Compassion as a moral duty
Gerard Aynsley
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.
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[1] Oliver Davies, A Theology of Compassion (London, SCM Press, 2001),12
[2] ibid. xix
[3] ibid. 18
[4] Google, for example, “The Good Samaritan study” or “The dime in the phone booth study”.
[5] cited in Oliver Davies, 235
[6] cited in Oliver Davies, 239
[7] Justin Oakley, Morality and the Emotions (London, Routledge, 1992)
[8] Oliver Davies,17
[9] Alasdair McIntyre, Dependent Rational Animals (Chicago, Carus Publishing Company, 1999),2.
[10] Alasdair McIntyre, Dependent Rational Animals
[11] David Hume, A Treatise of Human Nature (Oxford: Clarendon Press, 1967), 386.
“When we walk to the edge of all the light …”
Sinéad Donnelly
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
Jo Walton
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.
Compassion Fatigue: an institutional issue
Michael McCabe
‘Most young doctors enter medicine with quite a profound desire to help other people. Somehow, across the first decade or so of training and work, that diminishes.
We call it compassion fatigue – the idea that doctors have a finite reservoir of caring that drains away over time, leaving some of them a cynical, couldn’t-give-a-damn husk of inhumanity.’
Nathan Consedine (North & South, September 2015, p.60)
The Greek word for compassion ‘splagchnizomai’ literally means ‘to be moved’ in ‘one’s bowels.’ Emotions were viewed as ‘residing’ in the bowels – literally ‘in the guts.’ Thus, a person without compassion was essentially unmoved by the plight of another and could be described as being ‘hard’, ‘heartless’, or ‘harsh’ with ‘no reach’ inside them.
Compassion fatigue is not limited to the healthcare professions. It is part and parcel of any professional role that involves advocacy for or care of others – it is potentially the Achilles’ Heel of all professions. Professional life is marked by the complex interplay between personal well-being, workload, role expectations, rapidly changing social and cultural norms, and by systemic issues, such as the strengths and particular shortcomings of the institutions in which the professions reside. Frequently the professional is caught in the crossfire of one or more of these dynamics with the result that his or her energy and passion for the profession and its goals dissipates. That feeling, described by many today, ‘of getting through the night’, is most notably marked by a reduced ‘reach’ of compassion, and, frequently, by cynicism.
Given its multi-dimensional nature and causation, compassion fatigue requires addressing on several levels – at a personal level, and at a communal or institutional level.
At a personal level compassion can only be sustained if the professional ‘tends to the soul.’ Being an advocate and caring for others drains the advocate and empties the caregiver. Whatever a person’s faith dimension or motivation, such roles demand ‘Sabbath’ time – times of refreshment and re-creation, times of rest and review in which we ‘listen again’ to our souls and nurture them in healthy and life-giving ways.
While bread-winners may well recognise this need for rest and recreation, such a ‘Sabbath’ break is not always possible given financial pressures on families and individuals and the demands of the profession. That is why the culture of the particular institution, be it healthcare, medicine, law, or religious faith, also requires refreshment and renewal if it is not to exacerbate or even be complicit in compassion fatigue amongst its personnel.
However, institutions themselves can demonstrate compassion fatigue, evident above all in the ways in which they respond to those who are most vulnerable, including the demands placed on personnel, the language used, and the prevailing attitudes and mind-sets of those vested with power. Nowhere is this insight being illustrated more profoundly than in the leadership and vision of Pope Francis.
In the recent Synod on the Family, Pope Francis gave a clear illustration of the need for the Church to return to the ‘compassionate reach’ of the gospel. In doing so he challenges those who would tie mercy and compassion to obedience to the law. For example, in his closing homily, commenting on the story of the healing of Bartimaeus, the blind beggar, he said,
“This can be a danger for us: in the face of constant problems, it is better to move on, instead of letting ourselves be bothered. In this way, just like the disciples, we are with Jesus but we do not think like him. We are in his group, but our hearts are not open. We lose wonder, gratitude and enthusiasm, and risk becoming habitually unmoved by grace. We are able to speak about him and work for him, but we live far from his heart, which is reaching out to those who are wounded. This is the temptation: a ‘spirituality of illusion’: we walk through the deserts of humanity without seeing what is really there…a faith that does not know how to root itself in the life of people remains arid and, rather than oases, creates other deserts.”
At the conclusion of the Synod Pope Francis then offered a number of antidotes to compassion fatigue, at both a personal and institutional level, including
- Attempting to see the ‘issues having to do with the family’ in the ‘light of the Gospel’ without ‘falling into a facile repetition of what was obvious or has already been said.’
- ‘Seeing difficulties and uncertainties which challenge and threaten the family in ‘the light of the Faith, carefully studying them and confronting them fearlessly, without burying our heads in the sand.’
- Portraying, once again, the vitality and vision of the Catholic Church, ‘which is not afraid to stir dulled consciences or to soil her hands with lively and frank discussions about the family.’
While Pope Francis was speaking specifically about the family, his wisdom and courage gives fresh heart to all caregivers and advocates of compassion and mercy and reminds us not to neglect the ways in which ‘compassion fatigue’ may permeate the very institutions within which we practice our respective professions.
Rev Dr Michael McCabe is the founding director of The Nathaniel Centre and Parish Priest of Our Lady of Kapiti Parish, Te Whaea o Kāpiti.
Carrying the Weight of Ourselves: Compassion and the Divine Art of Kindness
Bernard Leuthart
I am riding to plague again.
Sometimes under a sooty wash
From the grate in the burnt-out gable
I see the needy in a small pow-wow.
What do I say if they wheel out their dead?
I'm cauterised, a black stump of home.
Seamus Heaney
Not so long ago, I had 86 year-old Alf in to cut a lesion from his shoulder. Alf is my idea of gracious old age - deep respect and real joy burning in his blue eyes as he spends everyday in service of someone else.
Things seemed to go very well with the procedure and Alf fell asleep while I worked. As I finished up, trimming and tucking my edges, Alf woke and made a strange declaration. He had been dreaming, he said, of an incident at the end of the War when he was assigned at age twenty-one as a sniper in Gibraltar. Guarding the harbour, he had been ordered to fire on a sailor whose craft had breached a strategic position. He had hesitated, and his sergeant had pressed him to take the shot.
"I killed him, I'm sure," said Alf. "A boy my age - I saw him fall dead into the sea."
Then graceful, radiant Alf broke into floods of tears.
"I am sorry to cry, " he said, "but I have been dreaming of the pain of that mother whose boy I shot and what she carried, and if anything was able to repair it?"
We shared a thought about the weight of life to be carried in struggling to be good and happy. He smiled his eyes again and left.
I have been troubled often in recalling Alf's story and what I think it tells us about carrying the weight of ourselves and working at happiness, holiness and kindness; the daily balancing act of bringing - dragging - the raw stuff of our humanity towards divinity. How that takes a daily act of faith; of fidelity to living compassionately.
The salient wisdom flowing out of Alf's story and the unspoken, transcendent experience that his life has become in redeeming his own narrative offer a potent reminder that if we are to manage the lumbering weight of ourselves, if we are to find our feet despite the numbness, enmity, dissatisfaction, brokenness, separation and fatigue in our complicated lives - let alone in the lives of those for whom we care - then we must embed compassion in our dailyness and ordinariness, down amongst our very matter. To know deep satisfaction in ourselves demands that we develop a contented, unconditional focus on the well-being of others; a disposition for kindness from a warm, alive, open heart.
Suzanne Aubert, who recently updatedis about to update her status to 'Venerable', nailed the attitude when she enjoined her sisters to; "Be easy of access. Receive others amiably. Have a heart ready to devote itself." But how to have such a heart so disposed amongst the clamour and shambles of ourselves fronting up at home and at work?
First, begin in contemplation. Compassion begins in practising being still and being present. Experiencing real presence requires a kenotic self-emptying - a preparedness to sit within the tension between disturbance and joy and practise forgetting ourselves; letting go and letting God. Being present, meditating and mindfully attending to breathing - shifting and sifting the weight of our very human selves - allows us to be buffeted about by the divine.
The effort required is a detachment from our own weight - our faults, our inability to reconcile and forgive, our old hates: in short, it is a letting go of our resistance to grace. The foul weight of resentment, numbness, and self-hate closes us to the possibilities of compassion (first, to ourselves). When we are unbound and more able to forget and forgive ourselves, God knows what compassion and abundance might flow into our divisions and our engagements.
Teresa of Calcutta wryly observed:
"People are unreasonable, illogical and self-centred: forgive them anyway.
If you are kind, people may accuse you of ulterior motives: be kind anyway."
Her words highlight for me the unease between carrying the cross-bar of ourselves and embracing the extraordinary lightness of being that opening abundantly to others can bring.
On a similar note, a good friend of my mother's told her at her dying:
"I've always believed that people are sacraments: - Be an outward sign."
Fidelity to living compassionately - as blue-eyed, deeply-loving and serving Alf has illustrated - offers us a means to open to the abundance and possibility that might break in and deeply disturb our tired humanity to show us divinity. The Dalai Lama, quintessential example of living graciously and warmly in the liminal space between disturbance and joy, reminds us that kindness is everything. We are invited, quite simply, to be an outward sign of this material.
Dr Bernard Leuthart is Clinical Director at Waiwhetu Medical Group in Lower Hutt.
Getting Tired of Me Getting Tired of You?
James Lyons
Donor fatigue is not an uncommon expression. The number of requests for donations coming through the mailbox and other media has been increasing to the point where deciding where and what to give has become very complex.
There are so many needs, one person told me, that I know my little contribution is never going to make a difference. Now I don’t give anything!
Others feel quite exhausted by the constant flow of requests. Some get bewildered. Some get angry. Tiredness means no energy. No energy means no motivation; good intentions do not translate to action.
Compassion Fatigue is similar but less visible. It affects in particular those in the caring professions. As a priest, I have been asked to reflect on this phenomenon from a pastoral perspective.
In the day-to-day pastoral ministry a priest or lay pastoral leader is confronted with a variety of human needs:
- A parent calls very worried about the teenage child who wants nothing to do with the Church.
- A family seeks help with the payment of school Attendance Dues.
- A knock at the door presents a need for assistance with food, perhaps housing or for an ear to listen to a sad tale of abandonment or embezzlement.
- A grandparent worries over grandchildren who haven’t been baptised.
- Parishioners in hospital or hospice need to be visited, their families comforted.
- A death in the parish requires other commitments to be set aside.
- Couples preparing for marriage need to be given time and attention.
The list is endless!
There have been times when, as a priest, I have caught myself racing through an appointment because of my familiarity with the issue. I forget that, for the person involved, this is their first experience of death or loss or setback, etc., while I have dealt with it several times.
It is easy to anticipate their questions and not to be totally alert and present to their unique situation. This can give the impression that I don’t care or do not take seriously their particular concern.
When one problem or emergency follows another, when you know there are several emails or phone messages awaiting your attention, the temptation to dismiss people as quickly as possible is hard to resist. Or else you carry on, but you feel so very tired, and you know you are not focussing as well as you could, or should.
Compassion fatigue, in the pastoral sense, is not so much exhaustion of motivation but more a loss or absence of the ability to concentrate and to fully engage. It is very much a case of “the spirit is willing but the flesh is weak”!
One factor that might allow this kind of fatigue to be less detected in the clergy, is that pastoral ministry quite often deals in the realm of the spirit and that’s harder to see. A doctor who, through inattention may misdiagnose or prescribe the wrong medicine, will be quickly called to account. But a priest who doesn’t really listen in the confessional or offers some outdated theological advice, or gives out some over-worn cliché response, is not going to be so readily caught out.
This sort of behaviour may not be so much the result of compassion fatigue but rather a laziness, perhaps even arrogance, that is irresponsible. Pastoral workers owe it to themselves as much as to those in their care, to stay relevant through study and reflection. Not to do so is to risk becoming a disappointment to themselves; that, in turn, can lead to depression and total shutdown.
While doctors and other professionals usually see people on an “appointment only” basis, priests are more “open season” to callers. A phone call or door knock can come at any time of day or night and there is an assumption on the part of the people that the priest will answer. No matter he may have just returned from a parish meeting or funeral preparation, the caller has a need that cannot be postponed.
Despite real efforts to hide weariness or annoyance at the interruption, the caller will often pick this up, going away with an “he doesn’t really care” impression.
Personally, the worst time is just before Mass: Someone wants you to remember a special intention at Mass; another tells you of the death of a relative overseas; a car has been parked with its lights on – can you please make an announcement; there’s a cake stall after Mass but we forgot to put it in the newsletter – will you tell everyone; today is a special day for Mr & Mrs… - can you give them a blessing; it’s my birthday, will you say a prayer for me…
Loving and caring as such requests show themselves to be, their timing is challenging. It is in these moments that compassion fatigue hits me between the eyes.
James Lyons is a priest serving in pastoral ministry for the Archdiocese of Wellington
Sustaining Compassion
Anna Holmes
Compassion means suffering with. It is about bearing witness to suffering. Bearing witness is not just being a bystander but entering into the world of the sufferer. Mirror neurones in human brains reflect this suffering. Medical students are encouraged to practice empathy. This is an act of spiritual connection, of compassion, that recognises our common humanity.
As a medical student in the early 1960s I was taught how to deal with suffering by observing the way in which my teachers dealt with it. We did not have formal teaching on ethics and relationships but we saw our teachers kneeling by bedsides, treating patients with gentleness and courtesy, as one human being to another. I accompanied a GP on visits, first in a poor neighbourhood where he took the prescription to the patient because, he said, “They will not go and collect it”’. Next we went to a patient recovering from a heart attack. The GP told me “He was just sitting in the hospital and I knew he would be better looking at his view of the Braid Hills. So I said I would look after him and he was sent home.”
Last month I read two articles on burnout in doctors, suggesting that many doctors in NZ and the US suffered from ‘compassion fatigue’. The NZ article suggests four key factors: fatigue, difficult patients, external distractions and clinical complexity. It was most common in younger GPs. It also suggests that turn offs for doctors are patients who are aggressive, smelly or dislikeable and compassion is lacking for such patients. The US article also suggested bullying by senior staff and not being supported were factors in compassion fatigue.
When I interviewed 22 NZ GPs for a thesis on spirituality, 16 of them said they had been burnt out. They were unable to respond compassionately to the needs of their patients, family and self. It was nearly always as a result of simultaneous personal and work problems and a lack of support. A number had also been bullied.
The advent of scientific medicine has changed expectations for doctors and patients. It has shifted the focus of medicine from caring to curing. The technological and therapeutic triumphs make students think that most things can be cured. They expect a medical world that is predictable and controllable. In fact it is nothing of the kind. An ageing population means that they are going to have to deal with many patients with chronic or terminal diseases. These are not curable but require care and compassion.
The innate compassion of many of the students is impressive. They spend five weeks working in a rest home and write an essay about their experience. These often show an extraordinary growth in understanding, from ignorance of the elderly to understanding them as treasures, even when they are demented or disabled. Students wonder at the rich and interesting lives of the ‘elderlies’ depicted in photographs on the walls of their rooms.
So how can compassion be enabled for doctors and patients?
Work conditions are important – recognising the limits each person has for work and providing mentoring and support. Having experienced working 80 hours a week as a house surgeon I do not think this is just about exhaustion. It is about having a community of work where all staff care for each other.
Dealing well with difficult staff is also important. I still relish the story of a contemporary of mine who when asked by a grumpy surgeon whether he thought he was God replied ‘No sir, just his house surgeon.’ The Royal Australasian College of Surgeons recently published a report about bullying in hospitals that found half the trainees had experienced it.
Doctors who continue to enjoy their work ensure that they have balance in their lives with body, mind, spirit and human connections all attended to. They have creative activities outside medicine that feed their spirit – painting, writing, gardening, climbing mountains, cooking and many others.
Junior doctors spend many hours working on computers to obtain and transmit clinical information about their patients. But they also need enough time to spend with patients and in reflection. I do wonder whether working shifts in medicine is as satisfying as caring for a patient from admission to discharge.
While spirituality is acknowledged as being important in health and healing, there is very little attention paid to it in medical school or hospitals. Scientific thinkers tend to reject concepts that cannot be explained by science. I believe that this may be partly responsible for the increase in burnout. If medical work connects doctors deeply to self, other, the natural world and the transcendent, it enables healing and growth. If cure is the main focus it fails to satisfy. Memorable patients for the doctors I interviewed were often those who died well under their good care. One of my memorable patients was dirty, smelly and unable to talk but he had a beautiful, toothless smile.
Anna Holmes MB ChB PhD is a Clinical Senior Lecturer in the Department of General Practice, Otago Medical School.
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References:
Time Magazine, Vol.180, No 9-10 September 7-14, 2015, p 44-50.
North and South, September 2015, p. 59-64.
Editorial: Compassion Fatigue
In a recent article in North & South Magazine[i], Donna Chisholm discusses the issue of compassion fatigue amongst doctors and some of the implications of this for patients. It is claimed that around 50 percent of doctors report compassion fatigue, and that there is an exodus of a quarter of young doctors from the country within three years of graduation, many of whom report stress and burnout.
Compassion fatigue has been described in terms of the draining away of what is seen as a finite reservoir of caring. However, recent research from Auckland University’s department of psychological medicine indicates that the ‘leaky reservoir’ model may not be adequate. Its survey of nearly 600 doctors indicates that, in fact, younger doctors report more obstacles to compassion. This work suggests that there are four key factors that need to be looked at and over which a doctor has little control: burnout/fatigue, difficult patients, external distractions and clinical complexity.
Chisholm highlights ‘difficult patients’ as one of the more interesting outcomes of the research. While ‘burnout’ tops the list of influences, “a patient’s attitude and demeanour are almost as important. That means if your doctor actually likes you as a person, you’ll probably get more compassionate care.” (p.61). One of the study authors suggests that “doctors are normal people. If they are confronted with a person who is unpleasant, demanding, non-compliant, ungrateful, malodorous … they won’t like them and they won’t care for them.” (p.61). The report’s author posits that there is an evolutionary aspect to this – it is inefficient to keep caring for people who don’t deserve it. He believes it is basic human functioning to ask ‘Do I like you?’ and that the answer to that question is the first decision that is made; in his opinion “no amount of professional training will ever get us past that fact. Ever.” (p.62).
A more hopeful analysis is offered by an Auckland City Hospital emergency department physician who suggests that while emergency departments are places where patient behaviour is likely to be at its worst, this is no reason for doctors to leave their compassion at the door. He has become considered by his colleagues the person best able to deal with the difficult cases - the angry drunks, the drugged and the homeless regulars who just turn up for a feed – and says: “I’ve learnt to like the people you wouldn’t normally like.” (p.62). Changing the way he thinks about patients has been the key to changing the way he acts, and while fatigue and burnout are factors in compassion failure, he believes that ‘healthy thinking’ can reduce it.
This approach is supported by other research undertaken with doctors that found that those who didn’t feel stressed had one main trait in common, that of being connected to their purpose, or a ‘higher calling’: “The doctors who are absolutely thriving all sound like they’re on a mission.” (p.62). One 60-year-old GP finds he now feels more compassion for his patients than he did 25 years ago. While he has over time become better at the ‘mechanical’ aspects, diagnosis and treatment, he also tries to listen to his patients, to understand what’s happening through ‘their eyes’. A fourth year student suggested that a lot of young doctors do not really listen to patients, “they’re filling out a check box in their head of things they feel they need to ask. I think that detracts from the fact that there’s a patient who’s an individual in front of you. Maybe they have information that’s not on your checklist.” (p.63).
A former primary-care nurse who trains health workers in how to better communicate with patients believes the ‘difficult patient’ problem is exaggerated and that ‘difficult patients’ are created by the way they are spoken to. At the same time, she does not believe every nurse and doctor can be taught to be compassionate and empathetic, and that around a third who attend her workshops “will never get it.”
The factors involved in compassion fatigue include a mix of environmental factors such as workload, the complexity of some illnesses, the behaviour of patients, as well as the evolutionary and personal factors that cause doctors to respond in certain ways to their patients. None of these is easily changed. However, finding ways of preventing compassion fatigue is important, for the doctors themselves but also because empathy and compassion are associated with better patient out-comes, and failure of compassion with poor decisions.
Of course, compassion fatigue is not restricted to the health professions; it also affects teachers, politicians, social workers, chaplains/pastors, prison workers, youth workers, counsellors and parents. With that in mind we have asked seven different practitioners from a variety of caring professions to offer their reactions to, and insights on, the North & South article.
We believe there is something of substantial personal value for every reader in the richness of the authors’ reflections offered in this issue.
Sue Buckley is a researcher for The Nathaniel Centre and Dr John Kleinsman is the director of The Nathaniel Centre.
[i] ‘Cold Comfort’ by Donna Chisholm. North & South, Issue 59, September 2015. Pp. 59-64.