Jerome Groopman, MD. The anatomy of hope: how people prevail in the face of illness. Random House, New York 2004, ISBN 0-375-50638-1.

Dr Groopman, a member of the haematogy-oncology faculty at Harvard Medical School, USA, has written many popular articles explaining intricacies of medicine. In this, his third book, he describes how people cope with serious illness.

He starts out by recounting the story of a young orthodox Jewish woman with advanced breast cancer. She asked Dr Groopman, who is Jewish, to be part of her treatment team even though he was just an intern. After surgery she confided to Dr Groopman that she had had an affair with her boss and the cancer was retribution for her sin. As a penance she initially refused chemotherapy. When she ultimately agreed, it was too late to change the outcome.

Young physicians were only taught to diagnose and treat illnesses but not how to interact with patients where hope is interwoven into their background and beliefs. Dr Groopman was unable to work through the patient’s beliefs and lead her to hope for a different life.

The author then illustrates the difference between false and true hope. He describes a patient with advanced colon cancer being held in check by increasingly strong chemotherapy. Whenever the patient or her daughter was seen by Dr Groopman, he maintained a positive attitude despite a bleak prognosis. As the end neared, the daughter expressed resentment that she and her mother had not been told the truth. Dr Groopman says that he felt guilty that the patient and her family had been given a false sense of hope.

True hope is based on knowledge and facts and not on denial of adversity. Dr Groopmans encountered this when a senior colleague and mentor battled his stomach cancer, a disease with poor prognosis. Colleagues were saddened to see the physician ask for, and receive, the latest aggressive treatments. They thought he was unreasonably optimistic. He proved their predictions wrong. When Dr Groopman asked how he continued treatment despite the grim statistics, the physician said he hoped that he would be among the slim percentage that survived, a hope based on a realistic assessment of his chances.

Groopman argues that hope is constructed from a rational deliberation of options and an amalgam of past experiences and feelings. He describes a man who refused treatment for a treatable lymphoma because he had seen his close friend die an agonising death from a similar cancer. He relates his own tenacious struggle with severe pain and limitation following spinal surgery and how hope kept him going with daily physical therapy.

Groopman is critical of Dr Elisabeth Kubler-Ross’s work on death and dying. She encouraged patients to keep hoping for a miracle, until the end. “Hope need not be a miracle,” says Groopman. Hope can have purpose and meaning. He describes the prolonged course of a patient with breast cancer who accepted that there was no cure for her disease. What was possible was a remission, a waiting period of indeterminate length. During these periods the patient continued an active meaningful life.

Finally he examines the biological basis of hope. Can hope contribute biologically to recovery? Groopman finds that the popular media promotes charismatic methods to channel the mind’s energy towards healing. The implication is that if the problem persists then the patient is somehow at fault. He feels that the occasional mysterious recoveries should be investigated scientifically. When he discusses this with a psychiatrist who has been studying the mind-body connection, he is told, “The mind is a manifestation of the brain. Products of the mind, thoughts, feelings, emotions, are a mix of chemicals and electrical circuits that have evolved over millennia…” The mind-body connection is an artificial construct. Placebos work through beliefs and expectations and placebos produce physiological results by altering brain pathways and chemicals. Variability in genetic and environmental factors may explain why some respond better than others. Past and present environments may shape brain circuits that produce neurotransmitters to produce different effects. Dr Davidson, an experimental psychologist, aims to understand how the brain generates enabling emotions. To him, hope is an interaction of cognitive and affective parts. Hope modifies how people reason. Fear, another brain emotion, counter balances hope. Without fear a person may be excessively optimistic which Groopman considers false hope.

Groopman has learned that “it takes much more than mere words to communicate information and to alter affect. …Each disease is uncertain in its outcome and in that uncertainty we find real hope because a tumor has not read the text book and a treatment can have an unexpectedly dramatic impact. …This is the great paradox of true hope: Because nothing is absolutely determined there is not only reason to fear but also reason to hope.”