Is compassion a necessary component of healthcare?

Last week, the Daily Mail reported on Dr Anna Smajdor’s paper in which she argues that compassion ‘is not a necessary component’ of healthcare. This claim contrasts interestingly with Jeremy Hunt’s recent proposal that all student nurses should have to prove that they are capable of caring by spending a year on wards carrying out basic tasks. This proposal, along with the suggestion that pay be linked to levels of kindness would, according to Hunt, go some way to improving the standard of NHS care.  The motivating idea behind Hunt’s proposals is that lack of compassion amongst NHS staff is partly responsible for poor care and, in some cases, for cultivating a ‘culture of cruelty’.

So is compassion a necessary component of healthcare? Is an adequate standard of care necessarily unattainable when compassion amongst staff is absent? In considering these questions I do not intend to embark on a detailed critique of Dr Smajdor’s paper. Instead, I will begin from her main ideas and use them to motivate a general discussion of the role of compassion in healthcare. According to the report, Dr Smajdor argues for two main claims: 1) that compassion is not a necessary component of healthcare – that acceptable standards can be attained without it – and 2) that compassion can actually be dangerous for healthcare workers, possibly resulting in impaired standards of care. 

Competency does not require compassion

According to the report, Smajdor’s main argument for the first claim – that compassion is not a necessary component of healthcare – is that ‘the crucial tasks associated with healthcare can be carried out in the absence of compassion’. For example: ‘one can remove an appendix without caring about the person it is taken from, empty a bedpan without caring about the patient who has filled it, or provide food without caring about the person who will eat it.’

This first argument is about the successful completion of tasks. The suggestion seems to be that compassion is not necessary for successful task completion: a task can be performed just as competently in the absence of compassion.

Detrimental effects of compassion

In relation to the second claim – that compassion can actually be detrimental – Smajdor first suggests that normal human beings may have limited capacities for compassion and so to demand that they regularly exceed this capacity would be to require too much (normatively and psychologically). She is reported as saying: ‘unless we regard healthcare professionals as saints, we cannot demand that they guarantee an unlimited flow of compassion for each patient. Indeed, it is not only unfair, but dangerous to do so.’ She suggests that requiring compassion would put the healthcare professionals’ mental health in danger, since those ‘who feel compassion’ may become ‘deeply distressed’ if they witness poor care on wards. ‘For this reason, the compassionate healthcare worker may be at risk of suffering burnout, fatigue, becoming desensitized, damaged and ultimately dangerous in the healthcare system’. This argument moves beyond the claim that compassion is not necessary (and hence unfair to demand) to suggest that it is psychologically unsustainable and ultimately could lead to adverse consequences for those who were to attempt to sustain a continuous flow of compassion.

I will focus mostly on the first of these two claims.

What is compassion?

In order to think about whether compassion is a necessary component of healthcare, we need to have a clearer idea of what compassion is. According to the Oxford English Dictionary, compassion is ‘the feeling or emotion, when a person is moved by the suffering or distress of another, and by the desire to relieve it; pity that inclines one to spare or succor’. This definition implies that compassion is principally a feeling, evoked by the suffering of another and characterized by pity. It literally means to ‘co-suffer’. It is also a motivating emotion, inspiring the person who feels it to attempt to relieve the suffering of the other. In psychological terms, it is accompanied by an ‘action tendency’.

For those who argue that compassion is a necessary component of healthcare, one possibility could be that it is the motivating element of compassion that is important: that compassion is a necessary component of healthcare because it alerts the healthcare professional to patients’ needs and moves them to attend to them. However, it does seem psychologically plausible, as Smajdor suggests, that many tasks can be performed competently in the absence of an emotional state of pity and a felt desire to alleviate the particular patent’s suffering. Indeed, if we imagine a surgeon removing an appendix, it may be entirely appropriate for the surgeon to approach the procedure in a practical and mechanical way, as long as her overall aim was to ‘succeed’ in the procedure. The surgeon can provide an acceptable standard of care without being emotionally moved by the adverse situation of the patient on her operating table.

Mechanistic vs. caring healthcare tasks

It could be argued, however, that there are some healthcare tasks that require compassion in order for their ‘successful’ execution – in order for them to be carried out to an acceptable standard. The washing of a patient may be one such example. This may be thought to be more than a mechanical task; one which requires the treatment of the patient as a person as well as a body. We can thus draw a distinction between mechanistic and caring healthcare tasks – whilst mechanistic healthcare tasks can be carried out to an acceptable standard without compassion, caring healthcare tasks must be accompanied by compassion.

However, whilst this distinction does seem to characterize some of the difference between various healthcare tasks, an objector could still ask whether we really mean to require that compassionate feeling accompany caring tasks. It seems to me that an involved emotional experience is not necessary for adequate care. Whilst compassionate feeling may in fact often motivate and facilitate the delivery of adequate care, emotional engagement with the patient and her situation does not seem to be necessary. Here we might draw a distinction between the emotional experience of pitying and truly caring about the particular patient and the act of treating the patient as if one truly cares about her. We might correspondingly draw a distinction between emotional compassion (which involves genuine feeling) and performative compassion, which makes the patient feel as though she is cared about as an individual, but does not necessarily involve genuine feeling on the part of the healthcare professional.

In the Daily Mail report, both of these types of compassion are invoked without the possible difference being elucidated. In one place, the author reports that ‘nurses and doctors do not need to treat patients with compassion, a controversial academic has claimed.’ This presents Smajdor’s position as one which denies the necessity of performative compassion. I have suggested that performative compassion is necessary for adequate healthcare, especially when it comes to caring tasks. However, elsewhere, the author reports that ‘Dr Smajdor thinks staff should be able to carry out daily tasks  – from removing someone’s appendix to feeding an elderly patient – without feeling any kindness towards them.’ This invokes the emotional experience of compassion which I have argued may not be necessary.

Is mere performance enough?

So far I have drawn a distinction between compassion as an emotional state and compassion as a manner of treating patients. I have suggested that whilst performative compassion may be a necessary component of some healthcare tasks, emotional compassion is not. But, it could be asked, is mere performance – simply going through the caring motions – really enough? For some healthcare tasks, I think that it is. Feeding a patient in a way that makes her feel cared for is sufficient. It may be easier for a healthcare professional to do this if she really does feel pity or concern for the patient – and no doubt many healthcare professionals do feel such emotions – but this sincere feeling is not necessary for adequate care.

However, there are some healthcare tasks that require more than mere performance; those that require consideration of the individual patient’s values and interests in order to make patient-sensitive decisions. We might here draw a distinction between routine healthcare tasks – like feeding and washing – and evaluative healthcare tasks, where a sensitivity to and appreciation of the individual patient’s values – and the weights she attaches to them – is necessary. These sorts of tasks will involve things like making decisions about treatment options or palliative care and requires an appreciation of what the individual’s situation is like for them: a sort of intellectual ‘co-suffering’. Whilst a sincere emotional experience of pity of, or sorrow at, the patient’s suffering is still not necessary, there must be a sincere attitude of compassion which takes seriously the patient as someone with unique values and interests.

The question of whether compassion is a necessary component of healthcare is a complex one. Its answer depends on the role of the healthcare professional and the particular task that is being carried out. I have argued that whilst sincere emotional experiences of pity (emotional compassion) are never necessary for adequate care to be provided, there are some tasks that do require performative compassion and others that require attitudinal compassion. In the wider discussions about the role of compassion in healthcare, it must be remembered that lack of emotional compassion does not necessarily result in cruelty or incompetence. Whilst many doctors and nurses and surgeons will care about their patients, they should not be expected to experience strong emotions towards them or their situations. Sensitivity to their individual needs and a caring manner is sufficient.

Further, any debate about the necessity of compassion must also take into account the practical realities of the working hours of nurses and other healthcare professionals, and what we can reasonably expect of them given these conditions. Capacities for attitudinal and performative compassion will naturally have limits. So, if we consider these modes of compassion necessary, we must ensure working conditions are such that healthcare professionals are always able to manifest these requisite attitudes and manners of care.