Towards an approach to development as mission: the category of personhood as addressed by Amartya Sen?

DrJohn Klaasen email@example.com
Towards an approach to development as mission: the category of personhood as addressed by Amartya Sen?
2FB713B84E057C1BDB3D744C9C465D3110.7832/42-1-2-49Senmissionpersonhoodagency
This paper is concerned with the role of personhood in development.I will be looking at the extent to which the influential model of development proposed by Amartya Sen does justice to the category of personhood.I will provide an overview of the work of Sen in the area of development and then provide some critical engagement.Drawing from the work of Sen this article provides some pointers or markers towards an approach to development as missionary role.Bosch's phrase "creative tension" provides a key principle for an approach to development.

Introduction

This article is concerned with the role of personhood in development.Development has been an integral part of the ecumenical church and specifically the World Council of Churches.In 1961 the World Council of Churches established the Committee for Specialised Assistance to Social Projects to provide the mission boards with resources to assist with their ministry (Van der Bent 1981:69).Within the ecumenical movement development was a natural flow from the church's quest to play a relevant role in the changing environment post World War 2. The churches which had a long tradition of mission and projects amongst the disadvantaged played a major role to get the development debate on the church's agenda (Dickinson 1991:269).This became evident at the ecumenical conferences in Geneva (1966), Uppsala (1968) and Nairobi (1975).

I will be looking at the extent to which the influential model of development proposed by Amartya Sen does justice to the category of personhood.I am interested in the complex process through which people come to accept responsibility for addressing their situations.This interest is based on the intuition that personhood may well be crucial for any notion of development, precisely in impoverished contexts.Even when people are made aware of their opportunities and capabilities and where the obstacles thwarting development are removed, that would not necessarily translate into accepting responsibility.There is a gap (widely acknowledged in ethical theory) between knowing what is right and doing what is right.It is here that reflection on the category of personhood may be crucial.The mission of the church which is embedded in the missio dei includes development of the individual and communities.The question that this article addressed is how the church can faithfully use personhood in light of development.The church has a tradition of engagement in the development debate especially post World War 2. This article seeks to identify some of the weaknesses of the development debate and then make some suggestions how personhood can contribute to the development debate within the church.

Sen and development

Sen gives us glimpses of the use of personhood in his conceptualization of his approach.His approach, widely used in both secular and theological literature, can be summarised with reference to concepts such as freedom, agent, well-being, capabilities and functionings.I will give an overview of Sen's capability approach by explaining his use of these terms.Implicit in these terms is pointers to the use of personhood.Personhood is more explicit in the attempt by Sen to apply his capability approach to the individual and how she can effect personal and societal change.A few critical remarks will elicit the extent to which Sen makes use of personhood for development and his neglect thereof.These critical remarks are followed by an introduction to an approach in theological discourse that can make a contribution to effective mission in societies where the poverty level are increasing despite the efforts of institutions such as the Bretton Woods.The approach concerns the use of "axle" as a metaphor for mission and specifically that of the role of personhood in development.Such an approach to mission keep widely accepted antagonistic categories such as individual and community, church and the world in creative tension.

Development as freedom.

Development is not only about Gross National Product or individual income, but also about moral behaviour and to this effect ethics is an important partner of economics for development.This implies that individuals cannot only be viewed as commodities, but is instrumental in the process of development.When this is assumed then development is not only about the interpersonal valuation, but also about the intrinsic value of the individual.Therefore Sen claims that development is about the freedom the individual has to choose what is of value to her.He thus defines development "as a process of expanding the real freedoms that people enjoy" (1999:3).

Freedom is central to the process of development for both the evaluative reason and the effectiveness reason.In other words freedom is a way of evaluating progress and this is done by asking the question, whether the freedoms of people are enhanced.The evaluative role refers to the success of a society based on the substantive freedom that the members enjoy.He explains this role by pointing out the differences between the capability approach and utility (happiness) or libertarian procedural liberty or real income approaches (Sen 1999:18).Sen includes classical utilitarianism of Bentham which are used by prominent economists such as Edgeworth, Marshall (1890), Pigou (1920), Ramsey and Robertson (1952).Utility is viewed as satisfaction or happiness.Also included in Sen's distinction of substantive freedom from utility is desire-fulfilment of modern utilitarianism.Hare (1981), Sidgwick (1874) and Gosling (1969) provide some of the clearest analysis of the pleasure and desire as modes of valuation (1999a:1-2).

With regard to the effectiveness reason, the question is whether the people are free agents.What is regarded as effective development refers to the choices that people can make about what they value.These choices pertains both to what effect the individual directly (nutrition and education) and indirectly (political and civil liberties) (Sen 1999:4-5).

It is worthwhile noting that the capabilities approach is not in contradiction with the traditional notion of economics, but it does depart from the notion that economic freedom is the end 2 .The traditional notion of economics is concerned with commodities and people, including how people make commodities, how they have control over it, what they do with it and what they get out of it (1999a:1).Sen points out that while people might have command over the characteristics or properties of the commodities, it does not guarantee the enhancement of the development of the person (1999:6) 3 .For example a person might own a car and possess the properties that go with owning the car.If the person cannot drive the car then we cannot judge the well-being of the person by the fact that she owns a car.Freedom then is the choice to, being able to drive, to choose whether a car will enhance that which the person value.

Another illustration is Aristotle's notion of wealth.It is not wealth, but freedom that enhances our life and foster development.Sen quotes Aristotle's words in the Nicomachean Ethics "wealth is evidently not the good we are seeking; for it is merely useful and for the sake of something else" (translated by D.Ross (Oxford: Oxford University Press, revised edition, 1980), book1, section 5, p.7).In this sense development has to do with enhancing lives and freedoms."Expanding the freedoms we have reason to value not only makes our lives richer and more unfettered, but also allows us to be fuller social persons, exercising our own volitions and interacting with-and influencing-the world in which we live " (1999:14-15).Freedom is about both the processes that foster freedom of actions and decisions and the opportunities that arise from personal and social circumstances.Unfreedoms can be a result of inadequate processes (violation of voting rights or political rights) or lack of opportunities (starvation, premature mortality).Freedom is connected to another important concept, well-being, which Sen uses in his notion of development.

Well-being is an important concept in the capability approach.Consistent with his critique of the overemphasis in the literature of the study of economics with commodities and personal wealth Sen claims that well-being cannot be effectively evaluated without considering at least five personal and social factors.The five circumstances are personal heterogeneities (different physical attributes like gender and abilities), environmental diversities (climate changes that can contribute to illnesses), variations in social climate (education, crime and violence), differences in relational perspectives (poor persons in rich communities requires more to be accepted and for fulfilment of self-respect) and distribution within the family (achievements depends on how the income is used and distributed amongst the members) (Sen 1999:70-72).

These personal and social factors can also not be limited to primary goods as in the case with Rawls's liberty theory.Primary goods are not an adequate valuation of well-being, because primary goods depend on how commodities are valuated between two or more persons.It also depends on the value that one give to a product compared to another.Capabilities have to do with actual real living or freedoms to be achieved.Well-being is directly related to the actual living of a person (Sen 1999:72-73).

Sen's approach is more about well-being and advantage than the narrow commodity approach.Well-being has to do with a person's achievements and advantage with the real opportunities compared with other possibilities.The use of opportunities must not be limited to its narrow sense of for example giving a disabled person the opportunity to attend a school that does not provide the necessary facilities for the person to function with real freedom.

Well-being is also closely associated with agency.Agency is different from well-being, though not completely independent, in respect to, "The former covers the person's achievements and opportunities in the context of his or her personal advantage, whereas the latter goes further and examines achievements and opportunities in terms of other objectives and values as well, possibly going well beyond the pursuit of one's own well-being" (Sen 1987:58-59).Agency is the person as doer of that which is beyond self-interest.An agent is actively involved in development of self, but also beyond the self.Whereas well-being deals with the self, agency can be fulfilled when the person contributed to the happiness of others.

Agency also has "effective power" to change circumstances and is therefore important for understanding the obligations of persons (Sen 2009:271).

Functioning is the fourth important part of the capability approach.Function is a means of valuing the well-being of a person.How well a person is, is reflected in the kind of life a person lives.Functioning takes in consideration the "doings" and "beings" of a person (1999a:19).It has to do with the actual activities that a person is able to do.It is not restricted to what the person knows of something but the capability to choose according to the value attached to the object.It is more about doing than knowing.In this sense it is about what is available to me and not necessarily what I make available to me.

Functioning moves beyond the possession of a commodity and has to do with what the person can do with the commodity.It answers the question, to what extend can the commodity be used by the person."A functioning is an achievement of a person: what he or she manages to do or to be.It reflects, as it were, a part of the 'state' of that person.It has to be distinguished from the commodities which are used to achieve those functionings" (Sen 1999a:7)."The valued functionings may vary from such elementary ones as being adequately nourished and being free from avoidable disease, to very complex activities or personal states, such as being able to take part in the life of the community and having self-respect" (Sen 2008:199).

These four concepts as used in Sen's notion of development give us glimpses of the role of personhood in development.Freedom, well-being and to a lesser extend agency and functioning is about the nature of the person.A person is here referred to as an autonomous individual.This is implicit in the close connection between Sen's view of freedom and the right to choose what is of value.This explains the emphasis of the person to the external factors such as institutions, policies and communities that provide or neglect that which is necessary for freedom and well-being.The relationship is of an I-it nature.The person does not have an interdependent relationship with the external factors.These factors only serve to increase the choices.Increase in choices also does not necessarily translate into well-being.At this stage personhood has little role in development because of the overemphasis of the external factors that influences the person.

In the conceptualization of the individual Sen attempts to keep the tension between individual and society.Deneulin maintains that this tension, while possible on a theoretical level, is not sustainable for development practice.The reasons for this assertion is that there is a strong rational for the evaluative space to be extended beyond the self, because the individual depend on a collective framework for its authority, assessment development demands consideration beyond the individual and thirdly socio-historical contexts are important for individual agency (2008:107).

Whereas development in the conceptualisation stage has been largely discussed as the individual and her own development, I now move to the individual and the responsibility she has towards society through rational behaviour.To some extent Sen deals with Deneulin's critiques.

Sen claims that the use of reason can promote better societies.

In order to substantiate his claim about the use of reason for better societies he points out three arguments against reason as an evaluative framework and then presents counter arguments.Firstly considering the heterogeneity of values and preferences of people, a coherent framework for reasoned social assessment is impossible.To counter this claim Sen argues that information other than rules form specific circumstances.In other words more information is needed.Sensitivity to individual development is also needed.The second argument against reason, concerns our ability to have what we intend to have is always in tension with the more frequent and common "unintended consequences".Sen argues that unintended consequences should not be viewed as negative, but reasoned intended assessment brings better results.Adam Smith, Karl Menger and Friedrich Hayek are proponents of unintended consequences.Unintended causes may not be unpredictable.Thirdly can our modes of behaviour go beyond self-interest?Sen says justice and values can also move people (1999:249-250).

Sen furthermore claims that even in self-interest there is a concern beyond the individual.For example imagine you are confronted with a malnourished person.If you respond because the person makes you unhappy and by helping the person you will feel happy, that is sympathy.But if you respond because you are using more information than that which relates to your happiness, say for example justice, then your response is related to a sense of injustice.This is not sympathy, but commitment.In both responses there is a strong sense of the person self.Sympathy is an action that is about self-interest and commitment and although it has not directly to do with self-interest, it has to do with the self, because the commitment is one's own.Both responses are also rational choices (1999:270).

We must tread with caution because here it seems that sympathy and commitment is so far removed from each that the one is in opposition or contrary to the other.This is the case with Sen's treatment of the two concepts.It has a bearing on our conceptualisation of personhood.As Bronowski rightly puts it, "There is, as it were, the commitment at my end: the sense of devotion.And coupled with it there is what moves and directs my devotion, what my devotion finds: sympathy for you" (1965:97).There is a reciprocal process that combines the other with the self that make the self, complete.The other is also complete with the action of the self that is characterised by tolerance and trust.Tolerance for any possible difference and trust that the reception of the gift is with gratitude and graciousness.

Commitment to a humanitarian course for example does not guarantee success although it may satisfy self-interest.But if sympathy guides commitment then the outcome will be beyond self-gratification or self-interest that denies the selfhood of another.When sympathy is attached with commitment in this way then the self develops in relation with the other without selfishness but out of collegiality or the prosperity of common humanity.

Sen rightly argues that freedom plays an important role in the connection between the individual and social commitment.Perhaps the most explicit evidence of Sen's notion of personhood lies in the following provocative claim, "It is not so much a matter of having exact rules about how precisely we ought to behave, as of recognizing the relevance of our shared humanity in making the choices we face" (1999:283).Here we find a shift from the individualism that has been evident in the conceptualisation of the approach by Sen to the individual having commonality with other human beings.We also find here an attempt to counter the criticisms of Deneulin.

It is the responsibility of people to develop and change the world.An individual makes choices that will effect herself, but not without consequences for others and considerations of the institutions that create the freedoms that individuals value.Right and exact rules about how to behave is important, yet rules cannot replace our shared humanity.Here seems to be a tension between the individual and her interest and society and its needs.The tension has to do with the responsibility of the individual and that of the society.

This clearly raises the question of the use of reason as ontology for humanity.In other words how is reason used in order to understand personhood as creative tension between the individual and the collective?Reason is not an abstract activity because persons are not abstract atomic.Reason is both an independent and dependent variable, it is formed and informed.By implication the self is not in isolation, but is formed, informed and transformed through critical engaged reasoning (Klaasen 2012:113).

Interdependence between freedom and responsibility

Social responsibility does not replace individual responsibility.This approach by Sen is precisely about the individual taking responsibility for her development, but not without substantive freedoms.In other words responsibility can only be taken for development if social and environmental circumstances are taken in consideration together with personal circumstances.It is important here to guard against what is called the "nanny state", enforcing choices upon the individual through coercion.The idea is that individual responsibility should be supported by the state and other institutions (1999:284).

Again freedom also applies to our treatment of others, whether we want to develop with all good intentions or whether it is out of commitment.Freedom also influences our view of the other.How do we view those who are different than us or those who hold values that contradict our values?"Freedom is valued in a culture that wants to encourage dissent and to stimulate originality and independence.It belongs to a society which is open to change, and which esteems the agent of change, the individual, above its own peace of mind" (Bronowski 1965:101).

Human capital and human capability

Sen gives us another glimpse into his notion of humanity when he makes the difference between human capital and human capabilities.Although the two is not mutually exclusive human capital enhances production while human capabilities concentrate on the abilities of people to lead the lives they value and enhance their choices.Both have to do with the role of human beings, although they assess different achievements.While human capital assesses indirect value, how does this add to production, human capability assesses both the indirect and direct value (1999:293).

Sen uses Adam Smith's pioneering work Wealth of nations and The theory of moral sentiments that stresses the point that education and learning is primary to production possibilities.Instead of promoting nature, he is a strong proponent of nurture.Development has to do with formation over a period of time and is influenced by many varied factors.In this sense human beings are not the means to an end, for example greater markets or more investments, but are also the end.To view humanity as means reduce humanity to merely mean of production.In other words nothing more than a commodity (1999: 296).

Sen gives a broader view of what it means to be a human being than the approach of modern economics.A human being is much more than a commodity or the total economic income accumulated.To be human is to have well-being.Well-being refers to the possession of the characteristics of goods and the capability to apply it so that it is of value to the person.Functionings is a way of evaluating what the person is able to do with the commodity or goods.In other words how best are the goods applied for the enhancement of the life of the person?Coupled with this is the practical and mental involvement of the person in the valuing of the commodity or goods.This is referred to as agency.The person is not a passive recipient, but an active participant in the development process.

Sen views a human being in relation to what options the person has, what the person values, who the person is and what the person can become."Sen presents in relation to his capabilities approach a very rich conception of the individual that gives not only a view of what a person is and does or could be and do but also of who the person is" (Teschl and Derobert 2008:126).Person is closely related to the individual with far less attention to humanity.The difference is that a person is exclusively an individual who is characterised by self-centredness and who has a relationship with institutions, non-living and other living beings as a selfish activity.The individual must be served in its quest for development.

Points of critique

The following points of critique can be raised in Sen's view of personhood.Firstly there is an overemphasis on individuality that limits the identity aspect of what it means to be human.To this effect Teschl and Derobert claim that "Sen presents a very rich view of the individual within the capability approach, without, however, ever linking it specifically to any concerns about identity " (2008:127).This assumption derives from the way Sen views freedom and the relationship between personal identity and social identity.Freedom is part of who the person is and development is determined by whether the freedom is expanded.Freedom is integral to how the individual view him/herself in relation to what she values for her life.In this sense freedom is also associated with personal identity because the person chooses that which is of value to her.Although there is a place for social identity, the person does not value the consequences of her actions or choices for the society more than the enhancement of her capabilities.

Secondly the overemphasis on individuality follows directly unto the nature of the relationship that the individual has with others and communities.The nature of the relationship is such that the others must serve the interest of the individual.This kind of relationship gives the individual independence from communities.Notwithstanding Sen's claim "of our shared humanity" (1999:283), the individual has a responsibility towards him or herself.Because of the distance between the individual and others, coupled with the evaluative and effectiveness aspects of freedom, a person will choose what is of value for herself.This turns persons into abstract individuals who have little regard for anything other than that which benefits its self-interest.Communities are there for the benefit of the individual and its value is determined not by its intrinsic value but by the role it plays in the broadening of the choices of the individual.

A third point of critique relates to the narrow view of the way agency is appropriated by Sen. Sen give little power to institutions and social arrangements in the capacity of the person.The agent is actively involved in expanding freedoms in a one dimensional relationship between the individual and institutions.Although institutions play a role in constructing individual freedoms, like communities, its role is limited to the enhancing of the freedom of the individual.Sen claims that, "Not only do institutions contribute to our freedoms; their roles can be sensibly evaluated in the light of their contributions to our freedoms" (1999:142).

Agency needs to take institutions seriously in its quest to expand the capabilities that is of value to the individual.Institutions have a dual role.It has value in relation to the agent and it has intrinsic value.Deneulin introduces the notion of Paul Ricoeur, 'structures of living together' to clarify the seemingly contradiction."Structures of living together can be defined as structures which belong to a particular historical community, which provide the conditions for individual lives to flourish, and which are irreducible to interpersonal relations and yet bound up with these" (2008:111).

When agency takes place within "structures of living" it does not surrender autonomy, but it does take seriously the interconnectedness of the different structures that impact the individual.Structures or institutions are a living organism that gives life to agency and enhances not only the capabilities, but also the freedom of the individual.

Sen's use of personhood does not address the role of personhood in taking responsibility for development beyond choosing what is available.Personhood should play a role before the availability of capabilities.It is a crucial sense of personhood that is lacking in Sen capability approach.

Christian mission, personhood and development

My assumption is that one of the crucial factors that enables a person to develop personal integrity and thus to accept responsibility is an understanding of what being a human being entails.The category of personhood helps to describe such an understanding of being human.This would include at least a notion of human distinctiveness, of being related to others, of human dignity, respect for the otherness of others and a sense of a common humanity (Ubuntu).

It is here that Christian theology and more specifically a Christian mission approach makes a significant contribution to development.From a perspective of mission, how do we understand personhood?A preliminary answer is that "freedom and community as axle" serves as a metaphor to conceptualise personhood.In both secular literature and theological literature "freedom and community" form an important pillar to come to terms with the notion(s) of personhood.

Bosch uses this axle in two ways.Firstly, the two "freedom" and "community" form the two central parts of the axle in Paul's notion of the church in the context of his missionary activities.Bosch claims that the communities that Paul established through his missionary activities, is called ecclesia, "commonly used in the Septuagint as translation for the Hebrew kahal.In contemporary Greek, ecclesia normally referred to the town meeting of free male citizens of a city of Greek constitution" (1991:165).The following can be derived from this understanding of ecclesia.The freedom of the citizens is closely connected to their status as found in the community.In the two letters to the Corinthians this new identity is especially re-enforced when certain members tried to assert their individual freedom to do as each of them pleases (1991:166).Freedom is bound up in the relationships that one has with the fellow members of the community.Freedom cannot be isolated from membership of the community.

Freedom is not restricted to the ability to choose what is of value for the self.To put it differently freedom is not thwarted when choice is for the well-being of the self.Freedom is integrated with the person's relationship with other members of the community.

Secondly, the axle is also used in the way the church community (ecclesia) relates to the world.The ecclesia is unique, distinct, new, and different but not an enclave in its relationship with the world.Bosch affirms that, "In Paul's understanding, the church is 'the world in obedience to God', the 'redeemed...creation' (Kasemann 1969b:134).Its primary mission in the world is to be this new creation...Yet precisely this has an effect on the 'outsiders'.Through their conduct, believers attract outsiders or put them off (cf Lippert 1968(cf Lippert :166f)" (1991:168):168).

The members of the community do not withdraw from other communities or do not put up barriers to prevent interaction, but they relate to other communities with a renewed humility and generous spirit to share their uniqueness and distinctiveness."The church is that community of people who are involved in creating new relationships among themselves and in society at large and, in doing this, bearing witness to the lordship of Christ.He is no private or individual Lord but always, as Lord of the church, also Lord of the world" (Bosch 1991:169).

The ecclesia "is possessed by a vision of God and the created order as open and engaged in a life-process.Unity is not to be equated with the denial of difference or the reduction of them all to one, but speaks of the mutual intercommunion and interpenetration of elements of difference" (Greenwood 1994:88).Even the differences is a result of our relations and its significance is not to emphasise the independent, complete product, but to the person in formation, through relation with other selves (Klaasen 2013:189).

When the world is seen, heard, spoken to and acted upon, it is experienced beyond the physical appearance.This kind of interaction "evokes mystery, compassion, reciprocity, and obligation.It is as we look into another person's eyes and gaze upon the face of another person that we see with the 'eyes of the heart' and stand in openness before her and his ineffable and inexhaustible mystery" (Medley 2002:177 quotes La Cugna ).

Personhood cannot be limited to the autonomous individual or collection of individuals that is bound together for the benefit of the individual or common causes.The former denies the creativity of relationships and the latter "reduces all members of human society to the status of disposable cogs in the machine of a corporate enterprise" (Greenwood 1994:89).Personhood on the other hand is about the creativity to create space for open, trustworthy and loving relations.Like an axle that binds two wheels, while the two wheels are independent, the one cannot turn without the other.

During the medieval period when the church was preoccupied with how humans differ from nature there was an awareness of the creative tension.This was a preoccupation that was necessary for the church's consistent guard against any teachings that were contrary to; "the two central doctrines of God as Triune (i.e., one divine nature possessed equally by three distinct Persons, distinguished only by their relations of origin to each other) and Christ as God-man (i.e., one divine Person possessing two distinct natures, one divine, one human) (Clarke 1994:211).

Clarke however claims that Thomas Aquinas and other medieval scholastics did develop a relational notion of the person.Clarke argues that Aquinas' notion of real being is about two sides of the same coin, one intrinsically active and the other self-communicating.A being is an active being that communicates about itself to others and by communicating is communicated to.In a sense being is about active self-communication.There are two reasons why persons pour forth natural activity: one because it is poor and drawing from others as much as its nature allows towards fulfilment and secondly because being is rich and naturally shares the richness with others (Clarke 1994: 214).

This explanation of being as activity is demonstrable of the relationality of persons that is inseparable from the substantiality.Clarke concludes that "Therefore, all being is, by its very nature as being, dyadic, with an "introverted," or in itself dimension, as substance, and an "extroverted", or toward-others dimension, as relational trough action… This dynamic polarity between substance and action-plus-relations was submerged and almost forgotten in the post-medieval period from Descartes on" (1994: 216-217).

The Enlightenment scientific, technological and free individualism has found renewed criticism from theologians.The Christian tradition finds itself in a paradigm shift that questions the absolute autonomous individual as the most objective and highest form of being.Being is not equivalent to self-determination, but the extent to which one mirrors the likeness of God.The likeness of God here refers to Trinitarian ontology of relation amongst Father, Son and Holy Spirit (Klaasen 2013:88).

In Hebrew theology as in Ancient Israel humanity had an I-Thou relationship with God.This relationship referred to each person created "in the image of God".This means that people are bound together in an inescapable relationship of mutual growth.Martin Buber, Jewish scholar reminds us that the "I-Thou" relationship is a very demanding one and many times the "Thou" gets reduced to an "it" because of the intensity of the "I-Thou" relationship on humans.The "it" is easier because it reduces the person to an object that makes fewer or lesser demands on us.It reduces the time, energy, giving of self and effort.De Gruchy reminds that this can be dehumanizing abuse and manipulation of others (2006:43).

Personhood points beyond the individual and engages with others in a reciprocal relationship that seeks to development both the self and the other.The nature of personhood is such that taking responsibility for development is not an activity that is undertaken for selfish reasons.It is undertaken for the transformation of the self and the other.The other here is all those who are in need of transformation in order to reach their full potential in a mutually enriching process.This is demonstrated in De Gruchy's notion of personhood.De Gruchy finds both a distinction and commonality in personhood.In describing a common humanity he makes the distinction between individual, persons and human.The individual is associated with post-Enlightenment and the emphasis on individual human rights against the monarchical, authoritarian and totalitarian forces.While such individualism is good for individual responsibility, the danger is that absolute individualism has been responsible for gross human rights violations and genocides in the last few decades (De Gruchy 2006:42-43).

Personal identity is more closely related to process.It is the construction of each person as unique persons from our birth into teens, middle age and old and finally death.The process is made up of particular and specific factors such as our gender, our bodies, sexuality and culture.Here, particularly the formulation of the Trinity is related to personal identity by the distinct, yet not isolated from each other.In other words personal is always interpersonal (2006:44).

Humaneness is about the sameness of humanity.The commonalities might be expressed differently, for example to love can be done differently by defend persons, yet love is common to all humans (De Gruchy 2006:46).These three individual, personal identity and being human is interrelated and through a process common humanity at birth right develops into human wellbeing.To this effect De Gruchy claims that, "If our common humanity is something given, everyone's birth right, becoming more truly human is shaped by choices and responses we make, in which we become more fully ourselves, more aware of our common humanity, and when we nurture the humanity of others.The wonder in all of this is that as people become more truly human, their different personalities are enhanced in terms of their own capacities-they become distinctly themselves yet more aware of their relationship to others" (2006:52)

Conclusion

Sen provides important glimpses into the role of personhood through the conceptualisation of the key concepts of his capability approach.The capability approach is a widely accepted one in secular and theological approaches to development.His emphasis on the capability of the individual to choose what the individual value for she does not adequately answer the question about the role of personhood in development.This is no weakness of Sen because he never claims to be doing so.However, in order to make choices for development implies an understanding of the self or the person and the intrinsic role that personhood plays in development.It is these implications of understanding the self or the person that both give us glimpses of the role of personhood and the imperative for a greater role of personhood in development if space is created for such a role.

This article has attempted to highlight Sen's use of personhood.I have also given some critique to foster greater critical engagement with the approach of Sen. Some of the critiques includes the overemphasis of the individual that limits identity.The one dimensional nature of the relationship between the individual and the other, including communities, leans towards sympathy and self -interest and not a commitment towards other social identity.The narrow view of the appropriation of agency excludes the role that structures and institutions play in the formation of personhood.

By using the metaphor of the axle to begin to conceptualise personhood one brings out some of the basic creative tensions that exist alongside each other.Bosch's use of the creative tension between the individual and community and the ecclesia and the world is a starting point for further development of the role of personhood in development.
 http://dx.doi.org/10.7832/42-1-2-49 Towards an approach to development as mission

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Basaloid carcinoma of the lung associated with central cavitation: a unique surgical case focusing on cytological and immunohistochemical findings

Sohsuke Yamada
Hirotsugu Noguchi
Atsunori Nabeshima
Takashi Tasaki
Shohei Kitada
Tetsuro Baba
Hidetaka Uramoto
Takeshi Hanagiri
Yasuyuki Sasaguri
Basaloid carcinoma of the lung associated with central cavitation: a unique surgical case focusing on cytological and immunohistochemical findings
C A S E R E P O R T Open AccessBasaloid carcinomaLungCytologyCavitation
A history of an increase in pulmonary mass was presented in the right upper lobe of a 72-year-old male. The bronchial brushing cytology specimens contained many sheet-like or three-dimensional clusters of malignant cells having small to medium-sized, uniform oval to round, and hyperchromatic nuclei, inconspicuous nucleoli, and scanty cytoplasm, admixed with mitotic figures. A coarsely granular chromatin pattern was predominantly noted. We first interpreted it as suspicious of malignancy, such as atypical carcinoid. A right upper lobectomy was performed, and gross examination revealed a centrally cavity-formed tumor lesion, containing asymmetrically thinned wall and looking grayish to whitish, partly adjacent to the bronchiolar wall. On microscopic examination, the tumor was predominantly composed of a solid proliferation of atypical epithelial cells without apparent glandular or squamous differentiation, often arranged in an alveolar growth pattern with peripheral palisading. Immunohistochemically, these atypical cells are negative for all three neuroendocrine markers and thyroid transcription factor 1, whereas positive for 34βE12, p63 and S-100 protein. Therefore, we finally made a diagnosis of basaloid carcinoma with cavity formation. We should be aware that, owing to its characteristic features, cytopathologists might be able to raise basaloid carcinoma of the lung as one of differential diagnoses, based on careful cytological examination. Virtual slides: The virtual slide(s) for this article can be found here: http://www.dianosticpathology.diagnomx.eu/vs/ 1519986488570234

Background

Although basaloid carcinoma (BC) of the lung is a rare subtype of nonsmall cell lung cancer, one original paper described that up to 32% tumors were reclassified as BCs among a large series of surgically resected lung cancers with retrospective review, originally classified as poorly or undifferentiated carcinoma [1]. In 1975, Spencer first reported the histopathologic, immunohistochemical, ultrastructural, and clinical features of BC of the lung [2]. Subsequently, this entity was established based on the following criteria, as previously described by Brambilla et al. in 1992 [3]: (1) A solid lobular or anastomotic trabecular pattern growing invasively in a finger-like fashion from the bronchial and/or glandular duct lining; (2) Small cuboidal to fusiform cells of mean diameter 12 to 15 μm, with moderately hyperchromatic nuclei and without prominent nucleoli. There was a scant but visible cytoplasm, and no nuclear molding; (3) Peripheral palisading with radially arranged cells at the periphery of lobules; (4) A high rate of mitosis, between 15 and 44 per 10 high-power fields. The World Health Organization (WHO) classification of tumours of the lung now records carcinoma with basaloid pattern, either as a pure BC, a variant of large cell carcinoma with above typical histopathologic patterns, or as a basaloid variant of squamous cell carcinoma when coexisted with areas of squamous differentiation [4]. BC of the lung often poses a diagnostic challenge to clinicians and cytopathologists, since its entity is difficult to diagnose pre-operatively [5,6]. In fact, one old paper reported that the cytologic differentiation of BC extensively overlap with those of small cell carcinoma [5]. Although another group demonstrated that patients with BC of the lung did not have a poor prognosis than the other nonsmall cell lung cancers [7], Brambilla et al. recently have confirmed that lung carcinoma with a basaloid pattern is a unique entity with a significantly worse outcome [8], similar to BCs in organs other than the lungs [3]. Thus, it would be critical to establish an accurate preoperative diagnosis by bronchial brushing and washing cytology.

Indeed, pulmonary BC could be a relatively uncommon disease, but not as compared with some recently published case reports of extremely rare tumor cell types in the lung [9,10]. Despite of that, we report a unique surgical case of BC of the lung, associated with central cavitation. Based on the cytology specimens, we preoperatively interpreted it merely as suspicious of carcinoma.

Materials and methods

The patient was a 72-year-old Japanese man. Bronchial brushing and washing cytology, and transbronchial lung biopsy from the pulmonary mass were performed, followed by a right upper lobectomy. The tumor specimens after fixation in 10% neutral buffered formalin were embedded in paraffin for histological or immunohistochemical examinations. All immunohistochemical stainings were carried out using Dako Envision kit (Dako Cytomation Co., Glostrup, Denmark) according to the manufacturer's instructions, and using commercially available  Table 1. Since all tumor specimens were fixed in formalin, transmission electron microscopy could not be performed.

Case presentation

The patient had a history of cerebral infarction 10 years ago. He was a heavy smoker over 50 years. There was no history of malignancy, immunosuppressive disorders, use of immunosuppressive medications, or unusual infections.

During a follow-up of his infarction, a chest X-ray showed a mass shadow with central cavity area in the middle region of the right lung 1 and half years before the surgery. The sputum culture examined detected colonies of Mycobacterium Gordonae, however, following that, a recent increase of pulmonary mass was presented. Laboratory data, including blood cell count and chemistry, were almost within normal limits, except for high levels of blood urea nitrogen (BUN; 38 mg/dL) and creatinine (Cr; 1.87 mg/dL), manifesting as mild renal dysfunction. Carcinoembryonic antigen (CEA; 4.3 ng/mL), squamous cell carcinoma antigen (SCC; 5.3 ng/mL), cytokeratin 19 fragment (CYFRA; 5.3 ng/mL), neuron specific enolase (NSE; 13.5 ng/mL), and pro-gastrinreleasing peptide (pro-GRP; 78.8 pg/mL) levels as tumor markers were modestly increased up, but carbohydrate antigen (CA) 19-9 and sialyl Lewis X-i antigen (SLX) levels were within normal limits. A chest CT scan revealed a relatively well-demarcated mass, measuring approximately 37 x 30 x 23 mm, associated with central and variably thin-walled cavity formation, in the right upper lobe, S2. CT scans of the head and abdomen disclosed no definite evidence of metastases in the lymph nodes or other organs. The patient had neither recurrence nor metastases of the lung cancer, respectively, however, was dead due to bronchopneumonia at 3 years after the operation.

Pathological findings

The first bronchial brushing cytology specimens were consisted of many clusters of cohesive and sheet-like or three-dimensional tumor cells and a small number of individual tumor cells without necrotic or hemorrhagic backgrounds ( Figure 1A). The bronchial washing cytology specimens were relatively inadequate, but very similar to the findings of brushing one. The malignant cells showed small to medium-sized (12 to 20 μm in diameter), relatively uniform, and round to oval with mild pleomorphism and had relatively scanty cytoplasm ( Figure 1B). Additionally, the nuclei were hyperchromatic, predominantly in a coarsely granular chromatin pattern, and often had inconspicuous nucleoli, but occasionally mitotic figures ( Figure 1B). Rosettes were absent, whereas a very small number of malignant squamoid cells was rarely seen. Based on that, we first interpreted it as suspicious of carcinoma, such as atypical carcinoid, and an ordinary right upper lobectomy was performed.

On the other hand, the transbronchial lung biopsy specimens from the pulmonary mass were too small to be diagnostic.

On gross examination, the cut surface revealed a centrally cavity-formed, relatively poorly-demarcated, and solid firm mass, measuring 35 x 27 x 25 mm, which looked from grayish to whitish in color, partially adjacent to the bronchiole (Figure 2A). This central cavity measured approximately 30 x 10 mm, but filled with no necrobiotic materials. The background of the lung had no remarkable change, i.e., not emphysematous ( Figure 2A). A scanning magnification of it showed that the cancer components, less than 30% in volume, were surrounded by the cavity and irregularly grew up along the asymmetrically thickened but relatively thin cavity wall, together with extension to the peripheral alveolar wall in a sheet-like fashion ( Figure 2B). This tumor lesion was partly adjacent to the bronchiolo-vascular bundle ( Figure 2B). These features might indicate a sequential progression from the bronchiole to the surrounding alveolar space. There were no carcinoma in situ components within our thorough investigation.

Microscopic findings showed a solid and sheet-like proliferation of relatively uniform and small to medium-sized atypical epithelial cells having hyperchromatic nuclei and scant eosinophilic cytoplasm, often arranged in an alveolar fashion with peripheral palisading, typical of BC of the lung ( Figure 3A). By contrast, rosettes structures were absent. Apparent keratinization, intercellular bridge, or glandular differentiation was also not evident, and there was not intracytoplasmic mucin with Alcian-Blue staining. On high-power view, mitotic counts were high (more than 15 per 2 mm 2 ) ( Figure 3B). The carcinoma cells partly involved the adjacent bronchiolar wall but without evidence of vessel permeation. Moreover, although foci of comedo-type tumor necrosis were not recognized within the cancer nests and the central cavity, the cancer-cavity junction sometimes contained coagulative necrosis of pre-existing alveolar wall ( Figure 3C). Immunohistochemically, these carcinoma cells were negative for all three neuroendocrine markers, i.e., synaptophysin, chromogranin A and CD56, TTF-1, CEA, CK20, h-caldesmon, α-SMA, calponin, and CD10, but specifically positive for 34βE12 ( Figure 4A), CK7 and p63 ( Figure 4B). Additionally, one part of tumor nests was positive for S-100 protein ( Figure 4C). On the other hand, MIB-1 labeling index was approximately 5% in the proliferating atypical cells of the cancer nests. All immunohistochemical profile of the carcinoma cells is summarized in Table 2.

Based on all these features, we suggested that these carcinoma cells were not characteristic of neuroendocrine, squamous, glandular, or transitional differentiation, and finally made a diagnosis of BC of the lung associated with central cavitation. Final pathological stage was determined as pT2aN0M0, stage IB, according to the International Association for Study of Lung Cancer (IASLC) classification [11].

Discussion

Unlike the current BC case, frequent carcinoma in situ components should cause advanced clinical treatment, including more aggressive surgery or adjuvant chemotherapy, even in the early stage for BC of the lung [8]. It would lead to confer a significantly poor prognosis of BC amongst nonsmall cell lung cancer in stage I to II patients [8]. Thus, it could be critical to establish an accurate preoperative diagnosis by bronchial brushing and/ or washing cytology, the clinical utility of which in diagnosing pulmonary tumors has been generalized. The cytological characteristic of BC of the lung would partly reflect the histopathological ones, showing cohesive, three-dimensional and/or sheet-like clusters of relatively small and uniform malignant cells, often having finely granular chromatin, inconspicuous nucleoli, high mitotic rate and scanty cytoplasm, arranged occasionally in a rosette-like pattern, as well as single cells formation in the background of possible necrosis [4][5][6]. However, in fact, the features of this relatively new and rare entity have not been well described or reviewed more recently. As in the present case, the cytology findings ( Figure 1 showed almost similar to those as described above, even though neither rosette-like fashion nor necrotic backgrounds were evident. In spite of that, a confident and accurate diagnosis of BC of the lung might be impossible only on cytology specimens, likely due to lack of experience, cytomorphologic variety, misinterpretation and/or sampling errors. Nevertheless, in cases without evidence of neuroendocrine or squamous or glandular differentiation, such as ours, cytopathologists should raise possibility of BC as one of differential diagnoses, other than large cell neuroendocrine carcinoma, atypical carcinoid, small cell carcinoma, poorly differentiated squamous cell carcinoma or adenocarcinoma, or basaloid variant of squamous cell carcinoma, at the very least. Future studies will be further required after collecting and examining a larger number of pulmonary BC cases.

It is very likely that our case report is histopathologically remarkable for two reasons at least: first, central cavitation accompanied uniquely within the tissue of BC ( Figure 2). Actually, to date, the number of 'true' cases reported as BC of the lung in the English literatures is not large, and most recent reference is from 2008 within our thorough investigation [8]. According to those papers, all BC tumors have exhibited nodular or mass lesions without cavity formation, not similar to our case. Furthermore, this case peculiarly showed coagulative necrotic foci of pre-existing alveolar wall in the cancercavity junction ( Figure 3C), indicating ischemic change of the pulmonary tissue surrounded by the BC areas. Xue et al. have very recently proposed that the solitary thin-walled cavity of lung adenocarcinoma would be formed via multiple processes: adenocarcinoma cells initially develop in alveolar wall and grow toward bronchiole, and next formed a unidirectional check-valve owing to lack of cartilage in bronchiole; the accumulations of gases enter alveoli; the alveoli rupture and fuse into cavity with separation; and finally, the cavity gradually gets larger and larger with the increased inner pressure [12]. As in our BC case, it was suggested that the carcinoma cells firstly developed in the bronchiolar wall and subsequently grew extensively toward alveolar wall, and vice versa, since BC of the lung could originate from a basal bronchial or bronchiolar epithelial stem cell, as described by Brambilla et al. [3]. In this scenario, the above peculiar histopathological findings ( Figure 3C) might confirm their above hypotheses with regard to the pathogenetic mechanisms of solitary thin-walled cavitation in lung cancer [12]. It would be intriguing to study

CD10

Calponin this topic after investigating many cases of it. Second, immunohistochemical expression of not merely p63 but S-100 protein was positively seen in the tumor nests ( Figure 4). Although there have been no large, detailed immunohistochemical studies of BC of the lung until now, the results indicate that those tumor cells have potential myoepithelial phenotypes, as well. We could provide the possible evidence for the first time that BC of the lung might arise from a ductal epithelialmyoepithelial cell, as a result of neoplastic transformation of outer supporting myoepithelial cells, as well as inner ductal epithelial cells [13]. However, since other myoepithelial markers examined, such as α-SMA, calponin, and CD10, were negative (Table 2), this suggestion may be highly speculative and partly unsupported. Despite of that, future convincing data will be further required to determine whether our hypothesis is significant or not.

Conclusion

We herein reported a rare case of BC of the lung associated with central cavitation. The present case was tentatively diagnosed as suspicious of carcinoma, not otherwise specified, on the cytology specimens, since its features showed unclear differentiation. All cytopathologists should be aware that its cytomorphologically characteristic findings from extensively careful examination might induce one of differential diagnoses, and possibly a correct diagnosis. BC of the lung may be more common than generally considered.

prediluted monoclonal antibodies against the following antigens: synaptophysin (Dako, diluted 1:20), chromogranin A (Dako, diluted 1:200), CD56 (NICHIREI, diluted 1:1), cytokeratins (34βE12; Leica Microsystems, Wetzlar, Germany, diluted 1:200, CK7; Dako, diluted 1:50, and CK20; Dako, diluted 1:60), p63 (Dako, diluted 1:30), S-100 protein (Dako, diluted 1:900), thyroid transcription factor 1 (TTF-1; Dako, diluted 1:100), α-smooth muscle actin (α-SMA; Dako, diluted 1:150), h-caldesmon (Dako, diluted 1:50), calponin (Dako, diluted 1:50), CD10 (NOVOCASTRA laboratories Ltd., Newcastle, United Kingdom, diluted 1:20), CEA (Dako, diluted 1:50), and Ki-67 (MIB-1; Dako, diluted 1:50). The profile of all these antigens is summarized in

Figure 1
1Cytomorphologic examination of the bronchial brushing cytology specimens. (A) The cytology specimens were consisted of many clusters of cohesive and sheet-like or three-dimensional tumor cells and a small number of individual tumor cells without necrotic or hemorrhagic backgrounds (Papanicolaou stains). Bar = 25 μm. (B) Those malignant cells showed small to medium-sized (12 to 20 μm in diameter), relatively uniform, and round to oval with mild pleomorphism and had relatively scanty cytoplasm. Additionally, the nuclei were hyperchromatic, predominantly in a coarsely granular chromatin pattern, and had inconspicuous nucleoli but mitotic figures (arrowhead) (Papanicolaou stains). Rosettes were absent. Bar = 25 μm.

Figure 2 Figure 3
23Gross and microscopic examination of the resected specimen. (A) On gross examination, the cut surface revealed a centrally cavity-formed, relatively poorly-demarcated, and solid firm mass, measuring 35 x 27 x 25 mm, which looked from grayish to whitish in color, partially adjacent to the bronchiole (lower side, inset). This central cavity measured approximately 30 x 10 mm, but filled with no necrobiotic materials. Bar = 10 mm. (B) A scanning magnification of it (H&E stains) showed that the cancer components were surrounded by the cavity and irregularly grew up along the asymmetrically thickened but relatively thin cavity wall, together with extension to the peripheral alveolar wall in a sheet-like fashion (lt. side). This tumor lesion was partly adjacent to the bronchiolo-vascular bundle (rt. lower side). There were no carcinoma in situ components in our case. Bar = 5 mm. Microscopic examination of the BC of the lung. (A) Low power view showed a solid and sheet-like proliferation of relatively uniform and small to medium-sized atypical epithelial cells having hyperchromatic nuclei and scant eosinophilic cytoplasm, often arranged in an alveolar fashion with peripheral palisading. However, rosettes structures were absent. Apparent keratinization, intercellular bridge, or glandular differentiation was also not evident (H&E stains). Bar = 100 μm. (B) On high-power view, mitotic counts (arrowheads) were high (more than 15 per 2 mm 2 ) (H&E stains). Bar = 25 μm. (C) Although foci of comedo-type tumor necrosis were not recognized within the cancer nests and the central cavity, the cancer-cavity junction contained coagulative necrosis of pre-existing alveolar wall (inset) (H&E stains). Bar = 1 mm.

Figure 4
4Immunohistochemical examination of the BC of the lung. (A, B, C) The carcinoma cells of BC were specifically positive for 34βE12 (A) and p63 (B). Additionally, one part of tumor nests was positive for S-100 protein (C). Bars = 50 μm.

Table 1
1The profile of all immunohistochemical antigensAntigens
Sources of antibodies
Dilution

34βE12
Leica Microsystems
diluted 1:200

CK7
Dako
diluted 1:50

CK20
Dako
diluted 1:60

Chromogranin A
Dako
diluted 1:200

Synaptophysin
Dako
diluted 1:20

CD56
NICHIREI
diluted 1:1

TTF-1
Dako
diluted 1:100

CEA
DAko
diluted 1:50

h-caldesmon
Dako
diluted 1:50

S-100 protein
Dako
diluted 1:900

p63
DAko
diluted 1:30

α-SMA
Dako
diluted 1:150

CD10
NOVOCASTRA
diluted 1:20

Calponin
Dako
diluted 1:50

Table 2
2Immunohistochemical profile of the carcinoma components in our case of BC of the lungpositive
negative

34βE12
Chromogranin A

CK7
Synaptophysin

S-100 protein
CD56

p63
CK20

TTF-1

CEA

h-caldesmon

α-SMA

http://www.diagnosticpathology.org/content/7/1/175
ConsentWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.Competing interestsThe authors declare that they have no competing interests. Author details
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Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution. Yamada, Diagnostic Pathology. 7175Basaloid carcinoma of the lung associated with central cavitation: a unique surgical case focusing on cytological and immunohistochemical findings. Submit your manuscript at www.biomedcentral.com/submitCite this article as: Yamada et al.: Basaloid carcinoma of the lung associated with central cavitation: a unique surgical case focusing on cytological and immunohistochemical findings. Diagnostic Pathology 2012 7:175. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit