A negative effort: Simone Weil and the ethics of attention in palliative care

Since 1984, modern medicine has attended increasingly to concerns about inattention.

It was in that year that Beckman and Frankel published a study, now hugely influential, in which they recorded 74 clinical office visits and analyzed whether, at the outset of these visits, clinicians were able to elicit the full concerns of their patients (Beckman and Frankel, 1984). The results were not entirely flattering: only 23% of patients completed their opening statements prior to interruption from the clinician, and (perhaps most infamously) clinicians waited only 18 seconds on average before that first interruption (Beckman and Frankel, 1984). News articles arose with titles along the lines of “Study Finds Doctors Aren't Good Listeners” and “Prescription for Doctors: Listen More” (Mauksch, 2020).

These titles, of course, suggest that interruptions are a failure of attention, and that paying attention is something doctors ought to be doing. Yet some have argued that not all clinical interruptions are “intrusive, competitive, or power-claiming,” and that many interruptions are, in fact, neutral or even beneficial for the clinical interaction (Herstoff, 2017; Mauksch, 2020). This debate takes on special meaning for the palliative care clinician, who by training and professional nature is not typically prone to interruptions. Is there a place for interruption in palliative care? If so, what are the ethical foundations and consequences of such interruption?

Born in 1909, in France, Simone Weil was a passionate and original thinker whose work spanned the social, economic, political, ethical, and metaphysical disciplines (Rozelle-Stone and Davis, 2021). An ultimate idealist, she had a deep, natural compassion for the afflicted, and she comes through in her work as someone “excruciatingly identical with her ideas” (Sontag, 1963). If such depictions make Weil an imposing historical figure, her writings on attention merit no less analysis from the modern palliative care clinician.

Attention, for Weil, is the beginning of all ethics, because one cannot know how to act toward another person if one has not first understood that person. Yet, according to Weil, we cannot understand others through sheer efforts of attention. She believes that the mind is constantly at work projecting its own imagination and valuations on itself and the world around it, and that these projections inhibit true knowledge. To translate her thoughts into the language of medicine, we could say that a clinician is always at risk of projecting their assumptions and biases, implicit and explicit, onto the patient.

But because the clinician's mind is the source of these projections, it cannot of its own strength counter them with a truer perception of the patient's reality. In other words, attention is not something that you create through conscious effort. A squinting of the eyes, a tightening of the muscles, a serious face: all these images of the concentrated individual leave us only more aware of ourselves. The goal is to become aware of the patient, and so we reach a clinical paradox: attention is a core component of our work in palliative care because it allows us to see others more clearly, but this attention cannot be willed in the same way as, say, the movement of one's arm.

The resolution of this paradox is to say that attention does involve effort, but a special sort of effort. According to the Stanford Encyclopedia of Philosophy, Weil's concept of attention is not “a ‘muscular effort’ but a ‘negative effort’ … involving … a growing receptivity of the mind” (Rozelle-Stone and Davis, 2021). It is not an action but something we position ourselves to receive, “less a moral position or specific practice and more an orientation” (Rozelle-Stone and Davis, 2021). To say that attention is a negative effort is to claim that our effort is used largely to empty ourselves of internal noise and narratives, and to allow the patient to fill in the gap. We forget about ourselves without forgetting our knowledge or our role as healers, and this new orientation consists “of suspending our thought, leaving it detached … empty … holding in our minds, within the reach of this thought, but on the lower level and not in contact with it, the diverse knowledge we have acquired which we are forced to make use of” (Rozelle-Stone and Davis, 2021).

When we pay this sort of attention, we undergo something similar to what poets experience in the process of composing a poem. “The poet,” Weil writes, “produces the beautiful by fixing his attention on something real. It is the same with the act of love. To know that this man who is hungry and thirsty really exists as much as I do — that is enough, the rest follows of itself” (Weil, 1997). Not only does attention help me to understand the human being toward whom I want to act ethically; attention is itself an ethical act because it grants dignity and autonomy to a person who exists independent of my own mental constructs. The more I attend to the patient, the more my own mental image of them is replaced by a truer reality, and the more I recognize — “the rest follows of itself” — my professional and moral obligations toward them (Weil, 1997).

An honest perception of the patient in front of me will, therefore, involve an honest recognition of what I feel and think around them; and the constant reorientation toward that patient will remind me to leave those feelings and thoughts to the side, allowing me to be morally and professionally shaped not by my own agenda but by the needs of the patient. One writer claims that “only such a move makes it possible to recognize the fundamental equality and identity of all people, which means it is also the only chance for justice” (Rose, 2022). Through Weil's philosophy, then, we see that compassion, ethics, and justice in medicine “are the result of one and the same act, a certain application of the full attention” to the patient. In that case, educators in palliative care could have few greater aims than “to prepare, by training the attention, for the possibility of such an act” (Weil, 1997).

One might argue that these ideas, however compelling, are nonetheless difficult to apply in the clinical realm. But there are methods for carrying Weil's thought into palliative care. Some possibilities include assigned readings on attention — by Weil and those whom she influenced, such as Iris Murdoch — during medical school, residency, palliative care fellowships, and other palliative care training programs (e.g., nursing school, hospice volunteering, continuing medical education); an increased focus on the growing literature on attention and mindfulness in palliative care; and an emphasis, from clinicians and educators in palliative care, on asking what the patient is going through before and after each clinical interaction (Shennan et al., 2011; Omilion-Hodges and Swords, 2016; Orellana-Rios et al., 2018). These interventions do not guarantee greater attention; but given the fast-paced nature of modern medicine, a philosophy of attention would provide welcome opportunity to increasingly place patients at the center of our vision and care.

From Weil, then, we can derive a definition of attention in palliative care as the unforced process of becoming less aware of yourself and more aware of the patient and what they are going through, while holding onto the skills, knowledge, and compassion that will benefit the patient and respond to their particular needs and context. This attention is ethical in nature because it “not only gives human recognition” to the patient but also allows the clinician “to take up a moral stance in response” to their desire for the patient's wellbeing (Rozelle-Stone and Davis, 2021).

We may therefore argue that clinical interruptions are neither universally appropriate nor wholly inappropriate in palliative care. A kind, caring interruption — a question, perhaps, or a perceptive remark — may be warranted when a patient in hospice spends hours blaming himself for mistakes that he had made earlier in his life, clearly damaging his self-esteem and removing himself from the present moment. But ideally, such an interruption would arise from the palliative care clinician's attentive impulse in response to what the patient is going through — how that patient needs to be affirmed, enlarged, seen. If the clinician's own frustration is, in the end, the main impulse, Weil would call for a reorientation. Interruption could then become appropriate if its motivation followed from an intuitive sense of the patient's needs. However, even then, the responsibility would lie with the clinician to attend to the patient's response to being interrupted.

Of course, Simone Weil is not the final authority on attention in palliative care. But in a cultural and professional moment where attention seems increasingly precious and increasingly difficult to protect, her writings offer profound motivation for “an endless seeing” of our patients: a clear and compassionate witness to their lives, their words, their humanity (Rose, 2022).

If she has anything to say to us, we should pay attention.