Imagined in Policy, Inscribed on Bodies: Defending an Ethic of Compassion in a Political Context Comment on “Why and How Is Compassion Necessary to Provide Good Quality Healthcare?”


Imagined in Policy, Inscribed on Bodies: Defending an Ethic 
of Compassion in a Political Context
Comment on “Why and How Is Compassion Necessary to Provide Good Quality 
Healthcare?”

Dave Mercer*

Abstract
In response to the International Journal of Health Policy and Management (IJHPM) editorial, this commentary 
adds to the debate about ethical dimensions of compassionate care in UK service provision. It acknowledges 
the importance of the original paper, and attempts to explore some of the issues that are raised in the context 
of nursing practice, research and education. It is argued that each of these fields of the profession are enacted 
in an escalating culture of corporatism, be that National Health Service (NHS) or university campus, and 
global neoliberalism. Post-structuralist ideas, notably those of Foucault, are borrowed to interrogate healthcare 
as discursive practice and disciplinary knowledge; where an understanding of the ways in which power 
and language operate is prominent. Historical and contemporary evidence of institutional and ideological 
degradation of sections of humanity, a ‘history of the present,’ serve as reminders of the import, and fragility, 
of ethical codes.
Keywords: Compassion, Ethics, Nursing, Health Politics, Neoliberalism, Austerity, Human Rights
Copyright: © 2015 by Kerman University of Medical Sciences
Citation: Mercer D. Imagined in policy, inscribed on bodies: Defending an ethic of compassion in a political 
context: Comment on “Why and how is compassion necessary to provide good quality healthcare?” Int J Health 
Policy Manag. 2015;4(10):681–683. doi:10.15171/ijhpm.2015.125

*Correspondence to:
Dave Mercer
Email: dmercer@liverpool.ac.uk

Article History:
Received: 30 May 2015
Accepted: 8 July 2015
ePublished: 10 July 2015

Commentary

School of Health Sciences, University of Liverpool, Liverpool, UK

http://ijhpm.com
Int J Health Policy Manag 2015, 4(10), 681–683 doi 10.15171/ijhpm.2015.125

Introduction
This short commentary is an invited response to Marianna 
Fotaki’s editorial ‘Why and how is compassion necessary to 
provide good quality healthcare?’ published in the International 
Journal of Health Policy and Management.1 It is a timely and 
valuable contribution to current debates about compassionate 
care in the context of specific failures in National Health 
Service (NHS) provision, and mediated reports of diminished 
public confidence in healthcare more generally. The 
title poses 2 key questions facing those individuals who, 
respectively, shape health policy, deliver caring services, 
or have responsibility for the preparation and training of 
future practitioners; and to each of these issues, ‘compassion’ 
and ‘ethical awareness’ are central constructs. Though, as it 
is noted, they are too often conflated and confused in both 
intellectual and ‘common sense’ accounts of the constituents 
of high-quality care; obfuscating individual attributes and 
organisational cultures.
In this reply, key themes from the paper are explored in 
relation to nursing academe, focusing on education and 
research which, it has long been argued, represent the 
foundations of progressive practice. Discussion is framed 
by an acknowledgement of the Foucauldian concept of 
‘discursive practice,’ as a way of understanding the historic 
and cultural rules that produce different forms of knowledge, 
and permit certain statements to be made.2 Translated into 
social research, this set of perspectives is represented by the 
contribution of discourse analysis as a form of inquiry that 

prioritises the ‘discursive construction of reality.’3 Here, 
attention is given to the performative, and collective, function 
of language in shaping the world around us, where what we 
‘know,’ or accept as ‘truth,’ are inextricably linked to power 
and ideology.4-6 These interrelated themes are elaborated 
below in terms of healthcare politics, research, practice, and 
education (wrapped up tidily in university ‘corporate speak’ 
as ‘knowledge exchange’). 

Politics and Research
In the United Kingdom, healthcare is a political issue. The 
NHS is the last vestige of traditional socialist ideals of welfare 
founded on the principle of ‘free to all, at the point of need’.7 
As an institution, its values are so deeply embedded in the 
public psyche that no ‘serious’ political party could campaign 
on an election manifesto that did not offer to protect the spirit 
of universality. Or, so it is routinely argued. Yet, results of the 
May 2015 election across England, Scotland, and Wales tell a 
different story, where any sense of collectivism was demolished 
by a surge of nationalism. The Scottish Nationalist Party 
(SNP) may have purveyed an ‘anti-austerity’ message to the 
voters and Westminster but, generally, identity prevailed over 
common interest. The reelection of a Government, freed of 
any coalition control, which systematically dismantled public 
services,8 is a harbinger of the ideological landscape upon 
which future debate about healthcare ethics, and practice, will 
take place.
Activists, academics, and health economists note the 

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Mercer

International Journal of Health Policy and Management, 2015, 4(10), 681–683682

detrimental effect, on health inequalities, of unchecked 
neoliberalism,9,10 as a global movement that, in short, 
celebrates market forces as the basis of political liberty. A 
scholarly review of how global financial crisis impacts on 
physical and mental health11 is summarised, more succinctly, 
as ‘austerity kills.’12 In the UK context, healthcare reforms 
– as a euphemism for privatisation – are coupled to further 
attacks on civil liberties with government proposals to abolish 
the Human Rights Act in favour of a British Bill of Rights; 
another example of de-universalisation as discursive practice 
in neoliberal times, where the ethical foundations of freedom 
and dignity are progressively chipped away.
Nurses, typically, work with vulnerable and marginalised 
groups, framed by a statutory duty of ‘care’ and ‘candour,’ 
to ‘treat people with kindness, respect and compassion’13; a 
laudable, and paramount, set of principles that stand proudly 
against the pro-genocidal discourse of tabloid reporting 
around immigration, asylum seekers, and refugees.14 The 
rise of the Nazi Party in pre-war Germany, though, is a dark 
reminder of how easily dominant nationalist ideologies can 
hijack intellectual and liberal aspirations, with import for 
how ethics are taught on nursing programmes today.15 Like all 
healthcare professionals, nursing research is guided by ethical 
principles enshrined in the Declaration of Helsinki (2000) 
that echo the Nuremberg Code (1947); a response to ‘human 
experimentation,’ and state sanctioned murder, in the death 
camps of the Third Reich.
The history of the Holocaust illustrates the extent to 
which doctors and nurses were willing to actively collude 
in bureaucratised killing of adults and children, in their 
care, with mental illness or a learning disability16-18; actions 
defended as ‘medical therapy,’ with individual ethics 
abandoned for the greater good of the ‘fatherland.’ The chief 
lesson to be learned is not rooted in the character traits of 
fascist street thugs or tyrannical sadists. Rather, it centres 
on the appropriation of psychiatric knowledge expressed 
in the spurious science of eugenics, within an ideological 
discourse that legitimated ‘mercy killing,’ without mercy19; 
deviance inscribed on the body of the ‘other.’ Such a ‘history 
of the present’20 raises profound and troubling questions for 
contemporary practitioners in the context of an increasingly 
visible, pan European, right-wing political presence.21,22 

Practice and Education
Given the past failure of ethics, discussed above, the nursing 
profession needs to define itself as a ‘moral community,’ 
coalesced around the ethics of witness and virtue.15 Two 
major UK inquiry reports, into high-secure care, published 
in the 1990s23,24 produced finding that characterised the worst 
excesses of the old asylum system, and led to major structural 
and legislative changes. They described an insular and 
oppressive world, with an institutional culture described as 
racist, sexist, and densely macho. More recent research findings 
suggest that little has changed since that time, despite massive 
capital investment and culture-change programmes.25,26 This 
raises questions for how ethical protection, and compassionate 
care, can be safeguarded for those groups who are vulnerable, 
excluded and marked by the stigma of a spoiled identity. 
Unlike current examples of a collapsed ‘duty to care’,27 related 
to general service provision for the seriously ill and elderly, 

prisoners and mentally disordered offenders do not make for 
the same sympathetic media coverage.
The idea of an ‘ethics of testimony’ as being important for 
nursing philosophy and science is also central to the work of 
Georges28 who sees self-reflection as one way of challenging 
Eurocentric reductionism, and reconceptualising the concept 
of ‘suffering.’ It is suggested that increased attention to 
structural inequalities like sexism and racism should replace 
dominant cultural narratives which equate problems with 
‘pathology,’ and solutions in terms of ‘therapy.’ Similarly, 
Ben-Sefer29 argues that it is knowledge of ‘suffering’ rather 
than ‘history’ that needs incorporating into the design of 
nursing curricula as a way of combating intolerance and 
hate crime. The involvement of ‘prisoner nurses’ detained in 
concentration camps, it is posited, reframes ethical theorising 
about ‘choice,’ and situates personal decision-making in 
the context of politics and power relations.30 It is suggested 
that masculinist discourses of ‘disconnection’ constructed a 
bio-political space in which moral categories collapsed, and 
corporeal violence was inscribed on the flesh of the inmate.
The disciplinary knowledge of psychiatry, and discursive 
practice of mental health nurses, is riven with ethical dilemmas 
from involuntary detention under mental health legislation to 
‘treatment’ methods31; described as a ‘web of power’ where 
tablets and talk can be equally invasive.32 Critical scholars 
suggest that: “Psychiatry is not a mere medical science: it is an 
intensely political system of interrelated practices, discourses, 
and institutions.”33 In such settings, the enactment of concepts 
like ‘advocacy’ and ‘therapeutic engagement’ are permeated 
by what is referred to as the ‘capillary power’ of the carceral 
system, or micro-physics of disciplinary regimes.34 For mental 
health nurses in general, and forensic staff in particular, any 
ethical framework is compromised, or constrained, by a dual 
allegiance to the person (care) and the state (control).
More generally, national and international evidence suggests 
that organisational cultures exert an impact on care and 
compassion in relation to, both, qualified members of staff 
and nurses in training.35,36 Typically, this is described as 
damaging and detrimental to the philosophy of the profession, 
and quality markers of health policy; a ‘hidden curriculum’ 
where ‘learning on the job’ in clinical settings incrementally 
erodes levels of empathy.37 Central to Fotaki’s paper,1 is a real 
concern about how compassion is cultivated, and embedded, 
in practice, and her discussion offers a valuable summary of 
philosophical and pragmatic issues in relation to a recent case 
study of care failures.27 Against this background, the author 
of the present paper, with a colleague, was commissioned 
by NHS North West to undertake a ‘values and behaviours’ 
evidence review.38 The findings, and themes, were congruent 
with the work of Fotaki. 

Concluding Remarks
Professor Fotaki has furnished an excellent editorial relating 
to a very real concern in UK healthcare, which deserves a 
wide readership for all those concerned with ensuring that 
compassion and care remain at the heart of service provision.1 
It artfully integrates ethical debate with real world strategies, 
but it is for the individual reader to interpret these in the 
context of their own role and responsibilities. This is what 
has been attempted in this response. None of the content 



Mercer

International Journal of Health Policy and Management, 2015, 4(10), 681–683 683

has been challenged, or alternative views expressed. As an 
academic nurse, with a long career in high-secure care, it 
was an interesting opportunity to rethink these issues in the 
context of an organisational culture that personally shaped 
an ongoing intellectual critique of ethics and politics in 
forensic psychiatry. I would like to thank the editorial team 
at IJHPM for inviting me to write this paper, and hope that it 
complements the original. 

Ethical issues
Not applicable.

Competing interests
Author declares that he has no competing interests.

Author’s contribution
DM is the single author of the manuscript.

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