Compassion in Jewish, Christian and Secular Nursing. A Systematic Comparison of a Key Concept of Nursing

Introduction

The major thesis of this research is that the biblical topos of the Compassionate God was the original model of compassionate nursing and that this topos represents the core of the ethics of compassion and of caring in nursing today. The analysis of the literary sources of the first four centuries CE supports this assumption for the eastern Mediterranean area, i.e. the birthplace of Jewish and Christian nursing (see first part of this article). Works of love and compassion on behalf of the suffering and the sick were one of their main features, and distinguished them from the polytheistic Greek and Roman culture. In the course of this period “the Church” and “the Synagogue” became the controlling institutions of nursing. They contributed to their consolidation. This is not the case for modern and post-modern nursing. Since the Enlightenment these are no longer determined by religious institutions. Secular societal movements and the rising of the medical and social sciences became increasingly influential for nursing. Hence, the values inherent in the topos of the Compassionate God (existential presence, availability, advocacy, commitment, active involvement, faithfulness) and its meaning for nurses and patients were challenged.

In this second part of the article the results of the investigation of the 3^rd research question is presented. To this purpose, literary sources of selected exemplary Christian, Jewish and secular nursing institutions in the German speaking countries and in North America were investigated. The methodological principles applied to the ancient texts (see first part of this article) were also used for the analysis and interpretation of the modern and post-modern ones. These documents were treated as samples. Text analysis and interpretation were used to find out whether or not the imitation of the topos of the Compassionate God or the tradition of compassionate nursing were continued.

Was the topos of the Compassionate God received in Christian, Jewish and secular nursing texts of the 19^th/20^th century?

The third research question asked for the investigation of whether or not modern and post-modern nursing received the topos of the Compassionate God. It could be anticipated that the sources of the Catholic and Protestant Nursing Orders as well as of Jewish nursing would contain actualizations of the biblical values inherent in this topos. However, it was less clear how this tradition would be dealt with in secular approaches to nursing because by definition, their intention was to be different from the religious. Because of this, it was particularly interesting to find out how they recontextualized the traditional values’ system.

Compassionate nursing in the spirituality of the Diaconate of Kaiserswerth

The Protestant Order of the deaconesses of Kaiserswerth (Germany) was founded in 1836 by pastor Fliedner and his wife. It was the first Diaconate in German speaking Europe (1). The original rule of this institution (2) was derived from the New Testament Evangelist Mark (2: Mk 8:34) where Jesus is quoted to say: “If any want to become my followers, let them deny themselves and take up their cross and follow me”. This is a reference to the imitation of Jesus, the incarnation of God the Compassionate. Another rule states that in this institution nursing is being practiced as a work of love for the Lord of Mercy and that “souls” who choose this “holy occupation” contain a priori the necessary features such as compassion (3). The deaconesses had to serve in obedience to God, thankful for the love of Jesus Christ, and trusting in the help of the Holy Spirit. Another biblical foundation of the Diaconate is Mt 25:40 (4): “And the King will answer them: Truly I tell you, just as you did it (charity) to one of the least of these who are members of my family, you did it to me.” This implies the New Testament teaching of Jesus Christ’s presence in every human being, i.e. in every patient. In nursing them they nurse Him, which means that nursing is a holy service (4). Fliedner also referred his deaconesses to Phoebe, the servant of the community of Kenchreä, who is mentioned in the NT-letter to the Romans (4: 16:1) (3).¹ Furthermore he emphasized that nursing unfolds its full meaning and significance in the care of the dying where the nurse’s love and compassionate care comforts patients most (5).

Compassionate nursing in the spirituality of the Diaconate of Bethany

The Diaconate of Bethany was founded 1874 in Germany by the Methodist Church. In Zürich, Switzerland, it started in 1887 (6). Also the deaconesses of Bethany were asked to imitate Jesus Christ’s total devotion to the human beings, in particular His bearing of all their suffering. Because Christ sacrificed His life for them, the Deaconesses had to be prepared to “put their lives on His altar”, i.e. to sacrifice their own lives or “to pawn” them. According to the NT-letter to the Romans (4: 14:8) “If we live, we live to the Lord, and if we die, we die to the Lord; so then whether we live or die, we are the Lord’s”. Because He gave his life for the needy the deaconesses should sacrifice their own lives for him. Jesus Christ served as role model of the deaconesses. Unlike the “ordinary” nurse the deaconess – as disciple of Jesus Christ – had to deny herself. To pastor Rexroth, the founder of this institution, it was “the privilege of the deaconesses to … practice the idea of holy service” in its purest nature. He said: “Somebody who nurses has to be able to put himself into the situation of a patient with all her sensitivity … with sacrificing love, Christian mercy, selflessness and full dedication …” i.e. compassionately (6).

In 1981 the Order confirmed its original value system, i.e. that the Church of Christ has to testify God’s love for the human beings in words and deeds. The diaconate is perceived as the visible implementation of this idea. In particular it is perceived to “… include the service for Christ, for one’s neighbor and for each other” (7). In many places amongst the rules of the Order of Bethany the work of the deaconesses is said to be founded in the imitation of God’s compassion, self-dedication and self-sacrifice. The rules explicitly ask the individual deaconess to exceed her role model with respect to these virtues.

The search for values pertinent to the topos of the Compassionate God in the Protestant Nursing Orders proved fruitful. Already the written intent of both, to revitalize the biblical idea of the diaconate, basically implies the continuation of that value system. In addition, even though the Compassionate God is not mentioned explicitly, the instructions of the deaconesses clearly show that they were asked, eagerly to imitate His ways of being and acting. The deaconesses’ work is perceived to be both religious and secular which also brings them near their role in early Christianity. Until today this ethos is leading the clinical practice of both the religious Sisters and the nurses of the two Orders. In contrast to the Church Fathers who associated compassionate care and the service to the sick with the spiritual enhancement of the cares, both pastors Fliedner and Rexroth – authors of the rules of these Protestant Orders – called for the deaconesses’ personal self-denial. However, they were confident that the Compassionate God not only had to be imitated but also that He gave the nurses the strength to do so (8).

Compassionate nursing in the spirituality of the Hospital Sisters of Lucerne

The catholic Order of the Hospital Sisters of Lucerne was founded in Beaune, Burgundy, France in 1443. The original rule of the Order gives evidence for the compassion of its founders Nicolas Rolin and his wife. They are reported to have been “… touched by the great misery in Burgundy” at that time (9). The presently stated creed of the Hospital Sisters includes the following passage: “… The Sisters …want to reply to God’s call to imitate His love for the poor and the miserable. In brotherly community ... they dedicate themselves compassionately to the service of the poor and sick, whom they accompany on the way to cure or to the threshold of death” (9). Similarly it is said that the Sisters should carry out their work with humility and dedication and in doing so they gain the kingdom of God” (9).

In 1830 the Order started in Lucerne, Switzerland. In 1956 the rules of the Hospital Sisters were revised. In this modernized version the Sisters call themselves “God’s assistants”. The edition of the rules of 1970 quotes the Apostle Paul’s metaphor of the “new” and the “old” man. Here the Sisters are asked to strip the “old man” and to get dressed with the new one. The unification with Jesus Christ in his self-sacrifice for humanity is said to be the Sisters’ goal in life. After the last Council of the Vatican in 1962–1965 the Sisters explicitly stated that the imitation of Christ is the foundation of their rule. Based on this they actualized their conception of nursing again in 1979. There they stated: “If the Hospital Sisters want to renew their spirituality, they cannot restrict themselves to activities of modern nursing techniques” (9). Nursing involves the care of an interpersonal relationship …, i.e. the art to be near the people, to express affection, care, friendship and solidarity for them.” In their Charisma of 1982 they stated: “Vis-à-vis the actual, one-sided expectations of achievement and growth, power and profit we advocate our sense for friendship, security, for compassion and grief, for encounter and understanding.” In 1992 they reformulated the cornerstones of their work: “Practicing and deepening God’s philanthropy, openness and availability for the people in need, empathy with the joys and troubles of human beings …”

The documentation of this catholic Order shows a continuous and successful actualization of the core of their traditional value system, i.e. to imitate God’s love and compassion for the suffering. This involves important aspects of the topos of the Compassionate God: presence and dedication. For the Sisters the ideal relationship between themselves and their patients is based on solidarity, a modern concept of fidelity. Moreover they stress their conscious delimitation of their spirituality from economically founded approaches to nursing. In accordance with the rules of the two diaconates theirs also asks the Sisters to practice in the confidence that God will support both the sick and themselves.

Compassionate nursing in the spirituality of modern Jewish nursing

In Judaism the care of the sick is considered to be everybody’s religious duty. Therefore in Europe professional Jewish nursing started only at the beginning of the 20^th century. Because of this and because of the prosecution of the Jews during the Second World War, very few documents about Jewish nursing in Germany and Austria are available. In Switzerland Jewish women were integrated in secular schools of nursing where they were free to practice their creed. Hence no particular rules were necessary. To gain insight into the continuation of the ethos of compassion in Jewish nursing for this research it was necessary to consult a variety of sources. One was a plate mounted on the wall of a Jewish Home for the Blind and Deaf-Mute in Vienna in 1873. It states: “… in thankful recognition of this work of philanthropy … May it be witness to future generations of the warm compassion of the founder for his suffering human fellows, and honor his name forever” (10). The anniversary journal from 1912 of the Society for the Visit of the Sick (chevra bikkur cholim) in another Austrian town contains the following statement: “We do not want gratification when we commit ourselves to such heroic work, rather we want to be aware of the fact that we fulfill a holy duty vis-à-vis of God … as they have been handed down by the Fathers” (11). A Jewish physician who fought for formal nursing education for Jewish women in Germany emphasized in an article that such education ought to be comprehensive and adhere to the Jewish tradition. “The technical education is necessary, but techniques alone are not good enough. Those who value nursing as manual performance can perhaps educate Jewish wardens but never Jewish nurses. We have to emphasize that our nurses have to be inspired by the spirit of Judaism” (12). In another place Feldmann wrote: “The main motif of nursing is and remains the sanctification of God, in that explicit Jewish sense that the sanctification has to take place through and in the daily work, by conscientious fulfillment of all duties … in the sense of our Fathers and by works of charity to all human beings (13). Furthermore a 1960 document of the Jewish Women’s Organization of Zürich states with direct reference to the Talmud: “The world rests upon three things: Holy teaching, holy service and charity. The first two are mainly carried out by men. But the third, upon which the world rests, is mainly a matter of us women … the exercise of alms and charity. Our Sages teach. In three ways gemilut chasdim is greater than zeddaka: we do not just give money, but our women commit themselves with their whole person to assure success to our efforts” (14).

These texts were written at quite different times and with quite different purposes. They do not explicitly mention the features of the Compassionate God or His acts. However they address the care of the sick, and all of them quote “the Fathers”, i.e. holy authorities such as Moise or Abraham, who fulfilled God’s law in exemplary way. This reference to the Fathers implies faithfulness to their teachings all of which are based on the Old Testament. In terms of the topos of the Compassionate God this means that the tradition of compassion is continued. Feldmann’s distinction between wardens and nurses reminds the reader of the text of the Diaconate of Bethany which also distinguish between secular nurses and religiously motivated deaconesses. At the same time this difference shows that the care of the sick simultaneously could be understood as a secular and a religious duty.

Compassionate nursing in the framework of secular nursing

In the second half of the 19^th century parallel to confessionally-oriented nursing secular nursing developed. It’s ideal type was the “Red Cross Nurse” of the turn of the 19^th to the 20^th century (15). Protagonists of secular nursing did not see themselves as imitators of God. On the contrary, they defined themselves anthropocentric and had an orientation towards a secular ethos: philanthropy. Their goal was the achievement of the good rather than of the holy. And they made clear that doing good should be regulated in terms of working hours, and should be paid. Nevertheless, many documents of this movement imply that the ethical tradition of compassion continued (15). For example at the beginning of the 20^th century a night nurse praised her duty as follows: “The well-being and the aches of the sick are partially in our hands; we can be saviors of his health but also destroyers of it, if in our duty we are not guided by true love for men. Is it not the most wonderful, delightful experience for a nurse to be able to give a charitable service to them when others rest? The most unknown person ceases to be a foreigner, you live and care for him, you love him (16). This passage on the one hand reflects the value of heroism which dominated the European turn of the century and which was combined with philanthropy. Also it shows the overlap of this with traditional nursing values: love, charity and care.

A director of a school of nursing in a degree ceremony expanded on the compassionate relationship that develops between patient and nurse: “If … a gifted nurse enters the room of the sick it is as if – from the first moment – invisible threads extended between her and him. She is in contact with him; she feels into his soul and into his body and knows what he needs. And again, the sick person himself feels that the nurse feels in his sense, that without his initiative she gives him all he needs and this takes off him all his sorrows and problems, he knows that he is in professional hands, in motherly care, and wonderful calmness overcomes him” (16). In this speech the intimate relationship between nurse and patient is conceptualized within a framework of motherhood, rather than of a religious act which is typical for a historical period during which motherhood was one of the few accepted roles of middle class women.

In the literature of the forties a leading nurse emphasized the importance of thinking and acting in the place of the patient (17) and of getting in his “world of thoughts and feelings” (16). A nursing officer of an operation theatre wrote in 1909: “The tasks which we have to fulfill conscientiously must not kill our human participation in the suffering of our neighbors. … I know from experience what comfort we can spend and what thankfulness we often earn when we show our patients in the operation theatre that we do not only want to help but also be compassionate” (16: 142f.). Here, at the beginning of the evolution of technical nursing the humane aspect of nursing is presented as complementary component.

In these examples compassion is no longer expressed by this term. Rather it is implied by words such as “caring”, “taking off the burden”, “participating” and “charity motivated by love” etc.. The examples show that the values previously derived from religion were now contained in the humanitarian ethos and stood in the service of middle-class gender ideologies, of nationalism and patriotism. Previously, to work hard without expecting gratefulness or pay was a religious ideal. Now this service was presented as an inner necessity of women or as a principle of motherhood. When before self-sacrifice, selflessness, faithfulness to the duties and submission under God and the clergy were required by the Church, it was now required in the service of the physicians, the family or the State. Hence, the break with religious nursing took place only in institutional and financial matters but not with respect to nursing’s value system. The mental situation of nursing remained essentially unchanged, but now was presented in the frame of a humanitarian ethos. Interestingly, modern Jewish nursing never required self-sacrifice and subordination of their nurses but instead, solid education and assertiveness.

From the middle of the 20^th century the secular nursing movement started to dominate the religious approaches. The confessional nursing institutions found themselves in crisis. At the same time and until today, nurses practice on the basis of religious motivations. In a recent study carried out in Switzerland 40% of the secular nurses confirmed that they want to nurse patients – amongst other reasons – because of religious or spiritual motives (18). Research on the effects of dying on practicing nurses they confirmed in many versions how they feel or suffer with the dying and their families (19).

Compassion in North-American academic nursing

From the beginning of the seventies of the 20^th century, nursing education in the German speaking countries started to import North American nursing approaches and it relies on them until today. For this reason I felt challenged in this research to investigate the position of compassion in these approaches.

The selection of the literature according to the two principles mentioned above led to texts about “compassion” and even more about “caring”. The literature analysis showed that there are as many definitions and descriptions of these concepts as authors. Sometimes “compassion” and “caring” are dealt with synonymously. Also, in American nursing science compassion only recently and to a very limited extent became a subject of research. If the American literature deals with “compassion” systematically within the framework of ethical analyses these reflections often are not written by nurse scientists but by medical ethicists or clergymen. For example, Nouwen wrote about compassion: “It hurts to enter into the places of pain, to share the brokenness, fear, confusion and anguish. Compassion challenges us to cry out with those in misery and to mourn with those who suffer loneliness, to weep with those in tears. Compassion requires us to be weak with the weak, vulnerable with the vulnerable and powerless with the powerless. Compassion means full immersion in the condition of being human” (20: 13). Donley describes the sharing of someone else’s suffering as an act of spirituality (21). To her the spiritual response of the carer is compassionate accompaniment, a search for meaning in the suffering, and action to remove the suffering. Dougherty and Purtilo proposed the following definition: “Compassion is the ability and willingness to enter deep enough into the suffering of a human being in order to experience how he suffers, and the resulting will to remove suffering or to comfort the suffering if nothing else is possible” (22). Father Smith stated that “Common to all religious traditions is an acknowledgement of the primary place in human life of compassion and solidarity … A truly compassionate health care giver will bring to the encounter with patients a habit of trusting and believing …(23). Reich maintained that a compassionate human being tolerates that something troublesome happens to him because it happens to somebody else without necessarily identifying with it (24).

The significance of compassion in American academic nursing

In the American nursing literature four main foci can be identified in relation to the discourse of compassion: the discussion about what compassion is; the controversy about the therapeutic value of compassion; the discussion about compassion as a basis for a caring relationship and the debate about the significance of compassion in the process of professionalization.

The discussion about what compassion is: Structurally compassion is presented as human trait, moral responsibility, type of interpersonal relation, basis and essence of a nursing relationship or as a nursing method.

The statements related to the therapeutic value of compassion are rather unspecific (25) and mostly consist of speculations or individual experiences that are generalized (26). So far, nursing has no means to measure the therapeutic effectiveness of compassion (e.g. how it influences pathologies or healing processes). Instead, it relies on descriptive evidence of patients’ experience of compassionate nursing. Summarizing such anecdotal observations of the “therapeutic” value of compassion reported in professional articles leads to the following results. Compassionate nursing is said to lead to a closer and more attentive nurse-patients relationship, to a more exact assessment of the patients’ vulnerability, to better hermeneutical understanding of patients, to a more careful selection of nursing interventions, to a greater motivation to help and less compromises on the part of the nurses (27). Hence compassion should lead to an identifiable quality of care which is distinct from that resulting from distancing nurse behavior. Therefore it seems to have a protective effect on patients. Donley (21) recognizes the outcome of compassionate nursing in the covenant relationship between nurse and patient. Its main features are the mutual promise to availability, advocacy, commitment and dependability in striving to achieve agreed goals. For LeVeille Gaul (28) compassion is a condition for a helping dialogue and at the same time increases the consideration of the particularity of a patient when decisions have to be taken. Unfortunately, in the analyzed literature there is no indication as to in what situations compassion can be contra-indicated although the comprehensive research works of Janice Morse and colleagues about suffering-enduring imply several (29).

Most texts about compassion in nursing converge in the conclusion that compassion leads to compassionate care (25) and that care without compassion cannot be called care (30). For Roach (27) the impulse to care that grows out of compassion is especially crucial for nursing in a technological context or in a reductionist health care system because it preserves the dignity of both nurses and patients. A compassionate approach to care contrasts the value of affect neutrality basically leading medical practice. Loewy (31) emphasizes that compassion influences the behavior of nurses and therefore has to be paired with reason when decisions are taken.

If in the American nursing literature compassion is presented as the basis of morally responsible nursing, i.e. of a caring relationship this often takes place in a theological frame of reference. This argumentation follows the New Testament metaphor of the Good Samaritan (32) which is a consequence of the topos of the Compassionate God. It is an actualization of the biblical covenant relationship between God and men.

However, also secular nurse scientists advocate nurses’ obligation to compassionate care. Hildegard Peplau and Joyce Travelbee (33, 34) explain the compassionate quality of therapeutic relationships with principles of humanistic nursing speaking of a “human-to-human” relationship. Based on her intercultural research Madeleine Leininger (35) concludes that in any helping act compassion is part of normal human behavior. It is the opposite of an attitude which favors egocentric behavior. Another secular interpretation of the human inclination to compassion and care originates in the philosophical tradition of sympatheia (36). It explains interpersonal understanding and empathy through the historically, culturally and socially shared horizon of meanings and through the human sharing of some crucial experiences such as suffering and compassion. Phenomenology calls this “inter-subjectivity” (37). Martha Rogers (38) interprets compassion as interpersonal relatedness of nurse and patient within a common energy field. When Jean Watson (39) in her New Age approach to nursing proposes compassionate nursing she goes as far as to say: “The person has one basic striving: to actualize the real self, thereby developing the spiritual essence of the self, and in the highest sense, to become God-like” (i.e. compassionate).

All approaches advocating compassionate nursing have in common the awareness that both caring and the omission of caring have consequences for both participants in the nurse-patient relationship. Thomasma and Kushner (40) state that compassionate care requires of the nurse a generous management of rules and regulations such as working contracts. This may mean that she has to bear the conflicts which are brought about through covenant partnership. However, according to Verena Tschudin (41) the satisfaction resulting from such a relationship gives the nurse the courage and energy to protect and preserve the dignity and rights of patients on a continuous basis.

The debate about the significance of compassion in the process of professionalization in nursing appears in sharp contrast to the enthusiastic though speculative presentation of the therapeutic value of compassionate caring. While in the clinical context compassion is seen as a virtue and strength related to the professionalization of nursing it is presented as a weakness. The concept of compassion is said to be too unspecific and useless in distinguishing nursing from other health professions (42). This author also worries that cultivating compassion to become the crucial feature of the nursing profession will undermine all scientific and political efforts to professionalize nursing.

The significance attributed to compassion in clinical nursing also contrasts the way, in which it is presented in the nursing literature. Many articles are expression of frustration, disappointments or of nostalgia and idealized traditions. An analysis of the categories and titles under which compassion is presented in the literature are: Editorials, stories (a day in the life of a nurse), Soapbox, Feature, End piece, Reflexions (a Christmas story). They are placed at the very beginning or at the end of scientific journals.

Conclusions

The research presented in this article (part 1 and 2) investigated what substantive elements constitute the topos of the Compassionate God in the primary Jewish and Christian sources, how it was received in nursing in the 1^st through the 4^th century CE and how it was received in Jewish, Christian and secular nursing in the 19^th and 20^th centuries. The results show that throughout these periods “compassion” was an important feature of nursing care and until the end of the 20^th century remained a defining feature of nursing’s professional tradition. The original theological topos of the Compassionate God involved existential presence, availability, advocacy, commitment, active involvement, and faithfulness. The biblical topos is bound to remain unchanged. However, the analysis of the literary sources show various interpretations and actualizations of this value system in ancient and modern Judaism and Christianity and even more in secular approaches to nursing. Both religious and secular interpretations start from the premise of a universal relatedness of all human being as the basis of compassion and of the obligation to help each other. All recognize the overarching gratification for compassionate care in the perfection of self. In the theoretical framework of religion this means imitation of God, i.e. the progressive sanctification of self and the approaching of the essence of the icona Dei. In the framework of humanistic psychology and New Age theories it means self-actualization and approaching a state of healing and wholeness. Also in post-modern nursing these values became the constituents of the construct “caring” with compassion being its core. All authors acknowledge a notion of transcendence in relation to compassion. It manifests itself for example in the question why the suffering of a person should motivate anyone to relieve him. All interpretations speculate about the therapeutic value of compassionate nursing care.

The almost universal advocacy of the concept of compassion within nursing shows that throughout history religious and secular nursing leaders succeeded to translate this value system into a distinct relationship between patients and carers: the covenant relationship. This seems especially crucial in times when caring is not the most prominent feature of a society because it ascertains patients’ safety and well-being.

An important detail of this research shows that whether or not compassion is motivated by religious (theocentric) or a secular (anthropocentric) argument is irrelevant for its effectiveness. Both, doing “the good” or doing “the holy” can be constitutive for the solidarity with the suffering as well as for the preservation and restitution of their lives. More research is required to clarify whether or not the topos of the Compassionate God plays a role in nursing in the context of the third monotheistic religion, Islam.