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Abstract

Feeling compassion is paradoxical. On the one hand, it is a fundamental dimension of human existence and not a peculiarity of the mind that one might or might not possess. On the other hand, experience teaches that compassion can be dangerous and irrational, and this is why in philosophy compassion often has a bad name. A foundational analysis of the roots of compassion is therefore needed and also presented. This leads to a further application of Emmanuel Housset’s creative contribution on compassion (“pitié” in French) to the ﬁeld of medical ethics. Several examples of the integration of compassion are presented, as they are typical for healthcare locally and globally. At the end, a link with the upcoming “ethics of care” movement is made, as also with the notion of compassionate care.

Introduction

Compassion is one of the personal feelings which we regularly experience. As human beings, we feel compassion with people who are suddenly confronted with the limitations of life, like those who are the victims of earthquakes and sudden natural events. We feel compassion with an uncountable number of refugees, with those who are touched by the outbreak of Ebola in African countries, and with AIDS patients and patients for whom there is no medication available or the terminally ill. Many medical and nursing students as also nurses and physicians refer to compassion when they are asked why they study or practice medicine and nursing. It is therefore no surprise that the humanitarian and compassionate basis of medicine has been recognized (Rhodes 1976). Compassion is an emotion which has a strong impact on the practice of healthcare and in line with this on bioand medical ethics. A conceptual clariﬁcation will lead into the deepest roots of the foundation of the medical and healing practice. The ethical challenges are therefore also symbolic for many actualizations of a “compassionate medicine.”

Conceptual Clarification

It is well known that Martha Nussbaum has largely contributed to a positive integration of compassion in many ethical theories. She considers compassion as a painful emotion directed at another person’s misfortune or suffering: “I have claimed that, other things being equal, the compassioned person will acquire motivations to help the person for whom she has compassion” (Nussbaum 2001). Another creative contribution for the clariﬁcation of the concept of compassion has been developed by Emmanuel Housset in his book L’intelligence de la pitié: Phénoménologie de la communauté (Housset 2003). His concept of compassion will be extensively used in this contribution. The core idea of Housset on compassion may be described “as the respectful awareness of being touched by the other person’s suffering.” His deﬁnition can be extended with the following elements: compassion arises in the mutual encounter of two persons. It presumes listening without judging and being empathetic to the unique other. It is not a withdrawal in one’s own feelings of compassion. It is a bodily, emotional, and intelligent experience. It leads to a community of suffering, appeals to take care of the suffering; and ﬁnally, it constitutes a source of respect for the other (Leget et al. 2010). Two alternative deﬁnitions of compassion complete the picture: the Oxford Dictionary (2005) deﬁnes compassion as “a strong feeling of sympathy for people who are suffering and the desire to help them.” In Wikipedia (2007), compassion is described as “an understanding of the emotional state of another” and as “a desire to alleviate or reduce the suffering of another.” This conceptual understanding will now be translated on the healing professions, like medicine, nursing, and other healthcare providers.

Compassion In The Context Of Medical Ethics

In the context of medical ethics, understanding compassion (and similar concepts like pity and empathy) warrants a clariﬁcation of the fundamental disposition of the medical/healing professions. It is easy to make here a link to the so-called relational philosophy with Martin Buber (1923) and even more Emmanuel Levinas (1974) as inﬂuential inspirers. The healing profession is indeed a relational profession, full of commitment and devotion to the patient.

In short, the approach of Levinas can be presented as follows (Burggraeve 1985):

the face of the Other signiﬁes the fact that I am touched by a being not in the indicative but in the imperative. Levinas explains this starting point from the weakness and vulnerability of the Other which is, in a most eminent and at the same time most painful manner, expressed in his mortality. By the powerless and helpless “humility” of the poor, widowed, orphaned, marginal or proletariat (and in the case of medicine: of the sick and ill patient), the Face, by its appearance, invites the I —which strives after happiness and power— to reduce the Other to the I’s self. As a being stripped and threatened, the Face dares me, as it were, to do it violence. Yet there is something very peculiar about this “attraction to violence” coming from the Face. The very moment that the I is seduced into seizing the Other in its “smallness”, it experiences and “feels” that which it actually can do, but in principle, must not do. This is —according to Levinas— precisely the core of the ethical experience. The I feels shocked in its self-sufﬁciency. It discovers itself in the unprotected eyes of the Face as the Other’s potential murderer. Yet, at the same time, it also realizes that this is absolutely forbidden. Levinas can rightly conclude that this is the ﬁrst, voiceless, word of the Other: You shall not kill. From this it becomes clear that the Face is not only marked by the humility of its misery (humilité) but equally by the eminent elevation of the prohibition which is written in the appearance of the Face itself. The Other is not only weakness but also strength, although this denotes an ethical rather than a physical or psychological power. This resistance is ethical since it appeals to the Freedom of the I. As a radical alterity (altérité), it demands an unconditional respect from me. Yet as a defenseless poverty, it cannot compel me to give this respect by means of a physical or psychological force. While turning to me, the Face asks me to come to its aid. By the powerlessness of its Face, the absolute demand becomes a cautious plea. The appeal of the Face, without a doubt, signiﬁes a call to responsibility for the Other. (Burggraeve 1985)

This relational grounding of the healing professions is very helpful for a foundational, even metaphysical, description of the healing relationship. As Leon Kass described this:

Medicine calls you to intrinsically self-manifesting and self-fulﬁlling activity, in which your good and the patient’s good coincide. In each daily encounter with your patients, you will serve yourself exactly in your efforts to help others, as you energetically respond to the call for help, exercising your art that makes help possible. If one regards the patient only as objectiﬁed body, then one may take care of the patient, but one does not yet care for the patient. (Kass 1991)

In another way, Sokolowski (1989) described the same foundational ethical disposition:

In acting according to his art the physician also seeks the good of the patient. Because the art of medicine aims at something that is a good for the patient, the doctor, in the exercise of his art, seeks the medical good of the patient as his own good. The nature of his art.. .makes him, in the good exercise of his art, not only a good doctor but also essentially a good moral agent, one who seeks the good of another formally as his own. The doctor’s profession essentially makes him a good man, provided he is true to his art and follows its insistence.

The insights of Buber and Levinas are not only crucial for the clariﬁcation of the fundamental disposition of the healing professions; they also present clear value orientations for daily medical and healing practices: the physician (healthcare provider)-patient (client) relationship must therefore be fully developed. The application of reproductive technologies, for instance, should not be isolated from this relational commitment of fertility experts to couples who ask for help. The same may be clear for the care of the dying patient. And even more, the ethical claim of extremely vulnerable patients, like Ebola victims or cancer patients, leads to a responsibility which is totally devoted to the well-being of those for whom one has taken up responsibility.

This anthropological background helps to better understand the insights of Housset. His clariﬁcation may also contextualize the impact of compassion in the context of medical ethics.

Good And Bad Compassion

Housset states that “feeling compassion is paradoxical.” On the one hand, it is a fundamental dimension of human existence and not a peculiarity of the mind that one might or might not possess. Indeed, a man devoid of compassion would be equally devoid of his full humanity, simply because he would have lost his capacity of sensitivity. Perhaps, the absence of compassion and sensitivity is what provides the basis and justiﬁcation for regarding psychopaths as social deviants. Without compassion, man would have no other possibility except that of sensing himself, and therefore, there would be neither world nor neighbor nor community to affect him and to trouble the illusory tranquility of his self-presence.

On the other hand, experience teaches that compassion can be dangerous and irrational, and this is why in philosophy compassion often has a bad name. Some philosophers classify compassion as a mere sentiment and therefore as hard to deﬁne and lacking in rationality: sentiments are rarely objective and do not adequately distinguish between good and evil. Good sentiments in general and compassion in particular often lead to evil actions, and this pity (another word for compassion, linked to the French “pitié”) cannot exercise any moral authority. Many philosophers denounce compassion as extremely dangerous, because it pretends to make us act righteously while saving us the trouble of going through any reﬂection, any consultation of reason. Moreover, compassion is for them uncontrollable: it can make us empathize with the worst criminal simply because a particular circumstance arouses our sympathy for him. Conversely, compassion can be absent for contingent reasons, simply because we are not moved by the misery of others.

Compassion is therefore a peculiar ethical phenomenon, and it is in trying to describe the phenomenon that it will be possible to understand when compassion is good and when it is bad, since here good and bad are not predetermined values that would only need to be applied, but they are what needs to be clariﬁed starting from any concrete situation of human existence. Recognition of authentic compassion, which respects others in their irreplaceable singularity and provides us with the intelligence of what we must do for them, allows us to free ourselves both from moralism and from an abstract rational morality, in order to envisage a tangible ethic.

The distinction between bad and good compassion is accepted by many. It helps in seeing the importance of a continuous critical hermeneutics of words, the possibility of compassion as a source of morality, and the fact that compassion constitutes and reveals a form of community. It is also important to be aware that compassion can be silenced or sidelined by the impact of institutions. It can be threatened by excess and one-sidedness. It can sometimes fall short, be completely absent, be sometimes falsely deemed to be there, or it can be turned into disgust.

Not only philosophers but also nurses and patient movements criticize strongly the integration of compassion. Mieke Grypdonck, a professor in nursing theory, is even more critical. She states that compassion places patients in a category apart from those who are normally neither in need of, not evoking, compassion. People with a chronic illness avoid falling into a deep hole by telling themselves that they are strong, that they can cope, that it all is bearable. These thoughts often are a very effective way of cognitive coping. Grypdonck is convinced that healthcare workers feeling and – even worse – expressing compassion greatly endanger these coping strategies. People with a chronic illness demand a discourse of rights. They have the right to proper healthcare, the right to (ﬁnancial and personal) assistance in order to participate in society, the right to proper treatment of their health problems, and the right to consideration when they (make the effort to) participate in “normal” social life. Compassion seems to make these rights less obvious, and if compassion is an emotion (as Housset would have us believe), one cannot guarantee proper care based on an emotion which is, by its very nature, poorly controllable. It is thus not only understandable but also reasonable that patients are afraid of compassion, and some may even hate it (Grypdonck in Leget et al. 2010).

It may be clear we need a ﬁne balance struck in the healthcare context between the good and bad arms of compassion. An excellent example of this is the transition in the American Medical Association (and afterwards in many other countries) from swearing oaths to the 1847 code of ethics: the transition from the personal ethics of oaths to the professional ethics of codes marks a radical transition from personally integrated “gentlemanly” ethics to collaboratively interpreted professional ethics – a transition so radical that it is properly described as revolutionary (Baker et al. 1999).

Never before had physicians voluntarily subscribed to a code of conduct this demanding. The speciﬁc obligations that the AMA physicians had unanimously imposed upon themselves far exceeded earlier rather vague Hippocratic and character-based commitments to help patients and to try to avoid harming them. (Baker et al. 1999)

Truth In Emotions

Housset admits that it is not easy to understand that there is a truth inherent in emotions and sentiments. Man is not a pure mind, and it is as a whole being, soul, and body that can experience compassion when he turns toward the other, not in order to use this other, but in order to let him manifest himself, to accompany him in his existence. Indeed, in true compassion, it is not I who forget myself, even in an illusory way, but it is the other who pulls me out of myself and gives a possible sense to my life.

When he continues analyzing the concept, it becomes clear how strong the impact of Levinas is on his work. Indeed, Housset states that compassion is a sentiment received from the encounter with the other, and, like suffering owing to love, it is not at ﬁrst a voluntary suffering, even if it can become so afterwards. In compassion, the power to exist and to act comes precisely from the distant one, and this is why in compassion one is taken beyond oneself. The other in front of me is neither a one more copy of the humankind nor an individual who has to learn to hide behind his role; he is that unique being who sends me out of myself and into exile, because he asks something of me, because he calls upon my knowledge or at least upon my presence.

Housset continues that compassion can thus be understood as an expression of human wisdom, insofar as this suffering through love is a humility allowing us in its weakness and its ﬁnitude to respond to the other. In this respect, one understands better that an ethic based purely on the will to be oneself and to expand one’s power cannot leave a place for compassion, because compassion demands a suspension, at least momentarily, of this self-afﬁrmation, that one limits oneself to assuming one’s choices against dispersion. Certainly, it is not a question of submitting one’s actions to the will of the other by renouncing one’s liberty, without which there is no ethical life, but one also has to be wary of that hardening that consists of wanting absolutely what one wants, against everything and everyone. From this point of view, compassion is not really a value: it is rather what enables values to lose their rigidity in order to rediscover a suppleness that is necessary to action. Invariably, compassion is not justice, but justice without compassion can become unjust because it is not attentive to individuals. To tell the truth is an absolute duty, but to tell it without compassion, that is, without attention to the one to whom we tell it and to his capacity to hear it, becomes a form of violence. Reason formulates the imperative to speak the truth since to hide it is a form of contempt. But compassion, on the other hand, requires that we reﬂect on how to speak it so that it can be heard.

Man is therefore not the Hercules that modernity sometimes dreams about, that is, a being capable of creating itself, perfectly in control of itself, without weaknesses, dedicated to the inﬁnite task of accomplishing its essence, and capable of enduring anything. If it is by our weakness that we are receptive to the other, then compassion as weakness of love cannot be inﬁnite, and no man is capable of taking upon himself all the suffering of the world. Such a recognition of the ﬁnitude of human compassion is indispensable, because it assures the possibility itself of compassion. If I can never be as compassionate as is necessary, I am at least assured that all ﬁnite acts of compassion are a good, and this certainty is what keeps me from losing myself in a feeling of impotence. This shows as well that compassion is not solitary, that it does not solely lock one into the relation between two persons, and that it presupposes a human community within which we learn to sense, to become available. Just as there is no man without body, there is no man without community, and it is together that we can learn respect for the other; it is in a community that we learn to be the guardian of the other and not his master, his judge, or his tutor.

Concrete Examples Of Compassion In The Healing Professions

Without any doubt, there are many examples in medicine and medical ethics where the importance of compassion can be observed. This implies that compassion – understood as presupposing a community – is operative also in less advanced healthcare systems such as in less wealthy nations as will be made clear by our more globally oriented illustrations in our overview.

Compassion constitutes an inherent element of healthcare. It makes understandable why some ethicists refer to compassion in the context of an academic medical training program in order to educate young medical and nursing students and prepare them to play a central role in the healthcare system of the future. Leget et al. (2010) consider education in medical ethics not so much as an intellectual mind game or a training in solution-oriented ethical engineering, but as an intellectual and emotional formation of the mind and the heart. Young medical and nursing students often express a desire to help people as their basic motivation. This motivation can be considered as an important source both for the development of morality and for medical education.

Although it was mentioned earlier that some nurses “hate” the notion of compassion, good compassion as a cultivated emotion can help nurses not to turn their back on patients they cannot help. It can also help them to give considerate and sincere care to a person who exhibits behavior which is different from what one should accept as a professional. Compassion therefore does not necessarily preclude proper and thoughtful action, even if what needs to be done will be painful, both for the giver and the receiver of care (Grypdonck in Leget et al. 2010).

Another example might be the end of life care. Compassionate love, which includes valuing the other fully, action and attitude driven by other-centered motivations, and clear discernment as to the most caring action, can effectively guide healthcare decisions and policies. Compassionate love requires that decisions be considered through a lens that views the other as having signiﬁcant value. By including compassionate love in decision making, the caregiver can better address the needs of the patient and enable a fuller expression of the humanity of the healthcare provider.

Although there is a strong negative reaction on compassion in the context of intellectual disability care, Liégeois suggests that a new concept of “empowering compassion” can help to handle the asymmetry in the care relationship (Liégeois in Leget et al. 2010). Empowering compassion is the respectful awareness of being touched by the other’s suffering and the growing empowerment to alleviate this suffering. This is his reaction on tendencies to paternalism, following expressions of compassion. The care providers risk to make decisions on the care receivers’ behalf, without respecting the care receivers’ choices enough and without giving them control over their own life.

Another example is the possibility of compassionate use in the pharmaceutical industry. Compassionate use and other special access programs provide individuals with the desired intervention, a much more appealing proposition than potentially being assigned to the placebo arm of a clinical trial. Granting individuals compassionate access can still be at odds with the protection of the common good if special access decreases the number of individuals willing to serve in clinical trials. The public is typically eager to grant individuals special access to drugs, devices, operations, and the like solely on the grounds of a duty to rescue those facing imminent, serious peril. When people face dire outcomes, we are compelled, morally and psychologically, to try to help them. We do not feel a need to justify this for any reasons other than compassion for their plight. It is important to face squarely this human desire to rescue. Acknowledging our urge to rescue allows us to confront other facts, for instance, that we are commonly more compelled psychologically and emotionally to rescue some types of people (e.g., children, “innocent victims,” the photogenic) than certain others (e.g., members of stigmatized populations, the elderly). We need to acknowledge that compassion toward individuals sometimes simply trumps the common good (Caplan and Bateman-House 2014).

On a more global level, compassion has functioned and still functions as a motivation to develop worldwide campaigns of care assistance. One of the most impressive examples is without any doubt Live Aid. In October 1984, images of millions of people starving to death in Ethiopia were spread by the BBC as also all over the world. Bob Geldof reacted to this confrontation with starving children by releasing with his colleagues the song “Do They Know It’s Christmas?” in the hope of raising money for famine relief. It became the fastest-selling single ever in Britain and raised eight million pounds. The new Ebola outbreak in 2014 has made him restart this initiative. The peculiarity of compassion becomes once again clear, when we observe that some doubt that the same “amount” of compassion can be raised with these patients. Indeed, compassion needs a “momentum” to have an impact.

Also here, there is the struggle with good and bad compassion. Compassionate care in developing countries might lead toward paternalism and less toward patient autonomy. This can be prevented by developing clear codes of conduct, respecting the rights of vulnerable populations and recognizing international conventions. An eminent example is the Declaration of Istanbul on Organ Trafﬁcking and Transplant Tourism (2008). Since the creation of the Declaration (prohibiting organ trafﬁcking and transplant tourism, because they violate the principles of equity, justice, and respect for human dignity), more than 100 countries have strengthened their laws against commercial organ trade. This illustrates how compassion with abused people in developing countries in the context of organ retrieval has given force to an internationally accepted standard of conduct.

Ethics Of Care And Compassionate Care

One of the outcomes of the increased interest in compassion as a foundational dimension of the healing profession is without any doubt the presence of an “ethics of care” movement in current medical ethics. It is a relatively new phenomenon, with as a starting point the critique of Carol Gilligan on Lawrence Kohlberg’s model of moral development. The proponents of an ethics of care intend not to set up a romantic utopian discourse apart from sociopolitical reality. Care can only be revalued and take its societal place if existing asymmetrical power relations are unveiled and if the dignity of caregivers and care receivers is better guaranteed, socially, politically, and personally (Van Heijst and Leget, in Leget et al. 2010).

In this context, the notion of “compassionate care” comes up. This is a special subtype of care, different from other morally valuable kinds of care. It is not exclusively the right attitude for healthcare professionals, however. Everybody who cares for persons in need in a nonsymmetric situation may be well advised to do this from a compassionate position. There is no additional element in compassionate care when compared to mere compassion, with regard to the attitude. Care, as such, can encompass different underlying motivational backgrounds. Compassionate care as an attitude is therefore exactly compassion. If one deﬁnes “to care about” as this attitude, it is identical to “to be compassionate with.” The concept of care, however, entails also another part: the part of “taking care of,” the activity of caring. Without this active aspect, the concept of care would be incomplete and superﬂuous. Caring is not only feeling and wanting; it is, essentially, also doing.

Conclusion

For those who argue that compassion is a necessary component of healthcare, one possibility could be that it is the motivating element of compassion that is important: it alerts the healthcare professional to patients’ needs and moves them to attend to them. However, it does seem psychologically plausible that many tasks can be performed competently in the absence of an emotional state of pity and a felt desire to alleviate the particular patient’s suffering (e.g., a surgeon removing an appendix). It could also be argued that there are some healthcare tasks that require compassion in order for them to be carried out to an acceptable standard. Certainly, there are some healthcare tasks that require more than mere performance: those that require consideration of the individual patient’s values and interests in order to make patient-sensitive decisions. For these reasons, it remains important to analyze compassion and its impact on medical and nursing ethics.

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