2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

The Oncologist’s Duty to Provide Hope:
Fact or Fiction?
Overview: There are many sources of conflict in oncology.
Conflicts arise because there are numerous therapeutic options,
each of which is imperfect, and these conflicts produce
ethical dilemmas. A recent American Medical Association
(AMA) publication outlined the principles of medical ethics for
managing conflicts. Common conflicts in oncology include
whether to resuscitate, to give more chemotherapy, and how
much truth to tell. These conflicts are magnified because of
the life and death scenario of advanced cancer. Denial,
avoidance, and hope are psychologic mechanisms that enable
adaptation to the life-threatening circumstances. Hope is
widely written about though poorly understood and defined.
Ethical statements regarding its virtue and importance to
preserve are frequently given. In an effort to progress the
THE ONCOLOGIST in clinical practice is conflicted in
several domains, including truth telling, resuscitation,
when to stop palliative chemotherapy, and changing goals of
care. The conflicts are magnified because cancer is a lifethreatening
illness.
Conflicts underpin ethical dilemmas. The conflicts today
are in part because of the success of modern medical oncology,
which has provided many therapeutic options. There
are different models of how to solve ethical dilemmas. The
AMA recently published the American College of Physicians
(ACP) Ethics Manual, which listed four principles of medical
ethics: beneficence, nonmaleficence, respect for patient autonomy,
and justice. 1 These principles assist in ethically
resolving clinical conflicts.
The ACP Ethics Manual also defines professionalism. It
declares that professionalism is “a code of ethics and a duty
of service that put patient care above self-interest.” 1 This
duty and attendant humility is another principle that encourages
ethical behavior. 2 It was disappointing not to see
noted in the AMA document the importance of selfawareness
(or self-knowledge) as a tool for physicians to
reflect on their motives in decision making and as a further
safeguard to ethical practice.
Are We Treating Patients with Cancer
Too Aggressively?
A recent Annals of Oncology editorial asked, “Why are we
not ceasing chemotherapy when it is useless, toxic, logistically
complex, and expensive?” This was based on statistics
that show up to 25% of patients with solid tumors receive
chemotherapy in the last month of life. 3 Unfortunately,
these statistics tell only part of the story. They cannot
include those patients who did respond to chemotherapy and
whose lives were prolonged and therefore did not die within
four weeks of initiating therapy. Furthermore, since we
cannot know with certainty how each individual will respond,
it is likely that we will have to treat a certain
percent—in retrospect, in futility—so others will benefit.
This holds true for many therapeutic scenarios in medicine.
Nevertheless, there are instances when we recognize in
advance that chemotherapy (and parenteral nutrition, radiation
therapy, and antibiotics) should not be given. It can be
harrowingly difficult to balance respect for autonomy and
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By Simon Wein, MD
understanding of hope, two critical features are defined:
(1) hope as a thought process only exists in the future, and
(2) hope is only ever associated with positive and good
thoughts. The future is unknown and uncertain; therefore,
hoping can be manipulated by presenting statistics in a way
to boost hoping. Thus a dilemma and specific ethical responsibility
falls on oncologists when discussing conflicts. Furthermore,
since hope is a subjective assessment of a
possibility that is considered “good” by the hoper, it cannot
be perceived as “false.” “False hope” is an erroneous assessment.
Finally, this article introduces the concept that there
might be a role to stop hoping—since hope of the future is also
filled with doubt and fear—and instead live in the present and
try to find joy and meaning today.
desire for beneficence against nonmaleficence. There is a
gray zone between ethical intent and clinical outcome.
Various factors influence the decision making of the oncologist
and include fear of death, medico-legal, pity, philosophy,
fear of failure, and burn-out. Sometimes the oncologist is
aware of these influences and at other times not. The
psychologic mechanisms that influence these factors include,
among others, denial, avoidance, and hope. This
article will focus on hope.
What Is Hope?
There is no agreed-on definition of what constitutes hope.
There is not even agreement on whether hope is an emotion
or a cognition. Some authors describe generalized and particularized
hope, while others see hope built around faith,
love, meaning, dignity, peace, and spirituality, even using
the words interchangeably. 4,5 More specifically, some of
these definitions mistake the mechanism (or process) of hope
for its content or goal. 6
Hope is a factor in many of the conflicts in decision
making, particularly at the end of life: parenteral nutrition,
chemotherapy, resuscitation, and truth telling (e.g., the
hope that further treatment will prolong or “save” a life, or
the concern that “telling the truth” will destroy a patient’s
hope and shorten life).
Daneault noted that there is “a growing awareness that
nurturing hope is one of the most important tasks in the
oncology clinic.” 7 Helft went further saying, “all patients
with cancer have a vital and inalienable right to maintain
hope.” 8 In the absence of a clear definition or even a
consensus on a description of hope, and with no research
measuring hope in oncologic care, such “important tasks”
and “inalienable . . . rights” are not evidence based. So how
From the Pain and Palliative Care Service, Davidoff Cancer Center, Rabin Medical
Center, Petach Tikvah, Israel.
Author’s disclosures of potential conflicts of interest are found at the end of this article.
Address reprint requests Simon Wein, MD, Pain and Palliative Care Service, Room 36,
Davidoff Cancer Center, Rabin Medical Center, 39 Jabotinsky St., Petach Tikvah, Israel,
49100; email: simonwe@clalit.org.il.
© 2012 by American Society of Clinical Oncology.
1092-9118/10/1-10