1The TLFI (Trésor de la langue française informatisé), CNRS online dictionary, defines the verb to care as follows: “To take care of the physical and moral well-being of a person”. “. Note that, according to this definition, we can treat someone who is not suffering: even if I feel good (or if I do not feel bad), I can feel even better when someone is “caring” for me. In this text, I will designate by the name of “patient” any person (since the first meaning of the term is “one who suffers”) who asks for and/or receives care.

2From now on, I will use the terms “health professional”, “doctor”, “nurse”, etc., to designate people whose profession consists, in principle, of providing care. Although, unfortunately, they do not always do so.

3When I use the word “caregiver†, it will be to designate a person whose concern is to provide care, whether or not it is a question of their profession. And who does.

4As soon as there is life, there are sensations, emotions and actions, indissolubly linked.

5The first cries that a newborn utters unfold the lungs and inaugurate its access to aerial life; but these cries, and those that follow trigger in the mother – and sometimes in other women present around – the secretion of oxytocin, a neuro-hormone which induces feelings of attachment.

6Let the baby be placed against the mother’s belly, and his mouth instinctively searches for the breast. Just as instinctively – even if this drive is then rationalized – the vast majority of mothers respond to this stimulation by breastfeeding their babies. And immediately, the baby calms down. The first thing a human being does when born is therefore to express vital needs and to accomplish the first act of his first relationship: he makes sure that there is someone there. to protect it, feed it and meet its expectations – in other words: care for it. In the best case, the baby will grow up and one day become a more or less autonomous adult. But by then, he will have taken habits and established with “his carers” – mother, father, sisters and brothers, other close family members or to ©expanded – a relational mode that will serve as a reference.

7The theories of attachment developed by John Bowlby and taken up by Mary Ainsworth from the 1950s made it possible to define what are now called attachment patterns. early childhood attachment1. For simplicity, there are three of them: ‘secure’ attachment, ‘anxious’ attachment and ‘avoidant’ attachment. Each of these forms of attachment is a learned behavior, intended to cope with the type of relationship the child has established with his or her “caregivers” – caregivers – during the first months and years of his life. As the individual approaches adulthood, his mode of attachment strengthens or softens depending on the relationships he establishes with the people in his environment. A child who has established a secure attachment will more often than not become an individual capable of forming satisfying relationships and remaining emotionally independent; anxious attachment, marked by inconstant, unpredictable, worrying caring relationships, will produce uncertain adults, always anxious at the idea of ??separation; avoidant attachment, often linked to abusive relationships, will produce adults who are unwilling to bond, indifferent, and sometimes rejecting or aggressive. The predominant mode of attachment in childhood influences all later relationships – including, of course, caring relationships. When an adult finds himself in a position to seek care, he will do so, spontaneously – and often unknowingly – in the manner familiar to him from childhood. Which means that depending on the case, he will establish a balanced relationship, a dependent relationship or an avoidant relationship with the professional caregiver.

8Let us add that in the same way, the mode of attachment formed in childhood strongly conditions the way in which each adult dispenses care. Autonomy, anxiety or detachment preexist, in the carer, to his professional training. We are not born caregivers, we become one, sometimes against our own inclinations. To ignore it is to risk perpetuating attitudes that are not conducive to the proper delivery of care – behaving in a dependent manner with patients or, on the contrary, in a detached and avoidant.

9Our life begins with care and, very quickly, we learn to take care of ourselves. Self-care is an evolutionary “chosen” behavior, and it’s easy to see how: Individuals who carried genes that prompted them to take care of ™themselves survived and transmitted them to their descendants. The others, no. We are all descendants of ancestors who engaged in self-preservation and (to some extent) self-healing behavior.

10Animals take care of themselves: thus, large mammals – elephants, hippos – fight parasites on their skin by spraying themselves with water or wallowing in mud. Cats and canines lick their wounds to clean them of debris and to deposit enzymes that kill bacteria. If you and I spontaneously suck on a finger after cutting ourselves, it’s because our saliva, too, has antiseptic properties. Even if we don’t know it, we inherited this behavior from ancestors who licked their little wounds.

11Similarly, we know intuitively that immobilization, rest and diet promote the healing of illnesses, the healing of wounds and wounds. If I twist my ankle, the pain when walking will make me stay still – which will not only make my sprain worse, but also promote healing. by redistributing blood circulation and the work of immune cells in diseased or injured areas.

12The feeling of fatigue or the desire to sleep, which sometimes takes hold of us suddenly, under the effect of stress or illness, is also a defense process. By imposing rest, the brain allows the body to repair itself. Without being fully aware of it, we are the caregivers of ourselves. Depending on the case, we are the best and the worst patient of this caregiver 2.

13We are endowed with an extraordinary capacity, also inherited from millions of years of evolution: empathy. This innate ability allows us to perceive and imagine what the other is feeling and to experience echoing emotions; she also sometimes encourages us to come to her aid.

14In his book The Age of Empathy, primatologist Frans de Waal shows that empathy is a characteristic common to many mammals, constitutive of human nature, like that of primates. It is part of the adaptive skills that have allowed us to survive individually and collectively. Indeed, contrary to what many philosophical and political theories have suggested, aggressiveness and competition are not the primary behaviors of higher mammals. Among primates (chimpanzees, bonobos, gorillas, orangutans, humans) but also among many other mammals (from dogs to elephants), supportive behaviors are more common. ques as aggression. This is because they are spontaneously drawn to empathy – towards their genetic parents, but also towards individuals genetically ©distant – that many so-called “social†species have survived as a group. Without empathy, there is no exchange or sharing; without exchange or sharing, no cooperation; without cooperation, there is no social organization – and therefore, no possible survival in the face of predators or the vagaries of the climate and the environment.

15Empathy is, like all human characteristics, present in the population in varying ways. Like lack of sensitivity to pain, complete lack of empathy is rare, but people with no empathy (referred to as “sociopaths”) and those whose empathy is limited to their closest surroundings cannot, understandably, deliver care. Because to heal, you have to know how to assess the needs of the person who is suffering, and therefore identify with what they feel. Unfortunately, to date, personality profile assessments are almost non-existent at the entrance to care training; the selection of empathetic people and, by extension, the selection of medical students does not seek to identify candidates who are not enough (or who are too much). However, this would make it possible to exclude problematic personalities and to provide others with appropriate training.

16If empathy is spontaneous, the gesture of helping the other is no less so. As Frans de Waal reminds us, chimpanzees and bonobos, the primates genetically closest to us, commonly practice encouragement, consolation and mediation among themselves. This type of behavior transcends borders between species. Many mammals – especially those that have been domesticated by humans and live with them, such as dogs and cats – respond altruistically to suffering or to the distress of humans and other animals. Witness the countless examples of adoptions and attachments between animals seemingly as different as chickens and cats, bears and tigers, humans and lions shown on YouTube in the thousands of videos os posted and consulted by millions of moved Internet users. As for humans themselves, researchers in developmental psychology have shown that from the age of one year, toddlers react to the cries of those around them and make the gesture of crying. caress them to comfort them.

17Like all these animals, human beings carry within themselves everything necessary to identify with the suffering of the other and to implement a form of care, however rudimentary it may be. In other words, treating and receiving treatment is, literally, within everyone’s reach.

18In The Age of Empathy, de Waal recounts the following experience: scholars once asked the students of a theological seminary to come from their building in usual study in another building, to hear there a conference dedicated to the Good Samaritan. Their route took them past a man slumped against a wall, motionless and with his eyes closed. Less than half the students stopped to ask him if he needed help. Those who were told, in addition, that they had to get to the conference as soon as possible were even less likely to stop.

19Mû by empathy, the act of care is, fundamentally, an altruistic gesture, but is not systematic; no one is forcing me to hold out my hand to the man who fell; no one forces me to dive to prevent the drowning person from sinking.

20Like many other mammals, humans also carry within them biological mechanisms that allow them to be relieved by the gesture of care, in particular what is called the placebo effect. The gesture of care that we make towards the other when he is in pain (like the parent covering with kisses the forehead of the little one who has hit his head) triggers the secretion of ™endorphins which, for a time at least, reduce pain. The gesture of care has another important effect: it reassures; in doing so, it decreases the sensation of pain, and makes it more bearable. As soon as I suffer less, I can resume an activity, which also reduces my perception of pain until it disappears. These notions explain in particular that people suffering from lumbago without anatomical lesion recover faster when they are allowed to move than when they are ordered to stay in bed.

21The placebo effect is not imaginary, it is a well-studied biological phenomenon, but its singularity is its relational character. A classic experiment, carried out several decades ago, has thus shown that the placebo effect acts even on the intense pain caused by cancers, although in a limited way. : two groups of patients were given injections containing either morphine or saline (without pharmacological effect). The treatments led to a decrease in pain in both groups of patients but in the placebo group, the pain returned more quickly and, when a new placebo was administered, was progressively less well relieved.

22The placebo effect is sensitive to the nature of the care gesture: some patients are better relieved by an injection than by a tablet of the same drug. It is also color sensitive: blue placebo tablets induce sleep in more people than red placebo tablets. The placebo effect and the nocebo effect (its opposite) depend on the caregiver: blood pressure measurement gives higher results if it is taken by a doctor than by a nurse, and higher if it is taken by a nurse than if it is a self-measurement, at home, with an automatic device. This means that the relationship between the caregiver and the patient introduces a modification of the physiological constants: the presence of a health professional triggers the secretion of adrenaline and raises the blood pressure. And this secretion of adrenaline is not indifferent to the status of the person – therefore, to the way in which the patient sees it. This means that the “benevolent neutrality” with which certain doctors adorn themselves is an absolute illusion – and a denial of neurophysiological reality. Not only is a doctor not neutral (his mere presence has effects on the patient’s body) but he is not always perceived as benevolent, whatever his behavior or his intentions.

23To tell the truth, the placebo effect does not even need the presence of the other to be effective. It only requires that we remember who treated us. When I was a child, I often had tonsillitis. I had a very sore throat, I couldn’t swallow anything and I also often had a fever, which didn’t help. My father treated me by giving me a particular combination of antibiotics and anti-inflammatories, to relieve the pain and prevent complications from a streptococcal infection. The angina ended up becoming less frequent over time, but one day, as an adult, I had severe angina again. I knew perfectly well that, after the age of twenty, almost all angina is cured without antibiotics. But I was in a lot of pain – and I felt dejected to find myself sent back to childhood. Two days after the start of the angina, I couldn’t take it anymore, I swallowed the “therapeutic cocktail” that my father gave me. Ten minutes later, I had no more pain at all.

24In general, this kind of anecdote elicits comments that range from the simple “It’s psychological†to the Lacanian “You have symbolically behaved with yourself as if you was your own father’. Both are a way of describing a biological reality; namely that, to relieve the pain of a body, it is necessary and sufficient to trigger existing self-relieving mechanisms in it.

25Although the placebo effect is often short-lived, it is powerful; and it is very dependent on the relationship between patient and carer. This is the meaning of what Michael Balint says in his book The doctor, the patient and the disease: “the doctor’s first medicine is the doctor himself HAS”. This is also confirmed by the most recent studies on the care relationship.

26In his book Emotional Intelligence, Daniel Goleman relates the following experiment conducted at Massachusetts General Hospital. During psychotherapy sessions, the elementary biological constants (blood pressure, heart rate, respiratory rate) of caregivers and patients were recorded simultaneously. The sessions were filmed. After the sessions, the patients were asked to review the recordings and indicate when they felt best understood by the therapist, and when they had it. perceived as distant or “out of touch” with what they were expressing. When patients felt understood, their biological rhythms and those of their caregiver were superimposed.

27Treating is putting oneself in tune with the other.

28Altruism is not a cultural invention but, once again, a behavior rooted in our biology. We define as altruistic an act that is beneficial to others and costly for the person who performs it. As Frans de Waal explains in another of his works, The Bonobo and the Atheist, the – first and oldest – prototype of altruistic behaviors is also the first caring behavior: it is the parenting behavior. Mammalian females (and for some species, males) invest time, energy and resources in rearing their young, long after gestation is over. e. (Gestation, which can take place without the pregnant individual intervening directly on her, is not altruistic in itself: a woman is not pregnant out of concern for her unborn child. She is pregnant because reproduction results from unconscious impulses in the vast majority of individuals. On the other hand, having her fetus listen to Mozart or avoid drinking alcohol or smoking while pregnant are altruistic behaviors.) Altruism towards offspring is not restricted to females: in many species, including humans, males have a nurturing and protective behavior with their offspring. The act of feeding, caring for and protecting her young is deliberate behavior, but it is influenced by unconscious calculations. As Sarah Blaffer Hrdy’s impressive book Mother Nature demonstrates, motherhood is not always associated with caring for offspring. Thus, male and female birds and mammals may decide to neglect a young if it is malformed or sick and focus their care on members of the litter that are in good health.

29Among mammals and large primates, individuals are not only altruistic towards their offspring but also towards their partner, towards the individuals to whom they are genetically linked3 but also others still, to which they are not. Grooming – delousing, toileting – practiced by great primates and many apes has the function of ridding an individual of the parasites which cling to his skin; it also strengthens the links between “carer” and “patient” and with the whole community. Indeed, in many species, we “delous” collectively. In chimpanzees and bonobos, reports Frans de Waal, it seems that grooming also has a stress-reducing effect and regulates hormonal activity, especially for females.

30Altruistic behaviors commonly exist between different species: there are countless examples of newborns of a species “adopted”, protected, warmed ©s by adult animals of another species; and should it be remembered that humans adopt and care for dogs, cats, small rodents, birds, fish, when it is not a question of much less sympathetic animals, for the sole purpose of their keep company?

31In human beings, spontaneous altruistic behaviors can be observed very early, well before the age of speech: as we said earlier, in creations ¨ches, from the age of one, children who walk will spontaneously console those of their little friends who are crying. Later, washing or combing one’s child or his/her partner is perceived, by both of them, but also by outside observers, as a gesture of benevolence, of intimacy and shared pleasure. In other words: care. If we like the image of a person who combs another, it is because it soothes us.

32Altruistic care provided between partners or companions not biologically linked is beneficial: married men or men living in a couple have better life expectancy and health than single men. And if celibacy does not harm the longevity of women, it is because they, more often than men, maintain a network around them throughout their lives. relatives.

33All these examples, human and non-human, show that the care given to the other-than-self is not the product of education or culture (even if these can strongly encourage or dissuade it), but an altruistic behavior engramed in our genetic baggage.

34Without altruism, there is no care. We will logically deduce that if we are not altruistic (nor, a fortiori, empathetic), it is difficult to treat.

35From a biological point of view, the first reason for empathy and gestures of care is the survival of our genes, through the individuals to whom we are related. But we also care for those to whom we are emotionally or socially connected. This is why in the three close circles of social life (nuclear family, extended family, social or professional group), support and mutual aid are not only the norm, but the rule: parents, allies and friends contribute to the preservation and survival of our genetic heritage and we contribute to the survival of theirs. Beyond these three circles, any altruistic gesture is perceived as pure generosity – I underline the word on purpose – or as an admirable vocation. It is for this reason that the members of associations of carers “without borders” who intervene in extremely disadvantaged regions, despite conflicts, bad weather, infectious diseases and parasites and natural disasters, benefit from such a positive aura: caring so far from home is, potentially, very expensive; many risk their health and their lives there.

36The relationships, temporary or lasting, that are formed when a sick person voluntarily calls on a stranger whose profession is to provide care constantly put extended altruism to the test. Because it has its limits. Helping a perfect stranger is very random: sometimes we know what we are risking, and nothing says that the stranger will return the favor or, worse, will not take undue advantage and will not abuse our help.

37″Free riders” and profiteers arouse outraged reactions in many social species, such as primates, which are very sensitive to “unjust” behavior. Thus, when a chimpanzee comes to the aid of one of its congeners (by sharing food, for example), it protests vigorously if this one does not return the favor when the situation arises. ready for it.

38This distrust of the “profiteer”, the “free rider” (in English free rider) is therefore a deep psychological mechanism, also inherited from the ™evolution. But it continues to underlie many of our attitudes towards others and, in particular, deeply colors caring relationships.

39Thus, when a doctor suspects a patient of wanting to “abuse” the system, his posture of mistrust is an instinctive mechanism, a tribal protective measure that goes back to Palé olithic – the time when human beings assumed the form they still have today. Our attitudes then were essentially aimed at ensuring the cohesion and survival of a limited social group (the tribe). A profiteer, a parasite, a traitor challenged this vital order. This type of distrust is unsuited to the reality of today’s world, to the current mechanisms for taking charge of care, and to the real needs of patients. Healthcare professionals sometimes fail to realize that their empathy – and therefore, their altruism – is variable and not only harms those they care for, but also to their own credibility as caregivers.

Most of us, passing a person sitting outstretched in the street, feel something: compassion, irritation, embarrassment, contempt, anger, condescension. Sometimes we release a play. Sometimes not. What makes us decide?

41Humans’ altruism can extend far beyond their familiar circle, but it is modulated by many factors: we are more empathetic when we feel fit; with our loved ones; with the individuals we find beautiful or attractive, those who make us feel good or simply smile at us; and those with whom we are engaged in a common work (a project, a job, or a professional group). We are less empathetic if we are sad, tired or worried; with strangers, individuals we find ugly or unsympathetic; those who seem hostile to us and above all, empathy diminishes or disappears, depending on the individual, in a competitive situation. This notion, as we will see, is crucial for understanding the behavior of certain doctors. It is never useless to recall that the Nazi doctors were for some good husbands, loving fathers, devoted friends, even good doctors for patients who did not ™were not in camps… Behavior towards loved ones is therefore in no way predictive of what it may be towards others. ©foreigners.

42Our apparently spontaneous and “instinctively” triggered altruistic gestures are, unbeknownst to us, modulated by prior stimuli. So, as I mentioned before, when you show pictures of happy, smiling faces to volunteers in an experimental setting, they are more tempted to give a coin to the homeless placed. © (volontairement et à leur insu) à la sortie de la salle de test que si on leur montre des visages tristes ou fermés. Ce type de comportement est indépendant de nos tendances « spontanées » : que l’on soit peu ou très altruiste, ce type de stimulation préalable modifie notre comportement. Et on peut comprendre qu’il soit difficile d’avoir des relations harmonieuses avec ses collègues lorsqu’un de nos enfants a passé la nuit à vomir, et qu’après avoir eu le malheur de trouver son avis d’impôt dans la boîte aux lettres, on n’a pas réussi à démarrer sa voiture.

43Puisque empathie et altruisme sont modulés par ce que vit chacun de nous, il n’est pas surprenant que l’engagement dans le soin ne soit pas une activité « mécanique ». Le soignant le plus dévoué peut avoir ses mauvais jours, des sautes d’humeur et des baisses d’empathie. Le fait qu’il soit un professionnel du soin ne le rend pas insensible à toutes les influences contraires. Ni aux conflits d’intérêts, nous le verrons.

44Prendre soin, soigner, donner des soins. Les expressions ne manquent pas pour désigner ce mouvement vers l’autre.

45Quand une personne souffre, nul besoin d’outils sophistiqués pour la soigner : donner à boire, envelopper d’une couverture, panser une plaie, apporter un soutien moral sont des soins. Et souvent, ils peuvent suffire. Les accidentés souffrent moins quand quelqu’un reste là pour leur tenir la main en attendant les secours. Ils souffrent plus quand leur sauveteur passif s’éloigne. Soigner ne se définit pas par la gravité de ce qui motive le soin ou le statut ou les diplômes de la personne qui le dispense. Soigner celui qui souffre, c’est faire un ou des gestes porteurs de soulagement, d’apaisement ou de réconfort (l’effet placebo encore, « l’effet médecin » décrit par Balint et confirmé depuis par de multiples études). C’est réduire sa dépendance, son assujettissement à ce qui le mine. C’est l’aider à s’affranchir de la souffrance, en tout ou en partie.

46Traiter (donner un traitement), en revanche, consiste à effectuer un geste ou une action spécifiques visant un symptôme ou une maladie particuliers – par exemple : administrer un antidouleur ; effectuer un massage cardiaque ; retirer chirurgicalement une tumeur. Traiter n’apporte pas toujours un réconfort : un traitement impose parfois de recourir à des gestes violents et invasifs (pratiquer une injection, réduire une luxation ou une fracture, retirer un organe). Par conséquent, traiter fait partie de la démarche de soin mais n’est pas synonyme de soigner : on peut soigner sans traiter ; on peut aussi, malheureusement, traiter sans soigner, et même, j’y reviendrai, maltraiter en croyant – ou en affectant de – soigner.

47La guérison, c’est le processus de réparation à l’issue duquel la maladie est complètement terminée et où – dans le meilleur des cas – le malade retrouve son état antérieur.

48Toutes les maladies ont un « cours naturel », une évolution spontanée en l’absence de traitement. Les maladies bénignes évoluent le plus souvent vers la guérison sans traitement ni soin particulier ; pensez au rhume de cerveau4 et à nombre d’infections virales de l’enfant, qui provoquent un peu de fièvre pendant quelques heures et disparaissent aussi vite qu’elles sont apparues. On peut guérir d’un cancer, parfois au prix de traitements lourds. On ne guérit pas d’un diabète, mais on peut, en théorie, en contrôler les symptômes et éviter pendant longtemps ses conséquences néfastes pour l’organisme.

49Cependant, il me semble important d’introduire ici une notion essentielle : quels que soient les soins et traitements qu’il délivre, nul n’a le pouvoir de guérir les autres. Qu’il s’agisse d’une pneumonie, d’une dépression ou d’une leucémie, quand la guérison survient, c’est toujours le patient qui guérit de sa maladie. Avec ou sans l’aide des soignants.

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can you talk about a patient without saying his name

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