In last month’s issue I reviewed the success rate of chemotherapy in treating solid tumors. Despite the fact that some form of chemotherapy is recommended to most individuals with cancer, evidence supporting its ability to improve survival is lacking. Life extension, when it does occur, is limited to a few months. Studies have shown that at least 25 % of people with advanced cancer will die more quickly as a result of receiving chemotherapy.

I listed some of the side effects of chemotherapy in the article, but I did not go into detail. Although the experience will vary depending upon the regimen prescribed and the constitution of the individual, treatment often produces ghastly results. Many have referred to chemotherapy treatment as torture.

Merriam-Webster’s Ninth New Collegiate Dictionary defines torture as “something that causes agony or pain”. It is an apt description of what many individuals undergoing a course of chemotherapy experience. Chemotherapy treatment would be considered a form of torture were it not for a loophole - an escape clause – that provides an exemption.

Medterms online medical dictionary provides a slightly different definition of torture:

An act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person (escape clause is inserted here). Survivors of torture often suffer from physical and psychological symptoms and disabilities. There may be specific forms of physical injury including broken bones, neurological damage, and musculoskeletal problems. Torture may result in psychological symptoms of depression (most common), post-traumatic stress disorder, marked sleep disturbances and alterations in self-perceptions together with feelings of powerlessness, fear, guilt and shame.

The definition above is a perfect description of cancer chemotherapy. Most regimens cause severe physical and mental suffering. The drugs are intentionally given, with full knowledge that the person receiving them will suffer serious consequences. Neurologic (brain and nervous system) damage commonly occurs, and many receiving chemotherapy report psychological symptoms of depression, post-traumatic stress disorder, marked sleep disturbances, alterations in self-perceptions, and feelings of powerlessness, fear, guilt, and shame. Were it not for the escape clause, chemotherapy would be the quintessential example of torture.

So why is chemotherapy not considered a form of torture in our society? It is because the medical dictionary defines torture not by results, but by intent. The escape clause reads, “for a purpose such as obtaining information or a confession, punishment, intimidation or coercion, or for any reason based on discrimination of any kind.”

Creating agony and suffering that results in profound and lasting physical and psychological challenges is considered torture only if the intent is to intimidate or punish someone. Since the physician’s motive in prescribing the treatment regimen is altruistic, seeking to ultimately improve the disease outcome, the suffering produced by the treatment cannot be defined as torture, no matter how horrific the effects of the drugs may be. If individuals were made aware of the terrible cost and limited benefit of submitting to chemotherapy they might not agree that good intentions trump agony and pain. If the oncologist presented the option truthfully he or she would need to state, “If you allow me to torture you for six months there is a slight possibility that you may live up to three months longer than if you don’t consent to treatment.” It is likely that many people would decline treatment if it were presented in that light.

A number of years ago I was involved in the care of an individual who presented with pancreatic cancer. She had been losing weight rapidly, which is one of the primary signs of pancreatic cancer. In spite of her weight loss she appeared healthy and was in no pain or distress. There was every reason to believe that she would live for at least six months.

Surgical removal was not an option, so her family encouraged her to see an oncologist to discuss what chemotherapy had to offer. The oncologist was honest and detailed the adverse effects she was most likely to experience while undergoing the treatments. She died three days later. No logical reason for her death could be identified. I believe that she willed herself to die rather than submit to torture.

The act of administering a chemotherapy drug can itself be a form of torture. While some drugs are given orally, injecting the drugs directly into a vein is often the preferred method. This can involve multiple needle sticks; vein access becomes progressively more difficult as treatment proceeds. The need for needle sticks to draw blood, administer drugs, and give blood transfusions can be diminished by the surgical implantation of a line that runs into one of the large veins of the body, but external catheters and internal ports have challenges of their own.

Pain during the first four or five days after insertion can be intense. Some people never become accustomed to the presence of the port and catheter. At times a lung is punctured during insertion. Blood clots and infections can occur during use.

The prevalent medical attitude regarding needle sticks and chemotherapy catheters is that people “get used to them” and that they therefore are not a significant concern. Needle sticks, however, are a major concern to many people. The United States’ Supreme Court deliberated the question of whether executions by lethal injection should be declared “cruel and unusual punishment”. This was due in part to the need for multiple sticks to establish an intravenous line in some instances and the concern that if the condemned person was not adequately anesthetized pain would be experienced as the lethal drug coursed through the vein.

Nearly every person undergoing chemotherapy experiences sessions in which multiple attempts are required to access a vein. Many experience burning pain due either to the drug’s toxicity or leakage of fluid into the tissues surrounding the infusion site. It is interesting indeed that what is suggested to be “cruel and unusual punishment” in the instance of a condemned criminal is deemed to be of little concern when inflicted upon individuals who are fighting cancer.

For many cancer patients the needle sticks and drug infusion is only the beginning of their torment. No less than 200 adverse effects are known to result from various forms of cancer chemotherapy. A single individual is unlikely to encounter all of them, and the number and severity of reactions will vary depending upon the drug or drugs received. This is of little comfort, for even one or two of the effects is often enough to make one miserable for an extended period of time.

Nausea is one of the most frequently reported side effects of chemotherapy. It often progresses to episodes of vomiting. Most people find the experience of vomiting one of life’s most miserable moments. Even if the nausea is not severe enough to induce vomiting it removes all possibility of enjoying a meal and the social interaction that often accompanies it. Medications to counteract the nausea are routinely given before many chemotherapeutic drugs are administered, but they are rarely completely successful in preventing the subsequent period of nausea.

Nausea may begin within 1 to 3 hours of treatment, but it may appear as long as four days later. The degree to which individuals are affected by this may be appreciated by recognizing that at least half of those receiving chemotherapy become nauseated in anticipation of their next treatment. This is referred to as anticipatory nausea and vomiting (ANV). When ANV develops post-treatment nausea is often more severe and even more difficult to control.

In addition to nausea, chemotherapy can cause a loss of appetite or change one’s sense of taste. This can be enough to trigger a dislike or aversion to certain foods, even those that have been favorites prior to the treatment. This can make it very difficult to maintain an adequate caloric intake.

A sore or ulcerated mouth is another common side effect of chemotherapy. Mucous membranes that line the mouth and other interior surfaces are particularly sensitive to the toxic effects of chemotherapy drugs. The drugs create inflammation that may present as severe dryness of the mouth, but which may progresses to form open ulcers. Little can be done to speed repair of the damaged mucosa. The healing process typically takes 10 to 14 days, during which time it may be difficult or impossible to consume adequate amounts of food and fluids.

Chemotherapy can have devastating effects on the body’s ability to manufacture blood components. As red blood cell counts fall and anemia develops an individual typically experiences profound fatigue and weakness.

Low levels of white blood cells severely compromise the body’s ability to prevent infections. Some, such as pneumonias, can be life-threatening. Others, like candidiasis, can cause intense burning in the mouth and throat along with itching, burning, and rawness of the skin.

As white blood cell levels fall, severe outbreaks of herpes simplex can occur. Under normal circumstances the virus can cause localized fever blisters, but when the body’s defenses have been compromised by chemotherapy the blisters can involve the entire mouth. Fatal herpes simplex infections of the brain and liver have occurred following chemotherapy.

The body’s ability to produce platelets, which are needed to stop leaks in blood vessels, is also severely compromised by many chemotherapeutic agents. As platelet levels fall, bruising becomes an issue. Nosebleeds, bleeding gums, and passage of blood in the urine or stool can occur, as can severe or fatal hemorrhages.

Often overlooked are the long-term adverse effects of chemotherapy. A high percentage of individuals who survive the treatments struggle with depression. Others exhibit the classical signs of post-traumatic stress syndrome. In either case, the joy of living is lost, and individuals spend their days in apathy at best and fear and anxiety at worst.

Chemotherapy is also known to cause persistent cognitive (thinking ability) deficits. This can be extremely troublesome to treatment survivors. Multitasking may be difficult or impossible, and short term memory may be poor as demonstrated by an inability to find one’s keys or remember frequently used telephone numbers.

When these and other immediate and long-term effects of cancer chemotherapy are given serious consideration there is no question that the practice meets any common definition of torture. The question is not whether chemotherapy is torture; that is indisputable. The question is whether the ends justify the means. Is it reasonable for an individual to submit to torture simply because he or she has been found to have a form of cancer? Can someone who truly loves that individual demand that he or she endure torture simply because it is recommended by an industry that measures success by such vague outcomes as “reduction in tumor size” or “length of time to first recurrence” without giving any consideration to quality of life issues?

I would argue that the answer to both questions is no. It is not reasonable for an individual who has been found to have cancer to submit to torture on the basis of that diagnosis. Demanding that a friend or family member submit to torture because he or she has developed cancer cannot be justified.

A diagnosis of cancer is not an automatic death sentence. Most people in whom cancer is detected at an early stage will do well. There is little, if any, support for the idea that giving chemotherapy to “eliminate any cancer cells that may have been left behind” will increase longevity or improve one’s chance of survival.

When it is discovered that cancer is widespread and the prognosis is poor, there is no justification for initiating chemotherapy. Studies have shown that chemotherapy is not effective in curing advanced disease and at least a third of those treated will die sooner from drug toxicity.

References Used in Chemotherapy and Chemotherapy as Torture