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Courage: The heart of the matter

Published online by Cambridge University Press:  07 December 2005

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Cancer is frequently compared with war. The daily newspapers report on such-and-such a person's battle against cancer. A patient declares, “I will fight it with everything I've got.” One country has called its peak body “The Association of War against Cancer.” In America the National Cancer Act of 1971 “declared war on cancer” (Levy, 2005). Thus is cancer declared the enemy, which must be conquered.

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Editorial
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© 2005 Cambridge University Press

Cancer is frequently compared with war. The daily newspapers report on such-and-such a person's battle against cancer. A patient declares, “I will fight it with everything I've got.” One country has called its peak body “The Association of War against Cancer.” In America the National Cancer Act of 1971 “declared war on cancer” (Levy, 2005). Thus is cancer declared the enemy, which must be conquered.

The concept of demoralization has traditionally been applied to war. Loss of morale—of the army and the public—is a great concern of any wartime leader. Recently demoralization has been rebadged to describe a syndrome in cancer patients, which consists of loss of meaning, hopelessness, existential distress, and ultimately a desire to die (Clarke & Kissane, 2002). Once again we have the metaphor of war aligned to cancer.

Morale is a concept that is generally applied to a person facing a challenge, trial, or tribulation. Morale is the psychological or spiritual wherewithal to keep going despite duress to achieve a certain goal. Churchill understood its importance when he walked through the rubble—with cigar and cane—during the Blitz of London in World War II. The message was clear—the enemy will not demoralize us, we will not be cowed nor beaten. Likewise, Lincoln's memorable speech at Gettysburg in 1863 during the Civil War. The speech, “that this nation shall have a new birth of freedom, and that government of the people, by the people, for the people shall not perish from the earth,” provided meaning in the face of so much loss and death, in order to sustain morale (Lincoln, 1991).

Which human traits secure morale? Having or finding meaning is critical to maintaining morale. This concept is supported by early research into demoralization (Kissane et al., 2004). At Gettysburg, Lincoln demonstrated that meaning can bolster morale (even now at a distance of more than a century). Meaning, strictly speaking though, is not an action. To generate activity, a different human characteristic is required that Churchill pinpointed, namely courage.

Courage is defined simply as the quality that, in spite of fear, enables one to achieve the goal (Griffith & Gaby, 2005). Fear is generic and is generated by many factors, including shame and humiliation. AIDS and cancer carry social stigmata, which creates a fear of exposure. Courage as a mechanism is required to overcome the barrier of fear. This point was beautifully made by Alexander and Mulasi, in their piece entitled, “Little boy blue” (Alexander & Mulasi, 2004).

I think morale is underpinned by meaning and courage. These two values are themselves intertwined in the sense that the more one values a thing, the more one fears losing it. And the greater the threat, the more courage is called into play.

Questions arise: How can we judge courage? What are the characteristics that make some people more courageous than others? Is the absence of courage necessarily its opposite, cowardice? How can we research courage? Can courage be used therapeutically? Is there an ultimate wellspring of courage?

In the olden days, courage was thought to come from the heart. Hence its Latin etymology, cor, meaning heart. In the postheart transplant era, however, it seems unlikely that courage really is sourced from the heart. It more likely derives from the less easily defined anatomies of character and spirit.

What is courageous to one person may be de rigeur to another, and vice versa. It may take great courage for an agoraphobic to walk in the park, whereas to us the challenge is incomprehensible. Therefore to judge courage, or indeed cowardice, objectively is difficult and fraught with risk. Miller tried to address this complexity by describing three types of courage: physical, moral, and natural (Miller, 2000). Nevertheless the stigma of receiving a white feather ensures that any judgment be prudently made (Mason, 1902).

In clinical practice we typically encourage our patients. We often do this through a life review. Griffith recently addressed this in a formal and practical way (Griffith & Gaby, 2005). Greer has spoken about the “fighting spirit” (Greer, 2000), while others have emphasized morale. A fighting spirit presupposes courage and morale.

Critical to any discussion about the struggle with cancer is the notion that one day things will get better. Neither meaning nor courage expresses this element of futurity. Nevertheless, a healthy morale necessarily looks to the future, to a time when the trial will have been accommodated or overcome. Hence hope, which by definition is placed in the future, becomes another key element of morale. Hope is intimately associated with purpose and meaning, and in addition has the intrinsic characteristic of focusing thinking in a salutary way.

In revisiting demoralization then, we hypothesize that its three key components are meaning, hope, and courage:

The strength of courage is that it entails an action. No more filibustering, nor rationalizing, nor excuse making. Courage is to act.

References

Alexander, C. & Mulasi, I. (2004). Little boy blue. Palliative and Supportive Care, 2, 329331.Google Scholar
Clarke, D.M. & Kissane, D.W. (2002). Demoralization: Its phenomenology and importance. Australian and New Zealand Journal of Psychiatry, 36(6), 733742.Google Scholar
Greer, S. (2000). Fighting spirit in patients with cancer. Lancet, 355, March 4, 847848.Google Scholar
Griffith, J.L. & Gaby, L. (2005). Brief psychotherapy at the bedside: Countering demoralization from medical illness. Psychosomatics, 46, 109116.Google Scholar
Kissane, D.W., Wein, S., Love, A., et al. (2004). The Demoralization Scale: A report of its development and preliminary validation. Journal of Palliative Care, 20(4), 269276.Google Scholar
Levy, M.H. (2005). Supportive Oncology-Palliative Care: What's in a name? Seminars in Oncology, 32, 131133.Google Scholar
Lincoln, A. (1991). Great Speeches/Abraham Lincoln. With historical notes by John Grafton. New York: Dover Publications.
Mason, A.E.W. (1902). The Four Feathers, New York: Macmillan Co.
Miller, W.I. (2000). The Mystery of Courage. Cambridge, MA: Harvard University Press.
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