COMPASSION AND MERCY IN THE PRACTICE OF MEDICINE

-------------------------------------------------------------------------------- BY DIMITRIOS G. OREOPOULOS, MD

Division of Nephrology, Toronto Western Hospital I borrowed the theme of my talk from the New Testament where, in relation to acts of healing, the concepts of compassion and mercy abound. I do not intend to proselytize any of you, but I strongly believe that health-care providers must reintroduce compassion into the practice of medicine if we are to provide true healing. "The human touch" has steadily decreased as science and technology has begun to dominate modern health care. I will begin with a review of compassion as it is seen in the Old and New Testaments. Definitions In the Old Testament this concept is represented in the Hebrew word, "Hessed", for which there is no adequate one-word translation in English. Sometimes it is translated as "compassion", sometimes as "mercy" and at other times as "pity". In the New Testament "hessed" is the equivalent of the Greek word "eleos". The word, hessed, also implies a dimension of action, which is not captured in any translation but, as we will see later, this dimension is an important component of compassion. It is for this reason that the title of my address contains both compassion and mercy. Jesus and Compassion Jesus asks His followers to "Be compassionate as the Father is compassionate" which I believe is a central point of His teachings. According to Thomas Aquinas, "compassion is the fire which the Lord has come to bring on earth;" However, despite its central position, compassion has often been neglected in much Christian teaching and in modern Christian literature. The Greek version of the Gospels uses two words to express Jesus' experience of compassion. The first, "eleos" (appeal for mercy) is used by the sick and disabled when they ask Jesus to relieve their pain and suffering. The second the Greek word "splachnizomai", means "I am moved in my (splachna) "viscera". According to Jewish thinking, true compassion originates in the (splachna) "viscera" bowels, which are considered to be the true seat of deep emotions. The Bible uses this word to express how Jesus responded to these cries for mercy. Thus "When he saw the crowds, he felt compassion for them because they were harassed and dejected like sheep without a shepherd; When two blind men asked him to give them back their sight, we are told that Jesus felt compassion for them and touched their eyes; When a leper asked to be cured, we are told that Jesus, feeling compassion for him, stretched out his hand and touched him. When he saw the widow of Nain grieving over her son's death "he felt compassion for her" and brought her son back to life. All these examples of Jesus "being moved in his "viscera" have two characteristics: The pain and tears of those calling for help first moves Jesus deeply; then he acts to relieve their pain. Jesus' teaching on occasions of healing underlies the starting point of all compassion, namely, that I am not only I but we are one with another. Also He brings in still a new and deeper mystery: That God suffers as we suffer, that God is relieved as we relieve the pain of one another. Compassion refuses to separate love of God from love of neighbor and, in such acts, we experience both at once. Two yet one at the same time: Because God is immanent in our neighbor, love of neighbor becomes love of God. Thus it is that the pain of God is immanent in the pain of the other and our action to relieve another's pain becomes our service to relieve his pain. Thus we can say with certitude that the Biblical meaning of spiritual perfection is to be compassionate and compassion becomes an expression of spiritual life. Arturo Paoli writes that . "The only sign of being touched by God is to be able to see yourself as a universal brother - and this means to be in communion with people and all beings. Compassion becomes the breakthrough between God and humans and the fullest experience of God that is humanly possible" (1). Good Samaritan The parable of the Good Samaritan is often held up to us as the primary example of human compassion that all of us and especially health-care professionals are bound to follow. In this parable instead of responding directly to the lawyer's question "Who is my neighbor"?, Jesus describes how a neighbor should behave. In doing so, he assumes that it was obvious to the Samaritan, as well as to the Priest and the Levite, that the wounded man lying at the side of the road was in need and knew what was in his best interests and acted accordingly. It is because they knew what their brother needed that the Priest's and the Levite's "passing by" was inexcusable whereas that the Samaritan's actions were compassionate and therefore praiseworthy (2). Citizens' in today's pluralistic society seem to assume that individuals are more or less strangers to each other and that autonomy is the only value shared by all members of such a society. However when this principle of autonomy is allowed to guide the patient/doctor relationship, it will lead to self reservation, distance between individuals, mistrust and, at times, abandonment, like the behaviour of the Priest and the Levite in the parable. The modern stance of libertarianism is at odds with the moral teaching of the parable of the Good Samaritan. The virtue of compassion presumes that human beings are not strangers to one another but instead are able to share in one another's passion, develop interpersonal rapport, assess and evaluate an other's interests and on that act beneficently (3). What is Compassion? Definitions Beyond the Gospels. In his effort to explain this virtue Matthew Fox, in his most interesting book on compassion, began by describing what is not compassion. He emphasized that compassion is not pity, it is not feeling sorry for someone else. Pity connotes condensation and that, in turn, implies separateness. "I feel sorry for you because you are so different from me - weak and inferior". Such tearful pity leads to philanthropy and to what has come to be known as "acts of good work of charity". However these acts are not compassion, because compassion never considers the other as weak or inferior. On the contrary compassion is born not of the consciousness of someone else's weakness, but of the awareness of shared weakness. Compassion arises in the hearts of those who have a feeling of togetherness, based on our common and shared humanity, and it heals by making connections among us. It is this awareness of togetherness and belonging that urges us to grieve at another's pain. This sense of grieving is the surest way to discern whether the feeling I have towards another person is compassion or merely pity. Thomas Merton said that the whole idea of compassion is based on a keen awareness of the interdependence of all living beings, who are all part of one another and all are involved in one another. Therefore, to develop compassion, one has to develop an ever-keener awareness of the interdependence of all living things. To reach this state, one must be able and ready to let go of ego, of a preoccupation with his/her own difficulties and remember that shared humanity that makes another's difficulties and suffering our own Thus compassion becomes a manifestation of spirituality and a way of living and walking through life. It is the way we treat all there is in life, ourselves, our bodies, our imaginations and dreams, our neighbors, our enemies, our air, our waters, our earth, our animals, our death, our space, our time. Compassion is a spiritual declaration that all creation matters. It is treating all creation(s) as holy and divine. (4) Compassion not only implies a passionate commitment and deep caring, which leads to acts of mercy, but it also implies an intellectual life. At times, putting one's intellectual life to the service of compassion will take work; effort, discipline and even asceticism. However there is no other way for the professional to learn compassion. Compassion and Medicine I believe that the concept of compassion must be presented to physicians in the above terms because medicine is a spiritual discipline and, as such, physicians, who want to be effective healers, should be concerned about the spiritual basis of life (5). If we are committed to healing patients as whole persons, we must understand not only what disease does to their bodies but also what disease does to their efforts to find answers to spiritual questions about the meaning of life, values and about relationships. How we answer these questions for ourselves will determine whether we can help our patients, when they struggle with similar questions (5). The capacity of a physician to become a transcendent healing presence is important not only in the management of the dying and of patients facing serious disease but also in those countless moments in the office or the hospital when he has an opportunity to communicate meaning and value to his patients. As I mentioned above, the physician can show compassion only if he/she knows that there is no space between him and his patients and that we are all interconnected and interdependent. The best example of this interconnectedness and interdependence is found in the response of parents who feel ill when their child becomes ill (3). We are all part of a communal web, what affects one affects everyone else, and what I do, in turn, will affect everyone else. In this interdependent universe, the sick and the healthy share a common destiny and compassion becomes the virtue that binds us together (3). The compassionate physician has the capacity to experience the suffering of another and to experience something of the total impact of the illness: That is the associated fears, the anxiety, the illnesses' assault on the whole person reflected in the loss of freedom and the patient's sense of utter vulnerability. However this response is not true compassion unless it is followed by a willingness to make some sacrifice, to go out of one's way in order to help (6). Without this practical commitment to help all those who put their trust in us, "compassion" is only an intellectual exercise. We must reach out and embrace not only the influential and bright and shiny patients whose association can give us prestige and make us feel important but especially the poor and underprivileged and the difficult and unresponding ones (7). The compassionate physician enters the patient's life not as a professional but as a fellow sufferer, one who shares the existential potential of disintegration because we share a common destiny (8). However human beings cannot have immediate experience of what others feel. I can never experience the other's sense of misery, beyond what my own experiences tells me. To know and feel what another person feels requires the ability to imagine the other's world and reconstruct the patients' world based on my own past experiences. This process of reflective interpretation involves a constant oscillation back and forth between observation of the patient and observation of our own responses, applying imagination, emotion, and memory - a self-conscious interplay between feelings and cognition (8). It is for this reason that physicians, who have some personal experience of suffering and diseases, are better healers than those who do not. In this introspective analysis, the compassionate physician is linked to the patient and, in this process, his inner life acts as a touchstone to the initial interpretation of the patient's inner world (8). In doing so the physician lets the patient know, with verbal and non-verbal expressions, that s/he has been heard and been accepted. In return such physicians are perceived by the patient as being present and this personal presence has a healing effect that Balint calls "the drug doctor" (8). A word of caution: During a career of caring for others many of us set excessively high standards for ourselves and when, on occasion we fail to live up to these standards we do not use our own compassionate skills to understand, accept, forgive and care for ourselves. This kind of compassionate self care is essential if we are to be compassionate with our patients (9). Mercy As I mentioned earlier compassion always includes an active component - a profound responsiveness to the one who calls for help. Some call this response empathy but I will call it mercy. Hence I will be talking about "merciful care". Levinas sees mercy as a way of "being for the other first; once we have escaped the centrifugal pull of our own identity, needs, interests and values and plot a new trajectory towards the other. No more I am driven by my personal agenda but I act for the sake of the other and his suffering (10). Serious illnesses threaten our identity and most of our relationships. They threaten our knowledge and sense of security and comfort in our world and we suffer a crisis of hope and faith. Mercy requires us to identify clearly the sources or cause of the patient's suffering and to marshall effectively all available resources to address and reduce that suffering (10). Cassel argues that "suffering occurs when an impending destruction of the self is perceived by the patient; it continues until the threat of disintegration has passed or until the integrity of the person can be restored in some other manner (11). Once we have identified with the suffering individual through our compassion, mercy will commit us to provide the time and efforts required to uncover the deepest needs, fears and values of the one who is suffering. Merciful care requires us to transcend institutional roles such as those of scientists, provider, patient, ethicist etc and often to refuse managerial decrees for greater speed, economy and efficiency. In such merciful care, we concentrate not only on alleviating physical suffering but also on relieving the suffering of the soul. Cassel reminds us that a full awareness of an individual's suffering requires intimate knowledge of the other as a unique person. He says: "To know in what ways others are suffering demands an exhaustive understanding of what makes them the individuals they are - when they feel themselves whole, threatened or disintegrated as well as their view of the future, past, others, the environment and their aims and purpose" (11). He argues that suffering is a profoundly lonely and isolating experience. Thus relief of suffering and mercy requires us to reach out to the suffering person and bring him/her back with the rest of us (11). Suffering is the substance of life and the root of personality, for only suffering makes us persons. When we have suffered ourselves, we are sometimes better able to understand others. Compassion for the suffering of others thus enriches our own understanding of what we too must sometime go through (6). Compassion and the Patient with Chronic Illness or the Dying Patient Compassion and mercy become even more critical in situations of prolonged illness, profound impairment or highly debilitating state or imminent death. In such circumstances, the compassionate physician becomes a partner in search of alternatives, encouraging the patient to examine a range of options for overcoming or transforming the suffering, so that a new person can emerge, with a new sense of meaning. The compassionate physician can facilitate this transformation by providing verbal support and offering acceptance to the patient (12). Even "when nothing more can be done" medically to cure a disease, we should never forget that dying patients need control of pain, preservation of their dignity and self worth and finally the ultimate "medicine" that of love and affection. Our presence, and warm and non-judgemental attitude can bring comfort and reduce anxiety and thus allow the patient elicit the thoughts and feelings that need to be communicated. The compassionate physician, showing respect to the patient's values, can function as a reflecting mirror to the patient and help him define, discover and express the meaning of his life which can bring healing and peace. I should emphasize here that all these take time, time to "be present" and listen, time to hold a hand, time to talk. Though not all patients die with all their conflicts and anxieties worked through, this time spend is still helpful for the dying patient and rewarding for the physician. Compassion and the Physician: A Virtue or a Duty? Is compassion a duty expected of all physicians or is it a virtue important for the care of patients but given the social milieu and the nature of medical school training curriculum, it is a virtue that cannot be expected from all physicians? (6). I agree with Dougherty et al that compassion is so deeply tied to the public's image of medicine and is so generally valued by patients that it must be part of the professional duty of the physician (12). The strongest argument that compassion is a duty of all physicians lies in the connection of compassion to the duties generally accepted to be part of all physicians' professional responsibility. Central among these duties are the fiduciary responsibility to put patients interests first, the duty of due care and the duty to maintain confidentiality that protects the vulnerability created by patients' revelations of intimacies and potent sources of suffering - private fears and anxiety, embarrassing secrets about life-style and feelings of guilt, abandonment and meaningness. The sharing that compassion facilitates, allows the physician to put the patient's interests first, to provide due care, and to better understand the vulnerability that such revelations create. The uncompassionate physician is less likely to appreciate and protect patient vulnerability and, without compassion, the physician may unwittingly compromise due care in myriad ways (11). Some believe that because physicians are fallible human beings with their own weaknesses, they will not be able to provide perfect compassionate and merciful care to all patients at all times. I believe it is important to recognize that we can always do better than we do at present. The key thing is to keep trying to improve one's professional services thus even when I feel tired, busy or important I should be big enough to be kind, caring and patient. Life as a physician can be demanding and soul destroying but is always rewarding. Contact with compassionate physicians who are sympathetic and have effective communicating skills increase the patient's satisfaction and improve the patient's compliance , which in turn, increases their ability to diagnose and treat all patients. As a bonus those characteristics reduce the risk of litigation (11). Some may be concerned that the continued practice of compassionate care may lead to burn out and in the long-run, can undermine the physician's performance and the detachment that has long been considered a necessary condition of medical practice it protects the physician from being overwhelmed and protects the patient by helping the physician to make objective decisions. At its heart, medical practice and especially the physician - patient relationship is an emotional connection. I believe that, instead of detachment, we need emotional resilience that will allow us to experience fully the emotional ramifications of patient care as an essential part of the practice (9). Compassion and Ethics Having lost touch with compassion, we have tried to create ethical values such as respect for autonomy, beneficence, non-maleficency and justice which we hope will guide the physician's practice. We do this even though the presence of compassion can and does serve as one of the most important motivators and modulators of ethical behavior in all these areas (6). Compassion comprehends and respects the moral claim of autonomy and recognizes the dignity of the sick as free participants in their own healing. Furthermore compassion encompasses the ethical principle of beneficence by going well beyond the minimalist requirements to avoid harm. It calls upon us to help others even when that involves inconvenience, sacrifice and denial of self interest (12). Compassion transcends the language of justice; it is not concerned with what one deserves, with being treated fairly or with securing one's rightful claim (14). With compassion the general "good" is based on the most loving thing to do, in that particular situation. Characteristics of Compassionate Physician A recent survey found that physicians, considered by their own peers as "compassionate" are younger and have fewer years of practice than those considered "non-compassionate". They are more likely to practice internal medicine and pediatrics than one of the surgical specialties. There were no differences with regard to gender. Those scoring high in compassion have higher levels of self esteem (15). This survey defined a compassionate physician as one whose pattern of behavior reflected a strong devotion to the welfare of patients on two crucial dimensions of patient care: a) scientific/technical (curing) and b) socioemotional (caring). The past decade has seen enormous developments in the former and, at the same time, widespread neglect of the latter (15). Benefits of Compassion Compassion benefits not only the sufferer but also the caregiver, who in such moments is afforded a rare moment of communion or connection and for a short while is set free from self-absorption. The compassionate physician is able to cease from the grinding striving for the primacy of his own existence and his own welfare and momentarily is relieved from the burden of individuality (6). Compassion teaches us that merciful care is never a unilateral act. It helps us recognize that our sick brothers and sisters are not alien to us. Each is a part of the human family and is vital to our own spiritual growth. The healthy need the sick to "humanize" them as much the sick need us to "care for them" their sickness (6). Such involvement with the patient in merciful care is the wellspring of medicine and is rewarded with knowledge. The healer who answers the call of the one who suffers and offers his/her skills may receive the gift of grace; this experience buoys them up rather than weighs them down. Barriers to Compassion In many physicians compassion is blunted or suppressed rather than absent. Our self- interest will blunt compassion and prevent us from seeing the plight of others. Also it may be blunted by societal forces that view individuals as isolated social entities (12). The present restructuring of the health care system by market forces is driven largely by the desire to contain costs; the demands for efficiency in competing health plans squeeze out the time needed for "feeling with the patient". I recognize that, nowadays, the industrialization of medicine and the emphasis on efficient management of resources threatens the spiritual foundations of medicine. It is not easy to be a compassionate physician with increased demands, a steady shrinking of the time spent with the patient, the filling out of forms, and the lure of financial incentives, which threaten to make the physician and the patient economical rivals. We can avoid these pitfalls only if we are able to see our work as service and as an opportunity for personal growth. We can achieve this only if we become compassionate individuals providing compassionate service. To counter these dehumanizing trends, the role of compassion in health care must be given a greater prominence in the current debate. It must be presented to the profession and the public as the moral and ethical basis of medicine, which it is. Any systemic change in health care that will be worthy of being called reform must protect and passion (16). Teaching of Compassion Medical faculties have provided few formal courses in humanism and compassion in their curricula. If we are to encourage greater humanism among our students we must be clear about its importance and insist that compassion is essential to the humane physician; that it is to be taught, nurtured and cultivated as part of the curriculum (7). To promote compassion in our students, they should be taught the following concepts: Pay attention to suffering; not just to pain but suffering; see not just what disease or disorder the patient has but what the patient is going through. Identify with the patient's suffering and see that suffering as your own. When the patient and caregiver become one, the suffering of the one becomes the suffering of both. Pleasure shared is doubled; pain shared is halved (17). Learn to see beyond the skin and beyond the social status, beyond the sight and the smell, beyond success and failure. Learn to use silence to encourage patients to talk, listen carefully, be non-judgmental, tolerate uncertainty. Ask the student to consider their own and their patients' emotions. Consider what these emotions mean. and whether that meaning can be reframed in ways that yield new insights (8). Listening and questioning are tools to achieve an accurate perception of the patient's experience. The student should learn to show a genuine interest in the patient, to develop the ability to read another's feelings, to recreate within one's self another's experience, to resonate with it, and to convey an appreciation of it. Communication through the language of facial expression is an important ingredient in the effective practice of compassionate medicine (7). Students should have an opportunity to experience what the patient experiences assisted by a course in communication and counseling. They should have opportunities to be taught by the patients, by their families and by nurses. They should also have many opportunities to discuss their feelings with each other and with older practitioners (18). If a student is to understand and become skilled in providing compassionate and merciful care they must receive training by skillful teacher who will handle them compassionately. Without them even the best curriculum cannot be implemented (19). Medical students and residents need teachers, who can function as mentors and role models and who will inspire the students by personal example. This kind of modeling illustrates Plato's dictum, "To know virtue, observe the virtuous man" (7). Role modelling of compassionate medicine is doomed to failure unless it is practiced daily by a majority of the faculty. Students/residents must learn to recognize and comment on its absence in their mentors. Its importance must be driven home to students by evidence of an institutional commitment to compassion equal to the commitment to science (7). Before teaching compassionate care to students/residents, teachers must first develop their own compassionate skills. Interpersonal skills of this kind can be learned only through experience (19). Faculty must teach by example without being afraid to acknowledge that they may not always do it well or even correctly. Even if the patient perceives that the physician is trying to understand how he/she feels, this by itself is therapeutic (7). Educational methods that have been used to teach compassion/mercy include (19). One-on-one preceptor submission. The resident is supervised in "live" patient encounters by a preceptor, who observes the intervention and comments at its conclusion. Case discussion in Balint groups. Such discussions involve 8-9 residents who meet weekly for two years under the guidance of an experienced physician. Each resident presents patients with whom they are experiencing interpersonal difficulties. Participants learn to recognize significant verbal and non-verbal clues, which are clinical manifestations of the patient's emotional state. A recent study (20) demonstrated that physicians attending an eight-hour communication skills training course showed a statistically significant improvement in compassionate behavior such as asking patients about their understanding of their illnesses and their expectations about treatment, offering reassurance, setting an agenda, and eliciting the full spectrum of patient concerns. Patients of trained physicians exhibited a greater reduction in emotional distress as long as six months after the medical encounter. However nothing can enthuse students more and encourage them to try to improve, than a compassionate physician/teacher who shows them respectful concern as person. Finally, rewards are a strong motivating force in human behavior. Generally continuous compassionate behavior does not receive a material reward and is of no consequence when promotion is considered. Such realities indicate the institution's lack of commitment to compassionate medicine (15). CONCLUSIONS As I was thinking how to conclude this talk I came across a paragraph in Fr. Paissios second book of sayings, entitled Spiritual Awakenings. He has summarized my ideas in a wise, clear and concise way and so I would like to finish by quoting him. "Geronda, How does one understand that the other has been helped by my prayer? You will be informed by the divine comfort that you will feel inside you after you make a passionate prayer from the heart. However first you must make the pain of the other your own pain and then pray from the heart. Love is a divine virtue that informs the other person. And in the hospitals when the doctors and the nurses really sympathize with their patients, this is a drug more powerful and effective than all the drugs they give to them. The patients feel that they care for them, feel safe, secure and comforted. You do not need too many talks to tell to the person who suffers nor to preach to him. The other understands that you sympathize with him and that he is being helped. Compassion is everything. If we feel compassion for others, we forget ourselves and our problems". -------------------------------------------------------------------------------- REFERENCES A. Paoli. "Meditations on Saint Luke". Maryknoll, NY: Orbis Books 1977. Welie JVM. Sympathy as the Basis of Compassion. Cambridge Quarterly of Health Care Ethics; 4:476-487, 1995. Nakasone RY. Illness and Compassion: AIDS in the American Zen Community. Cambridge Quarterly of Healthcare Ethics; 4:488-493, 1995. Fox M. A spirituality named compassion and the Healing of Global Village. Hampton & Row Publishers, San Francisco, 1979. Sulmasy DP. Is Medicine a Spiritual Practice? Academic Medicine; 74(9):1002-1005, 1999. Thomasma DC, Kushner TA. Dialogue on Compassion and Supererogation in Medicine. Cambridge Quarterly of Healthcare Ethicss; 4:415-425, 1995. Rabin D, Rabin PL. 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