Providing Compassionate Healthcare

Challenges in Policy and Practice

Sue Shea, Robin Wynyard, Christos Lionis, Sue Shea, Robin Wynyard, Christos Lionis

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781134501229
• Edition: 1
• Topic: Medicine
• Subtopic: Caregiving

Despite the scope and sophistication of contemporary health care, there is increasing international concern about the perceived lack of compassion in its delivery. Citing evidence that when the basic needs of patients are attended to with kindness and understanding, recovery often takes place at a faster level, patients cope more effectively with the self-management of chronic disorders and can more easily overcome anxiety associated with various disorders, this book looks at how good care can be put back into the process of caring.

Beginning with an introduction to the historical values associated with the concept of compassion, the text goes on to provide a bio-psycho-social theoretical framework within which the concept might be further explained. The third part presents thought-provoking case studies and explores the implementation and impact of compassion in a range of healthcare settings. The fourth part investigates the role that organizations and their structures can play in promoting or hindering the provision of compassion. The book concludes by discussing how compassion may be taught and evaluated, and suggesting ways for increasing the attention paid to compassion in health care.

Developing a multi-disciplinary theory of compassionate care, and underpinned by empirical examples of good practice, this volume is a valuable resource for all those interesting in understanding and supporting compassion in health care, including advanced students, academics and practitioners within medicine, nursing, psychology, allied health, sociology and philosophy.

Part I

Introducing the concept of compassion

This section discusses the concept of compassion, what we mean by the use of the word ‘compassion’ and how current definitions and usages of the term may have altered over time. Current attempts to define and conceptualize compassion will be briefly discussed. The two chapters included in this section attempt to lay the foundations on which the other sections of the book can be built. In its very nature health care does not follow a neat diachronically process in time, and compassion as a concept goes in and out of the thoughts of health care professionals depending on the social and cultural context existing at any one time. In this section, the historical origins of the concept of compassion are discussed, together with the implementation of compassion in nursing history.

1 Understanding compassion: the tangled roots of compassion: historical origins, modern day reflections and concerns: Robin Wynyard

2 Compassion in nursing history: attending to the patient’s basic human needs with kindness: Ann Bradshaw

1 Understanding compassion: the tangled roots of compassion

Historical origins, modern day reflections and concerns

Robin Wynyard

Introduction

I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them. I will never give poison to anyone though asked to do so, nor will I suggest such a plan.

Hippocratic Oath – Hippocrates, 460–370 BC

As this leading quote shows, what might be deemed to be compassion has a long history. This chapter as an introduction to the book looks at the roots of compassion in history, philosophy and religion and how in the context of these the word compassion has somewhat tangled origins rather like the roots of an old huge, tangled tree.

Compati is a Latin word meaning to ‘suffer with’, and as a word it has been with us a long time. Having said that as a word it is not easy to conceptualize and to say whether it is always good, or whether it is sometimes bad. In exploring the tangled nature of the word compassion in this chapter, I am trying to unravel this tangled nature by looking at how history has used it as a word and concept, how philosophers have used it, how the modern social sciences have used it. Finally I want to show how the media as a very important player in bringing the nature of compassion to millions of people worldwide, has used the concept. This last point has become very important following the extensive media coverage following the revelations of Robert Francis QC (2013) leading to the publication of the Francis Report.

Looking at the history of compassion, it is something that held a fascination for both the ancient Greeks and the writers of the Bible. In both instances, it was not always seen as a force for good.

Before discussing this, I would like to mention a modern writer who spans both the medical and the sociological. Thomas Szasz in his book entitled Cruel Compassion (Szasz 1994). Has expressed some doubt on the way the concept of compassion has been used by the medical profession. Cruel compassion is a good example of oxymoron in which apparently contradictory terms appear in conjunction. Most of us assume that being compassionate is the exact opposite of cruelty. Szasz a psychiatrist shows how compassion has been misused by the psychiatric profession, where unintended consequences of its use have produced all sorts of effects to the detriment of the psychiatrist’s patients. His argument is that compassion, which is often seen as a virtue, is no such thing at all: ‘A little self-scrutiny would quickly show us that compassion is not always or necessarily a virtue’ (p. 3). The major thrust in his argument is that far from restoring patients to a self-regarding equilibrium, it removes a person’s free will thus placing the patient totally in the hands of the psychiatrist – ‘guided by the light of the fake virtue of compassion, we have subverted the classical liberal conception of men as moral agent, endowed with free will’ (p. 3). Through in-depth historical research he shows that there is a deep flaw in the way we view compassion precisely because history has always drawn a distinction between two groups of people who might be deemed worthy recipients (or not) of compassion. These are defined as the ‘deserving’ and the ‘undeserving poor’. This fits with the history of British health care policy from the earliest to modern times, where distinctions have always been made as to who or who does not deserve compassion and thus help.

‘Sturdy Beggars’ was a term used throughout the Middle Ages describing those who were fit and able to work, but begged or wandered for a living instead. Such individuals were punished by being branded on the cheek and placed in the stocks for punishment. The Statute of Cambridge (1383) differentiated between sturdy beggars and the infirm i.e. those genuinely incapable of work and thus deemed worthy recipients of care from their local parish which provided a levy for such contingencies. Further Parliamentary Acts like the Vagabonds and Beggars Act (1495) sought to firm up this distinction. Historically where compassion is concerned morality always lurks in the background.

Compassion as a virtue considered by the ancient Greeks

Although not actually using the term ‘compassion’ the ancient Greeks were certainly interested in what we would deem to be component parts of compassion. In exploring the parameters of compassion they exposed much that was ambiguity, oxymoron and doubt surrounding its use. As Hannah Arendt said ‘… the ancients regarded the most compassionate person as no more entitled to be called the best than the most fearful. The Stoics saw compassion and envy in the same terms’ (Arendt, quoted in Szasz p. 4). So according to the Stoics, compassion was not a virtue at all and might in fact do more harm than good.

There was a debate amongst the ancients, as there is today, as to whether virtues including compassion could be taught? Or did such virtues already exist inside us and simply need the right techniques to evoke them? Plato thought that virtues could not be taught and as far as compassion is concerned it is only known after an act has occurred whether compassion has taken place. Socrates in Plato’s Meno in argument with the Sophist Protagoras illustrates that only by going through certain procedures of the act in particular circumstances, can we know if a particular act is good, virtuous or compassionate. Socrates demonstrates this via the slave boy, who is capable of answering a complex geometry problem because he already has the questions in his soul (Plato 2005: 118–120). As Socrates said: ‘Well, all I can say is, I’ve often asked that question (can we be taught to be good?) … and for the life of me, I can’t find the answer (p. 118).

So where Socrates appeared to argue that no one teaches virtues, Protagoras appeared to argue that everyone teaches them. In recent times Pence (1983) takes this argument further in saying that compassion can be taught in medical training. According to him ‘whether compassion can be taught depends in part on what we take it to be’. It must not be confused with related but different moral qualities, for example, like pity. What needs to be instilled in medical training is we want doctors, nurses, HCPs etc. to be compassionate towards their patients where qualities such as imagination ‘play a key role in compassion in achieving understanding of, and feeling for, suffering people’. Pence draws attention to the nature of ‘Trust’ as something else that is needed in the practitioner/patient relationship: ‘honesty, and the time and willingness to listen’. Pence points out that although we can teach compassion in medical training, it isn’t going to be easy! So unlike Protagoras the Greek who argued that everyone possesses it, the problem with compassion is that it has a structural dimension as well as a pedagogical one. This is something I mention later when I talk about compassion distance. Pence argues that we must change the medical system to incorporate teaching compassion. Existing compassion in students must not be undermined by their medical training and time must be made available during the training to allow students ‘to pursue particular cases in which they are involved’. There must also be ‘systematic acceptance by medical teachers that such activities and the moral qualities they develop are worth encouraging’. In teaching compassion, medical training must give importance to illustrations through films and literature, these are points strongly endorsed in this chapter and which will be returned to later.

Not all ancient Greeks would agree with Socrates about compassion not being taught, as many of them were astute in providing tools for interpreting compassion and unlocking the key to it within ourselves. In Greek plays by playwrights such as Sophocles the chorus interpreted the plot for the audience, more or less as a running commentary, informing the audience what should or should not happen and how outside influences affect the behaviour of the protagonists. Through technical devices like the role of the chorus the ancient Greeks cultivated inner values that made for a fuller humanity which presumably made for a more compassionate person.

In Greek literature, compassion is sometimes treated with in passing often bound up with religious ritual and spiritual and mental health care. Homer gives a good example of what passes for compassion in the Iliad. Basically the plot of Homer’s Iliad is about mass slaughter and degradation of basic human values, but you can still find a moving example of compassion which seems so powerful as to subvert the nature of nastiness within the epic. King Priam of Troy’s son Hector has been killed by the mighty Greek warrior Achilles. Achilles conducts a shameful and very non-compassionate act by tying Hector to his chariot and dragging his dead body around the walls of Troy in full view of Priam, Hector’s father. Priam under the cover of darkness sneaks into Achilles tent to beg for the return of his son’s body ‘I put to my lips the hands of the man who killed my son … Those words stirred with Achilles a deep desire … To grieve for his own father .’ (Book 24 the Iliad). From this example we see the two-way nature of a compassionate act, what is instilled by the giver is returned in kind by the recipient. Hence we come back to the Latin definition of compassion cited earlier, by which we suffer together.

Compassion as dealt with in the Bible

Historically the Bible is a good source of quotes and treatment of compassion. It is interesting to compare the Old Testament with the New Testament. There is really very little that passes for compassion in the Old Testament and it is difficult to relate biblical quotes like the following with anything remotely related to a concept of compassion: ‘Now go and smite Amalek, and utterly destroy all that they have and spare them not; but slay both men and women, infant and suckling, ox and sheep, camel and ass’ (Samuel 15:3). In the New Testament on the other hand, the word compassion occurs on many occasions e.g. Mark 1:41; Luke 7:12; Luke 15:20 and in the quote that follows there is great feeling for spiritual leadership in compassion that can be provided by great religious leaders such as Jesus ‘… but when he saw the multitudes, he was moved with compassion on them, because they fainted and were scattered abroad as sheep having no shepherd’ (Matthew 9:36). The imagery used here is of the compassionate person as a shepherd as an organizing force for the flock. In a religious context this had a very contemporary feel to it when the new Pope Francis spoke about certain skills that priests need, presumably inherent to the compassionate, where there is a need to ‘smell the sheep in his flock .’ (BBC News 28 March 2013). Compassion is used by all ‘people of the book’ including Judaism, Christianity and Islam. The Koran acknowledges the role that the prophet Jesus plays in furthering compassion. Speaking of Jesus: ‘we gave him the Gospel, and put compassion and mercy in the hearts of his followers’ (Koran 17:27).

The difficulty of studying compassion is that the journey is full of twists and turns. We can see how the Old Testament which does not readily advocate ‘turning the other cheek’ differs in treatment to the New Testament which bursts full of the nature of compassion. But later on this is not necessarily seen as something to be praised. In the philosopher Nietzsche’s critique of Christianity, he does not reject compassion (although it is difficult to find any support for it by him), but he does say that within a Christian context, compassion is driven by feelings of hatred and resentment and applied in an unhealthy way. What he is saying is that compassion in Christianity (and Buddhism) is just as much about personal power and control as it is about selfless devotion to others:

I regarded the inexorable progress of the morality of compassion, which afflicted even illness, as the most sinister symptom of the sinister development of our European culture.

(Nietzsche 2008: 101)

Even more vitriolic: ‘How many tons of sugary spirits of compassion … one would have to export from Europe today before the air began to smell pure once again’ (p.133).

As I have been arguing, historically the study of compassion is never straightforward and supporters and detractors of compassion are somewhat evenly balanced.

Perhaps a key point regarding compassion is that it does not exist as a free floating idea, but in fact it is closely related to societal variables connected with issues such as the state of the economy, and work availability. Lord Beveridge’s Report of 1944, in laying the...