Hope

Definitions

  • a desire accompanied by expectation of or belief in fulfillment.
  • to cherish a desire with anticipation : to want something to happen or be true.
  • Hope implies little certainty but suggests confidence or assurance in the possibility that what one desires or longs for will happen.

    Merriam-Webster

What is Hope?

  1. Hope is a confidence about what will happen in the future. This confidence, however, is independent of the likelihood of the desired outcome. The more unlikely that outcome is, the stronger the hope must be.
  2. Rather than being simply a feeling, hope is a virtue that is foundational to the practice of medicine.
  3. The virtue of hope entails four core elements.
  4. An idea of a higher purpose is essential in maintaining the virtue of hope.

Why should we practice the virtue of Hope?

  1. The practice of medicine fundamentally rests upon hope.
  2. It is essential for patients to sustain hope, even in the face of a threatening and progressing disease.
  3. Hope is necessary to maintain resilience and avoid burnout.

Aristotle’s Doctrine of the Mean

Aristotle’s Doctrine of the Mean emphasizes balance as the essence of virtue, symbolized here by a mountain peak with a flag representing the ideal midpoint. Each virtue lies between two opposing vices—deficiency depicted on the left, and excess, on the right slope. For example, courage is the balance between cowardice (deficiency) and recklessness (excess). In a medical context, this principle guides healthcare professionals to strive for the peak of ethical behavior, avoiding the pitfalls of extremes to ensure thoughtful and compassionate care.

Hope Balance
Exploitation Deficiency
Naivety Excess

Case Studies

  1. Case 1
  2. Case 2

It’s 7:20 PM and you are the admitting resident just minutes from the end of your shift. You happen to have a high school student shadowing with you who has expressed interest in medicine. It’s been a taxing day, your sixth in a row, but the 7:30 PM cutoff is coming soon, and you’ve managed to come up with sufficient plans to ensure the safety of the patients you’ve admitted so far. Your eyes blur as you scroll down the computer screen, praying you’ll be spared a final admission, which will easily add an extra hour to your shift. All you want is to go home to your apartment (currently in disarray), eat a small meal, shower, and see how much you can catch up on your sleep debt before returning for another shift.

But then it happens. The gnawing alarm of your pager at your side causes your stomach to drop. You curse silently under your breath—an admission at 7:25. There’s no use in fighting it, you’ve tried that before; it will only delay the inevitable. Hopefully, this is an easy one. You pull up the chart and slump back in your chair. It’s Mr. Jones, a patient well known to you. He is a sixty-five-year-old with heart failure, obesity, chronic obstructive pulmonary disease, narcotic dependence—the problem list is long. Under your breath you declare that this patient is “hopeless,” knowing that this will easily add an extra hour to your shift.  

A fellow resident laughs, looking at the shadowing student and commenting cynically, “You think Mr. Jones is hopeless, medicine is what’s really hopeless.” The student laughs politely but looks crestfallen. She accompanies you as you admit the final patient. A few hours later, walking out of the hospital, she asks you, “Should I really do this? Is medicine really hopeless?”

Discussion Questions

  1. The first part of hope is apprehension of the good. What is the good to be apprehended for the patient? Is the good the same for you, the resident? If not, then what is the good?
  2. What are the barriers to the good for the patient? For the resident?
  3. What would acting with hope look like for the resident in this case?
  4. If the resident were to give up hope on this patient, what would the consequences be, both for the resident and for the patient?
  5. What should the resident say to the shadowing student?
  6. Why should we have hope against the odds, when it may seem like a waste of time and unrealistic?
  7. How can we give a patient hope in the face of a grim prognosis?
  8. What is the higher purpose of medicine which is the source of hope in the face of overwhelming discouragement?

You are a fourth-year medical resident on your internal medicine rotation. You’ve been assigned to see Mrs. Silver, a 48-year-old woman recently admitted for a pulmonary bronchoscopy and biopsy. Her primary care physician discovered a firm, supraclavicular lymph node just last week and sent her for a CT scan of her chest which revealed a large mass suspicious for lung cancer. The pathology results are pending. You enter the room and introduce yourself, explaining your role as a student and gathering the history and physical data specific to your role on the clinical team. Suddenly, the patient asks you, “Is there any hope this isn’t cancer?”

The pathology results come back confirming large cell lung cancer. The patient has already discussed her prognosis with the pulmonologist and the rest of her clinical team by the time you see her. From your understanding, the prognosis is rather grim, even as the patient is pursuing aggressive treatment. As you talk with the patient, she says offhand, “I have to hope that I can better. Is that crazy? Do you think there is hope for me?”

Discussion Questions

  1. If the resident had told the patient that there was hope that she did not have cancer, would that have been foolish? Would it have been honest? Why or why not? How would it affect the patient? Would it make the arrival of the news that she had cancer more difficult?
  2. If the resident tells the patient that there is no hope, how would that affect the patient?
  3. If the resident does not have hope for the patient, how would that affect him or her?
  4. How can a physician maintain hope, even when he constantly observes that the hopes of various patients end up unfulfilled?
  5. In a bad situation, you often hear people say, “All we can do is hope.” Is there any merit to this? What is the point?
  6. If what is hoped for does not come to be, will there have been any benefit to hoping?

How do we foster Hope?

  1. Have a sound practical reason, a firm ability to understand and apprehend the good in patients and ourselves.
  2. Have a firm understanding of the obstacles to that good. 
  3. Have a forward-orientation despite a constant element of uncertainty.
  4. Learn how to act in the face of such uncertainty, to be spurred on when we do not have all the answers, and to seek out practical actions toward the good of our patients’ health.
  5. Maintain an idea of a higher purpose and acting for the common good
  6. Find role models and mentors who exemplify the virtue of hope.