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Coulehan, Jack, MD

doi: 10.1097/01.ACM.0000396497.57138.c4
Medicine and the Arts

Dr. Coulehan is senior fellow, Center for Medical Humanities, Compassionate Care, and Bioethics, Stony Brook University, Stony Brook, New York; e-mail:

“ Hope springs eternal in the human breast.” So wrote Alexander Pope1 in his long poem, “An essay on man.” Perhaps “eternal” hope is too lofty an aspiration, but experience teaches that hope is very durable. Doctors have long considered hope an effective tool in reducing the suffering of illness. In fact, doctors traditionally manipulated hope as part of their prescribed regimen for critically and terminally ill patients. Their principal method of doing so was to modulate disclosure of information about prognosis because, they argued, telling a patient the truth could be devastating.

This belief among doctors was based on assumptions about the nature of hope that have little in common with those expressed by Emily Dickinson in the three poems printed here. In “Hope is the thing with feathers,” Dickinson, like Pope, evokes the durability of hope: a bird that “perches in the soul” and continues singing in the face of violent storms and extreme situations. In the second poem, Dickinson employs the metaphor of invention (“a patent of the heart”) to place hope at the core of human existence, marveling at how tough it is: “In unremitting action/Yet never wearing out.” Clearly, unlike the precautionary wisdom of clinicians who say, “Be careful, or the patient will lose hope,” the Amherst poet considered hopefulness an enduring attribute that is not likely to be blown away by bad news.

Likening hope to a bird suggests a second insight that varies markedly from the traditional medical perspective. According to Dickinson, hope's song is wordless, a sweet melody without lyrics. The absence of words seems to rule out a specific object of one's hope: no love to be won, no injustice to right, no pot of gold to find at the end of the rainbow. The poet implies that her hope, at least, exists without a target or agenda, unlike the concept of hope in a medical setting that predicates a specific (no matter how unlikely) thing hoped for. To hope in the face of serious illness is to project oneself into an imagined future: to overcome the disease, to experience a remission, to survive another month or year. What can Dickinson's vision of hope mean in this context? Perhaps there is a deeper dimension of hope that affirms the future simply by affirming one's present experience of value and meaning in life. Perhaps the wordless melody arises from love and forgiveness. If such a quality as hope-without-words exists, it must have important implications in the care of dying patients.

Dickinson intimates another contrarian feature of hope in “Hope is a subtle glutton.” Here she uses the metaphor of a glutton gorging on a delicious feast. No matter how much he eats, “the same amount remains.” His overindulgence is subtle because it seems not to change anything. It certainly does not hurt the glutton. The poet tells us that no matter how much hope one consumes (internalizes), it cannot be excessive, a concept that flies in the face of the medical belief that patients and families sometimes have too much hope, a condition doctors label “false hope.” They consider false hope a distortion that compromises medical care rather than enhancing it. How can this seemingly dark side of hope be reconciled with the poet's feast?

In an article entitled “Hope for the best, and prepare for the worst,” Beck et al2 suggest a key to this quandary. They present a clinical framework in which doctors can promote the dual agendas of hoping for the best outcome, even if it is very unlikely, while preparing the patient to cope with a more realistic outcome. This allows the patient to proceed with living and hoping, while at the same time embarking on the emotional and spiritual work of dying. In this context, false hope is not a problem of hoping too much but, rather, of neglecting to prepare for the worst.

Effective metaphors shed light. They point toward meanings and relationships that go deeper than ordinary language expresses. Dickinson's “thing with feathers,” “patent of the heart,” and “halcyon table” do just that. In these and other poems, she evokes a deep and enduring human attribute that may underlie every specific hope that our patients—and we, too—generate and express.

Jack Coulehan, MD

Dr. Coulehan is senior fellow, Center for Medical Humanities, Compassionate Care, and Bioethics, Stony Brook University, Stony Brook, New York; e-mail:

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1Pope A. An essay on man: Epistle 1. In: An Essay on Man and Other Poems. Mineola, NY: Dover Editions: 1994.
2Beck AL, Arnold RM, Quill TE. Hope for the best, and prepare for the worst. Ann Intern Med. 2003;138:439–443.
© 2011 Association of American Medical Colleges