COMPASSIONATE LOVE

Compassionate love describes attitudes toward and service for others, motivated by a desire for the good of the other. It includes caring for, valuing, and respecting the person so loved. The combination of the two words "compassionate" and "love" highlights features in both words: this combination describes sympathy towards the other, in a way that is caring, respectful, and appropriately emotionally engaged, which leads to appropriate action in service of the other person. Compassionate love can operate through the relief of suffering, but also through acknowledging life's full possibilities and making space for each human being to reach his or her potential. Compassionate love encourages fullness of life in the other. By the early twenty-first century, compassionate love was also bolstered by scientific research and incorporated into a social science model. It provides a sound concept to guide action benefiting those who are in need, in various situations. Compassionate love is a valuable quality to bring to the care of those who are sick, and would be beneficial to include in treatment, care, and decision making.

Definitional Issues

Some of the most noble human actions are those that express compassionate love. A person acting with compassionate love perceives the suffering, needs, or potential of another, and chooses to act in ways that can better the condition of the other, placing the other's needs in higher priority. There are other moments when one sets aside selfish needs for those of others, when one expresses to others, by words or actions, that they are of value. This occurs in both professional and personal relationships. To contribute to a better understanding of the concept, some definitional points are helpful. Important features of compassionate love include:

1. free choice;
2. some degree of cognitive understanding of the situation;
3. some understanding of self;
4. fundamentally valuing the other;
5. openness and receptivity; and
6. a response of the heart (heart is here defined as "core, " where emotions and cognition integrate).

The particular nature of individual personalities, social setting, cultural setting, genetic predisposition, and other factors limit the freedom of individuals. This makes up the substrate, the basic starting situation, in which individuals begin to act with compassionate love. This starting point is different for each person, and situations in which action takes place differ as well.

The full expression of compassionate love towards those who are ill relies on appropriate motive. Although helpful behaviors are good and useful, and can contribute to the well-being of another, motives focused more on the self than on the other can decrease the positive effect on the person being served, as well as on the moral growth of the individual giving the love. There are many attitudes that can diminish motives, such that they are less likely to result in compassionate love being fully expressed. These include a variety of possible needs or wants for the self: guilt, fear, needs for love and success, fears of failure, desire to claim the upper hand, reputation. Motives are usually mixed, but when self-centered needs predominate, compassionate love cannot be fully expressed.

Research Model

Research specifically on compassionate love is needed in order to determine how best to foster this quality in people's lives, and to assess the particular impact of this quality in the care of the sick. Results from research can help to give appropriate priority to this quality in the training of healthcare providers, and in the settings and circumstances provided for those who are sick. In order to do adequate research on compassionate love, it is important to clearly articulate the various essential components, the conditions that might foster and those that might impede its expression, and to develop methodologies for assessment. There are over fifty large research projects specifically gathering data on this topic, some in healthcare settings.

Figure 1 illustrates a research model that has shown promise in this area. It starts with the substrates discussed previously. Given those starting points, as one encounters a specific person in a specific situation, one must make a decision to act (shown centrally in the figure), and a motive drives that decision. Motive is particularly hard to research, but there are some ways to begin to investigate it, such as experimental models (especially those from economics and social psychology), implicit-explicit models, observational studies with multiple actions, insightful self-report, and neural imaging. When motives for self outweigh those for others, or there is an inappropriate action given the various factors to be considered, the result is frequently negative for the person being served. Good actions can also emerge from motives not full of compassionate love, such as the motive to look good in the eyes of others or to feel needed, but ultimately the feedback of repeating these kinds of behaviors on the moral development of the healthcare provider can be detrimental. It is also possible that the more self-centered, condescending, or less respectful motive is noticed by the sick person, and care is not as effective. These kinds of motives can also adversely affect discernment of appropriate care for the sick person.

In the center of the model is both motive and discernment. Compassionate love fully expressed is not just good intentions, but doing what is really good for the other. This kind of discernment occurs continually in healthcare settings. Short-term distress may be necessary to serve the longer-term interests of a sick person. Weighing the relative

FIGURE 1

needs of others, including appropriate care for self, is also critical to good discernment leading to effective actions.

Revised "Professional Distance"

Compassionate love is not the same as romantic love, familial love, or affection, although it can accompany these other forms of love and blend with them. The professional in a healthcare setting needs to avoid becoming too attached to the patient, and compassionate love allows for this. In fact, one critical aspect of compassionate love is that it is not a "need love, " the kind of love that focuses on the needs of the person giving love. In its focus on the needs of the other, compassionate love's non-attachment is very harmonious with the concept of "professional distance, " but actually can be more satisfying to both the patient and healthcare provider: it enables an emotional component to be appropriately engaged, if that is called for in the specific setting.

Improving Well-Being and Health

In the United States and many other medical healthcare systems, a fee for service operating basis, or fee for time, results primarily in action from duty and obligation. However, there is leeway even within this operating system that provides opportunity to "go the extra mile for the patient, " or engage in compassionate caring for the sick person.

Initial research has shown that empathy, valuing the patient, and giving the patient a sense that he or she is understood can be powerful factors in contributing to improvements in health outcomes, both through increases in adherence to regimens and more direct effects. Ongoing research is exploring whether increasing compassionate love on the part of the healthcare provider can improve patient outcomes.

It is generally acknowledged that there exists a placebo effect in medical treatments, such that placebos, usually inert substances, are included in most major clinical trials; the various constituents of this effect are currently unknown. Conditioning, optimism, improved self-efficacy, and natural regression to the mean are some of the most frequently cited mechanisms, but the role of the patient-provider relationship on outcomes is just beginning to be explored fully as a part of the placebo effect. Compassionate love is one of the components patients report as being important to them: being valued, feeling understood, feeling cared for, having a provider that goes beyond mere duty. This attitude of the healthcare provider can encourage the sick person to better adhere to medication regimes, and with a more positive attitude toward themselves, exert better efforts towards self-care and preventive measures. There may also be additional effects on health.

The therapeutic relationship is important for the person who is ill, as has long been asserted in psychotherapy. From the ill person's point of view, feeling valued, cared about, and understood is important, and this works synergistically with the actual treatment—even in treatment for physical illness. This kind of care also can contribute significantly to the well-being of the ill person in areas where health cannot be significantly improved, such as chronic progressive illness and end of life care. This is not a minor issue for healthcare in the twenty-first century context of a continually aging population, and extensive chronic diseases.

Effects on the Healthcare Provider or Administrator

As described in the model (Figure 1), various substrate factors affect the ability to give compassionate love. Supportive factors can be provided by the healthcare organizational structure, cultural setting, family, religious background, relationships, and others in the healthcare organization. Support from these sources helps to avoid the burnout problem that can occur when one's work focuses continually on those in need. Supportive elements can provide the strength needed to sustain those who care for others.

Outside of the work setting, social relationships, community involvement, family, and religious institutions encourage the healthcare provider's ability and desire to act with compassionate love. Many religions and particular social micro-cultures value this quality, and the nesting of the impetus to act within a religious or social context is useful, as it can provide an infrastructure and additional reinforcement for attitudes and actions.

One who gives compassionate love is also significantly affected by feedback from the one helped. When a good balance (see Figure 2) exists as decisions are made, and the motivation is well grounded, giving compassionate love fully can be satisfying and strengthening to the one who gives it. Feedback from patients can provide a real, positive input for this kind of work, and the ability to express this quality and engage the self more fully in care can be satisfying and add to one's own well-being. This can enable the healthcare provider or administrator to gain more joy from their job.

Compassionate Love within the Social Network

Social support can contribute positively to a person's health. Compassionate love is nested within social relationships, and it is not only the healthcare provider who improves health and quality of life, but also people within the sick person's social support network. This idea is central to providing healthcare systems and healthcare that value and nurture supportive relationships. Although material support in and of itself is important, scientific literature continually illustrates the value of emotional support. The concept of compassionate love as a contribution to quality of life and well-being can be particularly powerful, and in 2003 is being studied in a variety of social contexts, including a World Health Organization study of contributors to quality of life.

Both the giving and receiving of support can improve well-being and quality of life. Those who are sick generally do not want pity; they want others to help them and understand them and care about them, but also, unless totally incapacitated, they want to give to others, and want to feel of use. One study of pain patients conducted by Frank Keefe, Ph.D at Duke University, is examining the use of a "loving kindness meditation, " a Buddhist-inspired practice that has patients dwell on compassionate love for themselves, close friends, those they have trouble with, and the whole world, to help those with pain experience less suffering. When sick people are enabled and encouraged to have good relationships with those around them, they can give to others within the constraints of their situation and this can be an additional positive outcome.

Making Healthcare Decisions

During a National Institutes of Health conference with the goal of setting a research agenda for end of life care in November of 2001, the physicians and nurses involved in care for patients and their families, the qualitative researchers, the economists, and those representing hospice and nursing homes identified a central theme: the importance of what the patient values, and what society values, as decisions needed to be made. Compassionate love, which includes valuing the other fully, action and attitude driven by other centered motivations, and clear discernment as to the most caring action, can effectively guide healthcare decisions and policies. In a study of over four thousand people from various cultures and religions worldwide, conducted by the World Health Organization, and presented by Kate O'Connell at the International Quality of Life meeting in Amsterdam in November of 2001, it was found that issues of being loved, cared for, and accepted contribute significantly to overall qualtiy of life, over and above basic health indicators.

Compassionate love requires that decisions be considered through a lens that views the other as having significant value. Decision-making based in compassionate love also can include various more consciously-articulated ways of

FIGURE 2

weighing competing factors (Figure 2). For example, the immediate desires of the patient may not be in the patient's long term interest, and therefore immediate relief of suffering is not always the most compassionately loving act. Decision-making that incorporates these qualities and complexities into the process can result in better decisions for both the cared-for and the caregiver. By including compassionate love in decision-making, the caregiver can better address the needs of the patient and enable a fuller expression of the humanity of the healthcare provider.

Conclusion

As a guide for action in healthcare settings, compassionate love can lift the care of the sick from a duty to be carried out to satisfying caring with joy. Attitudes toward and care for those who are ill are enriched by taking a respectful, caring, understanding approach that values each individual. The sick person can benefit substantially from this, and various social and behavioral sciences are contributing to a body of literature demonstrating how compassionate love positively affects health. Structural changes in healthcare environments and payment models need to adopt the value of compassionate love in order to improve care.

lynn g. underwood

SEE ALSO: Buddhism, Bioethics in; Care; Emotions; Feminism; Hinduism, Bioethics in; Human Dignity; Human Nature; Medical Codes and Oaths; Narrative; Responsibility; Transhumanism and Posthumanism; Virtue and Character

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