In his article The Perils of Hope, Lawrence Schneiderman evaluates the ethical complexity of hope in healthcare. Schneiderman demonstrates that the common role of hope in patient-physician interactions is often psychologically, medically, and morally damaging. These concerns and criticisms illuminate his definition of beneficial hope and highlight necessary changes in medical culture. Through an examination of Schneiderman’s evidence and claims, one may outline the specific needs for patient hope and argue for a shift toward a more ethical, healthy, and valuable approach to hope in healthcare.
The Perils of Hope provides evidence and reasoning to prove that the conventional role of hope in patient-physician relations is dispiriting, harmful, and unethical. The widespread function of hope in healthcare is perilous when hopes are unrealistic. Schneiderman explicitly draws this connection as he describes failing forms of hope as “unrealistic, and therefore unhelpful” (237). The author cites convincing evidence, which refutes the belief that hopefulness benefits medical prognoses. Schneiderman links this misconception to religious tradition, enabling him to directly contrast unrealistic hope with truth and science. He writes, “Indeed, one has to wonder whether the central role of miracles in Christian mythology may not underlie the contemporary expectation, or at least hope, for medical miracles” (237). The role of expectation is especially important in this equation. Because of hope’s strong cultural association with prolonging life, patients who cling to fanciful hopes as a survival effort are bound to despair from the collapse of their unreasonable expectations. By inflating the probability of medical success and deflating risks, patients who are unrealistically hopeful are likely to feel dejected and helpless when faced with reality.
When defining the dangers of hope, many thinkers echo Aristotle’s rule of the ‘golden mean’ between two detrimental extremes. Total despair and wishful thinking are the extremes that must be avoided. In Schneiderman’s view, situating hope within the context of life or death is in and of itself the extreme. Unrealistic hope is an irrational denial of science. He conveys that this fallacious hope ultimately demoralizes the patient and leads to despair. In addition to the psychological turmoil produced by erroneous hopes, physical harm is another potential danger. As Schneiderman describes, hopefulness may cause patients to ignore and deny symptoms or even insist on aggressive, hazardous medical procedures, despite a physician’s recommendation. When hope prevents patients from receiving the best care or arouses unnecessary suffering, the effects of hope counteract the patient’s goals for improved health and prolonged life.
Schneiderman discusses the ethical problems of the role of hope in common patient-physician interactions, but his argument falls short in fully articulating the greater consequences of specific moral issues. The article considers the “dubious sources” from which many people obtain hope—television and the Internet (236). As Schneiderman describes, the media often portrays an inaccurate probability of medical miracles and dramatic operations that overlook all realistic risk. Influenced by this false perception of medical success, patients’ hopes are likely to be unrealistic and therefore perilous. This observation is too briefly mentioned in The Perils of Hope. Schneiderman identifies the patients’ lack of knowledge, but he does not explain how this misinformation importantly contributes to medical unethicality. A core principle in medical ethics is the standard of informed consent. Informed consent is only valid when a patient is fully competent to make medical decisions based on all essential information. What Schneiderman describes as a “lack of knowledge” based on false perceptions from the media is really an impaired ability to give informed consent. Many people are falsely educated about medical reality through TV shows and the Internet, resulting in unrealistic hopes and establishing an obstacle for legitimate informed consent. Without addressing this difficulty, essential medical ethics are at stake.
Another significant dilemma rooted in this unrealistic hope is the possibility for untruth in a physician’s communication with a patient. Schneiderman warns of the compromise that physicians often undergo when addressing a patient. He writes, “The belief in the medical value of hope may impose on the physician contradictory obligations: to maintain hope while at the same time to be honest” (235). When the pressure to be unrealistically hopeful overrides the moral standard for truth, physicians may “intentionally mislead their patients, usually by being unduly optimistic” (236). It is certainly unacceptable for a physician to lie to a patient. Encouraging unrealistic hopes is not exactly lying, but it is still an untruth in that it generates misinformation. A physician’s excessive optimism may belittle real risks and probabilities just as effectively as popular TV shows. Schneiderman presents this evidence, but his argument can be extended further to declare that a physician’s compromise of honesty in order to foster unrealistic hope is unethical.
With an understanding of the psychological, medical, and moral damage that often develops from the conventional role of hope in healthcare, the goals of patient hope (and the methods to achieve them) may be explored. What should hope accomplish in healthcare? Schneiderman suggests that hope can be a patient’s “defense against despair,” a property “enabling patients to cope with ‘profound life challenges’” (235-236). In order to successfully safeguard against despair, a patient’s hope must be founded in the acceptance of reality and reasonable expectations. Not only will this realistic hope offer inner strength during difficult times, but it will also enable the patient and physician to make the safest and best medical choices. Integral to this beneficial hope, which Schneiderman asserts is based on a ‘polyphonic narrative,’ is an acceptance of the reality of death and the unforeseeable future. The article reads, “Rather than focusing on preexisting milestones, these patients are open to ‘uncertainty about the future’…” (237). For Schneiderman, beneficial hope requires this uncertainty. With too much certainty, hope is unrealistic—it contradicts science, leading to despair and harm. This discussion of hope and uncertainty echoes the thoughts of Jonathon Lear in Radical Hope. Lear demonstrates the power of hope in the face of an unknown future. He writes that a hoper must “imagine a radical new future without becoming too detailed about what this future will be” (76). Openness to uncertainty grounds hope in unpredictable reality, avoiding the common pitfalls of patient hope that Schneiderman considers.
Introducing the idea of “hope-as-meaning,” Schneiderman offers an alternative to the widespread practice of situating hope within a context of life or death (237). Instead of viewing hope as a means for survival, hope may be a method to seek and achieve meaning in one’s current situation. The author contrasts this beneficial conception of hope with the linear restitution and linear chaotic narratives of hope, which cling to unrealistic expectations and normal goals despite an illness. Schneiderman neglects to discuss the underlying reason why many patients grasp these unrealistic forms of hope—a need for stability when faced with total uncertainty.
Confronted by illness and an unknown future, many patients seek comfort by relying on familiar expectations despite a transformed reality. This type of hope is understandable, but Schneiderman demonstrates that it is unrealistic and perilous. When one feels helpless, the most comforting solution is to obtain a sense of personal agency. Agency may offer a patient the comfort of continuity and stability that is needed to cope with the reality of illness and uncertainty. In her piece The Art of Good Hope, Victoria McGeer asserts that hope is the key to agency. She writes, “Hope involves a complex dynamic … because it is, more deeply, a unifying and grounding force of human agency” (101). With the “desire to find and fulfill a meaning in life,” human agency is inherent in the hope-as-meaning approach presented by Schneiderman (237). Beneficial hope in healthcare fosters a sense of agency, which breeds an acceptance of reality, an adoption of realistic expectations, and openness to the unforeseeable future.
Physicians are professionally and ethically responsible for helping to facilitate this beneficial hope. The Perils of Hope teaches that psychological, medical, and moral damage result from the conventional role of hope in healthcare. Change is needed. Schneiderman proposes that modern physicians must “discard the conventional, narrow view of hope as a means to prolong life. That version of hope is perilous. Rather, hope should provide a wider illumination” (238). He argues that physicians should reveal the goodness of life and promise, when inevitable, an easy and comfortable death. By removing hope from the context of survival, patients can employ hope as a means of coping with reality in a psychologically and medically responsible way.
Schneiderman’s argument concludes with this righteous call for change, but his evidence and claims need not stop there. Physicians should create an environment of empowerment and assure patients of their agency by encouraging the search for and fulfillment of life’s meaning and goodness. This hope-as-meaning must be saturated in an informed, realistic understanding. Physicians must consider the vulnerability of patients toward unrealistic hope, due to the media’s fallacious presentation of medical probabilities and risk. In order to obtain informed consent, physicians need to avoid bias and dishonesty, which are inherent in an excessively hopeful presentation of medical information. Schneiderman writes that a patient’s “lack of knowledge and denial” may be “reinforced unwittingly by the physician” (236). Physicians’ unawareness of the complexities of hope in medical decisions and ethics demands a larger cultural shift. Discussion about the dangers and benefits of hope in healthcare should be integral to the education and training of medical professionals. Scientific literature must emphasize realistic probabilities and risks to offset the media’s widespread falsities about medical successes. Physicians should integrate the assurance of continued agency into their honest, realistic presentation of medical information to patients. With these institutionalized changes, healthcare workers will more effectively repress perilous hope and cultivate their patients’ meaningful, realistic, and informed agency. A physician’s awareness, self-consciousness, and outward empowerment will surely usher in a more healthy, moral, and beneficial hope in healthcare.
By Lucille Marshall
Written for The Problem of Hope in a Secular Age with Professor Alan Mittleman at the Jewish Theological Seminary of America.
Lear, Jonathan. Radical Hope: Ethics in the Face of Cultural Devastation. Cambridge, MA: Harvard UP, 2006. Print.
Mcgeer, Victoria. “The Art of Good Hope.” The Annals of the American Academy of Political and Social Science 592.1 (2004): 100-27.
Schneiderman, Lawrence J. “The Perils of Hope.” Cambridge Quarterly of Healthcare Ethics 14.02 (2005): 235-39.