Hoping With Your Whole Body : HEAD FIRST: The Biology of Hope <i> by Norman Cousins (E. P. Dutton: $18.95; 304 pp.; 0-525-24805-6) </i>

About 10 years ago, after a distinguished career as a magazine editor and leader of liberal causes, Norman Cousins began a new career--also, I think, distinguished and courageous to boot--as a medical kibitzer. Unlike some critics of medicine, he has immersed himself in it, and in illness--dues rarely paid by such pundits. He has been teaching and seeing patients at the UCLA Medical Center as well as lecturing and consulting on medical topics throughout the world. It seems to me that he is practicing medicine without a license, but that is not necessarily bad, since he more or less knows his limitations, and dispenses advice under the supervision of real doctors.

This is his third book about illness and medicine, and it continues his eloquent plea for two needed emphases: more humane doctor-patient relations, and greater patient involvement in the struggle with disease. Unfortunately, it also repeats his exaggerated faith in the power of hope to overcome illness. Because so many of us profoundly need to believe in it, this weakest aspect of his work receives the lion’s share of attention. A current ad for the book, under the heading “Inspirational Reading,” offers “Proof That Hope Can Make You Healthy.” The book itself ends: “Belief becomes biology. The head comes first.”

These words have two meanings. One, indisputable and accepted by all doctors, is that to survive illness you must decide to live. You must eat and drink--often in a particular way--avoid certain substances, dress your wounds, take your pills and other treatments, even, sometimes, go to the doctor. People die from lack of hope every day--through failure to take these pragmatic expedients.

The other meaning--that hope exerts a direct influence on the body’s chemical milieu and thus has a privileged power to stave off illness--is hotly disputed. That is not because it is guaranteed to be wrong, but because there is not yet enough evidence--actually, not nearly enough--to constrain us to believe in it. And in medicine, we tend not to believe things for which the evidence is insufficient, especially when they are notions that sorely tempt our belief. If this approach seems to you cranky and obstinate, try thinking of it as the main reason why you feel more confident than your great-great-grandmother did of the doctor’s ability to improve your chances.

Cousins’ first book, “Anatomy of an Illness,” recounted the touchstone experience for his contribution to medicine. As he told it, he was suffering from a particularly rare collagen disease that was worsening relentlessly and threatening his life. With his doctor’s reluctant collusion, he discharged himself from the hospital and, at a nearby hotel, treated himself with funny movies, vitamin C and large doses of hope. He also stopped taking his medicine. Full recovery ensued, and he went on to tell his story to the medical community and the world. Both were responsive, and he entered a long-term relationship with one of our great medical centers, a position from which he influences a great many doctors, medical students, and patients.

Now, as Cousins must know, the illness he was supposed to have was and is very difficult to diagnose definitively. It is easily confused, by the best doctors, with other less degenerative conditions, and indeed some specialists would rule out this particular diagnosis just because he recovered. A cynic would say that Cousins merely proved the old medical adage that most patients have ailments that the doctor never identifies and that are resolved with or without treatment. He also knows that if the average patient with a really serious illness were to check out of the hospital, stop taking prescribed medicine and follow a regimen of vitamins and Marx Brothers, the overall result would be a marked increase in pain and death.

Despite his own experience, in this book he explicitly rejects the substitution of hope, humor, defiance and other emotions for medical and surgical treatments, and he states: “Yes, I know that my optimism can be carried too far. . . .” I hope that these warnings are heard loudly and clearly. Everyone in medicine has seen some patients jeopardize their lives by substituting unorthodox treatments for proven ones. Cousins doesn’t dwell on their stories, but they are at least as numerous and tragic as those of the mainstream medical blunders he presents in abundance.

In a more subtle vein, the complex and varied suffering of people with serious illnesses is not always and everywhere mitigated by emphasizing the possible role of mental states in illness. I once wrote an article in a national publication warning against the overemphasis of such factors, and many of the letters I got were from patients or family members who had been made to feel that they mentally caused or failed to resist their own or their loved ones’ illnesses. Reading my article helped relieve them of a burden of guilt.

The evidence, in fact, is complex and puzzling. One of the most solid sections of the book is Cousins’ report to the dean of the medical school summarizing his 10 years of experience there. Another is a joint statement signed by him and a physician-scientist who had criticized him. In these places, Cousins is more circumspect than in the rest of his text, noting that the evidence, in both human and animal studies, remains suggestive, and is often inconsistent, contradictory and bewildering.

Some studies show that stress, for example, enhances the body’s immune defenses, others that it depresses them. Several studies suggest that what might be considered a bad mental state--intense and angry struggle--improves survival in breast cancer, which seems quite different from Cousins’ emphasis on hope and laughter.

A new and very good study, published after Cousins’ book had gone to press, has shown a positive effect of psychotherapy on survival in advanced breast cancer--fascinating but paradoxical, given the previous results. The frontier of knowledge is moving, but it is not clear where, and there is no specific recommendation to be drawn from the evidence presently available.

Cousins is aware of these inconsistencies, but he allows his main line of argument to gloss over them. In this, he succumbs to a temptation that physicians often are faced with: to avoid at all cost taking away the patient’s hope. Yet, increasingly--partly because of the good offices of the legal, not the medical, profession--we believe in truth-telling. Physicians in Japan still lie to patients about cancer, but we consider that unscionable in most circumstances. Yet we try to avoid clobbering patients with depressing information that may not help them. Even as I write, I worry that I may be spreading despondency in the service of scientific precision. This is not a new conflict, nor is it one that physicians should be asked to resolve by themselves.

Meanwhile, Cousins’ other message--that poor doctor-patient communication and insensitivity to the psychosocial dimensions of illness have become endemic in modern medicine--is very apt. Even if there is not a shred of truth (an unlikely conclusion anyway) in the notion that mind directly affects immune function, there is no doubt that lives are lost and suffering increased through this little-studied category of medical error. Inhumane treatment can be useless, or even worse than no treatment at all. When doctors get sick these days, they frequently come to the same conclusion that other patients come to: Modern physicians need to become much better at the human dimensions of care.

The title--”Head First”--is therefore a half-truth; a better one might have been “Head Too.” Cousins has learned much from his decade of medical immersion. He influences many people, so I hope that he will become ever more careful in generalizing, and more appropriately patient as we await new research findings.

He has a lot to contribute, but there is nothing like clinical experience to make you realize how complex and difficult the battle against illness is--and how capriciously it defies our pieties, including these new ones about hope.