Catholic Medical Quarterly Volume 64(1) February 2014

Faith in Medicine

Compassion in Medicine

Patrick Guinan
University of Illinois, College of Medicine

It is a given that compassion is essential in the practice of medicine. But has the tradition of compassion been reflected in medical codes and oaths? We will review the concept of human compassion, compassion’s origins in medicine, and how it has been applied to medicine.

Medicine is an art and a science, but it also has a humanitarian dimension. This latter aspect includes ethics and compassion. Ethics is the cognitive appraisal of the rightness or wrongness of behavior, while compassion is the volitional concern expressed for a sick patient. It can be argued that Greek, or Hippocratic, medicine lacked, or at least did not emphasize, compassion in its ethos. Christianity in its healing activities did, and in this regard has positively influenced medicine ever since.

At the outset, the meaning of several terms should be clarified. These terms are compassion, sympathy, and pity. All are aspects of love, understood broadly as a “desire for the good,”in this case of, or for, another person. Compassion, sympathy, and pity all imply an emotional bonding with another’s suffering. For the purposes of this paper I will use the single term “compassion.” Empathy, on the other hand, is an intellectual appreciation of the suffering without any emotional involvement.[1] Of all these terms, compassion is the one most frequently associated with the doctor-patient relationship.

Medicine is perhaps the most respected of professions. Not only are knowledge and competence required, as they are of other professions, but something more is demanded of a physician. It is embodied in an ethical imperative usually expressed in an oath taken upon entry (usually at graduation) into the field of medicine. The oath, the prototype being the Hippocratic Oath, requires that the physician act in a competent and ethical manner. However, the oath does not specify that the physician must be compassionate.

In this essay I will attempt to

1. define the ethical, as opposed to the compassionate, aspect of Greek medicine;
2. review the humaneness of Christianity and its influence on Greek and subsequently early Western medicine;
3. make some observations on the deleterious effect of modern culture on Christian medical compassion.

In summary, I will define Christian medical compassion as a physician’s deliberate act, or habit (as in Aristotelian psychology), of explicitly seeing in the doctor-patient relationship a suffering person and relating to that patient with “agape,” the term Christians used to describe self-giving love. Compassion means literally “suffering together.” This is in distinction to the detached empathy of Hippocratic medicine.

Greek medicine

Greek medicine was a combination of science and art. It was “techne,”or knowledge realized when put into practice.[2] But this “techne” had to be combined with “phronesis,” or practical wisdom, which was learned over time by being an apprentice to an experienced physician. Another element required by the Greeks was virtue, or probity of life. The Hippocratic Oath sums up the erssentials of what the Greeks thought should be reflected by a good physician and also what should be good medicine.

The eight paragraphs of the oath reflect covenants of the physician with the gods, his teacher, his students, and his patients. The latter paragraphs are strictures on the physician’s relating to the patient. Empathy or the detached intellectual appreciation of the patient’s suffering might also be present. But nowhere is compassion, in the sense of love for the patient, a “suffering with,” specifically mentioned. As a matter of fact, Leon Kass, in keeping with the Greek outlook, specifically states that “moral virtue” should not be a goal of medicine.[3]

The genius of the oath is acknowledged. Its insistence that the physician be competent and virtuous is perhaps the single most important reason that medicine has consistently been the highly regarded profession that it is. But the oath has been criticized for being paternalistic and essentially a set of rules of etiquette maintained by a privileged club. It also lacks an imperative for compassion.

This is somewhat surprising, because it was the Greek thinkers, particularly Aristotle, who discussed the meaning of love. Natural love is directed to the acquisition of a good object as perceived by the intellect. Aristotle emphasized two goods and therefore two forms of love: “eros,” or desire for a physical good, and “philia,” or desire for the good of human friendship. Christianity, citing Christ’s sacrificial death, elevated a third form of love, called “agape,” or altruistic self-giving to another, to a higher level. “Agape” gained its special significance in the New Testament.[4] Compassion is an aspect of “agape” and is the emotional response that results in a desire to help a fellow human being who is suffering from an illness or disease.

Greek medicine, as reflected in the Hippocratic Oath, emphasized clinical competence combined with an intellectual ethical imperative of not harming. While some Greco-Roman, Chinese, and Hindu medical writers hinted at the concept of compassion,[5] it was not expressly promoted. Christian medical practitioners, taking their cue directly from Christ, were not only directed to cure but were also encouraged to emphasize the humaneness of the doctor-patient relationship. This elevated love to a higher level: “agape.” More recently, bioethics, with its academic obsession with analytic principles, has discounted Christian medical compassion.

Christian compassion in medicine

It is difficult to overestimate the impact of Christianity on the culture of the Roman world and, in particular, on medicine. Whether one has religious beliefs or is a skeptic or an agnostic, it is agreed that Christ preached a gospel of love, primarily by the example of his death, which was an act of redemption for the sins of mankind. This was the essence of “agape,” or giving of oneself.

Incidentally, the gospels record that, perhaps above all else, Christ was a healer. Of his forty-four listed miracles, thirty-four (or 77%) involved healing sick individuals or raising them from  the dead. Christ is referred to specifically as a “physician” in the Christian tradition.[6] Indeed, the evangelists specifically mention that in seven of his miracles Christ healed because He was moved by “compassion.”

It was not until 313 and the edict of Milan that the Christian view of “agape” began to gradually permeate the broader culture. But even the church of the catacombs translated “agape” and compassion into specific care for sick members of the Christian community. This was the responsibility of the deacons. In 325, at the Council of Nicea, Canon 75 mandated facilities (including hospitals) for the care of those in need. Another term for “agape” was “philanthropia” (love of mankind) which became the hallmark of the Christian, and which may well have been the reason for the remarkable growth and spread of Christianity.

As pressure on the western Roman Empire from the Germanic tribes of the north increased, civil society broke down and, along with it, organized medicine. The care of the ill, particularly the sick poor, fell to the monasteries, and from 500 to 1100 much of clinical care was in the form of clerical medicine, or medicine practiced by clerics.[7] As medical schools opened and medical guilds requiring licenses were formed, the need for “clericalis medicalis” lessened and finally its practice was prohibited by the Council Lyons in 1262.

In the eastern Roman Empire, because of its relative civic stability, there was an elaborate system of civil institutions including orphanages, old people’s homes, and, in particular, hospitals, whose foundations were motivated principally by the concept of Christian charity, or “agape.”

As a matter of fact, a not insignificant impetus for the founding of these hospitals was the desire to minister to the spiritual needs of patients, especially those in danger of death. This religious motivation was so strong that in some instances medical treatment was secondary, or was even withheld, until a patient’s spiritual life was in order. Also, given the general ineffectiveness of the then-available Hippocratic and Galenic medicine, spiritual consolation was at that time of relatively greater importance and benefit.

To reiterate, it is difficult to exaggerate the influence that Christian compassion exerted on the practice of medicine from 300 until about 1700. It would not be an oversimplification to say that Christian “agape” was the energy that drove the healthcare system during this time. Its demise was due to a variety of circumstances, not the least of which was the destruction of the religious orders and the monasteries following the Protestant Reformation as well as the rise of self-centered patient autonomy.