• © 2012 by American Society of Clinical Oncology

Blindness: Looking but Not Seeing

“Blinder than he who has lost his eyes is he who closes them tightly and refuses to see the light of day.”^1(p76)

A 76-year-old man—a married architect with prostate cancer and bone metastases—was confined to a wheelchair because of weakness, lower back pain, and leg pain. There was hardly room for the patient's wheelchair in the oncologist's office, given the size of the physician's desk. The oncologist scanned the patient's medical records on a computer located in the center of the desk and relayed unemotionally that the latest test results were normal. When the patient's wife commented anxiously about her husband's continued pain, the oncologist suggested (while typing and without looking up from the screen) that the patient increase his doses of an opioid and acetaminophen. The patient requested a letter to bring to his family physician, and the oncologist instructed him to wait outside while it was typed. The patient and his wife complied with the physician's instructions, but they felt alone in their suffering.

Blindness can be a metaphor for failed communication. To see can mean to look with one's eyes, but it can also mean to understand. Thus, a person may be symbolically blind (ie, not understanding, not connecting) or may be physically without sight. We asked ourselves: What is the meaning of failing to see a patient's anguish, as in the case described? Is this a form of blindness?

Two literary works can assist us in exploring the idea of blindness as a trope to illuminate impaired communication: Blindness,² a novel written in 1995 by the Portuguese Nobel Prize winner Jose Saramago, and The Country of the Blind,³ a short story written in 1904 by the English writer H.G. Wells. In these fictional, allegoric tales, both Saramago and Wells use blindness as a metaphor to describe psychosocial ills.

In Saramago's novel, blindness is created by self-induced mass hysteria, which spreads like a contagious disease as people struggle to survive in rapidly changing conditions. Society degenerates, and a state of emergency prevails, as people stop seeing the needs of others and become indifferent to suffering; blindness becomes a catalyst for apathy.

Wells, in contrast, describes a lost village in the South American Andes where all inhabitants are genetically blind. One day a hiker from the outside world stumbles on this isolated civilization. At first, the hiker is surprised by the prosperity and peacefulness of the villagers; he cannot understand how anyone who is blind can live a happy and meaningful life. The newcomer tries to explain the wonder of sight to the blind inhabitants, but without a frame of reference, they cannot understand the concept. The village doctor even suggests removing the hiker's eyes, because his strange talk indicates that they might be diseased and harming his mind. Wells' themes include the suggestion that the barriers between some cultures or groups are insurmountable, despite insight, empathy, and even love.

In the clinical case described here, the oncologist made recommendations that were technically correct but failed to note or act on the patient's distress. Saramago claims that individuals have a choice of whether to see. Saramago's unconscious, self-inflicted blindness parallels the process of denial. Denial is a survival mechanism and a process to aid coping.⁴ All of us have seen patients deny unto death, to protect themselves from fear or anxiety. Oncologists also engage in a form of denial at times, which is comparable to losing insight. This form of denial is a mechanism of defending against the frustrating emotions wrought by failure to save or prolong life in the face of serious illness. Denial and avoidance may transiently protect, but they prevent us from connecting with our patients and deepening our understanding of their experiences.⁵

Wells, in contrast, describes sight or blindness as innate, similar to empathy, which is modifiable but for which some individuals may have a greater intrinsic capacity than others on a neurophysiologic basis. Exploration of empathy is at the core of Wells' story; the protagonists have to imagine in their minds' eye what it is like to be blind or to be sighted. Empathy is also part of the oncologist's diagnostic skills in eliciting and elucidating symptoms, both physical and psychologic. Yet at the same time, empathy may awaken unrecognized death anxieties in the clinician.⁶

Blindness can manifest in many ways in the consulting room. The physician can be blind to the patient's repressed anger and depression, blind to tension between partners, blind to the misery of loneliness and regrets. And we can also be blind to our own feelings of fear, helplessness, guilt, and ambivalence. This blindness or lack of self-awareness may lead to over-identification with the dying patient, exaggerated feelings of personal failure, or simply missing of important personal clues provided by the patient and family.

Powerful messages can be conveyed by a mere glance. In a personal narrative, a Western oncologist described the difficulties of communicating with a patient from a culture in which the faces and eyes of women are traditionally covered. Not having direct eye contact with the female patient diminished the physician-patient relationship as he knew it. Eventually, however, as trust developed, the veiled woman did expose her eyes, and the physician learned how to meet her gaze and provide care.⁷

Not once during the brief consultation described here did the physician take his eyes off the computer screen. Although electronic medical records have many practical advantages, the computer represents yet another potential barrier between patient and physician, another obstacle to seeing. The oncologist's letter to the family physician stated: “The tumor markers were normal, and imaging tests unchanged. Despite his wife's complaints about his pain, the patient appeared well, and there were no objective neurologic findings.” The patient and his wife had been seen neither physically nor personally.

Psychologic blindness can be overcome with experience and self-reflection. However, where blindness is part and parcel of the human condition, it can make seeing—especially of masked emotions—difficult. Communication courses, mentors, didactic teaching, and medical humanities all play a role in enabling us to open our eyes. Words and silences are often not enough. Touch is frequently inadequate. Eye contact, we believe, is a basic prerequisite.

The last words belong to Saramago, who left with us a choice, albeit ambiguous: “It used to be said there is no such thing as blindness, only blind people. I think we are blind. Blind but seeing. Blind people who can see, but do not see.”^{2 (p307)}

• Received November 30, 2011.
• Accepted April 19, 2012.