Care infuses medicine. Well, the word ‘care’ infuses the language of medicine – Healthcare, Intensive Care, Palliative Care, Standard care, Standard of care, Best supportive care, Care Quality Commission. But what actually is medical care?Good medical care perhaps primarily describes the quality delivery of evidence-based therapeutic interventions, for example drugs, operations, scans, anaesthetics, and the organisation of services to permit these. It must also necessarily refer to the judgments around such interventions, that is to say the ethical consideration towards appropriate medicine. A skilfully performed pneumonectomy may not reflect good medical care in a patient dying from advanced lung cancer, for example. It seems reasonable then, to suggest that good medical care demands quality clinical medicine and ethical judgment. That the former requires rational thought may not come as a surprise, but the latter? In fact, contemporary ethics and moral philosophy place reason and rational thought at the core of what it is to make moral judgments and act ethically.
However, schools of ethical thought don’t always agree on what it is that constitutes the basis for moral action in medicine. For example, lying to patients may be considered to be bad because lying is bad in principle, or good if the lying perpetuates good outcomes such as hope, or bad again if the consequences, despite the good outcome of hope, generalise towards the negative, such as an erosion of trust. Further to disagreeing on the basis for moral arbitration, the centrality of ‘reason’ may be questioned. ‘Care ethics’ gives weight, beyond rational thought, to the place of sympathy, emotional understanding and relationships in informing ethical judgments (Beauchamp and Childress 2001, p. 369)
Jonah Lehrer, in his book ‘The Decisive Moment’, describes the place of emotional understanding in morality: ‘At its core, moral decision-making is about sympathy. We abhor violence because we know violence hurts. We treat others fairly because we know what it feels like to be treated unfairly. We reject suffering because we can imagine what it’s like to suffer.’ (Lehrer 2009, p 174) He goes on to elaborate on the evidence for emotion having a central role in ethical judgment and paints a very interesting picture in aligning often very rational thinking with clear acts of immorality. Even so, what about this, the idea of sympathetic and compassionate care in medicine?
Well, firstly, it seems as though, unlike the parameters of clinical/ technical care in medicine, compassionate care is harder to measure. Technical care is relatively easily measured and to a certain extent such data form the basis of the new outcomes framework for the NHS. Healthcare staff in general and doctors in particular recognise this and to a certain extent aspire towards it. For patients and relatives, these data may be more opaque, unless significantly removed from the mean. As such, responsibility for judging, monitoring and delivering technically good care may be readily handed over to the profession.
Compassionate and empathetic care is harder to measure and in many respects therefore it just isn’t. Where currently is the section in our appraisal folders entitled compassion? Doctors seem to value it much less and indeed we almost feel uncomfortable when discussing it. Patients and families though, recognise this much more readily and indeed are generally very sensitive barometers of it. Their assessment is probably more reliable, consistent and reproducible than any parametric measure we might use. We all know (and can recognise ourselves when we become patients) the health worker who cares.
Such care can be a simple and empirical prompt towards good medicine, through sympathetic imagination: how would we want our family or indeed ourselves to be managed in such a situation? Of course this isn’t enough and is potentially open to abuse. But so is a version of medicine informed simply by good technical skills or good ethical judgment.
Compassionate and sympathetic care is arguably a primary prompt and governing steer for the entirety of good medical care. And it is the platform for engaging patients at times of often profound vulnerability. It might motivate finding the bed, asserting the need, chasing the results, over-booking the clinic, calling the family, developing the service, asking for opinions, clarifying all the evidence, seeking consensus, admitting the uncertainty and withdrawing the treatment. It is antithetical to hubris and necessarily connected to a proper medical professionalism, one founded upon a duty to patients rather than the rights of a privileged set.
How do we teach and foster this care? By recognising its importance – now more than ever in a resource -constrained, exponentially more technical NHS with increasing demand and possibility. By selecting students, training doctors and consultant appointments with this in mind. And, perhaps most challenging, but also most pressing, by decanting it through professional example.
Beauchamp, T. and Childress, J. (2001) Principles of Biomedical Ethics, Oxford, Oxford University Press
Lehrer, J. (2009) The Decisive Moment, Edinburgh, Canongate