A psychiatrist wonders if hopelessness has its place
As a psychiatric physician, I have sometimes found myself on the horns of a dilemma. I am caring for a severely impaired patient—with chronic, treatment-resistant schizophrenia, say—who asks me a seemingly simple question: “Is there hope for me, Doc?” Physicians in other specialties often face similar questions—and sometimes, the most accurate response may be dispiriting or even injurious to the patient’s emotional well-being. How should doctors navigate between the rocks of nihilistic hopelessness and unrealistic optimism?
Americans are supposed to be optimists, and our culture bombards us with messages of hope every day. Bumper stickers tell us that “hope changes everything” and urge us to “hang in there!” because “things will get better.” A presidential candidate titled his memoir The Audacity of Hope and ran on the slogan “Hope and Change” (a phrase later ridiculed as “that hopey, changey thing”). Hope, with a side of faith and charity—the trio of virtues commended by the apostle Paul—is central to Christianity.
But what if hope sometimes misleads or betrays us? What if Friedrich Nietzsche was right in claiming that “hope is the worst of all evils, because it prolongs man’s torments”?
Consider a recent New York Times op-ed by the philosopher Simon Critchley. Taking his cue from Nietzsche, Critchley asks, “Is hope always such a wonderful thing? Is it not rather a form of moral cowardice that allows us to escape from reality and prolong human suffering?” Critchley deplores what he calls “moral idealism” and favors, instead, “an affirmative, even cheerful, realism.” For Critchley, modest and realistic hope may be useful; starry-eyed optimism, not so much.
Critchley has support from surprising quarters: the Buddhist tradition. In When Things Fall Apart, Pema Chödrön, an American Buddhist nun, argues that hopelessness is the beginning of real wisdom. “Without giving up hope,” she contends, “we will never relax with where we are or who we are.” By “hopelessness,” of course, she does not mean pessimism, nihilism or gloom and doom. She means a clear-eyed acknowledgment that the universe is an unruly place—that all things fall apart, including our bodies—and that we have nowhere to run for comfort and safety. For Chödrön, there is no cosmic babysitter to rescue us from our human predicament. We can only come to terms with the radical impermanence of everything in life—our homes, our health, our loved ones—and learn to live with the ambiguity of the present moment.
So who is right—the prophets of hope or the proponents of hopelessness? As a physician, I am usually expected to be a messenger of hope (witness the name of the hospital ship USS Hope or the 1990s medical drama Chicago Hope). When I was seeing severely depressed patients in my private practice, one of my most urgent goals was to instill the hope that recovery is possible—though I always added, “It may take us a long time to get you there.”
Indeed, there is a long tradition in Jewish medical ethics that counsels caution in giving bad news. With full disclosure of a terminal illness, observes the medical ethicist and Judaic scholar Dr. Fred Rosner, “the patient may give up hope, suffer severe mental anguish (tiruf hadaat), become despondent and die sooner than otherwise.”
On the other hand—and in Jewish ethics, there is always “another hand”—Rabbi Elliot Dorff has pointed to the substantial risks in concealing medical information from patients. His work in hospice care has led him to conclude that most people who are terminally ill do much better if they are told the truth about their condition—even when that truth may take away an illusory feeling of hope.
So where does wisdom lie? And what does ethical practice demand? Here, I find some guidance in the Buddhist principle of the middle way. A physician can refrain from misleading the dying patient, while also refusing to destroy all hope. After all, physicians are notoriously inaccurate in predicting when someone will die—and sometimes, against all realistic expectations, “terminally ill” patients recover. Some call these recoveries “miracles.” I prefer to believe that we simply know less about the universe than we sometimes claim—and this leaves plenty of room for hope.
Ronald Pies, M.D., is a clinical professor of psychiatry at the School of Medicine. He is the author, most recently, of a collection of essays, Psychiatry on the Edge (Nova Publishing), and a novel, The Director of Minor Tragedies (iUniverse).