Microsoft Word - 3 Journal of Medical Ethics and History of Medicine Compassion in Jewish, Christian and secular nursing. a systematic comparison of a key concept of nursing (Part I) Silvia Käppeli Center for Nursing Research and Development, University Hospital Zürich, Switzerland *Corresponding author: Silvia Käppeli Address: Center for Nursing Research and Development, University Hospital Zürich, Switzerland. Tel: (+41) 44 25 53 954 Telefax: (+41) 44 25 54 395 E-mail: silvia.kaeppeli@usz.ch Received: 3 Oct 2008 Accepted: 15 Nov 2008 Published: 1 Dec 2008 J Med Ethics Hist Med. 2008; 1:3. © 2008 Silvia Käppeli; licensee Tehran Univ. Med. Sci. Abstract Background The topos of the Compassionate God is a dominant motive of the Jewish and Christian traditions. It is relevant for nursing because it asks the nurse to imitate God so as to become God‐like. Also, to think that God suffers with the suffering believers is thought to give comfort to them. Because in the western world the topos of the Compassionate God represents the basis of the ethics of compassion/caring, this piece of basic research is important for clinical practice. This study explores to what extent Jewish and Christian nursing adhered to the biblical topos of the Compassionate God at different periods and in different cultural contexts. Method A mixed methods approach was used. It included variations of hermeneutical text analysis as used in historical, philosophical, theological, science of religion, and nursing research. Results The analysis of the literary sources shows that the topos of the Compassionate God was interpreted differently in different cultural contexts. However, at all times it directed religious and secular nursing. Since the beginning of the 21 century it builds the core of “compassionate caring” as propagated by North American nursing science. Conclusions The topos of the Compassionate God laid the foundation of the tradition of the ethics of compassion in nursing. More research is required to learn whether it also plays a role in Islamic nursing. Keywords: Compassion, Caring, Religious and secular nursing, Nursing ethics. J Med Ethics Hist Med 2008, 1:3 Silvia Käppeli Page 2 of 7 (page number not for citation purposes) Introduction In this research project I investigated if and how the biblical topos 1 of the Compassionate God was received in the spirituality, theologies, ideologies and theories of nursing during the 1 st through the 4 th century of the Common Era (CE) and in the 19 th and 20 th centuries. The topos of the Compassionate God is one of several motifs of the Jewish and Christian traditions which give comfort to the suffering believers. To think that God suffers with them can help patients bear their misery. The scriptures of both religious communities contain many texts which give evidence for both, the need of suffering people for a Compassionate God and for his continuing comfort (1). In the Old Testament (OT) a Psalmist let God say: “When they call to me, I will answer them; I will be with them in trouble, I will rescue them and honor them. With long life I will satisfy them, and show them my salvation” (2: Ps 91:15). In the beginning of the Jewish and Christian traditions the topos of the Compassionate God served as a model for people who cared for the sick. Jews and Christians were asked to base their practice on this topos. Those who adhered to it hoped to do justice to both the need of the suffering and to religious expectations. Thesis The thesis for this research was that the biblical topos of the Compassionate God provides the original model of compassionate nursing. It represents the core of today’s ethics of compassion and of caring in nursing. Research questions The focus of this study lay on the history of compassion in nursing. In order to clarify the proposed thesis I investigated the following questions: 1. What substantive elements constitute the topos of the Compassionate God in the Old Testa- ment, in the Christian New Testament (NT) and in the Jewish Talmud? 2. Can the topos be identified in later generations of Jewish and Christian texts (Church Fa- thers/Midrashim) 3. Was the topos received in Christian, Jewish and secular nursing texts of the 19 th /20 th century? Methodological approach This research is based on the assumption of a typological utilization of the tops of the 1 In this context “topos” can be compared to a theological construct; it can be an idea or become a dogma. Compassionate God in nursing. “Typological” means that an originally historical event – in this case the Compassionate God as a spiritual reality for Jews and Christians – becomes a symbol or a paradigm which no longer is tied to the historical event. Finally, the symbol is more important than the event which produced it. This process of transformation makes possible the transfer of past events (in this case the experience of God’s comfort to people in troubling situations) into the present or into the future and the generalization of a paradigmatic event (3). To investigate the history of a particular topos means to investigate its interpretation during various historical periods and in different societal contexts (4, 5). Such research has to be transdisciplinary and methodologically pluralistic. It includes aspects of historical research (the analysis of the historical contexts of nursing (6), of philology (the clarification and interpretation of words and concepts such as “compassion”), of theology (the analysis of traditions of suffering) (7), aspects of the science of religion (the comparison of defined parts of Christianity and Judaism) (8, 9), of nursing science (the investigation of the consequences of compassion) (10) and of social research. This variety of perspectives required the utilization of all available sources. Linguistic and hermeneutical problems a) Compassion presupposes an experience of suffering, and any interpretation of compassion in a given text requires a qualitative and quantitative analysis of this underlying suffering and its context. This means that “compassion” remains a multifaceted and ambiguous concept. b) “Compassion” is a comprehensive concept which includes the total of the experiences, expressions, activities of and interactions with the suffering. Concepts such as compassion represent “worlds”. c) The Rabbinical texts are of Semitic origin, the Christian texts follow Greek tradition. Hence in the rabbinical texts stories, in the Christian texts rather abstract conceptualizations dominate. This raises the question of how to compare narrative descriptions with concepts. d) Many New Testament and Talmudic texts do not describe extensively the qualities required of the carers but refer to an Old Testament text which has to be consulted for adequate interpretation. e) The variety of expressions containing aspects of compassion presented a serious problem as the following examples show (11, 12, 13): Hebrew: Chamal, rachamim, chesed, zeddaka, ahava J Med Ethics Hist Med 2008, 1:3 Silvia Käppeli Page 3 of 7 (page number not for citation purposes) Greek: sympaschein, sympatheo, splanchni- zomai, oiktirein English: compassion, empathy, sympathy, caring German: Mitgefühl, Empathie, Mitleid, mitleiden To discover the true meaning of these expressions in a given context a study of the texts in their original language was necessary. Steps in the research process The investigation of the research questions required the following research steps: 1. Analysis of Old and New Testament and Talmud texts to establish the topos of the Compassionate God 2. Analysis of texts of the Rabbis and of the Church Fathers from the 1 st through the 4 th century CE 3. Analysis of the Christian, Jewish and secular nursing literature of the 19 th /20 th century (USA, German speaking countries) 4. Comparative analysis of results according to the research questions Selection of the research material The research material for the investigation of the first and the second research questions originates mainly in the eastern Mediterranean world. The time of consolidation of Rabbinic Judaism and Christianity were characterized by rich literary activity. The texts answering the third research question originate in the western world. During the 19 th and the 20 th centuries in the German speaking countries the protestant and catholic nursing orders as well as of Jewish and secular schools of nursing started. This also applies to the American nursing scene. At the same time in both places humanita- rian, social science, philosophical and New Age approaches to nursing developed. I selected the research material according to two principles: a) terminological selection involving texts which contain the word compassion, b) subject related selection involving texts which imply compassion. The research material included Jewish and Christian sources (Old Testament, Babylonian Talmud, Midrashim, New Testament, Church Fathers) in their original languages and in various translations; secondary literature of scholars with expertise in the relevant substantive fields or language; Modern texts (historical documents, reports, comments, diaries, biographical notes, rules of institutions, nursing literature). Results The systematic hermeneutical analysis of the selected literature shows that the topos of the Compassionate God forms the foundation of the ethics of compassion. It represents a dominant tradition of nursing since its documented beginnings. In this section I will present some of the literary evidence answering the research questions and supporting this thesis. What substantive elements constitute the topos of the Compassionate God in the Old Testament, in the Christian New Testament and in the Jewish Talmud? The writings of the Rabbinic and early Christian texts are based on the Old Testament (OT). The following of these OT-reference texts illustrate God’s closeness to and compassion with his people. Isaiah paraphrases God as follows: “For this says the High and Lofty one who inhabits eternity, whose name is Holy: I dwell in the high and holy place and also with those who are contrite and humble in spirit, to revive the heart of the contrite …” (2: Isaiah 57:15-19). In another place Isaiah says: “… it was … His presence that saved them (the Israelites); in His love and in His pity He redeemed them; He lifted them up and carried them all the days of old” (2: Isaiah 63:9). Referring to the meaning of such texts, Matthew, an Evangelist of the Christian New Testament said: “This was to fulfill what had been spoken through the prophet Isaiah: ‘He took our infirmities and bore our diseases’ “(2: Mt 8:17). Probably the clearest witness of the image of God, who gets involved actively in the fate and in the suffering of the (prosecuted) believers is Hebrews (2: 4:15) the author of which states: “For we do not have a high priest (Christ) who is unable to sympathize with our weaknesses, but we have one who in every respect has been tested as we are, yet without sin.” The most powerful NT-metaphor which teaches compassion to the Christians is the parable of the Good Samaritan (2: Lk 10:25-37). Also the Jewish Talmud implies both God’s compassion and man’s obligation to imitate Him. In the Talmud Rabbi Chama ben Chanina referred to the first and second OT-books of Genesis and Deuteronomium, when he addressed the members of his community: “’Ye shall walk after the Lord your God’ (2: Dtn 13:5) … The meaning is, to walk after the attributes of the Holy One, blessed be He … He visited the sick, for it is written: ‘And the Lord appeared unto him (Abraham) by the oaks of Mamre’ (2: Gen 18:1), so do thou also visit the sick…’” (14: bSota 14a/bNed 40a). In another place the Talmud teaches: “… and He will have mercy upon you and show mercy to you. Who has compassion with his fellow human beings will be J Med Ethics Hist Med 2008, 1:3 Silvia Käppeli Page 4 of 7 (page number not for citation purposes) shown mercy in heaven …” (14: bSab 151b). Rabbi Akiba referred to the Psalms when he wrote: “Not visiting a sick person equals shedding blood” (14: bNed 40a). “Who visits a sick person will be saved from the punishment of purgatory, because it is written (2: Ps 41:2): ‘Hail him who cares about the weak, in times of misfortune the Lord will serve him’ and “weak” means a sick person. What is his reward in this world? The Lord will protect him and keep him alive …” (14: bNed 39b). Many teachings about and descriptions of the compassionate God in the Holy Scriptures of both religions converge in a few elements that constitute the topos of the Compassionate God: • He is existentially present near the suffering. • He is available for them. They can pray to him any time. • He is their advocate. • He is committed to their care. • He is actively involved in their suffering. • He is faithful and dependable. • He suffers Himself because he is compassio- nate. In their holy scriptures Jews and Christians are equally asked to imitate God’s attributes and acts. Moreover they are promised a number of gratifications for their compliance. Therefore believers of both creeds applied them in everyday life and in the care of the sick. Can the topos of the Compassionate God be identified in later generations of Christian and Jewish texts? The reception of the topos of the Compassionate God, i.e. His presence with the suffering and his care could be identified in the writings (sermons, letters) of most Church Fathers who were active during the 1 st through the 4 th century CE in the region of the eastern Mediterranean as the following examples show. The Christian writer Tertullian who lived in the 2 nd century CE wrote to a group of Christian martyrs (198 CE): “Above all, you blessed people, do not provide sorrow to the Holy Spirit who accompanied you to prison …” (15: Letter to the Martyrs, §§1-3). The intent of Tertullian’s letter was to comfort the martyrs. The certainty of the presence of the Holy Spirit should enable them to transcend their pain. Cyprian, Bishop of Cartago, who lived in the 3 rd century CE wrote to the prosecuted and suffering Christians in Rome: “I am suffering, brothers, I am suffering with you, and my personal well-being is no comfort to me, because if the flock gets injured the shepherd is even more afflicted. I am one with every single one of you. With every single one I share the burden of grief about the great loss. I am complaining with those who complain, I am crying with those who cry, I am feeling crushed with those crushed … In the shattered brothers compassion has also shattered myself” (16: Letter to the inhabitants of Rome, §3). From North Africa Cyprian paraphrases an NT-passage and uses the NT-metaphor of the shepherd and his flock to strengthen his bereaved companions in the distant community. Basil the Great (329-379 CE), Bishop of Caesarea in Cappadocia, asked his colleagues for mercy: “… But now we ask you … to get dressed with mercy and compassion … You heard of our misery. As disciples of the Apostle who teaches that the love of your neighbor equals the fulfillment of the law, you probably are not untouched … therefore we ask you to engage yourselves with eagerness … stop hesitating …” (17: Letter to the Bishops of Italy and Gallia, §§1f.) Basil the Great was one of the most excellent proponents of the care of the needy in the 4 th century CE. In this letter he asked his Christian fellows to be compassionate with the people in his institution. He wrote: “Who would have a heart as hard as a diamond, who would be as rough and without sensitivity as not to be shattered by the complaints which reach our ear from anywhere and which sound like one choir of the grieving. Who would not be bent to the ground and destroyed by such indescribable sorrow?” (18: Letter to the Church of Antiochia, §1). One of Basils instructions which directly concerns nursing can be found in his sermon for the martyr Julitta: “How could we show compassion and deep love … toward our neighbor? Should we not cry when we meet people who suffer from serious disasters? Should we not shed tears? But we must not believe that the one who cries aloud and complains with the suffering fulfils the law. I cannot praise a physician who instead of helping the sick allows himself to be contaminated by them … The same applies to the one who visits the mourning but who is not able to offer them anything reasonable or comfortable but instead meets them with inappropriate empathy. It is quite alright to mourn with those who suffer trials and tribulations. In this way you will become the confident of the suffering … but you are not allowed to be carried away by the suffering … This would mean to increase the misfortune rather than to soften it. Don’t you see that the pain increases if fever is added to wounds and swelling? But a soft touch with your hand could sooth the pain? Hence, don’t make worse the suffering by your own presence and don’t fall with those who fell. Who wants to erect those lying on the ground has to stand higher than those who fell. Who has fallen equally deep, also needs somebody to erect him. On the other hand it is right to have compassion with the events and to mourn silently about the misfortune of others and also to express the corresponding mood with one’s face and dignified earnest. It is not right when talking to the suffering to make reproaches as if one wanted to step on them with one’s feet. If you allow them to J Med Ethics Hist Med 2008, 1:3 Silvia Käppeli Page 5 of 7 (page number not for citation purposes) complain and lament – this cannot harm – and in this way the pain will decrease soon and you find opportunity for tactful comforting” (18: 4th Sermon for the martyr Julitta, §§7f.) Basil also borrows a metaphor of the NT-Apostle Paul when he asks his fellow Bishops in a region where at that time the Christians were less prosecuted to act on behalf of his own community in Asia Minor. With respect to his own community and the sick in his hospital Basil sketched a sort of theology of caring. In this text Basil explains the delicate balance between compassion and distancing with respect to the suffering of others in order for the compassio- nate carer to remain therapeutic. In one of his sermons also Gregor of Nyssa expanded on the phenomenon of compassion in relation to the witnessing of suffering people: “… Compassion is the opposite of toughness. The compassionate in his heart enters into a relation with the needy; through this he becomes like the broken minds of the suffering desire. In fact, compassion – if one conceptualises it – is a sort of sadness which the human being bears voluntarily because of the suffering of others” (19: 5th Speech, chpt. 1). Gregor of Nyssa conceptualises compassion as a sort of identification of the observer with the suffering when he said: “Because in the face of accidents of others we are being touched painfully… In the face of such events a certain painful state of participation develops in our soul …” (19: 5th Speech, chpt. 4). His fellow Bishop, Gregor of Nazianz, referred to the most prominent NT-models when he taught his community: “If we have to believe Saint Paul and Jesus Christ that love is the first and most important law, the major content of the law of the prophets, I declare the devotion to poverty, compassion with the suffering as the greatest love. Because nothing is more specific to God than compassion…” (20: 14th Speech, About the love for the poor, §5). And later on in his sermon he explained: “… Even if you give little to the needy it is not little for someone who has nothing … If you have nothing to give to them, show your good intention. If you have nothing at all, give your tears. Compassion that comes from the heart is a great comfort for someone who is miserable. True compassion is a great relieve in misery...” (20: 14th Speech, About the love for the poor, §§27f.). Gregor of Nazianz identified love as Gods most prominent feature and the most important to be imitated by the believers. Unlike him Bishop Chrysostomos focused on compassion as the deepest human trait: “It is our nature to be moved by compassion and no other disposition is fixed as firmly as this. Therefore one could ask why it roots as deeply as this in our nature so that we are moved to tears easily, … and that we are inclined towards compassion. Compassion remains so deeply with us that we feel even with animals…” (21: 5th Homilie, §4,). Chrysostomos praises compassion as a Christian virtue. All the texts quoted here show that the Church Fathers “celebrated” compassion with more or less direct reference to the Compassionate God as a biblical virtue which cannot be renounced in the care of suffering people. Similarly the Jewish scriptures of the 1 st through the 4 th century (the Midrashim) continue to refer to the topos of the Compassionate God. The following midrashic confirmation by God of his compassion speaks for itself: “God said to Moise: ‘Don’t you realize that I am in trouble if the Israelites are in trouble? From this you can see that: In the place in which I am talking with you, from the thorn bush, I participate in their suffering’” (22: ShemR on Ex 3:2). In Judaism nursing is part of those works of charity (gemilut chasadim) which ought to be practiced spontaneously towards everybody in need. It involves not only material support but requires the whole person. Holy texts such as the following encourage such actions. “The Holy one, blessed be He, said: ‘Who acts in the way of my works resembles me’” (23: TanchB Bechuqqotai §56 on Lev 27:1f.). This text tells the believers that by imitating God they will increasingly resemble His image. In the Jewish tradition bikkur cholim, the visiting of the sick has special value among the prescribed works of charity. “Visiting the sick” means nursing them, because it is unconceivable that one visits a sick person without comforting him, nursing him physically, sharing his suffering and without wishing him well or praying with him. The following examples from the rabbinical writings give an impression of the duties that go along with the visit of the sick: “Who visits a sick person does not sit either on his bed or on a bench or on a chair. Rather he wraps himself and sits on the floor. The Almighty comforts him on his “bed of pain”” (14: bNed 40a). This picture implies God’s presence with the sick rendering his bed in a holy place. It commands other visitors to prove their humbleness by staying on the lowest possible level. In another place a Rabbi taught: “Who visits a sick person takes off him the 60 th part of his illness” (14: bNed 39b). This implies that sharing the burden of the sick reduces their suffering. Rabbi Levi said: “If you have nothing to give to the poor, comfort him with the words: ‘My soul wants to emanate because of you, because I have nothing to give to you’” (24: WaR 34:15 on 25:25). This Midrash teaches that compassion, the spiritual touch of a fellow human being, is equally powerful as material gifts. Also the Mishna vividly illustrates how God expresses His compassion: “What expression does the Divinity use when a human being suffers agony? My head is gone, my arm is gone! If God grieves so much over the bloodshed by the offenders, how much more over the blood of the pious…” (25: J Med Ethics Hist Med 2008, 1:3 Silvia Käppeli Page 6 of 7 (page number not for citation purposes) mSan VI). At the same time this is an illustration of God’s forgiveness vis-à-vis the sinners. Similarly in the Twin-Parable of “The two who were beaten” (22: ShemR 2:5) Rabbi Jannai said: “Like those twins: when one of them suffers from a headache, then also the other! So, (if permitted) the Holy One, blessed be He, said: ‘I will be with him in trouble’ (2: Ps 91:15) and it is written: ‘In their entire affliction He was afflicted’.” “… Like one who took a stick and beat two people. Both were hit and experienced his pain. Likewise misery and oppression of Israel were obvious and known to the One who spoke and the earth became, as it is said: ‘… I know their sufferings’ (2: Ex 3:7). This twin parable confirms God’s compassion with the Israelites. The Old Testament confirms that wherever they are and whatever happens to them God is with them and suffers the same adversities. In another text Rabban Gamaliel said in the name of Rabbi: “Always, when you show compassion with the creatures, you will be shown mercy in heaven; if you do not show compassion with the creatures, you will not be shown mercy from heaven” (26: SifDev 13:18 §96). With this reference to God’s power of retaliation the believers are reminded to care about fellow human beings. Rabbi Akiba, a scholar who was teaching at the beginning of the 2 nd century in Palestine made this even more explicit when he said: “Everywhere, where the Israelites were banned, the Schekhina (God’s presence in the world) was with them. They were banned to Egypt and the Schekhina was with them, as it has been said: ‘I am being banned to the house of your Father, as they were in Egypt (2: 1Sam 2:27). They were banned to Babylon, the Schekhina was with them, as it is said: ‘Because of you I was sent to Babylon (2: Jes 43:14).’ They were banned to Edom (Rome), the Schekhina was with them… And if they will return, the Schekhina will be with them. As it is said: ‘And the Eternal, your God, will return with your prisoners (2: Dtn 30,3)” (27: MekhY on Ex 12,41). Rabbi Akiba presents God as a companion of his people in exile. Thanks to His presence the Israelites retain their inner integrity and completeness. The quoted literary works teach that the Eternal was compassionate not only towards the just and the pious Israelites but also towards the sinners. His compassion therefore can be said to include His willingness for reconciliation and forgiving. Also self-inflicted suffering is no reason for Him not to be compassionate. The Talmud thus states: “Every day God cries about three kinds of human beings: about him who can preoccupy himself with the Tora and does not do it; about him who cannot preoccupy himself with the Tora but does it nevertheless and about the president of the community who behaves himself arrogant vis-à-vis his community” (14: bHag 5b). For both the suffering and the carers this example is important because they can be certain that even if they cause their suffering themselves they will not be abandoned by God and they can expect his compassion like all the others. Conclusion of the first part of the study The analysis of the Jewish and Christian sources of the 1 st through the 4 th century CE show that their authors and editors picked up the topos of the Compassionate God as presented in the OT. However, none of them includes all aspects of it. Rather – depending on the purpose of a text (teaching, comforting, and asking for help) selected attributes appear. All of them more or less explicitly refer to the compassionate presence of God, the Schekhina, the Holy Spirit, a Saint or the authors themselves as their representatives. Most of them ask the people addressed to imitate these characters through actively demonstrating their compassionate care towards their neighbors. The texts imply that compassion is not only an emotional gesture but involves caring acts. Hence, it can be concluded that the scriptures of both religions start and consolidate a tradition of compassionate care in relation to the sick. In late Antiquity the imitation of God’s mercy vis-à-vis the suffering was the strongest motivation of Jewish and Christian believers to nurse their sick. The topos presents itself as a religious motif of great variety, be it that the instructions for the carers simply refer to the requirements of the imitatio Dei, be it that they describe in detail how to behave. 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