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Harvard Commentaries
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Medical Myths Medical Myths
 

The Limits of Willpower


October 10, 2013

By Robert H. Shmerling M.D.

Beth Israel Deaconess Medical Center

We've all seen this scene in the movies: Someone's been shot in a war and lies bleeding on the ground. A trusted companion props him up and implores him to "stay with me," to keep talking, to keep fighting, to not give up. This creates a great dramatic effect but, unfortunately, it's unlikely to accomplish much else. And it perpetuates a myth about the power of one's will over medical illness or injury.

Overestimating the Power of Will

When it comes to rebounding from an injury, attitude and willpower do matter to a point. For example, if you injure your arm and have to wear a sling for several weeks, your shoulder may be stiff and sore when you're finally able to take off the sling. If you're not willing to push through at least some discomfort, your shoulder may become even stiffer over time. But if you work hard, persevere and push through some pain and stiffness, you are more likely to regain and preserve motion in your joint.

On the other hand, loss of consciousness follows an inability of the brain to function. Consider these common reasons people pass out:

  • Head injury – This may cause a concussion or bleeding into the brain.
  • Blood loss (including "internal bleeding") – When enough blood is removed from the circulation, blood pressure falls and can no longer maintain brain function.
  • Lung damage – A chest wound can cause bleeding into or collapse of the lungs and a critical fall in blood oxygen levels; when low enough, the brain can no longer do its job.
  • Heart disease – A narrowed heart valve or an abnormal heart rhythm may cause a sudden drop in blood pressure. Fainting or prolonged loss of consciousness may follow.

It's hard to see how the urging of another person can have any effect on these situations.

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What Determines Consciousness?

Along with other vital functions, such as heart rate, blood pressure and breathing, the brain stem controls level of consciousness. This "deep" part of the brain lies at the intersection of the cerebrum (the largest portion that looks a bit like cauliflower) and the spinal cord. As you might expect, its location is very well protected. A major injury, stroke or interruption of the blood supply to the brain stem will cause loss of consciousness and death, often within a matter of seconds.

More reversible causes of loss of consciousness include drug or medication effects (as with anesthesia), low blood pressure, lack of oxygen and low blood sugar. This is why the first actions taken by emergency personnel when treating an unconscious victim are:

  • Lying a person down
  • Measuring vital signs
  • Giving oxygen
  • Providing intravenous fluids and sugar
  • Limiting blood loss
  • Reversing certain sedating medications

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Why the Myth?

My own view is that this myth, like many others, is perpetuated by a combination of wishful thinking and confusing cause with effect. Here's why:

  • We'd like to think we have some control over a terrible situation. A person who is not responding may be unconscious, but repeatedly shouting at him or her is a bit like repeatedly pressing the elevator button — it may seem like the thing to do but in fact it accomplishes nothing.
  • Unresponsiveness is an effect of brain trouble. Interacting with an injured person may confirm consciousness but it won't cause it. It may seem logical to try to "wake up" an injured person who is lapsing into unconsciousness. But injury-induced unresponsiveness is very different from sleeping.

What a Positive Attitude Can Do

Everyone seems to have a story about how maintaining a positive attitude or not giving up helped them (or a loved one) overcome a seemingly insurmountable medical problem. Although these examples may be inspiring, it's hard to know whether things would have turned out any differently with a pessimistic or angry outlook.

While a positive outlook may not directly alter a person's medical condition, it could lead to behaviors that improve the situation. For example, having a positive attitude could make it more likely a person will exercise or take their medications as prescribed.

That's not to say we should discount mind-body connections. Research has demonstrated that response to vaccines and wound healing can be affected by how much stress a person is experiencing. But, there are significant limits to the ability of "will power" to change the course of a serious illness.

If you've ever helped care for a person after a head injury, you may have been told to awaken them throughout the night. That's to confirm that they are sleeping (rather than unconscious). If you don't do this and the person appears to be sleeping, it's possible they have lapsed into unconsciousness without anyone realizing it. Medical care might be delayed with disastrous results.

Still, there is the danger that dramatizations that provide misleading information will lead to unrealistic expectations or, even worse, blaming a bad outcome on the victim who didn't "try hard enough" or didn't "stay positive."

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The Bottom Line

If a soldier's been shot on the battlefield, he or she may or may not pass out. The outcome will depend on the injury and how soon the person gets help, not the urgings of fellow soldiers. Maintaining consciousness is a complex process that we rarely have to think about. It requires little intentional input from us. But when things go wrong, consciousness is rarely something you can influence by verbal encouragement.

If he could, the actor in the war scene would do well to prop himself up and calmly reply "Thanks for the encouragement but it'd be much more helpful if you could stop shouting at me, apply a tourniquet and get me to a hospital."

Robert H. Shmerling, M.D. is associate physician at Beth Israel Deaconess Medical Center and associate professor at Harvard Medical School. He has been a practicing rheumatologist for over 20 years at Beth Israel Deaconess Medical Center. He is an active teacher in the Internal Medicine Residency Program, serving as the Robinson Firm Chief. He is also a teacher in the Rheumatology Fellowship Program.

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