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

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.