In medical ethics, there is an important distinction between a patient's being realistically hopeful and her being “unrealistically optimistic.” The latter state can also be expressed as “self-deception” or as “being in denial.” Generally speaking, being realistically hopeful is thought to be a positive state, one to be encouraged. Additionally, the loss of all hope is complete despair or perhaps complete apathy. These are states that we want patients to avoid. By contrast, being unrealistically optimistic is normally understood as a negative state, and traditionally one that healthcare professionals ought to correct in their patients. One standard argument for this traditional view is that unrealistic optimism is bad because it undermines patient autonomy. In this paper, I explore a recent challenge to that argument.

I formulize the traditional view that unrealistic optimism threatens patient autonomy in what I call the “Autonomy Undermining Argument.” I then discuss an important recent criticism of this argument.

I argue that the criticism of the Autonomy Undermining Argument fails. Specifically, I claim first that waiving realistic beliefs is not analogous to waiving information with respect to informed consent requirements. Second, I argue that regardless of whether unrealistic optimism would affect a patient's decisions, there are still significant autonomy concerns.

Critics of the Autonomy Undermining Argument make a broader claim that we ought to be more permissive in our treatment of unrealistically optimistic patients. I conclude, however, that concerns about patient autonomy give us reason to resist this claim. Unrealistic optimism does run the risk of significantly undermining patient autonomy.