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Invited Commentary
June 27, 2011

Optimism Amid Serious Disease: Clinical Panacea or Ethical Conundrum?Comment on “Recovery Expectations and Long-term Prognosis of Patients With Coronary Heart Disease”

Author Affiliations

Author Affiliations: Family Medicine Research and Centers for Ethics, Medical Humanities and Palliative Care (Dr Gramling), and Department of Family Medicine, Psychiatry, Oncology, and Nursing, and Center for Communication and Disparities Research (Dr Epstein), University of Rochester, Rochester, New York.

Arch Intern Med. 2011;171(10):935-936. doi:10.1001/archinternmed.2011.40

It seems that to be American—or maybe merely to be a human being living in modern times—requires us to maintain optimism in the face of less-than-optimistic evidence. In essence, we ask of ourselves to “beat the odds,” or at least to deeply hope that we do. Consider 2 American icons—Captain Kirk and Commander Spock from Star Trek. Is it the hyperrational, unemotional Spock whom we emulate? “Captain, the statistical likelihood that our plan will succeed is less than 4.3 percent.” Or are we drawn to the ever-optimistic (and usually correct) Captain Kirk? “Spock, it will work.” Well, when it comes to our hearts, we generally aspire to Captain Kirk.

Indeed, population-based surveys about cardiovascular disease reveal our cultural optimism about our heart health.1Although scholars have called this phenomenon by various names—unrealistic optimism, ignorance, denial, positive thinking, self-enhancement, sense of uniqueness—when asked, we are prone to say that we’ll beat the odds.

Clinical panacea?

In this issue of the Archives, Barefoot et al observe that, among patients recruited at the time when their coronary heart disease was confirmed by angiography, those who endorse more favorable expectations for function and survival were, in fact, substantially more likely to experience better long-term function and to survive longer. These observations add to a compelling body of evidence that endorsing optimistic expectations for one's future heart health is associated with clinically important benefits to cardiovascular outcomes. These observations apply to the likelihood of survival for those with established cardiovascular disease as well as the likelihood of developing it.2,3 The degrees of benefit observed in these studies suggest that optimism is a powerful “drug” that compares favorably with highly effective medical therapies.

The authors propose 2 causal mechanistic hypotheses. First, optimism may lead to better problem-oriented coping and healthier behaviors triggered by perceived threats to health. Second, optimism may buffer against proatherogenic stress physiologic conditions. In addition, perhaps these positive expectations also reflect patients' interoceptive capacity—their ability to perceive their own physiological and psychological states. Or, it may be that optimism is merely a marker for other confounding factors, such as lack of depression, but recent findings argue against this explanation.3 Given the magnitude of effect that optimism has on heart health and survival, more research is needed to unveil the pathways underlying this phenomenon.

Ethical conundrum?

Over the past century, medicine has veered away from discussions of prognosis. The art of prognostication stood alongside the art of diagnosis and the art of treatment as 3 pillars of medical training and practice. However, as treatments advanced and diagnostic technologies grew, prognosis became less and less prominent.4 Whether it is fear of self-fulfilling prophecies, discomfort with prognostic variability and uncertainty, and/or lack of training or modeling, we physicians will often actively (eg, via optimistic framing) and/or passively (eg, silence) support ill patients' optimistic beliefs about the future.

In the context of a recent acute event (in this case, the unequivocal message, “you have heart disease, a potentially fatal condition”), the study by Barefoot et al might suggest that optimism is good, and the more the better; after all, optimistic perceptions of prognosis lead to better outcomes. And, having some degree of optimism seems to facilitate contemplation and decision-making.5 The growing evidence might lead physicians toward routinely promoting optimistic outlooks (“ . . . but I think you’ll beat the odds”) for patients facing potentially life-threatening illness. We might even consider ourselves ethically justified in withholding or obfuscating poor prognoses from patients.

However, the effects of an unbridled optimistic “overdose” can be disastrous. Patients with serious incurable illness harboring unchallenged optimistic perceptions tend to choose burdensome treatments that they might not have chosen if they had a more balanced understanding of their overall prognosis.6 These treatments not only lower their quality of life and complicate their loved ones' bereavement7 but also plausibly shorten survival.8 It is important to note that extreme or unbalanced optimism may leave patients unprepared, alone, and devastated when the reality of their situation sets in.

Finally, even if no measurable harm results, does unbalanced support of optimism at the expense of what we believe to be realistic abandon our duty to be honest with our patients?

Can we do both—be optimistic and pessimistic, realistic and hopeful?

Dispositions, perspectives, and decisions are not simply a result of dispassionate analysis of data. Rather, they are shaped by prior beliefs, experiences, affects, and perceptual abilities, all of which inform how we see the world. Optimism is a belief system imbued with and informed by emotion (in this case, hope). In fact, when our perspectives are deprived of emotion, we tend to make poorer decisions.9 Thus, the ideal approach to the “optimism-pessimism” messaging problem should take into account emotions as well as data. Furthermore, optimism and pessimism (or hope and realism) should not be viewed as mutually exclusive; recent studies in experimental psychology confirm William James's observations over a century ago that a well-developed mind can consider positive and negative thoughts simultaneously, even though the messages may seem contradictory.5 Thus, a “hope for the best, prepare for the worst” approach10 can build on the notion that the salutagenic effect of hope is complementary to, and not in direct conflict with, communicating clearly about a less-than-optimistic reality.

Uncertainty in medicine is usually presented as something to be reduced or eliminated. Yet, the very idea of hope acknowledges a degree of uncertainty, in contrast to rigid beliefs that ignore or discount any disconfirming evidence. Individuals with serious illnesses frequently hope for a miracle, yet the process of affirming the possibility (or probability) that a miracle might not happen allows patients the benefits of hope and the dignity to make balanced choices. Thus, clinicians, patients, and families do not need to choose between hope and realism—between Kirk and Spock—but rather to affirm the importance of both.

Correspondence: Dr Gramling, Family Medicine Research, University of Rochester, 1381 South Ave, Rochester, NY 14620 (Robert_Gramling@URMC.Rochester.edu).

Published Online: February 28, 2011. doi:10.1001/archinternmed.2011.40

Financial Disclosure: None reported.

Funding/Support: Dr Gramling is funded by grants from the National Palliative Care Research Center and the Greenwall Foundation.

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