Dr Paulina Taboada
Profesor Centro de Bioetica
Pontificia Universidad Catolica de Chile
Alameda 340 Correo Central 1
In his book “Rethinking Life and Death” (1994) Peter Singer defends the thesis that, confronted with the technological development of contemporary Medicine, traditional ethical theories have collapsed. The whole book is conceived as a demonstration of the lack of coherence between traditional ethics and the actual practice of contemporary medicine. Indeed, it is by way of pointing out the inconsistencies between the actual ‘feelings’ and modes of acting of health care professionals, and traditional ethical theories, that Singer (1994, p. 6) argues for a “new, more compassionate Medical Ethics, [that] will offer practical solutions to problems we now find insoluble, and allow us to act compassionately and humanely, where our ethic now leads us to outcomes that nobody wants.”
In short, Singer’s criticism is that Bioethics should become more appreciative of the actual experiences of practitioners and more attentive to the context in which physicians, nurses, patients, and others experience their moral lives, e.g. the roles they play, the relationships in which they participate, the expectations they have, and the values they cherish. The physician patient relationship is neither a-historical, a-cultural, nor an abstract rational notion; persons are always persons-in-relation, are always members of communities, are immersed in a tradition, and belong to a particular culture.
Hence, Singer (1994) proposes that compassion must play an important role in determining the concrete content of the ethical principles in contemporary medicine. According to Singer, a ‘humane and compassionate’ ethics will lead to a radical change of the main ethical principles that have traditionally oriented medical praxis. In evident opposition to this traditional medical commitment, he suggests (Singer, 1994, p. 190 – 206) to replace these ‘traditional’ principles by the following five ‘new commandments’:
1. “Recognize that the worth of human life varies;
2. Take responsibility for the consequences of your decisions;
3. Respect a person’s desire to live or die;
4. Bring children into the world only if they are wanted; and
5. Do not discriminate on the basis of species.”
Although I cannot agree with Singer’s practical conclusions, I do think that compassion is an important moment of the ‘lived ethical experience’ of health care professionals. Indeed, compassion is an essential element of the emotional-cognitive response in the face of another person’s suffering. The ethically relevant dimensions of suffering are first and foremost experienced through compassion. Moreover, this experience itself is already a moral response to suffering and provides therefore a way of understanding the person herself in ethical terms. Hence, medical ethics has to take into account this primordial experience of health care professionals. Nevertheless, I shall show that an authentically ‘compassionate’ medical ethics does not lead to Singer’s conclusions.
The term ‘compassion’ is commonly understood mainly as synonymous to pity. Nevertheless, this is not the way in which I am using it here. With Dougherty & Purtilo (Physicians’ Duty of Compassion. Cambridge Quarterly of Healthcare Ethics, 1995, 4, 426 – 433), I would rather define it as “the virtue by which we have a sympathetic consciousness of sharing the distress and suffering of another person and on that basis are inclined to offer assistance in alleviating and/or living through that suffering. Therefore, there are two key elements of compassion: 1) an ability and willingness to enter into another’s situation deeply enough to gain knowledge of the person’s experience of suffering; and 2) a virtue characterized by the desire to alleviate the person’s suffering or, if that is not possible, to be of support by living through it vicariously.” (p. 427)
Hence, the compassionate response seems to involve essentially both a passive and an active moment. The main passive moment is the point in which the free center of the subject is ‘touched’ in the face of a fellow’s suffering. Nevertheless, this rather passive moment presupposes that the subject is able to grasp another person’s suffering in her otherness. And this grasping does not seem to be merely ‘passive’. It presupposes some free attitudes and dispositions on the side of the subject, like openness, ability to listen, etc. On the other hand, the compassionate response does not seem to be completed in the moment in which a subject becomes aware of a fellow’s suffering. For a compassionate response to be authentic, a further ‘active’ moment seems to be required, namely, the moment in which the subject takes the free decision to actually do everything that is in her power to overcome or alleviate this other person’s suffering. In other words, after being emotionally and cognitively ‘moved’ by another person’s suffering, the subject has to ‘move’ himself in concrete acts.
At this point the question arises about what it means to be a compassionate person. Compassion cannot be considered just as an emotional response in the face of suffering. As already stated, a compassionate response involves both passive active moments. Essential to compassion is an attitude of self-commitment to the other; a continual readiness to perform the fundamental acts which corresponds to the reality of compassion, and all other acts which spring from it and which it gives their proper character. It then becomes clear that compassion can be conceived - in a somewhat existential sense - as a state of consciousness and an attitude on the part of the individual. In other words, compassion can thus be conceived as an act and also as a permanent disposition (habitus) from which particular acts derive. Thus, we must consider compassion in this ‘potential’ sense, that is to say the readiness to engage in certain types of acts, what we may call ‘compassionate attitude’. In simple terms, we may say that an attitude is an active relationship, but not yet an action. It involves ‘taking up a position’ and being ready to act in accordance with it.
Compassion — understood as a moral virtue — is thus directed primarily to the person and secondarily to her sufferings. Since it entails the willingness to effectively alleviate a person’s sufferings, it demands to unfold the corresponding expertise or “knowing how”. And it is evident that human sufferings have many different sources. Under this perspective, medical interventions able to benefit a seriously ill person cannot be narrowly understood as those having the potential to produce certain physiological effects on the person’s body, which is doubtless an important goal of medical care. But the medical commitment towards a suffering person reaches far more than her body. And in the context of Palliative Care, a peculiar source of human suffering is the person’s natural fear of imminent death derived from the clinical condition itself. Thus, health care workers should develop a special sensitivity towards these aspects, permitting their patients to reflect on their moral duty to accept death and to receive the necessary psychological and spiritual assistance, if they want. This will require — among other things — being aware of the importance of preserving the patient’s state of consciousness, as long as the clinical condition and the therapeutic goals allow it.
If it is true that compassion is primarily directed to the person in virtue of her sufferings, and only secondarily to her sufferings — as said above — then, we can draw two further practical conclusions. Whenever a medical intervention is judged as proportionate, the respect due to the dignity of each person will require us to implement this measure. On the other hand, in situations of extreme and prolonged sufferings a truly compassionate attitude will prevent health care providers from the temptation of accelerating death in order to alleviate their patient’s sufferings. This is so because an act of true compassion cannot eliminate its primary object (the person) in order to eliminate her sufferings. On the contrary, a compassionate attitude may disclose health care providers the way in which their competent medical knowledge can best be used to palliate sufferings in a way that truly respects each person’s life and dignity, even in the events surrounding an unavoidable death.
Dr. Paulina Taboada, MD, PhD
Palliative Care and Bioethics