Catholic Medical Quarterly Volume 63(2) May 2013

Can you teach compassion?
St Thomas and the NHS

Sister Margaret Atkins

We include here a summary of discussion on compassion from the annual Health and Salvation week at Boarbank Hall.  Attendees had asked this year to be introduced to philosophy.  They wanted to understand how it worked, and why it might be useful for thinking about practical matters in the area of healthcare.  As the theme of the week was ‘Love your neighbour’, and in the light of recent discussions in the NHS, it was decided to look at the question of whether compassion could be taught. 

We examined this question with the help of the great medieval philosopher and theologian St Thomas Aquinas (1225-1274).  We followed the format that he standardly used in his discussions of specific questions.  In particular, we used his method of beginning by raising the most difficult objections to his eventual conclusion.  (For example, his best known work, the Summa Theologiae, is written entirely in this style.) St Thomas took such objections extremely seriously, never brushing them aside.  His discussion always aimed to show how any points of importance in his opponents’ views were integrated into his final analysis.  In this way, he offers us a model for constructive dialogue, in which we can all learn from each other’s ideas and experience. 

The following question, in the style of St Thomas, is closely based on the discussion during one of our seminar groups, which included in it doctors, nurses, carers and hospital chaplains.  Nearly all of the points made here are thus based on the practical experience of senior healthcare professionals.  Very many thanks to all the participants, and also to Professor David Jones, for their contributions in the seminars and their comments on the written text.

Can compassion be taught? (Utrum compassio doceri possit?)

Why might compassion be unteachable?

Objection 1) According to the Jesuit saying, ‘Give me a child for his first seven years and I'll give you the man,’ our characters are already fixed by the time we become adults.  Therefore to try to teach compassion to adults is to leave it too late.

Objection 2) Compassion comes from the heart.  You can teach people to follow rules, but you can’t teach them to do so with the right attitudes and feelings.  For example, a new ward manager in charge of a badly run ward might introduce Intentional Rounding to enforce basic standards of care.  Staff would be taught that they must, for example, ensure that each patient is properly fed.  If they failed to do this they would be penalised.  But these staff would simply be carrying out specific tasks, not doing so out of compassion.

Objection 3) Compassion is a feeling, and therefore has no ethical relevance.  We should not be trying to teach compassion, but rather moral principles and rules that govern good actions.

Objection 4) Formal teaching requires examining, which requires measuring achievement.  But compassion cannot be measured, therefore it cannot be taught.

Objection 5) Compassion is given by grace, therefore it cannot be taught by human beings.

But on the other hand

Our Lord said in the Gospel, ‘Learn from me, for I am gentle and humble of heart’ (Mt.  11.29).  This shows that it is possible to learn gentleness from other people.  Again, in Portia’s great speech about mercy she says, ‘We do pray for mercy, And that same prayer doth teach us all to render the deeds of mercy’ (Shakespeare, Merchant of Venice, 4.1).  Therefore we can be taught mercy, through experiencing it at the hands of others.

Discussion and conclusion

Compassion begins with feelings, but goes beyond them.  First, it requires a stable and reliable tendency to feel in a certain way, that is a disposition.  Secondly, that disposition is a disposition for what is good, and so needs to be shaped by wise understanding: sentimental sympathy is not true compassion.  (For example, a doctor who indulged a patient’s desire to smoke heavily would not be showing true compassion.) In this way, compassion can be identified as a virtue, that is a stable disposition of character to act wisely and well.  Specifically, it is the disposition to notice, feel for and be moved to assist those who are suffering, in their particular needs.  St Thomas says that if you possess a virtue, you will act in accordance with it ‘readily, reliably and with pleasure’.  This is because the actions ‘come from the heart’, that is, you are doing them because you see the point for yourself and want to act in this way; you are not doing them because someone or something else is pushing you to do so.  In this way a compassionate person acts with compassion quickly, reliably, and cheerfully.

St Thomas also argues that the virtues are interlinked: to be fully compassionate, for example, you also need some wisdom and courage.  So, for example, a nurse or doctor may need to be brave in order to speak out for what a patient truly needs, against bureaucracy, maybe, or against less caring colleagues.

In order to learn the virtues, we need some basic potential for them: some people, for example, are naturally more courageous or good-tempered than others.  Then we need to be guided by the example and authority of more experienced people, beginning as children with our parents.  In this way, we practise doing good actions.  Through practice, we gradually internalise the ability to behave in this way, so that it becomes what St Thomas calls ‘second nature’; we also gradually internalise the point of doing so.  Thus, for example, nurses should learn to move away from a tasked-based tick list and become able to give their own rationale for what they are doing. 

In other words, when someone becomes virtuous, he or she begins to want what a virtuous person wants.  In this way, learning the virtues is like learning a sport or a musical instrument.  A child can be forced to practise and aquire some skills, but she will only become a good violinist or a good footballer when she herself desires to play well.  St Thomas compares a good teacher to a gardener.  The ability to grow is within a pupil, as it is within a plant.  The role of the teacher or gardener is to nurture this ability by providing the right conditions, and by protecting the pupil, or the plant, from damage. 

When it comes to virtues and morality, older and more experienced people teach first of all by example.  Particular individuals can be very influential, but even more important is the shared example of the community.  So, for example, in a hospital setting a ward which has a good collective ethos and that emphasises teamwork will develop the right attitudes and virtues in its new and inexperienced staff.  Sometimes we do need to teach explicitly, in the form of rules or guidelines perhaps.  But if people are told to follow rules without being given a good example, they will learn only to tick boxes and avoid being caught out. 

It is the example of others that will enable our capacity for compassion to grow.  Leadership is very important in this: for example, a ward manager who works alongside the nurses to deliver basic care can become an inspiring role model.  Conversely, the imposition of Intentional Rounding without the encouragement of good examples of compassionate care would not develop compassionate nurses.  As soon as external enforcement disappeared, the staff would be likely to return to their earlier bad practice.  However, if they are helped by good example and advice to see the point of the good practices, they could then internalise both the practices and the attitudes appropriate to them.  In other words, they would acquire compassionate hearts.

Because compassion requires the capacity to imagine oneself in others’ shoes, personal experience of suffering can also teach people to be more compassionate.  As Portia’s speech suggests, we learn compassion in particular through realising our own need for others’ compassion in times of pain or unhappiness.  For this reason, it is common for people to become more compassionate as they grow older.  Very often, for example, it is the older nurses on a ward, who have a wider experience of life, who seem to notice more instinctively the needs and feelings of a patient.  (On occasion, conversely, it can be the very young student nurse, coming on a ward for the first time, who can show true compassion, because she has fresh eyes and has not lost hope in the system or the possibilities of what healthcare professionals can achieve.)

Because compassion involves more than simply following a set of rules, it cannot be assessed by measuring results.  It can be recognised by those who are attentive and sensitive to it and who are themselves compassionate.  Some subjects, like mathematics, and some skills, like javelin throwing, are amenable to assessment by measurement, and in this case such assessment can provide a useful aid to teaching.  However, there is no reason to believe that because a skill or disposition cannot be assessed in this way, it cannot be taught.  You can teach without formally assessing the results; you can also judge the quality of many things without using measurement.  Our own culture tends to emphasise procedural accountability rather than responsibility; this brings the danger of neglecting those fundamental elements of good medical practice that cannot be measured.  Doctors and nurses need both certain skills and competences that can be measured and certain virtues and abilities that cannot.

We should not underestimate how difficult it can be to acquire and to act with compassion.  The difficulties are twofold: from sin and from external constraints.  We are all susceptible, to different degrees, to the temptations of inattentiveness, impatience, laziness, irritation, fear and even hard-heartedness.  Such temptations are stronger when we are tired or under pressure.  Growth in the virtues involves learning how to avoid or resist such temptations, so that their power over us is gradually weakened.  In addition, external constraints, for example inappropriate targets, shortage of staff or a poor ethos in our place of work, increase the temptations to give in to our weaknesses.  For this reason it is very important that the structures and patterns of work within the healthcare profession support rather than undermine the development of compassion and other virtues.

Finally, St Thomas, in keeping with Catholic tradition, teaches that grace builds on nature.  Christian believers are likely to recognise the exceptional gentleness, humility, kindness and compassion of certain people as due to the effects of prayer and grace.  Grace acts to heal the effects of sinfulness in someone and thus to enhance their ability to develop virtues.  However, such graced compassion works through, not against, our natural temperaments and the human processes of learning and teaching.  Grace is indeed a gift, and cannot be taught.  For this reason no programme or planning could produce exceptionally compassionate individuals.  However, teaching (including example) can develop the ordinary human potential for compassion in each individual.

Responses to the arguments against

Response to Objection 1) It is true that childhood is very important in forming character.  Someone whose childhood experiences have significantly damaged their capacity for compassion is unlikely to be suitable to work in healthcare.  Again, there may be a few people who are naturally unsympathetic, so that healthcare would not be their vocation.  However, because compassion is developed through experience, it is something that we can continue to learn throughout adulthood.  People in their twenties, thirties and even forties may often develop significantly in this respect.

Response to Objection 2) This objection points very properly to the dangers of a ‘tick-box mentality’.  Protocols, rules and regulations can never teach compassion on their own; their proper function is as prompt or reminder of what a good practioner knows should be done and already wants to do.  If well used they can provide a useful tool for the teaching of compassion, which takes place primarily through the example, encouragement and guidance of inspiring individuals and a healthy collective culture. 

Response to Objection 3) True compassion integrates feelings and emotions with principles into a compassionate disposition from which compassionate actions flow, in the way explained above.

Response to Objection 4) Although assessment through measuring is sometimes a useful adjunct to teaching, this is not so in all cases.  Therefore, it would be a mistake to try to audit the results of teaching compassion, especially by attempting to measure them.

Response to Objection 5) The exceptional compassion given by grace is a gift.  However, a natural capacity for compassion can be developed through education, when this is mediated by good role models and a positive collective ethos.