Hope and deception.

Convinced of hope's therapeutic benefits, physicians routinely support patients' false hopes, often with family collusion and vague, euphemistic diagnoses and prognoses, if not overt lies. Bioethicists charge them with paternalistic violations of Patient Autonomy. There are, I think, too many morally significant exceptions to accept the physician's rationales, or the bioethicist's criticisms, stated sweepingly. Physicians need to take account of the harms caused by loss of hopes, especially false hopes due to deception, as well as of the harms of successfully maintained deceptive hopes. As for autonomy, hopes -- even if based on deception -- can protect and enhance autonomy, understood broadly as the capacity to lead a chosen or embraced life. Deception aside, patients' hopes often rest on beliefs about possible rather than probable outcomes -- beliefs themselves supported by optimism, 'denial', or self-deception. Such 'possibility-hopes' may conflict with physicians' often more fact-sensitive 'probability hopes.' To resolve such conflicts physicians may try to 'down-shift' patients' or parents' hopes to lesser, more realistic hopes. Alternatively, physicians may alter or enlarge their own professional hopes to include the 'vital hopes' that define the lives of patients or parents, as well as 'survival hopes' needed to face and bear the loss of loved ones, especially children. A principle of Hope-giving might help guide such sympathetic hope-accommodations. More generally, it would give Hope a distinct place among Beneficence, Autonomy, and the other moral factors already highlighted by canonical principles of Medical Ethics. To formulate such a principle, however, we will need a collective Project Hope to pursue deeper philosophical and psychological studies.