Citizenship

Citizenship and compassion in healthcare

Compassion in healthcare needs to be rethought in terms of citizenship especially the obligations of citizenship. A civic context and civic concepts can help all of who think about healthcare get a handle on compassion education.

Our kind of society is reluctant to affirm any one comprehensive system of values or beliefs as being the only one or the true one. There’s a reticence about being definite about the beliefs or values which hold us all together just because there is no widespread agreement.  

So we’re bound to ask how thick the values which define a public institution, such as a healthcare institution, can possibly be. What do mottos such as ‘Compassionate Excellence’ mean when they are at work? How substantial a vision of compassion can an institution hold, when the people who work in it and the people who use it may believe different things about healing, suffering, life and death; or believe quite similar things in name but for quite different reasons. Compassion is a good example here: everyone agrees ‘compassion’ is a good thing. Who could be against ‘compassion’? But people seem to believe quite different things about what it means in theory and in practice.

When people are asked to summarise British values, we often hear something like ‘fairness’. Now ‘fairness’ is important: you will almost certainly know if the processes which govern your life are not fair, if there is an injustice taking place.  But the term ‘fairness’ does not say much about the values and goals which should govern our common lives: fair with respect to what, we might ask? For that we need something more substantial, a vision of what is good and bad in life. Such a vision orients what we value and what we value allows us to clarify what it is we ought to feel compassion about.   

The question of substantial values has a great deal to do with citizenship. In the UK, across continental Europe and in the USA (to name just a few contexts), there is a richness of intersecting lives and cultures which make up the body of citizens. In such contexts, the practice of compassion in healthcare requires an understanding of these diverse cultures so that discussion about the nature and practice of compassion can be better informed. This is the case for both patient and healthcare practitioner: both are citizens and the views of all parties about compassion are part of the civic discourse.

But, here’s the problem: such discussion, like any civic discussion, must foster an understanding but one which is not simply accepting but is in some sense discerning. Compassion has to do with ‘co-suffering’: participating in another person’s suffering so as to understand the depths of feeling through which the other person sees themselves and the world. But co-suffering is not simply agreement with a person’s perception of their suffering. Our language suggests this: we worry about someone being lost in or wallowing in self-pity. When we say this, we are not being callous – there may be much for the person to be sorrowful about. But it articulates a concern that a carer ought not to wallow with someone so sorrowful. Rather they are to sit with a person, listen and enable them to endure what they perceive as their suffering better and, if possible, recover.

The care of those who suffer from mental illness may help here. In mental health contexts, we do not expect the compassionate practitioner to affirm the beliefs of those who have deeply unkind feelings towards themselves or other people. Instead, we expect the practitioner to be a counsellor of some sort. Compassion then may be akin to a kind of counselling. A person’s perception of their suffering can be gently and patiently discussed even if that perception involves deep sorrow, fear or anger or other affection. The fact that this discussion is possible is what makes compassion a matter of citizenship. Because citizenship has to do with discussion, with communication, with discernment, with helping each of us to know that being unwell need not and must not remove us from the benefits and blessings of friendship and citizenship.

In this sense, compassion must be, in principle, a kind of persuasion. Why is such persuasion necessary? It is necessary because the danger of dehumanisation in modern society lurks and threatens especially those who are vulnerable. In healthcare, we are reminding those who are unwell and those who are well of what it is to be a human being. In healthcare, we deny that sickness, even serious sickness, undermines that basic reality. For many citizens, even death cannot put an end to what it is to be a human being. Compassion which is attentive to these rich streams of our common life involves a kind of constant civic argument we have we ourselves, as we attempt to maintain a humane vision of life.

Does this make healthcare exceptional? Does it place undue burdens of moral expectation of everyday citizens? We should, perhaps, not demand that doctors or nurses be saints. Or, by extension I suppose, that managers and commissioners be of a higher moral pedigree than the patient population they serve.

We certainly can’t expect that all those involved in healthcare will be exceptional citizens. Christian theology is realistic about all our tendencies to moral failure. Healthcare institutions are not in this sense distinct from other public institutions. They are, like other institutions, the meeting points of different values, different strengths and weaknesses.

But healthcare institutions have a peculiar capacity to focus our minds on what values citizens hold and to ask, with discernment, what values citizens should hold.  There’s an intensification of the question of value in healthcare: a concentration on life, suffering, and meaning. Why? Just because the stakes are of a higher order than the stock market or one’s exam results or job: bodily health and life are the basic goods upon which employment and education depend.

That intensification of focus highlights then a special obligation on those who work in healthcare to seek to understand the values of those who suffer. But, they’re not the only citizens to have obligations. There is an obligation on those who organise and fund healthcare to make such understanding at least a little more possible. There is also an obligation on patients, as citizens, to have compassion for and understand the values of the healthcare practitioners with whom they interact. This obligation is admittedly more attenuated because of the circumstances which may inhibit personal interactions. But with that said, it’s often those who are suffering most who are most able to show compassion. These patients reveal a general principle: a patient is still a citizen, whatever condition she or he is in, having obligations just as practitioners have obligations.

But how flexible should our civic understanding of compassion be?

Compassion cannot be infinitely flexible. Each citizen will bring their own perspective on what compassion is into healthcare; but not every perspective should be approved. The most obvious case would be the demanding patient who thinks that compassion for him or her requires that they jump the queue. More seriously, perhaps, what about entering into the feelings of those who believe their suffering is their own fault and they deserve it; or not their own fault and nothing to do with behaviour and lifestyle. How are practitioners to learn to navigate such a range of possible perceptions of suffering, without necessarily agreeing with all or indeed any of them? A complex mix of emotional engagement and emotional detachment seem to be required, not one or the other.

Education then needs to pay attention to culturally informed approaches to sickness, suffering and compassion: these narratives unite sub-cultures and groups; they may be religious cultural forms – Christian, Muslim, Jewish, Sikh; or cultural forms which are less influenced or not influenced by religion.  Compassion education needs to pay attention to these diverse forms of self-understanding. How? Well, it’s not going to be easy. What is required is a system of education which encourages accurate, sympathetic, discerning description of the understandings of the life-course which people understand themselves to have.

Further reading

Joshua Hordern publications

Compassion in Healthcare: Practical Policy for Civic Life (OUP, forthcoming 2019)

Marketisation, Ethics and Healthcare: Policy, Practice and Moral Formation, coedited with Feiler and Papanikitas (Routledge, January 30th 2018) link