In 1971, then-President Richard Nixon declared a “war on cancer” in the United States and predicted its demise by America’s bicentennial in 1976. In some sense, like the Vietnam War, that war was doomed to failure from the start—frustrated by a lack of understanding of the “enemy.” Indeed, the question “What is cancer?” still has yet to be answered satisfactorily. Philosopher of medicine and bioethicist Mary Ann Cutter has taken on this challenging question in an insightful book on the meaning of breast cancer—specifically her breast cancer. It should be quickly noted that Cutter acknowledges the help of “eleven great women who have spent hours upon hours listening to me rehearse the details of my clinical appointments and suggesting ways to think about the options that were before me” (p. v)—although, in the end, this is Cutter’s story.

Following a preface and an introductory chapter, the book proceeds with four chapters that address how breast cancer can be described, explained, and evaluated as a disease, as well as how it can be understood as a social phenomenon. A subsequent chapter then explores the relationship among these four dimensions, with a penultimate chapter examining the ethical issues that arise in breast cancer care. At the beginning of each chapter, Cutter offers personal musings on the topic in question, and her final chapter extends these musings in terms of seven lessons learned from her experience as a breast cancer survivor. The book also contains two glossaries defining medical and philosophical terms.

In the preface, Cutter begins matter-of-factly: “In late 2012, I was diagnosed with invasive ductal carcinoma of the right breast with nodal involvement and underwent a bilateral mastectomy, lymphectomy, and breast reconstruction” (p. xiii). Thus, the stage is set for inquiry into what breast cancer is from a philosophical perspective. This question of breast cancer is then broken down into six manageable sub-questions. After an introductory chapter in which Cutter discusses the reasons for thinking about breast cancer, especially from a philosophical perspective, her next chapter launches into the first question of how breast cancer can be described. According to Cutter, the description of breast cancer depends on several metaphysical or ontological assumptions, which come in three contradictory pairs. The first is realism versus antirealism. Realism is the belief that a mind-independent world exists, while antirealism does not hold to this belief. The relevance of this pair for describing breast cancer is that although the disease itself certainly exists, it exists in terms of a framework that ranges from biochemical to social. For example, how breast cancer is described depends not only on technical issues but also on gender and racial issues. The second pair is physicalism versus idealism, with the former holding that reality is physical and the latter holding that it is conceptual. Breast cancer is physical in that mutated genes are part of its etiology; however, it is also conceptual in that the etiology can change with new clinical observations and findings. The final pair is reductionism versus holism. Reductionism assumes that the whole is simply the sum of its parts, while holism claims that the whole is greater than the sum. Again, although breast cancer can be reduced to mutated genes, breast cancer as an illness—as the patient experiences it—is much more. Invoking George Engel’s biopsychosocial model [1], Cutter concludes that “breast cancer is not just a condition of the body, but a condition of a patient within a social context” (p. 46).

The next question, taken up in chapter 3, is how breast cancer is explained. Whereas the preceding chapter is concerned with the ontology of breast cancer (i.e., what it is), this chapter is concerned with its epistemology (i.e., how the medical profession knows that what it knows about breast cancer is true). To that end, Cutter entertains four epistemological issues. The first is the distinction between empiricism, which claims that knowing is justified by sensory observation, and rationalism, which asserts that reasoning is the basis for knowing. Certainly, empiricism is important for knowing about breast cancer, but as Cutter adds, “clinicians bring to their diagnosis of a disease rational frames of reference through which they ‘know’ an object or experience” (p. 57). In the end, both empiricism and rationalism complement one another in knowing breast cancer and justifying that knowledge. The second epistemological issue concerns four causal relationships: (1) a necessary causal relationship in which the causal factor is required in order for the effect to materialize; (2) a sufficient causal relationship in which the causal factor brings about the effect but is not necessarily required for the effect to materialize; (3) a contributory causal relationship in which the causal factor contributes, along with other causal factors, to bring about the effect; and (4) a spurious causal relationship in which the factor appears to be causal but is not. Obviously, knowing the causal relationships for breast cancer is important in both prognosis and treatment. But, as Cutter acknowledges, there is tremendous uncertainty in knowledge about what brings about the disease, which is the third epistemological issue discussed. Traditionally, medicine strives for absolute certainty; but it has been unable to attain such certainty and therefore settles for probability. The question is how best to act given this lack of certainty. Atul Gawande has captured this conundrum accordingly.

The core predicament of medicine—the thing that makes being a patient so wrenching, being a doctor so difficult, and being a part of society that pays the bills they run up so vexing—is uncertainty. With all that we know nowadays about people and diseases and how to diagnose and treat them, it can be hard to see this, hard to grasp how deeply the uncertainty runs. As a doctor, you come to find, however, that the struggle in caring for people is more often with what you do not know than what you do. Medicine’s ground state is uncertainty. And wisdom—for both patients and doctors—is defined by how one copes with it. [2, p. 229]

The issue of uncertainty leads to the fourth and final epistemological issue—skepticism. Cutter identifies three types: (1) absolute skepticism in which doubt is cast on whether knowing is possible at all; (2) philosophical skepticism in which doubt is cast on theoretical assumptions about knowing; and (3) common-sense skepticism in which doubt is cast on practical assumptions about knowing. She concludes that given the uncertainty surrounding explanations of breast cancer, the patient should practice “a healthy sense of skepticism about clinical diagnosis, prognosis, and treatment” (p. 76).

In the next chapter, Cutter introduces axiology, or the study of value, to take on the question of how breast cancer as a fact should be evaluated. For her, a fact is an “empirically verifiable statement,” and a value represents a “sign of worth or assessment of comparison” (p. 81). She discusses four axiological issues surrounding the relationship between fact and value vis-à-vis breast cancer. The first is the distinction or contrast between value neutralism, in which values do not influence facts, and normativism, in which they do. Although breast cancer is a fact, values do play a role in determining how to proceed in treating patients who are suffering from the disease, especially in terms of harm resulting from the treatment itself. The next issue pertains to the types of values brought to bear in the clinical setting. She identifies four such types: functional values assign worth to how something works, instrumental values assign worth to meeting certain goals, aesthetic values assign worth to beauty, and moral values assign worth to the ethically praiseworthy. According to Cutter, “our understanding of breast cancer involves choices regarding what is good and proper function, what ends are to be sought, what is aesthetically pleasing, and what is the right or good thing to do” (p. 94). The third issue is value certainty, in terms of value subjectivism (or personal preference) and objectivism (or independence of personal preference). The relevance for breast cancer is that values qua personal preference can have an impact on decisions about how to proceed with treatment. Finally, the issue of value skepticism—whether absolute, philosophical, or common-sense—factors into breast cancer care from a nihilist position on practical concerns.

In chapter 5, Cutter entertains the question of how breast cancer is a social phenomenon. She begins with musings about her status as a survivor, about her concerns over the uncertainty of whether treatment has cured her. She then proceeds to address four sociological issues associated with breast cancer. The first is the collaborative view of knowledge according to which biomedical science is a social institution and its knowledge is shaped by its institutional structure. The second is a tendency toward medicalization that construes the patient’s life under the aegis of medical authority and scrutiny. The third issue is the commodification not simply of breast cancer qua disease but of the breast cancer patient, who is then subject to market forces—particularly in terms of breast reconstructive surgery. The final issue is the politicization of breast cancer through public policies and campaigns, like the pink ribbon campaign, which often stress treatment or earlier detection rather than prevention through lifestyle changes. In sum, Cutter paints a dire picture of the social ethos that confronts breast cancer patients.

In the next chapter, Cutter discusses the relationship or interplay among the descriptive, explanatory, evaluative, and social dimensions of breast cancer. The relationship goes like this. Description of breast cancer relies on the mechanistic and theoretical models available to explain cancer—in other words, observations at the level of symptomology are theory-laden. In turn, both descriptions and explanations of breast cancer depend on evaluative norms, and all three are then framed within a social context. Importantly, these four dimensions of breast cancer are interrelated such that changes in one dimension can have an impact on another dimension. Given this interrelationship, Cutter explores the role of integrative medicine in providing the best health care for breast cancer patients. Specifically, she considers personalized medicine, especially in identifying the genetic mutations associated with breast cancer. “But keep in mind,” warns Cutter, “that personalized medicine is not simply about discovering genes. It is about understanding biological uniqueness and variability” (p. 148). She concludes the chapter by emphasizing the complexity of breast cancer in terms of these four dimensions and underscoring the need to understand and appreciate their interconnectedness in order to promote well-being and to avoid patient harm.

In the penultimate chapter, Cutter explores the ethical implications of breast cancer treatment. Her approach is in terms of principlism. The first principle is respect for patient autonomy and the associated notion of informed consent. She raises a very troubling problem to this effect in that patients are simply not knowledgeable enough to be completely autonomous in their consent. Moreover, given the uncertainty of medical knowledge about breast cancer and the risks associated with it, she worries that such consent is more likely to be uninformed than informed. Next, she discusses the principles of nonmaleficence and beneficence vis-à-vis risk factors. With respect to the principle of nonmaleficence, she explores the ethics of exposing patients to the risks of harmful side effects from breast cancer treatment. With respect to the principle of beneficence, the issue lies not only in assessing the risks of treating breast cancer patients but also in detecting breast cancer at early stages. As Cutter says, “In the end, developing an appreciation of risk assessments is not just a matter of minimizing patient harm and maximizing patient welfare. It is a matter of clarifying and questioning our assumptions, priorities, and investments in breast cancer care” (p. 170). She then takes up the final principle, justice, particularly in access to breast cancer care. The aim is to ensure that health care resources are not squandered through overdiagnosis and overtreatment or underdiagnosis and undertreatment. To that end, she recommends, inter alia, developing technologies to avoid false positives and negatives. Finally, Cutter proposes an ethical framework for breast cancer care that integrates these four principles—autonomy, nonmaleficence, beneficence, and justice. The principles are not applied in isolation but function according to a “reflective equilibrium” [3, p. 404], so that the appropriate principle informs the appropriate ethical situation. As Cutter concludes, “Reflections on bioethical issues in breast cancer care are best framed integratively for the values, principles, and theories in moral philosophy are themselves situated and relational” (pp. 183–184).

In the final chapter, “Extended Musings,” Cutter enumerates seven lessons she learned from her breast cancer experience. The first is that breast cancer is a complex disease, which is expressed uniquely in individuals. The next lesson is that although she developed breast cancer because of dysfunctional estrogen receptors, these dysfunctional receptors were only part of the pathophysiology, much of which remains uncertain. The third lesson is that breast cancer diagnosis directs breast cancer treatment, often with little regard for the patient’s values. The fourth lesson for Cutter concerns her assumption of a new social identity as a survivor: she is not alone with this new identity but shares in it with other members of a breast cancer “club”—one that not only provides support through community, but also functions as a social unit subject to the choices and social forces that inform how breast cancer is understood in our society. The fifth lesson speaks to the integrative relationship among the descriptive, explanatory, evaluative, and social dimensions of breast cancer, as discussed in chapter 6. The penultimate lesson is about problems in giving informed consent to breast cancer care, especially when risk assessment and treatment efficacy remain uncertain, as addressed in chapter 7. Finally, the seventh lesson underscores the issue of uncertainty in breast cancer care, for which she provides seven pieces of advice that can be summed up as follows: learn as much as possible in order to make the best decision. Although many of the preceding lessons raise the specter of concern over uncertainty in breast cancer etiology and treatment, Cutter’s hope is that “a fruitful dialogue between philosophy and medicine continues, with the particular hope that dialogues in breast cancer medicine continue to benefit patients” (p. 196). Her book is certainly an advance in the realization of that hope.

As Cutter notes several times, she considers herself a survivor of breast cancer. The notion of “cancer survivorship” entered the world of cancer patients to signal that, as Fitzhugh Mullan noted from his own experience as a cancer patient, “the simple concepts of sickness and cure were insufficient to describe what was happening to me” [4,p. 271]. Although there is no consensus definition for the notion in the literature, the National Coalition for Cancer Survivorship describes it as the “broad experience on the cancer continuum—living with, through, and beyond a cancer diagnosis” [5]. Today, many cancer patients embrace not only the label of cancer survivor but also other labels, such as “thriver” [6], to denote their identity. Similarly, Cutter does not simply don the survivorship label for her “new social identity,” but also casts herself as “coward, warrior, and worrier” (p. 188). In other words, although survivorship certainly characterizes part of her new identity, so too do other labels, given a plurality of social contexts. While the label of warrior fits well with the military metaphor in the war on cancer, the labels of coward and the worrier reflect the vulnerability and uncertainty that cancer brings into a person’s life. These latter labels and the identities they represent need greater exposure and analysis within the cancer community.

In the chapter containing her extended musings, Cutter acknowledges that prior to breast cancer she “innocently” thought more was known about breast cancer diagnosis, treatment, and prognosis. After breast cancer, she now realizes just how naive this assumption was, considering how little is known not only about the etiology of breast cancer but also about how best to treat it. Indeed, as Cutter recounts in the preface, upon asking a clinician whether she would survive after treatment, the clinician retorted “How can I say? I don’t have a crystal ball!” (p. xiv). Reflecting on this impudent retort, Cutter wonders, “if doctors do not know the future prognosis of a clinical problem, how can they go about recommending treatment?” (p. xiv). Herein lies the Gordian knot that medicine simply cannot untie but rather with its technology cuts, as a surgeon cuts out a tumor. How can the question of whether medicine should treat breast cancer patients be addressed when so much uncertainty exists? At least two seemingly opposed answers are possible. The first is optimism in the bold pursuit of cure. After all, contemporary breast cancer care is the best currently available, even though so much uncertainty is associated with it. Unless another treatment becomes available, medicine has no choice but to soldier on with its best option. The second response is medical nihilism, engendering a gentler approach to care than the slash, burn, and poison modus operandi of contemporary medicine [7]. A third answer—a systems approach [8]—might be to seek a middle ground that navigates between unbridled optimism and cautious nihilism.

Finally, Cutter’s book is an excellent example of how philosophy can assist in the personalization of medicine, which has become impersonal and commercial in its delivery of clinical care. What makes her book so persuasive is that she exhibits full personhood both as patient and as agent. As patient, she recounts the impact not only of breast cancer but also of its treatment on her personal life. As agent, she exemplifies Karen Kaiser’s comment on breast cancer survivors: “By crafting meanings, women reclaim agency after a medical event that can be highly impersonal, abstract, and technical” [6, p. 86]. Cutter exercises this agency by perceptively “thinking through breast cancer” and its meaning for her in her life. Cutter’s book should be read not just by philosophers of medicine, but also by patients and health care professionals and administrators as well as policymakers.