Compassion & Global Health
Annotated Bibliography of the Literature, 2010
Valerie DiPonio
David Addiss, MD, MPH

Altman SH, Brecher C, Henderson MG, et al. Competition and Compassion: Conflicting Roles for Public Hospitals. Ann Arbor, MI: Health Administration Press; 1989.

Review

Four major public hospital systems were studied: New York City Health and Hospitals Corporation; Los Angeles (Calif.) County Public Hospitals, the Hillsborough County Hospital Authority, Tampa, Florida, and the Regional Medical Center, Memphis, Tennessee. Capitalizing on the experiences of these systems, the editors develop a conceptual model against which to measure public hospital performance using three performance criteria; efficiency, quality, and access.  These criteria are then compared to four aspects of each system’s structure and operations – form of governance, financing arrangements, linkages to teaching institutions, and market strategy – to determine how these affect performance.

The authors conclude that the single most important factor influencing the financial strength and, ultimately, the quality of care provided in the institutions studied is “the fiscal condition of their state and local government combined with the social philosophy of their community toward their public hospital system.”  It is the emphasis on public service that affects efficiency, access, and, to a larger extent, marketing, and makes the public hospital system unique.

Comment

In the title of the book, the authors characterize the mission of public hospitals in terms of compassion – in juxtaposition with the reality of market-driven competition.  They found that the two major determinants of quality of care in these hospitals were the fiscal status of the state and local governments and the “social philosophy” of the community.  This book suggests that compassionate care is enabled both by community attitudes and by fiscal resources.

Benatar SR, Lister G, Thacker SC. Values in global health governance. Global Public Health. 2010;5(2):143-153.

Abstract

In the 60 years since the Universal Declaration of Human Rights was promulgated, the promise of achieving respect for the human rights, health and well-being of all is becoming an ever more distant prospect. We have not even remotely met the challenge of improving health for a large proportion of the world’s population, and the prospects for improving global health seem to be receding in the current deteriorating economic and political climate. As global health remains one of the most pressing problems of our time, we must question the values that direct our actions and current approaches, which proclaim ‘human rights to health’ but which subsume these rights to a broader paradigm of unregulated global market economics and national politics, rather than working to make these oft-contradictory goals mutually compatible through justifiable and accountable global governance processes. We suggest that a new balance of values and new ways of thinking and acting are needed. These must transcend national and institutional boundaries and recognize that health in the most privileged nations is closely linked to health and disease in impoverished countries. Sustainable development of health and well-being is a necessity for all, and values for health should permeate every area of social and economic activity.

Comment

While acknowledging recent successes in global health and increases in official development aid and donations for global health, the authors state that “the prognosis for improving global health will remain poor until we successfully address the underlying values and conditions that prevent improvements.”   What are these values that dominate global health in the rich ‘western’ world?  They include: “individualism and respect for human rights; economic liberalism; corporate managerialism; a narrow focus on scientific rather than social solutions to health problems, and an oversimplified, linear approach to health problems.”  The authors address each of these, and conclude that we need “an ethics of public health to enable us to deal rationally with threats to global health as a systemic challenge” instead of our current focus on “individual autonomy and interpersonal ethics.”  What is needed, they argue, is to “develop sustainability” rather than to “sustain development.”  “Bioethics needs to adapt to global health realities through an expanded discourse that goes beyond the micro-level of interpersonal relationships and individual health to include ethical considerations that impact health at the level of institutions and international relations.”   In the end, the value of equity remains central: “constructing new ways of achieving economic redistribution is key to resolving many global problems.”

Blinderman C. Palliative care, public health and justice: setting priorities in resource poor countries. Dev World Bioeth. 2009; 9(3):105-110.

Abstract

Many countries have not considered palliative care a public health problem. With limited resources, disease-oriented therapies and prevention measures take priority. In this paper, I intend to describe the moral framework for considering palliative care as a public health priority in resource-poor countries. A distributive theory of justice for health care should consider integrative palliative care as morally required as it contributes to improving normal functioning and preserving opportunities for the individual. For patients requiring terminal care, we are guided less by principles of justice and more by the duty to relieve suffering and society’s commitment to protecting the professional’s obligation to uphold principles of beneficence, compassion and non-abandonment. A fair deliberation process is necessary to allow these strong moral commitments to serve as reasons when setting priorities in resource poor countries.

Comment

The author makes the case for palliative care as a public health priority in resource-poor countries.  He first discusses palliative care from a perspective of justice, which is concerned with “protecting opportunity.”  He then moves, in his terms, “beyond justice” to address the relief of suffering.  Palliative care “raises issues about compassion and beneficence that go beyond questions of justice.”   “For [John] Rawls, the emphasis on the least well off has more to do with a distributive model of justice with the goal of preserving fair opportunity in society.  According to Lindemann Nelson, health care, and hospice care specifically, is a right ‘because the protective membrane between any of us and unbearable suffering is often so thin.’”

In making his case for palliative care in resource-poor settings, the author weighs the principles of justice and compassion.  He argues that, at least in the setting of palliative care, compassion is a more fundamental principle than justice – even in resource-poor countries.

Buchanan DR. An Ethic for Health Promotion: Rethinking the Sources of Human Well-Being. New York, NY: Oxford University Press; 2000.

Review

What are the goals of health promotion and the most appropriate means of achieving them? The prevailing view is that these goals are to prolong life and reduce mortality rates. Since the leading causes of morbidity and mortality are now largely attributable to lifestyle behaviors–smoking, diet, exercise, etc.–the means of achieving reductions in heart disease, cancer, strokes, diabetes and other chronic conditions are to identify more effective techniques for changing people’s behavior. Virtually all health promotion research is currently directed towards accomplishing this objective. But at what cost? As researchers strive for more effective ways to change people’s behavior, what are the implications for individual autonomy, integrity, and responsibility? Buchanan sets out to explain why a science of health promotion is neither imminent nor estimable. He argues that health promotion is inescapably a moral and political endeavor and that goals more befitting the realization of human well-being are to promote self-knowledge, individual autonomy, integrity, and responsibility through putting into practice more democratic processes of self-direction and mutual support in civil society.

Comment

This is a thought-provoking book that addresses motivation, the use of power, and the underlying assumptions in the field of health promotion.  According to Buchanan, the field of health promotion is at a crossroads. “As the field heads down the path of technical efficiency, we are in danger of losing sight of how different means affect the quality of outcomes… We cannot promote integrity, autonomy, responsibility, caring, trust, or justice through the exercise of power – through the development of more effective techniques – no matter how strictly protocols for obtaining voluntary consent are enforced.”

“Fortunately, there is a tradition in health education that has worked to strengthen individual autonomy and social solidarity through practices centered on caring and fulfilling our collective responsibility for creating more humane living conditions for all people.  Change and growth are possible when community members connect with one another as human beings in caring relationships characterized by trust and mutual support.  It is a type of health promotion practice that is fully accountable, yet not dependent on exercising instrumental power to accomplish predetermined outcome objectives.”

“In contrast to the logic of exchange, people have traditionally entered the health field out of a sense of caring for others, not to maximize self-interests.  Most people in public health still feel that to be a health professional means to have a vocation, a sense of calling.  They strive to create a healthy society in which no one will be handicapped from participating due to unnecessary illness and suffering.  They continue to work in the field out of feelings of sympathy and solidarity with those in need.  The yardstick by which their work is measured is the realization of a collective good that flows from the elimination of disease, pollution, hunger, poverty, and oppression.”

“Many of my colleagues have expressed a vague discomfort with the growing enthusiasm for social marketing.  At the bottom of these intuitions are concerns about the corruption of means, the deterioration in ends, and the uneasiness that the encroaching use of the language of marketing is warping the terms for thinking about what we are doing and the values for which we stand.”

In his chapter on Justice, Caring, and Responsibility, Buchanan takes exception to some of the positions of John Rawls, for whom justice is concerned [only] with promoting human equality.  Buchanan notes that another common understanding of justice is based on the concept of desert – “rewarding people proportionately for their contributions to the common good.”

Buchanan offers several thoughtful passages on caring, which he defines as “the expression of solidarity with fellow community members, paying homage to our interdependence.”  “But the value of caring is being drained these days.  As caring has increasingly come to be equated with curing, many health care providers, especially in the nursing profession, see signs that technological procedures for effecting cures are displacing the moral dimensions of caring practices.”   He cites Robert Bellah, “The distinction needs to be drawn between caring as a sentimental psychological attitude and caring as responsible practice, aware of its own limits… Genuine caring does not see those in need primarily as victims.  Genuine caring involves a profound sense of moral responsibility, but it does not imagine that all caregivers have the technology or the power to heal all wounds and cure all ills.”

Quoting Jean Bethke Elshtain, Buchanan writes, “Pope John Paul’s name for this alternative aspiration is ‘solidarity,’ not ‘a feeling of vague compassion or shallow distress at the misfortunes of so many people’ but a determination ‘to commit oneself to the common good; that is to say, to the good of all and of each individual because we are really responsible for all.’  Through solidarity, John Paul said, we see ‘the other… not just as some kind of instrument … but as our neighbor, a helper… to be made a sharer on par with ourselves in the banquet of life to which we are all equally invited by God.’”

Finally, Buchanan notes the potential for scientific research to depersonalize.  “The value of scientific research is directly proportional to the generalizability of its findings.  Scientific theory is useless without generalizations beyond the particular observation on which it is based; it is the very breadth of its application that gives scientific theory its power and utility.  The whole of health promotion research is currently directed toward identifying such generalizable risk factors… In searching for generalizations, the scientific outlook looks in quite the opposite direction from a caring orientation based on respect for the individual.  He quotes Steven Lukes, “Respect for persons requires, among other things, that we regard and act toward individuals in their concrete specificity, that we take full account of their specific aims and purposes and of their own definitions of their social situations.”

How can public health, and global health in particular, with their necessary focus on populations, not lose sight of caring and respect for the “concrete specificities” of individual humans?

Childress JF, Faden RR, Gaare RD, et al. Public health ethics: mapping the terrain. J Law Med Ethics. 2002;32(2):232-242.

Abstract

Ethics dilemmas have been present throughout the history of public health, and bioethics has devoted considerable attention to issues relevant to public health. Only recently, however, has public health ethics emerged as a recognized subfield of bioethics. Public health ethics requires that public health improvement come through just and respectful means. Bioethics in the future not only will take on more issues of public ethics, but will apply it extensive scholarship in distributive justice to questions of global public health.

Public health ethics, like the field of public health it addresses, traditionally has focused more on practice and particular cases than on theory, with the result that some concepts, methods, and boundaries remain largely undefined. This paper attempts to provide a conceptual map of the terrain of public health ethics.

Comment

This paper outlines the “terrain” of public health ethics and distinguishes these from medical ethics.  It focuses on moral considerations and how to weigh competing claims.  Of interest is that there is no mention of the word “compassion.”

Crigger NK, Brannigan M, Baird M. Compassionate nursing professionals as good citizens of the world. ANS Adv Nurs Sci. 2006;29(1):15-26.

Abstract

Globalization is reshaping the world and its people. Nursing, likewise, is in the process of expanding its worldview to one that accommodates global care. The authors further articulate a global ethic for nursing by distinguishing two concepts: world citizenship, as described by Martha Nussbaum, which calls nurses to critically evaluate personal and culture-based beliefs, and compassionate professional, which calls nurses to nurture partnerships of mutual respect. It is also important that nursing participate and support professional and international organizations that address social injustices related to healthcare, poverty, and public health.

Comment

This paper provides a framework for nurses as “global citizens” and reflects on the skills needed for nurses to engage effectively in global health.  The authors distinguish empathy, sympathy, and compassion.  “Empathy traditionally means ‘to feel with’ and is the emotional and intellectual identification with the other that allows one to enter into the other’s state.  Sympathy is one’s ability to feel distress for the condition of the other.  Compassion may result from empathic encounter and is understood, for our purposes, as the suffering or distress for another that is linked to a desire to help.”

The authors draw on Buddhist notions of compassion, noting that it is the “supreme virtue” in that tradition.  Indeed, compassion in Buddhism has “the characteristic of devotion to removing others’ suffering.”  Undergirding the ethic of compassion in Buddhism is the awareness that we are interdependent and connected to all living beings.

They then contrast this notion of compassion with justice, which is “a moral obligation rather than a beneficent and compassionate response to help the other.”   The authors go on to state that “the compassionate nurse professional is in the process of being defined” along the lines of social justice, rather than compassion alone.  “In the past and present, nursing is a profession of caring and compassion especially within our own borders.  As compassionate nurse professionals and citizens of the world, nurses embody a commitment to social justice in healthcare for people of all cultures and nations.”  And, finally, the appeal of international health organizations such as WHO and UNICEF to “rights rather than beneficence infers a stronger obligation for a more global equity of resources, including health care.”

Thus, these authors seem to make the case that a compassionate health professional will be one who works for social justice – that compassion for individuals is not enough.

Danielson RD, Crawley JF. Compassion and integrity in health professions education. The Internet Journal of Allies Health Sciences and Practice. 2007; 5:2. http://ijahsp.nova.edu/articles/vol5num2/cawley.pdf. Accessed August 12, 2010.

Abstract

Issues related to professionalism have come to the fore in health professions education. Strategies designed to evaluate and increase components of professionalism are now of interest to educators. Skills in improving levels of professionalism can be accurately assessed and taught. Professionalism encompasses attributes of compassion and integrity. Tools to measure indices of compassion have been developed. There are three critical stages in which attributes of compassion and integrity can be assessed: prior to admission, during education, and graduation standards. One effective means of transferring skills related to professionalism is modeling. Health professions educators need to be more aware of the issues related to the assessment of elements of professionalism.

Comment

This article focuses on the role of compassion and integrity in professional health professions education, and highlights the difficulties in assessing the degree to which students manifest them.  It mentions several tools to assess compassion.  Can compassion be learned?  Why do measures of compassion tend to decrease with medical education?  The authors focus primarily on settings of education for clinical care, rather than for public health.

Dossey BM. Florence Nighingale: a 19th-century mystic. J Holst Nurs. 2010;28(1):10-35.

Abstract

Florence Nightingale (1820-1910) received a clear and profoundly moving Call to serve God at the age of 16. Through a lifetime of hard work and discipline, she became a practicing mystic in the Western tradition, thereby becoming an instrument of God’s love, which was the primarily source of her great energy and the fabled “Nightingale power.” To understand the life and work of this legendary healer, who forever changed human consciousness, the role of women, and nursing and public health systems in the middle of the 19th century, it is necessary to understand her motivation and inspiration. This article will discuss her life and work in the context of her mystical practice and to show the parallels between her life and the lives of three recognized women mystics. In her epic Crimean war mission (1854-1856) of leading and directing women nurses in the army hospital at Scutari, Turkey, Florence Nightingale burst into world consciousness as a spiritual beacon of hope and compassion for all who suffered. Her historic breakthrough achievement–pioneering the modern administrative role of nurse superintendent with measurable outcomes supported by irrefutable data–in the face of incredible adversity was merely the cornerstone of her life work.

Comment

This article highlights the role of the inner life and a sense of calling in the work and motivation of a great early figure in nursing and global health, Florence Nightingale.  The author makes that her spiritual life, indeed her mysticism, fueled her legendary dedication and her compassion for all who suffered.

Dunn DJ. The intentionality of compassion energy. Holist Nurs Pract. 2009;23(4):222-229.

Abstract

Compassion energy is the converse of compassion fatigue. Nurses will grow and thrive if they understand how to self-generate vigor as compassion energy, preventing compassion fatigue or burnout. The compassion energy experience can elicit implications for nursing practice to add to the caring process.

Comment

The author describes the importance of compassion in nursing, and using terminology and a framework that is somewhat New Age in orientation, discusses “compassion energy.” She begins with various definitions of compassion, which arises out of a sense of interconnectedness and of identifying with others.  She places compassion above duty: “a nurse may perform actions for the nursed with a sense of duty or moral obligation.  The nurse, in this case, acts out of duty, not out of compassion.  The value of human care and caring involves a higher sense of spirit of self.  Compassion is a gift and cannot be acquired by advanced skills and techniques.”  She claims that “compassion is the energy of caring,” and highlights the importance of self-care in fostering the capacity to care for others and to sustain compassion as a nurse.

Evans K. Finding meaning in medicine. Greater Good. 2006-2007;3(2):18. http://greatergood.berkeley.edu/article/item/finding_meaning_in_medicine/. Accessed July 28, 2010.

Abstract

Physician burnout, rushed and impersonal care for patient – this is what’s ailing the medical profession today. Some doctors have a prescription for change.

Comment

This article, from the electronic journal “Greater Good,” reviews the problem of “physician burnout” and provides perspectives on compassionate care and physician self-care from leaders in this field, including David Shlim, Rachel Naomi Remen, and James Gordon.

Farley J. Bilharzia: A History of Imperial Tropical Medicine. New York, NY: Cambridge University Press; 1991.

Review

The advent of tropical medicine was a direct consequence of European and American imperialism, when military personnel, colonial administrators, businessmen, and settlers encountered a new set of diseases endemic to the tropics. Professor Farley describes how governments and organizations in Britain, the British colonies, the United States, Central and South America, South Africa, China, and the World Health Organization faced one particular tropical disease, bilharzia or schistosomiasis. Bilharzia is caused by a species of blood vessel-inhabiting parasitic worms and today afflicts over 200 million people in seventy-four countries. Author Farley demonstrates that British and American imperial policies and attitudes largely determined the nature of tropical medicine. Western medical practitioners defined the type of medical system that was imposed on the indigenous populations; they dictated which diseases were important and worthy of study, which diseases were to be controlled, and which control methods were to be used. Historians, historians of medicine, parasitologists, and experts in tropical medicine will find this a fascinating study.

Comment

Lest we be tempted to view the history of global health and tropical medicine through rose-colored glasses, Farley’s book offers a detailed description of the many factors that influenced the control of schistosomiasis, including human greed, political gain, imperial ambition, and dumb luck.  A fascinating read.

Finfgeld-Connett D. Meta-synthesis of caring in nursing. J Clin Nurs. 2008;17(2):196-204.

Abstract

AIM: The aim of this investigation was to enhance the understanding of the concept of caring. BACKGROUND: Despite many analyses and studies of caring, the concept is not fully understood. This lack of clarity is unsettling given that caring is suggested to be the essence of nursing and a component of nursing’s guiding paradigm. Meta-synthesis methods offer a way to push the understanding of caring forward using existing research findings. DESIGN: Qualitative meta-synthesis. METHOD: Meta-synthesis and grounded theory strategies were adapted to synthesize findings from 49 qualitative reports and six concept analyses of caring. RESULTS: Results from this work indicate that caring is a context-specific interpersonal process that is characterized by expert nursing practice, interpersonal sensitivity and intimate relationships. It is preceded by a recipient’s need for and openness to caring, and the nurse’s professional maturity and moral foundations. In addition, a working environment that is conducive to caring is necessary. Consequences include enhanced mental well-being among nurses and patients, and improvements in patients’ physical well-being. RELEVANCE TO CLINICAL PRACTICE: It appears that caring has the potential to improve the well-being of patients and nurses. It is recommended that healthcare agencies and educational institutions devote more resources to cultivate caring among employees and students. CONCLUSIONS: The findings explicate a cohesive process of caring. They provide insight into the human attributes and clinical milieu that are necessary for caring to emerge. They also offer clarity regarding the therapeutic benefits of caring.

Comment

This informative exploration of the concept of caring within nursing highlights its relational and moral dimensions.  The author delineates both the antecedents and the consequences of caring based on a meta-analysis of the literature.   Caring occurs in the context of physical, psychosocial, or spiritual needs, and requires awareness both on the part of the nurse and the patient.  Caring also involves specific skills and competencies, moral foundations, and a conducive environment.  It results in increased wellbeing both for patients and for nurses.  Of interest, the article does not mention compassion, which raises a question as to the relationship between caring and compassion.  Is caring a type of compassion-in-action, the outcome of compassion, or does caring (a response to need) subsume compassion (a response to suffering, which is only one expression of need)?  Is caring a more comfortable term than compassion for those in public health?

Frank DI, Karioth SP. Measuring compassion fatigue in public health nurses providing assistance to hurricane victims. Southern Online Journal of Nursing Research. 2006;7(4):2-13.

Abstract

Background: It has been documented that disaster care providers are at risk for compassion fatigue (CF). However, there is only a beginning understanding of the factors that places nurses at risk for CF. This survey research measured the risk for CF in public health nurses who provided care to hurricane victims during the 2004 hurricane season in Florida. Method: One hundred seventeen nurses responded by completing the Compassion Fatigue Self-Test regarding how they were feeling during the time they were providing care, as well as how they were feeling at the current time (three to four months post hurricane).Results: Findings revealed the majority were at low risk for CF. This may be because the majority were deployed for only two weeks and this was their first time to provide assistance to disaster victims. Variables correlated with increased risk for CF during the hurricane assistance and post hurricane included the sense of personal/family/normal job responsibility disruption, preferences to work less time that they did, and number of hours worked. Conclusions: The findings of this study suggest that nurses are vulnerable to CF. Disaster relief agencies need to develop plans for deployment of nurses that minimize this risk. It suggests that research is needed in looking at the risk for CF in first-time responders as compared to those who may perceive a deployment as a “here we go again” experience of burden.

Comment

Despite several important limitations of this article, it is one of the few that documents compassion fatigue in a public health setting – i.e., providing basic public health services to hurricane victims.

Hofrichter R. Health and Social Justice: Politics, Ideology, and Inequity in the Distribution of Disease (Public Health/Vulnerable Populations). San Francisco, CA: Jossey-Bass; 2003.

Review

Health and Social Justice draws on the growing body of recent literature to offer a comprehensive collection of articles written by a panel of expert contributors who represent a broad range of fields: sociology, epidemiology, public health, ecology, politics, organizing, and advocacy. Each article explores a particular aspect of health inequalities and demonstrates how the sources of health inequalities are rooted in injustices associated with racism, sex discrimination, and social class. This book examines the political implications of various perspectives used to explain health inequities and explores alternative strategies for eliminating them. Health and Social Justice covers a broad spectrum of topics and

  • Analyzes the politics of health inequities
  • Shows how market values often dominate over collective needs for well-being
  • Examines the politics of methodology and its implications for research and public policy
  • Critiques the ideological implications of contemporary health promotion as a model for public health
  • Reviews approaches that influence the social determinants of health
  • Evaluates strategies drawn from the European experience, and others, aimed at eliminating health inequities
  • Proposes principles for action and research
  • Analyzes the role of the mass media in influencing the conceptualization of public health issues

Comment

This volume provides an overview of the issues at the intersection of justice and public health.

John J, Yatim FM, Mani SA. Measuring service quality of public dental health care facilities in Kelantan, Malaysia [published online ahead of print May 10 2007]. Asia Pac J Public Health. Accessed July 28, 2010

Abstract

This study investigates patients’ expectations and perceptions of service quality in public dental health care and measures their “satisfaction gap.” This descriptive study involved 481 dental outpatients in Kelantan, Malaysia. A modified SERVQUAL 20-item instrument was used to assess patients’ expectations before and perceptions after receiving dental treatment. The “satisfaction gap” was then measured. Results showed that patients visiting for management of dental pain were more satisfied (P = .007) than those visiting with appointment. The most significant service quality dimensions were related to responsiveness, assurance, and empathy of the dental health care providers. There was a significant difference between the patients’ expectations and their perceptions of service provided (P < .01) with regard to all dimensions. In conclusion, dental service providers should give emphasis to the compassionate and emotional aspects of care and to remember that they are integral components of quality service.

Comment

This paper is one of the few that addresses compassion from the perspective of the recipients of public health services. The authors interviewed dental outpatients in Kelantan, Malaysia who indicated that empathy and responsiveness on the part of the providers were highly values and were seen as integral to quality service.

Kass NE. An ethics framework for public health. Am J Public Health. 2001;91(11):1776-82.

Abstract

More than 100 years ago, public health began as an organized discipline, its purpose being to improve the health of populations rather than of individuals. Given its population-based focus, however, public health perennially faces dilemmas concerning the appropriate extent of its reach and whether its activities infringe on individual liberties in ethically troublesome ways. In this article a framework for ethics analysis of public health programs is proposed. To advance traditional public health goals while maximizing individual liberties and furthering social justice, public health interventions should reduce morbidity or mortality; data must substantiate that a program (or the series of programs of which a program is a part) will reduce morbidity or mortality; burdens of the program must be identified and minimized; the program must be implemented fairly and must, at times, minimize preexisting social injustices; and fair procedures must be used to determine which burdens are acceptable to a community.

Comment

Like other articles on public health and ethics, this one, which proposes a 6-step ethics framework for considering public health interventions and programs, is notable for making no mention of compassion.

Kellehear A. Compassionate Cities. New York, NY: Routledge; 2005.

Review

Imagine if whole communities – not simply a community’s direct health services – really cared about its member’s health and social well-being. Imagine if that care extended to the dying, death and losses experienced by everyone in that community. Imagine if “death” was an idea that went beyond the “death of the body” and came to include the deaths of identity and belonging as these endings apply to people living with dementia or the aftermath of sexual abuse, dispossession of indigenous or refugee peoples. Such community and policy frameworks partly do exist in the World Health Organization’s “Healthy Cities” international programs, but they often do not include end-of-life care issues such as death, dying and loss. This book takes the idea of the Healthy City and extends these policy and practice ideas to include frequently overlooked end-of-life care experiences and concerns. Compassion is an idea that goes beyond “health” and “welfare” and embraces and promotes empathy and support as new forms of “health promotion.”

Beginning with an examination of the parallel histories of public health and end-of-life care the book moves to a critique of the current limits of both for human experiences of death, dying and loss. The theory and policy ideas of Healthy Cities are introduced and a comparison with Compassionate Cities policies made. Policies of Compassionate Cities are discussed alongside their sociological basis. The strengths and weaknesses of such large-scale programs are examined. The final sections of the book outline and summarize basic models of community development and action strategies for implementing a “Compassionate Cities” program.

This is a book for practitioners who want to include end-of-life care issues into their health promotion and community development practices. It is also a book for end-of-life care practitioners who want to include community development and health promotion ideas into their practice. For social sciences, public health and end-of-life care academics this book argues that the integration of death, loss and compassion into contemporary public health ideas may address important long-standing limits and criticism of public health. “Compassion” may go beyond “infection control” and “health promotion” and invite us to think of a “third wave” movement of public health that joins empathy, equality and action together as practical policies for future domestic and international well-being.

Comment

The author gives serious consideration to how our cities might look, function, and feel if empathy and compassion were infused into public health and social policy.  Although one major focus is end-of-life care, the author goes well beyond this to explore broader public health and policy issues.

Keltner D, Marsh J, Smith JA. The Compassionate Instinct: The Science of Human Goodness. New York, NY: The Greater Good Science Center; 2010.

Review

Why would a Palestinian ambulance driver pledge to help a wounded Israeli soldier who had killed his brother? In contemplating the remarkable commitment of this ambulance driver – and in dozens of other settings – the contributors to this volume recognize an aspect of human nature that has long eluded scientific scrutiny. But in the 35 essays and interviews here collected (all originally published in Berkeley’s Greater Good magazine), readers watch talented psychologists, neurologists, and primatologists investigate the riddles of human compassion. In the selections gathered in the first section, contributors probe the mysterious origins of human empathy, describing an evolutionary history that has primed the human brain for selflessness. In the second section, contributors explore ways to convert our biochemical potential for altruism into day-to-day behavior. Readers learn, for example, how wise management policies can promote caring collaboration even in the cubicle labyrinth. And in the final section, contributors outline strategies –such as anti-bystander education – for fostering ethical health in society as a whole. Though uneven, this collection stimulates serious reflection.

Comment

Keltner, a leading social psychologist in the study of compassion, and his colleagues argue that the “compassion instinct” is as innate as the “selfish gene” – and as necessary for well-being and survival of the human species.

Kleinman A. On caregiving: a scholar experiences the moral acts that come before – and go beyond – modern medicine. Harvard Magazine. 2010; July-August:25-29.

Preview

Arthur Kleinman is Rabb professor of anthropology and psychiatry at Harvard Medical School, and Fung director of the Harvard University Asia Center. He is the author of What Really Matters: Living a Moral Life Amidst Uncertainty and Danger. This essay was adapted from two articles written for The Lancet’s Art of Medicine department, “Catastrophe and caregiving: The failure of medicine as art” (371:9606, 22-23; January 5, 2008) and “Caregiving: The odyssey of becoming more human” (373:9660, 292-293; January 24, 2009).

Comment

Kleinman describes in a moving and eloquent reflection his own experience as a caregiver to his wife with Alzheimer’s disease.  He says that “caregiving is a defining moral practice.  It is a practice of empathic imagination, responsibility, witnessing, and solidarity with those in great need.  It is a moral practice that makes caregivers, and at times even the care-receivers, more present and thereby fully human.   He cites an ancient Chinese perception that “we are not born fully human, but only become so as we cultivate ourselves and our relations with others” – which is similar to the notion of “Ubuntu” described by Archbishop Desmond Tutu. Tutu says, “One of the sayings in our country is Ubuntu – the essence of being human. Ubuntu speaks particularly about the fact that you can’t exist as a human being in isolation. It speaks about our interconnectedness. You can’t be human all by yourself, and when you have this quality – Ubuntu – you are known for your generosity.”

Levy B, Sidel V. Social Injustice and Public Health. New York, NY: Oxford University Press; 2009.

Review

Two past presidents of the American Public Health Association edit this book, on the ways in which social injustice underlies public health problems. Their previous books, War and Public Health, and Terrorism and Public Health, both dealt with specific issues of social injustice as they relate to public health. The current book addresses a similar set of issues in a more comprehensive manner. This book defines social injustice as the active denial or violation based on the perception of the inferiority of specific groups. These groups are socially defined in terms of racial or ethnic status, language, country of origin, socioeconomic status, age, gender, sexual orientation or other perceived group characteristics. Social injustice manifests in many ways ranging from various forms of overt discrimination to the wide gaps between the “haves” and the “have-nots” within a country or between richer and poorer countries. It increases the prevalence of risk factors and hazardous exposures, which in turn lead to higher rates of disease, injury, disability, and premature death. Public health professionals as well as students need to have a clear understanding of social injustice in order to address these problems, but relatively few books address the wide range of issues involved. This book will enable readers to understand social injustice and its underlying mechanisms, and as a result, will prepare them to recognize, document, investigate, and prevent social injustice and its effects on health. This book is organized so that health professionals, students in the health professions, and others will find it of practical value in public health and medical practice, research, education, policy development, and advocacy.

Comment

This book focuses on social injustice in its various forms and manifestations.

Lown BA, Manning CF. The Schwartz Center Rounds: evaluation of an interdisciplinary approach to enhancing patient-centered communication, teamwork, and provider support. Acad Med. 2010;85(6):1073-1081

Abstract

PURPOSE: To assess the impact of Schwartz Center Rounds, an interdisciplinary forum where attendees discuss psychosocial and emotional aspects of patient care. The authors investigated changes in attendees’ self-reported behaviors and beliefs about patient care, sense of teamwork, stress, and personal support. METHOD: In 2006-2007, researchers conducted retrospective surveys of attendees at six sites offering Schwartz Center Rounds (“the Rounds”) for > or =3 years and prospective surveys of attendees at 10 new Rounds sites that have held > or =7 Rounds. RESULTS: Most of the retrospective survey respondents indicated that attending Rounds enhanced their likelihood of attending to psychosocial and emotional aspects of care and enhanced their beliefs about the importance of empathy. Respondents reported better teamwork, including heightened appreciation of the roles and contributions of colleagues. There were significant decreases in perceived stress (P < .001) and improvements in the ability to cope with the psychosocial demands of care (P < .05). In the prospective study, after control for pre-survey differences, the more Rounds one attended, the greater the impact on post-survey insights into psychosocial aspects of care and teamwork (both: P < .05). Respondents to both retrospective and prospective surveys described changes in institutional culture and greater focus on patient-centered care and institution-specific initiatives. CONCLUSIONS: Schwartz Center Rounds may foster enhanced communication, teamwork, and provider support. The impact on measured outcomes increased with the number of Rounds attended. The Rounds represent an effective strategy for providing support to health care professionals and for enhancing relationships among them and with their patients.

Comment

This intervention study evaluated the impact of interdisciplinary “Schwartz Center Rounds”, which foster awareness of the psychosocial and emotional aspects of patient care.  The focus is “relationship-centered care” rather than compassion per se.  Although respondents reported that attendance at rounds improved their sense of support and decreased their stress and sense of isolation, the authors did not observe significant changes in perceived empathy between pre-round and post-round surveys.

McFarland DA. Clanging symbols. Religion and Theology. 2007; 14(1-2):84-93.

Abstract

Health systems in Africa confront mounting disease burdens in very poor populations with meagre financial and human resources. Religious health assets, tangible and intangible, can be a fulcrum for specific strategies to strengthen health systems resting on a set of guiding principles, that they are: Based on covenants as contrasted with contracts; predicated on trust; recognize the interaction of multiple health systems operating simultaneously in health seeking behaviour; intentionally pro-poor; transparent and accountable; driven by local needs and concerns not global agendas. Recent efforts to strengthen health systems derive from a neoclassical market model of health care that ignores, at best, or disparages, most often, the role that religious health assets play in the lives of both providers and consumers of health care. On this basis, this contribution will describe the approach to health systems strengthening taken by the African Religious Health Assets Programme (ARHAP).

Comment

The author argues that the social values typically encouraged by religion, such as compassion, trust, concern with the poor, and personal accountability, can be an effective basis for strengthening public health and health systems in resource-poor countries.

Mooney G. Public health, political morality, and compassion. Aust N Z J Public Health. 2002;26(3):201-202.

Abstract

OBJECTIVE: To put the case that public health professionals have a responsibility to foster a more informed, autonomous community. METHOD: To argue that the current Australian Federal Government is failing to provide the impetus for building a compassionate society, particularly with respect to social justice for asylum seekers and Aboriginal people. RESULTS: There is a need for public health professionals to assist in promoting an informed debate about what it means to be a minimally decent Australian. CONCLUSIONS AND IMPLICATIONS: Education of the citizenry and by the academy in public debate and public debating is the lifeblood of democracy. This is the ethical goal of public health.

Comment

Although the author concludes that the ethical goal of public health is “education of the citizenry,” he arrives at this conclusion on the basis of “empathetic imagining” and a deep recognition of our shared humanity.  He quoted Nussbaum in this regard, “We want leaders whose hearts and imagination acknowledge the humanity in human beings.”   Quoting Callahan and Jennings, he argues that public health must be based on “sound judgment, ability to recognize and analyze ethical issues, tolerance for ambiguity, and capacity for a moral imagination.”   We must be “confident in our emotional judgments [emphasis added]”.  The author asks, “What if the Good Samaritan had not had confidence in his own emotions?”

Morone JA. Enemies of the people: the moral dimension to public health. J Health Polit Policy Law. 1997; 22(4):993-1020.

Abstract

This essay explores the effects of morality on health policy. Moral images and stereotypes, I argue, have powerful political consequences. They are the difference between fighting poverty and fearing the poor, between expanding social welfare programs and cracking down on crime, between public health campaigns and drug wars. I begin by locating morality within traditional paradigms of American politics (which are designed to overlook the issue); I then suggest how moral stigmas are constructed; show how they are deployed in debates over public health issues, such as alcohol abuse and drug addiction; and briefly sketch an alternative approach to defining community and seeking public health.

Comment

The author explores how our propensity to classify humanity into social categories of “us and them” leads to stigmatize “them” as immoral and how such stigmatization affects health policy.  He writes, “the imagery of a beleaguered us surrounded by immoral others dominates the contemporary debate.”  The author provides a fascinating historical critique to support his position that that moral images and stereotypes shape American public policy and public health.  Three examples – liquor, illegal drugs, and sexually transmitted diseases – illustrate how public health is a theater for moral conflict.  “American politics is powerfully shaped by images of vice and virtue.  The divisions sharply mark health issues.  Apparent efforts to improve public health – alcohol prohibition, drug wars, campaigns against sexually transmitted diseases – often turn into ways of dividing American society, of sorting out the moral us from the threatening them…. Public health approaches become relevant only as the need to erect barriers to depravity fades and as the misbehavior typical of them turns into an illness affecting many of us… Public health ultimately rests on the search for a shared solution to common troubles.”

Chokyi Nyima Rinpoche and David R. Shlim. Medicine and Compassion: A Tibetan Lama’s Advice for Caregivers. Boston, MA: Wisdom Publications; 2006.

Review – Claire Panosian, MD, UCLA

Like most doctors, I sometimes lack compassion. Once, as an intern, exhausted beyond caring, I discharged a favorite patient from the hospital despite his obvious downward spiral due to renal cell carcinoma. My so-called excuse? I needed to lower my inpatient census! Today, almost 30 years later, I am still pained when I remember the baleful looks that he and his wife cast my way when he was readmitted the following morning. They knew that I had abandoned him, and so did I.

At other times, I have been compassionate beyond the call of duty, returning to the bedside of a patient who had received an infectious diseases consultation but who could no longer be helped by heroic antibiotic therapy-or by any treatment, for that matter. That I can clearly recall such moments is telling, however. Buried and forgotten-figuratively and literally- are many more people whom I did not comfort during their final days and hours.

Medicine and Compassion: A Tibetan Lama’s Advice for Caregivers is full of wisdom for any doctor whose well of medical empathy has at some time run dry. It represents the collaboration of a Tibetan Buddhist monk from Nepal and a Western-trained doctor, David Shlim, who first crossed paths when Shlim was director of the largest Western medical clinic in the Kathmandu Valley in Nepal. Shlim now lives in Jackson Hole, Wyoming, and has recently led several courses with his longtime friend and teacher, Chokyi Nyima Rinpoche. In writing this book, the two have tapped a genuine need in contemporary American medicine.

The first section of the book (“Human Nature”) touches on universal truths, as well as classic Buddhist teachings. However, a central theme of this section that is beyond debating is the profound influence of emotions and mental attitude on the experience of aging, sickness, and death. Another inarguable fact is that many health care professionals, from rookie interns to senior surgeons, have not yet experienced a serious illness themselves. If they had, the authors remind us, they would be far more likely to strive to alleviate the suffering of patients, rather than to merely focus on “solving their problems.”

The second section of the book (“Training”) examines our potential for and various means of achieving a greater level of compassion. In Tibetan Buddhist practice, these means include a disciplined, daily focus on doing good, as well as regular relaxation, meditation, and monitoring of one’s own mental state. In the third section (“Practical Advice”) come simple but profound thoughts on how to render the best possible care to all patients-including the aged, irritable, aggressive, or uncooperative- as well as how to nurture lifelong attitudes that ease the process of dying.

From the ancient Jewish philosopher and physician Maimonides (“Medical practice is not knitting and weaving and labor of the hands, but it must be inspired with soul…the soul is subject to health and disease, just as is the body”) to the 19th century’s Sir William Osler (“We are here to add what we can to life, not to get what we can from life”), many great doctors throughout history have unabashedly combined medical and spiritual teaching. But in this data-driven, technologic era of doctoring, the spiritual focus is easily lost. Medicine and Compassion is a good reminder of the lessons that ancient teachings and contemporary religion can offer to our collective 21st century profession and to our individual humanity as healers.

Comment

This book argues that although compassion is innate, it is more difficult to access in situations of fatigue, threat or conflict, particularly those outside one’s own group.  However, consistent with Buddhist teaching, the authors argue that intentional training can increase one’s capacity for compassionate action even in the most challenging situations.  This position is increasingly substantiated by neuroscience research, such as that being done at the University of Wisconsin by Richard Davidson and colleagues. It also is manifested in the lives of leading figures, such as the Dalai Lama.

Rumbold B. The spirituality of compassion: a public health response to ageing and end-of-life care. Journal of Religion, Spirituality & Aging. 2006;18(2):31-44.

Abstract

The recent revival of interest in spirituality in later life marks a significant step forward in the person-centered care of ageing people. The benefits will, however, be of limited value if we do not attend to the settings in which spirituality is to be lived. In contemporary society many aged people are located in environments unsympathetic to spiritual belief and practice. Health care settings focus on professionally-assessed physical needs and are dominated by concerns about the cost of services. The national social policies that direct health care services and less directly shape older people’s place in contemporary society are strongly influenced by globalised neoliberal economic policies characterized by individualism, competition, and greed. For robust and viable spirituality to develop at the individual level we need compassionate social policies that support interdependence within communities and between nations.

Comment

This paper makes a case for spirituality as foundational to compassion and compassionate care, especially at the end of life.  The author cites Kellehear, 2005 (see above), and writes, “compassion is a core value of interdependence.  A number of recent theories of care have been built around the concept of love, but the problem with this is that multiple meanings render the term capable of being individualized, sentimentalized, or abused.  Compassion aligns itself with agape from amongst the multiple meanings of love.  It is universal and inclusive, a core concept for a range of religious traditions and spiritual practices.  It links empathy, understanding and justice, promoting interdependence.”  He quotes Soygal Rinpoche (1992) as saying, “To train in compassion is to know that all beings are the same and suffer in similar ways, to honour all those that suffer, and to know that you are neither separate from nor superior to anyone.”

“Our social understandings of care can no longer afford to be shaped by clinical practice that presents care as a paid activity dominated by risk management procedures… We need to recognize that care – giving and receiving – is at the centre of human experience, and that compassion is an ethical imperative for human societies.”

Sanghavi DM. What makes for a compassionate patient-caregiver relationship? Jt Comm J Qual Patient Saf. 2006;32(5):283-292.

Abstract

BACKGROUND: During Summer 2005, the Kenneth B. Schwartz Center asked hospitals to hold rounds to discuss the topic, “What Makes for a Compassionate Patient-Caregiver Relationship?” Review of questionnaires and transcripts of the rounds held at 54 hospitals in 21 states yielded three major categories: communication, common ground, and respect for individuality. COMMUNICATION: Suggestions to improve compassionate care often focused on style and content. Rounds attendees felt that compassionate care also depends on imparting medical facts in a clear and useful manner to patients–often difficult for complex medical issues. COMMON GROUND: Compassionate care depends on showing empathy for a patient’s illness experience no matter what his or her background. Rounds participants felt that caregivers could make a conscious choice to care deeply for patients. Sharing personal information with patients and admitting mistakes were key methods for identifying common ground. TREATING THE PATIENT AS AN INDIVIDUAL: Compassionate care requires striking an individualized balance between providing guidance and allowing autonomy to achieve shared consensus, especially with complex information. A PRESCRIPTION FOR CHANGE: Most interventions target students yet do not continually reinforce compassion. Advocates for compassionate care should instead treat lack of compassion not as an acute trauma but as a chronic condition requiring a lifetime of continuous support, regular guidance, repeated reinforcement, specific targeted outcomes, and more innovative care programs.

Comment

This paper summarizes the experience and insights gained from the original series of “Schwartz Center Rounds” conducted in 2005.  It highlights the importance of empathy, individualized attention, and reinforcement in providing compassionate care.  More information appears at the Schwartz Center website, http://www.theschwartzcenter.org/bibliography/index.html.

Schout G, de Jong G, Zeelen J. Establishing contact and gaining trust: an exploratory study of care avoidance. J Adv Nurs. 2010;66(2):324-333.

Abstract

AIM: This paper is a report of a study conducted to explore the competencies – especially deep-rooted personal qualities – of care providers who succeed in making contact and gaining trust with clients who are inclined to avoid the care they need. BACKGROUND: Demands, thresholds and fragmentation of services hinder the accessibility of health care, such that some severe mentally ill people do not receive the treatment they need or avoid healthcare services. Methods of establishing contact and gaining trust in mental health care include practical assistance, realistic expectations, establishing long-term goals, empathy and a client-centered and flexible approach. METHOD: A public mental healthcare practice in The Netherlands with outstanding performance was studied from 2002-2007 using participant observation, interviews with experienced care providers and interviews with clients with a long history of avoiding care facilities, conflicts and troubled relationships with care providers. FINDINGS: A number of personal qualities are vital for establishing contact and gaining trust with these clients: altruism, a degree of compassion, loyalty, involvement, tenacity, a critical attitude to the mainstream, flexibility, optimism, diplomacy, patience, creativity, and a certain degree of immunity to stress. CONCLUSION: Care providers who establish contact and win trust employ ‘non-judgmental appreciation’. They start from the acceptance of what is and try to connect with the client and their world. These professionals use their initial actions to identify and praise qualities and achievements of clients. This style of work is supported by a set of deep-rooted personal qualities we can summarize as ’empathy.’

Comment

The authors assess the characteristics that health professionals need to gain the trust of those who tend to avoid the care they need – a group of particular relevance to public health.  Compassion is one of those qualities.  Such health care providers “start off from the acceptance of what is and try to connect with the person and his or her world.”  Of interest, they also have a capacity “to set aside demands and regulations of institutions, and connect to the world of clients.”

Smith JK, Weaver DB. Capturing medical students’ idealism. Ann Fam Med. 2006;4(1):32-37.

Abstract

PURPOSE: Students’ idealism and desire to work with underserved populations decline as they progress from preclinical training through clerkships and residency. With an increasingly diverse population and increasing health disparities, academic health centers need to incorporate changes in their curricula to train socially responsible and idealistic physicians. International electives can provide valuable learning experiences to help achieve these goals. METHODS: Sixty-six preclinical medical students at the University of Texas Medical Branch participated in an international elective from 1997 to 2005. After 1 week of didactics, they spent 3 weeks as part of a multidisciplinary medical team in rural Nicaragua. Post-elective questionnaires were administered. From students’ responses, we identified common learning themes and grouped them under the categories of attitudes, awareness, and skills. Limitations included a self-selection bias, lack of a control group, and limited follow-up. RESULTS: After the elective, students had an increased interest in volunteerism, humanitarian efforts, and working with underserved populations both in the United States and abroad, as well as more compassion toward the underserved. Students also reported a heightened awareness of social determinants of health and public health, and a broadened global perspective, as well as increased self-awareness. CONCLUSIONS: Our findings illustrate that a well-structured, mentored experience in international health can have a positive impact on preclinical students’ attitudes, including their compassion, volunteerism, and interest in serving under-served populations, all measures of idealism.

Comment

This paper provides evidence that participation in a global health elective can significantly influence medical students’ attitudes and awareness and increased their compassion toward the underserved.

Other References Identified in Our Search

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Daniels N. Just Health: Meeting Health Needs Fairly. New York, NY: Cambridge University Press; 2008.

Dumont S, St-Onge M. Social Work, Health, and International Development: Compassion in Social Policy and Practice. Binghamton, NY: The Haworth Press; 2007.

Figley CR. Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized. London: Brunner-Routledge; 1995.

Fox M. A Spirituality Named Compassion. Rochester, VT: Inner Traditions Traditional; 1999.

Gawande A. Letting go: what should medicine do when it can’t save your life? The New Yorker. 2010. http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande. Accessed August 12, 2010.

Powers M, Faden R. Social Justice: The Moral Foundations of Public Health and Health Policy. New York, NY: Oxford University Press; 2006.

Stevenson AC. Compassion and patient centred care. Aust Fam Physician. 2002;31(12):1103-1106.

Thurston JM. Death of Compassion: How Managed Care and Bureaucracy Are Strangling the Heart of Medicine. Waco, Texas: WRS Publishing; 1995.