Reflections on Compassion in the Midst of Violence

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At 2:50 pm, Monday, April 15th, two bomb blasts destroyed the celebratory spirit of the Boston marathon, three people died as a result of the blasts, and the lives of hundreds of survivors and those who cared for them would be forever changed in that moment. The compassion of those present on the scene was tested and it saved lives.

The crowd, frozen in the first few moments, quickly returned to reality and turned to run in all directions. However, footage and photos showed many health professionals, first responders, and bystanders running toward the blasts to aid the victims, stripping off shirts and belts to stem hemorrhage from limbs if they were still attached to bodies. Many were not. Blood-filled streets marked the finish line as victims poured into the medical tent. Many of the medical volunteers, untrained in emergency medicine or surgery, had no idea how to help after CPR and tourniquets had been applied, and watched in horror as victims were loaded onto ambulances and transported to nearby hospitals. A hospitalist who was volunteering in the medical tent recalled, “An injured womanI couldnt tell whether she was consciouslay on the stretcher, her legs entirely blown off. Blood poured out of the arteries of her torso; I saw shredded arteries, veins, ragged tissue and muscle. Nothing had prepared me for the raw physicality of such unnatural violence.” 1 Clinicians responded by caring for those they could. A physician sat beside a patient in psychological shock but with less severe physical injuries, saying, “Im a doctor, and Im going to take care of you, and Im not going anywhere. Now you are safe.” 1 The marathon finish line in Boston’s Copley Square was cordoned off as a crime scene.

Off-duty healthcare professionals didn’t bother to call in, they went directly to their hospitals to assist in the care of the wounded. Runners who had finished the marathon continued to run on to Massachusetts General Hospital to donate blood. Stunned and injured bystanders and their family members supported each other, and helped the staff in emergency waiting rooms move the more severely injured through to be treated. Recalling the chaos, a nurse at Boston Medical Center commented, “…in the center of that seeming cauldron of chaos, tiny lights of hope and kindness bloomed and spread. Whats your name? Im your nurse. Its okay. Hold my hand. And as the hours wore on, and the overwhelming scope of the tragedy became clear, the staffs special expertise shone. And though surely spent, they never gave up. What do you need? What can I do? Let me help.” 2

Did we witness and experience compassion in Boston? Did our ability to recognize and resonate with the fear and pain of the bombing victims motivate and result in action to relieve their suffering? Yes, of course. Human beings across all cultures are born with the capacity to recognize emotions and to act with compassion. We don’t all respond similarly to the suffering of others, however. As would be expected, many ran, terrified, to protect their loved ones and themselves, while others, regardless of training or role, amidst the smoke and potential for continued danger, ran towards the victims. Science has yet to help us fully understand why each of us responds differently in various contexts.

In less urgent circumstances, when we recognize the distress and suffering of others, our neural pathways for empathy are activated, and we have some time to process our resulting thoughts and emotions. When coupled with pro-social motivation and the capacity to respond, this process results in compassionate, helping behaviors. In circumstances of instantaneous suffering and disaster, there is little time for this process to unfold. Some individuals don’t think about it, they simply act if they can despite potential danger. This is heroism—that is, compassionate or altruistic action that incurs risk to oneself without expectation of reward. Those running towards the victims knew more bomb blasts could follow. A former Army nurse and first responder flashed back to Iraq and, saying to himself, “That was an IED (improvised explosive device),” 3 anticipated the second blast and then rushed towards the scene. One physician texted his wife, “Theres a bomb at the finish line and we have to help.” Later he reflected, “I didnt want to die, but there were people out there.” 1 Most of us are not put to the test for heroic compassion unless we’re working in war zones. Yet compassion remains an enduring professional value. Our patients, their families, and we ourselves expect that we will act consistently with compassion.

We each bring ourselves to the suffering of others with whatever abilities and capacities we have available at the particular moment in time when they are called upon. Beyond understanding and connecting with other’s emotions, compassion also requires the ability to regulate one’s own emotions, feeling capable of helping, and successfully accessing one’s existing internal and external resources for coping. Many health professionals felt compelled to call home to be sure their children were safe, and to speak with their loved ones before they were able to fully attend to helping the wounded after the bombings. Feeling another person’s loss as one’s own, or feeling unable to cope with that person’s needs can cause in us sadness, immobility, anxiety, anger, or blame. Repetitive exposure to suffering, loss, and trauma, without opportunities to process these experiences, causes distancing and emotional exhaustion that degrade compassion. Compassion is a messy process that depends on context and on so many intrapersonal, interpersonal and system-based variables.

Did we witness and experience compassion in Boston? Yes of course.

Whats your name? Im your nurse. Its okay. Hold my handWhat do you need? What can I do? Let me help.” 2

Im a doctor, and Im going to take care of you, and Im not going anywhere. Now you are safe.”1

These words represent the tenderness and steadiness we feel and express when what we have to offer is our compassionate presence.4 Not everyone can act with heroic compassion. And not everyone will be able to experience and express compassion all of the time. Some have this ability more than others, and the degree with which any one of us expresses compassion will vary depending on our capacity in the moment. Perhaps what we must do is to hold tightly to compassion as a personal ideal and as a professional expectation, to teach and model it, to remove the barriers to acting compassionately in order to make it easier for all to express. And when our capacity for compassion flags, we must accept and forgive ourselves, pick ourselves up, and try again to cultivate compassion in ourselves, for ourselves, and for each other.

Here in Boston, in the aftermath of the bombings and ensuing events, we are learning about acute-traumatic and post-traumatic stress, but also about post-traumatic growth—finding meaning in the wake of senseless violence, and developing resilience. Human beings share the capacity to recognize emotions and to respond to distress and suffering with compassion. Compassion has sustained our species and helps protect us from extinction, or it would if we could understand how to access it consistently, remove barriers to its expression, and to offer it to others whenever and wherever the need arises.


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    Gately R. Inside the ER. Available at the Huffington Post. Accessed June 20, 2013.

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Beth Lown is the medical director of the Schwartz Center for Compassionate Healthcare in Boston, associate professor of medicine, Harvard Medical School, and internist at Mount Auburn Hospital. She would like to thank Cheryl Tupper at the Arthur Vining Davis Foundations for encouraging her to write these reflections, and to acknowledge the Foundations and the Schwartz Center for their support of caring attitudes and compassionate health care.

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The author declares no conflict of interest.

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Correspondence to Beth A. Lown MD.

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Lown, B.A. Reflections on Compassion in the Midst of Violence. J GEN INTERN MED 28, 1554–1555 (2013).

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  • Iraq
  • Emotional Exhaustion
  • Finish Line
  • Medical Volunteer
  • Unnatural Violence