Unrealistic Optimism, Revisited

Unrealistic Optimism, Revisited

George W. Sledge, MD, FASCO

May 30, 2011
You may remember a blog I wrote a few months ago commenting on an article describing cancer patients entering Phase I trials as being guilty of “unrealistic optimism” regarding their chances of benefiting from experimental therapy. I thought I would offer an interesting recent follow-up.

You will remember that the ethicists considered this “unrealistic optimism” ethically problematic and were hoping, to quote the Time article, “to delineate the factors involved in evoking this biased response in patients” in hopes of eliminating “those optimistic biases that impair a patient’s autonomy.” Well, it turns out that this might be more difficult than one might think. It seems our brains are hard-wired for optimism. Tali Sharot, a research fellow at University College London’s Wellcome Trust Centre for Neuroimaging writes about the evolutionary basis for what she calls “The Optimism Bias” in the June 6 issue of Time magazine.

Note to ethicists: I can’t help being optimistic, I was born that way. To quote Sharot’s fascinating article, replete with solid science, “It is tempting to speculate that optimism was selected by evolution precisely because, on balance, positive expectations enhance the odds of survival.” Optimists, it turns out, live longer and are healthier than pessimists, and optimism is tied to specific genes and neural pathways.

Why might things have developed that way? According to Sharot, humans uniquely are capable of “mental time travel,” the ability to move back and forth in space and time in our minds. It is a useful trick that allows us plan ahead, but also renders us conscious of our own impending mortality (not just cancer patients; all of us). Mental time travel would have been an evolutionary dead end, chronic reality-induced depression dogging our days, had we not also been programmed for unrealistic optimism. We’re wired for Phase I trials, in other words, because our entire existence is one, a struggle against inevitable non-existence. So cheer up!


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Anees B. Chagpar, MD, MPH

May, 30 2011 6:22 PM

Thank goodness for that! Optimism has to be hard-wired into us . . . not just for cancer patients for whom hope is a necessary ingredient that allows them to get through our toxic therapies in an effort to improve their quality and quantity of life, but for everyday practicing oncologists. If it weren't for "unrealistic optimism", we would stop all research (after all, do you really think you're going to cure cancer?), we'd stop all clinical work ('cause everyone's gonna die sometime), and we'd stop all teaching (what's the point in imparting knowledge if it won't make a difference?). In short, life would be pretty darn miserable! I don't think we could do what we do without unbridled optimism and a joie de vivre that allows us to believe that there will be a rainbow after the storm . . . we deal with death and dying every day, and it is this glimmer of hope that allows us, as oncologists, to carry on.

To the ethicists out there who find such optimism "problematic", I understand your concern about unrealistic hope and futility . . . but this is where informed consent comes in. Patients eligible for Phase I trials have few options, and yes, they may be grasping at straws . . . but there is science behind these trials, and every once in a while, there will be dramatic results, and these patients will help us to propel the field forward . . . Not always, perhaps not even often . . . but sometimes. If you want to argue based on the ethical constructs, such behavior could be supported by either a utilitarian view that would say that their behavior is helping the many or the libertarian who would say their participation is a matter of autonomy . . . but if you ask me, for patients with potentially incurable disease, participation in Phase I trials gives them hope, that perhaps at the end of the storm, they too can see the rainbow – and there has to be some ethical value in that.

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