Karuna is “…born of grief on account of loss or difficulties of [persons] near and dear.
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difficulties of others by putting forth any amount of efforts.” It is also defined as
“…to treat a stranger, a relative, a friend or foe as one’s own self,” as someone
who is as susceptible to suffering as I am.
Karuna
is “…born of grief on
account of loss or difficulties of [persons] near and dear.”
Anukampa
means “to
experience mild and gentle movement in the heart following the observance of
pain and suffering in the other person.”
7
It is evident from these definitions that they are based on critical reflection
and address a number of pivotal underlying questions that are deeply relevant
to nursing ethics. These questions include:
Is compassion a virtue? If so, what kind of virtue? Is it innate or learned?
Can compassion be taught? Is compassion the same as sympathy or pity?
Does compassion involve empathy or mercy? Is compassion a response?
What is the function of compassion? Is compassion nothing more than
a feeling? Is compassion a cognitive decision? Does compassion require
tangible action? Who or what is the object of compassion? Who or what is
worthy of my compassion? Is compassion toward one’s self or a loved on
the same as compassion toward a foe? Need a person merit compassion?
How does compassion relate to my own potential or real suffering? Is the
one who expresses compassion in a superior position? Are there degrees of
compassion? If there are degrees of compassion, on what are those degrees
based? Are there constitutive elements in a compassionate response? Why be
compassionate? Must I show compassion toward myself?
Within the sacred Hindu texts one finds discourses that grapple with these
questions and provide profound answers.
Buddhism also addresses compassion. The Buddha lived sometime between
the 6
th
and 4
th
centuries BCE. The words of the Buddha were originally passed
via oral tradition, then recorded in the
Path of Purification
(
Visuddhimagga
) and
other works. The Buddha’s understanding of compassion was as follows:
When there is suffering in others it causes (
karoti
) good people’s
hearts to be moved (
kampana
), thus it is compassion (
karuóá
).
Or alternatively, it combats (
kióáti
)
others’ suffering, attacks and
demolishes it, thus it is compassion. Or alternatively, it is scattered
(
kiriyati
) upon those who suffer, it is extended to them by pervasion,
thus it is compassion (
karuóá
).
8
Restated in more modern language: “Compassion is that which makes the
heart of the good move at the pain of others. It crushes and destroys the
pain of others; thus, it is called compassion. It is called compassion because it
shelters and embraces the distressed.”
9
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In Buddhist thought, compassion is a virtue. Compassion rises above respect,
sympathy, and pity. In compassion we identify with the other and try to
understand from her or his point of view. Buddhist scholar William Irwin writes:
Compassion and kindness are virtues that direct us away from
ourselves and our craving…. We owe it to ourselves to treat other
people with something greater than respect, namely compassion…
Compassion involves both the recognition that others are suffering
and the fellow-feeling that the recognition brings…. I do not feel
sorry for them or have pity for them; I have compassion for them,
recognizing their state of being as my own…. Compassion thus
involves an ethics of intention. While the carelessness and foolishness
of certain actions makes them blameworthy even with good intentions,
it is charitable, kind, and appropriate for us to consider others’
intentions. Looking to others with their intentions in mind helps me
to cultivate compassion… And on a daily basis, empathic listening
requires compassionate intentionalist interpretation. The goal is not
to understand the other person as suits me; or from my point of view;
or to find some piece of common ground. The goal is to understand
the other from his point of view, as he intends and hopes to be
understood.
10
Note that the questions that underlie Hindu perspectives on compassion are
shared in the Buddhist considerations—and those of other religions as well.
Religious discourse on compassion goes beyond the definitional and
theoretical to encompass actual “interventions.” Take, for example, the man
named Job in the Jewish
Tanakh
(Bible). The Book of Job dates between the
7th and 4th centuries BCE, with the 6th century as the probable date.
11
Job,
a righteous man experienced calamity. His children were killed when a wind
caused their house to fall in, his sheep and servants were killed in a fire storm,
his camels stolen, and Job himself became covered with “loathsome sores…
from the sole of his foot to the crown of his head.”
12
In addition, he had a
nagging wife and friends with a knack for saying exactly the wrong thing. But
his friends did get one thing right: they showed compassion.
Now when Job’s three friends heard of all these troubles that had come
upon him, each of them set out from his home… They met together to
go and console and comfort him. When they saw him from a distance,
they did not recognize him, and they raised their voices and wept aloud;
they tore their robes and threw dust in the air upon their heads. They
sat with him on the ground for seven days and seven nights, and no one
spoke a word to him, for they saw that his suffering was very great.
13
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In their compassion, Job’s friends engage in
presence
, a key means of
expressing compassion. Presence receives considerable discussion in theological
literature, and is a concept and intervention fundamental to nursing and one
that nurse scholars have recently begun to explore. However, the Jewish
literature also offers insight into hearing another’s
lament
. It is in expressing,
fully expressing, one’s lament—and having that lament heard by another rather
than stifled that compassion meets and mitigates suffering. There are, in this
ancient literature, specific literary forms or templates for the expression of
individual and collective lament. These forms guarantee the full expression of
lament and prompt the person to end on a note of hope that they can draw
from within.
14
These are but three examples. Extensive discussions of compassion are found
in all major and most smaller religious traditions. There are also discussions of
compassion in the philosophical literature.
Aristotle (384–322 BCE) held that there are five essential social virtues
(sing.
arête’
; pl.
aretai
): courage, compassion, self-love, friendship, and
forgiveness. He sees virtues as larger than moral virtues alone. For Aristotle,
moral virtues
are aimed at
fine
and
right
action. He taught that virtues, as moral
aspects of character, can be learned, cultivated, and strengthened. The goal of
moral education is to control unruly desires and habits so that desires might
be rightly ordered and that virtues might be cultivated. (See Chapter 5 for
additional discussion of virtues.) Aristotle distinguished compassion from pity.
Pity is condescending and not welcome by its recipient. Compassion, on the
other hand, sees the suffering of the other as if it were one’s own suffering.
It is possible to have an excess of compassion—softheartedness—as well as a
deficiency of compassion as cold-heartedness or callousness. Aristotle ascribes
distinctive content to each virtue, including actions, motives, and capacities.
15
Aristotle argues that compassion is a painful emotion in response to another
person’s suffering or misfortune.
16
There are three constitutive elements for
compassion: (a) the person’s misfortune or suffering must be of significance,
that is, not trivial, (b) the person has no role in causing her or his suffering, i.e.,
it is undeserved, and (c) an awareness that I, and those whom I love, share in
the vulnerabilities and weaknesses of this person and are likewise susceptible
to suffering. Martha Nussbaum takes issue with Aristotle’s third condition and
maintains that:
in order for compassion to be present, the person must consider the
suffering of another as a significant part of his or her own scheme of
goals and ends. She must take that person’s ill as affecting her own
flourishing. In effect, she must make herself vulnerable in the person of
another. It is that
eudaimonistic
judgment, not the judgment of similar
possibilities, that seems to be a necessary constituent of compassion.
17
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5
Eudaimon
, often translated as happiness, welfare or even well-being, is more
accurately understood as a concept of
human flourishing
. What Nussbaum is
saying is that we all have a concept of what
human flourishing
looks like and
we make a
eudaimonistic
judgment
about persons who are suffering—that they
are or are not flourishing—consistent with our understanding of the goals and
ends we would seek for our own flourishing. She agrees with Aristotle that we
all share in the human condition of susceptibility to suffering, and thus share
in a sense of common human community. Where she disagrees with him is
that she believes that is it not a judgment of similar possibility of suffering that
drives compassion, but rather a judgment about what it takes for me or that
person to flourish.
Aristotle is hardly alone in his concern for compassion. Other philosophers
have argued about compassion, including the Stoics, Seneca, Schopenhauer,
Hume, Hutcheson, Nietzsche, and Kant.
Nurses tend to skim the religious or philosophical literature in their
investigations of compassion. Van der Cingel is an exception; she explores
selected philosophical works, including those of Aristotle, Schopenhauer, and
Nietzsche (largely through Nussbaum’s work). She writes that:
Compassion is an answer to suffering despite the fact that suffering
will not disappear by it. Serious suffering can happen to everyone
because to suffer is part of human existence. Still, suffering is not
always easy to recognize because the meaning of what is lost
differs from person to person. In order to recognize the meaning
of a loss it is necessary to set aside one’s own perspective. This is
troublesome when the relevant perspective is remote from one’s own
experience and ideas…. Imagination and reflection…help to develop
susceptibility for the other person’s perspective…. Compassion is also
defined by the specific thought that suffering is terrible…. Further,
compassion is unconditionally valid for everyone suffering…. There
is a choice to be made in showing or not showing compassion. To
acknowledge suffering by showing compassion means to acknowledge
the loss of something valuable, to deny this means adding suffering
to suffering that already exists. Therefore, compassion is the morally
right thing to express.
18
In the empirical portion of her study (with older persons with chronic diseases),
she identifies seven dimensions of compassion: attentiveness, active listening,
naming of suffering, involvement, helping, being present, and understanding.
19
While not identical to the discussions of compassion in the philosophical
literature, her findings corroborate a number of the elements that they raise.
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Only a few, including van der Cingel, have drawn rigorously upon the rich
religious sources on compassion that are available.
20
Those resources continue
to develop through theological discourse, and also through such vehicles as the
Parliament of the World’s Religions and the
Charter for Compassion
. In these
venues, compassion becomes a social and political force, much like the context
of an
ethic of care
(see Chapter 2) that extends beyond the dyadic nurse–
patient relationship.
Compassion
becomes a social force to address suffering
globally by addressing the social determinants of suffering. The text of the
Charter for Compassion
says, in part:
The principle of compassion lies at the heart of all religious, ethical and
spiritual traditions, calling us always to treat all others as we wish to be
treated ourselves. Compassion impels us to work tirelessly to alleviate
the suffering of our fellow creatures, to dethrone ourselves from the
centre of our world and put another there, and to honour the inviolable
sanctity of every single human being, treating everybody, without
exception, with absolute justice, equity and respect. It is also necessary
in both public and private life to refrain consistently and empathically
from inflicting pain. To act or speak violently out of spite, chauvinism,
or self-interest, to impoverish, exploit or deny basic rights to anybody,
and to incite hatred by denigrating others—even our enemies—is a
denial of our common humanity. We acknowledge that we have failed
to live compassionately and that some have even increased the sum of
human misery in the name of religion.
21
Note that the
Charter for Compassion
encompasses many of the facets of
compassion addressed by the religious and philosophical traditions noted
above, speaking to many of the concerns that nursing shares. The extension of
compassion into the larger social and political realm can also be found in these
same traditions.
Considering how important compassion is to nursing, it does not appear in the
codes to the degree that it should. The successive revisions of the Code err on
the side of scientifically skilled nursing, and to some degree have neglected the
art of nursing
for the science of nursing. This is, in part, a reflection of nursing’s
aspirations to be regarded as scientific and as a profession. To some degree,
compassion, comfort, and care were assumed and subsumed under rights and
patient protection language. In addition, the codes were rightly influenced by
shock and outrage at the Nazi experiments exposed after WWII, the disclosures
by both Beecher and Pappworth of morally reprobate medical experiments in
the United States and UK, the multiple international documents incorporating
human rights and self-determination, as well as the rise of bioethics in the
mid-1960s emphasizing respect for autonomy. (See Chapter 7 for additional
discussion.) These influences lead to a resolute affirmation of rights, self-
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7
determination, respect for autonomy, and the like in the successive iterations
of the Code. This content displaces the interpersonal art of nursing concerns
that remain at the heart of nursing care and are encompassed in part in the
developing
ethic of care
. (See Chapter 3). Though
compassion
is not mentioned
specifically, the
Tentative Code
(1940) does state that the nurse is a “bearer of
comfort,” “a source of strength and comfort,” and that “honesty, understanding,
gentleness, and patience should characterize all of the acts of the nurse. A
sense of the fitness of things is particularly important.”
22
Compassion appears
in the 2001 revision of the Code: “Provision 1. The nurse, in all professional
relationships, practices with compassion and respect for the inherent dignity,
worth and uniqueness of every individual, unrestricted by considerations of
social or economic status, personal attributes, or the nature of health problems.”
23
The 2015 revision of the Code retains the concern for compassion and
continues to assert it in the actual provision itself: “Provision 1: The nurse
practices with compassion and respect for the inherent dignity, worth, and
unique attributes of every person.”
24
Compassion
is inextricably linked to valuing the
other
, whether the
other
is
another human being, other sentient life, or the environment. This valuing calls
for a response of respect in the case of human life, and more specifically those
lives that come into contact with nurses, respect for human dignity.
1.1 Respect for Human Dignity
Human dignity
first appears in the 1960
Code for Professional Nurses
, and
in every successive revision thereafter. This is, again, reflective of the
international concern for the protection of human dignity. There are some
subtle shifts in language as the “dignity of man” (1968 Code) subsequently
becomes “human dignity.” The concern for human dignity shifts from the
second to the first provision after 1960. Through 1985, the emphasis is
on affirming and preserving human dignity in patient care. From the 2001
revision forward, the Code emphasizes affirming and preserving the human
dignity of all those with whom nurses have contact, in all nursing roles and
settings. This would include the preservation of the human dignity of patients,
clients, participants in research, nursing students, co-workers, other health
professionals, and colleagues—in short, everyone, including ourselves!
The requirement to respect, affirm, protect, and preserve human dignity still
does not explain or define the concept of
human dignity
. When the concept of
human dignity was introduced through the 1948 UN
Universal Declaration of
Human Rights
no attempt was made to define human dignity.
25
Düwell notes
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that when human dignity was introduced, it was intended to serve as a moral
reference point and that:
Most people believed that they knew what human dignity was about:
a consensus within the humanistic tradition, a secularized version of
the Judeo-Christian concept of Imago Dei [humankind made in the
image of God], an overlap between the ethical doctrines of important
thinkers like Kant and Confucius, the normative core of the natural
law tradition, a moral-political statement against the atrocities of
the Nazi régime, etc….it thus appeared superfluous to strive for a
theoretical explanation and justification of the concept.
26
Sulmasy identifies three different uses of
dignity
in moral discourse:
attributed
,
intrinsic
, and
inflorescent
.
27
Attributed
dignity
refers to worthiness
conferred upon a person based on one’s social standing, reputation, or civic
office; it is based on
merit
in a social or public sense.
Intrinsic dignity
, based in
Immanuel Kant’s formulation, is:
that worth or value that people have simply because they are human,
not by virtue of any social standing, ability to evoke admiration, or
any particular set of talents, skills, or powers. Intrinsic dignity is the
value that human beings have simply by virtue of the fact that they
are human beings. Thus we say that racism is an offense against
human dignity. Used this way, dignity designates a value not conferred
or created by human choices, individual or collective, but is prior to
human attribution. Kant’s notion of dignity is intrinsic.
28
This is the sense in which this Code and all prior codes
use the term
dignity
.
Inflorescent
is an odd term, as it refers to a flower coming into bloom.
Inflorescent dignity
, for Sulmasy, refers to the person who is coming into the
“full bloom” of virtuous humanity:
to individuals who are flourishing as human beings—living lives
that are consistent with and expressive of the intrinsic dignity of the
human. Thus, dignity is sometimes used to refer to a state of virtue—a
state of affairs in which a human being habitually acts in ways that
expresses the intrinsic value of the human. We say, for instance, that
so-and-so faced a particularly trying situation with dignity.
29
Inflorescent dignity is seen in the caring, compassionate, skilled nurse who
brings genuine comfort to the anxious patient; in the researcher who diligently
and rigorously pursues a line of inquiry with integrity, skill, perseverance, and
a best effort; and in the nursing educator who seeks to advance the knowledge
of both the strongest and weakest students with rigor, compassion, wisdom,
and devotion to their learning. We can also see inflorescent dignity in the
legend of Florence Nightingale, the attributed founder of modern nursing.
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9
Düwell identifies five models of the term dignity that correlate with
Sulmasy’s three forms. Düwell’s particular concern is to identify that form
of dignity that will undergird human rights. Of the five models—rank, virtue
and duty, dignity and religious status, the cosmological status of the human
being, and respect for the dignity of the individual human being—he identifies
respect for the dignity of the individual human being as best suited to the
task of undergirding human rights, with direct links to the moral and political
dimensions of life:
30
the specific idea can be distinguished that each single human
individual would have dignity. In this line, human dignity should
be seen as an expression that signifies a status which other human
beings and political institutions have to respect. This respect can be
interpreted primarily in a sense of moral obligations or – as happened
in the twentieth century – in the sense of individual rights that can
be legally enforced. And since this respect is of immanent importance
from a moral point of view, it can be seen as a reason to understand
the entire legal and political state and international order as based on
the respect for the dignity and rights of each individual human being.
This concept of ‘human dignity’…is universal; it signifies a status that
cannot be lost, and thus may provide a foundation of rights.
31
This perspective on human dignity is that which is found in the nursing
ethical literature: that human dignity has three distinct features: it is
inherent
(i.e., it is essential and permanent as it inheres, or “sticks” and is “fixed”),
intrinsic
(i.e., it is “situated within”; “inner,” and naturally belonging), and
inviolable
(i.e., it may not be violated).
32
However, Macklin has maintained that bioethics has no need for the concept
of human dignity, that “dignity is a useless concept in medical ethics and can
be eliminated without any loss of content.”
33,34
While she uses the principles
of
respect for per
sons and
respect for autonomy
interchangeably, she argues
that the principle of respect for persons or respect for autonomy will suffice
without the concept of human dignity. Nursing, and particularly an
ethic of care
(see Chapter 2), would challenge Macklin on this point and would agree with
Schulman, who notes that:
in locating human dignity entirely in rational autonomy, Kant
was forced to deny any moral significance to other aspects of our
humanity, including our family life, our loves, loyalties, and other
emotions, as well as our way of coming into the world and all other
merely biological facts about the human organism. His exclusive
focus on rational autonomy leaves Kant with a rather narrow and
constricted account of our moral life.
