Hope, ethics, and public health

Short abstract

Considerations of hope and hopefulness should figure more prominently in ethics frameworks and other conceptual models for public health practice.

Hope is a universal human phenomenon that exists across nations and cultures. It has been examined and conceptualised from many diverse perspectives and disciplines.¹,² For example, it is a part of religious faiths and traditions including Judaism, Christianity, and Islam.³ Writers, scholars, and historians have long recognised that hope plays an important part in human existence and achievement, especially in difficult times. For example, testaments of hope appear throughout the recorded history of the American Civil Rights Movement.⁴,⁵ Clinical ethicists have also examined issues pertaining to hope in the context of doctor‐patient relationships, care for dying patients, and other concerns in medicine.²,⁶

The human occurrence of hope is also of scientific interest and has been subjected to scientific description and inquiry. Studies have examined patterns of hope experienced by people with serious illnesses or in special life circumstances, such as patients undergoing cancer chemotherapy, those receiving news about a life threatening illness from their physician, or those at the end of life.¹,⁷,⁸ Such studies have suggested hope has different dimensions and is not a single construct. While care must be taken to avoid instilling false hopes, hope is often conveyed by physicians and other health care providers, such as when patients are given information about their prognosis or when their informed consent is obtained for medical or surgical procedures. Hope has sometimes been measured in psychological and behavioural studies using scales or indices of hopefulness or hopelessness.⁹,¹⁰ Measures of hopefulness have been found to be positively associated with indices of life satisfaction and wellbeing.¹⁰,¹¹

Although hope has frequently been studied in clinical medicine and psychology, it has been less commonly examined in public health. Nevertheless, some community studies have assessed hopefulness. For example, a focus group study of colorectal cancer screening involving 55 African Americans found that hope was an important mediator of barriers to cancer screening such as mistrust of providers or the health care system, fear of cancer or of colorectal cancer screening procedures, and fatalism.¹² The authors defined fatalism as the belief that screening and treatment may be futile.¹² In a study of fear, hope, and social desirability bias among 60 women at high risk for human immunodeficiency virus infection in West Africa, respondents frequently reported a desire to have a better life.¹³ Results from these and other studies suggest that hopefulness is related to measures of better health and wellbeing, and lower psychological distress in diverse communities.¹²,¹³,¹⁴ Hope is likely to mediate other variables and constructs that are known to be associated with population health. For example, hopefulness is an important part of some positive coping strategies that people may use to tolerate or minimise stressful events.¹⁵ Conversely, people who lack hope may be more likely to use negative coping strategies to alleviate stressful circumstances.

Although it is clear that public health professionals can have a role in studying the occurrence of hope in communities, in relationship to various health mediators and outcomes, the role of public health practitioners and institutions in instilling or sustaining hope among the public has not been clarified. The virtue of instilling or fostering hope in people and communities is not mentioned in ethics frameworks that have been proposed for public health. ¹⁶,¹⁷ Nor is hope mentioned in ethics guidelines that have been developed for public health professionals or institutions.¹⁸,¹⁹,²⁰,²¹ For example, the Public Health Leadership Society's statement of principles for ethical public health practice does not mention the virtue of instilling or sustaining hope.¹⁸ However, such a virtue is consistent with principles set forth in the statement, such as the observation that, “Public health should advocate and work for the empowerment of disenfranchised community members, aiming to ensure that the basic resources and conditions necessary for health are accessible to all.”¹⁸ Ethics guidelines developed for the American College of Epidemiology, which deal with ethical issues in both epidemiological research and public health practice, mention several virtues (for example, honesty, prudence, excellence, and integrity) but fail to mention the virtue of fostering or sustaining hope among members of populations targeted by public health practitioners.¹⁹ The guidelines do note that epidemiologists and other public health practitioners should meet their obligations to communities by undertaking public health research and practice activities that address health problems and by reporting results appropriately; that all research findings and other information important to public health should be communicated quickly, responsibly, and in an understandable way so that the widest possible community can benefit; and that in confronting public health problems, epidemiologists sometimes act as advocates for affected community members. The guidelines emphasise scientific objectivity in these undertakings.¹⁹

Although instilling false hope should be avoided, considerations of hope and hopefulness should figure more prominently in ethics frameworks and other conceptual models for public health practice. Sustaining or fostering hope among people and communities is consistent with the virtuous conduct of public health. In the presence of natural and manmade disasters and socioeconomic, ecological, and public health challenges, hope can be a mediator of coping, recovery, and resilience. From other fields of endeavour (for example, history, psychology, and clinical ethics), there is overwhelming evidence that the experience of hope has important connections to human wellbeing, health, amelioration of suffering, and adaptation to illness. To strengthen and clarify the evidence, however, there is a need for additional public health research to further identify mechanisms by which hope engenders health and wellbeing, among people with and without illness or injury.