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Chapter 1: Optimism
A pessimist asks you if there is milk in the pitcher; an optimist asks you to pass the cream. —FOLK SAYING
It troubles me to recall him even now, many years later--the fifty-year-old attorney who gave me my most painful lesson in the value of optimism and what happens when it fades away. He was at the peak of his career, father of three, athletic, a picture of health. His only concern was a minor stomachache that had come and gone for a couple of weeks. Even though his physical examination was normal, he insisted on an abdominal scan just to be sure nothing was wrong. Although I thought this overkill, I went along. To my surprise, the scan showed a mass in the pancreas the radiologist said was probably cancer. I discussed the situation with him and proposed a diagnostic workup, including the possibility of eventual abdominal surgery. "No surgery!" he declared emphatically. "It's worthless. Nobody survives cancer of the pancreas." I pointed out that he was mistaken. Although the statistics are not favorable, people do survive this disease. In any case, we weren't sure of the diagnosis and further tests were needed to confirm it.
He consented to be hospitalized that very day, but a light went out in him. He seemed terrified, and nothing I could say would comfort him. He began to stare straight ahead, refusing to speak to me or the nurses. When I made rounds that evening, he lay silent and rigid in bed with clenched jaws and furrowed brow. Even when I informed him that his preliminary blood tests were normal, he didn't seem to care. In his mind he was a condemned man going to the gallows. I resolved that if his behavior did not change by morning, I would ask a psychiatrist to consult on his case. I didn't get the chance. That night the nurse found him dead in bed.
His was a "hex death," widely recognized in premodern cultures, in which a previously healthy individual dies shortly after being cursed. The curse--in this case, his certainty that he had a fatal illness--removes all optimism and hope, and substitutes the inevitability of death.
Optimism is the tendency to believe, expect, or hope that things will turn out well. Debates have raged over the past few years about whether it affects our health and the course of specific diseases. I find these arguments tedious, because I believe evidence of the healing power of optimism is in plain sight. These effects are most obvious when they vary from day to day, like shifting winds. In the 1950s, Dr. Bruno Klopfer reported such an example that involved a patient he was treating for advanced lymphoma. The man had large tumors throughout his body and fluid in his chest, and was terminal. Klopfer was so convinced that he would die within two weeks that all medical therapy except oxygen had been discontinued. In a last-ditch effort he gave the man a single injection of Krebiozen, an experimental drug later said to be worthless. Klopfer describes the results:
What a surprise was in store for me! I had left him febrile, gasping for air, completely bedridden. Now, here he was, walking around the ward, chatting happily with the nurses, and spreading his message of good cheer to anyone who would listen. . . . The tumor masses had melted like snow balls on a hot stove, and in only these few days they were half their original size! This is, of course, far more rapid regression than the most radiosensitive tumor could display under heavy x-ray given every day. . . . And he had no other treatment outside of the single useless "shot."
Within ten days the man was practically free of disease. He began to fly his private airplane again. His improvement lasted for two months, until reports cropped up denouncing Krebiozen. When he read them, the man appeared cursed, and his attitude and medical condition quickly returned to a terminal state. At this point Klopfer urged the man to ignore the negative news reports because a "new super-refined, double-strength product" was now available--a complete fabrication--and injected him with sterile water. The man's response this time was even more dramatic than initially, and he resumed his normal activities for another two months. But his improvement ended when the American Medical Association released a report stating that nationwide tests had proved Krebiozen useless in the treatment of cancer. A few days after reading this statement, he was admitted to the hospital, and two days following admission he died.
If optimism can make such dramatic differences, you'd think we physicians would do everything in our power to increase it in our patients, but sometimes we seem hell-bent on depriving them of it. Some of these instances are so outrageous they are almost funny.
Andrew Weil, MD, who is director of the program in integrative medicine at the University of Arizona in Tucson, often sees patients for a second opinion. "You wouldn't believe what those doctors did to me," one woman related. "The head neurologist took me into his office and told me I had multiple sclerosis. He let that sink in; then he went out of the room and returned with a wheelchair. Then he told me to sit in it. I said, 'Why should I sit in your wheelchair?' He said I was to buy a wheelchair and sit in it for an hour a day to 'practice' for when I would be totally disabled. Can you imagine?"
In his book The Lost Art of Healing, Harvard cardiologist Bernard Lown gives examples of "words that maim" by depriving patients of optimism and hope. They include, "You are living on borrowed time," "You are going downhill fast," "The next heartbeat may be your last," "You can have a heart attack or worse any minute," "The . . . angel of death . . . is shadowing you," "You are a walking time bomb," "I'm frightened just thinking about your [coronary] anatomy," and "Surgery should be done immediately, preferably yesterday."4 To these medical hexes, Weil adds a few more: "They said there was nothing more they could do for me," "They told me it would only get worse," "They told me I would just have to live with it," and "They said I'd be dead in six months."
Why do we physicians find it so difficult to accord optimism a role in health? Why is it so hard for us to be optimistic? You might think we'd be positively euphoric, because we have more potent tools in our black bags than ever before, and the human lifespan is at an all-time high. Why aren't we joyful? The fact is, physicians are trained to be realists, not optimists, and our realism often shades into pessimism. The specter of death hangs over every clinical encounter, a shadow that never goes away no matter how powerful our therapies become. We know that all our treatments will eventually fail and the patient will die; never has there been an exception. Thus the beginning assumption of medicine is tragedy. No other profession rests on such a morbid foundational belief. This is why it is so natural for a physician to be a pessimist, and why optimism is the hard thing.
Pessimism dominates some physicians and colors everything they do. I've known physicians who actually cultivate cynicism and take pride in a morose, gloomy personal style. Some wear their pessimism as a badge of honor. This often involves what's called "hanging crepe"--black crepe, as at a funeral--in which the physician emphasizes the worst possible outcome of any situation. If the prophecy comes true, the physician is wise; if not, he is a hero, having rescued his patient from his dire predictions.
It is unethical, we are taught, to paint a rosy future for a patient who is facing a grave health challenge when we know the outcome is likely to be the opposite. The problem, however, is that the physician's realism can trigger disastrous results. Consider medical prognosis. When a physician tells a patient she has a fifty percent chance of living twelve months, the patient is likely to interpret this as a fifty percent chance of dying by the end of a year. The patient, failing to understand that the doctor is simply making a calculated guess, often converts the statistical prediction into a death sentence by dying on schedule.
But it is never only a matter of the words that a physician uses to deliver bad news, it's also how they are conveyed. Some physicians are able to express bad news with such compassion that the sense of impending tragedy is annulled. How do they do it? The way physicians always have--through deep empathy and caring for those they serve. They convey a sense of love and oneness with their patient, as if to say, "Together we will do our best. No matter what happens, I am with you every step of the way; you will never be alone."
If profound pessimism can kill, why is it so widespread? Why would evolution have permitted it to persist? What purpose would pessimism have served? "The benefits of pessimism," suggests psychologist Martin E. P. Seligman, former president of the American Psychological Association and author of Learned Optimism, "may have arisen during our recent evolutionary history. We are animals of the Pleistocene, the epoch of the ice ages. Our emotional makeup has most recently been shaped by one hundred thousand years of climatic catastrophe: waves of cold and heat; drought and flood; plenty and sudden famine. Those of our ancestors who survived the Pleistocene may have done so because they had the capacity to worry incessantly about the future, to see sunny days as mere prelude to a harsh winter, to brood. We have inherited these ancestors' brains and therefore their capacity to see the cloud rather than the silver lining."
The survival value of pessimism may date from the era when humans descended from treetops onto the savannas of Africa. These open grasslands were the home of the great stalking cats and were dangerous places. Pessimism would have lent an edge in the struggle to survive--not pessimism that overwhelmed and drove our ancestors back into the safety of the forests, but enough to guarantee wariness and survival.
But perhaps we should not concede too much to pessimism. It is difficult to imagine how Homo sapiens could have advanced from savage to barbarian to civilization without a sense that things might be better. How could we have journeyed from caves to castles, from skins to silks, from dominance to democracy, without optimism? Without the beckoning light of a brighter future, it would have been easy to quit in the early days and settle for the status quo. Something kept us going toward a dawn not fully glimpsed, and optimism is as good a name as any for this indwelling itch.
Ultimate Optimism
It's easy to be optimistic about optimism these days. Research shows that optimists on average get sick less often and live longer than pessimists. The immune system seems to be stronger in optimists, and the cardiovascular system more stable. Optimists are the go-getters, achievers, and leaders who are held high in public esteem. Optimists are generally likable; they pump others up, and people enjoy their company more than that of pessimists. There is a new field, positive psychology, that stresses the value of optimism. Optimism is so hot it recently made the cover of Time magazine.
Optimism is on a roll--and I sometimes feel as if it is about to roll over me. Although I am personally inclined toward optimism, I tremble at the showy, smiley-faced, shotgun variety that is advocated these days by the insufferable optimism merchants. I favor a quiet, indwelling variety of optimism that I keep to myself as a calm certainty. I hesitate to name this attitude; even calling it a "cognitive style," as the positive psychologists do, is going too far. As Stendahl said about happiness, "To describe [it] is to diminish it." My approach is akin to what medieval theologians called the via negativa, the negative way, which emphasized the fullness and reality of the Divine by dwelling not on positive attributes, but on the fact that the Divine is beyond description. Attributing any quality to the Absolute was a form of anthropomorphic idolatry, dressing up the godhead in human form. Meister Eckhart, the thirteenth-century German mystic, was a proponent of the via negativa. He said, "Then how shall I love him?--Love him as he is: a not-God, a not-spirit, a not-Person, a not-image; as sheer, pure, limpid unity, alien from all duality. And in this one let us sink down eternally from nothingness to nothingness. So help us God. Amen." In keeping with Eckhart's view, perhaps I should call my attitude not-optimism.
For me, linking optimism and the Absolute or Divine, however named, is not hyperbole. The connection is natural: Optimism comes from Latin words meaning "highest" or "best," which is what we consider the Divine to be. Julian of Norwich, England's sublime fourteenth-century mystic, understood this relationship. At a time when the Black Death was stalking Europe, she found no difficulty associating optimism and the Divine. In enchanting prose she exulted, "But all shall be well, and all shall be well, and all manner of thing shall be well . . . He said not 'Thou shalt not be tempested, thou shalt not be travailed, thou shalt not be diseased,' but he said, 'Thou shalt not be overcome'" Or as poet Maya Angelou has echoed in our day, "You may encounter many defeats, but you must not be defeated."
Optimism unanchored to the Absolute is hard to sustain. If one takes the distant view of modern cosmology, the scenario is bottomlessly depressing. Our expanding universe, scientists tell us, will eventually undergo heat death and will descend into irreversible disorganization. This means that life and consciousness will perish. Against this backdrop, optimism is a worthless, pitiful Band-Aid. But if consciousness is linked with the Absolute, the outlook changes. The Absolute stands above all, including whatever may happen to the cosmos. Our connectedness with the Absolute implies that we share qualities with it--qualities which, much evidence suggests, include infinitude in space and time. If so, we are in some sense eternal and immortal: the ultimate justification for being optimistic, and a finger in the eye of doomsaying cosmologists.
