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Compassion
EXPLORATIONS
Compassion “How is one to live a moral and compassionate existence, when one is fully aware of the blood, the horror inherent in life, when one finds darkness not only in one’s culture but within oneself? If there is a stage at which an individual life becomes truly adult, it must be when one grasps the irony in its unfolding and accepts responsibility for a life lived in the midst of such paradox. One must live in the middle of contradiction, because if all contradiction were eliminated at once life would collapse. There are simply no answers to some of the great pressing questions. You continue to live them out, making your life a worthy expression of leaning into the light.” —Barry Lopez, Artic Dreams1 compassion: to suffer with another; sympathy for the suffering of others, often including a desire to help empathy: the ability to identify with and understand another person’s feelings or difficulties
he most profound healing event I personally remember was being touched by a nurse when I was recovering from anesthesia following an appendectomy. The surgery was a rushed-up affair that took place in the Student Health Center at the University of Texas at Austin, when I was a senior student preparing to enter medical school. I never met the surgeon beforehand; he thought it unnecessary. Neither did I meet the anesthesiologist in advance; he was too busy. When I awakened, I was anxious, alone, and in pain. I still did not know who my physician was, or what he had found at surgery. The nurse simply
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held my hand. Her lingering touch conveyed to me—silently, powerfully, unequivocally—that everything was going to be all right. It was; the pain vanished, along with the anxiety and sense of isolation. This simple act is seared into my memory as a profound example of the power of compassion. Heck, I became so enthusiastic about nurses I married one—Barbara—nine years later, 34 years ago.
COMPASSION, WISDOM TRADITIONS, AND GOLDEN RULES An emphasis on compassion and empathy lies at the heart of the major religious traditions that have sustained and nourished humanity for over two millennia. As theologian Karen Armstrong says, most of these traditions came into being at roughly the same time, during the socalled Axial Age, about 900 to 200 BCE. “Why should we go back to these ancient faiths?” Armstrong asks. “Because they were the experts. In this period of history people worked as hard to find a cure for the spiritual ills of humanity as we do today trying to find a cure for cancer.”2 We often forget that these great teachings had nothing to do with religion and religiosity. As Armstrong explains, “What has intrigued me is that none of them was interested in doctrines or metaphysical beliefs. [At that time] a religion was not about accepting certain metaphysical propositions: it was about behaving in a way that changed you. What the Axial sages put forward was that compassion was the key. Compassion doesn’t mean feeling
sorry or pity for people but feeling with the other, learning to dethrone yourself from the centre of your world and put another there. Not only would this be the test for any religiosity but it would also be the means of entering into enlightenment.”2 Compassion, therefore, now as then, involves radical surgery on the notions of I, me, and mine. Golden Rules are endorsements of compassion and empathy, and because compassion runs through all the great Axial traditions, it is not surprising that some version of the Golden Rule is found in all of them. Confucius was the first to propound such a recommendation: “Do not do to others as you would not have done to you.” As Armstrong says, “[Confucius] was the person who equated religion with compassion—it was compassion: it wasn’t about theology, it wasn’t about going to heaven, it wasn’t about defining what you meant by the divine or the sacred, it wasn’t about being right. It was about ‘humanheartedness,’ the exercise of compassion.”2 The Confucian sage Mencius3 agreed, saying, “One should not behave towards others in a way which is disagreeable to oneself.” Rabbi Hillel, the older contemporary of Jesus, once told a Pagan who had asked him to define the whole of Judaism, “That which is hateful to you do not do to your neighbor. That’s the Torah. The rest is commentary; go and learn it.”2 As all Christians know, Jesus propounded a similar version: “And as ye would that men should do to you, do ye also to them likewise” (Luke 6:31).
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In Taoism, we find, “Regard your neighbor’s gain as you own gain, and your neighbor’s loss as you own loss.”3 Within Islam, we read, “Not one of you truly believes until you wish for others what you wish for yourself.”3 Similar views permeate traditions outside the Axial traditions. For example, the Roman Pagan religion contained this exhortation: “The law imprinted on the hearts of all men is to love the members of society as themselves.”3 And as Black Elk (1863-1950), a Sioux medicine man, said of Native American spirituality, “All things are our relatives; what we do to everything, we do to ourselves. All is really One.”3 And from the Pima tradition, “Do not wrong or hate your neighbor. For it is not he whom you wrong, but yourself.”3 Compassion, of course, is not limited to the religious. The contemporary philosophy of secular humanism, which many religious fundamentalists love to hate, also affirms compassion and empathy. In the Humanist Manifesto II, we find, “ critical intelligence, infused by a sense of human caring, is the best method that humanity has for resolving problems. Reason should be balanced with compassion and empathy and the whole person fulfilled.”4
A TREASURE HIDDEN IN PLAIN SIGHT At first glance, there seems to be nothing new about valuing compassion; it’s an idea that has been around for thousands of years in both the religious and secular worlds. But perhaps it is the universality of compassion that has lulled us into undervaluing its importance. Compassion has largely become a treasure hidden in plain sight, a phenomenon toward which we are selectively blind. Of course, everyone says compassion is important, and compassion and empathy are widely acknowledged by healthcare professionals to be characteristics of humane care. But when serious illness strikes, they are often regarded as less important than physical interventions such as drugs and surgical procedures. But as we shall see, a variety of evidence suggests that compassion and empathy are correlated with positive health outcomes, and they can evoke measurable physiological effects in sick persons, even when the individual is unaware that these factors are being extended to them. As a consequence, compassion and empathy should not be
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regarded as optional niceties in medical care but as fundamental factors promoting recovery from any illness.
EVIDENCE OF A COMPASSION EFFECT Mind-body researcher Jeanne Achterberg is a veteran explorer of indigenous healing methods and the role of imagery and visualization in healthcare. These interests led her to the island of Hawaii, where she spent two years observing the culture and healing methods of indigenous healers, many of whom took her into their confidence and freely shared with her their methods. Achterberg was interested in exploring whether healers can exert a positive influence on a distant individual with whom they have no sensory contact, as healers universally claim. She and her colleagues5 at North Hawaii Community Hospital in Waimea recruited 11 indigenous healers to participate in a healing experiment. The healers were not casually interested in healing; they had pursued their healing tradition for an average of 23 years. Each of them was asked to select a person they knew, with whom they had previously worked professionally, and with whom they felt an empathic, compassionate, bonded connection, to serve as the recipient of their healing intentions. Although the researchers referred to the healing endeavors as distant intentionality, the healers themselves described what they did in various ways—prayer, sending energy, good intentions, or wishing for the highest good. Each recipient was isolated from all forms of sensory contact with the healer and placed in a functional magnetic resonance imaging scanner. The healers then sent their various forms of distant intentionality to their subjects at random, twominute intervals that could not have been anticipated by the recipient. When the functional magnetic resonance imaging brain scans of the subjects were analyzed, significant differences in brain function were found between the experimental (send) and control (no-send) conditions. There was less than approximately one chance in 10,000 that these differences could be explained by chance (P ⫽ 0.000127). The brain areas that were activated during the healing or send periods were the anterior and middle cingulate, precuneus, and frontal regions.
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When the experiment was repeated, using subjects with whom the healers felt no empathic bonding, no significant functional magnetic resonance imaging changes were found in the recipients during either the send or no-send conditions. This study suggests that compassionate, empathic healing intentions can exert measurable physical effects on a recipient, even when the recipient is not aware when the attempt is being made. This study appears to shred the perennial complaint of skeptics that these are placebo effects, due only to suggestion, expectation, and positive thinking on the part of the recipient. The study of Achterberg and colleagues5 does not stand alone. Several prior experiments have examined correlations in brain function between empathic individuals who are widely separated and who have no sensory contact with each other.6-9 A proof-of-concept study, the experiment of Achterberg and colleagues was designed to test whether a nonlocal, compassion-mediated, physiological effect exists. It did not explore whether or not such an effect could alter the course of an illness. But prior studies have done just that, including in AIDS. In 1998, researcher Sicher and colleagues10 at the University of CaliforniaSan Francisco School of Medicine/California Pacific Medical Center studied the effect of distant healing intentions on patients with advanced AIDS. In a doubleblind pilot study, they found that AIDS patients who were extended healing intentions from veteran, seasoned healers fared better than those who were not: 40% of those not sent healing intentions died, compared to none of those who were extended healing intentions. The study was expanded and repeated. By this time, multidrug, antiretroviral therapy had come into widespread use, and all the subjects in both the intervention and control groups were treated with such. Probably as a consequence, there were no deaths in either group in the expanded study. However, the intervention group who received distant healing intentions had a statistically lower incidence of AIDS-associated illnesses, a lower rate of hospitalization, shorter hospital stays, fewer physician visits, and better psychological profiles during the course of illness when compared
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with the control group, which was treated with only antiretroviral medications. The healers in this study, as in the experiment of Achterberg and colleagues5 that would come later, were not casually interested in healing; healing was a serious pursuit for them and they had spent many years practicing their calling. Nearly all gifted healers recognize the importance of deep caring and love toward the individual in need. Their depth of compassion may set them apart from less-experienced healers and may account for why some healing studies achieve positive results whereas others do not. This is a touchy point. Many people insist that healing is a purely democratic pursuit that can be practiced with equal facility by anyone. This is a noble thought, but is probably an exaggeration. W recognized different levels of excellence in all pursuits. Prodigies exist in music, literature, athletics, mathematics, cooking, art, and so on. Why should healing be different? And the difference may be due largely to the degree of compassion, empathy, and sense of oneness the healer is able to summon during the actual healing effort.
SUPPORTIVE EVIDENCE Studies exploring nonlocal healing effects are numerous. In a 2003 analysis of this field, Jonas and Crawford11 found over 2,200 published reports, including 122 controlled laboratory studies and 80 randomized controlled trials. How good are the controlled clinical and laboratory studies? Using strict Consolidated Standards of Reporting Trials to assess the quality of the studies, Jonas and Crawford gave an “A,” the highest possible grade, to laboratory studies involving the effects of intentions on inanimate objects such as sophisticated random number generators. They gave a respectable “B” to the nonlocal healing studies involving humans, cells, tissues, plants, and animals. The depth and breadth of this research remains little known among healthcare professionals. Consequently, the occasional critiques of this area are almost never comprehensive, and they often rely on philosophical and theological propositions about whether remote healing can or should work, and whether experiments involving healing intentions and prayer are heretical or blasphemous.12,13 Dossey and Hufford14 have examined the 20 most
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common criticisms of this field and found most of them unconvincing. On balance, these studies, of which approximately one half show statistical significance, attest to the fundamental importance of compassion and empathy in healing. Although researchers have no “compassion meters,” the healers themselves generally insist that an emotional bond is crucial in eliciting the healing effect, a contention that was affirmed in the experiments of Achterberg and colleagues5 and Sicher and colleagues,10 as mentioned.
HYPOTHESES An obstacle to a serious consideration of this evidence is the lack of an accepted explanation of how these studies could be true. However, many hypotheses recently have been advanced by a variety of scholars, including Nobelists, in fields such as neurobiology, mathematics, and physics.15 Several invoke concepts based in recent discoveries in quantum physics. Researcher Dean Radin,16 in his recent book Entangled Minds, suggests quantum entanglement as a hypothesis for nonlocal, paranormal, or psi-type events, including distant healing effects. In the following passage, one may substitute “nonlocal healing effects” for “psi”: If physics prohibits information from transcending the ordinary boundaries of space and time, then from a scientific point of view psi is simply impossible. But here’s where things become interesting. [T]he old prohibitions are no longer true. Over the past century, most of the fundamental assumptions have been revised. This is why I propose that psi is the human experience of the [quantum-] entangled universe. [T]he ontological parallels implied by [quantum] entanglement and psi are so compelling that i believe they’d be foolish to ignore.16 Quantum physics does not validate nonlocal, compassion-based healing or any other consciousness-mediated event, but it does provide potent metaphors that may prove helpful in understanding these phenomena. In any case, the lack of an explanatory theory does not invalidate data. Often in the history of medicine we have known
that something works before we have understood how it works, as our use of aspirin, colchicine, penicillin, general anesthetics, and many other therapies attests.
COMPASSION AND TEARS A revealing study of patients with rheumatoid arthritis (RA) suggests that we cry as a way of relieving chronic pain and inflammation.17 Japanese researchers at Tokyo’s Nippon Medical School exposed RA patients to deeply emotional visual stimuli and correlated various neuroendocrine and immune responses in their bodies with how easily they were brought to tears. These responses included blood levels of the stress hormone cortisol, the immune protein interleukin-6, and CD4, CD8, and natural killer immune cells. They found that patients who were easily moved to tears generally did better clinically over the course of a year than those who did not cry, and did so with less pain, swelling, and need for pain medications. The researchers concluded that shedding tears suppresses the influence of stress on their neuroendocrine and immune responses, making their RA easier to control. Shedding tears in this study demonstrated an ability to experience compassion, empathy, and a sense of connectedness with the evocative situation or the person in need. This experiment suggests that compassion is good for the individual experiencing it, as well as for the person to whom it is directed. This is consistent with the adage that healing efforts benefit the healer as well as the healee. This study goes against the grain of the grin-and-bear-it school, which says that pain and illness should be endured without complaint or whimper.
BREAKING THE BOND People commonly say that they pray for their loved ones when they are sick. This implies that they know the individual in need, that an emotional bond exists between them, and that they are willing to pray for them unconditionally and without reservation. In contrast, many healing studies involve strangers praying for strangers. Moreover, the double-blind nature of these experiments means that healing is not unconditional, because the patients are told that they may or may not be prayed for; they are in a cloud of uncer-
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tainty. As a result of these conditions, in these experiments the rich personal connection, emotional bonding, and unconditional support between loved ones is severely reduced or eliminated. These are surely reasons why these studies frequently show marginal, neutral, or even negative results. An example is the well-known 2006 prayer study from Harvard Medical School involving 1,802 postcoronary artery bypass surgery patients at six US hospitals.18 Of these patients, 604 were told they might or might not be prayed for, and were; 597 were told they might or might not be prayed for, and were not; 601 who were told they would be prayed for, and were. Prayers were offered by two Catholic groups and one Protestant group. The intercessors were provided brief written prayers they were required to recite, but were otherwise free to use their own. They were provided with the first name and the initial of the last name of the prayer recipients. Prayers were initiated on the eve or day of surgery and continued for two weeks. Among the group told that they might or might not be prayed for and were, 52% had postsurgical complications. Among those patients told they might or might not be prayed for, and were not, 51% had postsurgical complications. Among the group told they would be prayed for and were, 59% had postsurgical complications. There is no agreement among analysts why prayer did not demonstrate a healing effect, and why those who knew with certainty that they would be prayed for and were fared the worst of all. Perhaps the reasons underlying these results are straightforward. Nowhere on earth is prayer used the way it was employed in the Harvard experiment (except in other prayer experiments). In real life, prayer is employed lovingly, compassionately, and empathically between loved ones, and it is offered unconditionally, not as a “maybe” or a “perhaps.” The media had a field day with the Harvard study. “Don’t pray for me! Please!” trumpeted a Newsweek report.19 Wrenching healing from a real-life context and artificializing it to suit the whims of researchers is a recipe for experimental disaster. Only by honoring the crucial role of compassion, empathy, and unconditional love—admirably demonstrated in
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the study of Achterberg and colleagues5— can researchers hope to reveal some of the mysteries of healing.
RESTORING THE BOND A perennial criticism by busy healthcare practitioners is that time is limited and resources are few; therapists don’t have the time required to deliver adequate physical care, let alone create a compassionate, empathic bond with a patient. The difficulties of conveying compassion may be overrated. Oncologist Linda A. Fogarty, of Johns Hopkins University School of Hygiene and Public Health, and colleagues20 demonstrated that conveying compassion and empathy need not be time intensive. They found that the perception of a physician as compassionate and empathic could be achieved by showing patients a compassion-oriented video whose duration was only 40 seconds. Another objection against rendering compassionate care is that it makes patients excessively dependent on their physician, thereby increasing consumption of healthcare resources. In other words, if patients like the doctor-patient encounter, they’ll want more of it. Researcher D. A. Redelmeier, of the University of Toronto, and his colleagues21 showed that this is not necessarily the case. In a randomized, controlled study involving homeless adults who rely on emergency rooms for care, they tested whether compassionate care, by improving patient satisfaction, can alter subsequent use of emergency services. They found that compassionate care of homeless adults decreases repeat visits to the emergency department, compared with care delivered in an emotionally neutral way. Medical educators may be waking up to the value of compassion in healing. In 2006, medical schools in Israel altered their admission procedures to require the presence of compassion and empathy in every entering medical student. High grades and intellectual skills continued to be important, but were judged insufficient to qualify one for admission. “It bothered us,” said Professor Moshe Mittelman, head of the admissions committee at Tel Aviv University, “that here and there you meet a doctor about whom you say, ‘He may know medicine, but he is not a decent human being.’ We are a school that educates people to work in the medical pro-
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fession, which is not only science but also humanism and dealing with people.”22 The majority of healing studies suggests that a healing effect is real and that it is mediated by compassion and empathy. Evidence further suggests that an empathic, compassionate bond between physicians and patients can be established quickly, and that compassionate care does not result in an increased demand for healthcare services. Why does this matter? Compassion and empathy are humanitarian gestures that not only make needy patients feel better, but are also correlated with measurable physiological effects and improved clinical outcomes. For these reasons, they are important elements in the decent care of any illness. Objections to compassion and empathy as integral components in disease treatment often conceal a mind-body duality in which emotional, psychological, and spiritual factors are considered less real than physical ones. But as the above evidence suggests, mind-body separation is not fundamental. As researcher Emily Mumford and colleagues23 suggested over two decades ago, “It is often argued that the medical care system cannot afford to take on the emotional status of the patient as its responsibility. Time is short and costs are high. However, it may be that medicine cannot afford to ignore the patient’s emotional status assuming that it will take care of itself.” It is a measure of our physicalistic age that we require “hard” evidence for the value of compassion in caring for the sick. Historians may look back with amazement on how we agonized over the role of compassion in healing, when for nearly all of human history its importance was selfevident. Yet, the vision remains. The value of compassion has been obvious to some of the truly great scientists of our age. No better example exists than Albert Einstein, whose ringing endorsement of compassion deserves to be a mantra for our time, because it is a remedy for the myriad hatreds that separate us from one another and from our endangered natural world: A human being is part of a whole, called by us Universe, a part limited in time and space. He experiences himself, his thoughts and feelings, as something separated from the rest—a
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kind of optical delusion of his consciousness. This delusion is a kind of prison for us, restricting us to our personal desires and to affection for a few persons nearest us. Our task must be to free ourselves from this prison by widening our circles of compassion to embrace all living creatures and the whole of nature in its beauty.24 Larry Dossey, MD Executive Editor
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REFERENCES 1. Lopez B. Quoted in: The Quotations Page. Available at: http://www.quotationspage. com/search.php3?homesearch⫽compass ion&startsearch⫽Search. Accessed July 17, 2006. 2. Armstrong K. Compassion is the key. Resurgence. 2006;235:33-34. 3. Shared Belief in the “Golden Rule.” Ethics of Reciprocity. Ontario Consultants on Religious Tolerance. Available at: http://www. religioustolerance.org/reciproc.htm. Accessed July 13, 2006. 4. Humanist Manifestos I and II. Ethics section. American Humanist Association. Available at: http://www.jcn.com/manifestos.html. Accessed July 13, 2006. 5. Achterberg J, Cooke K, Richards R, Standish L, Kozak L, Lake J. Evidence for correlations between distant intentionality and brain function in recipients: A functional magnetic resonance imaging analysis. J Altern Complement Med. 2005;11:965-971. 6. Wackerman J, Seiter C, Keibel H, Walach H. Correlations between brain
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13. 14.
15. 16. 17.
electrical activities of two spatially separated human subjects. Neurosci Lett. 2003;336:60-64. Standish L, Kozak L, Johnson L, Johnson LC, Richards T. Electroencephalographic evidence of correlated event-related signals between the brains of spatially and sensory isolated human subjects. J Altern Complement Med. 2004;10:307-314. Duane TD, Behrendt T. Extrasensory electroencephalographic induction between identical twins. Science. 1965;150-367. Radin D. Event-related electroencephalographic correlations between isolated human subjects. J Altern Complement Med. 2004;10:315-323. Sicher F, Targ E, Moore D, Smith HS. A randomized double-blind study of the effect of distant healing in a population with advanced AIDS–report of a small-scale study. West J Med. 1998;169:356-363. Jonas WB, Crawford CC. Healing, Intention and Energy Medicine. New York, NY: Churchill Livingstone; 2003:xv-xix. Chibnall JT, Jeral JM, Cerullo MA. Experiments in distant intercessory prayer: God, science, and the lesson of Massah. Arch Intern Med. 2001;161:2529-2536. Thomson KS. The revival of experiments in prayer. Am Sci. 1996;84:532-534. Dossey L, Hufford DB. Are prayer experiments legitimate? Twenty criticisms. Explore (NY). 2005;1:109-117. Dossey L. Reinventing Medicine. San Francisco, CA: Harper SanFrancisco; 1999. Radin D. Entangled Minds. New York, NY: Paraview; 2006:235. Ishii H, Nagashima M, Tanno M, Nakajima A, Yoshino S. Does being easily moved to tears as a response to psycholog-
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ical stress reflect response to treatment and the general prognosis in patients with rheumatoid arthritis? Clin Exp Rheumatol. 2003;21:611-616. Benson H, Dusek JA, Sherwood JB, et al. Study of the therapeutic effects of intercessory prayer (STEP) in cardiac bypass patients: a multicenter randomized trial of uncertainty and certainty of receiving intercessory prayer. Am Heart J. 2006;151:934942. Kalb C. Spirituality: don’t pray for me! Please! Newsweek Periscope. Available at: http://www.msnbc.msn.com/id/121128 10/site/newsweek/. Fogarty LA, Curbow BA, Wingard JR, McDonnell K, Somerfield MR. Can 40 seconds of compassion reduce patient anxiety? J Clin Oncol. 1999;17:371-379. Redelmeier DA, Molin JP, Tibshirani RJ. A randomized trial of compassionate care for the homeless in an emergency department. Lancet. 1995;345:1131-1134. Mittelman M. Quoted in: Traubman T. Wanted: Medical student, compassionate and personable. Haaretz. Available at: http://www.haaretz.com/hasen/pages/ RegisterSiteEng.jhtml?contrassI ⫽ null& requestid⫽233637. Accessed April 15, 2006. Mumford E, Schlesinger HJ, Glass GV. The effects of psychological intervention on recovery from surgery and heart attacks: an analysis of the literature. Am J Public Health. 1982;72:141-151. Einstein A. Quoted in: The Quotations Page. Available at: http://www.quotationspage. com/search.php3?homesearch⫽compassion &startsearch⫽Search. Accessed July 17, 2006.
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Compassion “How is one to live a moral and compassionate existence, when one is fully aware of the blood, the horror inherent in life, when one finds darkness not only in one’s culture but within oneself? If there is a stage at which an individual life becomes truly adult, it must be when one grasps the irony in its unfolding and accepts responsibility for a life lived in the midst of such paradox. One must live in the middle of contradiction, because if all contradiction were eliminated at once life would collapse. There are simply no answers to some of the great pressing questions. You continue to live them out, making your life a worthy expression of leaning into the light.” —Barry Lopez, Artic Dreams1 compassion: to suffer with another; sympathy for the suffering of others, often including a desire to help empathy: the ability to identify with and understand another person’s feelings or difficulties
he most profound healing event I personally remember was being touched by a nurse when I was recovering from anesthesia following an appendectomy. The surgery was a rushed-up affair that took place in the Student Health Center at the University of Texas at Austin, when I was a senior student preparing to enter medical school. I never met the surgeon beforehand; he thought it unnecessary. Neither did I meet the anesthesiologist in advance; he was too busy. When I awakened, I was anxious, alone, and in pain. I still did not know who my physician was, or what he had found at surgery. The nurse simply
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held my hand. Her lingering touch conveyed to me—silently, powerfully, unequivocally—that everything was going to be all right. It was; the pain vanished, along with the anxiety and sense of isolation. This simple act is seared into my memory as a profound example of the power of compassion. Heck, I became so enthusiastic about nurses I married one—Barbara—nine years later, 34 years ago.
COMPASSION, WISDOM TRADITIONS, AND GOLDEN RULES An emphasis on compassion and empathy lies at the heart of the major religious traditions that have sustained and nourished humanity for over two millennia. As theologian Karen Armstrong says, most of these traditions came into being at roughly the same time, during the socalled Axial Age, about 900 to 200 BCE. “Why should we go back to these ancient faiths?” Armstrong asks. “Because they were the experts. In this period of history people worked as hard to find a cure for the spiritual ills of humanity as we do today trying to find a cure for cancer.”2 We often forget that these great teachings had nothing to do with religion and religiosity. As Armstrong explains, “What has intrigued me is that none of them was interested in doctrines or metaphysical beliefs. [At that time] a religion was not about accepting certain metaphysical propositions: it was about behaving in a way that changed you. What the Axial sages put forward was that compassion was the key. Compassion doesn’t mean feeling
sorry or pity for people but feeling with the other, learning to dethrone yourself from the centre of your world and put another there. Not only would this be the test for any religiosity but it would also be the means of entering into enlightenment.”2 Compassion, therefore, now as then, involves radical surgery on the notions of I, me, and mine. Golden Rules are endorsements of compassion and empathy, and because compassion runs through all the great Axial traditions, it is not surprising that some version of the Golden Rule is found in all of them. Confucius was the first to propound such a recommendation: “Do not do to others as you would not have done to you.” As Armstrong says, “[Confucius] was the person who equated religion with compassion—it was compassion: it wasn’t about theology, it wasn’t about going to heaven, it wasn’t about defining what you meant by the divine or the sacred, it wasn’t about being right. It was about ‘humanheartedness,’ the exercise of compassion.”2 The Confucian sage Mencius3 agreed, saying, “One should not behave towards others in a way which is disagreeable to oneself.” Rabbi Hillel, the older contemporary of Jesus, once told a Pagan who had asked him to define the whole of Judaism, “That which is hateful to you do not do to your neighbor. That’s the Torah. The rest is commentary; go and learn it.”2 As all Christians know, Jesus propounded a similar version: “And as ye would that men should do to you, do ye also to them likewise” (Luke 6:31).
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In Taoism, we find, “Regard your neighbor’s gain as you own gain, and your neighbor’s loss as you own loss.”3 Within Islam, we read, “Not one of you truly believes until you wish for others what you wish for yourself.”3 Similar views permeate traditions outside the Axial traditions. For example, the Roman Pagan religion contained this exhortation: “The law imprinted on the hearts of all men is to love the members of society as themselves.”3 And as Black Elk (1863-1950), a Sioux medicine man, said of Native American spirituality, “All things are our relatives; what we do to everything, we do to ourselves. All is really One.”3 And from the Pima tradition, “Do not wrong or hate your neighbor. For it is not he whom you wrong, but yourself.”3 Compassion, of course, is not limited to the religious. The contemporary philosophy of secular humanism, which many religious fundamentalists love to hate, also affirms compassion and empathy. In the Humanist Manifesto II, we find, “ critical intelligence, infused by a sense of human caring, is the best method that humanity has for resolving problems. Reason should be balanced with compassion and empathy and the whole person fulfilled.”4
A TREASURE HIDDEN IN PLAIN SIGHT At first glance, there seems to be nothing new about valuing compassion; it’s an idea that has been around for thousands of years in both the religious and secular worlds. But perhaps it is the universality of compassion that has lulled us into undervaluing its importance. Compassion has largely become a treasure hidden in plain sight, a phenomenon toward which we are selectively blind. Of course, everyone says compassion is important, and compassion and empathy are widely acknowledged by healthcare professionals to be characteristics of humane care. But when serious illness strikes, they are often regarded as less important than physical interventions such as drugs and surgical procedures. But as we shall see, a variety of evidence suggests that compassion and empathy are correlated with positive health outcomes, and they can evoke measurable physiological effects in sick persons, even when the individual is unaware that these factors are being extended to them. As a consequence, compassion and empathy should not be
2
regarded as optional niceties in medical care but as fundamental factors promoting recovery from any illness.
EVIDENCE OF A COMPASSION EFFECT Mind-body researcher Jeanne Achterberg is a veteran explorer of indigenous healing methods and the role of imagery and visualization in healthcare. These interests led her to the island of Hawaii, where she spent two years observing the culture and healing methods of indigenous healers, many of whom took her into their confidence and freely shared with her their methods. Achterberg was interested in exploring whether healers can exert a positive influence on a distant individual with whom they have no sensory contact, as healers universally claim. She and her colleagues5 at North Hawaii Community Hospital in Waimea recruited 11 indigenous healers to participate in a healing experiment. The healers were not casually interested in healing; they had pursued their healing tradition for an average of 23 years. Each of them was asked to select a person they knew, with whom they had previously worked professionally, and with whom they felt an empathic, compassionate, bonded connection, to serve as the recipient of their healing intentions. Although the researchers referred to the healing endeavors as distant intentionality, the healers themselves described what they did in various ways—prayer, sending energy, good intentions, or wishing for the highest good. Each recipient was isolated from all forms of sensory contact with the healer and placed in a functional magnetic resonance imaging scanner. The healers then sent their various forms of distant intentionality to their subjects at random, twominute intervals that could not have been anticipated by the recipient. When the functional magnetic resonance imaging brain scans of the subjects were analyzed, significant differences in brain function were found between the experimental (send) and control (no-send) conditions. There was less than approximately one chance in 10,000 that these differences could be explained by chance (P ⫽ 0.000127). The brain areas that were activated during the healing or send periods were the anterior and middle cingulate, precuneus, and frontal regions.
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When the experiment was repeated, using subjects with whom the healers felt no empathic bonding, no significant functional magnetic resonance imaging changes were found in the recipients during either the send or no-send conditions. This study suggests that compassionate, empathic healing intentions can exert measurable physical effects on a recipient, even when the recipient is not aware when the attempt is being made. This study appears to shred the perennial complaint of skeptics that these are placebo effects, due only to suggestion, expectation, and positive thinking on the part of the recipient. The study of Achterberg and colleagues5 does not stand alone. Several prior experiments have examined correlations in brain function between empathic individuals who are widely separated and who have no sensory contact with each other.6-9 A proof-of-concept study, the experiment of Achterberg and colleagues was designed to test whether a nonlocal, compassion-mediated, physiological effect exists. It did not explore whether or not such an effect could alter the course of an illness. But prior studies have done just that, including in AIDS. In 1998, researcher Sicher and colleagues10 at the University of CaliforniaSan Francisco School of Medicine/California Pacific Medical Center studied the effect of distant healing intentions on patients with advanced AIDS. In a doubleblind pilot study, they found that AIDS patients who were extended healing intentions from veteran, seasoned healers fared better than those who were not: 40% of those not sent healing intentions died, compared to none of those who were extended healing intentions. The study was expanded and repeated. By this time, multidrug, antiretroviral therapy had come into widespread use, and all the subjects in both the intervention and control groups were treated with such. Probably as a consequence, there were no deaths in either group in the expanded study. However, the intervention group who received distant healing intentions had a statistically lower incidence of AIDS-associated illnesses, a lower rate of hospitalization, shorter hospital stays, fewer physician visits, and better psychological profiles during the course of illness when compared
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with the control group, which was treated with only antiretroviral medications. The healers in this study, as in the experiment of Achterberg and colleagues5 that would come later, were not casually interested in healing; healing was a serious pursuit for them and they had spent many years practicing their calling. Nearly all gifted healers recognize the importance of deep caring and love toward the individual in need. Their depth of compassion may set them apart from less-experienced healers and may account for why some healing studies achieve positive results whereas others do not. This is a touchy point. Many people insist that healing is a purely democratic pursuit that can be practiced with equal facility by anyone. This is a noble thought, but is probably an exaggeration. W recognized different levels of excellence in all pursuits. Prodigies exist in music, literature, athletics, mathematics, cooking, art, and so on. Why should healing be different? And the difference may be due largely to the degree of compassion, empathy, and sense of oneness the healer is able to summon during the actual healing effort.
SUPPORTIVE EVIDENCE Studies exploring nonlocal healing effects are numerous. In a 2003 analysis of this field, Jonas and Crawford11 found over 2,200 published reports, including 122 controlled laboratory studies and 80 randomized controlled trials. How good are the controlled clinical and laboratory studies? Using strict Consolidated Standards of Reporting Trials to assess the quality of the studies, Jonas and Crawford gave an “A,” the highest possible grade, to laboratory studies involving the effects of intentions on inanimate objects such as sophisticated random number generators. They gave a respectable “B” to the nonlocal healing studies involving humans, cells, tissues, plants, and animals. The depth and breadth of this research remains little known among healthcare professionals. Consequently, the occasional critiques of this area are almost never comprehensive, and they often rely on philosophical and theological propositions about whether remote healing can or should work, and whether experiments involving healing intentions and prayer are heretical or blasphemous.12,13 Dossey and Hufford14 have examined the 20 most
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common criticisms of this field and found most of them unconvincing. On balance, these studies, of which approximately one half show statistical significance, attest to the fundamental importance of compassion and empathy in healing. Although researchers have no “compassion meters,” the healers themselves generally insist that an emotional bond is crucial in eliciting the healing effect, a contention that was affirmed in the experiments of Achterberg and colleagues5 and Sicher and colleagues,10 as mentioned.
HYPOTHESES An obstacle to a serious consideration of this evidence is the lack of an accepted explanation of how these studies could be true. However, many hypotheses recently have been advanced by a variety of scholars, including Nobelists, in fields such as neurobiology, mathematics, and physics.15 Several invoke concepts based in recent discoveries in quantum physics. Researcher Dean Radin,16 in his recent book Entangled Minds, suggests quantum entanglement as a hypothesis for nonlocal, paranormal, or psi-type events, including distant healing effects. In the following passage, one may substitute “nonlocal healing effects” for “psi”: If physics prohibits information from transcending the ordinary boundaries of space and time, then from a scientific point of view psi is simply impossible. But here’s where things become interesting. [T]he old prohibitions are no longer true. Over the past century, most of the fundamental assumptions have been revised. This is why I propose that psi is the human experience of the [quantum-] entangled universe. [T]he ontological parallels implied by [quantum] entanglement and psi are so compelling that i believe they’d be foolish to ignore.16 Quantum physics does not validate nonlocal, compassion-based healing or any other consciousness-mediated event, but it does provide potent metaphors that may prove helpful in understanding these phenomena. In any case, the lack of an explanatory theory does not invalidate data. Often in the history of medicine we have known
that something works before we have understood how it works, as our use of aspirin, colchicine, penicillin, general anesthetics, and many other therapies attests.
COMPASSION AND TEARS A revealing study of patients with rheumatoid arthritis (RA) suggests that we cry as a way of relieving chronic pain and inflammation.17 Japanese researchers at Tokyo’s Nippon Medical School exposed RA patients to deeply emotional visual stimuli and correlated various neuroendocrine and immune responses in their bodies with how easily they were brought to tears. These responses included blood levels of the stress hormone cortisol, the immune protein interleukin-6, and CD4, CD8, and natural killer immune cells. They found that patients who were easily moved to tears generally did better clinically over the course of a year than those who did not cry, and did so with less pain, swelling, and need for pain medications. The researchers concluded that shedding tears suppresses the influence of stress on their neuroendocrine and immune responses, making their RA easier to control. Shedding tears in this study demonstrated an ability to experience compassion, empathy, and a sense of connectedness with the evocative situation or the person in need. This experiment suggests that compassion is good for the individual experiencing it, as well as for the person to whom it is directed. This is consistent with the adage that healing efforts benefit the healer as well as the healee. This study goes against the grain of the grin-and-bear-it school, which says that pain and illness should be endured without complaint or whimper.
BREAKING THE BOND People commonly say that they pray for their loved ones when they are sick. This implies that they know the individual in need, that an emotional bond exists between them, and that they are willing to pray for them unconditionally and without reservation. In contrast, many healing studies involve strangers praying for strangers. Moreover, the double-blind nature of these experiments means that healing is not unconditional, because the patients are told that they may or may not be prayed for; they are in a cloud of uncer-
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tainty. As a result of these conditions, in these experiments the rich personal connection, emotional bonding, and unconditional support between loved ones is severely reduced or eliminated. These are surely reasons why these studies frequently show marginal, neutral, or even negative results. An example is the well-known 2006 prayer study from Harvard Medical School involving 1,802 postcoronary artery bypass surgery patients at six US hospitals.18 Of these patients, 604 were told they might or might not be prayed for, and were; 597 were told they might or might not be prayed for, and were not; 601 who were told they would be prayed for, and were. Prayers were offered by two Catholic groups and one Protestant group. The intercessors were provided brief written prayers they were required to recite, but were otherwise free to use their own. They were provided with the first name and the initial of the last name of the prayer recipients. Prayers were initiated on the eve or day of surgery and continued for two weeks. Among the group told that they might or might not be prayed for and were, 52% had postsurgical complications. Among those patients told they might or might not be prayed for, and were not, 51% had postsurgical complications. Among the group told they would be prayed for and were, 59% had postsurgical complications. There is no agreement among analysts why prayer did not demonstrate a healing effect, and why those who knew with certainty that they would be prayed for and were fared the worst of all. Perhaps the reasons underlying these results are straightforward. Nowhere on earth is prayer used the way it was employed in the Harvard experiment (except in other prayer experiments). In real life, prayer is employed lovingly, compassionately, and empathically between loved ones, and it is offered unconditionally, not as a “maybe” or a “perhaps.” The media had a field day with the Harvard study. “Don’t pray for me! Please!” trumpeted a Newsweek report.19 Wrenching healing from a real-life context and artificializing it to suit the whims of researchers is a recipe for experimental disaster. Only by honoring the crucial role of compassion, empathy, and unconditional love—admirably demonstrated in
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the study of Achterberg and colleagues5— can researchers hope to reveal some of the mysteries of healing.
RESTORING THE BOND A perennial criticism by busy healthcare practitioners is that time is limited and resources are few; therapists don’t have the time required to deliver adequate physical care, let alone create a compassionate, empathic bond with a patient. The difficulties of conveying compassion may be overrated. Oncologist Linda A. Fogarty, of Johns Hopkins University School of Hygiene and Public Health, and colleagues20 demonstrated that conveying compassion and empathy need not be time intensive. They found that the perception of a physician as compassionate and empathic could be achieved by showing patients a compassion-oriented video whose duration was only 40 seconds. Another objection against rendering compassionate care is that it makes patients excessively dependent on their physician, thereby increasing consumption of healthcare resources. In other words, if patients like the doctor-patient encounter, they’ll want more of it. Researcher D. A. Redelmeier, of the University of Toronto, and his colleagues21 showed that this is not necessarily the case. In a randomized, controlled study involving homeless adults who rely on emergency rooms for care, they tested whether compassionate care, by improving patient satisfaction, can alter subsequent use of emergency services. They found that compassionate care of homeless adults decreases repeat visits to the emergency department, compared with care delivered in an emotionally neutral way. Medical educators may be waking up to the value of compassion in healing. In 2006, medical schools in Israel altered their admission procedures to require the presence of compassion and empathy in every entering medical student. High grades and intellectual skills continued to be important, but were judged insufficient to qualify one for admission. “It bothered us,” said Professor Moshe Mittelman, head of the admissions committee at Tel Aviv University, “that here and there you meet a doctor about whom you say, ‘He may know medicine, but he is not a decent human being.’ We are a school that educates people to work in the medical pro-
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fession, which is not only science but also humanism and dealing with people.”22 The majority of healing studies suggests that a healing effect is real and that it is mediated by compassion and empathy. Evidence further suggests that an empathic, compassionate bond between physicians and patients can be established quickly, and that compassionate care does not result in an increased demand for healthcare services. Why does this matter? Compassion and empathy are humanitarian gestures that not only make needy patients feel better, but are also correlated with measurable physiological effects and improved clinical outcomes. For these reasons, they are important elements in the decent care of any illness. Objections to compassion and empathy as integral components in disease treatment often conceal a mind-body duality in which emotional, psychological, and spiritual factors are considered less real than physical ones. But as the above evidence suggests, mind-body separation is not fundamental. As researcher Emily Mumford and colleagues23 suggested over two decades ago, “It is often argued that the medical care system cannot afford to take on the emotional status of the patient as its responsibility. Time is short and costs are high. However, it may be that medicine cannot afford to ignore the patient’s emotional status assuming that it will take care of itself.” It is a measure of our physicalistic age that we require “hard” evidence for the value of compassion in caring for the sick. Historians may look back with amazement on how we agonized over the role of compassion in healing, when for nearly all of human history its importance was selfevident. Yet, the vision remains. The value of compassion has been obvious to some of the truly great scientists of our age. No better example exists than Albert Einstein, whose ringing endorsement of compassion deserves to be a mantra for our time, because it is a remedy for the myriad hatreds that separate us from one another and from our endangered natural world: A human being is part of a whole, called by us Universe, a part limited in time and space. He experiences himself, his thoughts and feelings, as something separated from the rest—a
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kind of optical delusion of his consciousness. This delusion is a kind of prison for us, restricting us to our personal desires and to affection for a few persons nearest us. Our task must be to free ourselves from this prison by widening our circles of compassion to embrace all living creatures and the whole of nature in its beauty.24 Larry Dossey, MD Executive Editor
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