In my 1996 book, “Compassion: The Core Value That Animates Psychotherapy, “ I characterized compassion as “the intelligent pursuit of kindness.” I meant, among other things, to contrast how much intelligence and ingenuity are enlisted in the pursuit of aggression with how rare it is to discuss intelligence and ingenuity in connection with the aim of kindness.
Of course, the deepest aim of medicine is to provide succor, to relieve pain and suffering as well as to prevent them in the first place. So compassion is the beating heart of medicine. Sometimes in the enormously complicated bureaucratic and technological structures where modern medicine functions, the heart ‘s beat is compromised. Of course, the term “pursuit” suggests that we are always striving to come close and perhaps not so often succeeding.
In 2012 I would say that compassion is the feelingful intuitive ingenious practical
persistent even stubborn pursuit of kindness. This makes explicit a great deal of what I left implicit in the previous millennium. I think we now might say that compassion was about “getting it” and then doing something with “it.” But what is “it”? “It” is the actual situation of the other as the other is experiencing it. “It” is the integral of what the other can say and what the other can’t say. “It” is what is obvious and what is denied.
I could go on in this vein, but this is enough to intimate that the realm of compassion lies beyond the realm of algorithms, of rubrics, even of easily stated rules and principles. It exists in the realm of the problematic fallible human. It exists in the realm of personal human initiative and responsibility, where by “responsibility” I mean not control, but response, making a serious try. Compassion can not be represented on a spreadsheet.
Let me step back and look at the situation of medical care, of nursing care, of health care in general. In the past century there were three large intertwined trends that continue apace in this century. Medicine became more effective, more industrialized and more bureaucratic. The increasing effectiveness was due not only to scientific discoveries but to the implementation of their delivery. Vaccines do not work unless large populations get vaccinated. A simple surgery is not so simple, requiring the coordination of much scientific knowledge including anesthesiology and infection prevention and control. Treatment of an episode of biliary colic may require the coordinated efforts of up to a hundred different people in a community hospital or a university hospital. Cancer care is fabulously complicated, as much from a nursing point of view as from a physician’s point of view. End of life care, especially where pain control is concerned, mixes large helpings of art with science. In psychiatric care, the building of holding environments requires complex cooperation.
As medicine became more powerful, more effective in ways that extend life and change the mix of diseases to be treated, subtle and not so subtle changes have occurred in the working situations and existential status of doctors, nurses and others involved in health care, so, too in the existential status of patients. Dr. Jerome Groopman is neither the only one nor the first to insist that “patient” and “customer” are not equivalent terms. The customer is supposed to get what he pays for. The patient is supposed to get what he needs to assuage his sufferings insofar as it is humanly possible to provide that for him.
The “customer” and the “patient” make their claims each in a different nexus. The customer’s is denominated in money and the patient’s is denominated in an ethical imperative. This is not to say that health care does not need economic and managerial disciplines. All we have to do is to note the rising share of health care in GDP to see the urgent need of these. But I believe that it is worrisome that all current plans for health reform seem to call for more bureaucratization, more administrative expense for more complicated administration. Perhaps this is inevitable but we all know that bureaucracy and administration are two edged swords that can both bring us closer to our goals and take us farther away.
The following may be an aside but it is not one that I can resist. During my years of working with seriously disturbed inpatients at Sheppard Pratt Hospital, I formulated the following theorem which seemed to fit the empirically observed facts rather well. If I was walking down the hall and encountered someone full of zest, with a smile on his or her face, a bearing that implied that they were doing good work for humanity, then this was most probably an administrator, or at least not someone involved in direct care of patients. If I was walking down the hall and encountered someone looking slightly or more than slightly downcast, worried, uncertain, preoccupied, sometimes so much so that he or she did not acknowledge me, then this was more than likely a person engaged in direct patient care, at grips with what was difficult, intractable, aggravating. This illustrates the point that the practice of compassion may not reward the practitioner with feeling better about himself or herself, but rather take a real toll , even involving the acquisition of a test case of what the patient’s difficulty is.
As medicine and health care have become more and more bureaucratized and industrialized, more and more doctors and nurses have become employees, trading in their status as more independent professionals for positions as part of a large team. We might say that they went from the status of “independent professionals”
to the status of “dependent professionals.” This is a complicated transformation with good features as well as bad. I speak from the point of view of a solo practitioner of psychiatry, a field so low tech or so high tech depending how you view the brain, that being a solo practitioner is still possible. The good features are back-up, the chance to consult and cooperate, the ability to undertake more complicated work, to name just a few.
What is not so good is the fact that the dependent professional serves two masters at least, the organization for which he works and his own professional conscience. He may easily come to equate his interests with those of the organization, to begin the trek down to the position described in American folklore as “good enough for government work,” although it should be noted that many who work for the government perform their work to the highest standards. But the effects of institutional pressures are insidious, not least being the tendency for an institution that is trying to change to push out all those who might not be in accord with the changes rather than listening to them and using their input to improve the course contemplated. Institutional power hierarchies tend much more to prefer “yes” men and women to those who might represent sand in the gears because they have ideas and convictions of their own. As has been richly documented, large institutions do everything in their power to destroy whistle blowers.
Compassion requires relationship. It requires knowing the patient both within his present predicament and as he has known himself prior to the predicament Compassion takes time and energy, takes mental space and emotional application.
As a result it can be very wearing. It involves being able to be available in all sorts of different ways that can not be described in a manual . The beloved family practitioner of a rural western town was forced to stop practicing at sixty when his blood pressure, his lipids and other physiological indicators were so far off that his wife was afraid that his work was killing him.
He was rightly beloved because he gave of himself so generously no matter what the time of day. He talked about having a collection of very old patients who needed an awful lot of tuning up to keep them going. Besides him , their care was more scarce than it might have been, but he understood and responded to their loneliness and fear and need. Can a doctor like this one be replaced by a health system? In some sense the essence of compassion is to experience the other as a close variant of yourself . As Donne put it so elegantly in Meditation 17, “any man’s death diminishes me, because I am involved in mankind, and therefore never send to ask for whom the bell tolls; it tolls for thee”.
After a broken hip, a surgical repair of the hip, assailed by a particularly nasty attack of shingles which began in the context of the stress of hospitalization, an eighty-two year old man was lying in bed in the evening with his wife sitting by his side. A nurse came sailing in and told his wife that she didn’t have to stay because “I’m here and if he needs anything I will take care of it.” Both the man and his wife, who have been married for sixty years with the degree of melding that might be expected, were a combination of offended and flabbergasted. However, neither one spoke up because they did not wish to offend the nurse, given how crucially dependent on her they were. The nurse spoke from a vain and well intentioned stupor. It was in that sense that what she said was stupid.
The wife was there because the nights were very tough on her husband, that other part of herself. He was in pain and lost and lonely, so unfamiliar to himself in this difficult, painful compromised state that he needed all he could get of familiarity, in much the same way that a small child needs this when under duress. Of course when we are sick and in pain and frightened we become as small children. This is normal and to be expected and even, although it may sound strange to say this, to be welcomed.
We hear all the time now injunctions not to allow a close relative to be hospitalized without a person who is a very close relative or friend with them virtually all the time. Hospitals are places of danger as well as of succor as are doctors’ offices, clinics and so forth. Nursing shortages and compassion shortages go together. Large, technically oriented institutions easily become impersonal, that is, places without any place for persons as persons.
A vital piece of compassion is to understand what is going on for the patient and how the patient is seeing us and what we propose, what our purposes may be. This requires the capacity to observe and to communicate, to wonder, to be curious, to speak to unasked questions and unarticulated concerns. It becomes very difficult to do this when one is in a hurry, when one is trying to make one’s way through a list as swiftly as possible. Sometimes patients will surprise us in ways that are very instructive. Many years ago a young manic-depressive man told me in therapy that he was perfectly fine, really in excellent health, but when he saw my pill coming towards him in the morning like an incoming missile that made him “sick.” In his view the treatment caused the illness.. He wished that he would never see that pill again because then he would be perfectly healthy.
I think of the 83 year old woman on 13 different medications who lined the pill bottles up on her mantel and declared that she was going to stop taking them all and that would make her feel good. It would be a cure of sorts. Now, in thinking about this, it is important to remember that sometimes stopping all the medications is a real help, although it can take real courage to try it. But in this case the woman was remembering how much better she felt when she was younger – substantially younger – and had no portfolio of pills. As with the young man, it was a question of magical operations designed to restore health.
Part of the problem in these cases is that, young or old, it is much easier to take medication, to treat yourself for an ailment, if you do not see yourself as all sick,
but rather as a more or less healthy person, who can then proceed to take measures to take care of what needs care. All-or-nothing thinking is toxic to treatment. We need to remember and keep on remembering that the patient is the head of the treatment team, at least as long as the patient is conscious and even when the patient is not we must be ruled by his wishes.. We may have various pieces of advice for the patient but if the patient is not disposed to hear these, not disposed to follow them, then we are pretty much stuck and need to try to work through the impasse. An exception, of course, is with patients who are incompetent and, for example, so psychotic that they are being medicated against their will.
I recall hearing a distinguished psychiatrist virtually yell at his patient, “I’m the doctor and you’re the patient and, if you won’t do what I tell you, then I can’t help you.”
On the one hand, this may have been quite true. The psychiatrist was incredibly frustrated and virtually at his wit’s end. But oftentimes in treating patients it is where we get after we reach our wit’s end that is the starting place. Whether the patient is, as the phrase goes, “not ready for treatment” or whether, turning the common phrase on its head, “the treatment is not ready for the patient” can require considerable discernment. If we try to do psychotherapeutic treatment from manuals, then we are going to have trouble in this area. Compassion is not of standard issue. In fact, it is likely to be quirky, to be willing to struggle, not to be all sweetness and light but sometimes to tell a few home truths. Compassion has to wrestle with situations like those presented by the “hug me but don’t touch me” patient who is starving for contact and intimacy but fears and rejects it. Compassion has to be willing to fight with a patient when he is against himself. These can be very bitter fights, too.
Modern medical care is also complicated for the patient by his having to deal not just with one or two doctors known over a long period of time and in the context of such relationship, but with a virtual posse of doctors. It is easier for doctors to behave like technicians in this situation, each claiming his own piece of the puzzle that is the patient and so sidestepping the need to relate to the patient as a person.
Specialization is a large part of what has made medicine into such a more useful part
of our lives. But it can produce a baffling, cold, expensive and alienated experience for the patient. We are rightly concerned with primary care, with ideas like a medical home, with notions like continuity of care. These have the central ingredient of relationship and are more honored in our talk that in actual widespread practice. Bureaucracies do not practice compassion. Only people do and then only when they are linked in relationship.
Can compassion be taught? This is a fraught question. A Midwestern internist about ten years out of residency was presented with this question and responded very assertively, “You can’t teach compassion. You either have it or you don’t have it. What should we do, try admitting more stupid people to medical school? I don’t think that would help. You would just have more stupid doctors.” There is an arrogance here compounded with radical insularity. I think he expressed a point of view that is widespread among physicians, self-serving and placing the value of compassion either out of reach because too difficult of attainment or downgrading it
below technical virtuosity.
As the old saying goes, “if teaching were telling, it would be easy.” If compassion can be taught, it surely can not be taught by telling alone. We can imagine though a contagion of compassion that spreads in a variety of ways, by example, as the result of having been in pain and jeopardy and having been met and treated with compassion. An ecology that encourages the growth of compassion surely can be imagined. Included in it is not a system of degrading and humiliating medical students and doctors in residency. Decades ago this used to be described as “pimping” the medical student or resident. It is interesting that, although we all know that positive reinforcement works much better than negative reinforcement, that the carrot is more powerful than the stick, we regularly rush to devise and apply sticks.
Compassion has to do with suffering and succor, an experiential couple very close to the heart of existence. We have all experienced as infants and children suffering and succor, dependence and terror, the sense of being unequal to the challenge of living without assistance and reinforcement. We have the knowledge base on which to elaborate compassionate response. We have it within ourselves. It is not about money, about prestige, about technical prowess.
That is, compassion involves knowing what can not be cured and being willing to live with it, rather than overweening ambition. Our medicine, in addition to being fraught with greed, is not good at recognizing its limitations. We tend to look over and over again for what can be done next when there really is nothing to be done next but to be with a patient and his or her family. In this sense, the discipline of palliative care is a discipline of compassion. Compassion is realistic. I recall vividly the master sergeant with an intractable huge site of infection on his buttocks who was on a striker frame to protect his wound from pressure while the surgical team sought desparately to debride the wound and attack it with anti-biotics as he slipped in and out of consciousness. Before he died, his last words were “God damn you all to hell.”
Compassion is not a heroic virtue. Either it is an ordinary, everyday virtue or it is not a virtue. Compassion has backbone and can fight. Compassion is not all sweetness and light. There is a Chinese saying, “Why do you hate me? I never tried to help you.” Compassion must be able to bear being hated. Compassion is not anti-cognitive. It is not anti-cognitive in two senses. Compassion requires thinking. It requires cognition to discern how to apply itself. This is cognition in relationship, based on a back and forth dialogue sometimes with words, sometimes wordlessly with the one who suffers. The second sense is that compassion is not incompatible with diagnostic thinking, with complex therapeutic thinking, with the imagination of new medical and life possibilities.
What are the alternatives to compassion? Principally, aloofness, coldness and numbness. I do not know how you would collect data on their relative prevalence, but I think numbness is very important as a defence. Numbness bespeaks being overwhelmed and needing to defend and preserve psychic functioning. “Medicine,”
as a cardiologist who wrecked three cars in a summer driving home from the hospital after taking care of a heart attack victim said, “is not child’s play.” It is about contact with so much that is difficult, dispiriting and defeating. Many lack the emotional infrastructure to manage this without withdrawing. If we want to help people who care for people from needing to withdraw, we need to advocate open and feelingful discussion of care and cares in the world of trying to provide succor to others. We are a long way from this now.
Patients complain bitterly of the remoteness of those who take care of them. The most common boundary violation is not intrusion but excessive distance. This is not to condone intrusion but to recognize that withdrawal, the production of an interpersonal vacuum, hurts terribly and can be lethal in that it cuts off the flow of vital information on which the enterprise of medical care so depends. The closeness of compassion, the careful finding of the correct distance, the correct angle of approach is difficult. It is tiring. But it is worthwhile because it reaffirms the human dignity fo what we do.