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Health Care Ethics USA Hope and the Ethics of Disclosure for Terminally Ill Cancer Patients
Cancer diagnosis presents a disclosure dilemma for patients and physicians. One horn of the dilemma is the physician's obligation to provide diagnosis so that the patient is equipped to make informed decisions regarding care. The other horn is the impact the diagnosis has on the emotional and physical well being of the patient. Historically, physicians resisted disclosing a diagnosis of cancer to protect the patient from the "harm" of a poor prognosis.1 This essay discusses how ethical discourse on hope can help to resolve this disclosure dilemma. Oncologists consistently report a moral obligation to foster hope both for their patients and for themselves.2 "Respect for hope" serves as an ethical guideline for diagnosis disclosure by oncologists, such that "[i]nformation is tailored . . . to the goal of instilling hope."3 Conversely, such "information tailoring" raises ethical concerns about truthful communication, paternalism, and trust within the patient-physician relationship. There are, however, two (possibly complementary) approaches to hope that are worth considering. These approaches can be described as the psychological-empirical approach to hope and the phenomenological approach to hope. The psychological-empirical approach to hope means that hope is "grounded primarily in the biomedical dimensions" of health care,4 and is contingent upon the empirical "probabilities of success and failure."5 This approach to hope has several characteristics. First, hope is used to implement a paternalistic role for the clinician who controls the relevant biomedical information. Second, this approach to hope seeks to foster psychologically the patient-physician relationship in order to realize desired empirical outcomes. However, this approach can be problematic insofar as an oncologist can justify withholding information to achieve two conflicting goals. On the one hand, the oncologist may withhold diagnosis information in order to promote unsubstantiated hope. On the other hand, the oncologist may withhold information to protect against unsubstantiated hope. Third, this approach to hope gives primacy to the oncologist's perceptions of hope over those of the patient. Such primacy can appear in oncologists' efforts "to instill and maintain hope,"6"to disabuse patients of what physicians perceive as impractical forms of hope,"7 and "to promote reasonable hope."8 In sum, this approach adopts a psychological approach to hope based on anticipated empirical outcomes, wherein the oncologist ascertains which empirical outcomes are attainable as a basis for the diagnosis disclosure to the patient, and the patient's hope is fostered accordingly. Despite the goals of instilling and maintaining hope, the psychological-empirical approach to hope raises significant concerns. First, the emphasis on information disclosure by the clinician related to the anticipated therapeutic outcomes can obscure a deeper understanding of dialogic communication in the patient-physician relationship as a basis for hope. Second, the emphasis on the oncologist's diagnosis disclosure can diminish the patient's understanding of hope as a lived experience, as described below. Third, an emphasis on the empirical and psychological aspects of the diagnosis disclosure can prevent an interpretive function of hope as a means of ascribing meaning and ascertaining understanding in particular experiences of cancer.9 Lastly, a psychological-empirical approach can detract from the transcendental aspect of hope, which seeks to ascribe relational and religious meanings. These concerns suggest the need for another approach to hope in addressing diagnosis disclosure for terminally ill cancer patients. A different approach to hope can be described as the phenomenological approach. This approach ascribes meaning to and ascertains understanding of practical circumstances (such as a terminally ill patient's cancer) by interpreting the phenomena that comprise human experiences. Inasmuch as the processes of ascribing meaning and ascertaining understanding require interpretation of the phenomena that comprise human experience, this entails what I refer to as a phenomenological hermeneutics of hope. Aphenomenological hermeneutics of hope offers a complimentary approach to understanding the role of hope in the ethics of cancer diagnosis disclosure. The phenomenological hermeneutics of hope proposed by Paul Ricoeur is particularly helpful, insofar as he addresses both the theological and the philosophical aspects of hope as lived experience. Ricoeur argued that hope is essentially a theological virtue, grounded in a Christian understanding of resurrection and freedom.10 Resurrection is the symbol of "a new totality of being," that communicates hope as a "superabundance of meaning."11 Additionally, hope yields both freedom from spatio-temporal and physical constraints, as well as freedom for imagining human possibilities, instantiating divine love, and "being-in-the-resurrection."12 In sum, for Ricoeur, hope can enhance freedom to discover meaning both within and beyond the spatio-temporal realm of knowledge. The phenomenological hermeneutics of hope can help oncologists deal with diagnosis disclosure to better address the disclosure dilemma when caring for terminally ill cancer patients. First, this approach to hope can help the oncologist to discover the patient's personal conceptualizations and expressions of hope. Second, this approach to hope privileges the patient's understanding of the disease diagnosis, prognosis, and prospects for palliative care. Third, this approach to hope connects the patient's disease with patient's overall well-being for which the clinician also has responsibility. In other words, the phenomenological hermeneutics of hope can complement a more traditional psychological-empirical approach to hope. The phenomenological hermeneutics of hope is attentive to what can be called a "superabundance of meaning" that is within a terminally ill patient's grasp. The particular clinical circumstances of disease should not exhaust the totality of meaning for a dying patient. This approach to hope can foster empathic dialogue that promotes trust and mutual understanding, far in excess of a more traditional paternalistic approach, between the oncologist and patient in the extraordinarily personal pilgrimage of dying. This approach to hope frees the oncologist and the patient from interpreting "success" and "health" solely in terms of empirical outcomes. Rather, hope, as freedom to interpret the empirical present, empowers the oncologist and patient to grasp transcendent meaning beyond the spatio-temporal realm of medical knowledge. In sum, a complementary relation between two approaches to hope can foster a better physician-patient relationship for the terminal care of cancer patients to address the diagnosis dilemma described previously. That is, the psychological-empirical approach to hope that can characterize the paternalistic role of the oncologist needs to be balanced with the phenomenological hermeneutics of hope that celebrates the interpretation of dying patients in their quest for transcendent meaning in the end stages of living. 
Rev. Greg Manship, M.Div., PhD(c) Suggested Readings Benzein, Eva and Britt-Inger Saveman. "Hope in Patients with Cancer: A Systematic Review of the Literature." Recent Advances and Research Updates 1: 87-96 (2000). Farran, Carol J., Kaye A. Herth, and Judith M. Popovich. Hope and Hopelessness: Critical Clinical Constructs. Thousand Oaks, California: SAGE Publications, 1995. Groopman, Jerome. The Anatomy of Hope: How People Prevail in the Face of Illness. New York: Random House, 2004.
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