Managing expectations is the new alchemy. All manipulators of opinion, from the US president down to the humblest peddler, now seek to minimize what people expect from them, hoping to maximize the effect of a better-than-expected performance.

Even pharmaceutical marketers know the drill: don’t promise too much for any serious-disease treatment, especially if it seems miraculous. Downplay the benefits, then let others sing its praises when the results prove surprising. The tactic often works well for products new to the market or still in research, as long as the outcome exceeds the original expectations—if only by a little.

But it is a dangerous game, requiring just the right balance of hope and hardness, without which the whole approach can backfire. At best, the tactic dampens disappointment without killing anticipation. At worst, it fosters a deadly despondence.

Creating realistic expectations for a future treatment may stand beyond reproach—if the intent is to avoid misleading the treaters and the treated. But reality means different things to different people. Realism for a marketer may look like doomsaying to a desperate patient. Rational business decisions can appear as tone-deaf madness to advocates pushing for a cure against all odds. One of those odds is the widespread notion that people should learn to live with conditions like spinal cord injury or AIDS rather than dream about a cure.

Yet, when miracles truly come, who will first proclaim them? Only those who believed in them all along. Yes, many medicines bring marginal improvements to peoples’ lives. But people in great need cannot live on margins. They must believe that miracles—pharmaceutical miracles—can and do happen. Because miracles are what they must have.

Expectations like those cannot be managed, nor should they be. Patients have a right

to dream. And they have a right to help make their dreams become reality.

Never underestimate the sophistication of the active patient base. They may be the ultimate realists. Those who imagine the most wonderful breakthroughs can also see the most daunting obstacles. Like the great bluesmen, they suffer each day by walking toward a brighter one.

Rather than playing the "lowered expectations" tune, pharma marketers would more wisely tune into patients’ deeper lament. They want honesty, but just as much, they yearn for better news. They hope for, and even expect, a total commitment from industry to a heroic search for the miraculous.

In truth, the divide between marketers and patients is only artificial, and therefore

tenuous. Marketers can become patients—the "expectation managers" can find their own hopes being managed—at any time.

When that happens, they should greet the event as a golden opportunity. Only then will they know firsthand the hard facts and the highest dreams of their fellow travelers in need. And they may learn to claim their own right to dream for an answer.