Posted by: ayrshirehealth | February 19, 2014

What’s love got to do with it? by @shaun4maher

What’s love got to do with it?

DonabedianAvedis Donabedian is a personal hero of mine. He was born in Lebanon of Turkish decent, his family having fled the Armenian Holocaust. He trained as a doctor in the 1940s and worked in Israel, the UK, eventually ending up in the United States working as an academic and a teacher. He ended his career as Professor of Public Health at the University of Michigan.

He is most famous for his extensive research and publications relating to the quality of healthcare and is considered to be one of the founding fathers of the modern healthcare quality improvement movement. Quality strategyHis seven pillars of quality undoubtedly form the foundation of the IOM quality dimensions used extensively across the globe today as an overarching quality framework, and indeed in our own NHS Scotland Quality Strategy.

His work focused on approaches that utilised principles of systems thinking and reliable design to improve quality. Specifically, he wrote extensively about the necessity of examining healthcare quality through structure, process and outcome.

The secret of quality is love      

He was also a deeply principled man and through all his work (and there’s a lot of it!) is woven a deep desire to good to his fellow man.  His personal philosophy is summed up by the following quote:

Systems awareness and systems design are important for health professionals, but are not enough. They are enabling mechanisms only. It is the ethical dimension of individuals that is essential to a system’s success. Ultimately, the secret of quality is love… If you have love then you can work backward to monitor and improve the system.”

What did he mean by this? What has love got to do with improving health and care for the average health professional? Or for that matter the man on the street?  I suppose the answer depends on what you mean by love?

Its all Greek to me!

GreekAfter speaking about this topic at an event recently I was asked by someone: “can we really love our patients?”  My response was: “it depends what you mean by love?”

The English word can and is used in many different ways to mean different things.  I love a walk in the mountains and I love my wife – same word but very different meaning – hopefully!

In the Greek language there are three different words for our English word love:

  • Eros is used to describe the emotional (and physical) love from which we derive our English word “erotic”.
  • Phileo is also an emotional word and is used to describe the deep friendship that occurs between people who are drawn to each other. It could be used to describe how you feel towards your best friend for example.
  • Agapé is the third word used. This word is different in nature from the first two. Agapé describes an intellectual process not an emotional one. Agapé describes an elective process by which you choose to do good to or for someone, sometimes even despite negative emotions you may have towards them, or even though it may inconvenience you or cause you discomfort – even harm. Agapé is not driven by emotion, but rather by a deep seated philosophical desire to do the right thing for another human being. The word has its roots in the Christian faith and is used extensively in the New Testament. Some have called it sacrificial love.

So, perhaps for many of us there is one special relationship where all three of these elements come together and combine to form a relationship that has all the physical, emotional and intellectual ingredients of love.  But then in all our other relationships there is a continuum where some elements are more prominent than others.  Our friends, neighbours, work-colleagues and all other human beings we come into contact with, can to one degree or another be recipients of our love.

In their book: “Intelligent Kindness: reforming the culture in healthcare” John Ballat and Penelope Campling refer to Agapé and suggest that this is exactly the ingredient that has been missing, or pushed out of healthcare culture in the NHS, resulting in tragedies like those seen in the Mid-Staffordshire NHS Trust or Winterborne View care home. They argue that Agapé cannot be regulated into health and care services by inspections or targets, its something that has to taught and modeled from the very top right the way through. It has to be explicit in the design of the system and in our behaviour – the way we treat our co-workers as well as those we support or care for.

Can we really love our patients?

So, can we love our patients? Well if its Agapé we are talking about the answer is an emphatic “yes!”  This isn’t about liking someone or feeling emotions towards them. PersonCentredIt’s not about sentimental niceness or even simple altruism.  No, this kindness, this true person centredness, is something that is generated by a deep seated intellectual understanding that self-interest and the interests of others are bound together.

I suppose this might be considered a characteristic of the consummate professional – the ability and the conviction to place the needs of those we serve before our own personal needs.

To quote from Ballat and Campling again, this deep sense of kinship: “emerges from a sense of common humanity, promotes sharing, efforts on others behalf, sacrifice for the good of the other.  It drives imagination, resourcefulness and creativity …  When people are kind they want to do well for others.”  But they also recognize that it can often be very difficult requiring us to overcome: “narrow self interest, anxiety, conflict, distaste and limited resources.  Kindness involves the risk of getting things wrong, maybe of being hurt somehow in the process… [however] Kindness is most effective when directed by intelligence” 

Feel the love!

I think this is probably the love that Avedis Donabedian had in mind and I think this is probably a good description of true love, true Agapé. AgapeThis is the type of love that really makes the world go round!

If we are to succeed in our ambition to continually improve our health and care services in Scotland, so that they are truly person centred, as safe as they can be and as effective as possible, then this is the philosophy that must underpin all of our efforts to improve, by whatever means.

So what has love got to do with it?  Well, as far as I’m concerned the answer is: its got everything to do with it – everything for everyone, everywhere.

How about you?

This week’s blog was by @shaun4maher (Shaun Maher) is an Improvement Advisor for the Person Centred Health & Care Collaborative; he is an ICU nurse and Patient Safety Fellow.


  1. Thanks for this amazing blog thought provoking and inspring, it has set me up for the day. I will endeavour to feel the love and indeed share it with others.

    • Elaine – I read your comment this morning and smiled. The power of engaging and blogging is borne out in your comment, simply put it can set someone up for a good day; I had one after reading your comment. Derek

    • Thanks Elaine, I’m glad it hit the mark for you.

  2. I think you have hit the nail on the head, Shaun. We have turned healthcare into a matter of technical competence and downplayed the agape element. I think this is true even in my own profession of psychology, where there is a focus on behaviour-change techniques and relatively little focus on relationship. It raises two questions for me: what would an organization look like if it were designed to support agape, and, at the level of the individual, is agape something that you can turn on and off when you arrive / leave work? Religion used to support individuals in this, but we live in a post-religious age for better or worse – “I don’t believe in God, but I do miss him” (Julian Barnes). In the absence of religion, we have ‘moral values’, but we have tended to adopt a relativistic approach to these – who’s to say whether my values are better or worse than yours? – so we have gradually sunk to the lowest common denominator – “what’s in it for me?” I think it’s going to be difficult to move from this position to the better position of “What’s in it for us?” or “What can I do for you?” As you say in your blog, we need to demonstrate the latter in our behaviour, and let’s hope that our organizations will support us in that!

    • Thanks John. You are right that in a relativistic moral environment it can be more challenging to get a consensus, but not impossible. I think the first step an organisation or system can take to support this type of culture is to understand purpose and then clearly articulate the underpinning values for delivering on that purpose. If leaders deliberately and systematically live by, and recruit to, these values – then that would be a start!
      Thanks again for your comment.

  3. I love that for you love has got to do with everything for everyone, everywhere. Now that is a hugely admirable perspective, and I’m sure many in the health field feel the same even if they might not express it that way. I hope so, at least! ~Catherine

    • Thanks for your comment. We sometimes shy away form this type of language in our rather reserved culture, but I think its important to articulate our interconnectedness in a meaningful way. If we were a bit more vocal about these vital underpinning values we would have a sure foundation to build on as we continually drive for the best we can be!
      Thanks again.

  4. Systems thinking and Agapé love in one blog – passion and mission brought together in a moving piece. Could we extend St Paul? “If I practice systems thinking, but have not love, I am a mere technician”
    Equally, we could extend Deming “Doing your best is not enough, neither is love enough” – without a method, love achieves nothing.

    With a motive and a method, we can move mountains. Mmm.

    • Your comment reminded me of one Paul Martin made when he was our CNO – are we carers in a technical environment or technicians in a caring environment – it was a challenge to nurses to remember to care. Your comment on ‘but have not love’ chimed for me with this. Thanks Derek

      • A good challenge to throw out. I believe the technical competence is vital but does not have primacy. At best it is equal with the need to care, and perhaps slightly subservient.

      • Absolutely – and I agree, care must have preeminence if we want to be truly personcentred.

    • Thanks Harry. I couldn’t agree more. Its all very well having the motivation and the values, but if you haven’t got a method you won’t get very far! Likewise, if you don’t address values and the ethical / cultural context in which you apply your method you may end up with all sorts of unintended consequences such as effort substitution and other such evils!

  5. A question from a related sector. In higher education we have an increasing problem of overwork, especially among casualised educators, and this has led to a helpful critique of the “Do What You Love” philosophy that has seen so many people in academic work become ill as the result of trying to do too much to preserve student experience in underresourced systems. The issues raised there involve the near impossibility of striking the balance between care of the self and care for others when systems/institutions themselves have lost the ability to regulate the impact of overwork. Do you have any thoughts about the risk of a “love” discourse in your sector?

    • As a PS, for an example of the new wave of thinking sweeping through health service leadership, have a look at last months blog on Person-Centred Leadership by Hazel Borland!

  6. Hi Kate
    We very much face the same challenge in the health and care sector. Health workers have the highest sickness absence rates in the public sector, and they are also off for the longest time of all public sector workers.
    There is no easy solution to this problem, but in a general sense it starts and ends with leadership.
    Firstly, leaders and managers have a responsibility to predominantly act on the system rather than on the people in the system – the reverse of is the current norm. Secondly, the political overlords of the system do not appear to have fully realised yet, that arbitrary targets, increased regulation and inspections are not the route to high quality services and optimal staff health. The current approach results in effort substitution, failure demand and harm to staff and service users. With regard to staff; an over-managed demoralised unhealthy workforce is the end result.
    That’s the bad news! On the positive side, there does appear to be a growing recognition amongst both system and political leaders that the person-centred approach in the context of systems thinking and improvement science has the potential to transform the public sector and undo these ills. However, for the time-being they seem reluctant to let go of the old ways and tyranny of targets and performance management embedded over many years. We have a very hierarchal bureaucratic culture with a lot of people who feel they have a lot to lose, if control over workers is relinquished and hierarchies flattened.
    We are just at the beginning of this shift. Transformation will take time, courage and a degree of resilience. For this reason we have a strong focus on staff health and wellbeing in the person-centred work in health and I would be happy to discuss this with you further. If you would like to know more – just contact me through Twitter @Shaun4Maher.

  7. A
    An excellent article Shaun. ‘Love is something you do, not something you feel’ is part of the answer, while observing someone who exemplifies agape love helps a lot. First Corinthians chapter 13 is for me the ultimate explanation of what agape is. John chapter 13 gives me the model.

  8. […] been thinking about quality in health care as well this week on the Ayrshirehealth blog. In ‘What’s love got to do with it?‘ he reflects on the work of Avedis Donabedian, a doctor who wrote extensively on the topic of […]

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