I contend that hope can be of significant value to individuals even as they acknowledge that there is no cure for their affliction. In particular, I argue that it is good for such patients to hope for (i) a meaningful quality of life in their remaining days and (ii) a good death. If this thesis is on target, then there is an important place for clinicians to employ the language of hope with reference to ends other than a cure. I then conclude with a few schematic comments on how the clinical aims discussed here might figure in a broader understanding of hope as a virtue.
GarrardEWrigleyA. Hope and terminal illness: false hope versus absolute hope. Clin Ethics2009; 4: 39. I think this is a fair characterization of the framework that Jerome Groopman uses to explore the value of hope through most of his essays in The Anatomy of Hope (New York: Random House, 2004). Likewise, Adrienne Martin focuses on the hope for a cure in discussing the possible misuses of such hope in clinical settings. See “Hope and Exploitation,” Hastings Center Report 2008; 38:49–55.
2.
I am, of course, aware that “we are all terminal,” and the fact that we will all die at some point is relevant to the argument I present here. Nevertheless, I think it is legitimate to make clinical distinctions between health conditions that are terminal and those that are not. In this way, hoping for a cure of one’s cold is different than hoping for a cure of one’s pancreatic cancer. The former is not characteristically terminal in the way that that latter may be. This distinction is also relevant to debates about the cure of various disabilities. Thus, whether or not it is good to hope for a cure for paralysis or autism is a separate question from the one that concerns me here, since neither of those conditions is terminal in any recognizable sense of the term.
3.
Garrard and Wrigley, “Hope and Terminal Illness,” 38–39.
4.
CasellaCGrazianoVDi LorenzoP, et al.
Unreasonable obstinacy: ethical, deontological and forensic medical problems. J Public Health Res2018;
7: 106.
5.
For their part, Garrard and Wrigley argue that, in the absence of the hope for a cure, clinicians should focus on nurturing what Gabriel Marcel has labeled absolute hope: a disposition to overcome despair that “involves rising above the fascination of one’s inevitable end and finding some means of retaining personal integrity or sense of self in the face of it” (“Hope and Terminal Illness,” 40). I confess that I find their proposal, and its clinical application, somewhat difficult to make out, perhaps because I think the objections they consider at the end of their paper are more convincing than they do. Nevertheless, there does not seem to be any straightforward inconsistency in our proposals, so that if the notion of absolute hope can be made sufficiently clear, it may constitute an additional hope that clinicians might work to encourage in patients along with the sorts of hopes I discuss below.
6.
I am going to leave aside any consideration of hopes regarding the afterlife. Clearly, such hopes play an important role in the outlook of many patients, and it is my view that, properly construed, they can be virtuous hopes to maintain. That said, in contexts where patients and caregivers may have very different assumptions about the possibility of life after death—and where such assumptions are often based on religious convictions that might not be shared—it seems to me better for encounters between patients and medical professionals to bracket any explicit appeal to the hope for an afterlife.
GawandeA, Being Mortal: Medicine and What Matters in the End (New York: Metropolitan Books, 2014), 155. Gawande’s evidence for this claim comes from Singer PA, Martin DK and Kelner M. Quality end-of-life care: patients’ perspectives. J Am Med Assoc 1999; 281: 163–168 and Steinhauser KE, et al., Factors considered important at the end of life by patients, family, physicians, and other care providers. J Am Med Assoc 2000; 284: 2476. Though Gawande talks very little about hope per se, my debt to Being Mortal for thinking about the importance of hope in the face of death will become clear as the discussion proceeds.
9.
Gawande, Being Mortal, 183.
10.
See, for example, Coyne JC, Stefanek M and Palmer SC. Psychotherapy and survival in cancer: the conflict between hope and evidence. Psychol Bull2007; 133: 367–394.
11.
QALYfying the value of life. J Med Ethics1987; 13: 117.
12.
Ibid.
13.
Ibid.
14.
Ibid.
15.
Ibid.
16.
Gawande, Being Mortal, 171–172. Gawande follows the sentence quoted by saying, “Hope is not a plan, but it is our plan.” It is clear, I think, that the hope to which he refers is the hope for a cure. Thus, I don’t think his claim is at all in tension what the sorts of points I have been making.
17.
FaustDG.The Republic of Suffering: Death and the American Civil War. New York: Vintage, 2008, 6.
18.
McPhersonJ.The War that Forged A Nation: Why the Civil War Still Mattes. Oxford: Oxford University Press, 2015, p.57.
19.
McPherson, The War that Forged a Nation, 57.
20.
Faust, The Republic of Suffering, 8.
21.
As support for this claim, Gawande points out that as “recently as 1945, most deaths occurred in the home. But by the 1980s, just 17 percent did” (Being Mortal, 6). The source for this statistic is Flory J, et al. Place of death: U.S. trends since 1980. Health Affairs 2004;
23: 194–200.
22.
Gawande, Being Mortal, 252.
23.
“Endings matter, not just for the person [who dies] but, perhaps even more, for the ones left behind” (Gawande, Being Mortal, 252).
24.
As Campbell and Cox note, “The terminology used to describe what occurs when a physician prescribes a lethal dose of medication for a terminally ill patient who subsequently self-administers the medication to hasten death has been a perennially divisive issue.” Hospice and physician-assisted death: collaboration, compliance, and complicity. Hastings Center Rep2010; 40: 28. For this reason, I have adopted the ostensibly neutral phrase “physician-assisted dying” as opposed to the more controversial “physician-assisted suicide.”
25.
Adam Kadlac, “The Virtue of Hope,” Ethical Theory and Moral Practice 2015; 18: 337–354.
