Empathetic imagination

I have a backlog of things I want to blog about. There’s a good reason for this: I’ve moved into the active writing phase of working on my dissertation. For the next year, give or take, other writing comes second, so I may be quieter than usual hereabouts. On the other hand, today there’s a number of things that I think are loosely related that I want to write about, so here goes:

It’s moving to hear about a politician who learns first-hand what it’s like to struggle through a certain situation, and gains empathy in the process. That’s a touching story, but it shouldn’t be a necessary one. We should be doing this kind of work, of putting ourselves in the position of those we’re thinking about and dealing with, on a regular basis. Among other things, we don’t have time for everybody to learn this first-hand.

Other politicians are seriously lacking in this empathy. They can talk about their distress when their “people are literally freezing in the winter and they’re without food and they’re without shelter and they’re without clothing,” in the wake of Hurricane Sandy, but why haven’t they been worrying about these very same bad things happening to people every day? Those others must be, in some indefinable way, not theirs. It makes me want to ask the old Christian Sunday school question: Who is your neighbor?

This is not just the lack of something, it’s also a necessary precondition to hatred. Here are two separate examples of conservative Christians who are associated in various ways with hate groups denying not only the value of empathetic imagination, but the very possibility of it: First, homophobes are incapable of imagining that someone who is straight would want to support rights for QUILTBAG folks, and second, an argument that assumes only parents and children are capable of caring for each other across generations.

Actually, I’m not anti-social for refusing to have children because I’m capable of caring about people – both older than me and younger than me – who are not my family. That’s how Social Security, and Medicare, and Medicaid, and a whole host of other things work.

I don’t care whether you call it the Golden Rule or the Rule of Three or the Law of Return or what, but the hard work of extending that kind of empathetic imagination is at the heart of how I do ethics. It’s sad to see the hypocrisy exposed in a politician who is suddenly shocked, shocked, to discover that his party doesn’t care about people who are having a hard time. It’s more revealing to notice people denying that this empathetic imagination can exist at all.

When you hear someone say that, look out – because they most certainly will not be willing to extend it to you if you once step out of their little box of “people like me.”

Act III: Paging Nurse Empathy

This series was started by an odd confluence of events: I saw the performance of Dr. Horrible, and shortly thereafter I ended up on one of those random Web-walks exploring doctors’ and nurses’ blogs. It started with ER humor, but I found myself drawn into blogs by regular floor nurses, like my mother.

Medical humor is often black humor, grisly humor created by people faced with a Sisyphean task (people do keep getting sick, after all) that all too often leads to compassion fatigue. What do you do, after all, with the third person this week with an iPod in a body cavity? (Have the Nanos made that any less of a problem, I wonder?) Or the thousandth person who comes to urgent care for antibiotics for their cold? Or the ten thousandth? And nurses get the worst of it: they are the front line of care for patients and families (nurses care for whole families, not just the person in the bed – just ask), which puts them at the interface between the medical system – usually doctors – and the people who are actually in pain, or dying, or depressed, or confused and combative, or throwing up, or all of the above. All too often, doctors shove the results of their compassion fatigue down onto nurses, and families who are in unfamiliar settings with scary things happening to loved ones amplify their anxiety up, sometimes in the form of defensive anger. Nurses get the brunt. And who else gets a college degree to spend most of their days wiping butts?

One strain of the anger and frustration that I saw on some blogs really started to bother me. It’s often hard for nurses to deal with people with major health issues that are caused or exacerbated by the person’s behaviors. Noncompliant diabetics who are obese, and going blind, and having amputations, sometimes in their 30s, are some of the most vivid examples. Diabetes is a terrible disease, but it is largely controllable – if. If the person will make the changes. If the person can make the changes. If the person isn’t trapped by the culture of the Diabetes Belt combined with, and including, her own personal circumstances.

The point when attitudes go beyond black humor, beyond compassion fatigue, is often marked by one signature phrase: “My tax dollars at work.”

It’s absolutely true that a lot of the people who need repeated health care for major medical problems are on public assistance, whether that’s disability, welfare, Medicaid, or combinations thereof. And so, yes, when a nurse is frustrated beyond words with a patient who is drinking herself into an early grave with sugared sodas, and as a result is so sick that she’s on disability and Medicaid for the repeated procedures that won’t halt the course of the disease and may not even delay it much, it’s true, the nurse’s tax dollars are paying for that person’s living allowance and medical care.

But the subtext is more than that. The subtext is usually: “I wish I wasn’t paying for that person.” Sometimes there are varying degrees of anger wrapped up in this, or greed (“My taxes wouldn’t be so high if…” If what? We just let them die?) or other unexpressed factors, but a lot of it is compassion fatigue, especially when there are degrees of personal responsibility involved. It’s exhausting to see people contributing to hurting themselves, especially when you know (but they may not) that there are alternatives, there are other choices they could be making. From your point of view, those choices may even look simple, or easy, or at least the only rational path to take.

And the nurses, especially, are tired of being the superheroes trying to swoop in and save people from the trap of the Diabetes Belt. They’re being superheroes from 7a-3p, 3p-11p, and 11p-7a, day in, day out, sometimes with the same patients, over and over again, up to their elbows in crap and paperwork and staffing cuts. They wish that some of their patients would stand up for themselves, and not be falling into the superheroes’ waiting arms over and over again. Their arms, and their hearts, are getting tired.

But the existence of the Diabetes Belt shows that this is about culture, not just about personal choice. If we want to change this, we’re going to have to change the culture. What kinds of food are available? Affordable? Accessible? What do families teach their children to eat? To cook? To enjoy?

It’s not that individuals don’t have responsibility, it’s that individuals don’t bear their responsibilities alone. We have to change the context and create opportunities for different kinds of responsibility from the top down, as well as demanding it from the bottom up. Because really, the “top” and “bottom” are parts of the same social, economic, and cultural web of interactions, and no one person can change the web alone. Even a superhero.

Even a villain. When he was trying to become a villain, Dr. Horrible believed he could make a difference. He believed that what he worked for would have the results he intended. He was horrified to discover otherwise: “You think your world’s benign, and justice has a voice, and we all have a choice…” When confronted by that horror, he realized that he had forced himself into a heartless position, and he allowed it to empty him out, he accepted that he had become what he hated. He only truly became a villain when he put on his nemesis’ gloves.

We are confronted with similar tragedies every day in the Diabetes Belt. What will we do in response? Will we embrace the role of villain, willingly becoming part of the problem, withdrawing and becoming heartless? When black humor crosses the line into suggesting, even implicitly, that we should withdraw public assistance from people, that we don’t want helping those people to be “our tax dollars at work,” that advocates one course of action. That’s Dr. Horrible’s course. That’s picking up the black gloves.

Battlefield nursing and magic

One of my favorite writers about health care, oncology nurse Theresa Brown, described her envy of some aspects of battlefield medicine as a way to illustrate the crushing burden of charting on nurses in her latest piece, “Caring for the Chart or the Patient?” But then, demonstrating her amazing ability to keep her sights on what matters most, she took a left turn into talking about compassion:

The care we give our cancer patients is obviously much different from what we do for soldiers who’ve had their legs blown off by an I.E.D., but the threat to life and limb is no less real. I have no drop-down menu for charting “Empathized with patient over fear of metastatic disease and death.” And yet, that’s exactly what the patient needed.

“If it isn’t charted, it isn’t done,” we hear. But as the paperwork demands proliferate, my worry is that if it can’t be charted, it won’t be done.

On the other end of the caregiver-patient relationship, I can say that her worries are well justified. In fact, I think that the way empathy has been marginalized by efficiency in “modern medicine” is fueling the interest in alternative medicine.

From a skeptic’s point of view, a lot of the benefit from therapies like acupuncture or Reiki comes from things incidental to what’s being touted as the treatment; they argue that a lot of the “therapy” is in fact therapy in the psychological sense: the patient gets to share her problems with someone who cares. I think there’s some truth there, and it’s a shameful commentary on “modern medicine” that people with health problems aren’t getting that empathy from the mainstream medical establishment. On the other hand, I don’t believe the skeptic’s reduction explains it all. I’ve felt what can only be described as chi moving along meridians and been surprised by the specificity of Reiki. There is more going on there than “just” the power of empathy. But even if empathy is the major contributing factor, Ms. Brown, and all good nurses and caregivers, recognize that’s powerful medicine. So powerful, in fact, that it’s almost magical.