Spinoza at the Bedside

Applying Darwinian dynamics and Spinozian necessity to the limits of maximum-tolerated dose oncology.

There is a sentence I have found myself saying to newly diagnosed patients, and I did not fully understand it the first time it came out.

“During humanity’s existence, cancer will be with us.”

I did not plan it. It arrived the way certain clinical instincts do — before the reasoning catches up. The newly diagnosed patient is in a particular kind of chaos: the information has landed but nothing has settled yet. The fear is large and formless. The questions are everywhere and half of them have not been spoken aloud. There is a very specific look that comes with it — not grief exactly, something more disoriented than grief.

Later, driving home, I kept turning the sentence over. It was not comfort exactly. It was something more structural. It seemed to move the patient — and me — away from the question of why this person, why this body, to somewhere that question could not quite take hold. I have found it useful across the whole clinical trajectory, at different stages and in different registers. But it does its clearest work right at the beginning, in that first window of confusion, before the “why me” has time to harden into something the patient will carry for years.

It took me years, and a 17th-century Dutch philosopher, to understand what I was actually doing.

The Philosopher Who Got Excommunicated

Baruch Spinoza proposed something that unsettled everyone who encountered it: God and Nature are not two things in a relationship. They are the same thing. One infinite substance, expressing itself through everything that exists. What happens in the world does not follow from divine will or intention — it follows from the necessity of nature’s own laws.

For oncology, this has a quiet but radical implication.

A patient’s diagnosis carries no cosmic teleology. No punishment, no karmic ledger, no universe singling anyone out. Separating illness from the language of fault and meaning is not nihilism. It is a kind of precision — clearing away a false question so the actual situation can be seen.

I have watched patients spend the first weeks after diagnosis trying to identify what they did wrong. The wrong diet, the wrong job, the wrong city they chose to live in. It is one of the first things the newly diagnosed mind reaches for — causation as a form of control, even retrospective control. Spinoza does not offer comfort in the usual sense. He offers something stranger and, I think, more useful: the possibility that the question itself is malformed.

The Drive That Everything Has

Spinoza also gave a name to the most basic drive of any existing thing: conatus — the innate striving of every being to persevere in its own existence.

He did not mean ambition or willpower. He meant something far more fundamental. Existence, at every level of organization, is primarily engaged in the project of continuing to exist. A bacterium, a hepatocyte, a person — the same underlying logic, expressed at different scales of complexity.

In biology, we would say it differently. But it is the same observation.

Darwin arrives two centuries later and describes the mechanism. Variation, selection, persistence — without a designer, without a preferred outcome, these forces generate complexity and competition as the natural consequence of organisms striving to survive. Two thinkers, different centuries, different methods, essentially the same position: nature produces whatever can sustain itself, with complete indifference to any particular outcome.

An Older Evolutionary Contract

Complex, multicellular life required an extraordinary negotiation. Individual cells had to suppress their own autonomous drive — toward independent survival, toward replication without constraint — for the sake of a collective organism.

Accept regulated growth. Accept programmed death when the body requires it. In exchange, participate in something capable of far more than any single cell could produce alone.

This is the evolutionary social contract of biology. And it is old. Very old.

It is also, by its nature, fragile.

Before the Agreement

I think about this sometimes in the middle of a chemotherapy ward round — the particular quality of silence in a room where someone is receiving their fourth cycle and knows, somewhere, that it is probably not working. There is a specific kind of tiredness in those rooms that has nothing to do with the drug side effects.

I have noticed that in those moments I tend to reach for the biology. It is easier to think about clonal evolution than to sit fully inside what that silence contains. I am aware that this is its own kind of retreat. But the biology, looked at honestly, does something the silence alone cannot — it dissolves the warfare metaphor from underneath.

Because the cancer cell is not broken.

This is the thing that metaphor consistently obscures, and it took me longer to fully accept than I would like to admit. Mel Greaves has argued that the tumor cell is reverting — returning to a pre-cooperative, ancestral biology that predates the multicellular agreement entirely. It has withdrawn its commitment to the collective and gone back to something older. Something that, for billions of years of evolutionary history, worked perfectly well.

The cancer cell is extraordinarily committed to existing. Seeing it this way — clearly, for what it actually is — is what Spinoza would have called adequate knowledge.

And adequate knowledge, it turns out, changes what you do.

The Trap of Maximum Pressure

Peter Nowell established in 1976 that tumors are not uniform masses. They are populations of genetically distinct subclones under continuous selection pressure, evolving in real time inside the finite ecological space of a single human body. Charles Swanton’s TRACERx program has since confirmed this with a granularity that still strikes me as remarkable — branching evolutionary trees, spatial segregation of subclones, the whole machinery of natural selection compressed into years.

When we apply maximum therapeutic pressure to that population, we are not eliminating the disease. We are selecting within it. We clear the sensitive cells, remove the competitive pressure they exerted, and give the resistant subclones more room.

Robert Gatenby’s adaptive therapy framework follows directly from this, treating the tumor as a complex adaptive system rather than a static target. The physician applying maximum pressure has made a conceptual error — treating themselves as external to the system, acting upon it from outside. The adaptive approach, maintaining treatment-sensitive cells as a competitive ecological check against resistant ones, is what adequate knowledge looks like translated into a treatment protocol.

Understanding the system you are inside changes what you do inside it.

Why That Sentence Works — and When

“During humanity’s existence, cancer will be with us.”

It is worth being precise about what kind of sentence this is. It is not consolation in the ordinary sense. And I want to be equally precise about what it is not: it is not emotional distance dressed as philosophy.

Spinoza was suspicious of conventional consolation. He would have placed it among the passive affects — something that momentarily softens the experience without changing the person’s relationship to it. Everything happens for a reason. You are stronger than you know. We’ll fight this together. These are offered with genuine warmth, and I have said versions of them too. But they make implicit promises about outcomes, or about meaning, that the situation may not keep. When they don’t hold, the patient is left more alone than before.

Stripping away the false question of why me is itself a protective act. The patient who spends the first months of their diagnosis excavating their past for the decision that caused this is spending irreplaceable energy on a search with no end. The sentence does not close down feeling. It redirects it toward what is actually there. That, to me, is the deepest form of empathy available in that room — not the warmth that promises, but the presence that stays and tells the truth.

What Spinoza called acquiescentia — a settled peace that comes from understanding necessity — does not feel like comfort arriving from outside. It feels more like the ground shifting slightly, so that the same situation can be stood in differently.

I said the sentence recently to a woman in her early fifties, three days after her diagnosis. She had asked me, for the second time in our conversation, what she had done to cause this. The question had a particular quality — not rhetorical, genuinely searching for something to hold. She was frightened, and the fear was looking for an object to attach itself to.

I did not rush past that. We sat with it for a moment before the sentence came.

There was a pause afterward — the kind where you are not sure if something has landed or if you have made a mistake. Then something in her face changed. Not relief exactly. Something quieter. She did not say anything immediately, and I did not fill the silence.

What the sentence does, I think, is interrupt a particular loop — the one where the mind keeps returning to the same question because it cannot find an answer, not knowing that the question has no answer to find. It offers something more honest about what cancer is: an evolutionary risk that belongs to the species, even when triggered by an individual’s environment or history. The fear does not disappear. The difficulty does not disappear. But the specific anguish of feeling singled out — of believing that a different version of your life would have spared you — loosens its grip a little.

This is not the same as absolution, and I try not to let it function that way. The sentence is a repositioning, not a verdict. It works because of what surrounds it — the quality of attention in the room, the fact that the physician saying it is not retreating but moving closer.

It does something different in palliative care. At diagnosis, the sentence interrupts the search — it meets a question that has no answer and gently closes it. At the end of life, the search is usually over. The sentence arrives differently there: not as a shield against confusion, but as permission. An acknowledgment that what is happening follows from the same natural necessity as everything else that has ever lived, and that there is no law being broken, no battle being lost. In that room, it becomes less about the mind and more about the body — an invitation to stop bracing against something immutable, and to rest inside it instead.

I have used it at both ends. But the diagnosis room is where it does its most specific work, because that is where the question is newest and still most available to be gently, carefully, dislodged.

Where the Physician Stands

The physician is not external to what is happening. This is harder to sit with than it sounds.

We are trained, in some ways, to inhabit the position of the external mechanic — the person who intervenes in a system from the outside, repairs it, and steps back. That framing has its uses. But it does not hold in the rooms that matter most: the room where someone has just been told, and the room where the treatment has stopped working.

In those rooms, there is no outside. You are inside the same processes that produced the tumor, the patient, the treatment, and its limits. Accepting this does not diminish the clinical role. It changes its quality. It makes possible a different kind of presence — meeting the patient as a fellow finite being, at a specific moment, rather than as evidence that something has gone wrong.

The ethical position that follows from adequate knowledge is not detachment.

It is something closer to the opposite.

The author is a medical oncologist. This essay reflects a personal clinical and philosophical framework for navigating the reality of illness, not institutional guidelines, nor does it replace standard, evidence-based treatment protocols.

Some wording and structural edits were refined with the help of an AI-based language model; the author reviewed and approved all content.