If there is one thing that is common to all patients that consult us, it is that they want things to be better for them than they currently are. They would like us to do or say something that would ease their pain, relieve their anxiety, alleviate their distress. They want us to change their future because their present is not to their liking. If on leaving our rooms they already feel better, it is simply because they have been given some hope that things will improve.
Hope. Patients need it – doctors and nurses need it – I need it. Hope keeps us going in the face of problems which seem insurmountable. Like Seligman’s dogs, who in his experiments on ‘learned helplessness’ were put in adverse situations they couldn’t change, without hope we become resigned to never ending difficulty and tend towards depression and passivity.
Jurgen Moltmann writes, “Present and future, experience and hope, stand in contradiction to each other”. He suggests that “hope is directed to what is not yet visible… and brands the visible realm of present experience…as a transient reality that is to be left behind”.
Some are uncomfortable with our constantly living in the hope of a better tomorrow. They suggest we spend either too much time living in the past, remembering what was, but is no longer; or too much time living in the future, hoping for that which is not yet. Bemoaning such behaviour, Blaise Pascal wrote “We do not rest satisfied with the present. We anticipate the future as too slow coming, as if in order to hasten its course; or recall the past, to stop its too rapid flight…We scarcely ever think of the present; and if we think of it, it is only to take light from it to arrange the future…So we never live, but we hope to live; and as we are always preparing to be happy, it is inevitable we should never be so.”
Pascal would, I think, have approved of mindfulness, the psychological process of bringing ones attention to experiences occurring in the present moment. Now, whilst mindfulness may have its place when we are overwhelmed by unnecessary anxiety concerning the future, grounding us, as it does, in the here and now and helping us appreciate what we have and can currently enjoy, if we imagine we can sort our patients’ very real problems by advising that they consider the intricacies of a tree, then surely we are mistaken. T.S.Eliot penned, “The knowledge derived from experience…imposes a pattern, and falsifies”. What we know from what we encounter is not enough to understand fully. We need to draw from outside of ourselves if we are not to be misled. The present requires the context given it by the past and is tempered by what is expected in the future. A powerful illustration of this is provided by John Piper. He asks us to imagine that, whilst walking through a hospital, we hear the screams of somebody in pain. He suggests that how we feel about what we hear will differ greatly depending on whether we are on an oncology ward or a labour ward. The future matters – it changes our present.
As health care professionals, we are in the business of changing the future for our patients – offering a promise of a better tomorrow for those with whom we consult. We seek to envisage what currently can’t be seen and then endeavour to bring it into reality for them. Moltmann again: “Hope’s statements of promise…stand in contradiction to the reality which can at present be experienced. They do not result from experiences, but are the condition for the possibility of new experiences. They do not seek to illuminate the reality which exists, but the reality that is coming.” So, for example, when we issue a prescription for pivmecillinam, it is the proffering of a hope, that the cystitis will come to an end. It’s a promise that what is not true now, will shortly be so.
But changing the future is an act worthy of the divine. Nonetheless, having too often in the past arrogantly acted as if we were God, increasingly, it seems, it’s now being demanded of us. And our attempts to satisfy that overwhelming demand is dragging us under because, of course, not all hopes can be so simply realised by the prescribing of a course of antibiotics. Furthermore, we can strive all we like to live in the moment but, as temporal creatures, we cannot escape the future. Not least, we cannot deny that we are cognisant of our own mortality. Death is a problem we all have to face and one which medicine, despite its best efforts, still can’t solve. To quote Moltmann once more, “The pain of despair surely lies in the fact that a hope is there – but no way opens up towards its fulfilment”. What then can we do when faced with the problem of death. Must we, if we are to carry on at all, agree with L.M. Montgomery that ‘life is a perfect graveyard of buried hopes’? Should we, with Dylan Thomas, “rage, rage against the dying of the light” or comfort ourselves with mere mindfulness as we “go gentle into that good night”.
Death is the one thing we can be certain of and yet, desperate that that were not so, too often we mindfully focus our attention on the detail of the here and now of our patients’ clinical parameters in an attempt to pursue and push eternal life. Not only is this unhelpful for patients weighed down by a medical profession too scared to address its own limitations, it’s also bad for doctors who are burdened with the Sisyphean task of delivering the undeliverable.
Regardless of what we may or may not believe about what happens after death, what is certain is that everlasting life is not a gift that is ours to give. We, and our patients, need to stop pretending otherwise.. If we’re not to make an almighty mistake, we need to stop playing God and acknowledge our remarkable ordinariness, the ocean of our ignorance and, what Atul Gawande calls, our ‘necessary fallibility’. We may not be the answer our patients are looking for.
But death is not the only future problem our patients face that medicine cannot solve. Many of our patients have lost hope of things ever being better – the future is something only to be feared. We live in an increasingly anxiety ridden society. Henry Thoreau wrote “The mass of men lead lives of quiet desperation, and go to the grave with the song still in them.” But Thoreau was wrong – the desperation is deafening.
Many of us will also know what it is to have a difficulty which appears beyond us, which wears us down and threatens both our present happiness and the happiness we desire for tomorrow. If then we are to solve the problem of the future, we must either limit its’ importance and be content to be satisfied by the joy of the present, or struggle to find the antidote to despair that is the hope of something better. There is much that medicine can do but we must not imagine that it is the only thing in which we or our patients should hope. Often that hope would be better placed elsewhere – after all, a misplaced hope is a false hope, and a false hope is no hope at all. We, and our patients, need to be directed towards a real hope that can lift us above the suffering of the here and now, something we can look forward to and which, despite everything, will keep us going; something which, even if it can’t get us to the top of the mountain we face, manages to draw us up a little higher and puts us in a place where we are able to at least imagine what the view from the top might look like.
When life is hard, whether at work or elsewhere, we all want things to be better – it’s then, more than ever, that we need a hope for the future to keep us keeping on, The exact nature of that hope will be different for each one of us. For some, the hope will sometimes be but modest – indeed when life is at its hardest, modest may be all we can muster. For others, or at other times, the hope may be more extravagant – transcendent even. But big or small, dependent on us or others, we need a hope that sustains us.
Despite our difficulties, we must make room for hope
We need to search it out knowing that, though we may not find it medicine or ourselves, there is always hope to be found.
And when it seems there isn’t, we need to hope against hope, that hope somehow finds us. Because, even then, though not, perhaps, in a form we once expected, a hope that does not give up still remains.