Hope in Medicine: Lucas Martuano and Mariana Kobata - Hope at the Bedside: Care Beyond Cure
What does hope look like when cure is no longer possible? In Hope at the Bedside: Care Beyond Cure, Brazilian medical students Lucas and Mariana explore hope as a virtue between despair and wishful thinking. Drawing on philosophy and the patient–physician relationship, they consider how honest communication, compassionate presence, and attention to dignity can sustain meaningful care, even at the end of life.
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Hi, and welcome to the Hippocratic Society Podcast. In this series of episodes, we break
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from our usual content to share presentations from the second annual Hippocratic Society
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Conference, during which physicians, trainees, and students from across our chapters came
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together to reflect on what it means to live out the virtue of hope in medicine. We hope
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you enjoy.
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do is go ahead and introduce. Yeah, let me go ahead. I'll go ahead and introduce our speakers. You guys are waiting on the slides. Yeah, yeah, yeah. Okay. All right. So we have two fourth year medical students that are presenting today. The first is Lucas Martuano, did I say that correctly? And Mariana Kobata Kyle. so I'll start first with Lucas. Lucas is
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In his final year of medical school at the Facultad de Ciencias Medicas de Santa Casa de Sao Paulo, Brazil, he conducts undergraduate research on spirituality and quality of life in patients with non-Hodgkin lymphoma, undergoing chemotherapy. He is the founder of the Center for Studies in Health Ethics and co-founder of the Academic Symposium on Mental Health at his medical school. His academic interests include psychiatry, medical ethics, philosophy of medicine, and mental health.
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Mariana is also in her final year at the same university in Brazil. She conducts research on quality of life in oncology patients as well as on artificial intelligence and education. She has also published research on autism spectrum disorder. She is the founder of the Center for Studies in Health Ethics and co-founder of the Academic Symposium on Mental Health at the same medical school. Her academic interests include neurology, neuromodulation, and health ethics.
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So, good afternoon, ladies and gentlemen. So, my name is Mariana Kobata. Those are my partners Isabella Salinas and Lucas Martuano. We are medical students from São Paulo in Brazil, and also the founders of NIS, our Health Ethics Study Group, a student-led initiative dedicated to discussing health ethics, humanities, and philosophy. Today we're going to share our reflections on hope.
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with our presentation, Hope at the Bedside Care Beyond Cure. So we would like to start with a story. Imagine for a moment that all the suffering in the world had once been absent. No illness, no grief, no fear, no loneliness, and no death. In the ancient Greek imagination, there was once such a time. Then Prometheus stole fire from the gods and gave it to humankind.
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Following that, Zeus answered, not only with punishment, but also with a gift. He ordered Hephaestus to fashion a woman from clay and water, and Atina clothed her, Aphrodite gave her beauty, Hermes gave her speech, persuasion, and cunning. The graces adorned her. Each of the gods placed within her some power, some quality, and some seduction. She was named Pandora. From the Greek Pandora.
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Pan all and daran gift. But his oath myth is unsettling because Pandora is both things at once gift and affliction, beauty and danger, blessing and trap. She is, in a sense, profoundly human, made of many things at once. Zooms himself calls her a beautiful evil, something humanity would not merely suffer, but embrace, something people would surround with love, even and
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when it wounded them. The gods placed in her hands a g a great clay jar. In Greek, it is a pitos. It's a large vessel used to store grain, wine, oil, even the remains of the dead. Pandora carried the jar into the road, and here, among us, she opened it. Everything escaped diseases, suffering, violence, exhaustion. All the plagues of human life escaped into the road, and
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Only one thing remained inside the jar. Hole.
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And this is where the myth becomes truly difficult, because Hizio never tells us clearly what it means that hope remained behind. Was hope preserved for humanity the last consolation left untouched the aim is suffering? Was if it withheld from us the one good thing that never reached the human world? Or does hope belong to the afflictions themselves, the final illusion that keeps human beings enduring, waiting, persisting, even when reality offers no resolution?
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The myth refuses to decide. And perhaps we have never fully resolved the question either, because in medicine, hope can heal, it can sustain meaning, it can make suffering bearable. But some people also think hope can deceive, postpone truth, or bind patients, families, and physicians to expectations reality cannot fulfill. So, before we ask whether hope is necessary in medicine, perhaps we should start with a more difficult question.
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What exactly is hope? So let's begin with some important definitions. The Merren Webster dictionary defines hope as a desire accompanied by expectation of obtaining what is desired or belief that it is obtainable. The Stanford Encyclopedia of Philosophy defines it as a compound attitude, gathering both cognitive and cognitive components.
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The cognitive side pertains to a certain logical operation on probability, one linked with the constant factual actualization of the perceived reality. We can conceive this side as what is often referred to as pure expectation, opered by intellect. On the other hand, the cognitive component draws upon our desires, irrespective of logic or probability. It entails an effective engagement with the object and is an act of will.
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This is the distinguishing feature of hope. But is it truly good? In the ancient Greece, hope was considered mostly evil. Aeschylus called it the food of exiles, and Euripides called it manskurs, viewing hope as an illusion, since for them fate was unchangeable. Across the centuries, many many other authors have also defended hope's dark side.
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So Colley said, Hope, fortunes, stealing, and lottery were for one price, a hundred blanks there be. Shelley said, worse than despair, worse than bitterness of death is hope. And as you already know, Nietzsche famously said, Hope is the worst of evils, for it prolongs the torment of men. But today we are here to show you our opposing view.
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Let's start with first and everly's definition of hope, which entails four attributes that constitute hope as a virtue. Those are a sound apprehension of the good, a clear appreciation of the barriers to that good, and a forward looking orientation in the face of uncertainty and an ability to spur direct effort and action to bring the good about.
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This is central to our notion of hope as something good and virtuous, as we intend to demonstrate. On this account, if we adopt the Aristotelian, more classic understanding of virtue as just the mean between two vices or extremes which orient humans towards good, we can conceive hope as an equilibrium between despair and delusion, the summit between two valleys. As we know, however, human beings are imperfect.
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And therefore rarely remain the at the peak of the virtue. We move along a continuum, sometimes approaching despair, sometimes illusion. Virtues cons consists not in never deviating, but in being rightly oriented and continually striving to return toward the center. We might also add that hope as a virtue has an intrinsic value, because the act of hoping can be meaningful in itself, as we're going to develop in this presentation.
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And if it is truly a virtue, it is far fair to wonder where does hope come from. Is hope merely a personality trait? Are some people simply born hopeful while others are born hopeless? There is good reason to think that hope has an innate component. Aristotle and Thomas Aquinas both describe human beings and as creatures whose existence unfolds through time.
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We are constantly oriented toward future goods, future possibilities, future threat threats. In that sense, hope is not an accidental feature of human life. It is rooted in our very condition as temporal beings, ones that exist necessarily in relation to fruity. Saint Thomas goes even further. Before hope becomes a virtue, it exists as a passion.
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A natural movement toward a future, difficult but attainable good. The capacity of hope is therefore part of our human constitution. Yet we observe that people differ. Some naturally gravitate toward confidence and possibility, others toward anxiety, pessimism, or despair. Temperament clearly influences how readily hope emerges. Maggie's model of hope is not a definitive
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psychological classification, but a useful illustration of how individuals may differ in their coping styles from unrealistic, hopeless to undisviable, hopeful, reflecting varying capacity to manage uncertainty, adversity, and hope. So our first conclusion is that hope appears to possess an innate foundation. We are born with the capacity for hope, but not
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All of us are equally disposed to exercise it.
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But temperament alone cannot explain hope. If hope were merely an inherited psychological trait, it could not be a virtue. Virtues are cultivated. This is whether character, experience, and relationship become essential. Several authors have noted that hope develops and flourishes through encounters with others.
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Trust, caregiving, education, and previous experiences of overcoming adversity all influence our capacity to hope. We may therefore distinguish two origins for the different dimensions of hope we previously covered. The cognitive dimension, the degree of effective engagement, appears closer to temperament, to our natural disposition. But the cognitive dimension, the the way we interpret possibilities, obstacles, and uncertainty.
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Seems deeply shaped by experience and learning. This distinction helps explain why hope can mature. A person may begin life with a hopeful temperament, yet become despairing through repeated frustration. Conversely, someone naturally inclined toward pessimists may learn through relationships and experience to sustain hope in adversity. In this sense, hope is neither purely innate nor purely acquired.
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It begins as a natural human capacity, but becomes a virtue on when cultivated into a stable way of perceiving and pursuing the good. Well, thank you for the attention this first part, and now Lucas is going to take it from here and talk about hope specifically in the context of medicine as we defend it assumes two major roles, foundational and paradoxical. Thank you. We argue that hope plays this two central roles.
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and by that we mean hope is first foundational, meaning every medical encounter in some sense depends upon it. And by paradoxical, we mean that the need for hope often becomes the greatest when the chances of a favorable outcome are at their lowest. So to begin with the first one, one of the most useful ways for us to understand the medical encounter is not merely as a technical exchange.
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But as a relational and effective dynamic established between two persons. That means to say the patient does not arrive as a neutral biological organism, and nor does the physician encounter the patient as a detached machine of diagnosis. Each one brings expectations, fears, desires, fantasies, memories, and implicit emotional attitudes into the consultation. In psychodynamic language, this can be understood.
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Through the concepts of transference and counter transference. Transference being the way the patients unconsciously project meanings, expectations, and emotional and relational patterns onto the doctor, and counter-transference the way that the physician's own emotional and relational responses are directed toward the patient. It is a mutually influencing human relationship.
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This relational structure there lies a wager, the fundamental condition of hope. That is to say, this entire structure exists solely because there is hope in the first place. The clinical encounter emerges because both patient and physician act in hope that some meaningful good may still be possible.
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cure or some form of meaningful help may still be attainable. Likewise, the physician acts because he or she believes that his or her knowledge, judgment, technical skill, or even presence may still be may still contribute to that good. Even the very idea of patient presupposes the capacity to endure uncertainty in view of a hoped for good. In other words, patience presupposes hope. You have to be you have to hope
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In order to endure being patient. But if hope founds the medical encounter, under what conditions does hope emerge at all? We talked about the definition of hope, what it is and what it is not, but let us now examine a few situations that help clarify how hope arises and how desire participates in it, in a model loosely inspired by Saint Thomas Aquinas and Jacques Lacan. If I am ill,
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or even if I merely perceive the possibility of an illness as in preventive medicine, I experience the absence of a good, namely health. This good then becomes the object of my desire. By projecting the recovery or preservation of this good into the future and by regarding it as still possible, I begin to hope for it. And precisely because of this hope I seek a physician. From this movement the doctor patient relationship is founded.
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The other alternatives, interestingly enough, seem to prevent the emergence of medicine altogether. If I already possess the good, there is joy or satisfaction and no reason to seek medical care. If I lack the good and therefore desire it but judge its recovery impossible, the result is despair and again no movement toward care. And if I lack the good but falsely believe I already possess it or see something impossible as possible, I remain under illusion.
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And either refrain from searching the physician or falsely believe in something extremely improbable, giving rise to therapeutic futility and hubris. Hope, therefore, occupies a very narrow and specific existential space, the space in which a good is absent, difficult, uncertain, and yet still perceived as possible. And this is precisely what gives rise to action. Hope moves the patient toward care.
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And from this movement, the clinical encounter itself becomes possible. Desire itself presupposes the absence of a good not yet possessed, and hope presupposes desire because one cannot hope for what one does not desire. But desire alone is not enough. Hope is what allows desire to persist through uncertainty and orient itself toward action. And strangely, hope becomes most necessary.
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precisely when outcomes are least likely. That is what we mean when we say hope is also paradoxical in medicine. The need for it increases precisely when the likelihood of a favorable outcome diminishes. And we propose the following explanation for this phenomenon. A worsening prognosis reduces the range of attainable future goods. So the subject S has an initial distribution of volition or desire
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Dispersed across many different objects, all currently absent but seen as possible. This vector or orientation relies in the fundamental belief of possibility or in a promised future. For any of us in this room, this may involve a multitude of tacitly assumed futures. Watching our children grow up, building a career, traveling to places we dream about, completing meaningful projects, helping others. In other words,
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Continuing to write our own story. Most of these possibilities are rarely held explicitly before us. They are simply woven into our ordinary expectation that life will continue. As harsh reality imposes itself though, possibilities narrow. At first glance, this reality update should undermine hope by weakening expectation and possibility leading to despair. Yet clinically, we often observe the opposite.
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Because desire stems from lack, the narrowing of possibilities makes the remaining goods rarer, and the rarer they become, the more evident the lack becomes. And the more evident the lack becomes, the more intensely desire concentrates around the few possibilities that remain. Hope reorganizes itself around the fewer but existentially denser remaining meaningful goods, and thus the clinging tightens.
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The paradox lies in this motion. The cognitive or expectant dimension of hope weakens, but the cognitive or desiring dimension overcompensates. And thus hope does not disappear when uncertainty increases. It becomes more necessary or intense precisely because the future becomes fragile. He needs to in order to embrace a greater uncertainty.
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Another paradoxical side that hope assumes relates to its own value as something to be strived for in itself. Hope matters perhaps not only for the future good to which it points so much, but for its capacity to sustain movement toward it. So the subject S hopes for an object O which is necessarily good, future, arduous, and possible. But paradoxically, the deepest function of hope may not lie merely in attaining the object that it points so much to.
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In medicine we know that certainty is never fully available, and as prognosis worsens, the hoped for object may change, from cure to symptom control, to dignity to reconciliation, to dying well. Yet hope persists, and in doing so it maintains a disposition for action in the person. It allows for movement, for change, for things to improve, for good to be brought about.
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If we examine it closely, we can see it becomes this vector which is good in itself. We are not talking about attachment to an outcome, but the dynamic orientation sustaining action, preserving agency, enabling endurance and preventing existential stasis. It is the last thing to die because it is this vital movement. It is alive. It is a present good here and now that orients to an absent future one.
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The two paradoxes thus converge in a single statement. Hope is for the so called hopeless. It is the remedy, the good remedy that allows care to take place. As future possibilities diminish, hope becomes more necessary, and as uncertainty increases, hope becomes more valuable, not merely for what specific good it seeks, but for the disposition it sustains. And that uncertainty, as I said, is a given in medicine.
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So how should a physician face it?
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In his famous speech, Aquanimitas, Sir William Osler defends imperturbability as the highest virtue in medicine. He defines it as a coolness and presence of mind under all circumstances, or as Marcus Aurelius said it, to be a promontory of the sea. But why is it a text still celebrated to this day? Perhaps because of the fact that Osler indeed captured a very real aspect of medical care.
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The inevitable encounter with adversity. He advocates that the physician should remain undisturbed in face of turbulence and uncertainty. And passiveness, if it were truly attainable, perfects action by way of eliminating a faction of the equation. Right? So the problem is this encounter with the patient, it leaves me affected, it makes me distraught because I see myself in the other and I feel for him or her.
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This impacts me. The solution then would be to not feel at all, or at the very least to not show this emotion. We believe that promising presence would be a better alternative, the ministry of presence, as we talked about today so much. Because in this case, emotional restraint becomes identified with excellence and detachment becomes virtuous. But is this imperturbability truly a virtue or is it a defense of
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Mistaken for one. The problem with aquanimitas is that imperturbability becomes this condition for confidence to arise in the clinical setting. In the original speech, it seems that to show one's authentic reaction is a great foul, that the physician must remain undisturbed, he must not expect too much of those amongst who he dwells. Otherwise he will falter and the patient will suffer. So essentially we are talking about a virtue.
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that suppresses emotion. But let's have a look at the eloquent words of the late Anatoly Broyard, an essayist of the New York Times who wrote about the psychological and spiritual challenges of f facing metastatic prostate prostate cancer. To the typical physician, he wrote, My illness is a routine incident in his rounds, while for me it is the crisis of my life.
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I would feel better if I had a doctor who at least perceived this incongruity. I just wish he would give me his whole mind just once. Be bonded with me for a brief space. Survey my soul as well as my flesh to get at my illness, for each man is ill in his own way. A very strong citation it invites presence and bonding. While the more typical classic virtues such as fortitude or temperance are
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aim at orienting emotion towards good, imperturbability seems to aim at an emotional eradication, one that ultimately sterilizes our ability to cultivate hope in ourselves and others. The physician who refuses to be affected often becomes unable to affect. It seems imperturbability can be seen as an attempt to glorify the natural, you could say, aversive reaction of detachment in face of suffering.
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Michelle Ballint, a Hungarian British psychoanalyst and one of the pioneers of relational medicine, argues in his seminal work The Doctor, His Patient and the Illness that disturbingly, even though the most frequently used drug in medical practice is the doctor himself, there seems to be virtually no account of his pharmacology whatsoever. For Ballint, the physician is never a neutral observer. The doctor himself is a
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Participates in the therapeutic field. Patients bring demands, fears, expectations, and offers, while physicians respond according not only to technical knowledge but also their own personality, emotional structure, and implicit moral convictions. A compromise is constantly established between the two. Balint also describes what he calls the apostolic function or apostolic mission. The physicians often vague yet remarkably firm.
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belief about how a patient ought to behave, suffer, endure illness, relate to treatment, and almost unconsciously physicians communicate these expectations and attempt to convert, so to speak, their patients to their own implicit standards of what is reasonable, dignified, acceptable, or in this case hopeful. In this sense, physicians impose not only treatments but also existential styles, so to speak, including ideals about how hope should be experienced.
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In this scenario, the emotionally detached physician does not become absent from the relationship. He becomes pharmacologically cold. Even Osler's more charitable notion of imperturbability still tends toward observational distance rather than relational participation. And there is a cost to this imperturbability because we see there is a gap between what the physician intends to convey and what the patient often perceives. Many times
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Calmness, neutrality, objectivity, and distance are seen by patients as coldness, indifference, superiority, and lack of care. Because there is no effectively neutral position truly. Even a benevolent benevolent detachment is experienced by patients as a particular kind of presence, and hope rarely emerges where care is not perceived. And to be clear, this is not an argument against a
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Composure in medical practice. Physicians cannot afford to be overwhelmed by every suffering they encounter. The problem arises when composure becomes this way of ceasing to remain present and b becomes a way of remaining distance from patients. For hope depends not merely on clinical competence, but on a form of participation that patients can actually experience as care. But still, the lingering question remains.
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How can there be hope where when recovery becomes less and less plausible and the worst seems inevitable? How to avoid clinging to wishful thinking? The true test of hope does not occur when medicine can still defeat disease, it occurs when it cannot.
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For it is only at the extremes that we perhaps discover hope's true nature. To answer that original question of the previous slide, we must turn to the limits of medicine and to its ends.
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The terminal period of an illness is often seen as being a hopeless situation, and yet many patients facing such a period can indeed make it a time of hope, a hope for what can be achieved. Better days can come in spite of the prognosis. But what better days are we referring to? Sometimes in so called hopeless scenarios, patients confront physicians with the difficult question So are you saying there's no hope left?
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The pediatrician Dominic Wilkinson argues against answering either yes or no. Instead, he suggests shifting or reframing the conversation toward what that specific patient hopes for. What meaningful goods still remain possible? And at this point hope becomes inseparable from dignity. As Harvey Chochinov argues, even when cure is no longer attainable, patients continue to seek meaning, recognition, and worth.
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Medicine doesn't fail in these circumstances. Quite the contrary, it actually assumes a vital role in fighting for those better days, affirming the value of the person and providing dignity conserving care. For the goal of medicine is not always to add days to life, but sometimes to add life to the days that remain. Or in other words, if we reduce hope to the expectation of a disease reversal,
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We mistakenly assume that the primary goal of medicine is to cure rather than to care. Yet if hope is grounded in the good of caring, attentive presence, truthful communication, technical excellence and accompaniment, then even in the shadow of death it remains significant and virtuous. In such green moments, hope resists despair not by denying reality, but by affur affirming meaningful good can still be done.
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leaving lasting effects on patients, families and clinicians alike. We'd like to thank our sponsors, without whom we wouldn't be able to be here, the Hippocratic Society for having us, Olga and Pietro, our co authors, also Vinicius, Thiago, Ana Beatriz and Mariana from Brazil, from our group, Professor Luiz Hadricci Professor Ingrid for their guidance, insights and expertise, and Professor Adriano Bechara.
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for his mentorship, encouragement and intellectual guidance. We thank you very much for your attention and we are delighted to take any questions you might have. Thank you.
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That's actually a very interesting question. We had a slide dedicated just to that part of the the miracle. We called it the artifice of miracle because we were going to frame it as this very difficult situation in which the future good to the best of our technical knowledge isn't possible, but patients somehow forge this kind of indestroyable this
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unwavering belief that is is it is a possibility to reverse some some disease or something. And for the physician I think it's a a very difficult spot to be in because on the one side you cannot go to a patient and and say, well this is actually impossible. You are wasting your energy by believing in this. It is full tile to do so because first of all we're not sure. So actually extraordinary thing
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Things can happen and they they happen every day, in fact. and also by doing that you you can destroy the patient's hope and therefore undermine the whole therapeutic possibility. But on the other hand, if you inflame it, if you encourage the belief in a miracle or in something very improbable, then you also hinder your possibility of offering proper care because then the patient
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will not be prepared for the worst, which in most cases will will happen. So it is a very interesting topic and we we wish to to further elaborate on it, the the the miracle and how it appears in those scenarios.
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Whatever the treatment is, right? And what you are offering in terms of alternatives for treatment, et cetera. But then you can also encourage the patient to continue to believe, you know, in Christ or whatever the religious background being a miracle. I don't know why they can't go hand in hand, you know. I feel like if you 'cause if you negate one, then you harm the patient by not acknowledging the other, if that makes sense. You know? I think it was Fulton Sheen,
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Father, you probably know better than I do, or when wasn't he the one that said, you know, hope is the extension of faith into the future. And that faith for some of us is what we believe in Christ or whatever our God is, but the faith is also in yourself, in your family, and your support. And so I think that can be a very beautiful way to bring them both together. I feel like we see it play out every day, you know.
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just going to say that yes I agree and what we know is that there's no there's not one answer because we're always going to be talking to one patient and they are different from the others but what we can do is provide what we have for information but it is not our role to destroy any hope that the patient has. So it's actually an art as we said a virtue to cultivate not never being in the extremes always trying to be in the peak and it's
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Not an easy question to answer because each scenario is the next scenario is going to be different from the other one. And it's basically a virtue that we have to cultivate and an art that we have to be able to to deal with, the fact that we're dealing with other people that actually believe in mirac miracles.
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situations we encounter the patient and the pa the family is clinging to hope, right? So there's this idea of a medical miracle that could take place. But at the same time, I'm wondering at what point does hope descend into illusion. You mentioned that hope increases at the likelihood of a faithful flow out that we have used it. At one point is that decrease lead to the absence of hope and now it's something else.
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Okay. And how do you help refrain in with speaking into thinking about other goods besides the help for your or medical or in shape also? Well,
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well, one of the things that I would like to think about what you're questioning is that we must ask the patient what the patient understands by miracle because sometimes it's not just the cure, as we said in our presentation, care beyond cure.
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And to reframe the the the expectation, the hope from the patient is something that maybe the the main point about cultivating this miracle we we are talking about, maybe the miracle we're talking about is adding life to the final days as we said in our presentation. And I think it I think this is the most important thing when you talk about miracles. Yeah, it's a a very interesting challenge in
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actual practice. And Dr. Ingrid Dieguis, one of our palliative care teachers at our university, we speak to her specifically about the the question of of the belief in miracles. And a very practical advice she gave was to to say to the patient who expresses this this belief that that that's what I wished for as well. But what if it doesn't
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come to happen what what if it doesn't come to fruition as you are framing it, then what are we going to to do? And so to make this give it back to the patient as a a question that helps together with with the patient reframe the the whole scenario and see what are the the values of the person and what meaningful goods remain possible.
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Thank you very much for joining and reflecting with us today. Keep up with new episodes by
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