Mr. C. is a mindless aphasic who smears paint on paper. His smearing does not issue forth from an inner impulse; no, it stems mainly (or only) from the therapist who guides his clumsily functioning left hand across the paper. At least, that is how I would describe what’s going on here. She most emphatically does not see it this way. She reckons she can sense in his arm which way his hand would like to go, if go it could, because it’s his left hand and he was right-handed before the stroke. When she leaves him alone for a moment to attend to another patient, it turns out that his hand does not want to go anywhere.
I have learned not to enter into a debate about this, because people who discern less soul in brain-damaged patients than others are easily dismissed as being insensitive, whereas people who manage to construct an entire mental life out of the wrigglings of a patient’s big toe regard themselves as blessed with a special gift.
But Mr. C. is severely aphasic, by which I mean to say that you really don’t have any idea of what thoughts lie behind his gently smiling face. His son doesn’t understand him either.
“I dutifully slip in my nickels,” he confides to me, “but I cannot see from his reaction if they drop anywhere inside him.”
He had tried to ask his father if he wanted to be hospitalized in case of a medical emergency. Dad gave him a beatific smile in response. Then the son had applied that oldest of all recipes, which has been used for centuries in this type of situation and is still completely useless: turning up the volume. “DAD, DO YOU IN CASE OF A …”. To no avail.
Next he tried speaking slowly, and asked his father with excruciatingly pre-cise e-nun-ci-ation the same question, with the result that his father started mimicking the elaborate motions the son made with his mouth during this attempt at verbal transparency. No use.
“Ah, well,” the son decided in the end, “we’ll cross that bridge when our chickens hatch.” Son not in the least aphasic, as you notice.
Mr. C. was a piano teacher before his stroke and the occupational therapist handed me a video “recorded only last year—it’s so touching to see how beautifully he played the piano.” I promised her I would have a look at it later, but when I got home that evening I knew I was not going to. It could not be touching to see him as he was last year. It could only be devastating. You do not prise open someone’s ill fate in order to have a good look at it.
I described Mr. C. as “mindless,” which sounds like a disqualification. I did not intend it that way. What bothers me about him is his equanimity, his incomprehensible compliance, which strikes me as mindless because, if mindful, he would be blazing with rage and despair at the horror of the situation he has landed in. He lacks that cast of mind, and this lack implies that he does not fully experience this, the way a blind dog may not know it is blind. I mean to say that I don’t regard C. as a great stoic who manfully shoulders his misery. I don’t know exactly what his burden is, but he carries it lightly.
“You can’t help wondering just what’s going through his head,” muses his son while he gently strokes his father’s face. “Maybe not much, eh, Dad?”
Relatives rarely if ever reach this conclusion when dealing with brain-damaged loved ones. We prefer to reason in the opposite direction. The other day I was standing right next to such reasoning in the case of Mrs. D. She is deeply demented, doesn’t come out of bed anymore, and only drinks from a baby’s bottle. Her daughter, who was visiting her, brought her face close to that of her mother while she kept asking the old woman in a rather nagging fashion, “Look at me, Mum. Will you look at me, please? Mum, look at me! You know me, don’t you?”
After a good deal of this harassment, the old woman muttered something incomprehensible which the daughter thought sounded like “Jonathan.” Jonathan? Her husband sat at a little distance from the scene, morosely smoking his cigarette. She told him about “Jonathan,” which he brushed off as absurd nonsense, adding in irritation, “She means Helen, of course!” After this he turned his back on the whole business and lit another cigarette. The daughter found this a reasonable conclusion, and when Helen came into the ward about half an hour later, she was greeted with the announcement that “Mum was just talking about you!”
The problem in such situations is that we find it next to impossible to switch off our capacity to read a human face—an indispensable skill with a long history. Living in a group, as all higher primates do, makes it absolutely vital that members know each other’s intentions. This knowledge must be gathered from the faces surrounding you: otherwise it is impossible to obtain food, sex, and safety. It helps, in this connection, to consider why we ascribe feelings to dogs but not to stones. “An inner process,” says Wittgenstein, “stands in need of an outer criterion.” If we do not adhere to this stricture, the ascription of mental activity turns into a wholly arbitrary business. If there is no external sign necessary for the idea of an inner process to arise, then there’s no way in which you could dismiss the possibility of a chair worrying about income tax, because “you never know, do you?”
Even my extremely sensitive interpreter, who only needs a wriggling toe to conjure up inner vistas, does need that wriggling. Otherwise she too would be staring at a blank wall.
How personal this impression of a mental presence is after brain damage appeared in the case of Terry Schiavo. Her husband stated that she was no longer there. Her parents felt differently, and the decision to let her die must have been horrible to them. A colleague of mine suggested a possible way out of the Schiavo case by means of a Solomonic judgment: her husband could have given “her” to her parents. After all, he was convinced that she was no longer there. If he really felt this, then handing over her soulless body would have been bearable to him. But as you are saying this, you immediately sense that to him the enterprise of a prolonged life for that body in the hands of her parents (as something like a live doll) would be the transgression of an indefinable rule of decency.
Philosophy and neuro-anatomy do not quite help us out here. They do not match what we experience. This goes for the parents as well as for the husband.
Bert Keizer works as a doctor at a chronic care facility in Amsterdam and writes frequently about medical and philosophical issues. He is the author of Dancing with Mister D as well as a book about Wittgenstein and an opera libretto about Alzheimer’s.
