13 Mapping the Language of Hope within Empirical Research onto Virtue Theory

Michelle A. Marvin

Many dispositions are colloquially referred to as virtues in today’s Western society, yet few have inspired as much recent debate over their formal inclusion within a virtue ethics framework as hope. Intuitively, hope is a positive character disposition with potential instrumental value; however, scholars disagree both over how to define hope and whether the cultivation of hope leads to a morally virtuous life. Scholars who favor hope as a moral virtue, such as Luc Bovens and Adam Kadlac,[1] claim that hope’s virtuous quality exists in its productive capacity to promote human wellbeing. Scholars who deny hope the status of a moral virtue, such as Christopher A. Bobier and Barbro Fröding,[2] ground their arguments in traditional definitions of virtue, contending that hope is not an intrinsically good disposition of character. This essay argues that the debate is currently irresolvable because contemporary virtue ethics does not give sufficient attention to the diversity of linguistic expressions associated with hope in various empirical research programs.

While maintaining a neutral position about whether hope is a virtue, this essay brings hope language from twentieth and twenty-first-century medical research into dialogue with virtue ethics in order to show that medical cases of hope cannot currently be used to substantiate claims about whether hope is a virtue. Although philosophers sometimes use a terminally ill individual’s hope as evidence for or against the claim that hope is a virtue, this essay argues that such evidence is insufficiently qualified to support an argument in either direction. As demonstrated by the qualitative empirical research in medical scientific literature, such as patient surveys and interviews, hope language contains a multiplicity of meanings including expectation and optimism. The purpose of this essay is to provide examples of these meanings within the medicalized language of hope in order to argue that virtue ethicists should give greater attention to the nuance with which hope language is imbued.

I begin by reviewing current positions in the philosophical debate over hope as a moral virtue in order to demonstrate how specific interpretations of hope language play a role in determining whether hope should be included in a virtue ethics framework. Next, given that virtue ethics frequently refers to medical cases of hope, I review the historical landscape that led medical and philosophical communities of the mid-twentieth century to concurrently take up an ethical interest in hope. Finally, as a case study, I analyze the way hope language is used by four terminally ill patients as documented in psychiatrist Elisabeth Kübler-Ross’s seminal work On Death and Dying.[3] This essay reveals the ways in which hope language is used to express expectation and optimism, dispositions toward the future that are ambiguous in a virtue ethics framework. The conclusion summarizes the challenges that hope language presents for a virtue ethics framework.

The Current Philosophical Debate over Hope as a Moral Virtue

Several virtue ethicists, such as Philippa Foot, Luc Bovens, and Adam Kadlac, argue for the inclusion of hope in a list of moral virtues.[4] In 1978, Foot included hope in a list of virtues in her article “On Virtues and Vices.”[5] Situating virtue ethics firmly on the foundations of classical traditions, Foot argues that “… it is best when considering the virtues and vices to go back to Aristotle and Aquinas.”[6] Foot interprets virtues as correctives for the development of human character, whereby virtues resist or correct certain temptations and guide a person towards the good life.[7] In her framework, just as courage resists the temptation of cowardice and temperance resists the temptation of pleasure, so hope resists the temptation of despair.[8] Additionally, Foot provides cases where collectively the three virtues of temperance, courage, and hope are necessary to preserve a person’s life.[9] By contrasting hope with despair and describing hope’s life-preserving capacity, Foot’s framework serves as a model for contemporary arguments that favor hope as a moral virtue in both philosophical and medical-scientific literature.

Following Foot’s hope and despair dichotomy, philosopher Luc Bovens adopts an Aristotelian lens for his approach to hope within virtue ethics. His 1999 essay “The Value of Hope” laments the notable dearth of attention given to hope as a virtue within philosophical literature.[10] Bovens claims that “hope seems to obey Aristotle’s doctrine of the mean. To live one’s life well one should not hope too much and not hope too little.”[11] This stress on finding hope a mean, or an average between two extremes, frames Bovens’s understanding of hope in terms of an Aristotelian virtue. Using dramatized hope from The Shawshank Redemption as a case study, Bovens argues that hope’s virtue exists as the mean of intrinsic, instrumental benefits.[12] When given a variety of future trajectories, Bovens argues that hope enables the realization of desired outcomes, reduces a focus on possible losses, and incites new, more realistic hopes.[13] If a person is given guidelines and assistance in cultivating hope, Bovens claims that hope can have an instrumental value that strikes a balance between overconfidence and despair. Balancing hope in order to optimize an individual’s wellbeing is a theme from Bovens’s work that continues to be addressed in scholarship across the disciplines.

Recent research in favor of hope as a virtue builds upon Bovens’s emphasis on hope’s intrinsic and instrumental value. Specifically, philosopher Adam Kadlac argues that hope’s value is not based on the goodness of its object or its alignment with future realities. Rather, Kadlac contends that hope is virtuous when it promotes a realistic perspective of the future, tempers confidence and avoids pessimism, promotes an attitude of courage, and advances solidarity with others.[14] In situations where hope fails to produce these benefits, Kadlac suggests that hope is tainted by other vices or underdeveloped virtues.[15] For example, if an individual hopes for a particular future but lacks the prudence to recognize that hope deters participation in meaningful activities while awaiting the future, then the virtue of hope is diminished by underdeveloped prudence. For Kadlac, the value that hope provides for guiding an individual’s life towards moral ends justifies his position that hope, itself, is a moral virtue.

Despite these perspectives that advocate hope’s inclusion in a virtue ethics framework, other scholars oppose hope’s status as a moral virtue. Philosopher Barbro Fröding argues that Aristotle often describes hope negatively, especially in cases where hope “…[causes] agents to feel inappropriately confident and trigger vicious self-delusion.”[16] In an Aristotelian virtue ethics, overconfidence is linked with excess courage that can lead to imprudent decision-making and harmful consequences. Fröding notes that it is not clear within the Aristotelian account whether hope is “something intrinsically valuable [or] perhaps even necessary to the leading of a good life.”[17] Contra Bovens and Kadlac, Fröding contends that an Aristotelian concept of human flourishing holds that virtues are not instrumental in themselves; rather, acting virtuously leads to the realization of flourishing. For Fröding, “agents must develop a deep understanding of a set of virtues. If they are successful in this, they will be able to think, feel, choose, and act in a certain manner that is conducive to their happiness.”[18] Thus Fröding suggests that hope may be a component of a virtue, but it does not meet the Aristotelian definition of virtue. Although it is not necessary that contemporary virtue ethics uphold Aristotelian standards, Fröding believes that the current debate over hope appeals to Aristotelian criteria in ways that fail to provide support for the case of hope as a moral virtue.

In further opposition to hope as a moral virtue, philosopher Christopher A. Bobier uses Aquinas’s distinction between hope as a passion and hope as a theological virtue to argue that scholars “…have moved too quickly from observing hope’s value to positing it as a moral virtue.”[19] Bobier uses Aquinas’s definition of hope as a passion to argue that the objects of human hopeful desires can be both moral and immoral. While a person may hope for something that is morally good, hope may also be directed towards that which is immoral. Because hope is intrinsically neither good nor evil, other moral virtues, such as prudence, can combine with the passion of hope to support rational moral decision-making. Aquinas does not assign hope to the set of moral virtues, yet he does allow for a specific kind of hope to be understood as a theological virtue. This kind of hope is “… a divinely implanted disposition of the will, or intellectual appetite, to depend on God.”[20] Given this definition, Bobier argues that hope as a passion situates an individual towards future outcomes in the world, whereas hope as a theological virtue orients the individual towards hope in God. In this framework, Bobier leaves no room for the possibility of hope as a moral virtue.

While the philosophical community argues over whether or not hope is a virtue, the medical-scientific community assumes that hope has an ethical value that is important for patient well-being. Hope is frequently used to gauge patient disposition and coping capacity, yet qualitative research from medical-scientific scholarship reveals that hope language is fraught with obscurity. Such ambiguity naturally occurs in an interview setting, but this ambiguity has gone largely unaccounted for by virtue ethics scholarship. The multiplicity of meanings in hope language reported in qualitative studies from the medical-scientific community may underlie some of the difficulty that is contributing to determining whether or not hope is a virtue.

The Mid-Twentieth Century: Virtue Ethics and Medical Hope

The tendency for philosophers to use medical cases as evidence of embodied virtues is a practice as old as Greek virtue ethics itself and continues to persist in virtue ethics scholarship on hope today. The twentieth-century interest in hope as a moral virtue is particularly associated with medical cases of hope, although this is not surprising given the development of new medical treatments and cures that allowed for hope in the face of previously devastating diagnoses.[21] The twentieth-century surge of renewed attention in virtue ethics initiated by G. E. M. Anscombe’s 1958 article “Modern Moral Philosophy” also coincided with shifts in the philosophy of medical practice, particularly in areas of physician-patient ethics.[22]

As Anscombe began to question the foundations on which secular moral philosophy could prescribe moral obligations, the medical community began to question its own moral responsibility regarding patient diagnoses. In 1951, the Journal of the American Medical Association described how only ten years prior, a cancer diagnosis was “…almost unmentionable between patient and diagnostician, and most persons did not wish to know or expect to be told of such diagnoses.”[23] As patients became more acquainted with cancer prognoses and the possibilities of survival, their physicians required additional guidance as to when, and how, terminal diagnoses should be discussed. The American Medical Association acknowledged that physicians were under tremendous pressure to maintain a patient’s hope, yet it asserted that it was “important to forestall the possibility of raising false hopes…” while providing the patient with “immediate reassurance…so that [the patient] will feel that everything is not hopeless.”[24]

The ability to balance and maintain hope became a moral standard for whether or not a physician should reveal the diagnosis of a terminal illness to a patient. This emphasis on finding a balance of hope in order to promote a patient’s individual flourishing indicates a shift in the practice of medical ethics away from a physician’s moral sense of right and wrong and toward an ethics of patient flourishing. While the changing medical ethics landscape of the 1950s corresponded with Anscombe’s transformative vision of moral philosophy, the language of hope within medical research had yet to begin accounting for the multiple meanings that patients could attribute to hope itself.

After the shift towards an ethics of patient flourishing, an emphasis on hope arose in medical-scientific literature on terminal illness. In the 1960s at Billings Hospital of the University of Chicago, psychiatrist Elisabeth Kübler-Ross began to conduct interviews with terminally ill hospital patients about their experience with the dying process. In her seminal 1969 book, On Death and Dying, Kübler-Ross reached the same conclusion as the American Medical Association: patients demonstrate the greatest confidence in doctors who balance hope. She writes that “[patients] appreciated it when hope was offered in spite of bad news. This does not mean that doctors have to tell them a lie; it merely means that we share with them the hope that something unforeseen may happen, that they may have a remission, that they will live longer than is expected.”[25] Without the option for hope, Kübler-Ross argues, patients decline into despair and give up the fight for life. In one case, a patient stated that his cancer diagnosis

…was more of a blow than it might be because [the doctor] gave me no hope… But after I got [to the hospital] and found out that there was some hope for my condition and that my condition wasn’t hopeless, then I found out that I had done the wrong thing…and that if I had only known it at the time I would be in top-notch shape right now.[26]

Upon interpreting this interview, in which the patient further revealed many personal losses including the death of his daughter, Kübler-Ross states that “what grieved him most, however, was the loss of hope.”[27] While this vignette appears to exemplify Kübler-Ross’s argument on the need for balancing patient hope, a closer look at the way hope is used to mean several different sentiments will provide greater insight into the complexity of locating hope within a medical context.

The Complexity of Hope Language in Elisabeth Kübler-Ross’s On Death and Dying 

In order to appreciate the multiplicity of meanings in hope language within medical-scientific research, I will examine four interviews with terminally ill patients in Kübler-Ross’s book On Death and Dying. I chose this particular work because Kübler-Ross makes the claim that “…no matter the stage of illness or coping mechanism used, all our patients maintained some form of hope until the last moment.”[28] Kübler-Ross’s research focuses on the patient experience of the dying process, and it is through her elaboration of this process that hope becomes a prominent theme. Through this work, Kübler-Ross influenced the following five decades of medical-scientific research on terminally ill patients; thus her presentation and interpretation of hope language is an important starting point for understanding the multiplicity of meaning in the language of hope.

According to Kübler-Ross, patient hope finds expression in many desires, including the possibility of new medical discoveries, a new drug or serum, a miracle from God, a mistaken X-ray reading, the realization that a pathological slide belongs to another patient, a natural remission, and so forth. From Kübler-Ross’s perspective, each of these articulated possibilities reveals that many patients hope toward the same goal: physical survival. However, expressions of hope contain different relations with personal agency, expectation, optimism, grounding within reality, and time to possible fulfilment. The remainder of this essay will focus exclusively on the relationship between hope, expectation, and optimism within Kübler-Ross’s patient interviews in conjunction with current scholarship on expectation and optimism in order to demonstrate the degree to which hope may be distinct from these terms.

Throughout Kübler-Ross’s work, the word “expectation” is rarely used, especially in relation to patient prospects for future outcomes. According to a 2009 review of hope and expectation in medical literature over the last forty years, expectation is best defined as “…cognitions about future events and experiences [that] derive from subjective assessment of probability that range from the unlikely but possible to the virtually certain.”[29] Using this definition of expectation that bases future outcomes on probabilistic reasoning, a 2016 psychiatric study with chronically ill individuals found that patients are more often willing to voice desires for the future in terms of hope than to describe actual expectations.[30] The authors of the study posit that because all forecasted probabilities have the chance of an unfavorable outcome, patients prefer not to hold expectations at all. High expectations leave a patient open to traumatic disappointment and low expectations have a culturally superstitious association with negatively influencing outcomes; therefore expectations are a risky investment.[31] However, patients feel less vulnerable to outcome possibilities when they frame future desires in terms of hope, since hope language allows for the expression of improbable desires.[32] Therefore, hope can disguise a patient’s actual expectations with a preference for more desirable outcomes.

Research comparing medical hope with expectation demonstrates that hope is most frequently driven by preferences for future outcomes, whereas expectations are driven by a sense of probability.[33] A patient’s preference for hopeful outcomes is often based on personal experiences or the stories told by others, rather than the probabilistic, calculated facts given by statistics.[34] This tendency for patients to use the language of hope in a way that veils expectations is evident in Kübler-Ross’s interview transcripts. For example, a woman with a terminal cancer diagnosis named Mrs. A becomes distraught over the knowledge that radiation will result in her sterility. Mrs. A expresses a firm desire to have children, despite her growing cancerous malignancy. Initially, her hopeful preference for having children and overcoming her malignancy without treatment results in her resistance to medical consultation. However, her preferential perspective eventually yields to probability: Mrs. A chooses to forsake the possibility of bearing children and undergoes radiation treatment, “hoping that this treatment might cure the malignancy.”[35] In this statement, Mrs. A’s hope represents expectation: a subjective assessment of the probability that her malignancy will not resolve without treatment, as the doctors have stated. While Mrs. A never uses the word expectation, she expects that her medical treatment will be successful and no longer holds the preferential hope that she will bear children. Although Kübler-Ross does not distinguish between hope and expectation when interpreting this interview, this close review of her case suggests that a subtle shift in future prospection has taken place in her interviewee.

A second case study demonstrates the use of hope language to disguise expectation. In the transcript of an interview with a farmer named Mr. Y who had never previously been to the city or the hospital, Kübler-Ross describes the distressed state of a hopeful and frantic man who was waiting for news about his terminally-ill wife’s recovery. Even though Mr. Y was very uncomfortable in the city hospital setting, Kübler-Ross writes that “…the big hospital bore the promise of extending [his wife’s] life and he, the old man from the farm, was willing to venture into such a place for the glimpse of hope that it had offered.”[36] Mr. Y’s “glimpse of hope” was more than an uncertain longing for his wife’s survival. His hope was invested in the “promise of extending [his wife’s] life,” indicating that he had high expectations that his investment in the unusual place and hospital culture would result in the benefit of his wife’s survival. Mr. Y’s hope had shifted from a preference of nurturing his wife back to health on his farm, to a subjective assessment of the probability that her terminal illness would not find relief without the resources of the city hospital. As in the interview with Mrs. A, this case demonstrates that a shift in the meaning of hope had taken place for Mr. Y, even though the language of hope remained the same.

As with the term expectation, there are occasions when optimism would be a better descriptor for the patient’s intentions than hope, and yet the patients in Kübler-Ross’s interviews do not use the word optimism. A 2013 psychological study suggests that hope is distinguishable from optimism because hope requires both personal agency and pathways towards favorable outcomes, whereas optimism requires only a generalized positive outlook on the future.[37] These criteria suffice to demonstrate that there are distinctions between hope and optimism that patients intend to express even when they only use the word hope. For example, in Kübler-Ross’s interview with a woman named Mrs. C, the patient states that “nobody knows how long this can still last. I surely have always held onto hope, but this is the lowest I have ever been. The doctors have not revealed anything to me.”[38] Even though Mrs. C is in her lowest affectual state, her desire to live is framed in an attitude of general optimism rather than an expression of specific pathways towards success such as cures or treatments. She claims that she has “always held on to hope,” yet her hope is not linked with any particular method of recovery nor with her own action towards the goal of survival; therefore her hope is an indiscriminate optimism towards the future.

Similarly, Kübler-Ross questions a patient named Mr. H about what motivates him to continue living, despite his terminal condition. Mr. H responds by stating: “well, it’s a kind of blind hope more than anything else.”[39] Mr. H’s hope is “blind” in the sense that he does not foresee a path towards ensuring his survival, nor a role that he can play that would result in a favorable health outcome. His hope, therefore, is also an expression of generalized optimism. In these two cases, each patient uses the word hope to describe experiences of optimism, though Kübler-Ross interprets these accounts as expressions of hope. As demonstrated in these case studies, research on expectation and optimism from the fields of medical science is just beginning to provide tools for analyzing and interpreting the multiplicity of meaning that lies beneath the language of hope in medical contexts.

Conclusion

As shown by these four cases, expectation and optimism separately play dominant roles in what patients mean when they use the word hope to the degree that expectation and optimism may be distinct from hope, though still called hope within qualitative research. Although I cited specific psychiatric and psychological studies acknowledging distinctions between hope, expectation, and optimism, the majority of scholarship conflates these terms or uses the terms ambiguously. While arguments for the inclusion of hope within a virtue ethics framework assert that hope obeys an Aristotelian mean, it is unclear whether expectations may adhere to an Aristotelian mean, whether optimism is distinct from hope’s extreme of overconfidence, and whether hope can be uniquely defined apart from optimism or expectation. In the philosophical debate over whether or not hope is a moral virtue, the degree to which expectation and optimism may themselves be considered virtuous, or assist in the virtuous life, requires further deliberation. By examining the subtleties in hope language, this essay has argued for virtue ethics to give greater attention to the diversity of linguistic expressions associated with hope in empirical research programs.

MICHELLE A. MARVIN is a Ph.D. candidate in Systematic Theology and the History & Philosophy of Science at the University of Notre Dame. Her dissertation brings the Catholic faith tradition into dialogue with research from contemporary neuroscience in order to contribute to a Christian discourse on memory loss. By analyzing the theological anthropology of the late Catholic theologian Edward Schillebeeckx, she contends that memory is more than merely neurobiological processes: it is a relational identity that is inherently indissociable from God and the community. Michelle’s research compares a theology of relational memory to a Western neuro-reductionist portrait of memory in order to address the philosophical presumptions that underlie contemporary paradigms of the memory-identity relationship. Beyond her dissertation, Michelle works in the University Writing Center and serves as the head liturgical musician at St. Paul’s Retirement Community in South Bend, IN.

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  • Anscombe, G. E. M. “Modern Moral Philosophy.” Philosophy 33.124 (1958): 1–19.
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  • Kline, Nathan S., and Julius Sobin. “The Psychological Management of Cancer Cases.” Journal of the American Medical Association 146.17 (1951): 1547–51.
  • Kübler-Ross, Elisabeth. On Death and Dying: What the Dying have to Teach Doctors, Nurses, Clergy, and their Own Families. 40th Anniversary Edition. London: Routledge, 2009.
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  1. Luc Bovens, “The Value of Hope,” Philosophy and Phenomenological Research 59.3 (1999): 667–81; Adam Kadlac, “The Virtue of Hope,” Ethical Theory and Moral Practice 18 (2015): 337–54.
  2. Christopher A. Bobier, “Why Hope is Not a Moral Virtue: Aquinas’s Insight,” Ratio 31.2 (2018): 214–32; Barbro Fröding, “Hope as a Virtue in an Aristotelian Context,” Philosophy, Psychology, & Psychiatry 19.3 (2012): 183–96.  
  3. Elisabeth Kübler-Ross, On Death and Dying: What the Dying have to Teach Doctors, Nurses, Clergy, and Their Own Families, 40th anniversary edition (London: Routledge, 2009).
  4. Philippa Foot, “Virtues and Vices,” in Virtues and Vices and Other Essays in Moral Philosophy (Berkeley, CA: University of California Press, 1978), 1–18; Bovens, “The Value of Hope”; Kadlac, “The Virtue of Hope.”
  5. Foot, “Virtues and Vices.”
  6. Ibid., 1.
  7. Ibid., 8.
  8. Ibid., 9.
  9. Ibid.,  13.
  10. Bovens, “The Value of Hope,” 669.
  11. Ibid.
  12. Ibid., 673–78.
  13. Ibid., 670–73.
  14. Kadlac, “The Virtue of Hope,” 338.
  15. Ibid., 351.
  16. Fröding, “Hope as a Virtue in an Aristotelian Context,” 184.
  17. Ibid.
  18. Ibid.,
  19. Bobier, “Why Hope is Not a Moral Virtue,” 232.
  20. Ibid., 221. Bobier is drawing upon Thomas Aquinas’s response to whether hope is a virtue in Summa Theologiae II. II. 17. 1.
  21. In particular, the development of chemotherapy treatments beginning the 1940s radically changed survival outcomes for patients with cancer diagnoses.
  22. G. E. M. Anscombe, “Modern Moral Philosophy,” Philosophy 33.124 (1958): 1–19.
  23. Nathan S. Kline and Julius Sobin, “The Psychological Management of Cancer Cases,” Journal of the American Medical Association 146.17 (1951): 1547.
  24. Ibid., 1548.
  25. Kübler-Ross, On Death and Dying, 113.
  26. Ibid., 74.
  27. Ibid., 88.
  28. Ibid., 214.
  29. Karen K. Leung, James L. Silvius, Nicholas Pimlott, William Dalziel, and Neil Drummond, “Why Health Expectations and Hopes are Different: The Development of a Conceptual Model,” Health Expectations 12.4 (2009): 348.
  30. Emery R. Eaves, Mark Nichter, and Cheryl Ritenbaugh, “Ways of Hoping: Navigating the Paradox of Hope and Despair in Chronic Pain,” Culture, Medicine, and Psychiatry 40 (2016): 42.
  31. Ibid., 50.
  32. Ibid.
  33. Leung, et al, “Why Health Expectations and Hopes are Different,” 348.
  34. Ibid.,  347–60.
  35. Kübler-Ross, On Death and Dying, 27.
  36. Ibid., 135.
  37. Gene M. Alarcon, Nathan A. Bowling, and Steven Khazon, “Great Expectations: A Meta-Analytic Examination of Optimism and Hope,” Personality and Individual Differences 54 (2013): 822.
  38. Kübler-Ross, On Death and Dying, 176.
  39. Ibid., 81.