Ludwig Wittgenstein: Grasping the logical nature of probability is one response to the news you have cancer
When you are diagnosed with prostate cancer you are faced with a number of aphorisms with more than a hint of paradox about them: "You are far more likely to die with it than of it"; "The cure, of course, is worse than the disease". And then your friend remarks, in the pub, "It's just God's way of telling you you've had enough fun".
"Cancer" is a powerful negative brand name, like "rat". With curiously crude symbolism we spotted rats on our premises for the first time in thirty five years around the time I was diagnosed with cancer. In each case there is a powerful instinctive reaction: Get rid of it! Now! Life cannot be lived until riddance is complete. I want life to be exactly as it was before. If that is an over-reaction to the rat it is probably quite wrong in relation to the cancer.
The problem now is that there is a choice of treatments and it is quite common — it was certainly true in my case — that you will not be advised which to choose. The three items on the menu, in the order of their invention, are:
1. Radical Prostatectomy
The prostate is removed by traditional surgery. The advantages are that all trace of the cancer is removed from the body with no prospect of return. The disadvantages are the probability of impotence, the possibility of incontinence and the certainty of considerable pain.
Three dozen or so blasts of external radiation. The advantages are that there is no radical or debilitating procedure and, apart from having to turn up at hospital so often, you can continue life fairly normally. The disadvantages are that you may suffer "burns" and other damage to adjacent parts of the body and that if the cancer returns it can't be operated on. If you choose this treatment in NHS hospitals you are normally offered a free parking pass.
A one-off procedure in which you are injected with radioactive metal "seeds". The advantage is that this is, in itself, by far the least disruptive procedure. The disadvantages are similar to those for radiotherapy, though the odds are probably better.
There is a further alternative, which is to do nothing. Compared with other cancers prostate cancer can be extremely unaggressive. My scores on the standard blood test, the PSA, fell into the guidelines suggesting treatment, but not by a huge margin and they actually went down. I asked a specialist if he would bet on me being around in ten years time if we did nothing. He was, surprisingly, prepared to reply and he said that he would. In fact before I was diagnosed I hadn't thought or worried much about cancer because I believed that none of my relatives had had it. But then one of my cousins pointed out that the death certificate of my maternal grandfather, whom I strongly resemble, recorded "prostate cancer" as the cause of death. He died shortly before his 80th birthday, in 1960. Of course, it would be fascinating to know how long he'd had it, but we will never know; the condition went largely undiagnosed in those days. Sadly, the same cousin was diagnosed around the same time as I was, but with a virulent form of spinal cancer; he died this summer.
I initially opted for a prostatectomy, instinctively liking the completeness of the solution and recalling that Harold MacMillan had lived 30 years without a prostate. But as I talked to people it became apparent that the unpleasant side effects of this treatment were drastic and highly probable, those of other treatments less so. I then chose brachytherapy, only to be told that my urine flow measurements were too low, suggesting that the procedure might stop me urinating altogether, setting off kidney and liver diseases. However, this could be remedied by a TURP procedure (trans-urethral resection of the prostate) which I probably needed anyway. At the third attempt and after some initial difficulties this was done successfully. Eighteen months after I was diagnosed I was finally treated for cancer, having had approximately 40 medical appointments of various kinds.
There's another aphorism which they don't quote at you and that is, "The knowledge of cancer is worse than the cancer." It's a pretty good reminder of the fact that one day you are going to die. I made a point of broadcasting the fact of my condition. The good thing about this was that I was contacted by a good variety of friends and acquaintances who had previously had it. This enabled me to hear about their experiences and to put the sort of information in the pamphlets you are handed, which tends to cover worst case scenarios, into a proper perspective.
The downside of this strategy is that people would come up to me, method-act a sad and concerned face and ask, "How are you?" To which, most of the time, I could only reply, "Well, I'm not in any pain, I'm not on any medication and I'm slightly higher up the tennis ladder than I was 20 years ago — though, apparently, there is a greater chance of my dieing in the next five years than was previously believed." Actually, of course, I usually missed the last statement out. There were further pleasant consequences of my broadcasting the information including a nice note from a lady with whom I'd had a one night stand forty years previously.
There is an interesting question about whether it helps to be religious when contemplating such a medical condition. But it isn't my question. My question concerns whether it helps to be philosophical in these circumstances, whether a training in logic and conceptual analysis and a knowledge of what people called "philosophers" have said has anything to offer at a purely personal level. Here are some candidates:
Accept the banality of causation
One of my favourite writers, Damon Runyon, contracted cancer in his mid-sixties. Sadly, he did not live to see his story, Guys and Dolls, become a hit Broadway show and then an Oscar-winning film. His essay about his cancer is called "Why Me?" in which he insists that chemistry is not enough; he craves some sort of explanation in terms of punishment and justice. I first read the essay when I was fourteen and found it very moving. (It's available in collected editions of his writing, though it fits oddly with the humour and inventive language of the rest.) I always assumed that I would have the same reaction, but far from it, mine was more like "Why Not Me?" I'm a lucky chap from a lucky place and a lucky time, lucky in love and lucky with money. Some time your luck runs out — and I've thought enough about cause and explanation to be satisfied with the tedium of chemical chance. I might have died 40 years ago, after all.
Grasp the logical nature of probability.
Statements about statistical probability are statements about what happens when n identical cases occur. But you are not an identical case: it doesn't apply to you. Statements about inductive probability are statements about how you would rationally bet, guess, act etc given the evidence. They do apply to you, but it is not rational to apply them to yourself. You don't know and — to extend Wittgenstein — you don't need to know. It is the case that you might die or become impotent, but it always was the case.
A Kantian phrase, but applied to a Benthamite concept. I am no longer cycling down this path because I want to be healthy in order to achieve X or Y. I am cycling down this path because the trees are beautiful and because there cannot be anything better in this moment than this moment. And tonight I will dine with my lovely wife in the same spirit.
Take note of Ecclesiastes
The words of the preacher seem to me more philosophical than religious. Time and chance happeneth to all. Time defines appropriateness. A time to sow and a time to reap. A time to be a lover and a time to be a grandfather. I found myself relishing the appropriateness of time. Far from ever regretting my sins I rather gloried in what my wife calls my "ridiculously promiscuous" youth without the slightest desire to repeat it while despising those (Dominique Strauss-Kahn? Silvio Berlusconi?) who do not know when to stop sowing. But also those (Malcolm Muggeridge in old age?) who think that because they're not young nobody should be.
Accept the nature of things
If you have prostate cancer it may spread and kill you fairly quickly. The condition — or the treatment — may reduce your capacity to make love or even to urinate properly. But you were decaying anyway and there was always a risk of death. Time. Decay. Risk. Death. These are the nature of things; the cancer is an extension of the nature of things, not an exception. And, as Jean-Jacques Rousseau put it, "The nature of things does not madden us, only ill will does." That is, only a fool is maddened by the nature of things.
It helps to be a sportsman: you win, you lose, you win, you lose. In the end you lose, but you are glad you once won. But it certainly helps to think philosophically and being philosophical in the technical sense helps with being philosophical in the popular sense. Raging against the dieing of the light is for poets, not philosophers.
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