A World Cleansed of Imperfections?
This article by Max Wind-Cowie dismantles the ‘choice’ argument used by those who promote abortion and euthanasia for the reason that individuals should have the right to decide for themselves. He suggests that ‘what starts out as a ‘right’ soon becomes an expectation and the ‘tradition of the sanctity of life is replaced with a new tradition of utilitarian eugenics.’
Compassion as a moral duty
In his extensive study, 'A Theology of Compassion', Oliver Davies describes compassion as "the voluntary sharing of the fate of others in order to be present with them in the time of trial"1 and as involving the "interweaving of self and other"2. Also, drawing on the work of Martha Nussbaum, he points out the three-fold nature of compassion as a combination of the cognitive (seeing another's distress), the affective (being moved by it) and the volitional (doing something about it)3. These descriptions help place compassion within the realm of ethics – as a response and quality that ought to be exercised and displayed. Placing 'compassion' within an ethical framework is required if compassion is to be regarded as an important and necessary force in our lives. The alternative is to regard compassion as simply a psychological disposition, or, worse, entirely subject to circumstance and chance and, as such, excuse ourselves from responding with the proper kindness to another person's suffering.
In recent years there have been numerous studies that show up the fickleness of human behaviour; proposing, for example, that being in a hurry or not, or having a little bit of good luck will have more bearing on behaviour than ethical principles4. Similarly, Auckland-based psychologist, Nathan Consedine, takes the rather pessimistic view that compassion is "part of our evolved psychological make-up" and that "caring for people who don't deserve it is inefficient from an evolutionary perspective" (North & South, September 2015, p.61). It may well be that human beings are fickle, but to excuse the requirement for compassion on the grounds of temperament or circumstance seems to diminish something important about our humanity. Human beings are moral beings and, as such, have the capacity to rise up to what ought to be done. This is what ethics teaches us.
The idea that compassion is an ethical characteristic has, traditionally, been rejected. It was seen as too closely aligned to our emotions, and so too irrational. Plato considered feelings of pity to be undesirable and the Stoics saw pity as "a weakness of the mind"5. Kant insisted that acting from sentiment – even if it leads one to do a good deed – has no moral worth, and Nietzsche takes things a step further, regarding compassion as a vice, believing that "suffering is spread through compassion"6. Nevertheless, that we have a duty of care for others is supported by most ethical traditions and with some rethinking it is possible to construct an understanding of compassion – incorporating the cognitive, affective and volitional dimensions – as an important ethical category.
First, as noted by Davies, there needs to be a place for affectivity. There have been some important recent works that develop this theme. Justin Oakley, for example, in "Morality and the Emotions"7explains how the affective dimension does have a place in moral decision-making and because of the relationship between our affective and cognitive capacities we can exercise some control over our emotions.
Secondly, there needs to be a rethinking of the self; a "radical de-centring of the self"8and a letting go of a notion of the moral agent who is traditionally "presented as though they were continuously rational, healthy and untroubled"9. This includes abandoning the notion of the 'sovereign' self who sees him/herself as the source of all knowledge and the source of the moral law and action. From this 'superior' stance the other person is too easily seen as a mere 'object' of my pity. Compassion, on the other hand, requires of me to begin with the other person in his or her uniqueness and to enter into their vulnerability; all the while recognizing that it is their suffering and not my own. As Alasdair McIntyre points out, human vulnerability goes hand-in-hand with our dependence on each other and this is the moral landscape in which compassion is experienced10. This shift in thinking about the self and the other is required if compassion is to be a legitimate ethical standpoint.
To take the other person in their vulnerability as the starting point is to take an imaginative step and so, as David Hume puts it, "to feel a sympathetic motion in my breast, conformable to whatever I imagine in theirs"11. The imagination enables us to grasp what is before us and to also 'see' more than what is materially present – e.g., we may first see a person drop a pile of papers, but the imagination enables us to also 'see' the person's distress and so 'see' the situation as one that requires a compassionate response.
Finally, ethics involves the conscious decision to transcend inclination and to do what is right. To be moral is to rise up and do what is right regardless of whether or not we like the person who requires our help, or we are in a hurry, or whether or not we happen to be having a good day. Unless compassion is something we aspire to as a matter of moral obligation we will never be capable of responding with the kindness and care that is so often needed.
Rev Dr Gerard Aynsley is a parish priest in the diocese of Dunedin. He holds a PhD in philosophy from Monash University in Australia.
 Oliver Davies, A Theology of Compassion (London, SCM Press, 2001),12
 ibid. xix
 ibid. 18
 Google, for example, “The Good Samaritan study” or “The dime in the phone booth study”.
 cited in Oliver Davies, 235
 cited in Oliver Davies, 239
 Justin Oakley, Morality and the Emotions (London, Routledge, 1992)
 Oliver Davies,17
 Alasdair McIntyre, Dependent Rational Animals (Chicago, Carus Publishing Company, 1999),2.
 Alasdair McIntyre, Dependent Rational Animals
 David Hume, A Treatise of Human Nature (Oxford: Clarendon Press, 1967), 386.
“When we walk to the edge of all the light …”
I am a palliative medicine doctor and recently I have returned to practice acute hospital medicine. As professionals serving others, doctors train to be aware of their human reactions to events, interactions and people. It is part of the discipline of being a doctor. From my years of experience I believe this is fundamental to good healing practice, resilience and growth. As Dr Tom Mulholland says in the article: “You have to live in the moment and practice mindfulness.” (North & South, September 2015, p. 62).
One might expect that Palliative medicine would be one of the principal areas for “compassion fatigue”. Yet it is also potentially a nurturing place for staff, aware of each other and kind to each other. Although compassion is called from us as doctors, nurses, chaplains and allied health staff, we also receive from each other. This mutuality sustains us. This does not automatically happen in a palliative care team, community or unit. It needs to be a conscious value of the team, attended to on a daily basis. We cannot be compassionate and kind to the patient if we are not kind to one another. A buoyancy of life is thus created which sustains us. In this space, although serving those who are dying and witnessing untold grief, we support each other.
Mr W (89) came to the Emergency Department during the night. The night registrar summarized the patient’s story – shortness of breath, attributing it to exacerbation of chronic obstructive airways disease. I met Mr W Saturday morning with Ella the registrar for that day. He was returning from the toilet, sitting now on the side of the bed and breathless. I was unsure how different this was from the time of his admission 6 hours before. I thought he had heart failure. We asked the nurse to give him frusemide. I thought the tracing of his heart (ECG) suggested ongoing damage to his heart. We continued on seeing other new patients.
About an hour later, an alarm bell rang in the Medical Assessment Unit - Bed 23 - Mr W’s bed. The nurse was there. He had just died. I decided immediately that CPR was not appropriate. Ella consoled the nurse who was upset that she had left him just before he died. I phoned his daughter as the identified contact person. She cried, clearly surprised and distressed. She said her mother was just then getting his clothes ready, preparing for him to come home that day.
They arrived about two hours later. His wife in a wheelchair, crying. She was afraid to go into the room where he lay. I encouraged them all to enter the room. Mrs W lifted herself out of the wheelchair by his bedside, leaning over him, almost lying on him, weeping, hugging him, talking to him. My heart was breaking now. The image of this small lady leaning over this man, her husband of 65 years.
I could not understand why I was so upset after 22 years in Palliative Medicine. I think it is because in acute medicine, unlike Palliative Medicine, you are so close to the front line; because in acute medicine you do not have your Palliative Medicine armour on. The chaos and uncertainty, the surprise factor of acute medicine, render me exposed and vulnerable. “Palliative” comes from the word “pallium” to cloak or shield. But now I know “pallium” used to shield me.
The poignancy intensified. I sent them a card offering my condolences. Mrs W responded, phoning me to request a meeting. “Oh dear,” I wondered ... A week later we sat again in the same room where she had hugged her dead husband. Mrs W said “The nurse phoned me that morning, said S wanted to speak to me”. As the nurse brought the phone to his bedside, “the battery died”. So they never spoke. She presumed he wanted to tell her to bring in his clothes, that he was going home. So she started to get his clothes ready. Now she wonders did he want to say he loved her. “Is that what he wanted to say…?”
Mrs W thanked me. They all thanked me. My heart was breaking. Acute Medicine – no place for the faint hearted.
Would repeated encounters like that with Mr and Mrs W wear me out and lead to compassion fatigue? Not necessarily. In this story there is a mutuality in the exchanges between us, a give and take, an ebb and flow, an emptying and a filling. I am called to be aware, be alert to all that is happening to the patient, the family and to myself. In that space of being fully present, I am emptied and I am filled.
“When we walk to the edge of all the light you have and take that first step into the darkness of the unknown, you must believe that one of two things will happen: There will be something solid for you to stand on, or, you will be taught to fly.” “Faith” by Patrick Overton - “The Leaning Tree”
Dr Sinéad Donnelly is a Palliative Medicine and Internal Medicine Physician in Wellington.
Compassion Fatigue in Nursing
There is a sentimental idea in many of our minds that nurses are the epitome of caring professionals: gentle, kind, friendly, compassionate, empathetic, capable and calm. Certainly this is an ethos that the profession attempts to live up to, and many of us would also add that nurses need to be skilful, articulate, courageous, ethical and resilient. The expectation that nurses will provide compassionate, respectful and trustworthy care is spelled out in the profession's Code of Conduct. The Code is framed around core values of respect, trust, partnership and integrity, and although the word 'compassion' is not used, it is inherent in the whole code, and nurses know they have a professional responsibility to live up to this standard.
In spite of expectations and codes sometimes nurses slip up and may behave in ways that are less than ideal. Sometimes their heart simply isn't in their work. As human workers and human beings, nurses, like everyone, are fallible. The very idea that nurses might lose compassion, become tired of caring, be at any time unable to give unconditional regard to patients and families is actually a rather frightening one. Nurses are people on whom any of us might (and do) depend in times of extremis, when sick, frightened, in pain, vulnerable, perhaps alone, whether as patients or as relatives or friends of those in need of care and protection.
Why would things go wrong in this way? I suggest there are three factors at play when compassion fatigue appears amongst nurses: the nature of nursing work itself, work demands and overload, and systems and institutional values that operate at odds with the values of nurses themselves.
Nursing work involves extensive elements of emotional labour. In their everyday work nurses deal with sensitive and intimate aspects of life, much of it in the domain of the private, often invisible and unspoken. While it is quite normal to discuss the fact that patients and families are troubled by fear, grief, sadness, it is less common for nurses to talk about the abject emotions they experience themselves. Anger, surprise, fear, dread, sympathy, joy are acceptable topics, but revulsion, repulsion, disgust, horror, terror, and libidinous arousal are not so easily slipped into a conversation, even an earnest one.
The mechanisms nurses employ to deal with the abject, and the fear and the anxiety that their work entails, have been explored both psychoanalytically and sociologically. Over several decades the received wisdom that nurses ought to conceal all their emotional reactions has been changing, and nurses now may (at times) laugh or cry with patients and families in their care. Nevertheless a full range of emotional expression would derail professional comportment and be counter to the value systems that hold the profession together. To work at their best nurses must hold their emotions in.
At the same time, nursing work itself is emotionally laden, driven as it is by the desire to help, to serve, to tend, to be compassionate (a voluminous literature backs this idea), in combination with an interest in things medical and mysterious, psychological and deep, bizarre and exotic and dangerous.
But it is not just disease and disability, sickness and health that nurses must deal with. There are also different needs and expectations of patients and the increasingly production-conscious environment in which nurses work. As financial pressures squeeze our health systems tighter, and the pressure for increased work volumes increases, nurses often feel they must ration care. Care rationing means that they must decide whose needs are most urgent and what care can and must be left undone. It means deciding what words can be left unspoken, what comfort can wait until later. It is a dreadful situation for nurses, patients and families to be in. While nurses are balancing unseen demands, patients and families are experiencing things rather differently. Time drags for those who are ill or waiting, but not for the staff who are preoccupied with getting everything done, who know that they must balance this patient's needs against that one's, this emergency over that potential problem.
In situations such as this nurses can feel overwhelmed by helplessness, frustration, tiredness and tedium. Lack of insight develops and ordinariness takes over. People who do not feel valued, who do not have the resources they need, who feel helpless to change things do not make good, compassionate, care workers. Emotional control can break down, and a desire not to care can creep in, when the load becomes too great to bear.
Nursing is hard work. Physically, psychologically, emotionally and spiritually. A firm sense of one's own values, driven and backed by a strong spiritual faith is some defence against failure, provides some insurance, some inoculation in terms of what is right and proper and why we chose this work. Compassion fatigue is a sign that health workers themselves need some help, care and relief. It is also a 'canary in the mine' signal that a larger system is in serious danger.
Jo Walton is Professor of Nursing in the Graduate School of Nursing, Midwifery and Health at Victoria University of Wellington and Deputy Chair of the Nursing Council of New Zealand.