., Stagnaro S. Cancro della mammella: prevenzione primaria e diagnosi precoce con la percussione ascoltata. Gazz. Med. It. – Arch. Sc. Med. 152, 447, 1993 5) Stagnaro S. “Single Patient Based Medicine” versus EBM. http://bmj.com/cgi/eletters/326/7398/1048#32299 (16 May 2003) Competing interests: None declared |
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Santhanam Sundar, Consultant Oncologist Nottingham City Hospital
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Stigmatisation is of overall benefit to the society and is an essential tool to counteract the ‘peer pressure’, which is a prime factor in inducing youngsters to take up smoking. On an individual level, Stigmatisation benefits even the smokers who develop a cancer (1). Compared with Never-smokers and Ex-smokers, Current Smokers i.e. patients who smoke while receiving treatment for their cancers have poorer survival rates (2 3). They also experience more treatment related toxicity (4). Moreover, even after the successful treatment of a smoking related cancer, patients who continue to smoke are at risk of developing a second primary cancer (5). Hence, smoking cessation even at diagnosis would benefit the smokers. There is no greater incentive to stop smoking than the diagnosis of a smoking related cancer. Hence, the associated stigma has a greater potential to benefit rather than harm cancer patients. References 1. Chapple A, Ziebland S, McPherson A. Stigma, shame, and blame experienced by patients with lung cancer: qualitative study. BMJ 2004;328(7454):1470-0. 2. Videtic GM, Stitt LW, Dar AR, Kocha WI, Tomiak AT, Truong PT, et al. Continued cigarette smoking by patients receiving concurrent chemoradiotherapy for limited-stage small-cell lung cancer is associated with decreased survival. J Clin Oncol 2003;21(8):1544-9. 3. Browman GP, Wong G, Hodson I, Sathya J, Russell R, McAlpine L, et al. Influence of cigarette smoking on the efficacy of radiation therapy in head and neck cancer. N Engl J Med 1993;328(3):159-63. 4. van der Voet JC, Keus RB, Hart AA, Hilgers FJ, Bartelink H. The impact of treatment time and smoking on local control and complications in T1 glottic cancer. Int J Radiat Oncol Biol Phys 1998;42(2):247-55. 5. Richardson GE, Tucker MA, Venzon DJ, Linnoila RI, Phelps R, Phares JC, et al. Smoking cessation after successful treatment of small-cell lung cancer is associated with fewer smoking-related second primary cancers. Ann Intern Med 1993;119(5):383-90. Competing interests: None declared |
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Keith A Walters, Consultant in A&E medicine Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY
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I remember a campaign many years ago encouraging doctors to record on a patient's death certificate that a smoking related death was due to smoking. Several years ago my father was diagnosed with lung cancer. He was a non-smoker and not even a passive smoker. In the months leading up to his death I became very concerned that in years to come people seeing his death certificate in the archives would assume that he died because of smoking. This upset me. After his death I asked the doctor providing the death certificate to state on the form that my father was a non-smoker. This was done. I had one hurdle left. I am pleased to say that the Registrar of Births and Deaths accepted the death certificate as it was written along with the comment that my father was a non-smoker. This helped me greatly in the days after my father's death. If doctors are to be encouraged to record on a death certificate that a patient was a smoker then I think it is only fair that the opposite can be appended as well. Competing interests: None declared |
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Ruth McManus, Post doctoral fellow Canterbury University, NZ
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Quote: There is no greater incentive to stop smoking than the diagnosis of a smoking related cancer. Hence, the associated stigma has a greater potential to benefit rather than harm cancer patients. If only! How does diagnosis of cancer relate to stigmatisation and the cessession of smoking? This statement relies on falsely assuming a link between a smoker diagnosed with lung cancer who decided to try and stop smoking and the impact that anti-smoking public health campaigns have on their targetted audience. The role of stigmatisation in public health campaigns is powerful and problematic. Stigmatisation is about judging people's character negatively and acting on that judgement on the basis of unwarranted or illogical assumptions (like shape of head, skin colour, diagnosis of HIV or lung cancer). I think it important to understand that the inferences being constructed in public health campaigns are about constructing moralised boundaries between people that work on the basis of changing societies moral tolerance of costly behaviours - of branding someone who drinks and drives a 'bloody idiot' or the mother who smokes in the same room as her children as a poisoner as in the current ad campaigns in NZ. These campaigns operate at the 'benign' edge of intolerance but with intolerance all the same, and that is the point that Chapple et al. are making. To presume that stigmatising cancer patients will benefit them (by somehow forcing them to stop smoking) shows a need to appreciate more the double edged sword of moral opprobation and the complexity of people's behaviours. A helpful introduction is E. Goffman (1990) Stigma: Notes on the management of spoiled identity, London: Penguin. Competing interests: None declared |
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Rory Coughlan, Assistant Professor of Health Psychology Trent University, 1600 West Bank Drive, Peterborough, Ontario, K9J 7B8
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The research article by Chapple, Ziebland & McPherson (2004) highlights the problems for patients who are diagnosed with conditions that are widely perceived as being consequent on individual patient behaviour and/or lifestyle. The authors report on lung cancer patients’ experiences of stigma and shame in discussing their condition but these results would no doubt be found to be reflective of patients suffering other illnesses to which they might be seen as partly culpable. This very interesting study and the results obtained brings to mind two allied factors. The first is the role of health promotion strategies in general and the unfortunate side-effects of patient education in contributing to the further individualization of health and disease management in addition to creating the conditions for widespread blaming of people for their illnesses. The shame and stigma felt by patients disrupts their social relations (as reported by the authors) but may also increase their chances of depression and anxiety with consequences for adversely affecting not only their quality of life and their ability for caring for themselves but their chances of recovery and survival ( Coughlan, 2004). The second inter -related aspect relates to the effects of support groups for patients in increasing their experiences of personal agency once diagnosed and for helping in overcoming the isolating effects of such stigma (Mullett & Coughlan, 1998). The focus on health promotion strategies in educating populations of their role in staying healthy is one that should be lauded and in most health systems in the industrialized world, could well use further encouragement and funding. Health promotion strategies increased as healthcare professionals realized that the major threats to health were more likely to be linked to chronic conditions rather than infectious disease. This meant a redoubled effort to educate patients regarding the role of problematic behaviour in contributing to ill health and encouraging personal involvement in maintaining active attention to healthy choices and treatment regimens (Coughlan, 2004). In addition, many professionals and policymakers were becoming increasingly aware of the role of industrial development in exacerbating the problems of chronic disease. Initially, health promotion advocates (especially in Canada) contextualized the experiences of individual cases of illness with a whole host of environmental, psychological, cultural and socio-economic factors (Mustard & Frank, 1991: Evans, 1988). Unfortunately this focus on the “determinants of health” was seen by some political and corporate bodies as perhaps too damaging to certain interests to sustain in major health initiatives. A much more “watered down” version that stressed individual responsibility rather than societal culpability in creating unhealthy societies was more palatable to many and this version received greater funding and became the generally preferred model (Frank, 1995). Thus while the determinants of health model was still a major field of study for academics, the major public education emphasis became a redefinition of the more richly contextualized version of health promotion for one that stressed personal lifestyle and choices (Townson, 1999; Frank, 1995). However this individualized version of health promotion is not without its critics. For instance many people (especially those in lower socio-economic groups) have less of a sense of personal agency for a variety of reasons and have much greater difficulty in changing either their behaviour or their situations (Wilkinson, 1996). Those who depend on certain heavy or chemical industrial processes for their livelihood may have a drastically increased lifetime burden of toxicity and simultaneously will tend to fail to see that they are able to change their situation. Even those working in the modern computer industry are now reporting serious illness as a result of toxic substances in the workplace. For those who have experienced little ability for making meaningful choices throughout their lives (again more probably affecting those at the bottom of the socio-economic hierarchy), changing habits such as smoking or drinking excessively is much more difficult. The individualized message of health promotion continues to be a positive one but the lifestyle changes and the consequent positive outcomes are more readily taken up by those who have experienced greater horizons for choice in general. Thus health promotion has worked much more effectively for those in higher socio-economic strata (Townson, 1999). Another serious downside to the individualistic tendency in health promotion emerges when a critical mass of society internalizes the connection between choice, behaviour and health but moves a step further to indulge in very divisive and unsympathetic views that harden into a common social-psychological phenomenon of “blaming the victim”. The social - psychological literature abounds with examples that demonstrate the ubiquity of this reaction in western individualistic societies and the harmful effects with respect to many different scenarios, including personal injury and rape situations (e.g. Dekeseredy & Kelly, 1993; Fischer, 1986). Chapple, Ziebland & McPherson (2004) demonstrate this in their results with lung cancer patients. However this phenomenon is also a common accompaniment to attitudes to health in general as many people are now more likely to blame the victims of even fairly minor illnesses for their condition (Bittman & De Fail, 1999). The real problems for the patient emerge when (as with the patients in the article by Chapple et al) these societal attitudes are internalized to such a degree that they further isolate and penalize those who already are coping with a serious life situation. Many studies have demonstrated that for those who are diagnosed with a serious illness, the co-occurrence of depression or anxiety not only diminishes perceptions of quality of life but will likely interfere with any possible recovery process and/or may hasten morbidity. This has been adequately demonstrated with many conditions and especially with cancer patients (e.g. Tjemsland, Soreide, Matre & Malt, 1997; Kiecolt-Glaser, 1995; 1996; Benson & Stark, 1997). In addition it was interesting to note that those who attended support groups were reported as not only discussing the shame and stigma of having been diagnosed with lung cancer but were more aware of other causes, especially those linked with industrialization and the culpability of tobacco companies in product promotion. This “resistance” to the stigmatization might also be seen as a resistance to the individualization of their illness. Indeed, we can place many sufferers of lung cancer at the centre of the nexus of choice if they consumed tobacco products but the tendency to blame individual sufferers glides too gently over the socio-economic arrangements that contribute to ill health in industrial society. The discussion of these issues by the support group members may well have positive effects with regard to recovery and survival for many of these patients. Many studies have detailed the positive psychological effects to patients from support group membership. With regard to the patients who participated in the lung cancer study it might be interesting to know of how the support group contributed to their quality of life, experiences of personal agency and if their “resistance” had any positive effects with regard to outcomes. References Benson, H & Stark, M. (1997). Timeless Healing: Biology and the Power of Belief. New York. Fireside. Bittman, B. & DeFail, A. (1999). Reprogramming Pain: Transforming Pain and Suffering into Health and Success. Touchstar. Meadville, PA Chapple, A., Ziebland, S. & McPherson, A. (2004). Stigma, shame and blame experienced by patients with lung cancer: Qualitative study. British Medical Journal 328:1470 Coughlan, R. (2004). Agency communication and embodiment. Using Qualitative research to explore healthcare relationships. Psychology & Health. (In review) Dekeseredy, W. S. & Kelly, K. (1995). Sexual abuse in Canadian university and college dating relationships: The contribution of male peer support. Journal of Family Violence, 10, 41-53. Evans, R. (1988). Health promotion or ideology. Health Psychology, 7, 203-19 Fischer, G. J. (1986). College students attitudes towards forcible date rape: Cognitive predictors. Archives of Sexual Behaviour, 15, 457-66 Frank, J (1995). The Determinants of Health: A New Synthesis. CIAR Programme in Population Health, Working Paper 54. Toronto. Canadian Institute for Advanced Research. Kiecolt-Glaser, J. K. (1996) Chronic stress alters the immune response to influenza vaccine in older adults. Proceedings of the National Academy of Sciences, 93, 3043-47. Kiecolt-Glaser, J. K. (1995). Slowing of wound healing by psychological stress. Lancet, 346, 1194-96 Mullett, J. & Coughlan, R. (1998). Clinicians’ and seniors’ views of Reference Based Pricing: Two sides of a coin. Journal of Applied Gerontology, 17, 3, 296-317 Mustard, J. F. & Frank, J. (1991). The Determinants of Health. Toronto. Canadian Institute for Advanced Research. Competing interests: None declared |
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