Conclusion

The author argues in this book that the exploitation of hope should be understood as inappropriately taking advantage of a partial entrustment with aspects of others’ well-being. This respect-based account should lead individuals to ask the following questions: (1) Should this interaction happen at all or the partial entrustment be accepted? (2) If the entrustment is accepted, how can the hopeful relationship be managed most respectfully? (3) As these relationships develop, new information is gained, and conditions change, should the hopeful relationship be continued? He concludes by arguing that respect-based accounts of exploitation should be emphasized or even replace fairness-based accounts. The account of exploitation developed in this book should be applied to exploiting hope in non-medical contexts and to exploitation more generally.

What Is Hope?

Chapter 3 turns to academic analyses of hope. The author largely adopts Adrian Martin’s account. She proposes what she calls the incorporation analysis of hope where hoping entails being attracted to an outcome, seeing it as possible, treating this attraction as licensing a reason for certain ways of feeling, thinking, and acting toward that outcome, and treating this attraction as giving sufficient reason for these feelings, thoughts, and actions. Hope can be false as derived from misinformation or failures in autonomous decision-making, but it need not be so. Fantasizing and planning for the hoped-for outcome is consistent with understanding the actual probabilities of this outcome, including in cases of hoping against all expectation, and active fantasizing about these outcomes can improve health and welfare. At the same time, false hope creates a vulnerability to exploitation, as does persevering in hope at the expense of other, more obtainable options.

Networks of Hope

Chapter 8 looks at crowdfunding for unproven medical interventions, which typically are not paid for by public or private insurance. This system of fundraising plays a significant role in the exploitation of hope by funneling resources to exploiters and creating a pool of hopeful donors who are often misled about the interventions they are supporting. This case demonstrates the sometimes complex web of the exploitation of hope, where even ill and exploited individuals can be complicit in exploitation given the need to build hope in others in order to fund their own hopes.

Legislating Hope

In Chapter 7, the author discusses the promise of early access to unproven interventions through so-called right-to-try legislation. This legislation was designed with the stated intent of expanding access to new medical interventions undergoing clinical trials where individuals could not participate in these trials. In practice, very few people have benefitted from this law and there is evidence that it was motivated largely be an interest in eroding regulatory authority over new medical interventions. While policymakers and political leaders are typically understood to exaggerate or misrepresent their achievements, in this case specific claims about the promise and achievements of this policy trade on the hope of seriously ill individuals for political gain.

Talking about Exploiting Hope

This chapter presents and analyzes popular uses of variations of “exploiting hope” drawn from the press. Popular accounts of exploiting hope often focus on cases of desperately poor and sick people struggling to survive or meet their basic needs. But they also include relatively privileged people who are hoping for fame, great wealth, or a beautiful appearance. These individuals may be forced into exploitative exchanges, but in other cases they are voluntary. Two factors unite these examples. First, these hopes are weighty in the sense of being transformative and having the potential to greatly improve the hopeful person’s life. Second, pursuing these hopes involves unusual risk-taking, trust in others, or what the author terms leaps of hope that make the individual especially vulnerable to exploitation. In all these cases, exploiters take advantage of these leaps of hope to benefit themselves with little to no regard for the good of the exploitee.

Selling Hope

Some individuals seek to sell unproven interventions directly to consumers ahead of evidence. Chapter 6 examines the case of direct to consumer sales of unproven stem cell products to seriously ill individuals. In many cases, clinics selling these interventions are owned by or employ physicians both to administer these treatments and bolster these business’ credibility. Physicians have been willing to misrepresent the evidence supporting such interventions and abuse the trust of their patients in order to pursue these business opportunities. In doing so, they can act against their patients’ welfare, prioritize their own private interests over the health of their patients, and thus exploit their patients’ hope.

What Is Exploitation?

Chapter 2 reviews academic accounts of exploitation. The dominant understanding of exploitation links it to a form of unfairness. Wertheimer argues that a transaction can have features that make it “specially” unfair, as when an employer has a monopoly on employment opportunities. Alternatively, an exchange can be unfair considering a structural injustice that systematically advantages the exploiter. In these cases, employers may have a political responsibility to address structural injustice to avoid exploitation. Contemporary accounts of exploitation also link it to a failure of respect for others. This failure of a duty of respect is linked to a specified duty of beneficence, where our entanglements with others serve to specify specific obligations to aid others in developing and maintaining their distinctive human capacities. The author argues that each of these accounts of exploitation picks out a different kind of moral wrong and is useful for understanding exploitation in different contexts.

Introduction

Hope presents a duality where it creates both sustaining promise for the future and vulnerability to those acting on this promise. There is a need to understand how hope can be taken advantage of or exploited while still acknowledging the power and importance of sustained hope. This introduction provides background on the concept of exploitation and outlines the structure of the book. It surveys various accounts of the wrongness of exploitation, grounded both in interpretations of Marx’s concept of exploitation and contemporary authors. Exploitation can be understood as a form of unfairness in specific transactions and exchanges, unfairness stemming from unjust background conditions, or a failure to express appropriate respect for others. While these accounts each capture dimensions of exploitation, this introduction makes the positive argument that exploitation – including the exploitation of hope – consists most fully of a form of disrespect for others, namely taking advantage of a partial entrustment of another person’s well-being.

Testing Hope

Chapter 5 examines human participation in phase I clinical trials for experimental cancer interventions and phase III clinical trials in low- and middle-income countries. In both cases, these participants may take part in these trials in the hope of accessing an experimental intervention that will improve their own health or that of their communities. Exploitation of hope is most likely to take place in these contexts when there is a confusion about the roles of researchers and the aims of clinical research such that participants misunderstand the likely outcomes of the trial for themselves or their communities. Researchers and their sponsors can contribute to this misunderstanding by not communicating the aims of clinical research clearly or by using the language of hope to encourage trial participation.

Exploiting Hope

In the Chapter 4 the author argues that fairness-based accounts of exploitation form a poor basis for understanding the distinctive wrongness of exploiting hope. Structural fairness or justice-based accounts are also problematic in the medical context. Structural exploitation can describe some instances of injustices giving rise to the potential for exploitation but not the distinctive character of exploiting hope. Rather, exploitation understood as a failure of respect gives the best interpretation of what is distinctly wrong with exploiting hope. Specifically, individuals with weighty hopes who take risky leaps of hope partially entrust their welfare to others. This entrustment creates obligations for others who may exploit an individual’s hopes when they use this relationship as an opportunity for gain without duly discharging their responsibilities for the hopeful person’s welfare. This is true of both genuine hope and false hope, where the hope is based on misinformation, misunderstanding, and/or fraud.