The Need for Compassionate Strangers

by Patricia Benner

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	Patricia Benner, RN, PhD is Professor of Physiological Nursing at the University of California at San Francisco.
	Post Date: April 10, 1998

The care ethic given to us in the Christian tradition has been marginalized in the current market model of health care systems. Market arrangements are developed for autonomous strangers or customers to meet and buy goods and services. The market model overlooks the many ways we are not prepared to be astute and assertive consumers when we are most in need of health care---in times of vulnerability and danger.

The story of the Good Samaritan suggests that the starting point in health care ethics should be in recognition and in relationship to the universal human reality of vulnerability and suffering. Moral worth and respect is to be accorded to all fellow human beings. Therefore, we are to be compassionate strangers to those who fall outside our own communities and kinships. Suffering and vulnerability are the common fates of finite embodied human beings. We each might need a fellow human being to respond with compassion to our needs for protection and comfort.

Nursing practice has a lively tradition of caring for, and meeting, the other in suffering and vulnerability. But this tradition is increasingly challenged, particularly in the U.S., by managed care. Contracts between third party payers and employers have created new styles of commodification. The market has become the central integrative mechanism for health care--fostering a system of money changers in a not so holy temple. For-profit insurance companies have placed incentives in the health care system for decreasing contact with patients and families, which encourages health care professionals to respond as the priest and the Levite. Stringent gatekeeping and disincentives for basic nursing care and social services overlook the fact that few incentives are needed for avoidance and neglect. Avoidance and neglect are very real human temptations in the face of suffering. The moral and emotional work of meeting and caring for the other in situations of need and vulnerability are required for justice and care.

We cannot do without the language and the ethical moorings of justice. Justice and mercy cannot be separated. A just society will create structures for safety, protection and nurturance for all citizens. The work of compassion requires just institutions structured for its work. However, justice is a minimal requirement. In the face of vulnerability and suffering, it is not sufficient. Mercy, generosity, hope and even love are required. At the very least, real relationships, where the other is met and known, are required if we are to avoid the ethical violence of neglect and abuse in the face of vulnerability and suffering. CBHD