Quam bene vivas referre: curing and caring in psycho-oncology†
- †International Psycho-oncology Society 2012 Arthur M. Sutherland Memorial Lecture.
Correspondence to: Clinica Psichiatrica, Dipartimento Scienze Biomediche e Chirurgico Specialistiche, Università di Ferrara, Corso Giovecca 203, 44121 Ferrara, Italy. E-mail: email@example.com
By examining the medical–philosophical Latin heritage, some psycho-oncology principles may be traced in Claudius Galenus and Lucius Anneus Seneca. The former hypothesized a link between depression and cancer; the latter strongly underlined the need for not wasting time, living in the present by searching for meaning and reaching well-being of the soul through virtues, even when dealing with misfortune and negative life events.
On these premises, what follows here is an analysis of the first steps in the science of psychosocial care in cancer starting with the work of Arthur M. Sutherland and moving on to more recent psycho-oncology research, which has shown the centrality of a biopsychosocial approach in cancer integrating cure and care (within the double meaning of the old Latin noun cura).
Studies of the biopsychosocial approach covering the psychological implications of cancer (e.g., prevalence of emotional distress, application of DSM/ICD classical, and more recent psychiatric classification systems), their psychobiological concomitants (e.g., inflammation and immune dysregulation mechanisms in depression and chronobiology of stress and cancer), and interpersonal issues (e.g., doctor–patient communication and role of neuron mirror system) are discussed.
Psychosocial oncology avoids the distinction between curing and caring and includes science and compassion in a whole approach to the multidimensionality of the human being in balancing evidence-based with person-centered/narrative-based oncology (values-based oncology). Copyright © 2013 John Wiley & Sons, Ltd.
Quam bene vivas referre, non quam diu – It is how nobly you live that matters, not how long
[Seneca: Moral Epistles, Liber XVI, Epistle 101, On the futility of planning ahead, 15].
If we try to reflect on some biopsychosocial principles in the approach to cancer, the Latin heritage of about 2000 years ago represents a good example, particularly in what visionary physicians, such Claudius Galenus (ad 129–201), and philosophers, such as Lucius Anneus Seneca (4 bc–ad 65), passed on and left as their legacy. Galenus, in the tradition of a humanistic medicine , based his profession following Hippocrates' holistic approach, with physicians committed to create an environment of concern, trust, and hope in their relationships with their patients.1 Galenus supported the humoral theory, and in the first and only essay of antiquity devoted to cancer, De Tumoribus preter naturam , he indicated that cancer was caused by an excess of black bile (‘atrabilis’ or ‘melanchole’), the same mechanism supposed to cause depression. In this way, Galenus hypothesized a link between depression and cancer, thus between psychosocial and somatic diseases.
Seneca on the other hand, as a philosopher and, as we might say, a precursor of modern psychotherapy, used the principles of Stoicism to help individuals to respond to life events, disease, and suffering by living fully and consistently. In many of his writings, particularly the Epistualae Morales ad Lucilium  and the Dialogorum libri , Seneca underlined the importance for the man not to waste time but to create meaningful purposes in his life.
Therefore, Lucilius, hold every hour in your grasp. […] While we are postponing, life speeds [Moral Epistles, Liber I, Epistle 1, On saving time, 3]
[…] who plans out every day as if it were his last, neither longs for nor fears the morrow. [Dialogues, On the shortness of life, VII: 9]
In Seneca's view, the wise person, when confronting with negative and traumatic life events, should accept his misfortune by adopting a fatalistic position, without fearing death and suffering, which are part of life:
Therefore, how foolish it is to fear it [death], since men simply await that which is sure, but fear only that which is uncertain! Death has its fixed rule, – equitable and unavoidable [Moral Epistles, Liber IV, Epistle 30: On conquering the conqueror, 11]
Fatalism was not, as often misconceived, a passive resignation but an active way to search for meaning and to live according to nature, meditating and confronting one's own mortality. The Stoic sage wants to preserve life and health by bringing knowledge about what actions are appropriate in the face of suffering, even if we ultimately cannot control our own fate [5, 6].
Consider, further, that the wise man uses foresight, and keeps in readiness a plan of action; […] he, consequently, will not suffer pity, because there cannot be pity without mental suffering [Dialogues, On mercy, II:5–6]
Then, by cultivating virtues and by taking care (cura) of one's own self, knowledge, wisdom, and well-being can be reached.
Make yourself happy through your own efforts; you can do this, if once you comprehend that whatever is blended with virtue is good […] What then is good? The knowledge of things [Moral Epistles, Liber I, Epistle 31, On siren song, 5–6]
Wherefore you may boldly declare that the highest good is harmony of the soul [Dialogues, On the happy life, VIII:6]. This abiding stability of mind the Greeks call euthyimia, “well-being of the soul,” I call it tranquility [Dialogues, On tranquility of the soul, II:3] Consolation results in a cure (cura) […] and whatever has uplifted the soul helps the body also. [Moral Epistles, Liber IX, Epistle 78, On the healing power of the mind, 3]
In fact, the noun cura (and its related verb curo, -as, -avi, -atum, and -are) in Latin integrated in itself the meaning of both ‘cure, remedy, medical treatment, or means of healing’ and ‘concern, solicitude, preoccupation, care or attention given to something or someone’.2
In this review, the following aims will be pursued: (i) to summarize some of the important accomplishments that psycho-oncology has reached by using a biopsychosocial framework and (ii) to discuss the concept of cura as a way to integrate the curing and the caring in a scientific yet humanistic approach to cancer patients.
The development of psychosocial oncology
The first scientific basis of psycho-oncology can be traced in the work of Arthur M. Sutherland (1910–1971), who, for his total commitment and dedication to improve psychological care of cancer patients, was a true pioneer in the field.3 Sutherland distanced himself from the psychosomatic etiological hypothesis of cancer, supporting instead the idea that the psychology of the cancer patient is the psychology of a person under a special and severe form of stress, during which many fundamental underlying emotionally charged convictions, based on the life history of the person and his or her experiences (e.g., pattern of relationship with attachment figures), are brought to the surface . He described six clinical types of psychological reactions commonly seen after diagnosis and treatment: dependence, anxiety, postoperative depression, hypochondriac response, obsessive–compulsive reactions, and paranoid reactions .
Adjustment to cancer was not, for Sutherland, at anytime independent of concurrent life situations, but, on the contrary, both life events and the patterns of adaptation fundamentally influence each other. He considered the importance of the relationship between the patient and his or her family, by taking into consideration several variables belonging to the family system (e.g., prior marital relationship, mutual support, and cohesion). The role of culture and ethnicity and the different meanings and values were also examined by Sutherland as a significant variable to assess when dealing with cancer patients who are in need for continuity of care [9, 10].
The cancer patient is a permanent patient, subject always to the threat of recurrence, to complications of sequels from his altered physiology or anatomy, to emotional upheavals in himself and his family, and to the prejudices of the ignorant. He needs continuing sympathetic contact, even be it at long intervals, with his physician, for it is he who must be the patient's guarantor of health and his shield against that flieth by day, and the terror by night .
Sutherland was also fully aware that perhaps in no other part of medicine is communication between doctor and patient more important and more difficult than oncology. He was profoundly convinced that the art of communication is an essential ingredient of the art of medicine, and he supported the need for a centralized and individualized communication, taking into consideration the individual, his or her personal history, and the context in his or her uniqueness .
Each patient must be considered as an individual with a particular type of cancer. Moreover, cancer itself is not a uniform disease. […] Each patient must be considered in the light of his individual problems; each one must make his own adjustment to the circumstances of his particular kind of cancer and its treatment. [The physician] should tailor the goals to suit his [the patient] needs, rather than force him to alien standards.
I am induced to believe that these were key concepts for the new psychosomatic movement and biopsychosocial vision in medicine, that some other pioneers, such as Zbigniew J. Lipowski (1924–1997) [12, 13] and George Libman Engel (1913–1999) [14, 15], were developing in those years. In line with what Sutherland applied to oncology, the personal experience of the disease, what it means to him or her, and how this meaning may influence his or her behavior and interaction with others were considered integral components of the disease, as a total human response. Thus, human life should be viewed as a wholeness, requiring and deserving both the tough-mindedness of the scientist and the compassion of the physician, integrating the cure and the care as inseparable parts of the medical approach .
Thirty years later, these basic psycho-oncology concepts still reverberate in biopsychosocial or psychosomatic medicine, which, although sometimes criticized as a model , maintains its quality of an interdisciplinary way of working in medicine in terms of humanism (e.g., the holistic consideration of the patient) and science (e.g., the need for the assessment of psychosocial factors through a scientific approach), for high-quality and individualized intervention in prevention, treatment, and rehabilitation [18, 19].4
The science of psychosocial care in cancer
Now, has the integration of science and compassion in oncology been reached? Do we have scientific data in psycho-oncology showing that both cure (in the sense of biomedical intervention) and care (in the sense of compassion, respect, and concern for the other) are part of a whole approach to illness? If we examine some of the areas investigated by psycho-oncology research, we notice that the literature is extremely vast [20-22] and that this has favored the development of societies, departments, units, and services delivering psychosocial oncology programs in clinical practice .
Since the repeatedly cited multicenter Psychosocial Collaborative Oncology Group (PSYCOG) study carried out in the USA in the early1980s , a bulk of research have clearly demonstrated that cancer is indeed a traumatic event causing clinically significant psychological symptoms meeting the criteria for a DSM or ICD psychiatric diagnosis in at least 30–35% of patients, especially in the area of mood disorders (e.g., major depression), stress-related disorders (e.g., adjustment disorders and post-traumatic stress disorder), and anxiety (e.g., phobia) . Research is growing with accumulating scientific data from psychosocial and behavioral sciences in oncology and refinement of classification systems.5
However, other dimensions, not necessarily diagnosable through the ICD/DSM, have been shown to be important in cancer patients. The Diagnostic Criteria for Psychosomatic Research (DCPR) , consisting of 12 clinical clusters (i.e., alexithymia, Type A behavior, irritable mood, demoralization, functional somatic symptoms, persistent somatization, conversion symptoms, anniversary reaction, disease phobia, thanatophobia, health anxiety, and illness denial), has been applied in patients affected by different medical illnesses , including cancer. Data have shown that about two-thirds of cancer patients meet the criteria for a DCPR diagnosis (e.g., health anxiety and demoralization), that among those with no formal DSM-IV diagnosis, more than half receive a DCPR diagnosis , and that a DCPR diagnosis is associated with poor well-being and poor quality of life . Furthermore, certain DCPR dimensions, such as disease conviction, affective inhibition, demoralization, and irritability, have been shown to be related to external locus of control and maladjustment to cancer [30, 31].
The main outcome of all these data has been the development and the implementation of guidelines and screening policies with the specific aims of increasing the likelihood of detection of distress as the sixth vital sign [32-34] and improving the standards of care in oncology [35, 36].
Relevant scientific data have been also collected in the area of psychological well-being. In agreement with Seneca's principle of well-being and a consistent life, concepts such as hedonic (subjective) (e.g., positive affect, life satisfaction, and happiness) and eudaimonic well-being (e.g., personal growth, purpose in life, autonomy, self-acceptance, positive relationships, meaning, and self-realization) [37-39] have been indicated to be extremely important in contributing to individuals' health through functional salutogenic brain mechanisms . In line with the idea that well-being is not just the absence of distress and that positive emotions are not merely the opposite of negative emotions , a number of authors have found that intervention centered on the aforesaid aspects can promote psychological well-being . Fava et al. have shown that well-being intervention, based on Carol Ryff's model of eudaemonic well-being , had a significant advantage over cognitive–behavioral therapy in reducing residual symptoms of depression , panic, and agoraphobia , and in treating generalized anxiety disorder .
In psycho-oncology, research on personal development and growth after the trauma of cancer, purpose and meaning in life, competence, and relatedness have broadened the concept of quality of life, showing the potential to modify the clinical approach to cancer patients in the different phases of illness [47-49]. Dispositional optimism has been related to better adjustment in cancer patients over time , whereas personality traits predisposing to interpersonal relationships and positive affectivity (low Type D personality) have been associated with better quality of life and mental health . Spirituality has also been investigated [52-55], with a number of studies indicating that spiritual well-being, in the dimensions of meaning and peace, is also related to better quality of life, adaptation to illness, and physical, emotional, and interpersonal well-being [56, 57]. The development of treatments explicitly oriented to fostering hope and finding meaning (e.g., meaning-centered therapy , spiritual-based interventions , and mindfulness-based interventions ) has been demonstrated to help cancer patients, including those in advanced phases of illness.
Major advances have been carried out with regard to the biological concomitants of psychosocial disorders among cancer patients. In psychiatry, it has been repeatedly indicated that depression is a systemic disease, involving the brain, hormonal, immune, and autonomic nervous systems . Some interesting data regard the fact that chronic inflammation and oxidative stress have been implicated in the pathophysiology of depression, and because similar mechanisms have been reported in a number of chronic medical conditions, including cancer, psychological and physical stressors have been considered possible cofactors in systemic diseases, and conversely, systemic diseases have been considered to facilitate the development of depression . This hypothesis is in agreement with data showing that chronic inflammation is implicated in the pathophysiology of immune suppression in the context of chronic illnesses, such as cancer, whereas markers of impaired cellular immunity (e.g., decreased natural killer cell cytotoxicity) and inflammation (e.g., elevated IL-6, TNFα, and CRP) are associated with depression , suggesting that immune dysregulation may be a central feature common to both depression and medical comorbidities.
The multiple interactions between stress, emotions, social support, and biological systems, including the hypothalamic–pituitary–adrenal axis and the autonomic and immune systems, have been examined [64, 65], with studies showing that stress-related processes can influence pathways, such as immune regulation and angiogenesis, with effects on the tumor microenvironment and possible cancer progression . Stress hormones and their effects into the crosstalk between tumor and stromal cells have been also suggested to have a critical role in modulating downstream signaling pathways, with possible implications for disease progression .
Regarding chronobiology and stress, alterations in the circadian axis, comprising a central clock mechanism and a downstream network of hypothalamic relay stations, have been proposed as a possible biological concomitant of fatigue, appetite loss, and sleep disruption in cancer patients . Furthermore, a clock gene regulation of tumor cell growth has been suggested, with psycho-neuroendocrine-immune stress-related pathways possibly influencing circadian disruption and negative implications for cancer prognosis [69, 70].
From the perspective of positive psychology, adaptive coping strategies, including anger expression, optimism, and well-being, have been related to a better biological response to stress, to an increase of immunity defense, such as natural killer activity, to a better physical functioning among cancer patients [71-73], and to a greater decline in cancer antigen 125 levels during chemotherapy .
Social and interpersonal issues
A bulk of studies have provided evidence of the importance of social support and interpersonal ties, including close (e.g., family and friends) and diffuse social support (e.g., social network) in improving coping abilities and adjustment among cancer patients . The impact of cancer on the couple and members of the family , the role of the family structure as predictor of adjustment to cancer, the effects of psychosocial interventions in family caregivers , and the family mechanisms involved in loss and bereavement  have been also the focus of intense research.
A special area regards doctor–patient communication and the importance of healthcare professionals' use of empathy in facilitating cancer patients' adjustment to illness. This is the territory where both cure and care integrate each other, and only within the space created between a dyadic clinical relationship, a mutual, holistic existence of two beings is created in terms of ‘physicianship’ . Such a healing space can be described, in Buber's and Levinas' conceptualization [80, 81], as an authentic encounter with true subjectivity being formed with and through the other . It seems to me that this may have some similarities with the Japanese vision of the person as a context (self as a contextual person) and with the concept of Aïda that Kimura introduced in his psychopathology essays , with the idea that there is something of myself in the deep parts of the other and vice versa.6
The scientific literature on these issues in cancer is extremely vast, ranging from the identification of the skills and the key competences oncologists and healthcare cancer professionals should have [84, 85] to the association between empathy and patient outcomes , the role of cultural background in communication , and the impact of education and training in changing doctors' communication behavior and attitudes and in improving the relationship with their patients [88-90].
Because of the mutuality in the doctor–patient relationship, a bulk of data are available on the emotional implication of curing and caring in oncology settings. Burnout, as described by physical and emotional exhaustion, detachment in the relationship with the patient and the family, and poor personal and professional accomplishment, is reported by about one-third of oncologists, with negative consequences on the quality of care, as well as on their own quality of life [91-94]. The overidentification with suffering, the overwhelming sense of compassion (compassion fatigue), up to vicarious traumatization, and the erosion in values, dignity, and will among healthcare professionals [95, 96] are all part of this scenario .
In this respect, interesting perspectives have been opened by neurosciences through the investigation of the biological mechanisms involved in communication, empathy, and interpersonal relationships. The work carried out in Italy by Rizzolatti et al. [98, 99], who discovered the mirror neuron system in the brain, is significant from this point of view. In fact, the mirror neuron system has been implicated not only in action but also in communication, language, and social interaction, with a possible extension to emotions, sensations, and thoughts . In other words, this matching mechanism might be related to the way in which human beings access and understand the minds of others (theory of mind, mentalization), facilitating social behavior and social competence [101, 102] and making intentionality and intersubjectivity possible . Thus, as Gallese suggested , neural mirroring seems to be a basic organizational feature of our brain, enabling our rich and diversified intersubjective experiences (shared manifold of intersubjectivity). Although this explains only a part of a more complex neural network involving subcortical and neurohormonal mechanisms associated with affective communication, parental care, and social attachment processes [105, 106], a series of data now exist trying to relate the mirror neuron system to interpersonal and behavioral problems in psychiatric disorders  and to understand compassion and empathic communication, as a mirroring-based interpersonal morality  in medical settings, including oncology .
The whole approach to cancer: from the cure/care dilemma to cura
All what said so far testify how, turning back to Sutherland's words, both science and compassion should be and are part of the same integrated approach to cancer.
The separation between curing and caring still reflects the paradox of a Cartesian dualistic model, which shows its absurd side as if it were possible to conceive a non-curative caring and a non-carative curing . Thus, as curing should not be confined in a ‘physicalizing tendency’ toward an unaffective (un-human) (cold science, objective, quantitative, high-tech) style of relation dealing only with the material body (Körper), as caring should not be confined in a ‘dematerializing tendency’ toward a ‘disembodied’ (idealistic, subjective, qualitative, high-touch) style dealing only with the lived body (Leib). Instrumental (cure) and affective (care) dimensions are complementary part of oncology profession, and without one of the two, the integrity of the profession collapses .
As Miles  strongly points out
Indeed, it is often said that until it is possible for clinicians to cure always or ameliorate completely, it is their “reasonable responsibility” to provide the comfort of genuine human empathy. Such reasoning […] seems to assume that comforting is a substitute for curing when curing is not possible, such that when curing becomes possible, it will substitute for comforting, that comforting and caring would somehow then become ipso facto redundant and unnecessary. In reality, curing should never be disassociated from comforting and caring; otherwise, medicine becomes nothing more than the application of technical procedures or the administration of medications outside of the context of the necessarily human encounter […].
It is a fact that the debate regarding the crisis of evidence-based medicine/oncology has grown over the past years. New paradigms (e.g., holistic, humanistic, narrative and narrative-evidence-based medicine, medical cosmology, and patient-centered medicine) [113-117] have been repeatedly proposed as a way to combat modern biotechnological reductionism and to put the person in all his or her dimensions, at the center of the therapeutic encounter.
However, the risk that a non-scientific approach can become equally reductionist and damaging was noted by Engel when proposing his biopsychosocial approach. In fact, as Smith and Strain  state,
[Engel] contrasted the biopsychosocial model with what he described as counter dogmas; those of ‘holistic’ and “humanistic” medicine. He stated that these qualify as dogmas to the extent that they eschew the scientific method and lean instead on faith and belief systems handed down from remote and obscure or charismatic authority figures.
On the other hand, the principles underlying humanistic medicine/oncology include aspects (e.g., open communication, mutual respect, and emotional connection between physicians and their patients), which indicate that care is the key element of these principles. But this does not imply that care cannot be part of observation (outer viewing), introspection (inner viewing), and dialog (interviewing), as Engel and Sutherland proposed as the basic methodological triad for clinical scientific study of medical diseases [8, 15].
Sixty years have passed since the first concepts regarding a comprehensive approach to cancer patients appeared in a structured way. Psycho-oncology paradigms, theories, evidence-based studies, and values-based studies, have largely demonstrated the benefit for cancer patients, their families, and the staff of an integrated model of care.
By recuperating the old Latin concept of cura, I tried to include both the technical remedies and the role of care of cancer patients' suffering. This is the approach to the multidimensionality of the human being, consisting of a physical (Umwelt), an individual psychological (Eigenwelt), an interpersonal (Mitwelt), and a spiritual dimension (Überwelt) . It was Martin Heidegger, in fact, that, in Being and Time , identified cura with his concept of Dasein, the existence, the being-in-the-world, and turned to the Latin tradition and mythology to express the humanistic, spiritual, caring, and values-based meaning of his Dasein. It is the myth of the divine creature of Cura that Gaius Julius Igiunus (ca. 64 bc–ad 17) bequeathed to us in his Fables (fabula CCXX) ,
Cura cum quendam fluvium transiret, vidit cretosum lutum; sustulit cogitabunda et coepit fingere hominem. Dum deliberat secum quidnam fecisset, intervenit Iovis. Rogat eum Cura ut ei daret spiritum, quod facile ab Iove impetravit. Cui cum vellet Cura nomen suum imponere, Iovis prohibuit suumque nomen ei dandum esse dixit. Dum de nomine Cura et Iovis disceptarent, surrexit et Tellus suumque nomen ei imponi debere dicebat, quandoquidem corpus suum praebuisset. Sumpserunt Saturnum iudicem. quibus Saturnus secus videtur iudicasse: “Tu Iovis quoniam spiritum dedisti, corpus recipito. Cura quoniam prima eum finxit, quamdiu vixerit, cura eum possideat; sed quoniam de nomine eius controversia est, homo vocetur, quoniam ex humo videtur factus est”.7
This myth, as Reich points out , represents an allegorical image of humankind in which the most notable characteristic of the origins, life, and destiny of humans is to be taken care of and to care for other individuals, because humankind as a social totality is brought into the world and sustained by care. Therefore, we can say that integrating curing with caring and linking science and technology (biomedical concern) with human relationship (compassionate solidarity) is the mission that psychosocial oncology has in the realm of health and illness.
This paper has been presented as a lecture for the 2012 IPOS Arthur M. Sutherland Award, which I dedicated to my family, those who work in and support psychosocial care, and my patients affected by cancer and their families.
Hyppocrates' aphorism Ars longa, vita brevis [Life is short, the art (craft/skill) long… The physician must not only be prepared to do what is right himself, but also to make the patient, the people around him and the externals cooperate] reflects the concept of the intertwining between the individual, in its biology and subjectivity, his or her interpersonal relationships and his or her environment and context to be considered by the physician.
Although the medical meaning of cure as a remedy of a disease has become more common, the old etymology of the Latin cura is still evident in words such as accurate (done with care) and secure (free from danger, safe). On the other hand, the word care has been variously defined as ‘honesty, patience, courage, sensitivity, dedication, commitment, knowledge, skills, feeling, mattering, autonomy, trust, assistive, facilitative, tenderness, growing, actualizing, involvement, relationships, dignity, being with, love, compassion, empathy, reciprocity, engrossment, respect, spirituality, supportive, satisfaction, integrity, and closeness’.
Arthur M. Sutherland was an attending physician and psychiatrist, Medical Service, at Memorial Hospital from 1949 to 1955; head, Research Psychiatry, Division at the Sloan-Kettering Institute for Cancer Research from 1954 to 1960; director, Rehabilitation Service, Memorial Center, from 1951 to 1957; and attending physician, chief, Neuropsychiatric Service at Memorial Hospital from 1957 to 1961. After retirement, he moved to Italy where he owned a house in Cetona, Tuscany, where he died in 1971.
In this paper, I use the term biopsychosocial to define the paradigm sustaining the centrality of the individual and his or her biological, psychological, interpersonal, and spiritual dimensions.
The upcoming DSM5 is better defining the classification of anxiety, somatoform, depressives, and stress-related disorders and is introducing new diagnosis, such as bereavement disorders, that will have an impact in psycho-oncology research.
Kimura explains this dual effect as reciprocal ‘being’ of the self (mizukara) and the other (onozukara).
As Cura crossed a stream one day, she saw some clay: picking up a piece in contemplation, she began to shape it. While she reflected upon what she had created, Jupiter approached her. Cura asked him to provide spirit to the clay form. This he was pleased to do for her. But when she wished to apply to the creation her name, Jupiter forbade it, saying that his name ought to be applied. While Cura and Jupiter argued over the name, the Earth (Tellus) approached and asked that the creation to be named after her since she had, after all, given it a part of her body. The three contenders then asked Saturn to settle the matter. And Saturn gave them decision, seemingly just, as follows: ‘You, Jupiter, because you have provided the spirit, should receive the spirit when the creature dies; you, earth, because you provided the body, should receive the body. But because Cura first shaped this creature, so must it be that she possesses it for the time of its life. And because the name is subject to dispute, so should it be that it is called “homo,” since it is made out of earth (“humus”)’. (Translated by Mary Grant)