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.
