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.

2023 年 4 月，《纽约时报》发表了作者兼心脏移植患者艾米·西尔弗斯坦 (Amy Silverstein) 的一篇评论文章 [ 1 ]。西尔弗斯坦女士的观点引起了一系列反应，其中一些人感到愤怒，因为他们认为她对生命中获得的第二次和第三次机会缺乏感激之情。然而，作为移植领域的专业人士，西尔弗斯坦女士的故事引起了我们的共鸣，特别是她对她所谓的“感恩悖论”的描述，即实体器官移植患者应该对他们所拥有的东西——一个新的、功能正常的器官——表示感激——并且隐含或明确地不鼓励寻求更多更好的移植后治疗方案[ 1 ]。虽然她的观察对我们来说是个人的，但我们看到了与整个医疗保健社区相关的相似之处。西尔弗斯坦女士指出，在她被诊断出癌症晚期后，她对两次心脏移植的感激之情与她的愿望之间是矛盾的，她说这一诊断可能是由于长期使用旨在保护移植器官的免疫抑制药物造成的。拥有更多的生活。她表达这种愿望并非忘恩负义；她确实如此。她只是一个人。虽然西尔弗斯坦女士的生活细节与移植领域相关，但我们相信她所表达的人类愿望应该引起整个医疗保健界停下来反思我们为什么选择这个职业以及我们固有的责任。

感恩悖论的概念并不新鲜。 BBC 记者凯特·摩根 (Kate Morgan) 在 2021 年的一篇文章中探讨了这个问题，探讨了在新冠肺炎 (COVID-19) 大流行之后对受聘者的感激之情的复杂性 [ 2 ]。她讨论了许多人所经历的困境：在失业率上升的时期庆幸自己能找到一份工作，但又感到雇主薪酬过低、价值被低估和负担过重 [ 2 ]。另一个更具历史意义的例子是“隔离但平等”法律，俗称吉姆·克劳法，该法律通过 20 世纪 60 年代的民权运动渗透到内战后时代的美国人生活中。在吉姆·克劳统治下，美国黑人经历了并被期望感激（或如戴维斯[ 3 ]所描述的，“令人愉快且没有挑战性”）的隔离条件，但事实证明，这些条件绝非平等。人们普遍认为，某些人群，特别是那些弱势群体，例如患有慢性疾病的患者、种族和族裔少数群体或来自较贫穷社会经济背景的个人，应该感谢在实现更好的生活方面取得的进展所带来的任何好处。生活。每当他们认为最低限度的要求还不够时，他们就会被视为缺乏感恩之心的麻烦制造者。

在我们的社会中，人们期望弱势群体应该为拥有的东西而感恩，而不是一无所有。当他们通过要求更多、更好来表达感激之情时，往往会遭到那些拥有更多的人的强烈反对，因为这个要求会引发防御性反应：我们还能做什么？我们认为，希望从像美国这样先进的医疗保健系统中获得更好的结果是一种合理的期望。艾米·西尔弗斯坦的观点文章中表达的情感强化了这一观点。

首先让我们考虑一下为什么我们有这些感恩的期望。作为医疗保健提供者，我们的职责是为患者提供尽可能最好的护理，并不断努力做得更好。例如，对于许多终末期器官疾病患者来说，最好的药物治疗是移植[ 4 ]。然而，当患者接受实体器官移植时，他们将面临终生的免疫抑制负担及其各种风险和不良后果[ 5 ]。对于移植行业来说，令人不安的事实是，在过去 25 年里，在改善移植受者的命运方面只取得了渐进的进展。因此，当对移植奇迹的感激之情被对更好、危害更少的移植后治疗方案的渴望所冲淡时，这真的是一个惊喜吗？我们要求其他学科的同事同样诚实地面对自己，尽管他们的努力虽然充满活力和善意，但并没有满足患者的愿望。

作为所有学科具有同理心的医疗保健提供者，我们必须验证冲突患者的经历；对治疗益处的喜悦和感激，对发生不良反应时的沮丧和恐惧，以及对更多更好的护理选择的渴望。我们必须努力为患者提供更多更好的挽救生命和增强生命的治疗选择。现状还不够好。我们要求所有同事反思，为什么当患者表达出更多更好的愿望时，向患者强加感激的期望而不是提供同理心和合作要容易得多。此外，我们要求医疗保健界以统一的声音来揭露何时严格遵守政治意识形态以及监管和政策框架阻碍了改善患者生活的进展。

我们要求我们的同事反思阅读西尔弗斯坦女士的文章时所经历的情感。我们建议，作为一个社会，我们将感恩的期望投射到他人身上，因为因所做的事情而获得赞誉比面对未实现的事情的局限性、不足和不平等更容易。医学职业固有的挫败感和绝望感是因为我们的患者面临的挑战超出了我们减轻他们痛苦的个人能力。因此，我们退到安全墙后面，这是我们对所提供的最低限度的感激之情的期望。问题是：我们如何停止退缩并开始放弃这些繁重的期望？我们是接受现状，还是抵制现状？

医学职业现在正处于十字路口，外部政治和社会力量准备摧毁以向他人提供服务为基础的职业的核心价值观。我们相信，现在是时候改变我们职业中感恩悖论的范式，并抵制更大的社会力量，这些力量试图最小化所有人拥有更好、更健康、更长寿的生活的内在愿望。为此，我们作为个人需要认识到并接受，那些弱势和边缘化的人的经历与他们的愿望在我们内心激起的感受、我们对感激的期望、我们对批评和失败的恐惧无关。作为医疗保健专业人员，我们唯一的任务是尊重他们的经历并支持他们追求更多更好的愿望。我们必须每天积极倾听并努力，以更加了解和接受患者的生活经历以及他们对独特生活的渴望。我们的责任是成为他们的盟友、倡导者和合作伙伴。现在是我们挺身而出、纠正不平等和不公正、克服阻碍为每个人提供更好医疗保健的感恩悖论的时候了。尽管如今作为一名医疗保健提供者面临着许多挑战，但我们幸运的是，我们每天都在服务于更高的目标。每一天，我们都有机会和荣幸帮助我们的患者实现更好的生活。西尔弗斯坦女士为所有医疗保健专业人员提供了服务，因为她提醒我们，我们来这里不仅仅是为了做得足够。我们每天都在这里为每位患者提供最好的服务。