A duty of kindness

The problem

‘When I can think of nothing positive to write about in a reference for a junior doctor, I say she is kind,’ commented a colleague. Kindness has now been relegated to an attribute of losers rather than being an integral part of a doctor’s duty to a patient. Because our medical culture does not consistently support the practice of kindness, doctors may view kindness as ‘nice’ but not an essential part of their practice. The Francis Report contained harrowing examples of unkindness to patients and failings in basic patient care. ¹ Medicine’s positivist view, prioritising technical progress, evidence-based medicine and targets, risks viewing a patient solely as an object of intellectual interest. ² Respecting a patient’s dignity now involves pathways, guidelines and risk assessments. The technical and scientific elements of medicine outweigh psycho-social care which is sometimes thought of as part of an outdated ‘nostalgic professionalism’. ³

Professionalism has a dark side and unkindness is often hard to challenge in a medical hierarchy. Some doctors can humiliate students and junior doctors by embarrassing them in the presence of patients and their peers. Unkindness may extend to bullying and harassment which often goes unchecked and even becomes an accepted part of a macho culture. Institutional unkindness may occur in prolonged investigations of complaints which may subject doctors to unbearable stress.

Unkindness to patients is often more subtle; by using distancing tactics such as appearing busy, concentrating on scans and the results of tests, and ignoring patients’ anxieties, doctors can leave patients feeling isolated. In a management culture which measures success in numbers, league tables and throughput, time spent with the patient addressing their concerns is not valued so is not seen as an essential part of a doctor’s duty. Medicine is not a competitive sport yet sadly some doctors take a lifetime to learn this. Competition is instilled in students from their school days. When they achieve a place in medical school they are aware from their first day that their future posts as Foundation Year doctors depends upon their grading throughout their medical undergraduate training. Is this the way to foster cooperation and kindness and inspire young people to learn the craft of medicine?

It is paradoxical that we have developed the most sophisticated methods of communication but at a personal level these seem to have isolated us from others. We find it difficult to find another human being to speak to face-to-face, to touch, to listen, to share our thoughts, to connect. Independence and self-reliance are now our ethical aspirations. We have come to deny our dependency on others. Rather than embracing dependence and vulnerability, we scorn them as though they are incompatible with autonomy. Kindness inevitably exposes our vulnerability and acknowledges our dependence on others. Kindness can have negative associations with patronising behaviour, pity or paternalism. It may also be regarded with suspicion as either a self-serving behaviour or a form of weakness.

Kindness

Kindness is an elusive concept which is easy to recognise but difficult to define. Kindness can be conceptualised as a virtue with links to other forms of pro-social behaviour such as compassion in its concern to benefit others. ⁴ A virtue is part of the moral character of a doctor while a duty implies an obligation to others, a rule of conduct. ⁵ Kindness is derived from kinship or concern for fellow human beings and acts as a connection between the self and the other. Ballatt and Campling ⁶ argues that kindness is no soft option but inspires people to build relationships with patients and to treat them well. An experienced and humane American physician describes how he was reprimanded after giving a patient a small amount of money from his own pocket to buy medication which he could not afford. ⁷ This small act of human kindness was regarded by some other doctors as unprofessional. They cling to a detached professionalism which discourages doctors from caring for and about their patients. ⁷ Students and doctors always remember acts of kindness by their teachers and trainers. I remember an inspiring consultant whose kindness and support for his junior staff extended through our careers. ⁸

Patients often appreciate acts of kindness more than the technical expertise of doctors. I remember the cardiologist who sat in his busy clinic and asked me ‘What’s it like to have atrial fibrillation?’ He took time to listen as I described how the arrhythmia had affected my life and work. After a successful laser ablation operation I will always be grateful for his technical skill, but it is his humanity and kindness that I most remember. Kindness may be expressed by giving time and sharing our humanity. Appropriate humour, self-disclosure and empathy may be ways in which we share in our human predicament and be perceived by the patient as kindness.

How did we get here?

Philips and Taylor ⁹ ask why does our society perceive kindness as a threat? The authors trace the history of kindness in medicine and society to seek an answer to their question. ⁹

Over 2000 years ago, Plato (428–347 BC) described two types of doctors. ‘For doctors, as I may remind you, some have a gentler, others a ruder method of cure. The slave doctors run about and cure the slaves…  practitioners of this sort never talk to their patients individually, or let them talk about their individual complaints. But the other doctor who is a freeman, attends and practices upon freemen; and he carries his enquiries far back, and goes into the nature of the disorder; he enters into discourse with the patient and with his friends, and is at once getting information from the sick man.’ ¹⁰

Plato’s different doctors are recognisable in our hospitals and communities today. Even Stoics who were notoriously resilient had a communal sense of the self. They described the attachment of the self to others as circles of Oikesosis (connection) gradually radiating outwards like the ripples on a pond to eventually include all humanity. ⁹

Hume, in the Enlightenment, thought that anyone foolish enough to deny the existence of kindness ‘has forgotten the movements of his heart’.^9,11 Hume’s notion of kindness was linked with sympathy but probably corresponds with modern notions of empathy.

In the 19th century, kindness was seen as a bridge between the self and the other. However, later in the century, Philips and Taylor ⁹ describes how kindness was feminised and selfishness became institutionalised in our society. In the Descent of Man, Darwin argues that we are a profoundly social and caring species. He concluded that evolution was not simply a matter of survival of the strongest but the survival of the best adapted, a cohesive group being better adapted to survive. ¹² Nowadays in our enterprise culture, practising medicine is often a life of overwork, anxiety and isolation, a competitive society breeds unkindness.

The notion that doctors should be detached from patients was endorsed by the famous physician Sir William Osler. ‘This neutrality in witnessing human suffering gives him (the doctor) a special glimpse into the “inner life” of patients.’ ¹³ An opposing view was presented in 1927, in a seminal paper, Peabody said ‘One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient’. ¹⁴ Twenty years ago, Weatherall ¹⁵ argued that many of the ills of the medical profession reflect a lack of ‘whole person understanding’. More recently, Spiro expressed concern that doctors who used to listen to patients now looked at a screen. ¹⁶

How can this change?

Philips and Taylor ⁹ remark that while kindness connects us to the other person, it also makes us aware of our own and others’ vulnerabilities. If doctors are to be kind in their practice they need to embrace vulnerability rather than pretending that they are omnipotent. We are all vulnerable at every stage of our lives, we are born dependent on others and die dependent on others. In clinical care, bearing another person’s vulnerability means connecting with them and sharing their suffering without necessarily relieving it. Desmond Tutu expands the concept of kindness in describing Ubuntu. ‘A person with ubuntu is welcoming, hospitable, warm and generous, willing to share. Such people are open and available to others willing to be vulnerable, affirming of others, do not feel threatened that they are able and good, for they have a proper self assurance that comes from knowing that they belong in a greater whole.’ ¹⁷

Can kindness be restored into medical care? Chochinov’s ABCD model of dignity care teaches us to understand that our approach and behaviour can affect a patient’s sense of self-worth. ¹⁸ One way of improving care could be by teaching students to value kindness, tolerance and an open approach to others. The challenge we face in the West is how do we institutionalise kindness as a duty, extend our kindness to family and friends and spread it to meet the needs of strangers? ⁹ Kindness is an integral part what makes us fully human. We depend on each other not just for survival but for human flourishing, a fulfilling of our potential, described by Aristotle as eudaimonia. ¹⁹ Modern medical education and clinical practice resists this truth in valuing independence and competition. We need now to establish kindness as one of the doctor’s duties to a patient.