Original article

Compassion and professional care: exploring the domain

Margreet van der Cingel RN MsN PhD student
Senior Lecturer, School of Healthcare, Windesheim University, Zwolle, the Netherlands

Abstract

Compassion unites people during times of suffering and distress. Unfortunately, compassion cannot take away suffering.Why then, is compassion
important for people who suffer? Nurses work in a domain where human
suffering is evidently present. In order to give meaning to compassion in
the domain of professional care, it is necessary to describe what compassion is. The purpose of this paper is to explore questions and contradictions in the debate on compassion related to nursing care. The paper
reviews classical philosophers as well as contemporary scientists main
arguments on compassion. First, I will examine the relationship between
compassion and suffering. Second, how does one recognize serious
suffering? This issue raises questions about the role of imagination
and the need for identification. Third, literature describes compassion as an emotion. Some philosophers consider emotions uncontrollable
feelings; others see a clear rational dimension in emotions. In order to
determine what compassion is, it is necessary to weigh these contradictional arguments. Fourth, I will discuss motives for compassion. Is compassion an act of altruism or egoism? In this debate Nietzsche and
Schopenhauer are well-known opponents. Today, analysis of their arguments leads to some surprising conclusions. Fifth, there is the issue of fault
and compassion. Can we only feel compassionate when people who suffer
are not to blame for their own suffering? Such a condition faces professional caretakers with a dilemma which needs a thorough analysis if
compassion is to be of use in the field of professional care. Finally, I will
explore the moral meaning of compassion. Compassion, described as a
concept with cognitive as well as affective dimensions, also has volitional
and behavioural aspects. These aspects specifically are of importance to
nursing care and further research of compassion in the nursing domain.

Correspondence: Mrs Margreet van der Cingel, Senior Lecturer, School of Healthcare, Windesheim University, Campus 2-6, 8000 GB
Zwolle, the Netherlands. Tel.: + 31 38 4 699 546; e-mail: margreetvandercingel@chello.nl; cjm.vander.cingel@windesheim.nl
This paper was written for a PhD thesis under the supervision of Prof. Dr L.M. Huijer. It was previously published in Dutch: van der
Cingel M. (2008) Compassie als antwoord op leed. Een verkenning naar compassie in het domein zorg. Algemeen Nederlands Tijdschrift
voor Wijsbegeerte, 100(2), 103120.

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Compassion and Professional Care

Keywords: compassion,
acknowledgement.

Introduction
Compassion is a valuable phenomenon which unites
people during times of suffering and distress. When
serious events, such as threats to health occur, it is
comforting to perceive that others share feelings
of concern. Unfortunately, compassion cannot take
away suffering. Why, then, is compassion important
for people who suffer?
Compassion is being described as a form of love
that needs critical reflection, but nevertheless has an
enormous power to humanize (Baart, 2006, p. 22).1 If
this statement is correct, then questions about compassion are specifically relevant for health care. The
goals of healthcare organizations as well as professional goals of healthcare workers evidently are
humane by nature. But during sickness and health
problems, hope is focussed on taking away suffering.
Dramatic improvements in medicine during past
decades increase expectations (Van Heijst, 2005, p.
21). Yet there is a lot of suffering that cannot be taken
away. Disabilities, chronic illnesses, loss of loved ones
all these are forms of suffering that cannot be cured
by healthcare professionals. Nurses, in particular, see
this kind of suffering because of the nature of their
work. The main characteristic of nursing is to offer
care when the consequences of health problems arise.
The nurses role is to be near to another person in
distress (Higgs & Titchen, 2001). Such a role description involves an obligation to humanity. Because of
this obligation the concept of compassion is highly
relevant for nursing.
The purpose of this paper is to explore questions
and contradictions in the philosophical debate on

nursing,

suffering,

emotion,

moral,

compassion related to nursing care.2 The paper

reviews classical philosophers as well as contemporary scientists main arguments on compassion in
order to explore the nature of compassion. When
compassion is studied, there are some specific issues
that compel attention.3 First, compassion is closely
related to suffering.4 Second, there is the question of
what is needed to feel compassion. Third, literature
describes compassion as an emotion or passion with
a cognitive aspect. Fourth, I will discuss motives for
compassion. The fifth issue is about the conditions of
compassion, followed by the sixth which explores the
moral significance of compassion. Finally, I will
address questions regarding the status of compassion
in nursing care which are also relevant for further
research and debate. The conclusion of the paper will
present a reflection on these six issues which form the
nature of compassion. Compassion can hence be recognized as a construct which can be distinguished
from concepts such as sympathy, empathy and pity by
its specific conditions and components.
2

The study focuses on the role of compassion in the nursing care

knowledge domain. In the second phase of the study the

research population will be limited to nurses who care for older
people with chronic illnesses (chronic obstructive pulmonary
diseases and rheumatic diseases) and their patients because the
author believes compassion specifically relevant for these groups
of patients.
3

For this review on compassion, literature is found in the follow-

ing databases: Academic Search Elite, Cinahl (Cumulative Index

of Nursing and Allied Health), Pre-Cinahl, Philosophers Index
and Medline.
4

Almost all philosophers describe suffering as a condition to

compassion. Duyndam is an exception; he wants to use the word

compassion in a neutral way. Compassion can relate to negative

Baart developed a theory of presence, in which attentiveness

as well as positive emotions (Duyndam, 2001, p. 18; Roeser &

and presence of healthcare workers in caretaking situations are

Willemsen, 2002, p. 61) suggest that the meaning of compassion

the central themes.

can be to feel joyful with as well.

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Margreet van der Cingel

Compassion and suffering

Many definitions of compassion originate from
Aristotelian virtue and justice theories, Christianphilosophical and Buddhist traditions and Ethics of
care theories. In these traditions suffering is considered to be the trigger for compassion.
What is suffering? Aristoteles (2004, 86a613) gives
a summary list: painful and destructive evils such as
death, physical injuries and disorders, old age, diseases, food deficiency, repeated disasters and also
having no friends. Nowadays, we still recognize this
kind of suffering. The consequences of old age are
very visible in our society, despite or sometimes
even thanks to spectacular life-prolonging medical
advancements. Old age in itself can cause suffering.
The risk of undernutrition for example heightens
the vulnerability of older people (de Groot & van
Staveren, 2002). As Aristoteles mentioned, suffering
consists also of the absence of friends. Depression
related to loneliness is an increasing problem in our
contemporary world (Adams et al., 2004). Aristoteles
list illustrates that suffering can exist in several
modes; it concerns for example physical, psychological and socially determined suffering (Tudor, 2001, pp.
1144).5
In case of health being compromised, then inevitably there is loss. The size of this loss indicates more
or less the seriousness of suffering.6 That is not to say
everyone perceives a loss alike or that the more
serious the suffering the more compassion is needed.
Of course, to bid life farewell when one has been

diagnosed with a deadly disease is the extreme situation in which compassion may be offered to the one
having the disease as well as his or her loved ones.
Suffering of this kind is closely related to an
approaching death. But the notion of the loss of
intellectual capacity in the first stage of Alzheimers
disease can also evoke severe suffering for the one to
whom it happens, and all stages of Alzheimer can
evoke suffering for family and near ones, even
though it does not necessarily lead to immediate
death.
One cannot weigh situations of serious suffering by
crude comparison: suffering is not something to
measure. On the other hand, it is of importance to
distinguish serious suffering from accidental trouble.
To sprain an ankle is inconvenient, but nevertheless
involves what is merely a temporary loss of possibilities.7 Without a distinction being drawn between an
awkward situation and serious suffering, the significance of compassion would be lost (Tudor, 2001,
p. 14).
From an Aristotelian perspective, suffering is,
besides a negative experience, also an event. Fate is
unpredictable. In everyday life events are only predictable to a certain extent, despite increasing knowledge about the origins of diseases and the predictors
of a healthy life. It is still possible to fall out of bed
and end up with a hip fracture, or to suddenly be
confronted with a disease. As a consequence of events
like that, physical reactions such as pain,8 and emo7

We sympathize with that but we do not specifically need to have

compassion for such an event because it is not to be compared

5

Since the scope of my research on compassion is limited to

with long-lasting losses. Sympathy refers to a concept very close

patient sample groups of older people with chronic diseases I

to compassion but is distinguished from it because of its refer-

will mostly use examples referring to this group of patients to

ence to temporary and therefore less dramatic events (Snow,

illustrate statements or arguments. That is not to say that, in this

1991, p. 197).

particular argument on the modes on suffering, suffering has no

other kinds of variations, e.g. suffering due to psychiatric ill-

awkward events while pain, as a physical reaction, is part of that

nesses or due to other specific issues such as guilt or shame. For

collection. Pain is the experience of an unpleasant feeling which

extended referees on suffering see for example Tudor (2001) and

refers to possible or actual damage to a part of the human body

Welie (1998).

(International Classification of Functioning, Disability and

When discussing the size of the loss one should not think in

Health, World Health Organisation, 2002, p. 68). Besides being a

terms of quantity but in terms of differentiating between kinds of

physical reaction, pain also is what someone says it is and has

loss and their consequences, the main differentiating aspect

impact on all dimensions of the quality of human life (Ferrel,

being the temporary or permanent character of a loss.

2005, p. 84).

Pain and suffering are distinct. Suffering is a collection of

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Compassion and Professional Care

tions such as anger, fear and sorrow occur. Compassion therefore, is also described as pain, sorrow or
grief for someone else (Snow, 1991, pp. 195197).9 To
think that a loved person is suffering is hard to
endure. It is difficult to comprehend compassion
without the notion of grief, according to Nussbaum
(2001, p. 590). But there is more to that. Besides grief,
sorrow, pain and anger also are intelligible emotions
for those who suffer. Also the reactions and emotions
of the sufferer and the onlooker are not necessarily
the same.10
In short, as a consequence of an unpredictable
event suffering causes limitations or even loss of possibilities. When a loss is permanent, compassion is a
relevant response.

Compassion and identification

What is needed to feel compassion? Many philosophers suggest identification, empathy11 and imagination as preliminary conditions. They differ in their
views on what way or how far these concepts are
conditional. British moralists of the 18th century such
as Hume and Adam Smith considered the human
9

Grief is differentiated from sorrow by the notion that grief

needs the thought that the object of the emotion is dead (Snow,
1991, p. 196). In accepting this definition of grief Nussbaums
claim is too narrow. When grief is accepted as the concept that
arises in several modes of loss her claim is valid. Nussbaum
(2001, p. 81) herself does not differentiate between sorrow and
grief; she does state grief to be a process that can reduce sorrow
or at least make it manageable.

being and his or her feelings as a black box only

accessible to the individual itself. From their point of
view, imagination has to be a necessity (Welie, 1995,
p. 479). Imagination in this case signifies: pretending
the event is happening to you rather than to the one
suffering. According to Schopenhauer, identification,
to its utmost extremity, is vital. Although it will never
be possible to feel exactly what the other person feels,
compassion comprehends feeling with the other
person in a metaphysical way (Schopenhauer, 1840,
pp. 131144). This aspect of feeling with the other
person comprehends the affective component of compassion (Scott, 2000, p. 126).
To suggest that imagination is a conditional feature
necessary to understand the other persons feelings
seems logical. Imagination is a necessity in order to
recognize human vulnerability as a general phenomenon. This is what Nussbaum (2001, pp. 315321), the
American classicist and philosopher, calls the eudaimonistic argument12 for compassion. When I am not
able to recognize what suffering would mean for
myself, how can I know the significance of suffering at
all? Yet there is a danger of losing a crucial element of
compassion by such a self-reflexive conception. That
feature of compassion is to be focussed on the other
person instead of being focussed on yourself. Imagination can be of use in very different ways. To de-self
oneself is a phrase applicable to the kind of imagination one would need for compassion.13 The more one
is able to de-self oneself the more one is able to
appreciate things in life that are not important to you
but are important to the other person. The less I am
able to de-self myself, the more my own interests
come first. Too much identification has the tendency

10

A group of scientists are currently looking for a physiological

explanation of compassion. In these theories compassion is lit-

12

erally evoked when pain and suffering and their non-verbal

has the same opportunity to come across trouble. When fate can

outings are observed. The person feeling compassion is imitating

strike all of us we are motivated to help each other and do good.

the person suffering in a reflex. In this interpretation the emo-

The concept Eudaimonia as an ethical doctrine is developed by

tions of the observer and the sufferer are the same (Schulz et al.,

Aristote. Eudaimonism is the perseverance of a good soul; eu

2007, p. 9). Not every theorist refers to this phenomenon as being

meaning good and daimon meaning soul in Greek.

compassion, Morse & Mitcham (1997, pp. 649656) introduce the

13

concept of compathy for this phenomenon.

de-selving based on the works of Iris Murdoch. To de-self

11

Clearly empathy is another concept from compassion. Never-

oneself refers somehow to letting go of your own values. The

theless, in many theories empathy is related to compassion as a

person whos observing well and in one way or another aban-

precondition for compassion.

dons his or herself will also act well.

The eudaimonistic argument refers to the idea that everyone

Roeser & Willemsen (2002, p. 62) introduce this concept of

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Margreet van der Cingel

to deteriorate and will not lead to compassion at all

(Roeser & Willemsen, 2002, pp. 6064). In psychoanalytical theories this phenomenon is known as projection and considered contradictory to empathy or
compassion (Duyndam, 1997, pp. 175178; Richmond,
2004, pp. 249250).14
When I try to imagine the significance of a certain
loss as if it would happen to me, then my values are
leading. But compassion is not about the interest I
take in certain needs or opportunities in life. The
interest of the person losing these is the issue. It is
easy to feel compassion when certain interests are
valued in the same way.When I like spicy food it is not
so hard to imagine how difficult it is to follow the
therapeutic regimen of a no-salt diet, for example. But
when one values interests differently, it is harder to
feel compassion. Compassion asks one to temporarily
set aside ones own values. In order to do that, the
capacity to distinguish between oneself and the other
person is needed. Because of that one can recognize
the interests of others (Welie, 1998, p. 111), contrary to
what, for example, Hume thought to be true. Keeping
a distance, in order to distinguish, therefore, is a necessary condition for compassion.
The next step in recognizing the seriousness of suffering is information. Sometimes the information will
be clear enough. When parents lose their child, for
example, few people will doubt the suffering of those
parents. The seriousness of a situation like that will
provide enough proof to validate compassion. In
other situations though, you will need more information. One needs to see what is salient (Pask, 2001, p.
42). One needs to know the significance of the loss as
the other person sees it. Without specific information
this is a troublesome task because of the subjective
meaning of a loss to someone. When you are not
aware of the important role a specific pet has for the
lonely widower who has to move to a nursing home,
for instance, you are also not able to see his fear of
leaving the pet behind. That is why one needs to give
14

Both Richmond and Duyndam use the same example of Anna

Freud (psychiatrist and daughter of Sigmund Freud) to illustrate

the sufferer time in order to better understand personal interests (Housset, 2007). If the value of a loss
or the threat of loss is unknown, the suffering because
of it can be invisible. On top of that there is a risk of
interpreting signals wrongly. A refusal to move into
the nursing home, for example, could be seen as stubbornness of the afore-mentioned widower. To feel
compassion means to read the other person without
imposing ones own interpretation (Teuber, 1982, pp.
225227).15
So do we not need to feel personally attached in
order to act with empathy? When compassion for
someone specifically starts with recognizing the significance of a loss to someone, it seems reasonable
enough to state some sort of a relationship is needed
in order to get this kind of personal information. One
needs to be subjective up to a certain level, in order to
see what is of relevance for the other person. Personal
attachment helps in identifying precisely when compassion is needed (Blum, 1980a, p. 78). On the other
hand, personal attachment can get in the way of
showing emotions for example, when the sufferer
wants to spare a loved one his or her feelings of grief.
In that case, a distant professional can be more of
help. Either way, keeping your distance or having a
personal attachment both have their pitfalls. Too
much compassion can end up in self-sacrifice, and too
little in neglect. You need to navigate between being
close enough in order to see what is really of importance and keeping ones own perspective in order to
let go of ones own opinions (Carse, 2005, p. 184).
Compassion is not about simply imagining how it
would be if something may happen to you. Compassion is not about ones own life after all; it is the other
persons life that is at stake.

The emotion compassion

Compassion is an emotion. Emotions are also called
passions. The word passion refers to a strong feeling
and suggests something from which it is most difficult
to escape. An emotion has an object, and is focussed

projective identification. A childless governess imagines living

the life of her friends to whose children she is very dedicated.

15

The example shows that projection does not lead to compassion.

a starting point for reflections on compassion.

Teuber is a philosopher who took the work of Simone Weil as

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Compassion and Professional Care

on something or someone (Solomon, 1980, pp. 251

253). The object of compassion is the other person in
his or her awkward situation. The thoughts you have
on the suffering of someone else support the emotion
(Peters, 1973, p. 73).
Opinions about emotions are very diverse in philosophic debates. According to stoic and rationalistic
views, emotions are unrestrained forces or physiological irregularities. From that point of view, the origin of
compassion is a primitive and instinctive response
(Taylor, 1999, p. 83). Although you can find remnants
of this opinion in contemporary views on emotions,
scientists today develop different theories explanatory of emotion. For example, there are scientists who
are researching emotions physiologically. Experimental studies suggest the possibility of a biological mirroring process in the neural system of the brain when
people react to emotions of others (Schulz et al., 2007,
p. 9). But most theories about emotions recognize
a cognitive, affective, volitional and/or behavioural
aspect (Charland, 1997, pp. 557562). In everyday life,
emotions and feelings are often considered the same,
whereas in literature there is a clear distinction. A
feeling is a physical experience. An emotion is of a
more complex nature, a phenomenon steered by
thoughts. A feeling can be something like an awkward
sensation in ones stomach for example. A conclusion
can be that it is nausea caused by specific medication.
In that case one is not being emotional, one is simply
being sick.A feeling caused by something physical can
of course lead towards rational conclusions but will
always be a physical state of being. In the case of
emotions this is different; one will not find a physical
cause.Another cause of the nausea could be fear of an
operation. In that case the thought of the operation
is determining what is going on; fear is causing
the nausea. Without a thought there is no emotion
because without the thought the emotion will disappear (Nussbaum, 2001, pp. 2930). If fearing the operation proves completely unnecessary, because nobody
ever died from the procedure, for example, the specific
fear for dying because of the operation will disappear.
Of course it is still possible that other thoughts supply
the reasons for fear.That is why it is necessary to verify
the thought that evokes the emotion. The verification
is also needed in order to understand the emotion

because emotions do have a narrative structure

(Deigh, 2004, p. 466).16 Fear, in this example, has a
personal history; there is a story to it that can cause
unrealistic thoughts that influence the emotion. When
it is hard for one to have faith in the ability of others,
one will probably hold on to the thought that the
operation will go wrong even though all the statistics
prove otherwise. This mechanism of holding on to
unrealistic thoughts explains why emotions are sometimes considered unreliable. Although this concerns
specific thoughts, in ordinary life people tend to speak
of such thought as feelings, especially when these
thoughts are still in the unconscious.
So in order to feel compassion, one has to have a
specific thought. Just to witness suffering, without the
thought that suffering is a terrible thing, is not
enough. That is why not every healthcare professional
will have compassion when confronted with suffering,
even though suffering is present from an objective
point of view.
Besides compassion, suffering can evoke other
emotions such as fright or disgust. These emotions
can occur simultaneously with compassion or even
prevent it. Misery can be very confronting when it is
explicitly visible (Hamblet, 2003, pp. 363364). The
person seeing a serious bedsore wound for the first
time, for instance, might wish he had never seen it.This
also shows specific thoughts are needed to have
specific emotions. To think is not a straightforward
process so it is possible more than one thought
mingles with another thought.These mingled thoughts
blur the sight so to speak (Blum, 1980a, pp. 7583).
Within the construct that compassion is, the knowledge of suffering that cannot be ignored is an important feature to distinguish the emotion compassion.

Motives for compassion

Stated that compassion is an emotion of which the
leading thought is that a person suffering is a terrible
16

Emotions tend to have a storytelling character, a personal

history. Several authors (Peters, Nussbaum, Deigh, Richmond)

refer to the emotional development in early childhood which
determines the origin of an emotion and which can still influence
the perception of events in adult life.

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Margreet van der Cingel

thing, we then need to answer the question of how this

particular thought comes into being. What is compassions motive? To retain a thought needs more than
just the passing of that thought. The structural thinking patterns are supported by ones value system.
Socio-cultural aspects influence emotions and views
on emotions (Solomon, 1980, pp. 276277).This is true
for philosophers as well. Assumptions often express
themselves in language. Using specific words can
betray specific opinions. A philosopher speaking of
the individual will think human autonomy an important value. An author using the word agent will
emphasize human behaviour as an important feature.
Within the debate on compassion, witness, onlooker,
individual, agent and person are being used to indicate the one that feels compassion. The one who is
object of compassion is often simply indicated as the
other, although the aspect of suffering sometimes
explicitly comes forward when sufferer is used
(Tudor, 2001). These indicators emphasize the different starting positions that play a role in the judgements on compassion as a human phenomenon. A
perspective in which autonomy, individuality and free
will are seen as the most important human values will
evaluate suffering differently from a perspective in
which relationships and human solidarity are central
issues (Snow, 1991, p. 200). Even the choice of using
the word compassion is not neutral, for that matter.
The prefix com expresses togetherness. Compassion
is, semantically, a concept inextricably bound up with
human relationships. Choices made for other words
closely related to compassion have meanings that
emphasize different aspects of the concept or even
express different concepts altogether. Pity, empathy
and sympathy have a different tone and meaning in
everyday conversations. One often-discussed distinction concerning motives of compassion is altruism
versus egoism. Schopenhauer is outspoken on compassion as an image of goodness. He sees compassion
as a counterpart of evil and as an absence of egoism.
This corresponds with views that consider compassion
to be a virtue (Mannion, 2002, pp. 9597). As a virtue
compassion has the same ring of goodness as empathy
and sympathy have and therefore rules out pity.
Nietzsches legacy on compassion is completely the
opposite and does indeed include pity and its negative

associations (Cartwright, 1988, pp. 560562).17 In his

opinion compassion has an egoistic motive because
the one who is supposed to suffer with is ultimately
looking for relief of his or her own pain. On top of
that, vanity is in the game, because doing good places
someone in a good light (Nietzsche, 1881, pp. 1617,
6970, 8388).18 Thinkers who relish the rationalistic
and Kantian tradition also do not like the idea of
compassion as a virtue. The Kantian line of thought
does not have room for altruism at all because only
rationality and duty are considered to be the foundation of morality.To take responsibility is valued highly
in this philosophy. Compassion is more or less a duty
to learn from each others fate, much more than primarily focussed on the relief of suffering. Compassion, in this view, stands in the way of exercising the
human capacity to bend fate in a positive way and can
turn someone into a victim (Smith, 2005, pp. 7687).
The question is what position does one take
towards another person suffering, when one clearly is
not the one suffering? How does the nurse has to
relate to the sufferer? Such a relationship inevitably is

17

Schopenhauer as well as Nietzsche use the word Mitleid in

their own language. In some translations Nietzsches Mitleid is

translated into pity and Schopenhauers Mitleid into compassion. The philosopher Cartwright (1988) made an analysis of the
demotic use of terms for compassion. His conclusion is that both
philosophers were discussing a different emotion. True, both
emotions are about the suffering of another person, but there the
comparison stops. Cartwright states the possibility that it was
Nietzsches intention to prove that altruism does not exist.
According to Cartwright Nietzsche did not succeed in this and
has solely proven that there can be pity in cases where compassion is possible.
18

In this context the analysis of Richmond (2004) is interesting.

She uses the theories of the psychoanalytic Melanie Klein to

bridge the gap between Nietzsches and Schopenhauers conflict.
She relates to the developmental stages of a child which influence the ability to distinguish ones own emotions of those of
another person. In a healthy development empathy can be used
as a human ability, while an unhealthy development inhibits this.
In this light Nietzsches pity is an outing of obstructed development while Schopenhauers explanation of compassion shows a
healthy development.

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Compassion and Professional Care

an unequal one. A healthy person does have more

chances to socialize than the person who is chronically ill and in pain. The horizon of suffering people is
a much more narrow one than that of those who can
live their lives as they want to. Unfortunately, an
unequal relationship can deteriorate into abuse of
power. One can feel heightened above the other
person because by feeling compassionate one does
the right thing. When inequality is the starting point,
compassion very quickly becomes an act of egoism.
But establishing the possible danger of egoism to
come forward in an unequal human relation does not
validate egoism as the one and only motive for compassion. This is also true for the argument that compassion can enhance ones position as a good human
being and therefore the longing for this position
becomes the one and only motive. This does not,
however, validate a causal relationship between compassion and vanity. There merely is a possibility of
becoming vain. Finally, to claim that compassion can
victimize people who suffer also has the same
inequality as a starting point. Of course there are
people who take advantage of their suffering position. But that is not to say that everyone who sincerely
evokes compassion is abusing this position. After all,
it is only natural that people who find themselves
in difficult circumstances want to improve their
situation.
It is people who give meaning to compassion, and
people have egoistic as well as altruistic motives. No
doubt, there are people who shape their human relationships out of egoism. Such relationships however,
do not include a very important feature of compassion. This feature is ones availability for the person
suffering simply because of the fact the other person
is suffering (Walsh-Frank, 1996). Compassion includes wanting the best for the one suffering; otherwise, it is not compassion we are speaking of. Also, it
is evident that ones own interests can exist besides
interests of others. Compassion is not about choosing
for oneself at the expense of choosing for someone
else. The other way around, compassion also is not
about choosing for the other at the cost of oneself
(Blum, 1980b, p. 512, 514). Compassion does not
involve that sort of dilemma. The other person suffering is already the one in the worst position.

Conditions on compassion
Are there conditions on compassion? As stated
before a certain seriousness of suffering turns out to
be necessary, as well as the necessity of being susceptible to the specific meaning of a loss. Also a specific
thought is needed and we found compassion only to
be genuine when the interest of the one suffering
comes first. So there would seem to be conditions on
compassion.
The philosopher Nussbaum claims the existence of
yet another condition. She explicitly states an undeserved fate to be necessary for feeling compassion.
Except for situations in which fate hits out of proportion, she claims there can only be compassion when
suffering is undeserved; otherwise, it is just not the
right emotion (Nussbaum, 1996, pp. 33; 2001, pp. 311
315).19 An undeserved fate implies that there can also
be such a thing as a deserved fate. Philosophers who
argue from justice theory will assume this condition to
be almost self-evident.20 Remarkably, philosophers
who have seriously studied compassion, such as
Schopenhauer or the contemporary philosophers
Tudor and Duyndam, hardly mention this condition.
A confrontation with fate is a feature of the sufferers perspective. If so, it matters what ones opinion
about fate is. In views on life the question of guilt
implicitly comes up for discussion. A view on life in
which something or someone (God, a higher power,
fate as stupid bad luck, insufficient knowledge about a
certain disease) is influencing circumstances will deny
the possibility of guilt. The view in which feasibility
has the upper hand will possibly in a somewhat easier
way lead towards self-reproach. Dilemmas such as
choices to be made in prenatal surveys focus on that.
19

Nussbaum (2001, pp. 364368, 397, 446) distinguishes compas-

sion from mercy. When one is not guilty of ones own suffering
compassion is the correct term; otherwise, mercy is in order.
20

Also Deigh (2004, pp. 468471), for example, does not question

suffering to be undeserved. He does, however, distinguish two

types of compassion, moral and non-moral compassion, the first
being a concept in which emotional conflict is present which
needs to be addressed with justice, the second being a phenomenon in which imagining the same emotion as the person suffering is present.

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131

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Margreet van der Cingel

Does a pregnant woman who accepts the risk of

amniocentesis blame herself when a miscarriage
occurs? In a view which holds human beings themselves primarily responsible for their own choices the
thought of what if? is almost inevitable. It influences
perception if one feels responsible for a situation in
which suffering occurs. Reactions to suffering encompass different kinds of emotions. These emotions can
evoke and obstruct compassion. Guilt or shame about
ones own role in suffering one can think of patients
who have venereal diseases for example defines a
different kind of behaviour than behaviour of patients
who are afraid of pain because of a less emotionally
charged illness. It then becomes clear that compassion
needs susceptibility of the one who is object of compassion as well. If suffering is felt as an injustice, compassion validates that injustice. If one feels suffering is
a just cause because of ones own mistake, compassion will be felt as invalid.21
Still, it is possible to recognize ones responsibility
for choices made and at the same time feel compassion. In other words, the recognition of responsibility
and compassion are two different matters which can
nevertheless coexist (Weber, 2004, p. 492). One who
thinks suffering to be meaningful in terms of penance
for guilt will put this question of suffering being
deserved or undeserved forward. But this question
has no relevance when it comes to compassion. Compassion does not need to be based on judgements of
right or wrong because there is no (moral) dilemma.22
To be responsible for a possibly deserved suffering is
a matter of forgiving oneself. It is when damage is
being done to another that jurisdiction is needed.That
is the place where choices of justice in true dilemmas
belong. Compassion is no such judgement, and certainly not when care is involved. There is no need for
21

This is not to say it is the responsibility of the sufferer to evoke

compassion. The philosopher Weber (2004, pp. 497498) therefore distinguishes an intrinsic and an extrinsic rule. Someone can

forgiveness; on the contrary, it is absolutely necessary

to withhold ones judgement and to rank the interest
of the sufferer first. Compassion encompasses tolerance in particular (Carr, 1999, pp. 422423).
This view is supported by the professional ethics of
health care which prescribes the right of equal treatment to everyone who needs care (International
Council of Nurses, 2005). It is a fundamental principle
in health care to perform justice in that way. Solely
by withholding ones judgement one can guarantee
this equal treatment. It comprehends unconditional
access to everything that encompasses professional
care. If compassion is to be acknowledged as an
important aspect of the concept of care, compassion
needs to be unconditionally available towards everyone who suffers. Nussbaums condition violates this
rule and puts healthcare professionals in an awkward
position. Therefore, it is better to claim that suffering
has no meaning (Tudor, 2001, pp. 16, 3444).23 When
suffering has no meaning, the question of guilt is irrelevant. Also, the practical consequence of Nussbaums
condition would mean there would not be a lot of
compassion if the determination of when compassion
is needed were to be dependent on the innocence of
ones own suffering (Fritz Cates, 2003, pp. 336338).24

The moral significance of compassion

Compassion is a construct. Besides the affective and
cognitive aspects of compassion there also is a volitional aspect (Carr, 1999, pp. 413414). Compassion is
a deliberate process of making a decision (Fritz Cates,
1997, pp. 178188). But can you choose to be compassionate? This seems contradictory. However, decisions can also be made, besides step by step, on the
spur of the moment. Expert healthcare professionals
recognize these decisions as clinical judgements. A
glance will tell them there is something wrong with a
patient. This clinical judgement seems to be a feeling

feel guilty despite the fact there is, morally and objectively
speaking, no guilt involved, and vice versa.

23

22

fering is intrinsically useless.

egoism; one does not have to choose between the interest of

24

oneself and another person, nor between someone guilty or

These traditions can also be found in nursing history which is

not-guilty.

grounded in caritas.

The same argument is valid to object against the reproach of

Tudor refers to Levinas line of thought which states that suf-

Fritz-Cates refers to Christian as well as Buddhistic tradition.

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Compassion and Professional Care

but actually is a very rapid interpretation of signs and

symptoms they recognize because of their long expertise (Cioffi, 1997, pp. 204205). Continuous reflection
on specific experiences, feelings and thoughts eventually lead to these snap decisions. It is a rational
process of practising in order to recognize signs and
symptoms which develops susceptibility for the decision that there is something wrong. The same is true
for compassion. We therefore can speak of practising
compassion.
If we state compassion to be a decision, what choice
is there to make? As stated before, compassion
expresses the knowing of suffering. What purpose
does compassion have if this knowledge is not made
clear to the person suffering? Compassion gives an
answer to suffering by acknowledging it.Acknowledgment of suffering gives us a choice of acting and
behaving in such a way that it is evident we want the
suffering to end. It is necessary to show acknowledgement in a clear and visible way. This can be verbally or
non-verbally, in being present or in taking actions
the precise manner in which compassion is showed is
not that important. Not to show acknowledgment
means suffering is being ignored, the loss being of no
importance. When the loss is of no importance, the
value of what is lost, health for example, is also being
denied. To show acknowledgment of suffering, on the
other hand, means assent to the fact that suffering
may exist and be visible because something of value is
been lost. So there is a choice: to acknowledge or to
deny suffering.
This choice places compassion in a moral order.
Compassion helps another person by answering emotions such as anger, anxiety, sorrow and grief that
come into being as a consequence of suffering. Suffering does not disappear because of compassion; it is
not a matter of taking over a part of the suffering.
Suffering will exist more than ever when compassion
has made it visible, but it also shows the other person
is not left alone (Duyndam, 1997, pp. 166167). This is
the right answer when suffering cannot be cured.
Compassion does set the standard (Fritz Cates (2003,
pp. 338). By showing compassion, the wish to be with
someone in ones misery becomes clear. This argument is morally preferable to that which involves
actions undertaken out of mere duty, as in the

Kantian line of thought (Sytsma, 1997, pp. 583585).25

In that perspective, emotions as a motive for moral
action would be unreliable. To give an addict money
for drugs out of compassion is example of that. Ones
capacity to overcome misery is not being addressed
(Smith, 2005, p. 85). There is another explanation
though. Not to show compassion adds suffering on
top of the suffering that already exists. Denial of suffering means the creation of more harm.26 Because
there is nothing worse than remaining invisible in
ones pain, sorrow, anxiety or anger. It means a discouragement to bear the suffering. If suffering does
not exist, then where does one find the strength to
bear it? Compassion therefore offers comfort.27 It is
comforting to know one is not alone. Compassion
shows that a loss is terrible, that suffering is visible
and one is not left alone.

Compassion and nursing care

There are several healthcare scientists who take part
in a debate of ethical and philosophical nature on
compassion. This debate explicitly relates compassion
to a moral dimension of care. Care ethics and feminist
theories such as those of Tronto and Held28 have
influenced the domain of health care. Therefore, the
importance of emotions concerning moral questions
in health care is much more recognized. Emotions can
help focus moral actions of healthcare professionals.
25

Incidentally, Weber (2003) and Sytsma do not interprete Kants

claims to be a condemnation of compassion.

26

Tudor (2001, pp. 1143) thinks to neglect someone or to with-

hold care are examples of, what he calls, moral suffering.

27

Murdoch (1970, p. 87) and Baart (Nuy/Baart, 2006, p. 23)

emphasize comfort or consolation as a consequence of compassion. Murdoch uses the word consolation in the context of
striving for goodness. Baart states that compassion is comforting
because of the social contact during times of suffering. The need
to comfort can also evoke from other emotions. Powerlessness
for example can evoke a wish to do something. Therefore, acting,
helping and comforting often are used synonymously.
28

Held (2006, pp. 4448) puts moral worth of human relation-

ships central to her theory of care ethics (including the virtue

compassion). Trontos (1993, p. 103) view describes care as a
moral concept which sustains life.

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Margreet van der Cingel

Compassion offers the opportunity to acknowledge

suffering and is therefore means to an end as such.
Does this mean compassion should explicitly be
included in concepts of care?
The nurse, being a healthcare professional, has a
position towards the suffering other. The role of the
nurse is a socially sanctioned role that aims to
enhance the health and well-being of others. In the
role of the nurse, striving for good and a moral dimension is found (Scott, 2000, pp. 124127). On top of that,
nurses have the chance to give voice to pain and
suffering, because of this role (Ferrel, 2005, p. 86).
Compassion is a motive for many healthcare workers.29 They are motivated to do their job because
they know suffering exists and they want to do something about it. Implicitly, compassion is woven into
concepts of care (Von Dietze & Orb, 2000, p. 166).
Concepts such as empathy and altruism which are, as
we have seen, strongly connected to compassion, are
being mentioned as features of the professional
conduct of healthcare professionals (de Boer-van
Ommen et al., 2007, p. 230). Nursing theories all
emphasize the importance of the relationship
between nurse and patient as being a condition for
good quality of care (Hem & Heggen, 2004, p. 20).
Nevertheless, compassion as a concept is hardly found
in nursing or care theories (Schantz, 2007, pp. 4952).
So how does compassion define the specific relationship between a patient and a nurse? This relationship is defined by a request for help and support. In
that way it surely fulfils the need of the nurse to want
to do something. The professional can give a place
to a form of general compassion in her day-to-day
working environment. But specific compassion, as we
have seen, needs more than that. Compassion needs
to be embedded in a relationship that is unequal but
at the same time includes mutual worth; the relationship needs the balance between professional distance
and being close as well. Compassion means setting
aside ones own interests, values and judgements and
not giving judgement on the possible guiltiness of
suffering. Compassion does require a great deal from
professionals. Compassion asks them to make a

choice to acknowledge the suffering of others. That

choice starts by seeing the other person truly.
Although nurses ask many questions, these questions are not primarily focussed on building a relationship with patients in which compassion is the
central issue. These questions are focussed on the
assessment of health and health-related problems.
There is no explicit formal order to offer compassion
by a way of an answer to a request for help.30 Still,
nurses see intrinsic value in their work, specifically
when they show compassion (Pask, 2003, p. 170).
Patients also think highly of aspects of care such
as personal attention, an individual and human
approach and help in showing emotions. These
aspects are considered criteria for good quality of
nursing care and the moral competence in nursing
practice (Jormsri et al., 2005, pp. 583590).31 To
patients it is of importance that suffering is known. So
the question remains as to how compassion in nursing
practice is shown, for nurses as well as for patients.
Questions such as these need to be researched if compassion is to be seen as an acknowledgement of suffering. Compassion deserves to have its place in care
practices.

Conclusion
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 ones
own perspective. This is troublesome when the relevant perspective is remote from ones own experience and ideas. If the interest of the other person is
put first, compassion is an altruistic emotion. Imagi30

Recently (2001) the Norwegian Council of Nurses included

compassion in their code of ethics. Nevertheless, several studies

show nursing practice lagging behind on statements of this kind.
Compassion does not serve as a rule (Pask, 2001, p. 43, 47; Hem
& Heggen, 2004, pp. 1928).
31

Jormsri et al. (2005) based her theoretical premises on the

29

several aspects, rules and components that form the Buddhist

Rognstad (2004).

definition of compassion.

See the studies of Collings (1997), Rheaume et al. (2003) and

2009 The author. Journal compilation 2009 Blackwell Publishing Ltd Nursing Philosophy (2009), 10, pp. 124136

Compassion and Professional Care

nation and reflection are the means to an end, for that

matter. They help to develop susceptibility for the
other persons perspective. This is what we call the
affective aspect of compassion. Compassion is also
defined by the specific thought that suffering is terrible. This is what we call the cognitive aspect.
Further, compassion is unconditionally valid for
everyone suffering because there is no dilemma in
which we need to choose between oneself and
another or between people. 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.
Compassion turns out to be a complex phenomenon. Compassion is a process in which thinking as
well as feeling takes place and can evoke conscious as
well as unconscious choices. This is complicated to
experience, certainly when other emotions are also
present. Still, compassion can be distinguished by
other emotions because of the comfort it offers. In
what seems a paradox, compassion offers comfort
precisely because it makes suffering explicitly visible.
This visibility makes very clear to the sufferer that
one is not alone.
Therefore, compassion is of worth for professionals
in a domain that has the removal or amelioration of
suffering as its purpose, but is indispensable in a practice of care where suffering exists.

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