Can We Mandate Compassion?

Coriolanus, the legendary fifth-century BC general who turned against his native city for banishing him, is painted by Shakespeare as the paragon Stoic warrior. Physically strong and detached, at home in the battlefield, he is the military man par excellence. Fearless, he sheds few tears. But the turning point in Shakespeare's play comes when Coriolanus remembers how to weep. He admits that "It is no small thing to make mine eyes sweat compassion."

The absence of compassion in health care is increasingly remarked upon. In 2009, it led to a campaign to broaden New Zealand's Code of Patients' Rights to include the legal right "to have services provided with compassion, including a prompt and humane response to suffering." As health and disability commissioner in New Zealand for the past decade, I was in the midst of the country's debate over this change. In this essay, I discuss the nature of compassion, its place as a virtue in medicine, and the implications of the proposed law change.

What Is Compassion?

Compassion has several shades of meaning, and it plays a central role in many faiths, including Buddhism and Christianity. In the Christian faith, the stirring of compassion prompts a virtuous response: "But whoso hath this world's good, and seeth his brother have need, and shutteth up his bowels of compassion from him, how dwelleth the love of God in him?"¹ Modern philosophers offer a different slant on the idea. Martha Nussbaum draws on the Stoics in her account of compassion in her major treatise, Upheavals of Thought. She defines it as "the painful emotion caused by the awareness of another person's undeserved misfortune." It has three cognitive elements: that the harm suffered is serious, the misfortune is not the person's fault, and the object of compassion is worthy of the concern of the bystander.²

Few would quarrel with the notion that health practitioners and institutions should respond promptly and humanely to distress, pain, and suffering (subject to some sort of reasonable limits). Note that this is not the same as a right to have suffering relieved, something that may be unattainable. The focus is simply on the swiftness and humanity of the response. But is this the same as requiring services to be provided "with compassion"—with fellow-feeling for the patient? Can compassion be proven? And can it sensibly be legally mandated?

Proponents of the proposed law change argued that a lack of compassion will usually be obvious because an ordinary person would judge that the consumer has suffered unnecessarily. Yet asking a health ombudsman to decide whether a consumer has suffered unnecessarily strikes me as a potentially vexed exercise. It would entail asking: How much did this person suffer? How much of their suffering could have been alleviated? What steps should the practitioner have taken out of compassion to relieve the suffering? These are deep waters.

Compassion has long been identified as an essential virtue in Eastern and Western medicine. The seventh-century Chinese physician Sun Simiao describes the ideal physician as one who develops "a heart of great mercy and compassion." The twelfth-century Jewish philosopher and physician Maimonides also identified the need for fellow-feeling in the medical practitioner. He prayed, "May I never forget that the patient is a fellow creature in pain. May I never consider him merely a vessel of disease."

What of codes of medical ethics? There is no mention of compassion in the Hippocratic Oath, which dates from the fourth century BC. But it does appear in several contemporary codes of ethics. The American Medical Association Code of Medical Ethics (2001) states, as its first principle, "A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights."³ In New Zealand, compassion appears as a principle in the Medical Association's 2008 Code of Ethics: "Practise the science and art of medicine to the best of your ability with moral integrity, compassion and respect for human dignity."⁴ The Australian Medical Association 2006 Code of Ethics goes a step further, expecting the doctor to "treat...