Compassion and Professionalism in the History of Medicine
Before examining the concept of compassionate healthcare in the rest of this book, it is useful to explore the formal relationship between compassion, standards of professionalism, and codes of conduct and ethics for people working in healthcare professions.
For medical doctors, compassion does not appear in the original Hippocratic Oath, which dates from the fourth century BC. That Oath commits doctors to ‘do no harm or injustice’ but does not specify values such as compassion as being central to the doctor’s work (Paterson, Reference Paterson2011). In 1964, the Hippocratic Oath was updated and modified by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, to place added emphasis on the qualities of ‘warmth, sympathy, and understanding’, as well as ‘the joy of healing’ (Tyson, Reference Tyson2001).
In more recent decades, formal guides to professional standards and codes of ethics for clinicians commonly make explicit reference to compassion. This is an historically interesting development which is welcome, albeit that, while compassion can be mandated, that does not mean it can or should be made mandatory. There is a difference between core values that should guide the health service (such as compassion) on the one hand, and rights (including to be treated with dignity and respect) on the other (Paterson, Reference Paterson2011). In the United Kingdom (UK), the ‘Constitution’ of the National Health Service (NHS) places considerable emphasis on compassion in its exploration of ‘Principles that guide the NHS’:
Respect, dignity, compassion and care should be at the core of how patients and staff are treated not only because that is the right thing to do but because patient safety, experience and outcomes are all improved when staff are valued, empowered and supported.
The NHS also emphasises compassion as one of the ‘NHS values’:
We ensure that compassion is central to the care we provide and respond with humanity and kindness to each person’s pain, distress, anxiety or need. We search for the things we can do, however small, to give comfort and relieve suffering. We find time for patients, their families and carers, as well as those we work alongside. We do not wait to be asked, because we care.
While these are strong commitments which find echoes in similar statements from other countries, they do not constitute a legal obligation on staff to be compassionate or a legal right for patients to expect compassionate care.
However, even if legislating for compassion is not possible, chiefly because the force of the law cannot be invoked to compel compassion, compassionate care can still be promoted through the articulation of principles centred on compassion (such as The NHS Constitution), education of clinical trainees about the nature and value of compassion, and modelling compassionate care in healthcare settings. Stories of compassionate care can also prove powerful (Nationwide Health and Disability Consumer Advocacy Service, 2010), and regulators can shape compassionate services by clearly indicating what is and is not acceptable in terms of conduct, behaviours, and attitudes, as well as setting standards (Firth-Cozens and Cornwell, Reference Firth-Cozens and Cornwell2009).
Against this background, this chapter examines the formal relationship between medical professionalism and compassion, looking at codes of ethics and practice guidelines, chiefly for medical professionals but also with reference to other healthcare workers. The chapter starts by exploring the importance accorded to compassion in ethical guidance for doctors in the UK, Ireland, the United States (USA), Australia, and New Zealand. It then examines guidance specifically aimed at psychiatrists, including documents published by the Royal College of Psychiatrists in the UK, the College of Psychiatrists of Ireland, and the American Psychiatric Association.
Many of these guides emphasise the importance of compassion and related values, with the Royal College of Psychiatrists providing particularly detailed suggestions about building and sustaining compassion in mental healthcare. Compassion and related values also feature commonly in codes of practice and ethical guidance for other clinical professionals in addition to doctors, such as nurses, midwives, social workers, occupational therapists, and others. This chapter concludes that, taken together, these statements of practice values and ethical principles reflect a welcome and growing emphasis on compassion in guidance for healthcare professionals across many clinical domains.
Codes of Practice for Medical Doctors
In many countries, codes of medical ethics have evolved in recent decades to reflect changes in medical practice, the challenges of technological developments in clinical care, and, in some countries, cases and reports indicating low standards of care, often involving a clear lack of compassion.
The General Medical Council (GMC) in the UK describes what it means to be a good doctor in its recently revised document titled Good Medical Practice 2024 (General Medical Council, Reference Council2024). In this publication, the GMC states that ‘treating patients with kindness, compassion and respect can profoundly shape their experience of care’ (p. 11), and specifies that doctors ‘must be considerate and compassionate to those close to a patient and be sensitive and responsive in giving them support and information’ (p. 14).
The GMC adds that one of ‘the duties of medical professionals registered with the GMC’ is to ‘treat people with respect and help to create a working and training environment that is compassionate, supportive and fair, where everyone feels safe to ask questions, talk about errors and raise concerns’ (p. 7). In addition:
Good medical professionals communicate clearly and work effectively with colleagues in the interests of patients. They develop their self-awareness, manage their impact on others, and do what they can to help create civil and compassionate cultures where all staff can ask questions, talk about errors and raise concerns safely.
The GMC also states that doctors ‘must help to create a culture that is respectful, fair, supportive, and compassionate by role modelling behaviours consistent with these values’ (p. 18), and ‘must be compassionate towards colleagues who have problems with their performance or health’, but ‘must put patient safety first at all times’ (p. 17).
This emphasis on compassion is echoed in Ireland in the ninth edition of the Medical Council’s Guide to Professional Conduct & Ethics for Registered Medical Practitioners (Medical Council, Reference Council2024). This guidance articulates ‘values and principles underpinning good professional practice’ and notes that ‘good professional practice requires that [doctors] provide a good standard of practice and care’, including a requirement to ‘act with honesty, integrity and compassion’ (p. 7).
The Medical Council places particular emphasis on ‘compassion’ in the context of ‘end of life care’:
When patients are nearing the end of life, you share responsibility with others to make sure they are comfortable, suffer as little as possible and die with dignity. You should treat them with kindness and compassion. You should make sure that patients receive appropriate pain management and relief from distress.
Compassion is explicitly mentioned again in the context of ‘unintended and unanticipated’ outcomes in healthcare settings:
Where an unintended and unanticipated outcome occurs, you must:
Make sure that the effect on the patient is minimised as far as possible and that they receive further appropriate care as necessary.
Facilitate timely and compassionate open disclosure and support the patient through this process [and]
Report the incident, learn from it and take part in any review of the incident.
The Medical Council further emphasises compassion when discussing ‘open disclosure’ to patients and others following such adverse events:
Healthcare is complex, and sometimes things go wrong, which may result in harm to patients. Open disclosure is an honest, open, compassionate, consistent and timely approach to communicating with patients, and, where appropriate, their family, carers and/or supporters, following patient safety incidents.
Compassion also features in guidance and codes of medical ethics in other countries. In the US, the American Medical Association has Principles of Medical Ethics which were revised in 2001 (American Medical Association, 2001). These are ‘not laws, but standards of conduct that define the essentials of honorable behaviour for the physician’. Principle 1 states that ‘a physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights’.
In Australia, the Australian Medical Association’s Code of Ethics requires their doctors to, among other requirements, ‘consider first the well-being of the patient’, and ‘treat the patient as an individual, with respect, dignity and compassion in a culturally and linguistically appropriate manner’ (Australian Medical Association, 2016; p. 1).
In New Zealand, compassion appears in the New Zealand Medical Association’s Code of Ethics, which states that ‘all medical practitioners, including those who may not be engaged directly in clinical practice, will acknowledge and accept the following Principles of Ethical Behaviour’, including that they ‘practise the science and art of medicine to the best of your ability with moral integrity, compassion and respect for human dignity’ (New Zealand Medical Association, 2008; p. 5). Compassion also features in the Code’s guidance about ‘teaching’:
Teaching involving direct patient contact should be undertaken with sensitivity, compassion, respect for privacy, and, whenever possible, with the consent of the patient, guardian or appropriate agent. Particular sensitivity is required when patients are disabled or disempowered, e.g. children.
Paterson notes that many complaints brought in under the Code are related to an absence of compassion (Paterson, Reference Paterson2011). This is likely the case in other jurisdictions too, which underscores the value of embedding compassion in ethical and practice guidance for medical practitioners and other healthcare professionals.
Compassion in Ethical Guidance and Codes of Practice for Psychiatrists
Compassion also features, directly or indirectly, in ethical guidance and codes of practice for psychiatrists. The Royal College of Psychiatrists’ publication Good Psychiatric Practice: Code of Ethics (Royal College of Psychiatrists, 2014) sets out standards of practice for psychiatrists and is aligned in many ways with the values articulated in the GMC’s Good Medical Practice (General Medical Council, Reference Council2024).
A number of the principles in the document from the Royal College of Psychiatrists relate to compassion. Principle 1 states that ‘psychiatrists shall respect the essential humanity and dignity of every patient’ (Royal College of Psychiatrists, 2014; p. 5). In addition:
Psychiatrists strive to work collaboratively with patients, respecting the patient’s views, beliefs and priorities to do good, to avoid causing harm and to promote social justice, while recognising and respecting the patient’s rights to privacy and confidentiality, autonomy and self-determination.
While this passage does not specifically mention compassion, humanism in healthcare is intimately associated with compassion. This theme recurs, again indirectly, in Principle 10, which states that ‘psychiatrists have a duty to attend to the mental health and well-being of their colleagues, including trainees and students’ (p. 17).
Compassion is explored more explicitly in a Royal College of Psychiatrists’ faculty report titled Compassion in Care: Ten Things You Can Do to Make a Difference (Royal College of Psychiatrists, 2015), which was published in August 2015, following the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis, Reference Francis2013). Compassion in Care emphasises the importance of context in shaping compassionate care:
In healthcare, compassion can help prevent health problems and speed up recovery. Compassion can improve staff efficiency by enhancing cooperation between individuals and teams and between patients and healthcare professionals. Compassion in healthcare is not a function of one individual – it is shaped and influenced by our environment and the systems in which we live and operate.
The College also explores ‘how to demonstrate compassion’, presenting ‘ten things you can do every day’; for example, ‘support the development of systems at work that give you and your colleagues a space to reflect on what you are doing, and attend those events when they happen’; ‘remember the importance of basic communication and interview skills: intelligent listening, mindfulness with regard to dynamics, proper interview setting’; and ‘model compassionate behaviour for trainees and other members of staff. Like it or not, you work in a complex system, and how you are affects others around you’ (p. 13).
Compassion also features in the Royal College of Psychiatrists’ document outlining Core Values for Psychiatrists (Royal College of Psychiatrists, 2017). This includes ‘compassion’ in its ‘core values framework’, along with such concepts as ‘advocacy’, ‘attentive listening’, ‘care pathway continuity’, ‘choice and consent’, ‘empowerment and hope’, ‘explanation’, ‘holistic’, ‘maximise potential for recovery’, ‘partnership’, ‘responsibility’, and ‘timeliness’ (p. 4). The College helpfully defines compassion as ‘paying attention to the quality of care and being sensitive to personal need’ (p. 9).
Guidance for psychiatrists in other countries also includes compassion as a core value. In Ireland, the College of Psychiatrists of Ireland, which was established in 2009, states that it ‘has six core values that drive its mission and objectives: wisdom, learning, compassion, excellence, professionalism, respect’ (College of Psychiatrists of Ireland, 2018). Compassion also features as one of the three pillars underpinning the College: ‘wisdom, learning, compassion’.
In 2019, the College of Psychiatrists of Ireland published a document outlining Professional Ethics for Psychiatrists (Human Rights and Ethics Committee, 2019). This was drawn up by the Human Rights and Ethics Committee of the College ‘following a request from the Medical Council of Ireland to each of the Colleges to draw up their own Code of Professional Ethics’ (Human Rights and Ethics Committee, 2019; p. 3). This guide ‘sets out the principles of professional practice and conduct that psychiatrists are expected to follow and adhere to, for the benefit of the patients they care for, themselves, and their colleagues’.
The document lists 12 principles, starting with ‘Principle 1: Psychiatrists shall treat every patient with respect’ (p. 5). Principle 11 explicitly mentions compassion: ‘Psychiatrists shall maintain the compassion, honesty, moral principles, and probity of the medical profession’ (p. 17). Subsection 11.1 refers to the WMA Declaration of Geneva (World Medical Association, 2006) and broader dimensions of compassion:
The Declaration of Geneva (or the Physician’s Oath) refers to the broader aspects of this principle, stating: ‘I will maintain by all the means in my power, the honour and the noble traditions of the medical profession’ and ‘My colleagues will be my brothers and sisters’.
The guide also states that ‘the work of psychiatrists depends on a relationship of trust with their patients and their families, and an open, honest communication’ (p. 17).
Consistent with this approach, the American Psychiatric Association (APA) lists ‘sensitivity and compassion for patients and their families’ as one of its values in its Vision, Mission, Values and Goals (American Psychiatric Association, 2024). In 2013, the APA published its Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry (American Psychiatric Association, 2013). This document presents ‘the AMA Principles of Medical Ethics, printed in their entirety, and then each principle printed separately along with an annotation especially applicable to psychiatry’ (American Psychiatric Association, 2013; p. 2).
The APA document repeats the AMA principle that ‘a physician shall be dedicated to providing competent medical care with compassion and respect for human dignity and rights’, and adds ‘annotations’, including:
A psychiatrist shall not gratify his or her own needs by exploiting the patient. The psychiatrist shall be ever vigilant about the impact that his or her conduct has upon the boundaries of the doctor-patient relationship, and thus upon the well-being of the patient. These requirements become particularly important because of the essentially private, highly personal, and sometimes intensely emotional nature of the relationship established with the psychiatrist.
Codes of Practice for Other Healthcare Professionals
In parallel with the growing emphasis on compassion in ethical guidance and codes of practice for doctors, including psychiatrists, other healthcare professionals have also moved to explicitly include compassion in their ethical standards and core values. The prominence accorded to compassion as an explicit value appears to be increasing generally, with some guidance providing particular detail about building and sustaining compassionate healthcare.
The Nursing and Midwifery Council is the professional regulatory body for nurses and midwives in the UK. Their code of ethical standards is published as The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates (Nursing and Midwifery Council, 2018). This guidance states that nurses should ‘treat people as individuals and uphold their dignity’, and, in order to achieve this, ‘treat people with kindness, respect and compassion’ (p. 6). Nurses should also ‘listen to people and respond to their preferences and concerns’, which means they should ‘recognise when people are anxious or in distress and respond compassionately and politely’ (p. 7).
This Code also states that nurses should ‘be accountable for [their] decisions to delegate tasks and duties to other people’, which means making ‘sure that everyone you delegate tasks to is adequately supervised and supported so they can provide safe and compassionate care’ (p. 14). This is especially important in order to ensure that delegation and teamwork support compassionate care, rather than diluting or even undermining it, especially in complex, multi-actor settings, such as healthcare.
In 2012, the Commissioning Board Chief Nursing Officer and Department of Health Chief Nursing Adviser in England published a vision and strategy for nursing, midwifery, and care staff, titled Compassion in Practice (Commissioning Board Chief Nursing Officer and Department of Health Chief Nursing Adviser, 2012). This strategy set out a shared vision of compassionate care, underpinned by the ‘6Cs: care, compassion, competence, communication, courage and commitment’ (p. 8):
For staff to make this vision a reality they need to be in supportive organisational cultures. All the people working in health and care are contributing to the same aims, to provide high quality, compassionate care and treatment, and to achieve the best possible health and wellbeing outcomes for each of the people we care for. The evidence on what enables us to do that is overwhelming. To ensure that patients receive good care, we all need to care about our colleagues.
This was followed in 2016 by Leading Change, Adding Value: A Framework for Nursing, Midwifery and Care Staff which emphasised ‘embedding the importance of consistent compassionate leadership as the cornerstone of a people-centred approach, in a shared ambition to achieve excellence, which includes recognition of the contribution of all nursing, midwifery and care staff, across all the sectors’ (NHS England, 2016; p. 25; see also Baille, Reference Baillie2017).
In Ireland, the body responsible for overseeing nursing and midwifery is the Nursing and Midwifery Board of Ireland. Their Code of Professional Conduct and Ethics for Registered Nurses and Registered Midwives emphasises the importance of compassion (Nursing and Midwifery Board of Ireland, 2021). Principle 3 addresses ‘Quality of practice’:
This principle focuses on safety, competence, kindness, compassion, caring and protection from harm. Patients have a right to receive quality care by competent nurses and midwives who practise in a safe environment.
The guidance adds, under the heading ‘Standards of conduct’, that nurses ‘should be kind and compassionate in [their] practice’ (p. 16).
Consistent with this, the Office of the Chief Nursing Officer in Ireland’s Department of Health published a position paper in 2016 identifying and endorsing ‘the core values of Compassion, Care, and Commitment at the heart of the nursing and midwifery professions’ (Office of the Chief Nursing Officer, 2016; p. 4):
Compassionate nursing and midwifery practice is characterised by an appreciation, sensitivity, gentleness, and deep concern that demonstrates an understanding of the person. Compassion compels nurses and midwives to support people by their presence, encouragement, and intervention. Excellence in practice is achieved by doing the right thing for people all of the time. This is demonstrated by using evidence to achieve the best outcome for the person. It is compassionate leadership in nursing/midwifery that never forgets that the most important part of the health service is the person.
This guidance goes on to list behaviours which demonstrate compassion in practice, including ‘showing kindness and patience’, ‘understanding the person’s perspective’, ‘being non-judgmental’, ‘respecting cultural sensitivity and diversity’, ‘promoting dignity and comfort’, ‘developing trusting relationships’, and ‘being genuine in interactions with the person, families and colleagues’ (p. 6).
Compassion and other values which are closely related to compassion commonly feature in codes of practice and ethical guidance for other clinical professionals too, in addition to doctors and nurses.
In the UK, the British Association of Social Workers (BASW) publishes The BASW Code of Ethics for Social Work which emphasises the importance of ‘acting with integrity and treating people with compassion, empathy and care’ (British Association of Social Workers, 2021; p. 9). It is important to emphasise this value in this context, not least because research confirms links between emotionally demanding work and burnout among social workers (Grant and Kinman, Reference Grant and Kinman2018).
The American Occupational Therapy Association (AOTA) includes ‘altruism’ among their seven core values in the AOTA 2020 Occupational Therapy Code of Ethics (American Occupational Therapy Association, 2020; p. 2). They define altruism as ‘demonstration of unselfish concern for the welfare of others. Occupational therapy personnel reflect this concept in actions and attitudes of commitment, caring, dedication, responsiveness, and understanding’ (p. 2). They also include ‘beneficence’ as a ‘principle’ which involves ‘a concern for the well-being and safety of persons’ (p. 3).
Taken together, these values encompass the definition of compassion and are consistent with the growing emphasis on compassionate values in codes of practice and ethical guidance across many clinical professions.
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