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Richard Smith: Promoting compassion
Edinburgh University's Global Health Academy has together with Stanford University created a Global Compassion Initiative, and, as I walked last week towards the launch of the initiative in one of Edinburgh's most elegant houses I wondered exactly what compassion is. I wondered too whether you can teach and promote compassion. What I was sure about is that we could do with more of it in the NHS and the world.
As I walked, I thought of the story I'd just heard of a 92 year old woman who had recently died after 10 months in a psychiatric hospital. She'd been very close to death three years before with a chest infection, but vigorous treatment kept her alive. Was that treatment compassionate? After two years in a nursing home she was sectioned after some mild aggressive behaviour and placed in the psychiatric hospital, in a room with no decorations and no view. Wheelchair bound she had nothing to look at and couldn't move. The hospital wouldn't allow anything on the walls "for reasons of safety and security." She was utterly miserable for the last three years of her life.
This sadly everyday story, dreadful stories from Mid Staffordshire, and patients' experiences at the end of life reported by the NHS Ombudsman show that compassion can sometimes be severely lacking in the NHS.
Stanford University's Centre for Compassion and Altruism Research and Education (CCare) has been researching and teaching compassion for 10 years. The centre was founded and is directed by Jim Doty, a neurosurgeon, and grew from a visit that the Dalai Lama made to Stanford. Compassion, as Doty said at the Edinburgh launch, is central to all religions and benefits those who give compassion as much as those who receive it. Indeed, as compassion is derived from the Latin cum passus, "travel with," perhaps there is no giver and recipient but a joint experience.
So what is compassion? I often quote the public health doctor Muir Gray misquoting Wittgenstein that "ultimately all problems are linguistic problems." If Edinburgh is going to be promoting compassion it'd better be clear what it is. I reflected before the launch that it is a word I rarely use. It sounds too grand and for me has religious overtones. "It's an old fashioned word," said my wife. The website of the Stanford centre has a Wiki discussing the definition of compassion and lists some 27 synonyms, including empathy, sympathy, altruism, and caregiving but not kindness, dignity, or healing.
The first definition of compassion on the website is the prosaic "concern for the wellbeing of others." This definition seems to lack the emotional intensity that must be part of compassion, and surely there must be action, not just "concern." I liked the more poetic Buddhist definition of "the heart that trembles in the face of suffering," or, as the Dalai Lama says "If you want to know what compassion is, look into the eyes of a mother or father as they cradle their sick and fevered child." It surely must imply action, the cradling.
Oliver Sack's, who has just died, was a doctor and writer who radiated compassion, and using the word "care" rather than "compassion," he produced a good definition in his essay written after the death of his friend the poet W H Auden:
"The amalgamation of accuracy and affection, knowing what is proper and loving what is dear—this is the essence of care, be it medical care, or any other sort of care; care for the body, care for the soul, care for the individual, care for society, were almost inseparable in Auden's mind. God for him was no mere geometer high in the sky, but the principle of decency and care."
This definition opens up the idea that compassion is a function not just of individuals but of institutions, health systems, and nations. Indeed, the Stanford website describes "3D Compassion," developing and practicing compassion in the three key dimensions of peace, green-living, and health.
I found myself wondering how pity might relate to compassion, and I had a feeling that it is something much less noble than compassion. The Stanford website is dismissive: "Pity is sorrowfully noting another person's suffering, but regarding them as outgroup, weak and/or inferior and hence, undeserving of any wish to alleviate, or efforts towards alleviating suffering." Pity is condescending and passive; compassion is affirmative and active.
So the essential ingredients of compassion are feeling the suffering of others and actively responding. It is more than empathy and goes beyond maintaining dignity.
It surely cannot be mandated. "You will as from Monday morning be compassionate." But can it be taught? Stanford is convinced it can and runs courses. Doty says that almost everybody can be taught to be more compassionate—all except the 3-6% of people who are sociopaths. Everybody else lies on a bell curve of compassion with most of us near the middle, and Doty insists that it's possible to "move the needle" a little for everybody. I could find no randomised trials showing improved outcomes for the patients of those who had received compassion training, but perhaps somebody can send me such a trial.
Inevitably compassion is strongly linked with healthcare, but the programmes in Stanford and Edinburgh extend, or intend to extend, well beyond healthcare into business, politics, and society. The Global Health Academy will establish a knowledge hub where law, business, social science, architecture, environment, divinity, and health will share ways in which compassion is created and sustained in these constituencies. There is a programme to promote compassionate cities, and the Edinburgh initiative includes Edinburgh City Council. Edinburgh, the city of festivals, may hold a Festival of Compassion in 2017.
The bold aspiration is that compassion will provide a focus for interdisciplinary research including neuroscience, clinical medicine, genetics, business studies, information science, theology, psychology, architecture, art, and the humanities, and all of those disciplines were represented at the Edinburgh launch.
Doty, a true Californian, told the launch that we are entering "the age of compassion." Let us hope so, but the challenge to all of those at the launch –"all of you are changemakers"—is to move beyond words to actions and improved outcomes.
Richard Smith was the editor of The BMJ until 2004. He is now chair of the board of trustees of icddr,b [formerly International Centre for Diarrhoeal Disease Research, Bangladesh], and chair of the board of Patients Know Best. He is also a trustee of C3 Collaborating for Health.
Competing interests: RS attended the launch in Edinburgh, spoke at it, and drank several glasses of champagne. He is a graduate of both Edinburgh (medicine) and Stanford (business) and may join the advisory board of the initiative. He's an external examiner for the Edinburgh Global Health Academy, for which he is paid a small fee.
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