On Making Compassion Tangible

I have written this book because I have faith in the individual practitioner—my colleagues in the helping professions. I believe that most of us came to clinical practice with idealism and a desire to make a difference in the world, if only we could be directed how to make compassion tangible" (p. xxii). Thus does Joseph Fins preface A Palliative Ethic of Care, which has much to teach all who care for the dying. Fins writes from the conviction that wisdom is at the heart of such care and that, with proper guidance, medical students and residents can learn to cultivate such clinical wisdom.

A self-described reformer, Fins advocates "clinical pragmatism," an approach to patient care and ethics consultation that draws on the work of John Dewey. Dewey's contextual analysis of ethically problematic situations strongly resembles the reasoning clinicians engage in to arrive at a differential diagnosis. The first third of the book reviews relevant ethical, legal, and institutional developments in caring for the dying in America since the 1960s. Part II elaborates a practical strategy for effective palliative care using an assessment tool the author and his colleagues developed to help clinicians transition from curative to palliative care. This strategy should become indispensable to planning such care, especially in institutional settings where the principal focus tends to be on rescue and cure. It presupposes a team approach to care and directs attention to clinician and patient (or surrogate) perceptions of the patient's condition, end of life care options (including withholding or withdrawing life-sustaining therapies), and changes in the patient's condition that may prompt a corresponding alteration in clinical management (including considering intensive care as well as comfort measures to relieve pain and distress).

That said, where does the "wisdom" of the book's subtitle come in? Fins begins the book with a fictional vignette in which he conjures a medical student who is feeling uncertain and uncomfortable in the presence of a dying patient. Just then, an admired senior physician enters the room, "adjusts the patient's facemask and pillows and elevates the bed just a bit. She places a hand on the patient's shoulder and offers a comforting word. You don't quite hear what she says, but you can tell that the patient was consoled by the change in his expression. His breathing is as labored but the brow is now less furrowed" (p. 6). The physician reassures the patient that she will manage his shortness of breath by adjusting his medicines and will honor his wish not to return to the intensive care unit. All the while, the novice is transfixed: ". . . how did she learn how to do this?" (p. 7). In fact, we might reasonably ask, what did she actually do? She adjusted the bed and the meds and the pillow, but she also "brought something more into the room" (p. 7). Here, in this moment of insight, is the beginning of wisdom. "Her confidence, her words, her engagement are what transformed discomfort into an eerie sort of ease" (p. 7). The student watches, reflects on what he has witnessed, and learns something of what it might mean to make compassion tangible.

A similar case, this one drawn from Fins's own experience as a novice, closes the book. It tells of a relationship between a no-nonsense businessman who had battled cancer for years and the physician, Fins's senior, who partnered with the man to help him live as long as possible while avoiding needless suffering. Years earlier, when talking together about what to do some day if a cure did not come, the man told the physician that he had always dreamt of being a poet and that "when it was his time, well, that's what he would do" (p. 257). On rounds one morning, the time had come to inform the man that his luck had run out. "We weren't quite sure," Fins writes, recalling the moment, "what would be said. . . . The attending sat at the bedside, adjusted a pillow, and looked him in the eyes. 'I think it's time to write poetry...