Moral disagreement and misaligned hope in healthcare

Introduction

Moral disagreements in healthcare often emerge when a patient’s convictions—whether religious, cultural, or personal—clash with the medical community’s evidence-based recommendations. One of the most significant areas of contention arises from the role of hope in medical decision-making. While hope can be a crucial motivator in treatment adherence and recovery, it can also lead to decision-making that contradicts medical advice.

In our recent paper, Misaligned Hope and Conviction in Healthcare, we explore the ethical challenges posed by conviction-based hope and argue for a middle-ground approach that respects patient autonomy while ensuring rational medical decision-making.

The Role of Hope in Medical Ethics

Hope plays an essential role in healthcare. It can drive patients to comply with treatment plans, endure painful procedures, and maintain emotional resilience. However, not all forms of hope are equally beneficial. Some hopes—particularly those based on deeply held convictions rather than empirical evidence—may lead patients to reject medical advice, delay treatment, or pursue unproven therapies. This raises ethical concerns about the limits of patient autonomy and the obligations of healthcare professionals.

The Tension Between Conviction-Based Hope and Medical Rationality

There are two extreme positions in ethical debates on conviction-based hope. On one side, libertarians argue that patients should be free to make healthcare decisions based on any belief system, no matter how irrational it may seem. On the other side, rationalist interventionists contend that decisions based on conviction-based hope should not be respected if they violate principles of theoretical rationality.

We propose a middle-ground approach—what we call the practical rationality view. This perspective acknowledges that patients may hold conviction-based hopes that influence their medical decisions but insists that such decisions should still conform to basic norms of rationality and informed consent. Patients should have the autonomy to make decisions in line with their beliefs, but only when they understand the medical realities involved and appreciate the consequences of their choices.

Case Studies of Misaligned Hope

Our analysis identifies four common types of misalignment between patient hope and medical recommendations:

Hoping for an unattainable outcome – Some patients, driven by religious or personal convictions, hope for miraculous recoveries despite overwhelming medical evidence to the contrary. For example, a pregnant woman might reject palliative care options for a fetus diagnosed with a fatal condition, hoping against medical evidence that the baby will be born healthy.

Unrealistically high expectations of success – Patients may refuse to accept a terminal prognosis, believing they will recover against all odds. This can lead them to reject palliative care and pursue experimental treatments with no realistic chance of success, as in the case of a critically ill patient who insists on seeking treatment in another country despite medical evidence suggesting the journey itself would be fatal.

Hoping for an outcome that deviates from medical priorities – Some patients prioritise values that differ from standard medical goals. For instance, an Amish burn victim may refuse skin grafts because he prioritises returning to work over minimizing scarring. While his hope for recovery aligns with medical objectives, the method by which he pursues it diverges from conventional medical practice.

Unrealistically low hope leading to fatalism – In some cases, patients’ conviction-based hope is too weak, leading them to reject potentially beneficial treatment. A woman who believes cancer treatment is futile due to religious fatalism may delay life-saving surgery until it is too late.

Balancing Autonomy and Medical Responsibility

In cases where conviction-based hope leads patients to make decisions that could harm them, healthcare professionals face an ethical dilemma. On the one hand, respecting patient autonomy is a fundamental principle of medical ethics. On the other hand, ensuring that patients make informed and rational decisions is equally important.

Our practical rationality approach suggests that healthcare professionals should:

• Encourage informed hope by ensuring patients understand the medical realities of their condition.
• Mitigate the negative effects of misaligned hope by guiding patients toward hope that aligns with achievable medical outcomes.
• Respect deeply held convictions when they do not pose significant harm but seek to balance them with medical expertise.

Conclusion

Moral disagreement in healthcare is often fuelled by conflicts between conviction-based hope and medical rationality. Rather than taking an extreme libertarian or interventionist stance, a middle-ground approach that respects practical rationality offers the best ethical solution. By ensuring that patients’ hopes are informed, reasonable, and compatible with the goals of medicine, healthcare professionals can navigate the complexities of moral disagreement while upholding both patient autonomy and medical responsibility.

This blog is based on the paper: Clarke, S., Oakley, J., Pugh, J., Wilkinson, D. (2025). Misaligned hope and conviction in health care. Bioethics, 39, 232–39. https://doi.org/10.1111/bioe.13370

Dominic Wilkinson, Steve Clarke, Justin Oakley, Jonathan Pugh. We were assisted by AI in the writing of this blog.