Abstract
Professional medical ethics demands of health care professionals in addition to specific duties and rules of conduct that they embody a responsible and trustworthy personality. In the public discussion, different concepts are suggested to describe the desired implied attitude of physicians. In a sequel of three articles, a set of three of these concepts is presented in an interpretation that is meant to characterise the morally emotional part of this attitude: “empathy”, “compassion” and “care”. In the first article of the series, “empathy” has been developed as a mainly cognitive and morally neutral capacity of understanding. In this article, the emotional and virtuous core of the desired professional attitude—compassion—is elaborated. Compassion is distinguished from sympathy, empathy and pity. Several problems of compassion as a spontaneous, warm emotion for being a professional virtue are discussed: especially questions of over-demand, of justice and of concerns because of a possible threat to the patient’s dignity and autonomy. An interpretation of compassion as processed and learned professional attitude, that founds dignity on the general idea of man as a sentient being and on solidarity, not on his independence and capacities, is developed. It is meant to rule out the possible side effects and to make compassion as a professional attitude and as professional virtue attractive, teachable and acquirable. In order to reach the adequate warmth and closeness for the particular physician-patient-relation, professional compassion has to be combined with the capacity of empathy. If appropriate, the combination of both empathy and compassion as “empathic compassion” can demand a much warmer attitude towards the patient than each of the elements alone, or the simple addition of them can provide. The concept of “care” that will be discussed in a forthcoming article of this sequel is a missing necessary part to describe the active potential of the desired moral attitude of the physician more completely. The reconstruction of the desired professional attitude in terms of “empathic compassionate care” is certainly not the only possible description, but it is a detailed proposal in order to give an impulse for the discussion about the inner tacit values and the meaning of medicine and clinical healthcare professions.
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Notes
There are several suggestions which goals medicine actually pursues (The goals of medicine 1996; Nordenfelt and Tengland 1996). Sometimes they are connected with a position in a special contested question, e.g. euthanasia; in stating a special goal of medicine in helping patients to die in dignity (Miller and Brody 2001). The German physicians’ association (Bundesärztekammer) accepts the goals of alleviating suffering, prolonging life, treating diseases and improving health (BÄK 2011). I hold that these (sometimes conflicting) goals are not much contested and describe adequately enough the internal orientation of medicine. If we try to condense it even more to the very core, we will get close to the position of Eric Cassell. According to him, helping suffering patients is the central goal of medicine (Cassell 1982, 1991).
It depends strongly on the kind of ethical theory if there is room for this intentional state within the theory, or if it is understood as something outside ethics as a philosophical discipline. Virtue ethics as agent-focussed theory has room to integrate moral motivations (Slote 2001).
As moral sentiments I do not only understand the feelings of guilt, shame, remorse etc., that is, of retrospective evaluation, but also those that have a benevolent (or sometimes called “altruistic”) implication like love, friendship and compassion.
It is necessary to distinguish clearer between affects, feelings, sentiments, emotions, perceptions, sensations etc., in order to get an encompassing picture of the role of affective states in agency in general, and moral agency in particular (Nordenfelt 1974; Kenny 1963, 2003). For the purpose of identifying and describing those professional virtues of physicians that involve affective states, however, most of these clarifications can be postponed. So the term “emotional” is used in the wide sense as mental state as opposed to “cognitive”. “Emotion” , however, is understood in the narrower sense of an intentional affective state with an identifiable object (Kenny 2003), that is, a dispositional attitude (Wollheim 2000).
The point about “spontaneous compassion” is not its spontaneity but its specific emotional content—I do not exclude totally that also “professional compassion” could occur spontaneously, though typically it is the result of a successful professional socialisation. All presented interpretations of “compassion” understand it as a dispositional attitude with inclusion of an emotional element. As the attitude of spontaneous compassion is not quite what seems to be expected as a professional attitude, particularly with regard to its emotional content, I focus on these emotional aspects of spontaneous compassion, in order to make clearer in which way compassion has to be developed in order to become a professional attitude.
“Identification” would be a further step in the direction of leaving the own personality, for a short time while acting or reading, or even permanently in pathological cases (Scheler 1970).
In moral psychology, it has become common to distinguish quite sharply between cognitive empathy and emotional empathy: the intellectual capacity to imagine what happens in other people’s minds (having a “Theory of mind”), and the emotional identification with the other person. In my reconstruction I understand the needed empathy as mainly cognitive one, while I try to describe a more specific morally-emotional disposition than the broad complex of so-called emotional empathy, which embraces all kinds of “altruistic” emotional dispositions).
According to M. Nussbaum, for Stoics like Seneca, cruelty and compassion are no opposites at all, but fruits of the same tree. Compassion is then the answer on behalf of others, where we would feel anger for ourselves, and react perhaps with cruelty in the extreme (Nussbaum 2001, pp. 361–363). For Stoics, compassion is, of course, no morally good attitude at all. However, if we would generally share this intuition, Szasz would have lost a good book title.
If not for a very strong deontologist. But for a practical focus like ours, it nearly needs no explanation why such a position would lead to dangerous and undesired results. If I as a totally inexperienced surgeon would operate patients in the best intention, the outcome would be foreseeable disastrous, and I defend the position that this would perhaps be benevolent, but no morally good action.
It is also possible to suffer oneself and be compassionate for a person in the same situation. Perhaps this should even be the paradigm case which makes the understanding and the good will and the wish to change the situation most genuine. It is not necessary in order to be compassionate, however. The focus in compassion is on the suffering of the other. The own suffering may help to understand, but it also can distract from concentrating to the other one’s suffering. So one may alternate between suffering, self-pity and compassion. I regard compassion as an asymmetric inclination to help, even in this situation (and I admire the compassionate person even more).
Surveys about preferences for prioritisation in healthcare show, that e.g. the German population supports nearly everything that can be done for children, while even severe psychiatric disease would be neglected (Müller and Groß 2009).
On behalf of the helpful replacement of a fully moral performance by means of dutifulness, Michael Stocker mentions in a footnote: “Such “feelings” are at times worn thin. At these times duty may be looked to (…) to get done at least the modicum of those things love would normally provide. To some rough extent, the frequency with which a family member acts out of duty, instead of love, toward another in a family is a measure of the lack of love (…). But this is not to deny that there are duties of love, friendship, and the like.” (Stocker 1976, p. 465).
And, of course, being incompetent, but this reproach is not in the focus of this article. However, it is worth remembering that good will and being the right kind of person is necessary but not sufficient for the image of a good doctor.
Having more tasks than one can manage in the given time, more psychological challenges than one can handle, and meaningless work with little responsibility for the outcome and thus little inner reward and satisfaction in one’s work are typical reasons for burn-out. Attitudes do not need extra-time, and appropriate attitudes can help handling dilemmas by offering orientation and meaning for one’s actions, and thus have the potential to feel more satisfaction and value in one’s profession.
On the other hand, a lack of compassion in a balanced partnership may also show a lack of respect and attention to the situation of the other. If only one of the partners is in a painful situation, compassion may be the appropriate additional feeling, not a contradiction or replacement of love.
This is also mirrored in approaches of human rights and human dignity. Both may follow one and the same moral intention, but they have a different focus. Compassion is related to dignity, and the obligations in an individual physician-patient relationship mirror the larger scale obligations in global humanitarian engagement.
That does not mean that the patient’s choices should be overruled. It is of course his right to decide for his own life, and if he does not need special consideration of his in comparison with the physician more vulnerable state, it should make medical decisions much easier, not more demanding.
Eric Cassell describes convincingly how different necessary aspects of modern medicine compete for attention and make a caring, compassionate attitude difficult. A good medical education should prepare students in all necessary aspects of good clinical practice (Cassell 2001).
For those who are interested in the archetypical description of good and evil in fiction, and the role compassion can play here, it might be telling to have a look at J. R. R. Tolkien’s “Lord of the Rings” and “Silmarillion”. Here, it is not only possible to learn compassion, by means of being with a person who is excellent in this and by exposing oneself to beings who need and deserve compassion. It is also the decisive distinction between the ultimate and non-corruptible good and the evil, between Gandalf and Sauron. Gandalf learns compassion from Nienna, and his sympathy and understanding for all kinds of beings that he gained and improved this way protect him from being corrupted by the fascination of power—his own power as well as the additional power of the evil ring. It does not seem far-fetched to see a potential in compassion of also protecting physicians from misusing their power or from being corrupted by secondary incentives.
Rosalind Hursthouse describes the learning of virtues as follows: “(…) many of the goals appropriate to scientific knowledge—universality, consistency, completeness, simplicity—are not appropriate to moral knowledge; the acquisition of moral knowledge involves the training of the emotions in a way that the acquisition of scientific knowledge does not (…)” (Hursthouse 1993 p. 32).
Until now I only have presented two of the three parts of the morally-emotional attitude of “empathic compassionate care”. In order to combine this virtue with medical knowledge and skills a further quality is needed which by several authors refering to Aristotle is called “phronesis”, or also “clinical judgement”. I suggest to describe the attitude from which this capacity is used as “responsibility”.
I am aware of the difficulties of examining attitudes and the danger of hypocrisy and rigidity. Probably it would be wise only to exclude extreme cases of psychopaths and habitually disrespectful people, like it is already done. Nevertheless it seems important to me today (more than in the past) to make unequivocally clear that the whole person is demanded in the profession of a physician, not only a splintered and exclusively cognitively-educated part. Nevertheless, I think it is sufficient and more appropriate to focus on demands on the right attitude, not the character of a health care professional.
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Acknowledgments
I wish to thank Bettina Schöne-Seifert, Münster (Germany), Lennart Nordenfelt, Linköping (Sweden), Kristin Zeiler, Linköping (Sweden) and particularly Rolf Ahlzén, Karlstad (Sweden) for reading and commenting earlier versions of this article. I am also indebted to the teams of the Institute for Ethics, History and Philosophy of Medicine in Münster (Germany), the Department for Health and Society in Linköping (Sweden) and the Centre for Applied Ethics in Linköping (Sweden), and to three anonymous reviewers.
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Gelhaus, P. The desired moral attitude of the physician: (II) compassion. Med Health Care and Philos 15, 397–410 (2012). https://doi.org/10.1007/s11019-011-9368-2
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DOI: https://doi.org/10.1007/s11019-011-9368-2