Understanding Suffering and Compassion.

Art and literature can be mirrors in which those who care for the sick can see the fugitive truth of compassion.

Art and literature provide essential knowledge for health-care professionals that cannot be found in ordinary health care literature and textbooks.

What is that essential knowledge? Why is it important? How can it make our life work more humane and fulfilling? This essential knowledge is reflective of a deeper understanding of suffering and its implications for health and healing. It is about the valuing of that suffering and the intrinsic human need for compassion. But, what is compassion? I believe compassion is born of wisdom and courage and can only be realized through devoted attention to its many facets and origins. It is most often misunderstood, misused, or dismissed as something merely soft and sentimental. (It is frequently confused with pity, empathy, and sympathy). The nature and work of compassion is more elusive and mysterious. But, it is not surprising that it is so often surrounded by such confusion -- and even dismissed. To understand compassion means to study the nature of suffering--the intertwining of moral, spiritual, psychological, and physical suffering. Compassion, like freedom, is a word whose meaning becomes clearer and finally clarified in practice, when known through desire and need, in hands-on exchange. Like freedom, compassion is a mutual experience given two or more people who act together for its realization. While freedom may seem an individual experience demanding that an individual act his or her way out of imprisoning conditions, including passivity, in fact, it too depends on action and reaction, an interchange of desires which form a passion for hope. This interchange is reflected profoundly and vividly in works of art whose artists have the depth and courage to depict and seek to understand the reality of suffering. No textbook can express what both art and a patient's actual voice can evoke and transfer understandings to those of us who seek to know how to relieve another of our common suffering. Thus, art and literature are mirrors for sharing in the action of compassion.

Selected works of Rodin, Tolstoi, Kurosawa, and Mason show us compassion in action and convince one of the importance of capturing "fugitive truth." This phrase "fugitive truth" is derived from the well-known Rodin-Gsell conversations on art, in which Rodin describes to Paul Gsell his method for capturing the state of soul of his subject in clay prior to carving in marble. Rodin tells us that he made many small, quick clay "sketches" of his models as they moved freely about his studio in order to capture what he called "fugitive truth." His premise was that these "sketches" caught the exteriorization of inner truths more accurately than working with a stationary posed model. His works validate these sculpting principles, as expressed to Gsell.

Generally the face alone is considered to be the mirror of the soul: the mobility of the features of the face seems to us the unique exteriorization of the spiritual life. In reality, there is not one muscle of the body that does not express variations within. Each speaks of joy or sadness, enthusiasm or despair, calm or rage. Outstretched aims, an unrestrained torso can smile with as much sweetness as eyes or lips. But in order to be able to interpret all aspects of the flesh, one must be trained patiently in the spelling and reading of this beautiful book.[1]

The question thus arises: how can we as students of the human condition undertake this necessary reading? How might we develop the aesthetic sense to appreciate the legibility of the human face and form more fully? The artist can help us here, for the artist "sees" the world through eyes trained to acutely appreciate color, light and shadow, surface and volume, and exteriorization of inner truths. In particular, Rodin's artistic techniques and insight offer the health care practitioner rich intellectual material for this study. A closer look at Rodin's masterpiece "The Burghers of Calais" amply illustrates what I mean.

Rodin was commissioned in 1884 by the Municipal Council of Calais, France, to design a monument to honor the secular martyrdom of the Burghers of Calais. These six men had offered their lives as a sacrifice in 1347 to end the eleven-month siege of Calais by King Edward III of England during the Hundred Years War. This event was vividly described by Froissart in his Chronicles. The Chronicles documented the events of this day, recounting the desperate state of the starving citizens of Calais.

Rodin did not attempt to capture the abstract emotion of devotion but rather that moment when the Burghers departed from the camp of the King to become his trophies of war to compensate him for losses of men and money during the siege. Rodin wished his sculpture to be read like a six-act play, a succession of movements and emotion, in a composition like chaplet, a living rosary. Ultimately the six Burghers represent the various emotional states that all pass through when they learn that they are going to die. Emotions, recollected scenes, gestures, and faces flood the mind of the reflective viewer of these depictions of suffering humanity. These powerful representations of the complex states of sorrow, fear, resignation, quiet rage, and disbelief stir memories of interactions not quite understood, behaviors unexplained, personal losses endured, and sacrifices made on behalf of others. It is at once comforting and disquieting to be reminded that these bewildering moments are common to humanity throughout time.

Caught up in these feelings evoked by the Burghers, one begins to notice the dramatic effect of their grouping and the relationship of each Burgher to the others. Although they stand in close proximity to one another, they do not touch. Although they are united by a common purpose and destiny, each suffers privately in different ways. Still, they exist in harmony with one another and in relation to their environment. The changing weather and light modulates their appearance. Different surfaces and hollows of the faces are more strongly highlighted on dark rainy days than on brilliant sunny ones. As the day progresses and the light shifts, each of the figures changes. On wintry days they stand out against the bleak sky in a particularly dramatic way.

Rodin has masterfully created a sense of movement in these stationary figures. Viewed from any angle, they seem to lumber slowly forward. Their dramatic gestures invite the eye to sweep around the ensemble. In fact, the gestures, which are so compelling, are clues to each Burgher's emotional state. Although their arms and hands do not touch one another, they do direct and lead the eye in a circular motion around the ensemble.

Rodin's Burghers show the inner turmoil one faces before death, regardless of age or background. They are united by a common desire to save their fellow citizens, yet at the same time they cling to their own lives. As a nurse I ask myself: What meaning can such a distant event have for those of us in contemporary health care? It might be perplexing to think that the themes of suffering and sacrifice need to be studied more deeply by those who already witness loss and suffering and death each day. But, in fact, a work of art that acknowledges the loss to which we are all born, especially a work of art that depicts its subjects compassionately, can for many provide insight and even comfort otherwise unknown. Furthermore, there is an inherent element of sacrifice in the daily arena of health care, ranging from the caregivers of patients with Alzheimer's disease and the parents who sacrifice sleep and resources for a sick child, from the nurse who repeatedly risks his or her health to care for those who are strug gling with AIDS and other infectious diseases.

Moreover, nurses know as do others in caring professions that an understanding of the human condition is not born of generalizations but rather of minute real-life encounters. Just as this artist built an entire work of art on truth within the moment, so does the nurse build the art of nursing practice on acute perceptions of visual clues to emotional states. For instance, vulnerable individuals, whether they be the very young or the oldest of the old cannot always articulate their fears and anxieties. Indeed, at times they may be unwilling or unable to speak. A sensitive understanding of the ways in which inner states are conveyed involuntarily by the human anatomy assists nurses in grounding their clinical judgment in the patient's experience in order to act creatively and compassionately on their behalf.

Similarly in Leo Tolstoi's The Death of Ivan Ilych we find a crucial source for understanding suffering and compassion and end-of-life issues that surpasses, in my opinion, theoretical studies and clinical textbooks on this subject. In the past decades there have been numerous essays that have looked at its importance for medicine and nursing, and with good reason.

Tolstoi's novella illustrates vividly, and almost clinically, the despair and isolation of a dying man in the middle-class society of nineteenth-century Russia. It specifically explores the deep moral and spiritual suffering of a lawyer and bureaucrat, Ivan Ilych, as he searches in his final illness for the meaning of his life. As readers face the knowledge of impending death with Ivan Ilych, his family and colleagues, they witness the need for recognition of moral and spiritual suffering and the hope which arises from forgiveness. Although completed over a hundred years ago, the themes of this short crystalline novel are familiar today in a world that like Tolstoi's honors promotion and gratification of the self before the interest of others. Tolstoi's microscopic yet rounded view of Ivan's world and personal suffering provide us with a fuller understanding of illness as a form of spiritual and psychological exile.

We know from the many biographical studies of Tolstoi that Ivan Ilych was the "artistic culmination of a profound spiritual crises in his life." [2] From an early age Tolstoi kept "death notes" which are evident in his letters, diaries, and other writings. He recorded his reactions and reflections on the deaths of his beloved aunts (who raised him), three of his own sons, friends, his younger brother, soldiers on the battlefield, and even a prisoner executed in Paris. He was perplexed and intrigued by the variety of his reactions. During a late nine-year period in his life, following the publication of his celebrated masterpiece Anna Karenina when he was unable to write fiction, he suffered dark nights in isolation during which he was terrorized by the question of immortality of the soul. [3]

Ivan Ilych is modeled after an actual judge, Ivan Ilych Mechnikov, whose death was described to Tostoi by the judge's brother. Mechnikov was the judge who sent countless men, young and old, to Siberia-many for minor infractions of the law, some of whom were innocent. Tolstoi sometimes comforted the prisoners at the train station where they awaited deportation, heads shaven and locked in chains. He was plagued by the "professional detachment which allowed this judge to treat others so inhumanely and then return to dinner with family and friends. Then one day Mechnikov's name appeared on the list of those sentenced to the ultimate dark and to the cold." Tolstoi began to write Mechnikov's story in the form of a diary titled "The Death of a Judge"-which became the fictional story-but he felt that he must include his own death fears in this story "because the chief reason why we can tolerate death in others, even in those near to us," he wrote, "is that it pushes it away from ourselves." [4]

Ivan, and through him Tolstoi, struggles with the eternal question addressed to God: "When I am not what will there be? There will be nothing. Then where shall I be when I am not anymore? Can this be dying? No, I don't want to." [5] Equally important, we are with Ivan when his stubborn resolve to believe that he suffers alone is pierced by his young son's grief as he reaches out to his father. There is in this reaching out a transfer of suffering that brings each to compassion. We are given a fresh understanding of the power of compassion which has arisen from this interchange of desire and need between father and son. This wordless interchange diminished Ivan's isolation and terror of the unknown, but also the fear that his life had no meaning but had only been materialistic and superficial. Moreover, this interchange releases his son from his isolation in which his father's care and love for him are at last acknowledged and each is released from his personal exile.

It is also in this novella that we witness the sometimes strange and bewildering behavior of relatives and friends at the time of death that all too often perplexes and confounds us. We experience with Ivan the anxiety and fright engendered by his caretakers' authoritarian, condescending, and detached manner. Ivan could not extract the truth of his condition from his doctors but only received detached pity, which he abhorred. We are refreshed by the care and comfort he receives form Gerasim, his young servant when he can no longer care for himself in any way. This young man performs all aspects of care calmly and with dignity, sparing Ivan any possible embarrassment. He alone is able to acknowledge the truth with Ivan - that he is dying and needs every consideration. His desire to relieve Ivan's suffering and his calm presence - responding to Ivan's need of release from the isolation of his suffering-foster hope.

Such struggles against despair and such questioning of suffering and death will be experienced in some form by us all. The desire not only to overcome but also to understand the pain and mystery of loss must be addressed and deeply considered by those involved in all aspects of health care. It is only through the wisdom derived of compassion that we, as nurses, can be of true assistance to our patients, their families, and ultimately, to ourselves. Tolstoi's art, I believe, fortifies and enriches our understanding of such compassion at a level of experience and perception unavailable in our professional textbooks.

The message of the Japanese director Kurosawa's film Ikiru is much like Tolstoi's, but the medium reveals it with greater vividness and immediacy. Akin Kurosawa's artistry developed through formal study of painting, dramatic arts, poetry, and fiction of his own culture and that of others both Eastern and Western. Ultimately, his film represents a culmination of his deep concern for humanity and his brooding about human life and mortality. He has said:

There are people who criticize my work...and say, it is not realistic. But I feel that merely copying the outward appearance of the world would not result in anything real -- that is only copying. I think that to find what is real one must look very closely at one's world, to search of those things that contribute to this reality which one feels are underneath the surface. These are the core around which the world moves, the axis on which it turns. The novels of Dostoevski, Tolstoi, and Turgenev show us what these things are. To be an artist means to search for, find, and look at these things: to be an artist means never to avert one's eyes. [6]

Through Kurosawa's principles for creative work we can learn much about the conduct of nursing practice and the art of nursing. Concentrating on these principles, he becomes our guide for seeing and hearing the world around us in a deeper, more reflective and fulfilling way. His model is one of collaborative art making (just as nursing is a collaborative art). Kurosawa appreciated the character of his actors themselves as they worked together to make a film (and as nurses we appreciate the character of our patients). He produced his films as research projects, bringing together the central question the film explored and the natural reactions of his actors' own responses to events as they evolve. (In the same way nurses approach each patient open to exploring concerns and needs which emerge from our collaborative conversations).

Perhaps one of his greatest gifts is his attention to detail. (This is also a particular gift of nurses). Kurosawa's artistic knowledge of color, perspective, shadow, and light; his understanding of Noh theatre, with its consideration of voice, tone, gesture, posture, movement, engagement, timing, and its revelation of inner spirit; his understanding of classical music traditions from the East and West; and his feeling for the poetry inherent in life -- all of these elements give his films both a lyric and a tactile quality. His ability to value silences, to leave unsaid what should not be spoken, helps us to realize that the sensitivity necessary for compassion can never be presumptive and must be nonintrusive. (As nurses we know that we cannot tell or presume to know what another wants or needs with absolute authority).

While there are numerous Kurosawa films applicable to our line of inquiry it is perhaps Ikiru, or "To Live," which reveals his gifts most relevant to the themes of our present concern. The film is set in postwar Japan in 1952. The film and The Death of Ivan Ilych have many parallels and counterpoints. Tolstoi's work begins with a man's funeral, Kurosawa's ends with one. But each event elicits similar behaviors from colleagues, even though one occurs in nineteenth-century Russia, and the other in twentieth-century Japan. Relatives of the main characters react in the same disparaging ways and with the same painful results. It is a stranger whose recognition of another's emotional suffering becomes a central figure in both stories. In each work one individual is able, by courageously acknowledging the truth of the central character's condition, to experience that fragile moment when a single revelation changes the life of the sufferer and that of others. Kurosawa, writing about his conception of Ikiru, says: "So metimes I think of ceasing to be -- and it is from these thoughts that Ikiru came." [7]

The artistry of the film guides one to share the character's values and beliefs and subsequently to examine one's own. The director's art seems instantly relevant to the life of the practicing nurse. This is no mere empathic imagining of what another needs or wants, but rather a fuller, deeper grasp of the others' fully visualized self.

Ikiru explores the layers of human existence to the depths of sorrow, folly, and nobility of which men and women are capable.

The film is the story of a Japanese bureaucrat, Kanji Watanabe, who learns from a stranger in a hospital clinic that his painful stomach troubles mean that he has cancer and will soon die. Watanabe believes the stranger's diagnosis although his doctors cannot admit the truth to him. Suddenly, he is awakened to the fact that he has not been truly living for the past thirty years. Dulled from a monotonous petty official's career, he has drifted through life since his wife's untimely death years before. His days are filled with paper work, stamping documents with his official seal. At the Citizen's Bureau he is surrounded by junior clerks who shuffle papers all day in much the same way. But the shock of impending death changes Watanabe's view of things. He is awakened to those around him as if for the first time, and the results of this startling awareness are not pleasant. His painful search for an affirmation of his life leads him on a course of action that ultimately transforms him and reveals the hidden nobi lity of his character.

Kurosawa uses many techniques to awaken us to Watanabe's plight: fascinating details, flashbacks, music, and narrative. Laced throughout the film are bizarre strains of American music and the big band sound, showing the effects of American culture on Japan in the early 1950s. Kurosawa uses every available means to make us feel what Watanabe feels in order to alert us to the dangers of passivity in our own personal and professional lives. He is very clear about the sacrifices that become necessary when one begins to fight -- to live fully and compassionately on behalf of others. He is telling us that it is possible to break out meaningless routine. This is strong preventive medicine -- for oneself.

This remarkable contemporary film is a rich source from which readers and specifically health care professionals can draw much understanding of themselves and their vocation.

Lastly, I turn to Herbert Mason's verse narrative of the Gilgamesh epic. [8]

Through this retelling of the ancient Sumerian story one realizes that the pain and mystery of loss are shared by humanity through the ages. This story of a god-like tyrant king (Gilgamesh) and an innocent, animal-like man (Enkidu) portrays the ways in which they become humanized through their friendship. When Gilgamesh loses his fraternal companion Enkidu in battle (which Gilgamesh contrived to defy the gods and to contend with evil), he is nearly paralyzed by grief and longing for the first time in his life. His personal loss and passion to find the source of eternal life, in order to bring back his friend, lift him out of his indifference to human life. He sets out on a perilous journey to find a wise man, Utnapishtim, chosen by the old gods to survive the great flood, who knows the secret of immortality. The journey is replete with adventures that nearly crush the grieving king and reduce him to a solitary, suffering "everyman." When Gilgamesh crosses the sea of death and is befriended by the aged and wis e Utnapishtim, who has grieved over the multitude of losses from the flood, he is given the secret plant of eternal life. Renewed by the plant and excited by the prospect of living forever, he pauses to bathe in a pool, setting the plant aside. A serpent (nature itself) then rises from the water and devours the plant, leaving it behind as slough. In ancient Mesopotamian literature the serpent did not represent evil but rather the natural cycle of life. For humanity, recognition of loss and acceptance of mortality lead to wisdom, which is humanity's unique attainment. Leaving it behind as slough is the final loss that reveals the journey's ultimate meaning for the young King: Wisdom can only be attained by his facing his own mortality.

In Mason's poignant rendition of Enkidu's death, Enkidu's words to his friend, Gilgamesh, reveal to us the depth of attachment and sorrow felt by the dying as they leave the known world. Referring to a woman sent to him by Gilgamesh at the beginning of the epic, Enkidu says:

She made me see

Things as a man, and a man sees death in things.

That is what it is to be a man. You'll know

When you have lost your strength to see

The way you once did. You'll be alone to wander

Looking for that life that's gone or some

Eternal life you have to find.

He drew closer to his friend's face.

My pain is that my eyes and ears

No longer see and hear the same

As yours do. Your eyes have changed.

You are crying. You never cried before.

It's not like you.

Why am I to die,

You to wander on alone?

Is that the way it is with friends? (Gilgamesh, 49)

And Gilgamesh, stricken with grief,

...wept bitterly for his friend

He felt himself now singled out for loss

Apart from everyone else. The word Enkidu

Roamed through every thought

Like a hungry animal through empty lairs

In search of food. The only nourishment 

He knew was grief, endless in its hidden source

Yet never ending hunger. (Gilgamesh, 53)

On his journey Gilgamesh discovers the depths of his loneliness in the Valley of the Precious Stones. Overcome with yearning to share this beauty with his lost friend he speaks.

Gazing into the valley

He felt overcome with pain

As a man

Who has been in prison

Feels his chains

At release from fear.

He spoke Enkidu's name aloud

My friend Enkidu

Died. We hunted together. We killed Humbaba

And the Bull of Heaven. We were always

At each other's side, encouraging when one

Was discouraged or afraid or didn't

Understand. He was this close to me.

He held his hands together to describe the closeness. It seemed for a moment

He could touch his friend.

Could speak to him as if he were there:

Enkidu. Enkidu. But suddenly the silence

Was deeper than before

In a place where they had never been

Together.

He sat down on the ground and wept:

Enkidu. Enkidu. (Gilgamesh, 60, 61)

These are the elements nourishing one's understanding of this majestic word compassion: the outward and inward grasp of the fugitive truth of our human condition; the unforeseen yet yearned-for intervention by a silent witness of our despairing passivity, by another enabling us to affirm life itself; and the sorrow born of loss that leads one on a journey in defiance of death and ends in the recognition and acceptance of our common humanity. Each work addresses the mutuality of our experience of compassion, and indeed from the most ancient of tales we discover the depth from which this compassion springs.

These works of art and literature are realizations of experience by their creators that correspond at a very deep level to the experience of nurses, physicians, and other health care clinicians. In over forty years of experience as a nurse and educator practicing in hospitals, clinics, and teaching in medical and nursing schools, I have found art and literature as useful for instilling the meaning and depth of compassion. This is, of course, what many others already know but it is not as yet widely recognized within health care practice and education.

Jeanine Young-Mason is Professor, School of Nursing University of Massachusetts Amherst and Co-Director of the Community Arts Health and Healing Project. She is author of States of Exile: Correspondences between Art, Literature and Nursing, 21 Words for Nurses, The Patient's Voice: Experiences of illness, and the forthcoming Nurses' and Physicians' Stories (tentative title).

Notes

For a further discussion of these and other works see my book States of Exile: Correspondences between Art, Literature and Nursing (New York: NLN press, 1995), and an essay entitled "Visual Clues to Emotional States: Rodin's 'Burghers of Calais.'" in The Journal of Professional Nursing 6, no. 5 (1996). This book and essay also contain a series of my photographs of "The Burghers of Calais." A trilogy of my essays on aesthetic research in Clinical Nurse Specialist 12, no. 3 and 5, and 13, no. 3, discusses aspects of Rodin, Tolstoi, Kurosawa, and Mason.

(1.) A. Rodin, Art: Conversations with Paul Gsell, trans. J. de Casso and P. B. Sanders (Berkeley: University of California Press, 1984).

(2.) R. Blythe, "On Tolstoi's Life and Work" in L. Tolstoi, The Death of Ivan Ilych (New York: Bantam Books, 1981).

(3.) Ibid. paraphrased

(4.) Ibid. paraphrased

(5.) L. Tolstoi, The Death of Ivan Ilych, trans. Alymer Maude (New York: New American Library, 1960).

(6.) A. Kurosawa, Ikiru (Japan: Toho/Kurosawa Productions, 1952). Cinematheque Collection, Los Angeles (VCR and Beta).

(7.) A. Kurosawa, Something Like an Autobiography (New York: Vintage Books, 1983).

(8.) Herbert Mason, Gilgamesh: A Verse Narrative (New York: Mentor NAL, 1972).