Challenging questions and ethical obligations: the ethics of everyday practice > 21 January 2015

Paquita de Zulueta


Compassionate conversations – the paradox of power and vulnerability

Suffering is caused by the loss or threatened loss of what we most cherish and involves the many dimensions of human existence. [1] Compassion is described as a deep awareness of the suffering of another coupled with the strong motivation to relieve it. [2,3] Even if suffering cannot be fully alleviated, ‘being with’ a patient – compassionate solidarity – can provide solace and support and help to construct a healing narrative. [1,2] The relief of suffering is arguably the primary goal of medicine. Despite this, empirical research of clinician-patient interactions reveals a systematic neglect of the existential domain of patients’ suffering and of the patients’ lifeworld, leading to a ‘moral offence’ and further suffering. [4,5] Patients’ accounts mirror this. [6,7] Unfortunately medical pedagogy disvalues emotional engagement and privileges the objective (science) over the ‘subjective’ (existential), leading to a narrow focus on the biomedical aspects of illness. [8]

Another neglected area in clinical ethics discourse is the role of power in relationships, and the understanding that disengagement is a device to avoid sharing power with the patient. [9] Compassion, paradoxically, involves the synthesis of power and humility – a willingness to reveal vulnerability to the sufferer, to acknowledge common humanity, whilst honouring the uniqueness of the patient’s narrative and retaining the ‘necessary distance’, or perspective, to lend strength and offer insight. [10] Compassion can be misrepresented, with power firmly held by the clinician and the patient depicted as vulnerable, helpless, and lacking any inner resources. Instead, I propose that respecting the dignity of patients involves both validation of their suffering as well as recognition of their strengths and achievements, and their capacity to self heal. Furthermore, compassion is a dialogical, iterative process and not unidirectional. [11] Contrary to widely held views, compassionate conversations do not require significant added time or effort. [12]

I will draw on the research literature as well as my personal experience as clinician and therapist to demonstrate these propositions. More specifically I will critique an account of ‘compassionate communication’ that in my view shows a failure of the clinician to engage with the patient’s lifeworld and to co-construct a healing narrative. [12]



1. Cassell EJ. The Nature of Suffering and the Goals of Medicine. 2nd edn. NY: Oxford University Press, 2004.

2. van der Cingel M. Compassion and professional care: exploring the domain. Nursing Philosophy 2009;10:124-136.

3. Chochinov H. Dignity and the essence of medicine: the A,B,C and D of dignity conserving care. BMJ 2007;335:184-7, p.186.

4. Agledahl KM, Gulbrandsen P, Førde R. et al. Courteous but not curious: how doctors’ politeness masks their existential neglect. A qualitative study of video-recorded patient consultations. J Med Ethics 2011 doi:10.1136/jme.2010.041988

5. Barry CA,Stevenson FA, Britten N et al. Giving voice to the lifeworld. More humane, more effective medical care? A qualitative study of doctor-patient communication in general practice. Soc Sci & Med 2001;53:487-505.

6. Sweeney K, Toy L, Cornwell J. A patient’s journey: mesothelioma. BMJ 2009;339: b2862:512 doi:10.1136/bmj.b2862.

7. Carel H. Illness. The Cry of the Flesh. Durham: Acumen, 2008 (Art of Living Series):44.

8. Pedersen R. Empathy development in medical education – a critical review. Medical Teacher 2010:32:593-600.

9. Brody H. The Healer’s Power. New Haven: Yale University Press,1992.

10. de Zulueta P. Compassion in 21st century medicine: is it sustainable? Clinical Ethics 2013; 7(4):119-128. Doi:10.1177/1477750913502623.

11. Frank. A. The Renewal of Generosity. Illness, Medicine and how to Live. Chicago: University of Chicago, 2004.

12. Mikesell L. Medicinal relationships: caring conversations. Medical Education 2013;47:443-52. Doi:10.1111/medu.12104

13. Cameron RA, Mazer BL, DeLuca JM et al. In search of compassion: a new taxonomy of compassionate physician behaviours. Health Expectations 2013;1:1-14. Doi:10.1111/hex.12160



(to be confirmed)


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