About the Author: Dr Odette Spruijt is a senior palliative medicine specialist in Australia. She completed her PhD in 2020, exploring Indian and Australian palliative care doctors’ responses to their patients’ suffering.
She established Australasian Palliative Link International (APLI) in 1996, which aims to foster relationships between Australian and Indian palliative care providers.
February 4th was the International Day of Human Fraternity. This day was first established by the United Nations General Assembly on December 21st, 2020, (resolution 75/200) as a way to promote greater cultural and religious tolerance.
It was inspired by the historic meeting between His Holiness Pope Francis and His Eminence the Grand Imam of Al-Azhar Sheikh Ahmed El Tayeb (representing the Catholic Church and Islamic Community respectively) in Abu Dhabi, UAE on 4th of February 2019. They published a declaration entitled Human Fraternity for world peace and living together.
The Declaration begins:
In the name of God who has created all human beings equal in rights, duties and dignity, and who has called them to live together as brothers and sisters, to fill the earth and make known the values of goodness, love and peace;
And states
(we) declare the adoption of a culture of dialogue as the path; mutual cooperation as the code of conduct; and reciprocal understanding as the method and standard.
This new international day joins nine other days related to the promotion of peace, solidarity, interracial harmony, cultural diversity, and interreligious harmony.
The history of United Nation (UN) international days is interesting. They are mechanisms of promoting the main fields of action of the UN: peace and security, sustainable development, protection of human rights and guarantee of international law and humanitarian action. They are often prompted by concern that these values are being eroded on the world stage. They remind us to reset our moral compass as an international community.
So what are the perceived threats to human fraternity that lead to the establishment of this international day? Wars, displacement, inequitable distribution of resources, moral and cultural decline all contribute. The authors were particularly concerned with violence in the name of religion reminding us that “God, the Almighty, has no need to be defended by anyone and does not want His name to be used to terrorize people.” (Pope Francis & Ahamad As-Tayyib, 2019).
Francis asks us to dream, “as a single human family, as fellow travellers sharing the same flesh, as children of the same Earth which is our common home…” (Pope Francis, 2020).
Organisations, whether corporations or not-for-profit associations, can be fraternal in nature where there is a will. They can become communities whose purpose is to work for fraternity, “whose sense of place, belonging and responsibility toward the human community …. creates possibilities of supporting others for the sake of the common good” (Zozimo et al., 2022, p. 1).
What is our dream for the IAPC? Becoming fraternal involves grappling with paradoxes and tensions arising from conflicting priorities, differing values of other organisations with which one interacts, and different levels of commitment with the goals within the organisation itself. Organisations need to “dynamically balance, without solving (as paradoxes persist …) these tensions” (Zozimo et al., 2022, p. 15). A key ethical imperative for fraternal organisations, corporate or not-for-profit, is authenticity, the degree to which their actions align with their stated goal.
We, in palliative care work in a specialty area of health care that is founded on human fraternity.
Saunders expressed this as openness to the other, which is key to hospitality and dialogue. This is a core insight arising from her care of the Polish Jewish patient, David Tasma, in 1948, when she was working in a large teaching hospital in London. He also told her he wanted to be a ‘window in her Home’ a beautiful metaphor for openness to all. And that “I want what is in your mind and in your heart”. From this she understood the importance of a commitment not only to research and scientific rigour, but also to the ‘friendship of the heart, the vulnerability of one person before another.’(Saunders, 2000, p. 8). She reminds us that we need our ‘personal meetings with dying people if we are to remain human and true to ever new challenges’. (Saunders, 2000, p. 13).
Some palliative care providers I speak with dismiss such ‘Saunderisms’ as outdated and no longer relevant to modern palliative care. Many new to palliative care, are unaware of these founding inspirations. For me, however, these concepts are at the core of our work, and a source of ongoing reflection.
Hospitality
All religions proclaim the importance of hospitality, recognising in the stranger, the guest, the face of God. In India, Atithi Devo Bhava reminds us to welcome guests with love and respect as we would welcome our God. Likewise, in Abrahamic religions (Islam, Christianity, Judaism), welcoming the stranger, hospitality, is a sign of fidelity to God. The word, hospice, derives from the Aramaic ishpuz, and the Arab word, hospes, meaning ‘host’, ‘guest’ or ‘stranger’.
Hospitality involves being receptive and responsive to another who may be vulnerable (in contrast to viewing another person as an object to be manipulated for personal gain, or diminished by intentional non-seeing). It involves being open to difference (Kearney, 2006; Stumm, 2014). It involves dialogue in which we engage in conversation, verbal or non-verbal exchange, with another. To be in dialogue with another means to focus on what happens between you, turning away from self toward the other, in order to receive and respond to the other.
The practice of country general practitioner, Dr John Sassall, was written about in the book, A fortunate man. It describes the importance of ‘welcome’ in the practice of medicine. “The door opens,” he says, “and sometimes I feel I’m in the valley of death. It’s all right once I’m working. I try to overcome this shyness because for the patient the first contact is extremely important. If he’s put off and doesn’t feel welcome, it may take a long time to win his confidence back and perhaps never. I try to give him a fully open greeting. All diffidence in my position is a fault. A form of negligence.”’ (Berger & Mohr, 1989).
This effort towards welcome, receptiveness, openness, was described by palliative care doctors who shared their stories with me. Patricia (pseudonym) said that she is “just trying to create a bit of a safe space for them, where they can say what they need to say or not, you know, and they’ll just know that I guess to give them some space where they can trust that they’ll be cared for”. Similarly, Vashti (pseudonym) said that she tries to “give them the feeling that you’re not listening only with your ears, you’re listening with your whole being”. (Spruijt, 2020)
Dialogue is the opposite of the self-directed orientation toward the world, of a dichotomy that creates a barrier to encounter with another. It is a deliberate movement toward encounter. ‘Genuine dialogue’ takes place through a ‘turning of the being’ to the ‘other’, (Buber, 1992, p. 78), with a willingness to see and be seen, to reveal and be revealed. Such mutuality is at the heart of dialogue and is present in any dialogical encounter. In this space of genuine dialogue, “there is the realm of the ‘between’. . .which will help to bring about the genuine person again and to establish genuine community” (Buber, 1947, p. 204). The ‘between’ is the place of the spirit lived by both partners in dialogue, and here, Buber’s dialogical concept of becoming articulates the spirituality so central to palliative care practice, the spirituality of connection with an ‘other’.
Sensitivity and mystery are inherent, but often overlooked, in inter-human encounters at any time. But I find this mystery and the opportunity for personal meeting is heightened in the encounters between a physician, or any health care professional, and a patient who is facing the end of their life.
I agree with Buber, and with Cohn, when she states that medicine is fundamentally about relationship and dialogue (Cohn, 2001). Within a medical encounter, as in any human-to-human encounter, there is potential to meet or to not meet one another, for transformation and for healing or not. Such transformation is quiet, usually unspoken, experienced in silence and involves a ‘dialogical knowing’ of the other (Brown, 2015), often too intimate and personal to lend itself to words.
Such moments of meeting are recognised in psychotherapy, and any healing- directed therapies, in which I include the practice of palliative medicine. To be with people in their suffering, we as practitioners are engaging in the deepest of human drama. We are challenged to be fully present, mind and heart and soul, to the person vulnerable before us, with us, to whom we are also exposed in our humanity. Our fears, courage, honesty, dishonesty, avoidance, exhaustion, are there to be seen. Our humanity. As are our patients’. They see us for what we are.
When doctors are supported by a medical culture that values interpersonal support, self-care and meaning-making for the health carers, wellbeing is better sustained (Kearney et al., 2009). Supportive interpersonal relationships with colleagues help doctors cope with the ‘loneliness and powerlessness related to their vulnerable professional position’ (Aase et al., 2008, p. 767). Attending to the dialogical, the fraternal, in all interpersonal relationships offers a renewal of healthcare at organisational levels and within the doctor–patient relationship.
References:
Aase, M., Nordrehaug, J. E., & Malterud, K. (2008). “If you cannot tolerate that risk, you should never become a physician”: a qualitative study about existential experiences among physicians. Journal of Medical Ethics, 34(11), 767-771. https://doi.org/10.1136/jme.2007.023275
Berger, J., & Mohr, J. (1989). A fortunate man. The story of a country doctor. Granta Books
Brown, J. M. (2015). Wherefore Art ‘Thou’ in the Dialogical Approach: The Relevance of Buber’s Ideas to Family Therapy and Research. Australian and New Zealand Journal of Family Therapy, 36, 188–203. https://doi.org/10.1002/anzf.1100
Buber, M. (1947). Between man and man (R. G. Smith, Trans.). Kegan Paul, Trench, Trubner & Co Ltd.
Buber, M. (1992). On intersubjectivity and cultural creativity. Chicago : University of Chicago Press.
Cohn, F. (2001). Existential medicine: Martin Buber and physician-patient relationships. The Journal of Continuing Education in the Health Professions, 21(3), 170-181. https://doi.org/10.1002/chp.1340210308
Kearney, M. K., Weininger, R. B., Vachon, M. S., Harrison, R. L., & Mount, B. M. (2009). Self-care of physicians caring for patients at the end of life: “being connected . . . a key to my survival”. JAMA, 301(11), 1155-1164. https://doi.org/10.1001/jama.2009.352
Kearney, R. (2006). Introduction. In P. Ricouer (Ed.), On translation (pp. vii-xx). Routledge.
Pope Francis. (2020). Encyclical letter Fratelli Tutti of the Holy Father Francis on Fraternity and Social Friendship. In: The Holy See.
Pope Francis, & Ahamad As-Tayyib. (2019). Document on “Human Fraternity for World Peace and Living Together” signed by His Holiness Pope Francis and the Grand Imam of Al-Azhar Ahamad al-Tayyib. In.
Saunders, C. (2000). The evolution of palliative care. Patient Education and Counseling, 41(1), 7-13. https://doi.org/10.1016/S0738-3991(00)00110-5
Spruijt, O. (2020). The empty-handed doctor. Responding to the suffering of patients approaching the end of life Lancaster University]. Lancaster, UK.
Stumm, B. (2014). The Intersubjective Ethics of Dialogue: Practicing Reciprocal Reception and Responsibility in Stolen Life—The Journey of a Cree Woman. Cultural Studies ↔ Critical Methodologies, 14(4), 385–395.
Zozimo, R., Pina e Cunha, M., & Rego, A. (2022). Becoming a fraternal organization: Insights from the Encyclical Fratelli Tutti. J Bus Ethics, 28, 1-17. https://doi.org/10.1007/s10551-022-05052-x
Note: This article is a republication from the Indian Association of Palliative Care‘s (IAPC) free monthly e-newsletter (March edition).
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