To hold, as it were, a mirror up to Nature

Who am I? No, really -where do I stop and something else begins? That’s not really as silly a question as it may first appear. Consider, for example, my need to remember something -an address, say. One method is to internalize it -encode it somehow in my brain, I suppose- but another, no less effective, is to write it down. So, if I choose the latter, is my pen (or keyboard, for that matter) now in some sense a functional part of me? Is it an extension of my brain? The result is the same: the address is available whenever I need it.

Ever since my university days, when I discovered the writings of the philosopher Alan Watts, I have been intrigued by his view of boundaries, and whether to consider them as things designed to separate, or to join. Skin, was one example that I remember he discussed -does it define my limits, and enclose the me inside, or is it actually my link with the outside world? I hadn’t really thought much about it until then, but in the intervening years it has remained an idea that continues to fascinate me.

Clearly Watts was not alone in his interest about what constitutes an individual, nor in his speculations about the meaning of whatever identities individuals think they possess by virtue of their boundaries. There was an insightful article in Aeon by Derek Skillings, a biologist and philosopher of science at the University of Pennsylvania entitled ‘Life is not easily bounded’:

‘Most of the time the living world appears to us as manageable chunks,’ he writes, ‘We know if we have one dog or two.’ Why then, is ‘the meaning of individuality … one of the oldest and most vexing problems in biology? …  Different accounts of individuality pick out different boundaries, like an overlapping Venn diagram drawn on top of a network of biotic interactions. This isn’t because of uncertainty or a lack of information; rather, the living world just exists in such a way that we need more than one account of individuality to understand it.’ But really, ‘the problem of individuality is (ironically enough) actually composed of two problems: identity and individuation. The problem of identity asks: ‘What does it mean for a thing to remain the same thing if it changes over time?’ The problem of individuation asks: ‘How do we tell things apart?’ Identity is fundamentally about the nature of sameness and continuity; individuation is about differences and breaks.’ So, ‘To pick something out in the world you need to know both what makes it one thing, and also what makes it different than other things – identity and individuation, sameness and difference.’

What about a forest -surely it is a crowd of individual trees?  Well, one way of differentiating amongst individuals is to think about growth -a tree that is growing (in other words, continuing as more of the same)- and contrasting it with producing something new: as in reproduction. And yet even here, there is a difficulty. It’s difficult to determine the individual identities of any trees that also grew from the original roots -for example from a ‘nurse’ tree lying on the ground with shoots and saplings sprouting from it.’

But it’s not only plants that confuse the issue. If reproduction -i.e. producing something new– counts as a different entity, then what about entities like bacteria? ‘These organisms tend to reproduce [albeit] by asexual division, dividing in half to produce two clones… and, failing mutation and sub-population differentiation, an entire population of bacteria would be considered a single individual.’ -whatever ‘individual’ might therefore mean.

And what about us, then? Surely we have boundaries, surely we are individuals created as unique entities by means of sexual reproduction. Surely we have identities. And yet, what of those other entities we carry with us through our lives -entities that not only act as symbiotes, but are also integrated so thoroughly into our metabolism that they contribute to such intimate functions as our immune systems, our weight and health, and even function as precursors for our neurotransmitters and hence our moods? I refer, of course, to the micro-organisms inhabiting our bowels -our microbiome. Clearly ‘other’ and yet essential to the functioning person I regard as ‘me’.

And yet, our gut bacteria are mostly acquired from the environment -including the bacteria colonizing our mother’s vagina and probably her breast milk- and so are not evolutionarily prescribed, nor thereby hereditarily transmitted. So, am I merely a we –picking up friends along the way? Well, consider mitochondria -the powerhouse of our cells. They were once free-living bacteria that adapted so well inside our cells that they, too, are integral to cell functioning but have lost the ability to survive separately; they are transmitted from generation to generation. So they are me, right…?

Again I have to ask just who is me? Or is the question essentially meaningless put like that? Given that I am a multitude, and more like a city than a single house, shouldn’t the question be who are we? The fact that all of us, at least in Western cultures, consider ourselves to be distinct entities -separate individuals with unique identities- makes me wonder, about our evolutionary history.

Was there a time when we didn’t make the distinctions we do nowadays? A time when we thought of ourselves more as members of a group than as individuals? When, perhaps sensing that we were constantly interacting with things outside and inside us, the boundaries were less important? Is that how animals would say they see the world if they were able to tell us?

Does our very ability to communicate with each other with more sophistication, create the critical difference? Is that what created hubris? In Greek tragedy, remember, hubris -excess pride and self-confidence- led inexorably to Nemesis, retributive justice. Were poets in that faraway time, trying to tell people something they had forgotten? Is that what this is all about?

I wonder if Shakespeare, as about so many things, was also aware of our ignorance: ‘pride hath no other glass to show itself but pride, for supple knees feed arrogance and are the proud man’s fees.’

Plus ça change, eh?

Disparate Opinions

I am always puzzled by assumptions of equivalence. Does success in one field attest to the quality of an opinion about another? I am usually suspicious of the value of, say, a celebrity commenting on the significance of a particular product. It may be interesting, but does that actually certify its worth?

I realize that when it comes to health topics outside my specialty, I am sometimes rather late to the post. But occasionally topics are forced on me by my more curious patients who want to know what I think about them. Moles, for example.

Now, of course gynaecologists are called upon to comment on some dermatological issues –but often by default, and even then, mostly about areas that many dermatologists are reluctant to examine. Fair enough, I suppose –somebody has to be in charge. And yet even here, diagnoses are difficult without a biopsy. Especially here, in fact. It would be nice if there were some reliable rule-of-thumb that would sometimes obviate the need for an often painful and certainly anxiogenic procedure like sampling the tissue in question. Something like: oh, if it’s smaller than a dime, or not blotchy, leave it alone. But, alas, there are no such rules that work for us in the nether parts.

But the arm? Well, that seems to be a different matter:

I have to admit, that until a rather starchy patient told me, I had never heard about it. I understand that it was all the rage when it was first reported, though: simply count the number of moles on your right arm and if there are more than 11 of them… well then you have a higher than average risk of getting skin cancer. The obvious corollary to that being that if you don’t, then you don’t… have an increased risk, that is. She liked the simplicity of the approach, and the proof that her being forced to learn the basics of arithmetic in school so many years ago was finally paying off.

But why, she demanded, and not too kindly, had we not found a similar rule applicable to the ‘private parts’ as she termed them in a barely audible whisper that I had to lean across the desk to hear?

“They’re made of skin as well, doctor,” she added in a more normal voice.

“Well…” I stalled, trying to think of a good answer to a rather naïve question -something that wouldn’t embarrass her. I hadn’t read the article she’d been describing and so I had to come up with something general. “Moles are just collections of pigment cells –‘melanocytes’,” I added to lend a little more credibility to my response. “They are a way the skin can protect itself against UV damage from the sun. The arm is exposed to the sun a lot…” I decided to leave it to her to decide why the arm might be different from that other area that seemed to be concerning her.

But she continued to stare at me as if I had only begun to answer her question. “And…?”

“Well, the more moles on the arm, the more it has likely been exposed to damaging UV light…” It seemed obvious to me. And yet her eyes never left my face and in the absence of any sign of understanding on her part, they were beginning to hurt. “The idea, I suspect, is that the more moles there are, the more that arm –or maybe the whole body- has needed to protect itself against the sun.” She blinked. “And so maybe that means it wasn’t able to protect against some of the damage…”

She rolled her eyes impatiently. “I understand that, doctor!” she said with a stern look on her face. “I’m not stupid, you know,” she added helpfully.

I smiled to disarm her, but I think she took the change of expression on my face as an attempt at refutation and a storm gathered in her eyes.

“Look. Moles are a protection mechanism against the sun, right?” she said testily. I nodded, glad of the chance to show I agreed with her. “So if you have moles somewhere, that means they’re there to help. Correct?”

I wasn’t completely sure if that followed –moles are just collections of melanocytes in the skin. They’re not necessarily related to sun exposure, either. Maybe some just appeared in an area by chance. It was an increasing number that suggested they were there for a particular reason. Counting them merely acknowledged that there was some sort of increased risk that demanded their presence. It was a crude, but easy way of quantifying that risk. But I smiled to show she was on the right track. “Yes, but especially if there are a lot of them –more than usual, I mean.”

“So there are usually less than 11 on the right arm…?”

“A little out of my area of expertise, but yes, I suppose so…”

It was her turn to smile –she was finally getting me to understand her point. “And how many down there” –and with that she pointed to where she was sitting- “How many down there,” she repeated to make sure I was still following her, “would you say was ‘usual’?”

“On the labia?” It was time to call a spade a spade.

She immediately blushed and unleashed her eyes once again to punish me. “We were doing quite well without using that disgusting word, doctor!” Then, realizing how silly that sounded, she softened her face and called off her eyes. “On the…” she forced herself to whisper the offensive word. “labia, yes. How many?”

I’d never really thought about a number before. “Well, it’s an unusual area to find a mole -it usually doesn’t get much sun…” I had a quick peek at her face and caught another blush in the making. “So I’d have to say even one would raise my suspicions.”

She looked uncomfortable when I said that. “So… three would be even worse…?”

I nodded –but slowly. Carefully. Now I understood why she had brought the subject up in the first place. Why that article had made her aware of the function of moles. “Have you noticed some on yourself… down there?” I said more respectfully this time, finally realizing how difficult it had been for her to introduce her concerns to me, a stranger -and a man.

She nodded bravely, but I could see tears gathering in those previously formidable eyes.

I smiled reassuringly and reached across the desk to touch her hand. “Would you like me to check, Esther?”

The relief was noticeable and a smile –a real smile this time- surfaced on her lips. “Please,” she said and actually squeezed my hand. “But I want you to come up with a three-or-less rule, okay?”

That sounded reasonable to me; maybe I could even get it published in the BBC News as well…