What Is Compassion?

Compassion can be difficult to define in words, but most people recognise compassion when they experience it. At its heart, compassion is the feeling of being motivated to act in the presence of suffering. The concept finds many roots, but likely has several independent origins across various spiritual traditions. Compassion is especially associated with myriad religious and spiritual figures, including Jesus, the Buddha, Muhammad, Gandhi, and Mother Teresa. Compassion has long been associated with wisdom and contemplative traditions as a way to relieve suffering, strengthen interpersonal bonds, promote pro-social behaviour, and even spur political action to create a better, fairer world.

The English word compassion derives from the Latin root ‘compati’, meaning to ‘suffer with’ (Pearsall and Trumble, Reference Pearsall and Trumble1996; p. 295). On this basis, compassion is variously described as an emotion, a state, a trait, a source of moral judgement, a determinant of altruism, and a pro-social behaviour (Goetz et al., Reference Goetz, Keltner and Simon-Thomas2010). From a psychological perspective, the construct is conceived as having two dimensions: state and trait. The compassionate state reflects the feeling of compassion or having a compassionate response in the moment, while a compassionate trait is more stable, reflecting a general tendency towards compassion or that a person feels or responds compassionately most of the time.

The recent re-emergence of compassion as a topic of research interest in healthcare has seen renewed focus on the meaning of compassion in many religious and spiritual traditions, especially Buddhism, among other approaches to the topic. There is also growing interest in the neural basis of pro-social behaviours such as helping, comforting, and resource-sharing (Wu and Hong, Reference Wu and Hong2022) and the neuroscience of compassion, which we explore in depth in Chapter 6 of this book (‘Neuroscience and Compassion’).

The current chapter explores fundamental ideas about compassion and examines the concept of compassion from psychological, evolutionary, and physiological viewpoints. It concludes that, despite useful and growing literature in these areas, a precise definition of compassion can remain elusive. The meaning of compassion is not written in stone; it flows. As a result, what the concept signifies, and how it works in practice, are made most tangible through providing compassionate care to patients, interacting with families, discussing compassion with colleagues, and teaching students about compassionate healthcare. Definitions are useful, but they need to settle, shift, and change over time. If compassion is defined flexibly and understood wisely, it can shape care in positive ways, improve outcomes, and change lives.

To begin, this chapter examines some ideas about compassion from Buddhist psychology and philosophy, before moving on to consider operational definitions of compassion, the relevance of evolution, and the application of these concepts to modern healthcare.

Compassion in Buddhist Psychology and Philosophy

Recent decades have seen a growth of interest in many areas of Buddhist philosophy and psychology around the world including, most notably, the Buddhist idea of ‘mindfulness’. Mindfulness can be defined as the awareness that arises through the practice of paying attention in the present moment, deliberately and without judgement, to our moment-by-moment experiences (Kabat-Zinn, Reference Kabat-Zinn2003).

Bunjak and colleagues published ‘a multitechnique bibliometric review’ which explored ‘the past, present, and future of the mindfulness field’ in 2022, and noted that ‘mindfulness-based interventions have been used in the last decades, mostly in the fields of psychiatry and clinical psychology, to treat a wide variety of mental disorders and in clinical contexts to help alleviate chronic pain’:

We will return to the topic of mindfulness later in this book. For the moment, however, it is necessary to move beyond mindfulness and into other areas of Buddhist psychology to explore further the roots of current concepts underpinning compassion.

The Brahma Viharas or ‘four immeasurables’ are a set of Buddhist virtues, states of being, or divine abodes that enlightened people dwell in and act spontaneously from. They include loving-kindness or benevolence (mettā), compassion (karuṇā), empathetic joy (muditā), and equanimity (upekkhā). Feldman describes these qualities as intrinsically relational, and constituting the foundations of healthy, respectful, and dignified relationships, families, communities, and societies (Feldman, Reference Feldman2017). Compassion is key amongst them.

In this Buddhist context, Wallace sees compassion as the desire that all beings are free of suffering, including ourselves (Wallace, Reference Wallace2010). Feldman views compassion as an understanding and an invitation to move beyond our own stories (the ‘self’) and to see our story in all stories and in all lives (Feldman, Reference Feldman2017). These concepts are symbiotic with other elements of the ‘four immeasurables’, which are interdependent and form a key element in the architecture of Buddhist thought.

Also in the Buddhist tradition, the Dalai Lama (spiritual leader in Tibetan Buddhism) identifies compassion as a pillar of world peace and the antidote to anger, frustration, and violence (Dalai Lama, Reference Lama1995). He states that true compassion is based on a clear recognition or acceptance that other people, like us, all seek happiness and have the right to overcome their suffering. On this basis, one develops concern for the welfare of other people, regardless of one’s attitude towards oneself – and that is what is meant by ‘compassion’.

Overall, this Buddhist conceptualisation of compassion both underpins current understandings of compassion in healthcare and – usefully – highlights the interdependence of compassion with other values such as kindness, joy, and equanimity. All of these values matter deeply in healthcare and are best cultivated together.

Operational Definitions of Compassion

While definitions of compassion vary to a degree, most definitions incorporate both the recognition of suffering and a motivation or desire to act to alleviate that suffering. The motivation to act is central to compassion. The emotions which accompany this motivation can vary considerably, depending on the context. For healthcare workers, grief can be a particular feature of the emotional landscape – both grief experienced by their patients and their patients’ families, and grief experienced by healthcare workers themselves, when outcomes are not as we would wish. In all circumstances, the motivation to act to alleviate suffering lies at the heart of compassion and compassionate healthcare.

In 2016, Sinclair and colleagues noted the lack of a uniform definition of compassion and the absence of an empirical model of the concept (Sinclair et al., Reference Sinclair, McClement and Raffin-Bouchal2016). They define compassion as the emotional response within a person to the suffering of another person, coupled with the desire or motive to alleviate that suffering. Both elements are essential – recognition and motivation to act – and both elements feature in most definitions of the concept.

Against this background, and given the centrality of compassion in areas such as healthcare, the Compassionate Mind Foundation was founded as an international charity in 2006 by Professor Paul Gilbert and colleagues including Professor Deborah Lee, Dr Mary Welford, Dr Chris Irons, Dr Ken Goss, Dr Ian Lowens, Dr Chris Gillespie, Diane Woollands, and Jean Gilbert.Footnote ¹ Paul Gilbert writes that the ‘essence’ of compassion ‘is a basic kindness, with a deep awareness of the suffering of oneself and of other living things, coupled with the wish and effort to relieve it’ (Gilbert, Reference Gilbert2013; p. xiii). This is the definition that is used throughout this book, except where we specify that we are looking at compassion from a different angle or using a different concept in order to gain another perspective on compassion.

Gilbert writes that compassion can be seen as an algorithm involving sensitivity to suffering in oneself and others, and a commitment to try to prevent and alleviate such suffering:

For people who are required to be compassionate in their everyday life or work, compassion requires sustained courage and a continued willingness to engage with suffering, rather than avoid it. It also requires the capacities to be moved emotionally (the sympathetic component), be tolerant of any distress arising, make sense of the distress (the empathic component), and hold all of this without judgement (the mindful component). Responding in these situations requires wise action for the alleviation of distress, and compassion emerges as caring with purpose, remaining mindfully aware, deliberate, and thoughtful (for more description, see: Gilbert, Reference Gilbert2013; Gilbert and Choden, Reference Gilbert2013).

Other definitions describe compassion as a complementary social emotion that is elicited by witnessing the suffering of other people and is linked with feelings of warmth and concern, associated with the motivation to help (Preckel et al., Reference Preckel, Kanske and Singer2018). The emotions associated with compassion can also depend upon the context, so a person engaged in action could also feel anxiety, anger, or deadness, depending upon the situation that is evoking their compassion.

Of particular relevance in healthcare, Feldman and Kukyen highlight various nuances of compassion, suggesting that compassion is also an acknowledgement that not all pain can be ‘solved’ or ‘fixed’, but that all suffering is made more approachable in a landscape that is shaped by compassion (Feldman and Kukyen, Reference Feldman and Kuyken2011). Compassion embraces kindness, empathy, acceptance, and generosity, as well as courage, tolerance, and equanimity. It involves openness to the reality of suffering and an aspiration towards healing.

Compassion and Evolution

Where does compassion come from? Evolutionary theory proposes that compassion is a distinct emotion and emotional trait that serves functions which Reference Feldman and Kuykenare separate from those served by distress, sadness, and love (Goetz et al., Reference Goetz, Keltner and Simon-Thomas2010). Evolutionary theory suggests that compassion involves distinct antecedents that centre on the reduction of suffering, which is the evolutionary problem that compassion evolved to meet. Given that the principal purpose of the human brain and immune system are to keep the body safe from a biological perspective (Slavich, Reference Slavich2020), it is not surprising that compassion evolved to have detectable physiological and neuroscientific correlates (see Chapter 6: ‘Neuroscience and Compassion’).

Examining evolutionary theory to understand how compassion as an affective state or trait evolved in humans, Goetz and colleagues offer three lines of reasoning that could explain the emergence in humans of an affective state that is oriented towards enhancing the welfare of others who are suffering (Goetz et al., Reference Goetz, Keltner and Simon-Thomas2010). These are that compassion evolved as (a) a distinct affective state and trait to ensure the welfare of vulnerable offspring; (b) an attribute in the selection of a desirable mate; and/or (c) an enabler of cooperative relations with non-kin. All of these would likely enhance the survival of the group and therefore be favoured by natural selection.

From a biological perspective, physiological responses and behaviours involved with caring for offspring could have led to the emergence of specific neural pathways and release of neurotransmitters which functioned as positive feedback mechanisms for completing compassionate acts and developing compassion as a state. In models that propose cooperative relations with non-kin, emotions such as compassion serve as both internal motivation and reward for societies that value and reward altruistic behaviour.

Gilbert, writing about the evolution of compassion into a psychotherapy, explores the importance of motive in the evolutionary context, describing three major life tasks that provide a basis for action: (a) the motive to avoid injury, harm, or loss (i.e., response to threat); (b) motives to acquire social and non-social resources that promote survival and reproduction; and (c) the motive to rest and digest when not involved in the first two (Gilbert, Reference Gilbert2020; see also: Gilbert, Reference Gilbert2014). All three motives link with compassion in various ways and can help explain its persistence and flourishing in the evolutionary framework.

Gilbert also points to the role of physiology in the connections between compassion and evolution:

There are also empirical foundations for compassion from the evolutionary perspective; that is to say, arguments and evidence that are based on observational experience rather than theory alone. These include the ideas that compassion should be universal in order to optimise benefit, and that it should include distinct experiential and physiologic processes which motivate the appropriate behaviour, for example, a particular approach to suffering, a desire to alleviate that suffering, and engagement in soothing-related behaviour (Goetz et al., Reference Goetz, Keltner and Simon-Thomas2010). These ideas will be familiar to many healthcare workers from their professional and personal lives.

There is also a requirement for compassion-related appraisals, reflecting the fact that sensitivity to suffering is constrained by the costs and opportunity costs of responding to such suffering. This aspect has implications for compassion in healthcare, where appraisals of the costs and benefits of responding can be fraught, not least because the witness is obligated by their professional role to act in response to the human distress that confronts them as part of their professional activity. An inability to respond to suffering in this context, owing to resource limitations, alternative demands on time, or emotional fatigue, can lead to distress, anger, and burnout.

Compassion in Modern Healthcare

Against this background, compassion in healthcare is both essential and, at times, complex. The pressured, convoluted nature of modern healthcare systems is not always immediately conducive to the development of compassion, but (arguably) renders it more necessary than ever. The irony is that the greater the need for compassion in a given situation, the harder it can be to generate a compassionate approach and to maintain a sense of compassion in the face of considerable challenges.

Malenfant and colleagues, in ‘an updated scoping review of the literature’ on ‘compassion in healthcare’ in 2022, noted the recent rise of interest in compassion and the concept’s clear centrality to many aspects of healthcare, notwithstanding its complexities:

Following their ‘updated scoping review of the literature’, this research group concluded that ‘research on the topic of compassion in healthcare while seeing considerable advances, remains largely theoretical in nature, with limited educational and clinical intervention studies’:

We return to the issue of training throughout this book. For now, it is sufficient to note that Gilbert, in the context of the evolution of compassion to a psychotherapy, points to a wide array of approaches and techniques which can prove useful:

Many of these ideas can be judiciously adapted and applied in other settings, including informing approaches to developing self-compassion, prioritising compassion in the delivery of health services, and creating networks of people whose work is actively shaped by compassion across entire organisations, including complex healthcare delivery systems.

From Eastern Contemplative Traditions to Modern Healthcare

Despite a growing and enormously useful literature on the topic, compassion can still be an elusive concept. It can be difficult to define compassion in theory, and sometimes in practice. For example, which is the more important consideration: being kind in the moment, or taking a longer view that some distress in the present (e.g., by delivering a difficult diagnosis directly) might have fewer negative effects in the longer term (e.g., by reducing the period of uncertainty)? It can be difficult to sit in the presence of distress, even if we feel that triggering this distress now is the most honest, authentic, and justified course of action, which will minimise suffering in the longer term. It is tempting to delay difficult conversations or hope that someone else will have them.

Compassion helps with these situations, rather than complicating them. Pausing and listening is the first step. Simply focusing on compassion consciously in our own minds can open a space for interaction, clarify our intentions in this situation, and elicit guidance, suggestions, or direction from the patient. Compassion is intrinsically relational, and so is clinical care. Humans are exquisitely sensitive to what other people are thinking and feeling, so patients quickly sense when our attitudes are explicitly compassionate – and they inevitably respond with generosity, curiosity, and care.

In many situations, it is instinctively understood when compassion is present, or when it is conspicuously absent. In healthcare, both the clinician and the patient might struggle to put words on this value, and might not need to, but the intention to be compassionate is invariably perceived and inevitably creates the context for more honest, supportive conversations – and therefore better care.

Even so, it can be difficult to define or delineate compassion in words in professional codes of practice or ethical guidance documents, despite its centrality to the missions of health and social care. Defining compassion for educational curricula is also complex, and raises a very real dilemma: how can we teach and model a value that we sometimes struggle to define in theory or practice?

It is important to approach the task of teaching compassion in a patient, constructive fashion that is compassionate towards ourselves as well as others. Taking this approach shows that reaching for a definition of compassion and shaping empirical structures around the concept can be enormously helpful in elucidating and operationalising it – provided such efforts at definition are held lightly rather than rigidly. There will always be some blurring at the edges of the definition of a concept such as compassion. This is good: it allows space for different views and personal experiences, and scope for revision as we engage in educational and clinical practice.

Compassion is not written in stone; it flows. As a result, what the concept means, and how it works in practice, can be best made tangible through providing care to patients, interacting with families, discussing compassion with colleagues, and seeking to teach it to students. Definitions are useful, but they should be allowed to settle, shift, and evolve over time. They are tools, not final answers.

The risk and the downsides of the renaissance of interest in compassion are that compassion might become just another word or concept that people speak about, rather than the truly transformative experience it can be. This would be a pity. Genuine, responsive, heartfelt compassion bonds people, shapes cognition and emotion, and features strongly in narrative medicine and on any occasion when an individual patient tells their story. Most of us can recall moments in our own lives when we experienced care and support that were genuinely compassionate, as well as times when they weren’t. Given a chance, compassion can shape care, improve outcomes, and change lives.

Over recent decades, the concept of compassion has evolved significantly, moving from its strong association with religion and a life of servitude (where religious orders cared for the poor and the sick as part of their vocation) to the reorganisation of caring as a profession (rather than solely a vocation or labour of love). In the past, compassion was associated with informal caring and servitude, and was not necessarily enormously valued in professional practice.

Over time, however, the significance of the concept and its relevance to professional identities shifted, especially as various healthcare professions evolved (Van der Cingel and Brouwer, Reference Van der Cingel and Brouwer2021). Today, compassion has emerged as a key concept that can shape better care. Compassion has moved firmly back into the realms of professional identity and has invigorated writing and research about key values that underpin health and social care. These developments are positive, useful ones which are explored further throughout the remainder of this book.