Jeremy Snyder, Exploiting Hope: How the Promise of New Medical Interventions Sustains Us—and Makes Us Vulnerable, Oxford, 2020
Marleen Eijkholt
Leiden University Medical Center
Leiden, Netherlands
Snyder’s book ‘Exploiting hope’ is as relevant as ever. His book is about the hope of desperate individuals seeking treatments that cannot (yet) be found in conventional medicine. The book engages with hope in the setting of phase I cancer trials, stem cell interventions, right-to-try laws and crowd funding, offering a new language to explain our discomfort with some of these quests. At the same time the book seems particularly relevant given current events. While despair and quests for novel interventions touched only a few patients with specific conditions up to a year ago, they are now familiar to us all. Early on in the COVID-19 pandemic all of us probably experienced hope for interventions that could save us from the imminent disaster.
Beyond theory and case studies, the book’s worth thus shows in its ability to label some of the recent discourse on hope. Issued preceding COVID-19, the pandemic serves as a test case for the book’s lessons to be translated to new settings. For example, as president Trump touted hydroxychloroquine as a ‘magic bullet’ early on, this promise felt wrong and uncomfortable. Yet it was difficult to satisfyingly condemn his promise on the basis that he created any false hope. Trump was not a physician but a politician, and his ideas about hydroxy were so premature in understanding COVID that no reasonable person could justifiably believe his proclamations. Hence, their hope could not really be false. Snyder’s book is worthwhile in that it gives readers a vocabulary to tag Trump’s exclamations as wrong without the need to refer to false hope.
The book’s main claim consists of three components: (1) There is something special about hope in the health care setting, (2) Thwarting of such hope creates a distinctive wrong: exploitation, (3) Such exploitation of hope is a problem of respect and a failure to fulfil a specified duty of beneficence. Developed over 8 chapters, these components are not always easy to identify. They disappear against the background of conceptual explorations and extensive case-studies. The claims are wrapped up in the two distinctive parts of the book—theoretical and applied—that are not explicitly separated. Chapters 1–4 lay out the theoretical foundations of Snyder’s claim, where his examples mainly engage with smugglers, immigration and sweatshops; topics with which Snyder is familiar (Snyder, 2010). In chapters 5–8 his claims become more tangible, as Snyder offers compelling examples from the health care setting to illustrate how hope can be exploited. These chapters offer new insights into the phenomena of exploitation, fairness and (false) hope and engage with responsibilities of identifiable people, clarifying Snyder’s claims. The theoretical chapters, preceding these, offer high-level insights on these issues too. Yet their content and claims are easier to appreciate in a second read, when the applied chapters have done their magic.
The book’s title “Exploiting Hope” illustrates Snyder’s high-level starting point. It raises the question: What does it mean, and how does this relate to ‘false hope’, a more familiar term in these settings? Snyder does not explicitly address this question, and it takes most of the book to understand Snyder’s starting point: that there might actually be a problem of respect in particular relations whereby hope is exploited, and that ‘falsity’ of the hope may not be the problem. Had Snyder engaged with the complexity of references to false hope, outlining how such references beg the question if hope could ever be false, (Eijkholt, 2020) his title and contribution would have been more concrete and clear-cut earlier in the book.
Snyder introduces the components of his primary claim in his first chapter, ‘Talking about Exploiting Hope’. As each of these components is rich in itself, their brief introduction makes the chapter dense and abstruse. Aside from engaging with exploitation, hope and false hope, he touches on the various definitions of hope and its potential synonyms and counterparts, such as dreams, hopes, fears and weaknesses. Setting the complexity of the chapter aside, its message is perhaps simple: that there can be exploitation of hope even without misunderstanding of the exploitee or fraudulent intent of the exploiter; two common presuppositions in the context of the case studies and discussions of hope.
Snyder engages with the question ‘What Is Exploitation?’ in chapter 2. He extensively sets out the intricacy in defining exploitation and its classification as morally problematic. Using the well-known example of sweatshop employees, he illustrates how exploitation has been justified as mutually beneficial in situations where these labourers might be relatively well paid and engage in this labour voluntarily. Snyder argues, however, that such exploitation would still be wrong, and uses theories of fairness to explain this. He differentiates between structural and transactional fairness, which proves to be worthwhile for the later chapters on hope in medical settings. This distinction whereby a person would, respectively, take advantage of unjust structural conditions or of unfairness in transactions, offers an explanation for two kinds of vulnerabilities that hope can create. However, without concrete examples of the medical settings to lean on, the value of this distinction for the hope discourse remained initially unclear to me.
The chapter: ‘What Is Hope’ discusses different definitions of hope, including takes from psychology, philosophy and sociology. Snyder explains that hope can sometimes involve a conscious component, but that individuals also make “leaps of hope” which may not be as rational. Hope then can give a reason to live and offer coping mechanisms as a means to control one’s destiny. Indirectly, Snyder thereby illustrates how definitions of hope struggle with rational components and affective (emotional) components of the term (Musschenga, 2019). Snyder chooses to “borrow heavily” from Adrienne Martin’s definition of hope in her book: How We Hope: A Moral Psychology (Martin, 2016) to argue beyond the limited “orthodox contemporary analytic view of hope”. He uses the enriched view of hope to illustrate that hope creates a vulnerability. This focus on vulnerability, instead of on hope’s cognitive and affective components, offers the foundation for Snyder’s claims around exploited hope.
Chapter 4 ‘Exploiting Hope’, brings the theoretical musings together, and offers the basis for one of the book’s claims: that there can be exploitation of hope on a third basis. Next to the basis in transactional or structural unfairness, exploitation may arise as a failure in the duty “to accord others the respect due to them by virtue of their humanity”. Snyder shortens this as: a duty of respect, which he eventually explains as responsibility by (partial) entrustment. In outlining this new basis, the chapter offers the bridge for transition to the case studies of the following chapter.
The case study in Chapter 5 ‘Testing Hope: Exploitation in Clinical Trials’ focuses on the hopes of individuals who participate in clinical trials. Snyder elaborates on phase 1 cancer trials and trials in low to middle income countries (LMIC) to make two points. First, he illustrates that an account of transactional fairness cannot explain potentially perceived wrongs in the creation of hope in these contexts. Indeed, participants in Phase 1 cancer trials are not reimbursed or required to pay for participation. Second, he illustrates that misunderstanding is not just about simple information provision, by illustrating the diverse origins and targets of hope. Accordingly. In the LMICs context, for example, individuals might hope that the trialled drug might become available in their region, but this is unlikely to happen. These hopes are not the result of false information, but most likely due to misunderstanding about the mechanics of drug purchasing, patenting regimes and power structures between richer and poorer countries.
The promise of stem cell interventions and miracle cures for untreatable diseases are spotlighted in chapter 6: ‘Selling Hope’. Snyder offers a snapshot overview of different unproven (expensive) stem cell applications, the promise of their all-encompassing curative powers and their regulatory context. He describes how hope might arise through consumer websites and exaggerated claims on social media. Additionally, he outlines different putative harms of buying into the promise of stem cells, and examines whether these harms define the problem of exploitation. Snyder submits that hope may be instrumental for individuals as a means to feel in control of one’s destiny, but wonders if a patients’ feeling of control and hope would be reasonable to trade off for a tumour, a serious concern with stem cell interventions, or for a significant loss of money. Snyder’s stance implies a negative answer. His application of terms like ‘trust’, ‘fiduciary obligations’, ‘relationships’ and ‘responsibility’ emerge as key features defining the exploitation of hope. These issues exist beyond financial exchanges or structural unfairness, and offer the key to Snyder’s claim about exploitation as a failure of respect, as set out in the next chapter.
In the chapter ‘Legislating Hope’, Snyder focuses on ‘the right to try’ and he finally illustrates how a failure of respect can be at the heart of exploitation. This chapter offers new dimensions to understand the exploitation of (false) hope. I.e. that hope might not be generated only through persons, but also arise out of legislation or a political context. Snyder describes the landscape and historical context of right-to-try initiatives, which were born out of hopes that experimental interventions would be available in much earlier stages of development. As Snyder explains, however, these ‘right to try’ laws do little to improve access to experimental interventions. For example, they do not require developers to actually provide the therapies. Thus, the hope for increased access remains fruitless. Snyder illustrates how ideological ends like personal liberty and freedom have driven legislative efforts. While the hope connected to right-to-try therapies might remain fruitless, this seems irrelevant for legislators and politicians. The fundamental problem is that politicians, in this case, are partially entrusted with the obligation to be transparent and open, yet they do not meet these responsibilities insofar as right-to-try initiatives are broadly fruitless. Accordingly, the primary problems with these laws do not lie in transactional and structural fairness. Such issues may arise, as some parts of right-to-try laws prioritize individuals with an ability to pay (an issue of transactional fairness). Further, they are a risk to the system in undermining institutions that need trust, such as the FDA (an issue of structural fairness). But for Snyder, the main problem with these right-to-try initiatives should be labelled as a problem of ‘respect’. That is, politicians do not honour obligations of transparency and instead exploit hope for political or ideological purposes.
Medical crowdfunding is the last case study in the chapter ‘Networks of Hope’. This chapter shows that the exploitation of hope isn’t just a matter of malicious intent, or only generated by malicious people. Snyder describes how medical crowdfunding creates communities who serve as a conduit for (false) hope. Communities are eager to assist in funding treatments. Online messages about these treatments on medical crowdfunding websites risk perpetuating false claims about the safety and efficacy of interventions and thus feed false hope. Snyder’s extensive and detailed overview narrates how the proliferation of false hope might be accidental rather than planned and might not necessarily be deliberate from those within the community of funders. Even if Snyder describes that the companies behind the crowdfunding initiatives have responsibilities, these companies are only indirectly involved in the exploitation of hope. Instead, Snyder submits that the communities are (unfortunate) networks of exploitation. In generating emotions and perpetuating false information connected to the hope for a cure, the networks and the crowdfunder violate their partial entrustment to make good use of the donor’s funds.
Snyder finishes the book by concluding that there are 3 reasons why the specific respect-based account to exploitation is preferable over any other basis designed to explain the exploitation of hope. He concludes that (1) Fairness-based accounts are either too limited or too wide. (2) Specified respect-based accounts are inclusive of the benefits and advantages of fairness based accounts, and (3) specified respect-based accounts allow for specificity to context lacking in other accounts. His conclusion is representative for the rest of the book: it is original though complex. The chapters each offer an interesting read, though sometimes they give rise to more questions than they answer. The conclusion, for example, is helpful for understanding all the points that Snyder wishes to make. Still, it makes us wonder if this book is really about hope and its exploitation, or if it is really about making an argument for how a respect-based account regarding the exploitation of hope is more helpful than anything else.
In conclusion, the overarching message of the book is worthwhile, but its message is not always easy to distill. Reading through some of its intricacies, the book offers a new way of thinking about medically relevant cases in which hope arises. While this hope may not necessarily be qualified as false hope, the book offers a language to explain distaste for how hope is generated and used. In introducing the phrasing ‘exploiting hope’ the book offers us a terminology to evaluate situations in which desperate people might fare on fruitless hope. Snyder’s book gave me a new way of expressing my discomfort with pursuits of unproven stem cell interventions, and beyond. To return to the beginning of this review, the book allows me to qualify Trump’s explanations without needing to refer to false hope. Instead I can refer to him exploiting the hope of despairing populations for his political gain.
Marleen Eijkholt
Leiden University Medical Center
Leiden, Netherlands
References
Snyder, Jeremy. “Exploitation and sweatshop labor: Perspectives and issues.” Business Ethics Quarterly (2010): 187–213.
Eijkholt, Marleen. “Medicine’s collision with false hope: The False Hope Harms (FHH) argument.” Bioethics 34.7 (2020): 703–711.
Musschenga, Bert. “Is there a problem with false hope?.” The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine. Vol. 1. No. 4. US: Oxford University Press, 2019.
Martin, Adrienne. How we hope: A moral psychology. Princeton University Press, 2016.