2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

DOCTOR’S DUTY TO PROVIDE
do we know when, how, and if to “nurture hope” in the
oncology clinic?
Definitions of Hope
Dufault and Martocchio define hope as “a multidimensional
dynamic life force characterized by a confident yet
uncertain expectation of achieving a future good, which, to
the hoping person, is realistically possible and personally
significant.” 4 This definition is broad and contains the core
features of hope (“the future” and “subjective good”). However,
by including multiple dimensions and “dynamic life
force” in the definition, researchers tend to apply attributes
such as faith, relationships and dignity to the definition
itself. These ‘life forces’ support hope but are not hope.
Snyder defines hope based on empirical research and a
validated (his own) hope scale. 9 His work has not been
extensively applied to oncology or palliative care. Snyder
firmly holds the view that hope is a cognitive and not an
emotional process. He defines hope as “the perceived capability
to produce workable routes to desired goals and the
requisite motivation to use those routes.” 9 That is, there is a
goal, a plan to get there, and the will to do it. Hope is a
consciously planned process, with emotions as an epiphenomenon.
Meaning, faith, and love are adjuvants or struts to
hope and influence Snyder’s “motivation” and “will to” but
are not themselves integral to the definition of hope. Although
Snyder’s definition is logical and measurable, it is
not easy to apply at the bedside.
Is Hope Good or Evil?
The Greek myth of Pandora involves a woman who had a
jar and was told not to open it. Curiosity got the better of
her, and upon opening the jar, various evils escaped: plague
and disease. She quickly shut the lid, but one thing remained
trapped inside: hope. 10 The ancient Greeks interpreted
hope as evil: “Precisely because of its ability to keep
the unfortunate in continual suspense, the Greeks considered
hope the evil of evils, the truly insidious evil.” 11 That is,
a person trapped in an unwinnable situation who still hopes
to escape, merely tortures himself in the futility of the task.
The parallel to incurable cancer and another round of
chemotherapy given “in the hope” is compelling.
However, later in history, Judeo-Christian and Western
philosophy associated life with an ultimate purpose and
goal. Hope became identified with good things. Menninger
said, “Love, faith, hope—in that order. The Greeks were
wrong. Of course hope is real, and of course it is not evil. It
is the enemy of evil, and an ally of love. Which is goodness.” 5
A Practical Description of Hope
The critical characteristic of hope is that it exists only in
the future. We cannot hope in the past or the present. The
KEY POINTS
● Clinical conflicts create ethical dilemmas.
● Hope exists only in the future.
● Hope may cause more harm than good.
● False hope is a self-contradiction.
● There is benefit in living without hope.
outcome of hoping is subjectively assessed as a probability
but neither a certainty nor an impossibility. It is this
characteristic that is important to bedside decision making.
The second immutable characteristic is that hope is egosyntonic.
That is, whenever we hope, it makes us feel good
and optimistic, not sad, distressed, or anxious. Even if we
hope something bad for ourselves (e.g., death), we note that
its primary motivation is good.
The key feature about the future is that it is unpredictable.
Since hope exists only in the future, it too is unpredictable
and unknowable. This is what Boris meant when he
said that “we create ambiguity in order to preserve hope.” 12
That is, by creating uncertain situations, we also create an
opportunity to hope. Into uncertainty we can hope. This is
the principle of gambling. An uncertainty is deliberately
created and people visit casinos not for the fun but for the
possibility to hope and the good feeling it creates.
Similarly, when we offer chemotherapy and the outcome is
uncertain (as it must be), this ambiguity or uncertainty of a
future outcome allows the patient to hope. A physician may
be deliberately vague about the possible benefit of a new
treatment or about the result of a scan, thus manipulating
hope. The physician does not create hope, nor can the
physician prescribe hope as such. More precisely, the physician
amplifies an ambiguity about the future to which the
patient may or may not respond.
Husebo, however, states that “hope is not just something
which is limited to an expectation of the future or afterlife.
Hope is closely connected to a person’s life story.” 13 Of course
hope is connected to a person’s values and history. Snyder
noted this is what determines the content of the goals of
hope and influences the determination to succeed. However,
hope—the verb and the noun—exists only in the future and
in the imagination. Hope is a figment of the imagination.
How can we understand hope in terms of good and evil?
The Greeks thought hope was evil, whereas Western society
sees hope as good. The appreciation that hope itself is “good”
exists, in part, because the goals of hope are always perceived
as subjectively good. The ancient Greeks were concerned
about this characteristic of “goodness” being
manipulated and abused.
A more accurate description was furbished by Kertesz in
his acceptance speech for the 2002 Nobel Prize for Literature.
He described how after invading Hungary, the Russians
controlled the people by manipulating hope and
similarly the Germans manipulated the inmates of the
concentration camps. Kertesz stated, “I understood that
hope is an instrument of evil.” 14 Hope itself is not evil, since
hope is a path and goal chosen by each individual in the hope
of a good outcome. Neither, however, is hope necessarily
beneficial to the hoper.
False Hope
Strictly speaking, hope can never be false since it is a
subjective thought process whose primary function is to plan
and achieve goals. The future is unknown, therefore, the
subjective evaluation of a possibility can be contracted or
expanded depending on psychologic needs. Thus, a 5%
chance of response to chemotherapy may generate hope for
some but appear futile to others. Similarly, after being told
there is 0% chance of being cured, people who believe in
miracles will still be able to hope. A miracle may be “false” to
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