Feeling guilty

Occasionally, a song, a tune or a musical phrase haunts us. We hear it in our brain and it keeps repeating itself. The first three notes of Yesterday by the Beatles, the opening bars of Beethoven's Ninth Symphony ("Ta-ta-ta-ta") or perhaps Raindrops Keep Falling On My Head. It could be neutral or maddening. I have not been afflicted by these mental musical Tourettes of late.

However, a few lines from Shakespeare intruded into my brain. I keep hearing them in my mind these last two weeks.

"Here's the smell of blood: all the perfumes of Arabia will not sweeten this little hand." (Macbeth: Act V, Scene I).

It could be that I recently encountered a few relatives of patients of mine who were burdened with strong feelings of guilt.

Miriam was diagnosed to have an early breast cancer. She was in her late 30's. It could have been treated by surgery, radiotherapy and an endocrine treatment given as a tablet to be taken daily.

At that early stage, over 90 per cent of patients would have been cured. Of course, cancer treatment is a bit inconvenient and unpleasant, but most patients get through it.

Miriam's benefactors persuaded her to have alternative therapy. It was a combination of herbs and prayers of intercession.

Expectedly, the cancer became worse. When she saw me 18 months after diagnosis, the cancer had reached a very advanced stage. A 20x20 cm purulent (full of pus), malodorous (very bad smelling) mass of haemorrhagic tissues (tumour bleeding endlessly) was all I could see on her chest wall. There was no semblance of a breast.

The benefactors were men of means and wanted me to do my best for her. "Please let us know if a million ringgit or two will help. We can easily foot the medical bills."

There was no need for a million or two. I started the patient on chemotherapy. She became better for a time, but eventually succumbed to her cancer. She died a year after commencing chemotherapy.

'If only'

The bill was only about a hundred thousand ringgit. During that year, and for some time after that, the benefactors were in deep mental anguish. They were plagued by "if only" questions. They wished they could turn back the clock and advise Miriam to undergo conventional evidenced-based treatment.

I was there for them to work through their feelings of guilt. These feelings persist till today, but fortunately, to a lesser extent.

Cassandra was 80 and had an advanced lung cancer. This was causing her a lot of pain and breathlessness. She was bed-ridden and dependent on oxygen. She also had insulin-dependent diabetes and hypertension.

I estimated her survival to be between two and six weeks. I told the patient's children that oxygen therapy, morphine and sedatives were all she needed. This was appropriate palliative therapy. It was to lessen her suffering and facilitate her last journey.

I also told them we should stop her insulin injection and all other drugs for her co-morbidities. These pills would not have made a difference. If anything, she had to endure unnecessary injections and pill swallowing and the side effects of such.

Chemotherapy was most inappropriate: it would certainly have shortened her life. The patient's children would have none of this. They were adamant that I continue with all the treatment for diabetes and hypertension, i.e. insulin injection and nine tablets each day. Chemotherapy was seriously considered by the relatives, but fortunately, they did not press on with this.

"We are hoping for a miracle. What happens if our mother lives to 100? Surely, control of hypertension and diabetes matters over the long term."

I spent three torrid days counseling them. Eventually, they came round to seeing things the way I did. They admitted that their somewhat irrational attitudes and unreasonable demands were borne not only of love, but of guilt. Had they loved their mother unconditionally when she was well? Did they do enough for her? What if their filial piety were questioned by relatives and friends?

Religious and cultural instructions prime us with do's and don'ts, rights and wrongs, "thou shalts" and "thou shalt nots". We are made to feel shameful and dirty when we flout these "laws".

Feelings of guilt are unavoidable as they are part of our survival kit and being human. The best we can do is to work through our guilt feelings. The sooner the better.

Lest we suffer the fate of Lady Macbeth. A lonely wretched soul, sleepless, treading the castle floors at night, forever ridden with guilt.

Dr Albert Lim Kok Hooi is a consultant oncologist.