care field is a setting where deep emotions and existential issues prevail. The stabilization and
regulation of the mental continuum in the face of dying on the part of clinicians can have
profoundly beneficial effects on both clinician and patient
I/I Axis and Prosocial Ethical Intention and Insight
One can ask the question: how do we regulate emotional responses like empathy so compassion
can be nurtured and one does not fall into reactions of avoidance, abandonment, numbness or
moral outrage, responses that are not uncommon in the clinical setting where the dying are cared
for? Clearly, one of the most important interventions is balanced attention and affect (A/A Axis), as
well as the ability to guide the mind in accord with one’s intentions and stabilize the mental
continuum in order to have insight about suffering, its origins and how to transform suffering. These
dimensions are characteristic of the I/I Axis, the cognitive dimension that entails intention and
insight. Both intention and insight must operate in conjunction with attentional and emotional
balance (A/A axis), which enhance one’s ability to have access to, be aware of and have potential
control of the attentional, affective and cognitive continuum. Intention and insight can also support
attentional and affective balance. From the point of view of this model, the attentional, affective,
cognitive and somatic domains cannot be isolated, one from the other, nor can these domains be
dissociated from the social, cultural and environmental surround of the individual.
Intention
The intention to transform suffering is one of the features that distinguishes compassion from
empathy. From the point of view of compassion, intention is a key process in the cultivation of this
mental faculty
. It is based in the prosocial experience of the motivation to transform the
suffering of others as well as oneself. Intention priming compassion is based in part on an ethical
orientation, which is the foundation of one’s motivation to not harm, do good and to help others.
This moral ground is fundamental to the practice of medicine. Even if one’s motivation is altruistic,
it can happen that aversive reactions and actions arise out of one’s conditioning. In working with
dying people, aversion is not uncommon. In this case, it is essential to override habitual responses,
engage in positive and realistic appraisal, and learn how to down-regulate arousal or shift away
from thoughts and behaviors that are destructive, from abandoning patients, engaging in moral
outrage, or simply becoming numb to the suffering of patients, families and colleagues. This is
usually done through the experience of insight based in self-awareness and supported by the
intention to decrease the suffering of the patient and all those associated with the patient.
Insight
The second aspect of the I/I Axis is that of insight. Insight can support a metacognitive perspective
and mental pliancy, hardiness and autonomy. In this cognitive dimension, self-awareness,
including access to memory, can lead to insights about the nature of reality and can foster
reappraisal and down-regulation, should that be necessary, when serving those who are dying. It
also primes perspective taking or cognitive attunement, which allows one to understand the mental
experience of another, whether colleague, dying person or family member. In a complementary
fashion, the I/I Axis can nourish insight into the distinction between another and one’s self, a key
feature in referential compassion, or compassion with an object
,
. Another dimension that is
engaged in the compassion process is the recognition of one’s moral grounding, which includes
the deep sense of a moral imperative in how we relate to the world, and moral sensitivity that
makes it possible for one to discern moral issues
These features lead to the development of
moral character, the basis of compassionate care
. In addition to these features in the cognitive
domain, insight into the truth of impermanence and interconnectedness is essential, as is the
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