Therapeutic doublethink: Making a case for the acceptability of unrealistic optimism in patients at end-of-life

Abstract

George Orwell coined the term "doublethink" to describe the concept of "holding two contradictory beliefs in one's mind simultaneously, and accepting both of them." Patients at end-of-life may be using “Therapeutic Doublethink” as a psychological mechanism to cope with the cognitive dissonance resulting from accepting a terminal diagnosis and desiring curative therapy. To develop the concept of Therapeutic Doublethink, we explored the literature on Unrealistic Optimism and decision-making, then grounded them in existing psychological and neurobiological concepts. Functional neuroimaging studies can help to explain the biological mechanisms that permit Unrealistic Optimism and Therapeutic Doublethink to exist, including a failure to track less desirable information and a focus on outcomes without considering the actions required to achieve them. These findings help us appreciate the challenges patients face when trying to make “rational” treatment decisions. They also raise questions about the effectiveness and potential harm of truth-telling, which is a common approach used by physicians who are confronted by Unrealistic Optimism. In some cases, physicians may be able to use Therapeutic Doublethink to harness the beneficial aspects of Unrealistic Optimism while simultaneously helping patients accept the terminal nature of their condition. This approach may be conceptually and ethically challenging for many physicians, but has important implications for improving patient care.

To know and not to know, to be conscious of complete truthfulness while telling carefully constructed lies ….

-George Orwell on the concept of “doublethink”, Nineteen Eighty-Four

Introduction: The concept of therapeutic doublethink

We, the authors of this paper—both palliative medicine physicians with backgrounds in bioethics—have observed that patients who have been diagnosed with incurable and progressive illnesses such as stage IV cancer may sometimes seem to understand the terminal nature of their illness, yet still harbor the belief that the therapy they are receiving is curative in its intent. As such, misinterpreting the aims of treatment to be curative does not seem to preclude acceptance of a terminal diagnosis. As introduced by George Orwell in his dystopian novel Nineteen Eighty-Four, “doublethink” is the concept of “holding two contradictory beliefs in one's mind simultaneously, and accepting both of them.” Following this, palliative cancer patients may not be in denial, but rather, are using unrealistic optimism as a psychological mechanism to cope with the cognitive dissonance resulting from accepting a terminal diagnosis and desiring curative therapy.

The concept of “doublethink” was given a negative connotation in Nineteen Eighty-Four as it was the mechanism through which a totalitarian regime justified and perpetuated their manipulative and controlling tactics. But doublethink has the potential to be of benefit in the palliative setting. To distinguish the traditional use of doublethink from its restorative potential, we have termed the latter scenario “Therapeutic Doublethink.”

Furthermore, when Therapeutic Doublethink exists, we posit that unrealistic optimism is morally acceptable and even beneficial for patients with advanced, incurable illnesses. This paper will first explore Unrealistic Optimism in the context of patients with advanced cancer. It will then develop the concept of Therapeutic Doublethink by (1) grounding it in existing psychological and neuro-biological theories and by (2) analyzing its practical ethical implications as it pertains to patient care and the physician-patient relationship.

Unrealistic optimism

Unrealistic optimism in patients with advanced cancer: Prevalence and causes

The concept of Unrealistic Optimism has been defined as when “a person believes that she is more likely to experience positive outcomes (or less likely to experience negative outcomes) than other similarly situated”. ¹ Rather than being the exception, studies have shown that Unrealistic Optimism is the rule where human psychology is concerned.^2,3 In fact, “Depressive Realism” is a popular theory that postulates that those who tend toward depressive tendencies have more accurate perceptions^4,5 and more realistic outlooks on life.^6,7

Optimism tends to be greater when it is required to minimize a negative event rather than elevate a positive event. ⁸ Furthermore, Taylor's theory of cognitive adaptation^9,10 describes the human mind's ability to adapt by creating positive illusions and postulates that when faced with a life-threatening event this finding is further enhanced. For example, a study comparing healthy patients to patients undergoing radiation therapy for cancer found higher levels of optimism and self-esteem in the latter group. ¹¹ All this results in a psychological state that leaves patients with advanced cancer or other life-limiting illnesses especially prone to Unrealistic Optimism.

Studies repeatedly indicate that a significant proportion (up to 70%) of cancer patients harbor unrealistic expectations around the curative potential of the palliative chemotherapy or radiation therapy they are receiving. ^1,12-14 In reality, the goals of these treatments are to prolong survival or relieve symptoms, but not to cure. Even more concerning, significant levels of Unrealistic Optimism have also been found in patients who are involved in early-phase oncology trials, where the study drug has not yet even been proven to be effective. ¹⁵

Potential Benefits and Risks of Unrealistic Optimism

Unrealistic Optimism has been linked to a number of positive health outcomes such as faster recovery from heart surgery and reduced psychological distress in HIV-positive men. ¹⁶ In patients coping with chronic illnesses such as multiple sclerosis and Type 1 diabetes mellitus, optimism was associated with better self-care behaviors. ¹⁷

Unrealistic Optimism has also been linked to better psychological outcomes for patients with advanced cancer. A 2001 study found that patients with metastatic renal cell carcinoma and metastatic melanoma who displayed treatment-specific optimism (such as the belief that chemotherapy would cure or halt progression of their cancer) were at a lower risk of depressive symptoms. ¹⁸ Another study found that the more likely they misunderstood their treatment to be potentially curative the higher patients rated their physicians’ level of communication. ¹² This would indicate that optimism, even when unrealistic, confers psychological benefit and may enhance the physician–patient relationship.

However, although research has linked Unrealistic Optimism to better outcomes in cardiac surgery and HIV-positive patients, other studies have found no such benefit in the same patient populations. ¹⁶ The optimism bias also may make people place less emphasis on the importance of help-seeking ¹⁹ and has been shown to be correlated with riskier behavior. ²⁰

In patients with advanced cancer, patients who have overly optimistic outlooks are more likely to have undesired outcomes such as hospital readmissions, resuscitation attempts, or die while on ventilatory support—all without any survival advantage. ²¹ As well, the studies that imply psychological benefit from Unrealistic Optimism are limited by their cross-sectional design and do not capture the decisional regret patients may feel later. ²² For example, patients may lament having not spent time with loved ones or feel overburdened by the financial costs of pursuing a more aggressive approach to care. ²³ A study looking at the perceptions of adult children and their parents’ with respect to elder care needs confirmed an optimism bias in the form of systematic underestimates of their own future care requirements. ²⁴ As a result, when patients become weaker, their surrogate decision-makers are often left with the burden of inferring what their loved ones would have wanted. Studies examining surrogate decision-makers and families of patients in the intensive care unit found post-traumatic stress disorder levels of distress during and even 6 months after the hospital stay.^25,26

Unrealistic optimism: how is it mediated and maintained?

Functional magnetic resonance imaging (fMRI) studies have helped us understand the biological mechanisms underlying our thinking processes and decision-making behavior.

One seminal study looked at how Unrealistic Optimism is maintained by measuring brain activity in response to new information that was better or worse than expected. ²⁷ Participants were informed of their risk of experiencing several adverse life events such as cancer or robbery. When the risk was better than what was expected, areas of the prefrontal cortex of the brain such as the left inferior prefrontal gyrus and bilateral medial frontal cortex were activated. When asked about their risk in a subsequent session, beliefs were updated to correlate very closely with this newer, better information participants had obtained. When the opposite occurred—when the actual risk was higher or worse than participants’ expectations—beliefs were much less likely to change. In the fMRIs, this was represented by decreased brain activity in the right inferior frontal gyrus, especially in patients who displayed high optimism traits. The investigators of the study speculated that the optimism bias so frequently persists because there is a decrease in neural coding of “bad news.” Similar findings were replicated in more recent studies, ²⁸ with one study demonstrating that this asymmetrical belief updating was not found in depressed patients. ²⁹ These findings are supported by previous studies that have shown that variations in neurotransmitters such as serotonin and dopamine can further influence optimism bias and realistic outlooks.^30,31

The conceptual implications of these findings are of considerable importance in the context of Unrealistic Optimism in patients with advanced cancer. Many times, clinicians may find themselves frustrated with patients who do not seem to understand the goals of their treatment despite numerous conversations. Perhaps this frustration could be mitigated if the clinician acknowledged that much of this lack of awareness is not a result of willful ignorance, but rather, is mediated by neurobiological mechanisms that are beyond the conscious control of the patient. Next, we will look at how despite maintaining a state of Unrealistic Optimism, a patient may still be able to simultaneously consider more realistic alternatives.

Neural mechanisms of therapeutic doublethink

The concept of Therapeutic Doublethink is a state-of-mind that involves Unrealistic Optimism, but also concurrently requires a person to hold realistic beliefs. There may be multiple ways this can occur including (1) the response of the mind to priming, (2) the “goods-based” model of decision making (i.e., the ability of the mind to make outcome decisions without consideration of the process), and finally (3) the “hypothetical bias” which describes the gap between what individuals choose in hypothetical versus real scenarios. Each of these pathways can be explained using data from existing cognitive neuroscience literature.

The response of the mind to priming

Priming is a well-known psychological phenomenon that describes the subconscious influence of a stimuli on a person's future response. For example, in a study that primed participants to think about healthy living behaviors, those who had pre-existing Unrealistic Optimism with regard to their risk of colorectal cancer voice greater interest in cancer screening post-intervention. ³²

How is this happening on a neurophysiological level? One study, which primed participants to think about either health or taste and then asked them to choose between a healthy food item (e.g., almonds) or an unhealthy item (e.g., cookies), found that those primed to think about taste were significantly more likely to choose the unhealthy item. ³³ fMRI imaging revealed that the left amygdala was activated when those who were primed to think about taste in fact chose the “tastier” item-—consistent with our understanding of the amygdala's importance in emotional responses. The study authors pointed to their results as evidence “that changing perspectives can modulate value- and choice-related neural activity”.

A similar mechanism may be at play in decision-making for patients with metastatic cancer. Just as the study showed how priming influenced choices through amygdala activation, the framing of conversations by different specialists may shift patients’ emotional focus and decision pathways. For example, when in the oncologist's office, where discussions often emphasize prognosis and survival, the emotional salience of life-prolonging treatment may be heightened—potentially activating the amygdala in ways that support choosing aggressive therapies. In contrast, when with a palliative medicine physician, the focus is more likely to be about symptom relief and quality of life—leading the patient to focus on interventions that will enhance those goals. The resulting changes in decision-making may appear contradictory, but can be understood as amygdala-mediated responses to differing contextual frames.

The goods-based model of decision making

The second way in which a patient can seemingly invoke Therapeutic Doublethink is by focusing on outcomes while laying aside considerations of how desired goals such as survival and comfort will be achieved. There are two predominant theoretical models for how our brains compare and make decisions. The first theory is the action-based model—in which people conceive of their desired outcomes in the premotor cortex, but only decide how to act once the actions that are required to achieve these outcomes are known. By contrast, the goods-based model argues that we can make a decision based on the desired outcome alone and only consider the actions required after the fact. One functional neuroimaging study proved that the latter hypothesis was possible ³⁴ by constructing a game where participants had to choose between two different geometric shapes on a screen. The decision was made using two distinct actions: Pushing a button or saccading the eyes. However, participants did not always know which action would choose which shape until a five-second delay had elapsed. Despite this, the fMRIs indicated that participants often had already chosen which shape they wanted as the ventromedial prefrontal cortex would activate (a post-decisional signal), even before the action required to obtain the shape became known.

The results of this study suggest that individuals have the ability to choose an outcome without consideration of the actions necessary to achieve their goal. It may explain why patients choose aggressive therapies—because they do not necessarily consider the time spent away from their loved ones or weigh the side effects they will have to endure. It also may shed light on why patients can seemingly choose two divergent care pathways. For example, a patient wishing to be free of side effects but also would like to live as long as possible may refuse chemotherapy but still wish for cardiopulmonary resuscitation in the event of cardiac arrest—even though the latter is typically viewed as a more aggressive and less effective intervention in the context of advanced cancer.

The hypothetical bias

The final theoretical mechanism is based on a well-known “hypothetical bias,” which highlights the discrepancy between what individuals say they would do in hypothetical situations and what they actually do when faced with real scenarios. ³⁵ In one fMRI study, ³⁶ participants in one research arm were each given £20. They were then asked how much money they would return to prevent a second subject from receiving a painful electrical shock to the wrist. In the other arm, the participants were asked only to imagine that such a scenario was occurring. True to previous studies looking at the hypothetical bias, participants in the real scenario displayed more self-interest and kept more money than those in the hypothetical scenario (£15.77 vs £14.45). Although the brains in these two scenarios shared some common neural networks, it was the differences that were so telling. The fMRIs of patients in the hypothetical scenario mapped to the Imagination Network of the brain, namely the posterior cingulated cortex, bilateral hippocampus, and the posterior parietal lobe. In the real scenario however, the amygdala and anterior cingulate cortex were activated—regions of the brain that process emotional stimuli. These findings suggest that real and hypothetical decisions are mediated on different neural pathways.

This can be meaningfully extrapolated to the concept of Therapeutic Doublethink in the context of serious illness. Decisions around pursuing treatments such as chemotherapy can be perceived as immediate and “real”—thereby engaging affective neural systems. In contrast, planning for future decline or end-of-life care may feel more abstract, allowing those conversations and actions to remain in the hypothetical domain. In essence, this theory explains the neural mechanism that allows for a patient to “hope for the best and prepare for the worst”—a technique that is frequently employed to encourage patients to take precautionary measures and plan for the future without abandoning the hope they wish to maintain.

Of note, while all the above studies offer valuable insights into the neural mechanisms underlying choice, we recognize that they cannot fully capture the realities of clinical care—where decisions are often made under uncertainty, and where patients’ goals and priorities may shift over time. The experimental tasks cited were highly simplified, involving minimal or no emotional stakes. In contrast, decisions in the context of serious illness are far more complex and emotionally charged.

Discussion: The practical and ethical implications of therapeutic doublethink

The ethical acceptability of Unrealistic Optimism in patients remains an active area of discussion in the bioethics literature. Some scholars advocate for a more permissive stance, suggesting that healthcare providers should tolerate, or even support, a degree of Unrealistic Optimism in certain contexts. ³⁷ Others, however, remain concerned about its potential to undermine patient autonomy. ³⁸

At face value, unrealistic optimism poses several ethical challenges. First, it may lead to emotional or physical harm, as previously discussed. Second, it can place physicians in a difficult position: The fiduciary relationship between physician and patient is grounded in trust and truth-telling, yet efforts to preserve hope may seem to conflict with the obligation to communicate honestly about prognosis. Third, there is the question of whether a patient can truly provide informed, autonomous consent for treatments such as chemotherapy or radiation if they do not fully grasp the intention behind the intervention or the reality of their medical condition.

However, the concept of therapeutic doublethink may offer a reframing of these ethical tensions. By recognizing the psychological mechanisms that allow patients to simultaneously hold contradictory beliefs—accepting a terminal diagnosis while hoping for a cure—it becomes possible to see unrealistic optimism not as a barrier to autonomy, but as a coping strategy that can coexist with informed decision-making under certain conditions.

Firstly, it may allow the patient to take precautionary measures (i.e., hoping for the best but preparing for the worst), as a “bridge” to ultimate realistic acceptance. Dr Sandra Schneider, a professor of psychology at the University of Florida, argued that “realistic optimism” is not necessarily an oxymoron, even in the presence of positive biases. ³⁹ In fact, she cites studies that support the notion that setting a lofty goal can paradoxically lead a person to then focus on the steps that will be required to achieve it, thereby promoting action-based thinking which can result in a net increase in realism. Complementing this perspective, Charles Snyder's Hope Theory ⁴⁰ argues that hope is not merely an emotional state but can be defined as the perceived capability to derive pathways to desired goals combined with the motivational agency to use those pathways—which ultimately leads to goal-directed behavior even amid uncertainty. Dr Schneider acknowledges that being realistic can be difficult when goals conflict, but states that people tend to be happier and healthier when they adopt strategies that allow them to satisfy those goals rather than deny them—such as the case with Therapeutic Doublethink.

Next, concerning the “virtuous” physician's duty to tell the truth, in Therapeutic Doublethink the concomitant acceptance of a terminal diagnosis significantly minimizes this conflict. Especially given the neurobiological mechanisms that mediate and maintain Unrealistic Optimism, physicians should not feel a sense of moral distress or moral failure if the patient doesn’t explicitly “accept” the truth. Of course, this statement is predicated on the assumption that clear and empathetic attempts to communicate prognosis and treatment goals have been—and continue to be—trialed appropriately.

It is also worth distinguishing between two clinical contexts: Those in which a treatment offers some potential benefit that may be misunderstood or overestimated by the patient, and those in which the treatment confers no meaningful benefit or may even cause harm. We propose that Therapeutic Doublethink may have a role in both scenarios by allowing patients to preserve hope while simultaneously accommodating the reality of their condition at some level. However, the physician's obligation to address misconceptions should be proportionate to the potential for harm associated with those misunderstandings—whether physical, emotional, financial, or otherwise.

Finally, concerning the autonomy of a patient, we can recognize that the neurobiological mechanisms that mediate Unrealistic Optimism and Therapeutic Doublethink are adaptive mechanisms that allow a patient to cope. They permit a patient to tolerate a situation in which goals cannot be reconciled with reality, and effectively their subconscious influences them to choose the side effects of chemotherapy over the distress of reality. Hence, Therapeutic Doublethink can be seen as a state of meta-autonomy, where our beliefs and decisions can transcend our conscious thinking and decision-making. In that sense, although a patient may not seem to understand the implications of a therapy explicitly, they understand it enough to choose it over the alternatives.

Conclusion

The concept of Therapeutic Doublethink offers clinicians a valuable lens through which to understand the seemingly contradictory behavior of patients who maintain a belief in curability despite a diagnosis of advanced cancer. Though the goal of physicians should always be to attempt truthful prognostication while maintaining healthy optimism, this is not always feasible. If a patient cannot be swayed from their beliefs that they may be curable, then a state of Therapeutic Doublethink—whether liminal or permanent—can be an alternative. The presence of such a mindset would allow a physician to help a patient work towards important life goals and take precautionary measures, while still respecting their autonomy and decision to proceed with active treatments such as chemotherapy.