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  • Commentary on "The Alzheimer's Disease Sufferer as a Semiotic Subject"
  • William M. Greenberg, M.D.

The paper under discussion explores the presence of agency in those with Alzheimer's disease (AD), focusing on two cases in particular. Steven Sabat and Rom Harré argue that relying on standard psychometric tests may keep clinicians from perceiving the personhood of some Alzheimer's sufferers, causing them to overlook the presence of fundamentally intact intentional beings. Two important caveats are noted: that the two afflicted subjects were motivated, previously articulate individuals with doctoral degrees and were therefore special in important senses; and that sometimes frustrated caregivers are prone to the opposite error, that of believing that AD sufferers intend to annoy the caregiver, when the behaviors in question originate mainly or solely from cognitive impairment.

Sabat and Harré appear to treat the question of whether or not an individual is a semiotic subject as a dichotomous categorical rather than a dimensional one, that is, a semiotically intact agent is either present or not present, with impairment perhaps only extant in the tools employed to express his or her intentions. This same approach is often encountered in medicolegal decision making (e.g., with regard to whether or not an individual is competent to give informed consent, or to make medical decisions for him- or herself), as well as in a family member's poignant query concerning a demented patient: "Is my mother still there, or is she gone?" It would often be more clinically accurate to recognize the kinds and degrees of impairment in afflicted individuals' abilities to appreciate meanings and form intentions. As the AD sufferer's brain "instrument" progressively erodes, so do its associated skills—the "optimistic" diagnosis becomes pessimistic. Further, although semiotic competence is important, how much does identifying a semiotic subject do for us? It wouldn't seem to protect against infantilizing or dehumanizing the subject. In the least demanding interpretation of semiotic competence (including acceptance of failures of appreciating public standards of propriety and rationality, as the authors seem to allow), connectionist computer programs might in limited contexts qualify as semiotic subjects. I'm also not sure that just "'wanting something'...logically presuppose[s] an intact sense of personal identity." Even bacteria, through Chemotaxis and directed movements, may meaningfully demonstrate that they "want something" in the environment, but they presumably lack an intact sense of personal identity.

The "technique" of not prematurely interrupting a patient's discourse more generally reflects [End Page 163] good clinical practice. Trained clinicians learn to identify and restrain their own biases, wishes, preconceptions, and impatience, and strive to attentively listen to and be with their patient; these skills are at risk of decline owing to the "objectivity" of quantitative scores and the "efficiency" of spending less time with patients and more with paperwork. The art of understanding the utterances and nonverbal behavior of a patient with Alzheimer's disease, like the art of understanding someone with a psychotic thought disorder (translating "schizophrenese"), or of interpreting a dream, involves the interviewer offering back proffered "clarifications," as in the cases presented here. Such clarifications nonetheless necessarily run the risk of "leading the witness," owing to patients' wish to please the interviewer, as well as their difficulties in thinking.

These caveats notwithstanding, the Sabat and Harré's work certainly has specific clinical value. Family and professional caregiving are emotionally challenging occupations. All too often we infantilize, if not dehumanize, patients. Those with mental retardation, dementia, or disorganizing psychotic disorders are particularly at risk. Sabat and Harré not only sensitively recognize patients' needs for dignity, self-respect, satisfying relationships, and meaning justifying their existence, but also appropriately warn of the limited ability of psychometric tests to demonstrate patients' best performances. Clinicians' black humor—expressed by describing one's work as "veterinary medicine" (ironically, veterinarians probably have little problem empathizing with their chosen subjects) or by saying that a patient has become "a vegetable"—is a sobering reminder of our own emotional limitations and tendency to dehumanize others (although we certainly also frequently commit the opposite error in the pathetic fallacy). Taking sufficient time to listen and be with such patients, and to discuss their lives in some detail...

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