Hope: Our Mind in Suspense
The human need for an 'optimal margin of illusion' during illness.
Posted December 30, 2019
Pandora, the “all endowed one,” was shameless and deceitful and given to man as a punishment from Zeus, so the myth goes. The cunning Prometheus had given fire to humans against the will of Zeus, and Zeus, in retaliation, created Pandora, the first woman, as a “gift” for Prometheus’ “scattered-brained” brother, who failed to heed Prometheus’ warning not to accept any gifts from Zeus. Before Pandora arrived, “the tribes of men were free from ills and hard toil and heavy sicknesses.” The story is told by Hesiod, an ancient Greek sheep farmer who claims he was inspired by Muses to write both his Works and Days (lines 42-105) and the Theogony (lines 507-616), where references to Pandora first appear, in the middle of the 8th century BC, years before Homer (Loeb Library Edition, HG Evelyn-White, translator). It was Pandora who opened a jar—not a box as mistranslated by 15th century Christian humanist Erasmus, who confused pithos with pyxis—and released the “countless plagues” that wander among men—evil and diseases. Only Hope remained within the rim of the jar.
“No myth is more familiar and no myth more misunderstood,” writes classicist Harrison (The Journal of Hellenic Studies, 1900). “The box of Pandora is proverbial and that is the more remarkable as she never had a box at all.” It is a “total mythological misconception." A pithos is a large jar, often partly buried in the ground and not something portable like a box.
Further, the myth often focuses on Pandora’s curiosity, but Hesiod never mentions Pandora’s curiosity, nor does he explain the role of Hope. Scholars have debated for centuries whether Hope was in fact part of the punishment—“endlessly thinking that things must get better, always to be disappointed” (Geoghegan, Critical Horizons, 2008). For example, when hope remains, “Was it to keep hope available for humans, or rather, to keep hope from man?” (Bloeser, C and Stahl, T. “Hope,” in Stanford Encyclopedia of Philosophy, 2017).
Philosophers from ancient Greece and Rome have commented on the role of hope in human life. The Greeks mostly considered hope negatively or even as an evil itself: “…since fate was unchanged, hope was an illusion” (Menninger, The American Journal of Psychiatry, 1959). Roman Stoic philosopher Seneca wrote in his Letters of the relationship of hope to fear, where both “belong to a mind in suspense, to a mind in a state of anxiety through looking into the future” (Bloeser and Stahl, 2017).
The concept of hope has been a “central feature in Judeo-Christian doctrine: it is mentioned 58 times in the New Testament and 75 times in the Old Testament” (Eliott in Eliott, ed. Interdisciplinary Perspectives on Hope, 2005, p. 5). For example, Aquinas considered hope a virtue, to be practiced and cultivated (p. 5). Poets as diverse as Dante and Emily Dickinson have written about it throughout the years. And even Benjamin Franklin weighed in on hope, “He who lives on hope will die fasting” (Poor Richard’s Almanac).
Friedrich Nietzsche, expounding on the myth of Pandora, saw hope negatively “…(man) does not know that the jar which Pandora brought was the jar of evils, and he takes the remaining evil for the greatest worldly good—it is hope, for Zeus did not want man to throw his life away… but rather go on letting himself be tormented anew. To that end, he gives man hope. In truth, it is the most evil of evils because it prolongs man’s torment” (All Too Human, 1878). For a historical survey of the concept of hope, see Bloeser and Stahl, 2017, and Eliott’s chapter, in her edited book, Interdisciplinary Perspectives on Hope, pp. 3-45, 2005.
Though poets, philosophers, and religious theorists were the ones who originally expounded on hope, there is at least one mention of hope’s role in medicine. Physician Oliver Wendell Holmes, Senior, and father of the Supreme Court Justice Holmes, in his Valedictory Address to Harvard medical students, spoke of the virtue of truth, “I have doomed people…on the strength of physical signs, and they have lived in the most contumacious and scientifically unjustified manner as long as they liked…Beware how you take away hope from any human being” (The Boston Medical and Surgical Journal, 1858; reprinted, The New England Journal of Medicine, 2010).
Only later in the 20th century, though, was there a “medicalization” of hope such that it was co-opted by—i.e. “marketed to”—the medical profession (Eliott, in Eliott, ed., p. 11, 2005). For example, psychiatrist Karl Menninger, in his now classic 1959 paper (The American Journal of Psychiatry) bemoaned the lack of books—“our shelves are bare”—on the place of hope in science and medicine. Even offering a patient a diagnosis “offered some hope, since it showed his condition was not unique.” Further, Kübler-Ross, known for her own classic book, “established hope as a valuable medical commodity” (Eliott, p. 18, 2005) and devotes an entire chapter to hope in her book (On Death and Dying, 1969, pp. 133-150, 50th Edition, 2019). She notes that patients seemed to show “the greatest confidence in doctors who allowed for such hope” (p. 135).
A poignant example of giving patients hope in a future and recovery is seen in a paper on the influence of emotions on the outcome of cardiac surgery: giving patients “an appointment in time” prior to their surgery—“I will see you in the recovery room this afternoon” commits them to a hope of survival (Kennedy and Bakst, Bulletin of the New York Academy of Medicine, 1966).
Roy Baumeister wrote of “an optimal margin of illusion”—seeing things as slightly better than they really are because “seeing one’s suffering as meaningless and random does not help people cope.” Baumeister, though, warned of both the beneficial and harmful effects of illusions—and hence the need for an “optimal margin” (Baumeister, Journal of Social and Clinical Psychology, 1989).
Likewise, Harvard hematologist-oncologist Jerome Groopman, by the early 21st century, wrote of belief and expectations as key elements in hope for patients and noted that diseases did not necessarily “read the textbook” (The Anatomy of Hope: How People Prevail in the Face of Illness, 2004, p. 80). Patients spoke of the “medicine of friendship” that a physician can provide (p. 135).
Over time, hope, as well, began to have “financial consequences”—what Eliott has called the “political economy of hope” whereby the funding of research depended, in part, on the idea of a disease as curable (Eliott, in Eliott, ed., 2005, p. 25) and has evolved into a “science of hope.”
While now firmly entrenched in medicine and accepted by most healthcare professionals as therapeutic, hope as a multi-dimensional concept has proved more elusive to define, even though there have been scales designed to measure hope quantitatively. Precisely what is being measured is “somewhat contested” (Eliott, p. 21 in Eliott, ed., 2005), and these quantitative studies have limited value because, for example, they have not been validated in different populations and have weak reliability (Doe, Nursing Science Quarterly, 2020).
Further, since it is seen as a “commonsense notion,” people often accept that it does not need any further elaboration (Schrank et al, Acta Psychiatrica Scandinavica, 2008). Both a noun and a verb, hope involves “an uncertain future” (Averill and Sundararajan in Eliott, ed. 2005, p. 140) and is a “paradoxical combination of opposites,” a cognitively complex concept such that it can acknowledge terrible realities and yet also entertain “a counterfactual belief that things can be otherwise” (p. 139). The fulfillment of hope is all about probabilities, which remain uncertain, and this “instability” is one of hope’s main features (Downie, Philosophy and Phenomenological Research, 1963).
“A universal definition of hope does not exist,” (Jevne, in Eliott, ed., 2005, p. 266) and it can manifest differently in different cultures (Averill and Sundararajan, in Eliott, ed., 2005, pp. 135-36). Essentially, hope is an orientation (Jevne, 2005, p. 259). Further, there are different “hope narratives,” including wish-based, coping-based, and faith-based, though faith-based does not necessarily imply any particular religion (Averill and Sundararajan, 2005, pp. 136-39). Some question whether we can even know the hope of another person (Olver, in Eliott, ed., 2005, p. 247).
Others question the concept of so-called false hope, as for example, the notion of “appropriate” hope as contrasted with “unrealistic hope” (Olver, in Eliott, ed, 2005, p. 241). Hope cannot be false, except perhaps when based on ignorance; it can only turn out to be false (Musschenga, Journal of Medicine and Philosophy, 2019), i.e., until proven by future events (Olver, in Eliott, ed, 2005, p. 250). Groopman, though, delineates false hope from true hope: false hope does not recognize risks and dangers in the way that true hope, which takes into account real threats, does, and false hope can lead to “intemperate choices and flawed decision-making” (Groopman, p. 198). Groopman also differentiates true hope from “blind optimism” (pp. 198-99). In the context of dieting and attempts at self-change, Polivy has written of what he called the false hope syndrome, whereby early successes are followed by relapses. False hope here, then, is based on inadequate assessments, unrealistic goals, and poor coping skills (Polivy, International Journal of Obesity and Related Metabolic Disorders, 2001).
The concept of hope is a paradoxical one (Eliott, Journal of Pain and Symptom Management, 2013). It has been seen as “positive, negative, divine, secular, interpersonal, individual, inherent, acquired, objective, subjective, a practice, a possession, an emotion, a cognition, true, false, enduring, transitory, inspired…” (Eliott, in Eliott, ed., 2005, p. 38). One consistent aspect, though, is its power and significance in human life and “one constant—its inspirational aspect” (Eliott, p. 29, in Eliott, ed., 2005). Further, it arises partly from a person’s personality and partly from that person’s construction of the future, but notions of hope come from past experiences and beliefs and also very much from the contribution of others such as family, friends, and particularly physicians and healthcare personnel (Brooksbank and Cassell, in Eliott, ed., 2005, p. 231; Doe, 2020).
Callahan, though, cautions about unrealistic hope in the face of impending death—what he has referred to as “pathologies of hope” that stem from a public “fed a diet of hope and expectation” by the media and medical researchers: the public then comes to anticipate medical miracles and “medical progress against death as a moral obligation” (Callahan, Journal of Law, Medicine, & Ethics, 2011).
Along those lines, one of the great motivators for participation in clinical research trials, particularly Phase I trials that are meant for gathering safety data and generalized scientific knowledge and not meant to provide any direct personal therapeutic benefit for a patient (Fried, Accountability in Research, 2001), is a patient’s hope for cure (Jansen, The Hastings Center Report, 2014). “Saying no to a clinical trial” has been equated with giving up (Gregersen et al, Scandinavian Journal of Caring Sciences, 2019). In their systematic review, these researchers found that many patients had a so-called therapeutic misconception, originally delineated by Appelbaum et al. (The Hastings Center Report, 1987), whereby they misunderstood the purpose of the trial (Gregersen et al, 2019). Appelbaum and his colleagues had explained that those who maintain a therapeutic misconception “deny the possibility that there may be major disadvantages to participating in clinical research that stem from the nature of the research itself” (Appelbaum et al, 1987).
Bottom line: From its first mythological appearance in the ancient Greek writings of Hesiod and his story of Pandora, hope has been a pervasive force in human thinking and has been explored by philosophers, religious leaders, poets, and most recently, the medical profession. It is a multi-dimensional, sometimes paradoxical construct, that defies a simple definition as well as quantitative measurement because of its complexity. Despite an inability to measure it accurately, most physicians believe it has therapeutic powers and feel it is cruel to withhold it from their patients. While some believe hope can be false, most believe it is only false when the outcome is known. Particularly during life-threatening illnesses, patients (and even healthcare professionals) may need an "optimal margin of illusion" that hope can provide.
Note: Special thanks to Kevin J. Pain, Library Research Specialist, of the Samuel J. Wood Library, Weill Cornell Medicine, for his assistance in obtaining from Cornell University Ithaca, via Inter-library Loan, a copy of Jaklin Eliott's Interdisciplinary Perspectives on Hope, 2005.