The gratitude paradox

In April 2023, the New York Times published an opinion piece by author and heart transplant patient, Amy Silverstein [1]. Ms. Silverstein's perspective provoked an array of responses, some of which were angry because of the perception that she lacked gratitude for the second and third chance at life she was given. However, as professionals in the transplant field, Ms. Silverstein's story resonated with us, particularly her description of what she called the “gratitude paradox” wherein solid-organ transplant patients are expected to be grateful for what they have—a new, functioning organ—and are either implicitly or explicitly discouraged from asking for more and better posttransplant treatment options [1]. While her observations were personal for us, we see parallels that are relevant for the entire healthcare community. Ms. Silverstein pointed to the conflicting emotions of her own gratitude for her two heart transplants in the wake of her terminal cancer diagnosis, a diagnosis she states likely resulted from long-term use of immunosuppression medications meant to preserve her transplanted organ, and her desire to have more life. She wasn't ungrateful in expressing that desire; she was simply being human. While the specifics of Ms. Silverstein's life are relevant to the field of transplantation, we believe the human desires she expressed should cause the entire healthcare community to pause and reflect about why we chose this calling and our inherent responsibilities.

The concept of the gratitude paradox is not new. The BBC correspondent Kate Morgan explored this issue in a 2021 piece examining the complexities of gratitude for being employed in the wake of the COVID-19 pandemic [2]. She discussed the dilemma many individuals experienced between being grateful to have a job during a time of rising unemployment and feeling underpaid, undervalued, and overburdened by employers [2]. Another, more historical example is the “separate but equal” laws, colloquially known as Jim Crow laws, that pervaded American life in the post-Civil War era through the Civil Rights movement of the 1960s. Under Jim Crow, Black Americans experienced and were expected to be grateful for (or as Davis [3] describes, “agreeable and non-challenging”), segregated conditions that proved to be anything but equal. There is a prevailing attitude that certain populations, in particular those who are vulnerable, such as patients with chronic medical conditions, racial and ethnic minority groups, or individuals from poorer socioeconomic backgrounds, should be thankful for whatever benefits of progress made in achieving a better life. They are viewed as troublemakers who lack gratitude whenever they suggest the bare minimum is not enough.

In our society, there is an expectation that disadvantaged and vulnerable populations should be grateful for having something that is one step above having nothing. When they qualify their gratitude by asking for more and better, there is often a backlash from those who have more because this ask provokes a defensive response: What more can we do? We submit that it is a reasonable expectation to want better outcomes from a healthcare system as advanced as the one in the United States. This viewpoint is reinforced by the emotions expressed in Amy Silverstein's opinion piece.

Let us consider why we have these expectations of gratitude in the first place. As healthcare providers, our duty is to provide our patients with the best possible care available and to continually strive to do better. For example, the best medical therapy for many patients with end-stage organ disease is transplantation [4]. However, when a patient receives a solid-organ transplant, they are confronted with the lifelong burden of immunosuppression and its varied risks and adverse outcomes [5]. The uncomfortable truth for the transplant profession is that for the past 25 years, there has been only incremental progress toward improving the fate of transplant recipients. Therefore, is it really a surprise when gratitude for the miracle of transplant is tempered by a desire for better, less deleterious posttransplant treatment options? We ask our colleagues in other disciplines to be just as uncomfortably honest with themselves about where their efforts, while vigorous and well-intentioned, are not meeting the aspirations of their patients.

As empathetic healthcare providers in all disciplines, we must validate the conflict patients experience; joy and gratitude for the benefits of treatment, frustration and fear when adverse effects occur, and desire for more and better care options. We must strive to offer our patients more and better life-saving and life-enhancing treatment options. The status quo simply is not good enough. We ask all of our colleagues to reflect on why it is so much easier to impose expectations of gratitude on our patients rather than offering empathy and collaboration when the desire for more and better is expressed. Moreover, we ask that the healthcare community speak in a unified voice to expose when the rigid adherence to political ideology and regulatory and policy frameworks impede progress toward improving the lives of our patients.

We challenge our colleagues to reflect on the emotions experienced when reading Ms. Silverstein's article. We suggest that as a society, we project our expectations of gratitude onto others because receiving accolades for what is done is easier than confronting the limitations, inadequacies, and inequities of what is not achieved. Inherent to the profession of medicine is a sense of frustration and hopelessness because the challenges our patients face exceed our individual capacity to relieve their suffering. Therefore, we retreat behind the safe wall that is our expectation of gratitude for the minimum that is offered. The question becomes: how do we stop retreating and start relinquishing these burdensome expectations? Do we accept the status quo, or do we resist it?

The profession of medicine is now at a crossroads, with external political and societal forces poised to destroy the core values of a profession whose foundation is providing service to others. We believe it is time to shift the paradigm of the gratitude paradox within our profession and to resist the larger societal forces that seek to minimize the innate desire of all people to have a better, healthier, longer life. To do so, we as individuals need to realize and accept that the experiences of those who are vulnerable and marginalized are not about the feelings their aspirations provoke within us, our expectations of gratitude, our fears of criticisms and failures. As healthcare professionals, our only task is honoring their experiences and supporting their desires for more and better. We must actively listen and work every day to become more aware and accepting of the lived experiences of our patients and their desire for a life unique to them. Our responsibility is to be their allies, advocates, and partners. It is our time to step up, rectify inequities and injustices, and overcome the gratitude paradox that is hampering progress to better healthcare for everyone. While there are many challenges to being a healthcare provider today, we are fortunate that each day we serve a higher purpose. Each day, we have the opportunity and privilege of helping our patients achieve a better life. Ms. Silverstein has done a service to all healthcare professionals, because she has reminded us that we are not here to just do enough. We are here to do the best for every patient every day.

The authors have no conflicts to report.

None.