Physicians by their creed and calling endeavor to use tried and true treatments for disease processes that can be measured in one way or another.  One measure of disease might be a high fever or a pain that the person has or a high blood cholesterol or abnormal liver tests, etc.  Over the past several hundred years, great strides have been made in diagnostic capabilities and treatments for various diseases.

    But there are some factors involved in human disease processes that thus far have defied our ability to measure them.  And yet they have tremendous impact on the state of a person's well-being and health.  One such factor is guilt.  Past columns have addressed the important health impact of anger and shame.  To recap, angry is a feeling one has when they have been treated unfairly or someone has  intruded  into  their "space".  Shame is the emotion one feels when they have performed inadequately.  In a sense, guilt is the opposite of anger.  Guilt is the feeling one has when they have treated another person unfairly or have inappropriately intruded into that person's "space".

There is school of thought in psychology that human beings have four basic fears.  First, there is the fear annihilation or dying.  Built into the natural hardware in our brains is a drive to survive.  Second, is a fear of abandonment.  Humans tend to be gregarious and to seek other humans with similar beliefs and  cultures.  Third, is a fear of failure.  To my surprise, the fourth basic  fear is a fear of treating others unfairly which explains why guilt is such a disabling emotion.  Human beings go to great lengths either to avoid being unfair to other people or to compensate for those incidences where a perceived unfairness has occurred.  Yet trying to measure a person's guilt and it's impact on the person can be very difficult.

    An example can be very enlightening regarding the nature of this type of problem.  I recently encountered a gentleman in his 50's who came to the emergency room late one evening because the left side of his face and his left arm had lost sensation.  He described the problem areas as feeling like they were "dead".  He could move his  arm or  face easily enough but if one put a coin or a marble or a key in his hand, he could not identify the  object because he couldn't feel it.  He had had a stroke in which the sensory part of the brain that detected his left side had been damaged.  His blood pressure was 220/140 and he indicated that he took no medications and had not sought medical attention in many years.  Evaluation indicated that there had been a small clot develop in a minor blood vessel to the part of his brain that  serves the left side of his body.  Often sensation will return if the blood pressure is effectively controlled and the damage has not been too severe.  Medications were started and his blood pressure was then effectively controlled and fortunately the sensation did come back to the left side of his face and his left arm.

    In taking his medical history, it was learned that his father had passed away after a prolonged illness ten years previously.  This gentleman was the eldest children in the family of six siblings.  It always seems that the eldest child is most effective at generating a sensation of guilt.  When his father passed away, it was made very clear that the eldest son was expected to take care of mother and not let her go to nursing facility.  As time passed, the mother developed an increasing infirmity with dementia and was very difficult to care for.  My patient's two children had grown and left the home.  My patient and his wife tried the 24 hour 7 days a week duty of caring for mother.  But increasing difficulties lead to dissolution of the marriage and his wife moved out of the home.  Now this gentleman was left with the responsibility of caring for his mother, trying to run the farm and maintain his relationship with his children.  He had been helping his son get though college but financial difficulties interfered with that.  This gentleman was a very physically strong stalwart member of the community and sobbed through this entire story to the point where he  was sedated so his pressure didn't go back up again.

    This  patient felt guilt because his father had financed his way through college.  His father had repeatedly pointed out the financial sacrifices the father had made in this endeavor.  His mother pointed this fact out repeatedly also.  She made it clear that to be "fair" he should take care of her.  His wife pointed out that it wasn't fair for him to expect the wife to take care of his mother.  His son pointed out that it wasn't fair to cut off his financial support in the middle of his college education and then finally while this gentleman was attending to farm business, his mother fell at home, broke her hip, and passed away soon thereafter.  He felt guilt because he had not been there to prevent her fall.

    This story illustrates several points about the concept of guilt.  First, it is most often true that guilt is something generated by a feeling of obligation.  Open ended obligations are destined for grief.  This gentleman somehow had accepted his father's point that financing a college education obligates him to take care of his mother for the rest of time without seeking the help of a nursing facility.  Single caregivers trying to care for a loved one 24 hours a day, 7 days a week are destined for a bad outcome.  They often ruin their own health and well-being while trying to care for the loved one.  When a caregivers health finally fails, then the loved one receives no care either.  In addition, the arrangement of accepting mother's care at home had so disrupted this gentleman's marriage that that failed also.  His relationship with his children had been tarnished by their perception that their mother had not been fairly treated.

    To counsel this gentleman, he first needed to recognize that he accepted responsibility for an undoable task.  What happened was a tragedy but had occurred because of his very high sense of duty, morality, and ethical standards.  It was pointed out to him that he had not treated his mother unfairly or his father unfairly.  He had done the best he could to care for them.  But his concept of guilt had lead him to make some unwise choices in his mother's care.  These same, very well intended choices based on concepts of guilt had lead to the dissolution of his marriage.  Finally these unwise choices had lead to his financial undoing with the property settlement from his divorce.

    The lesion from this story may bother and offend some people but the brutal truth is that concepts of guilt can be very destructive.  This gentleman's primary problem was a creation of guilt based upon his father's dying wishes.  Note that very frequently, the guilt an individual feels is fostered or even created by another individual.

    Dealing with guilt or shame or anger is critical to the maintenance of one's mental and physical health.  This comes under the heading of "stress management".  The question to ask to one's self in regard to guilt is, "Am I really being unfair to the other person?  Is what I am doing fair to myself, and fair to various other people who will be impacted by my decisions?"  Guilt is often something used by other people to control you.  I submit that it is rarely a constructive emotion even if well intended.