Hope as Virtue: Opens up a New Space for Exploring Hopefulness at the End of Life and Raises Some Interesting Questions

Barilan’s (2012) essay “From Hope in Palliative Care to Hope as a Virtue and a Life Skill” provides a novel way of exploring hope as experienced by people at the end of life. He proposes that hope can be usefully seen as an Aristotelian virtue; something to be “conscientiously chosen” as a “habit of behavior, perceptiveness and mental response, holistically considered” (Barilan 2012, 166). Hope coalesces with other virtues, particularly courage, in the terminally ill, to enable human flourishing even at this time of great uncertainty, loss, and ultimately personal annihilation. The virtue of hope in an individual might manifest itself in various ways, particularly in creativity and caring relationships.

Hope, however, is quite a wide-ranging concept. It is generally accepted that hope is a defining characteristic of human life (Fromm 1968). Life cannot be lived without hope. However, what does hope mean in the context of terminal illness and death? A recent review of research studies on hope in palliative care found two overarching themes: ‘Hoping for something’ and ‘living with hope’ (Kylma et al. 2009).

Eliot and Olver (2002) analyzed the speech of 20 cancer outpatients who were discussing ‘do not resuscitate orders.’ This group used hope in several different ways. Hope could be a noun. This was demonstrated in two ways: The first they defined as ‘objective,’ where hope was reified into something that the healthcare specialist could quantify (the doctor said that there was no hope); the second was subjective and constructed by the patient’s or their carer’s beliefs (there always has to be hope, no one can be sure that the disease will progress further). In contrast, hope could be expressed as a verb. This functioned in a similar way to the subjective noun, with the action generated by the patient (I hope that my death will be painless and dignified [Eliott and Oliver 2002]). Defining ‘hope’ too narrowly, therefore, becomes problematic and needs to be borne in mind in any discussion of the subject.

Considering hope as a virtue involves taking a fresh perspective where the grounds for possessing and expressing hope can be examined. As with the other virtues, presumably for hope there exists a ‘golden mean.’ The golden mean of courage lies between timidity and reckless abandonment to danger; ‘virtuous’ hope lies between despair, where there is no hope at all, and extreme optimism, where hope does not have any grounding in reality. That said, and as Barilan indicates, realistic hope can exist without any great chance of the hoped-for event materializing. In fact, it is very difficult to be sure that a seemingly unrealistic hope is in fact unrealistic. As clinicians, patients often surprise us; for instance, a mother’s hope to see her young children grow up when she has been diagnosed with advanced breast cancer might seem unrealistic; however, when the patient survives several years and her hope is realized, it cannot be dismissed as unrealistic, although at the outset it seemed highly improbable (Francis 2008). Or a patient with advanced lung cancer and poorly controlled symptoms who decides to holiday abroad against medical advice (because their doctor thinks their hope of enjoying such a holiday is unrealistic) is somehow able to enjoy the holiday despite the odds being stacked against it. In the end, hope may only be judged as realistic or unrealistic after the event. By this token, hope that turns out to be realistic may have seemed to a clinician to be ‘extreme optimism’ when it was first expressed by the patient; however, maybe hope needs to be judged by how it enables a patient and those around them to face their illness and even flourish in the face of it.

Barilan distinguishes two types of hope: Prevention focus (I hope I won’t die) and promotion focus (I hope I can finish my biography). Prevention-focused hope is rather more limited in its scope and does not lead directly toward creativity or personal achievement. Barilan...