From CMF files - cmf file 50 (2013) - care and compassion
(Right click and choose 'save as...' to download a printable version of this article)
While it is generally assumed that care and compassion are fundamental parts of medicine and nursing, in recent years it has become apparent that this is not always the case.
A series of news stories and reports from statutory bodies over the last few years have questioned how caring our healthcare institutions and professions actually are, and showed that institutions and structures within the NHS can actually allow poor care to go unrecognised. (1) (2)
These reports have highlighted examples of poor basic care, communication and neglect of patients, (3) and in extreme cases, appalling abuse of vulnerable adults and children. (4)
The overwhelming professional, political and popular consensus is that compassion is an essential part of nursing and medical care (5) (6) and the general public and media are understandably outraged at perceived failures to care compassionately. But it is harder to define what we really mean by compassion, why it is important and how we can ensure that it is an integral part of healthcare.
The questions that this CMF File will seek to address include: What exactly is compassion? Is it innate or learnt? Why has there been a perceived increase in an uncaring attitude in care in the NHS? Why is it important? And what is the Christian understanding of compassion?
Compassion is not as easy to define as one might expect. One approach is to focus on the Latin roots of the word – com [from cum - with] passus [past participle of the verb pati, to suffer] - literally to 'suffer alongside'. However, this could suggest entering into suffering of another in a manner that so overwhelms the second party that they are effectively paralysed by it. Most definitions tend to focus on this emotional understanding, but in the context of nursing and medicine it is better understood as a spur to action and an entering into the suffering and needs of another in order to understand how best to meet those needs actively. Florence Nightingale warned her nurses to let compassion be a spur to action, but not to let emotional responses to the suffering of their patients overwhelm them. (7)
All this suggests a strongly relational component; in other words that compassion comes out of a relationship that is built up over time. This does not preclude a compassionate response to a person in a first encounter however, so this also suggests that compassion is an attitude we take into each encounter with another person that then shapes our relationship and interactions with them. (8)
Therefore, a working definition could be that compassion is an attitude of active attentiveness to the needs and suffering of the other that seeks to take effective action to address that need. However, as we shall see, this is still only a partial definition, especially in light of a Christian understanding of compassion.
Recent neurological research suggests that compassionate responses to another's physical or psychological pain involve a change in activity in the anterior insula, anterior cingulate, hypothalamus, and midbrain – all brain structures involved in emotional responses. However, there is also evidence of cortical activity on the posterior medial surface of each brain hemisphere, regions implicated in self-related processes. (9) This suggests that there is more than just an emotional response, but also a cognitive effort of self-identification in the suffering of the other.
The basis for compassion (and any altruistic behaviour – putting the needs of others above one's own needs) has long been argued in the field of evolutionary biology from the concept of 'kin selection'. That is, we seek to put the needs of those who share the same genes as us (close family and in particular, offspring) above our own needs as this ensures our genetic line continues. This could well explain the idea of compassion when dealing with those in our immediate circles, even those not related to us (mutual care ensures the safety of both gene lines). (10) However, as with most models, this is necessarily reductionist and does not adequately address altruism to those outside the immediate group, where there can be little or no chance of benefit to one's own gene line, nor the fact that compassion towards animals is closely linked to compassion towards fellow humans. (11) (12) The instinct to care is more complex in its origins than just neurobiology or preservation of genetic lines. As we shall see though, the notion of caring outside of one's immediate group (ethnically, religiously or otherwise) is not universal.
There is considerable debate on this subject, particularly around whether we should select medical and nursing students on the basis of innate empathic ability and compassion (if it were even possible), or whether those qualities can be inculcated during training. Some evidence suggests that those students with a high innate empathy are more likely to be more caring and compassionate in practice. (13) More recently, there has been debate about teaching compassion as part of the core curriculum in nursing training. (14) This seems counterintuitive if we understand empathy and compassion to be innate personality traits, but if we understand compassion as being an attentive, practical skill rather than a purely reflexive response then it makes sense to train those already exhibiting strong empathy in the skills of practical compassion. Indeed historically, nursing in particular as a profession has always seen compassion as a quality or virtue to be developed in training, alongside the acquisition of technical skills. (15)
Before the 20th Century in the West, the notion of care and cure went hand in hand, principally because medicine was limited in the illnesses and injuries where effective cures and treatments were available. As a consequence, often the best and only treatment in many instances remained compassionate care that enabled the body to heal itself, or allowed for the minimisation of suffering in instances where no cure was possible. Edward Trudeau, the pioneer of TB treatment in the 19th century said that the aim of medicine was'to cure sometimes, to relieve often, to comfort always'.
At the same time, for most of Western history, religion, science and medicine were not separate disciplines, but were all seen as part of accessing divine knowledge. As Francis Bacon put it: 'God has, in fact, written two books, not just one. Of course, we are all familiar with the first book he wrote, namely Scripture. But he has written a second book called creation.' (16) However, natural philosophers in the 17th and 18th centuries and early scientists in the 19th and 20th centuries began to use principles of observation and experimentation, so a lot of earlier learning about the natural world moved from ancient texts to what we now call the scientific method of observation, hypotheses, experimentation and theory. The shift in thinking during the 18th century Enlightenment towards more scientific models of medicine was part of a revolutionary change in Western thought that divorced the arts and humanities from the sciences. (17)
At the same time the caring component of medicine began to be seen as secondary to the curative. Whereas in medieval and Renaissance Europe, both male and female were involved in caring and curing, medicine now became almost exclusively male and nursing almost exclusively female – the former seen as objective and scientific and increasingly high status, the latter as of lower status and the provenance of women of 'poor repute'. Nightingale and the Lutheran Deaconess movement did much to raise the status of nursing, but it was still seen as subordinate rather than complementary to medicine.
The ironic consequence is that as medicine has become more able to treat a widening range of illnesses and traumas successfully, so there has been a shift in emphasis away from care and compassion towards technical care. Our health system has subsequently become very good at 'Transactional Care' - the technical provision of treatment for illness and injury – often employing complex technology, surgical techniques and pharmacology with great precision and efficacy. 'Relational Care' – the interpersonal, human interactions that expresses care and compassionate concern for the individual in their suffering and treatment has become less and less prioritised in practice. Both are essential to effective medicine, but as technology and technical skill are more measurable and more highly valued, the focus tends to be on the transactional rather than the relational. (18)
At the same time, the increasing business orientation and market driven approach to health service delivery in much of the West has been seen by many as the source of a drive towards the measurable (and therefore, costed and chargeable) over the unquantifiable (and thus of no monetary or market value) (19).
There is also evidence that the very process of training doctors seems to militate against compassion and empathy, especially once trainee doctors begin their clinical placements. (20) So medical training and the structures of the health service and its underlying value system seem to be set against compassion being developed or practised in the modern health service.
More and more research and commentary suggests that this loss has been to the detriment of patient care. As an earlier CMF File 21 has pointed out, meeting the emotional and spiritual needs of patients has a significant impact on recovery and prognosis, and a failure to address them can lead to poorer clinical outcomes.
Compassion should be an integral component of cure, not an optional add-on.
Anne Bradshaw, senior lecturer in nursing at Oxford Brookes Faculty of Health and Life Sciences, states that:
Throughout nursing history, compassion has been viewed as a quality associated with an individual's character. Compassion stems from virtue. It is about the intent and practised disposition of the nurse. It is nurtured in, and by, the culture and ethos of clinical practice 22 [emphasis added].
Compassion as a virtue is a familiar concept. Our Western understanding of virtue stems (at least in part) from the Greek notion of the virtues as principle human strengths that generate and are generated by the character of the individual. However, in Greek thinking the main virtues were mostly masculine (courage, strength, restraint, wisdom, etc.) and compassion was not regarded as one of them. Indeed if anything it was seen as a weakness in a man, and of only passing value as displayed by a woman to her family (and even positively harmful if expressed to strangers or foreigners). A virtue was not innate but was a habit of heart and mind that was developed studiously by effort over time until it became 'second nature'. Therefore a person of virtue was very much self-made, and one who lacked virtue had only oneself to blame.
Virtues in New Testament understanding are something quite different. Firstly, the authors of the New Testament recognised humanity's inability to be truly virtuous. This is because the true virtue is to live sinlessly according to God's will and purposes, something that fallen humanity is unable to achieve alone. (23) To become truly virtuous is only possible as a result of inner transformation by the indwelling power of God the Holy Spirit. (24) It is about a transformation of character and will, in which we play a part, but which is ultimately God's work in us. (25)
As NT Wright puts it:
Christian virtue... is both the gift of God and the result of the person of faith making conscious decisions to cultivate this way of life and these habits of heart and mind. (26)
Compassion (or kindness and gentleness) is seen as one of these virtues, or as the Apostle Paul puts it, part of the 'fruit of the spirit'. (27) These include qualities of character and virtue that God brings to life in us and that we then express in our lives, individually and as a community, through the power of the Holy Spirit. (28)
In Greco-Roman thought, compassion was an emotional response, and not a product of mind, from whence came virtue. Therefore to show compassion and kindness was merely affectation – not a virtue. At best, it was a natural response to the needs of friends and family, and certainly went no further than one's fellow countrymen.
The Bible gives us a different image, showing that compassion was part of the very character of God himself. God created a world to be good and fruitful, (29) which as a consequence of the disobedience and sinfulness of humans (and angels) is now fallen. Pain and suffering are an intrinsic consequence. (30) But while the nature of existence is now mixed with sorrow and pain, (31) God himself shows kindness and compassion on his fallen creation and on humanity itself, supremely in sending Jesus to die and take the punishment for sin so that we can be fully forgiven and become reconciled with God. (32) So the healing and reconciliation to God of a hurting world can be achieved, with the final hope and expectation that there will be a new creation where suffering and pain will cease. (33) The Bible speaks throughout of a God who passionately cares for his creation and acts constantly out of compassion towards his people. (34) Christians are called to walk in his footsteps and to display his character. (35)
Jesus exemplified God's compassion in his life and teaching. He made it clear that compassion was an essential virtue, but that is was to be expressed to those outside the normal parameters of kin and close friends. Compassion was all the more a virtue when shown to the stranger, the prisoner and the outcast, and even more to those who illtreated you, hated or even persecuted you. (36) Compassion was for any and all who were in need, because in caring for them we care for Jesus himself. (37)
Jesus lived this out in practice. Regularly, when confronted with people in need (spiritual or physical) he was moved to compassion. (38) In each case, his compassion led to action that transformed the situation.
Jesus showed compassion in its most selfless sense by choosing to lay down his life for others on the cross, (39) firstly as an act that paid the price for sin and thus brought reconciliation with God, but also as an example of self-sacrifice for others, even those who hated him or did not know him. (40)
Christian understanding of compassion is also shaped by our understanding of the Incarnation. God himself entered into our suffering by becoming human, a servant and ultimately a condemned man who died for us. (41) As John Wyatt says:
Because Jesus was a baby, all babies are special. Because Jesus was a dying man, all dying people are special. (42)
Jesus, by identifying with us so completely endowed our humanity with a profound dignity and worth. So it is that the Christian understanding of compassion comes with a strong sense of respect for the dignity of the person in need. It is not 'pity-love', but 'respect-love', recognising the image of God in the other person. As Mother Teresa put it, 'It is more than pity that motivates us, it is respect mingled with compassion.'
Thus in Christian thought compassion becomes one of the highest virtues. It expresses the very heart and actions of God himself, being a God-given quality that sees value and dignity in every human being made in the image of God. It also seeks to imitate Jesus by meeting the need of the other person as an expression of both service and worship of God. It was this that spurred the early church into action caring for the poor, the dying, the disabled and abandoned infants, to the scandal of respectable Roman and Greek society. (43)
This understanding of Christian compassion shaped the thinking of many of the pioneers of modern medicine and nursing. Space does not allow a detailed survey, so I will look very briefly at two of these pioneers. Thomas Sydenham (1624 –1689), called by some the 'English Hippocrates' due to his influence on the development of medicine in Britain, laid out four key principles for any godly physician:
It becomes every man who purposes to give himself to the care of others, seriously to consider the four following things:
First, that he must one day give an account to the Supreme Judge of all the lives entrusted to his care.
Secondly, that all his skill, and knowledge, and energy as they have been given him by God, so they should be exercised for his glory, and the good of mankind, and not for mere gain or ambition.
Thirdly, and not more beautifully than truly, let him reflect that he has undertaken the care of no mean creature, for, in order that he may estimate the value, the greatness of the human race, the only begotten Son of God became himself a man, and thus ennobled it with his divine dignity, and far more than this, died to redeem it.
And fourthly, that the doctor being himself a mortal man, should be diligent and tender in relieving his suffering patients, inasmuch as he himself must one day be a like sufferer. (44)
This understanding of shared human frailty, shared human sinfulness and need for God's grace, and a shared human dignity informed Sydenham's view of compassion as a central component of good medicine. Sydenham also emphasised the notion of 'vocation' or calling. Medicine was not a career to advance one's own interests, but a means of service to God and man.
Florence Nightingale (1820 –1910), the founder of modern nursing, made it clear that being an effective nurse required compassion, but that this was a virtue to be worked at.
Nursing is an art: and if it is to be made an art, it requires an exclusive devotion as hard a preparation, as any painter's or sculptor's work; for what is the having to do with dead canvas or dead marble, compared with having to do with the living body, the temple of God's spirit? It is one of the Fine Arts: I had almost said, the finest of Fine Arts. (45)
However, she also understood that nursing was a science. (46) It needed to be evidence-based and required technical skills, just as Sydenham understood medicine to be as much an art as a science, requiring diligence in compassion as much as in knowledge and technical skill. Both understandings are deeply informed by Christian faith as well as science, and I would argue that in Nightingale and Sydenham's synthesis of both perspectives we can see that the care/cure split in Western thought is largely an artifice. It also belies the popular view that higher levels of academic training in nurses and doctors necessarily mitigate against compassion.
That many experience this to be the case suggests that the training process and wider professional and organisational culture of the health service and professions is failing to value compassion or to help people to acquire the skills and attitudes of mind necessary to develop it as a virtue.
Compassionate care is integral to good medicine and nursing, but our understanding of what compassion is and how it is developed have become confused. While there are innate qualities in our biology and character that can lead some people to show greater compassion than others, compassion is a virtue that can (and must!) be developed and nurtured in all who come into the professions.
Furthermore, a Christian understanding of compassion requires us to accept it as a virtue that is a gift from God, to be cultivated out of our on-going relationship with our Creator and in community with other believers. It requires us to respond to the needs of others, even those who we find difficult to care for or towards whom we are naturally unsympathetic or even antagonistic. Compassion is a practical response, not an emotional state or affectation, but it starts from a quality of character and an attitude of mind.
Modern healthcare, from training institutions to clinical monitoring and financial management, tends to devalue compassion, so if we are to nurture it in the nursing and medical professions there is a need for a change in values and culture. This comes from strong and visionary leadership that leads by example. 47 We need to make sure that the professions and the health service as a whole become environments where compassion and the art of medicine and nursing are nurtured as much as scientific and technical excellence.
Steve Fouch is CMF Head of Allied Professions and a former nurse.
1. eg Healthcare Commission's Investigation into Mid Staffordshire NHS Foundation Trust (2009)
2. Francis R. The final report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, 6 February 2013
3. Triggle N. Why can't the NHS get basic care right? BBC Online, 22 November 2012
4. Four arrests after patient abuse caught on film. BBC News, 1 June 2011
5. Prime Minister's Commission on the Future of Nursing and Midwifery. Front Line Care, 2010
6. Cumming J, Bennett V. Developing the culture of compassionate care; Creating a new vision for nurses, midwives and care-givers, Department of Health & NHS Commissioning Board, September 2012
7. Nightingale F. Notes on Nursing: What It Is, and What It Is Not. Dover Publications Inc. 1898. New impression edition, 4 May 1970.
8. Davison N, Williams K. Compassion in nursing 1: defining, identifying and measuring this essential quality. Nursing Times, 14 September 2009.
9. Immordino-Yang MH et al. Proc Natl Acad Sci USA 2009;106(19): 8021–8026 (12 May). Published online 20 April 2009
10. Dawkins R. Twelve Misunderstandings of Kin Selection; Z Tierpsychol 1979; 51:184-200 Verlag Paul Parey, Berlin und Hamburg TSSN 0044-3573 / ASTM-Coden: ZETIAG
11. Meng, Jenia. Origins of attitudes towards animals. Brisbane: Ultravisum, 2009.
12. Ascione FR, Arkow P. Child abuse, domestic violence, and animal abuse: linking the circles of compassion for prevention and intervention. Lafayette, IN: Purdue University Press.
13. Magalhães E, Costa P, Costa M. Empathy of medical students and personality: evidence from the Five-Factor Model. J.Med Teach 2012;34(10):807-12.
14. Davison and Williams. Op cit
15. Bradshaw A. Compassion: What history teaches us. Nursing Times 2011; 107(19,20): 12-14
16. Bacon F, Pitcher J. The Essays. London: Penguin Classics,1986 (first published 1597)
17. MacCulloch D. A History of Christianity, the First Three Thousand Years, Part IV God in the Dock – Natural and Unnatural Philosophy (1492-1700). London: Allen Lane, 2009.
18. Iles V, Sweeney K, Vaughan Smith J. What makes good doctors practise bad medicine? ReallyLearning.com 2009
19. Gerada C. NHS doctors are under pressure to replace caring with market values, Comment is Free, guardian.co.uk, 20 October 2011
20. Hojat M, et al. The Devil is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School. Academic Medicine 2009; September: 84;1182-1191.
21. Bunn A, Randall D. Health benefits of Christian Faith. CMF File 44, 2011
22. Bradshaw. Op cit
23. Romans 3:21-25
24. 2 Corinthians 3:18
25. Philippians 2:12-13
26. Wright NT. Virtue Reborn. London: SPCK Publishing, 2011
27. Galatians 5:22-23
28. Colossians 3:12-14
29. Genesis 1
30. Genesis 3
31. Proverbs 14:13
32. Ephesians 2:1-10
33. Revelation 21:1-6
34. eg Psalm 116 (esp. v4-9); Isaiah 30:7-9
35. Ephesians 5:1,2; 1 John 2:6
36. Luke 6:27-36
37. Matthew 25:31-46
38. eg Mark 8:1-8; Luke 7:11-15
39. John 10:14-18
40. Romans 5:6-8
41. Philippians 2:1-11
42. Wyatt J. Matters of Life and Death. London: Inter-Varsity Press, 2009:78
43. Davey F. Introduction to Heralds of Health, Browne, Davey & Thompson Eds. London: Christian Medical Fellowship, 1985:1-16
44. Edmunds V, Scorer CG, (Eds) Ideals in Medicine. London: Tyndale Press, 1958:155
45. Nightingale, Op cit
46. Nightingale, Op cit
47. Francis R. (2013) Op cit
Unless otherwise stated, Scripture quotations taken from The Holy Bible, New International Version Anglicised Copyright © 1979, 1984, 2011 Biblica, formerly International Bible Society. Used by permission of Hodder & Stoughton Publishers, an Hachette UK company. All rights reserved.
"NIV" is a registered trademark of Biblica. UK trademark number 1448790.