Its reintroduction is certainly being called for in buckets – NHS England planning guidance says: “we want everyone to have greater control over their health and wellbeing, supported to live longer, healthier lives by high quality health and care services that are compassionate, inclusive and constantly improving".
I want to suggest that in this call for improvement the inclusion of compassion as if it can be insisted upon and legislated for entails an inherent conflict with other concepts, such as providing greater choice, and that addressing these conflicts is the joint responsibility of a range of players in the care system including leaders, policy makers, managers and care givers. I will then further suggest that there are 4 things we need to attend to if compassion is to re-take its place in our care system. Compassion is ‘sympathetic pity and concern for the sufferings or misfortunes of others’ (Oxford Dictionary). But if this is just about a feeling or emotion it can only go so far in attending to any failure to act compassionately. If, however, there is to be a stronger link between an emotional feeling of empathy and the way we act and behave, then thinking about compassion as a virtue may be helpful. Virtue ethics insists that we find virtuous action ‘in the mean’, which means a mid-point between either an excess or deficit in that virtue, either of which would lead equally to a vice. This is about balance. Applied to compassion we can see that a deficit could lead to cruelty or negligence and that an excess could lead to an overpowering paternalism. But getting this balance right requires careful thought and an appreciation of context, i.e. what is paternalistic in one relationship, say in dictating a course of action and therefore limiting choice for an informed patient, may not be in another situation, for example when a parent or guardian takes a certain action on behalf of a young person. Generational and cultural differences can also inform whether an act of compassion is virtuous or tends toward either an excess or deficit. If compassionate care, seen as a virtue, requires the sort of subtlety indicated above – the ‘practical wisdom’ of virtue ethics – then it is clearly difficult, if not counter-productive, to legislate for compassion. Further, when compassionate acts display what we could describe as ‘going the extra mile’ or acting in ways that demonstrate the ‘suffering with’ root of the word, then we simply hollow out this meaning as soon as we make compassion a requirement – as soon as ‘going the extra mile’ becomes a requirement, it simply ceases to go beyond a requirement. But what about the conflict I suggested above? Are compassion and choice really incommensurable? If choice is brought about by giving due respect, and we view respect through a virtue lens, then an excess or deficit in respect can also lead to a vice rather than a virtue. Putting choice on an ordinal scale as if it is always true that ‘more choice is better’ is to ignore this dynamic – as well as the evidence that too much choice can lead to bad choices. It can also undermine the skills and experience of the professional conduct we prize. And this is where the dynamic between respect and compassion comes into play. When we bring them together we might expect, and hope for, a system in which both are in balance. However, any surplus in the value of respect, which leads to an excess of individual choice, could contribute to the very sense of neglect that suggests a lack of compassion. Too much respect, leading to too much choice will reinforce the very outcomes that lead us to recoil at the deficit of compassion. So we can see that seen through the lens of virtue ethics we cannot compensate for the lack of one virtue with a surplus in another and neither can we simply stack up each quality as if more is always better. In fact, the example of compassion and respect demonstrates the opposite, i.e. that an imbalance in one virtue can contribute to an imbalance in another. To develop as a virtuous person, or to build a virtuous team, organisation or system, requires an appropriate ‘mean’ to be found in each virtue. To insist, as Sir David does, that we must increase both choice and compassion, without regard to this sense of balance in each, is therefore potentially counter-productive. I would suggest, therefore, that the explanation for a deficit in compassion is, in part, due to competing expectations of other values where there is also an imbalance. As a systems practitioner I would simply point to one of the systems thinker’s golden rules, i.e. that a system is perfectly designed to produce the results that it gives. If we have a deficit of compassion, stuffing more in without addressing wider systemic imbalance or failures will result at best in a temporary ‘fill-up’, but at worst in the continued long term leakage of compassion as the more dominant features of the system re-assert themselves. What then must we do, given this dilemma? We have leaked compassion from a system in which nobody is entirely blameless. We need to recognise the interconnectedness of policy directives, leadership qualities, management practices and the final act of care giving in our health and care system. And we need to tackle the leakage of compassion in a similar spirit, without resort to acts that are either counter-productive or that re-enforce the dynamic behaviour of the current system. I have written a little more fully on the following 4 contributions to lifting us out of a seemingly vicious cycle of compassion leakage, but offer them here for your thought and comment:
- We need to build a new understanding between professionals and the public, informed by an open debate, that re-establishes trust and reduces the call, and the need, for an over-legislative and inspection dominated system.
- We need a better understanding and recognition of the inter-relationships within the complex systems we work in and seek to manage.
- We need to recognise, measure where possible and take deliberate action to build relational values in our health and care systems, evidenced by improved outcomes for patients and those who care for them.
- We need to install mechanisms and processes that move away from legislation and inspection toward an empowering peer-led approach to continuous improvement.
We cannot go into detail on each of these in this blog. Much needs to be explored, explained, researched and tested. However, generating a public debate, taking a systems approach, valuing relational qualities and working to embed these in our health and care system, from top to bottom, means that compassion, amongst other things, is certainly not just for nurses.