Summary of a lecture by George P. Chrousos in the Conference of Human Empathy and Compassion, at the Library of Congress, Washington DC, USA in the spring of 2011.
“He who has committed himself to the art of medicine must convert wisdom to medicine and medicine to wisdom.” Hippocrates, 5th c BCE
Compassion, i.e. the ability of empathizing with other human beings -or by extension with other living beings- and of expressing this empathy with acts of mercy, is a virtue of the soul and one of its most exalted properties. However, the feeling and expression of compassion can take a grave toll on a person, when certain conditions are not met. Before going over these conditions, it would be of interest to define exactly what we mean by the term compassion. The ability to empathize is a fundamental, deeply inherent and necessary property of human beings. Missing the feeling of empathy is utterly pathological for both the person that lacks it and for those around him or her. Indeed, two human conditions, both individually and socially detrimental, that are characterized by deficient empathy, are autism and psychopathy.
Recently, the neurological substrate of inter-human communication and attunement and, hence, socialization has started to be revealed. Special neurons, the “spindle” or “von Ecomomo” neurons in the prefrontal, insular and anterior cingulate cortex subserve social interactions, while other “mirror” neurons resonate between human beings in visual communication, a phenomenon which has been termed “resonance”. I believe “consonance” would be a more accurate appellation.
“Em-pathy” is a Greek term meaning feeling inside another human being, as opposed to “sym-pathy”, feeling together or in parallel with another person, or “a-pathy”, not feeling what somebody else feels at all. The Latin term “com-passion” is a congener of “sympathy”, however, over time it has come to mean empathy combined with action based upon the feeling.
Expression of compassion means interaction between two emotionally resonating stressed persons: the caring and the cared. The recipient of compassion is already the victim of some calamity, serious disease, trauma, loss etc, and, hence, by definition, in a state of distress. The caring compassionate human feels the victim’s distress, vicariously, by empathizing, and is, thus, also distressed. In both instances, distress is expected to take a toll. What can be done to minimize the impact of distress in both the cared and the caring? The proper care of the victim is palliative and, hence, diminishing his or her distress. On the other hand, administration of care should not take a toll on the caregiver influencing his or her wellbeing and, naturally, because of this, potentially decreasing the quality of care provided. This is what we call “principled compassion”. The caregiver empathizes with and achieves the best possible comfort for the cared without harming herself or himself in the process. Actually, and even better, the caring might transform the compassioned act into a positive experience arising from the feeling of altruism.
There have been many studies on caregivers, including relatives, or proffessionals, such as physicians, nurses and others involved in the care of the sick, all showing frequently the negative psychological and physical effects of chronic stress. These include increased psychiatric and cardiovascular morbidity and mortality and a curtailment of their life expectancy. Burnout, depression and post-traumatic stress disorder are common in caregivers and there is an increased risk of suicide. All of these are explained by the deleterious effects a chronically activated stress system and its mediators may have on the mind and body.
The genetically and constitutionally unsuitable and unprepared caregiver, who is distressed during the provision of care, usually provides suboptimal care to the already hurting subject. In that distressed person’s behavior we can distinguish the three hardwired stress program options of a stressed subject: flight, fight or freeze. In his or her behavior we see the effects of an activated amygdala -fear and anger- and stress system-high levels of the stress hormones cortisol, adrenaline and noradrenaline- and a suppressed dopaminergic reward system, i.e., dysphoria or even anhedonia. Fear is expressed as avoidance or appearance of lack of caring, while anger may be associated with aggressive behavior toward the cared, her or his relatives, and/or the other caregivers, even against the self. Freeze or helplessness is expressed as emotional numbing. Lack of “reward” and, in fact, presence of actual “punishment”, is expressed as anxiety, depressive feelings, anhedonia and guilt. Undesirable changes in appetite and sleep patterns appear, and the unwanted obesity, metabolic syndrome, and cardiovascular changes that accompany chronic stress gradually establish themselves. It is clear that people that have to provide optimal care to less fortunate human beings without suffering the consequences of their empathy must be prepared for this difficult task and this preparation comes down to “principled compassion”, which is, in my opinion, proper stress management of the caregiver.
To decrease the effects of stress on our organism, we can take two not mutually exclusive actions: First, we can try to change the environment that causes the disturbance and, second, if this is not possible, to change our coping strategies towards the stressor. The former is frequently, but not always, unavoidable, while the latter is usually achievable. Empathy that damages the person that expresses it is an uncontrolled emotional response, activates the stress system, with all that this entails. The solution is empathy combined with emotional control and, hence, good stress coping or management, i.e. compassion. Such principled compassion cannot only prevent the feelings and somatic consequences of distress, but can in fact provide the caregiver with the superior mental reward of service to others, altruism and other-centeredness.
While thinking on empathy and compassion and what they mean for the caring and the cared, I realized that principled compassion can be natural in a small proportion of fortunate humans that are this way because they have the right combinations of genes and exposure to a propitious developmental environment. Unfortunately, the majority of human beings have to struggle for long to achieve this equanimous state, which is a component of or at least has many similarities with the exalted state of wisdom.
The qualities, which the Greek sages deemed present in every wise person—pertaining respectively to the logisticon, thymeticon, epithymeticon, and dioraticon — correspond in Latin to the four cardinal virtues of prudence, fortitude, temperance, and justice. On the other hand, in his recent book on Wisdom, S. Hall (Wisdom: From Philosophy to Neuroscience, Vintage Books, 2011) summarized the ingredients of wisdom as follows: Fearless aggregation of knowledge, emotional regulation, dealing with uncertainty, moral judgment, sense of fairness, and other-centeredness, including principled compassion.
After a long discussion with Joan Halifax, we re-classified these ingredients of wisdom into 4 categories, those pertaining to eugnosia, i.e. proper attainment and use of knowledge, euthymia, i.e., proper emotional control, eupraxia, i.e. proper behavior, and eusomia, i.e., good physical health. These are summarized in Figure 1 and shown below:
Proper Emotional Regulation -Euthymia
Dealing with Uncertainty
Patience- Delayed Gratification
Good Somatic health -Eusomia
It is obvious that the attainment of wisdom requires time and effort. However, it is all worth it. Wisdom leads to feeling good and getting from life all life can give to a human being.
Let me close with the words of three wise men. Aristotle in his eulogy at his teacher’s Plato funeral said of him:
“…. he showed with his deeds and the method of his logic that for somebody to be happy one has to be good…”
On the other hand, John Mill gave a statement that summarizes the connection of eupraxia with happiness:
“ Those only are happy, who have their minds fixed on some object other than their own happiness; on the happiness of others, on the improvement of mankind, even on some art or pursuit, followed not as a means, but as itself an ideal end. Aiming thus at something else, they find happiness by the way.”
Finally, Epicurus, a totally misunderstood ancient philosopher, wrote a letter to his student Idomeneus on the last day of his life, showing that death is not necessarily stressful and that a wise person can temper his feelings and even be serene at those last moments of life.
“I have written this letter to you on a happy day to me, which is also the last day of my life. For I have been attacked by a painful inability to urinate, and also dysentery, so violent that nothing can be added to the violence of my sufferings. But the cheerfulness of my mind, which comes from the recollection of all my philosophical contemplation, counterbalances all these afflictions. And I beg you to take care of the children of Metrodorus, in a manner worthy of the devotion shown by the young man to me, and to philosophy”
I am convinced that the higher wisdom one attains in his or her life, the better it is for him, those around him and the Society at large. Providing care to the severely ill is an act that can be associated with major distress that is expected to harm people who are not inherently “wired” or prepared mentally and emotionally to deal with it. Not all young physicians, nurses or patient relatives are born with the innate ability to control their emotions and provide care with principled compassion. All of us should be preparing for coping with stress and learn from others, and this is a life-long process. In the mean time, the general rules that help develop resilience to stressors should be followed: adequate sleep, proper diet, moderate bodily exercise, some form of brain exercise and being or doing good. Preparation for dealing with stress can convert even caring for a sick fellow human, a process that is usually associated with distress, into an ultimately positive experience, a process characterized by Hans Selye as eustress, i.e. stress with a good outcome.
George P. Chrousos, MD, Professor and Chairman, First Dept of Pediatrics, University of Athens, and John Kluge Chair in Technology and Society, Library of Congress, Washington, DC