Restoring Dignity Through Compassionate Care
by Jeremy Henzell-Thomas
Many people will have been deeply shocked by the recent UK Healthcare Commission report Dignity in Care which brought to light the appalling neglect of old people in our hospitals. Less than one in five elderly patients who need help because they cannot easily feed themselves actually receive such help from nursing staff. The statistic was so bizarre it was difficult to digest. Less than 20 per cent of this needy group receive the basic standards of care to ensure human dignity? And this was only one of the many failures of NHS trusts to treat elderly patients with the respect and dignity they deserve. Only five out of 23 trusts are reported as complying with dignity-in-care standards. Help the Aged described the findings as "intolerable".
This report follows close on the heels of another report, published in August, by the Joint Committee on Human Rights, which called for a "complete change of culture" in health and care services. That equally shocking report detailed how elderly people are suffering from abuse, neglect and malnutrition in hospitals and care homes up and down the land. Evidence was found of "historic and embedded ageism" within healthcare services. One elderly woman, who had difficulty feeding herself, "appeared to be slowly starving to death" because visitors who could have helped her were discouraged from staying during meal times. The Charity Age Concern estimates that half a million elderly people are subject to abuse at any one time, mostly in healthcare settings, and Help the Aged declared that "the shocking examples highlighted by this report provides all the evidence the government needs to justify urgent action".
Ivan Lewis, the Minister for Care Services, said that the government recognised the "anomaly". The use of the word "anomaly" rings a bell. If my memory is correct it was the word used by Tony Blair to describe the Guantanamo Bay gulag. It is one of those value-free abstractions which distance us from a full realization of how rotten something actually is. The word means an "irregularity of motion or behaviour" and is derived from a Greek word meaning "uneven". An embedded culture of intolerable neglect and abuse is not a mere irregularity; it is a shameful disgrace.
The fact is that there have been dozens of previous reports which have exposed similarly disturbing cases. The Observer reported over a year ago on 16 April 2006 that the neglect of the elderly would be targeted that very week under new guidelines forcing hospitals to respect patients' dignity. Professor Ian Philp, the government 'tsar' on services for old people admitted at that time that "things happen to older people that, if they happened to children, would end up in the criminal courts, but don't even get mentioned; they're swept under the carpet."
Is this representative of the value of "social responsibility" which government ministers tell us is one of those distinctly "British values" to which we all need to adhere in defending our "way of life"? If it is, then we need to reclaim it, and people of faith need to be in the forefront of that enterprise to heal our social maladies for all our people, and not just for special interest groups. Dr. Rowan Williams, Archbishop of Canterbury, has affirmed his intention to speak out. "Is our society broken? I think it is." So he said in a recent interview for the Daily Telegraph.
My grandmother, who had nursed patients suffering from shell-shock and neurasthenia during the First World War, would have turned in her grave if she had heard of the mistreatment of the elderly in our hospitals and care homes. She loved to tell me stories about the rigorous standards of hygiene and personal hands-on nursing care which were part and parcel of the hospital culture of her times, and how they were overseen and enforced by draconian matrons, one of whom once severely reprimanded her because, having overslept, she had the temerity to turn up on the ward without wearing a corset!
It would be inconceivable for my grandmother to have neglected to feed a patient who would have gone hungry without such basic help. I know this from personal experience because I saw her at the age of 70 make daily visits to a family friend who was suffering from an incurable brain tumour and whose growing loss of sensory faculties and physical coordination made it increasingly difficult for him to direct a spoon into his mouth. His wife found this task of personal care difficult and distressing, but it had been integral to the nursing culture my grandmother knew and she gladly offered her help.
And it was not simply the detached performance of a functional task she had been used to doing so many years before, but first and foremost an act of human compassion. An authentic concept of a human profession or occupation, and especially a vocation, combines the idea of mastering a set of skills with that of adhering to a code of principled behaviour, a set of human (and humane) values which impart a higher purpose and dignity to one's calling. In traditional societies, both the skills and the code of values associated with a craft would often have been passed down by an artisan to his apprentice, who might often have been his own child. At its root, this is an exalted and sacred conception of work, through which higher virtues as well as useful and sublime skills can be perfected and passed on through the generations. But it goes far beyond a matter of mere competency acquired through training and monitored quantitatively by "management". Rather, it is something intrinsic and qualitative, a deeply rooted reverence for the way in which all work can ultimately be a form of service and an expression of an authentic inner impulse to make every action both an offering to God and a loving contribution to improving the lives of our fellow human beings.
Now, we can do without the corsets my grandmother was expected to wear, but we can't do without a culture of care and compassion, especially for those who are vulnerable and in need.
What can we learn about the characteristics of a caring culture from the underlying meaning of the word nurse?
The word nurse comes from a Latin word which also gives us nourish and nutrition. It originally meant 'suckle' but this earlier sense of feeding and caring for children was later generalized to 'look after' and it was not until the end of the 16th century that it came to mean 'care for sick people'. The word nursery still retains its associations with children, and by extension with young plants.
The neglect of old people's nutrition in hospitals is profoundly ironic in the light of the original meaning of the act of nursing, which was an act of feeding, nourishing and rearing.
And that act of nourishing, of providing sustenance, is no less than the embodiment of the divine nurturing principle enshrined in the Arabic word rabb. Muhammad Asad chooses to translate this word in the Qur'an not as 'Lord' but as 'Sustainer'. Commenting on the phrase rabb il 'alamin in Qur'an 1:2 he points out that this includes the sense of "rearing, sustaining and fostering anything from its inception to its final completion". In his view, the word 'Sustainer' better reflects the wide complex of meanings associated with the Arabic root.
Islamic education is often referred to as tarbiyah, from the same root. The qualitative emphasis of this concept is mercy (rahma) and it has the essential sense of nurturing and developing latent potential, like Latin educere ('draw out'), the source of the English word education.
Qur'an 2:3 also tells us that one of the qualities of the God-conscious is that they "spend on others out of what We provide for them as sustenance." Asad notes that "Ar-rizq (provision of sustenance) applies to all that may be of benefit to man, whether it be concrete (like food, property or offspring) or abstract (like knowledge or piety). The 'spending on others' is mentioned here in one breath with God-consciousness and prayer because it is precisely in such selfless acts that true piety comes to its full fruition." Speaking to 'Asma, daughter of Abu Bakr, the Prophet said, Give without calculating lest God calculate concerning you; and don't hold back, lest God hold back from you. Give as much as you are able.
I remember well hearing a BBC interview last year with a very senior nursing officer on the mistreatment of elderly people in the healthcare system. Her explanation for the culture of neglect and abuse was simple. Fewer and fewer people, she said, had any religious faith, nor any belief in an afterlife. They therefore saw old people not as human souls approaching the transition to the next stage of existence but only as dispensable material bodies which had outlived their usefulness.
This rings true. Ageism and the culture of contempt for the old is the ultimate consequence of a brutal and nihilistic materialism which reduces everything to base physical utility, to a mere mortal body devoid of soul and spirit. The Qur'an tells us that God created man from "sounding clay, out of dark mud transmuted" and that after He had formed him He breathed into him His spirit (15:28-29). He then commanded the angels to prostrate themselves before this human being, but only after he had been imbued with that divine spirit. No angel was expected to worship lumpen clay devoid of that breathed-in holiness. And without that reverence for the holiness within, it is easy to see how the quality of care can degenerate. Ironically, nurses have often been referred to affectionately as "angels" for the comfort they can bring to the sick and dying. We should not forget, in the midst of this crisis, that here are of course many nurses who richly deserve this accolade and who enter the profession with the highest ideals.
The materialism which reduces the human being to a lump of clay is especially prone to contempt of the aged because it is only the condition of the clay which is valued, not the inner qualities of character which animate the clay. The many newspaper cartoons of Sir Ming Campbell during the recent Liberal Democrat Party Conference, depicting him as a doddereing ancient or even a crumbling skeleton attest to this rampant and infantile ageism. There is an old tradition that the Golden Age was the age of the Senex, an age founded on wisdom. Such is the inversion of our times! And Sir Ming is mere 66 years old! On that basis, in six years, I too will be for the scrap heap.
As always, there is an opportunity for Muslims, together with all those who uphold the sanctity of human life, to act as role models in reclaiming an exalted conception of healthcare for all people regardless of their age. The first nurse in Islamic history was Rufaidah bint Sa'a who lived during the time of the Prophet. Long before Florence Nightingale reformed nursing in the 19th century, Rufaidah set up a training school for nurses, developed the first code of conduct and ethics, and actively worked for community health. She had a strongly empathetic personality, a distinctly human touch. Sandy Lovering, Chief of Nursing Affairs at the King Faisal Specialist Hospital and Research Centre in Jeddah explains that "the recognition of Rufaidah as the first Muslim nurse and role model is a very recent phenomenon as Muslim nurses seek roots in their history and grounding of the nursing role within their own religious framework."
There is another role model, too, in British nursing history, a contemporary of my grandmother. This was Edith Cavell who became famous during the First World War. Anyone who walks down Charing Cross Road in London towards Trafalgar Square will have doubtless seen her statue near the National Portrait Gallery. She was executed by a German firing squad for helping hundreds of soldiers from allied forces to escape from occupied Belgium. She became a popular martyr and her case was exploited in British propaganda throughout the war. However, her true humanity, derived from her Christian faith, transcended the "patriotism" which made her a popular heroine. The night before her execution she said these words to the Anglican Chaplain: Standing as I do in view of God and eternity, I realise that patriotism is not enough. I must have no hatred or bitterness towards anyone. These beautiful words are inscribed on her statue.
Let me end by returning to the concept of 'provision' (ar-rizq). The heart of this concept is that whatever we can give to sustain others is provided for us through the limitless generosity and mercy of the ultimate Sustainer, our Rabb. If our hearts are open to that divine plenitude, our quality of care partakes of that bounty. The best quality of care must be premised on a deep spiritual awareness of the divine origin of every human soul and an understanding that it is to God that every human soul returns. There can be no partiality in nursing, no preference for one community above another. As God nourishes and sustains all Creation, so the nurse cares for all patients with equal compassion, no matter what their religion, nationality, race, gender, age, social class, or wealth. The Prophet instructed us that the best people are those who are kindest to God's creatures.
How compelling are the many opportunities before us to demonstrate the impartial humanity of Islam!