In Defense of “Denial”: Difficulty Knowing When Beliefs Are Unrealistic and Whether Unrealistic Beliefs Are Bad

Abstract

Bioethicists often draw sharp distinctions between hope and states like denial, self-deception, and unrealistic optimism. But what, exactly, is the difference between hope and its more suspect cousins? One common way of drawing the distinction focuses on accuracy of belief about the desired outcome: Hope, though perhaps sometimes misplaced, does not involve inaccuracy in the way that these other states do. Because inaccurate beliefs are thought to compromise informed decision making, bioethicists have considered these states to be ones where intervention is needed either to correct the person’s mental state or to persuade the person to behave differently, or even to deny the person certain options (e.g., another round of chemotherapy). In this article, we argue that it is difficult to determine whether a patient is really in denial, self-deceived, or unrealistically optimistic. Moreover, even when we are confident that beliefs are unrealistic, they are not always as harmful as critics contend. As a result, we need to be more permissive in our approach to patients who we believe are unrealistically optimistic, in denial, or self-deceived—that is, unless patients significantly misunderstand their situation and thus make decisions that are clearly bad for them (especially in light of their own values and goals), we should not intervene by trying to change their mental states or persuade them to behave differently, or by paternalistically denying them certain options (e.g., a risky procedure).

Keywords:

• population
• public health
• race and culture/ethnicity

This article is referred to by:

Propositions and Pragmatics

Hope, Denial, and Third-Party Effects

In Defense of Common Human Responses

Off-Target Effects of a Defense of Denial

When Denial Hurts the Children: An Argument for Accountability of Denial in Parental Decision Making

We Convey More Than We (Literally) Say

“I Know I'm Going to Beat This”: When Patients and Doctors Disagree About Prognosis

Why (Some) Unrealistic Optimism is Permissible in Patient Decision Making

Denial and Dyads: Patients Whose Surrogates and Physicians Are Unrealistically Optimistic

Response to Open Peer Commentaries on ‘‘In Defense of ‘Denial’: Difficulty Knowing When Beliefs Are Unrealistic and Whether Unrealistic Beliefs Are Bad”

The Unintended Consequences of Reframing Denial, Unrealistic Optimism, and Self-Deception

Weaponizing Hope: Sources of Hope, Unrealistic Optimism, and Denial

ACKNOWLEDGMENTS

The authors thank the audiences at NYU Center for Bioethics and University of Pittsburgh Center for Bioethics and Health Law, and also Professor Bill Ruddick for helpful comments on this article. ▪

Notes

1. Jane’s case is a real one drawn from a qualitative study in the referenced paper. In this this study, transplant status had been explained to LVAD patients and candidates in person and in a formal letter; however, 7 of 15 LVAD patients still considered themselves on a transplant trajectory and 10 of 15 LVAD candidates considered themselves on a transplant trajectory when they were not.

2. For an excellent overview of philosophical accounts of hope and related phenomena such as self-deception, wishful thinking, see Martin (2013). As Martin notes, hers is the first book-length project on hope in the philosophical literature. Martin develops her own account of hope, which involves an explanation for why a person engages in behaviors such as thinking about or planning for the desired outcome: The person “sees” the probability of the desired outcome as justifying such activities. For other philosophical accounts of hope, see, for example, Bovens (1999), Day, (1969; 1970), Meirav (2009), Pettit (2004), Walker (2006), McGeer (2008), Snow (2013), and Kadlac (2015). C. Richard Snyder is a psychologist who has developed a robust theory of hope (as involving “pathway” thoughts about how to get to the desired outcome and “agency” thoughts about one’s ability to take the pathways or find new ones) along with a validated measure. See, for example, Snyder (2000). For the most referenced account of unrealistic optimism, see Weinstein (1980). For a robust account of self-deception and denial, see Mele (2000).

3. We do not discuss the phenomenon of “false hope” in this article because understood literally, false hope is quite uncommon since it is rare for specific outcomes to be impossible–more often, they are very unlikely. Thus, what people typically mean by the charge of “false” hope is that hope is unreasonable, or, more precisely, that the person’s response to the actual (usually poor) odds is unreasonable in some way. For example, the person could be spending too much time thinking about or planning for the desired outcome given the odds, or the person could be engaging in risky behavior as a result of this hopefulness. This is the focus of the second part of this article—whether and how the various states of hope, unrealistic optimism, self-deception, and denial are desirable or not.

4. Brackets and emphasis ours.

5. One way to explain what is going on with Rodrigo on this view is that he “believes” the probability to be 5% but “alieves” it to be much higher. This is the view of Tamar Gendler. Gendler gives the example of walking over the glass walkway of the Grand Canyon. She writes that people “believe” that the walkway will hold, but alongside the belief that the walkway is safe have “something else” going on—namely an “alief” with the following content: “Really high up, long long way down. Not a safe place to be! Get off!” (635). She also gives the example of forgetting her wallet at home while traveling. Although she “believed” her wallet was hundreds of miles away at home, she still found herself rooting through her bag to put cash into her wallet, “alieving” something very different. The alief had the content of “Needs to go into a safe place. Active wallet-retrieval motor routine now” (637).

6. We put quotation marks here to indicate that the researchers took themselves to be studying unrealistic optimism, but the point of this section of the article is to open up the question of how terms such as these should be defined and conceptualized. Note: The researchers took unrealistic optimism to mean ranking positive outcomes as more likely for oneself than others and/or ranking negative outcomes as less likely for oneself than others (Jansen et al. 2016, 1).

7. For an excellent discussion of this matter, see Kelly (2003).

8. Feudtner does not offer an unqualified defense of hope, but rather, argues in favor of approaching patients with compassion as one guides them toward changes in the content of their hopes (i.e., towards “smaller hopes”). A related notion is that of “regoaling” developed by Hill and colleagues. See Hill et al. (2014).

9. There are also potential disadvantages to hope. We do not mean to imply that there are not. However, since our main aim is to offer a qualified defense of denial and related states, we focus here on the benefits of hope and argue that they extend to denial and related states. For readers interested in the potential disadvantages of hope, we refer them to the section of the article outlining the potential concerns about denial/unrealistic optimism/self-deception, since, after all, part of our argument in the first part of the article was to point to the difficulty in drawing such tight distinctions between these states and hope. For a particularly poignant articulation about the potential disadvantages of hope in the clinical setting, consider the following passage from Pedro Weisleder, a pediatric neurologist: “Hope blinds and shackles; hope is daunting and discouraging; hope is disempowering. Hope is alluring but vague; hope is revered but ineffable … Hope puts our mind in an indeterminate state, a mind that is in suspense … Hope, as designed by Zeus, is an evil” (Weisleder 2012, 1618). This is a strong view, and as we have argued in the article, states of hope or denial are not inherently bad (or good)—it depends on the particulars.