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Medicine, Health Care and Philosophy

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27.03.2019 | Editorial

Clinical sympathy: the important role of affectivity in clinical practice

verfasst von: Carter Hardy

Erschienen in: Medicine, Health Care and Philosophy | Ausgabe 4/2019

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Abstract

Bioethics has begun to see the revaluation of affects in medical practice, but not all of them, and not necessarily in the sense of affects as we know them. Empathy has been accepted as important for good medical practice, but only in a way that strips it of its affectivity and thus prevents other affects, like sympathy, from being accepted. As part of a larger project that aims at revaluing the importance of affectivity in medical practice, the purpose of this paper is to develop a clinical sympathy that can serve as a trainable skill for medical professionals. While everyday sympathy may be problematic as a professional skill for physicians, this does not imply that sympathy should be entirely rejected. As a natural part of our moral psychology, sympathy is an intersubjective affect that aids in our interactions with others and our decision-making abilities. I present here a theory of clinical sympathy as an affective response to patients, in which physicians are both attuned to their affective response and understand how their affects are influencing their beliefs and judgments. In this way, clinical sympathy serves as a trainable skill that can aid physicians in their interactions with their patients.

I prefer to use the term affectivity when talking about individual affects since I do not think there is a clear divide between an experience being an emotion, feeling, and mood. Rather, individual affects, like happiness, tend to be experienced as emotions, feelings, and/or moods. Especially when it comes to empathy, which has many competing definitions and explanations, identifying it with one type of affect—such as an emotion—would oversimplify the experience of empathy. To make things more complicated, there are different theories of emotions, feelings, and moods, and empathy could be fit into any one of these. However, this paper is about sympathy, not empathy, so arguing for a specific theory of emotion and how empathy either does or does not fit this theory, is outside of the scope of this paper. Especially since empathy is now more associated with a cognitive skill/faculty than and affective experience, it may even be fruitless to provide such an argument. Instead, in this paper, I am accepting the current theory of empathy as a cognitive understanding of the other, and approaching sympathy considering this interpretation of empathy.

This is elsewhere called merely the simulation theory of empathy. It will be explained further in later sections of this paper.

These include theory (Baron-Cohen 1993, 1995; Gopnik 1988, 1993, 1996; Gopnik and Meltzoff 1997; Gopnik and Schulz 2004; Gopnik and Wellman 1992; Karmiloff-Smith 1988; Kitcher 1988; Wellman 1990; Wellman et al. 2001), and interaction theory (Gallagher 2001, 2004, 2009, 2012; Gallagher and Hutto 2008).

I phrase this as such since, even with the way empathy is being defined, it is still possible to understand parts of the other’s situation without empathy. Empathy allows for a more holistic understanding, but there is still an understanding of some aspects of the other’s situation without empathy.

Similarly, “empathy” has different meanings in English than simply the imaginative, projective empathy that Titchener and others discussed. For now, it is worth noting—as both Lanzoni and Andrea Pinotti note—that “there was never one simple psychological depiction of Einfühlung or empathy: projection, transfer, association, animation, personification, vivification, fusion, identification, among others were all possibilities” (Lanzoni 2012, p. 306; Pinotti 2010, p. 94). Philosophers and psychologists have been unable to agree to one use for the term. This has led to the debate concerning the true nature of empathy.

While many like to think that the experience of most (if not all) affects is independent of the existence of other subjects. For Scheler, most affects are made possible by our primordial intersubjectivity, and we experience them with others. That is, we are always, already being with others in the world, and it is only within this context the we experience affects. As such, he sees love and sympathy as fundamental features of the lives of persons. Affects are perceptions of values, and they can be divided into levels based on the things in which they perceive value, as well as how such value is perceived. Intersubjective affects—especially sympathy—allow us to experience affects with and for others, sometimes to the extent that we merge back into our primary intersubjectivity by achieving a feeling of oneness with each other. In this way, our affective lives are an important aspect of our intersubjective lives because they allow us to experience a valued world with others.

Genuine sympathy is sympathy guided by love—when it is “embedded in, and sublated by, love” (Vandenberghe 2008, p. 39). This is important to the development of clinical sympathy.

Aside from the intersubjective importance of sympathy and empathy, emotional sharing allows us to genuinely share an emotion with the other. It is our ability to enter into the same situation as the other in the world—to literally “be with” others in an affect. Additionally, emotional contagion has a special role in the way that it bonds us to the world with others. It shows how we are pulled into the same affective world with others, even if we do not realize it happening. Finally, a feeling of oneness brings us back to our primary intersubjectivity.

Lief and Fox list: “exploring, examining, and cutting into the human body; dealing with the fears, anger, sense of helplessness, and despair of patients; meeting emergency situations; accepting the limitations of medical science in dealing with chronic and incurable disease; being confronted with death itself.” (Lief and Fox 1963, p. 13).

As Halpern says, it is “detachment with a veneer of generic tenderness” (Halpern 2001).

Detachment is trained to assist with emotional experiences, such as death and dying (Fox 2006, p. 945; Lief and Fox 1963, p. 13; Underman and Hirshfield 2016, p. 95). And it is argued that it taken on partly due to the examination of cadavers during autopsies (Underman and Hirshfield 2016, p. 95).

This is understood to be a useful coping technique for students to learn. (Fox 2006, p. 945).

These authors also note that students “made jokes or blamed the patient to reduce their anxiety. This kind of emotional socialization led to dehumanizing and objectifying patients” (Underman and Hirshfield 2016, p. 95). In these ways, students foster detached concern as way to cope with emotion-laden experiences.

Halpern warns against situations like this where there is a risk that “one person’s irrational emotions are transmitted to others” (Halpern 2001, p. 9). This can happen when the patient is experiencing a strong emotion that is transmitted to the physician, but it can also happen when a physician transmits a strong emotion to the patient. It is the latter that is particularly troubling here.

I address one option for this in another paper (Hardy 2017). I argue that Shaun Gallagher’s interaction theory is a promising alternative theory for clinical empathy. This theory explains the physician’s understanding of patients from diverse backgrounds as an ability to learn and apply narratives. I find this to be a better theory of empathy because it provides a more holistic understanding of the patient and the patient’s situation, in the sense that it incorporates both what the physician perceives of the patient and the patient’s point of view on the patient. I do not explain this distinction here, since this paper is more concerned with sympathy than empathy. In other words, this paper is focused on the role that sympathy should play in medical practice if we continue to accept the current theory of empathy (rather than trying to redefine it). We could either redefine empathy to provide a more holistic understanding of the patient, or we can accept the current theory of empathy and incorporate a theory of sympathy to aid in the holistic understanding.

Some even argue that empathy serves as the foundation upon which all other intersubjective affective engagements are established, such as “pity, sympathy, affective matching, perspective taking etc., [which] arise at the secondary level” (Daly 2014, p. 231).

Paralleling and directly connected to the feeling/cognitive divide in the philosophy of emotion, this dichotomy between subjective feelings and objective cognitions can be shown to be both untrue and problematic. There is a need to overcome this divide and see both empathy and sympathy as affective phenomena that are important in and of themselves.

This is similar to how Halpern talks about the emotional resonance that she argues is an aspect of empathy. She says that emotional resonance is the physician’s first clue to understanding the patient’s “emotional point of view” (Halpern 2001, p. 16). It is the physician’s attunement to the patient’s relationship to the world It immediately established the patient’s affects “as presences, rather than as mere possibilities” (Halpern 2001, 74). However, many physician’s pass over and ignore the opportunity to explore this clue because they focus too narrowly on facts, rather than to “the emotional meanings of patients’ words” (Halpern 2007, 697).

It is also worth noting that Gelhaus defines sympathy in the way that Scheler defines emotional contagion—“sharing the same feelings with the other” (Gelhaus 2012b, p. 399).

These are also identified by Gelhaus in her discussion of compassion as a professional attitude.

This goes back to the divide between detached concern and sympathy. These are established as extremes in medicine, where sympathy is an overly strong emotional engagement with the patient and detached concern is devoid of emotional engagement. Detached concern can easily lead to unwarranted paternalism, whereas sympathy risks leading to either paternalism or avoidance, based on the physician’s affective response to the other.

Aring, Charles. 1958. Sympathy and empathy. Journal of the American Medical Association 167 (4): 448–452.

Baron-Cohen, Simon. 1993. The concept of intentionality: Invented or innate? Behavioral and Brain Sciences 16 (1): 29–30.

Baron-Cohen, Simon. 1995. Mindblindness: An Essay on Autism and Theory of Mind. Cambridge, MA: MIT Press.

Blumgart, Herrman. 1964. Caring for the patient. The New England Journal of Medicine 270 (9): 449–456.

Cadge, Wendy and Clare Hammonds. 2012. Reconsidering detached concern: The case of intensive-care nurses. Perspectives in Biology and Medicine 55 (2): 266–282.

Carel, Havi. 2011. Phenomenology and its application in medicine. Theoretical Medicine and Bioethics 32 (1): 33–46.

Coulehan, John L, et al. 2001. “Let me see if I have this right… Words that help build empathy. Annals of Internal Medicine 135 (3): 221–227.

Daly, Anya. 2014. Primary intersubjectivity: Empathy, affective reversibility, ‘self-affection’ and the primordial ‘we.’. Topoi 33: 227–241.

De Vignemont, Frédérique, and Pierre Jacob. 2012. What is it Like to feel another’s pain? Philosophy of Science 79 (2): 295–316.

Derksen, Frans, Jozien Bensing, and Antoine Lagro-Janssen. 2013. Effectiveness of empathy in general practice: A systematic review. British Journal of General Practice 63 (606): e76–e84.

Di Blasi, Zelda, and Jos Kleijnen. 2003. Context effects: Powerful therapies or methodological bias? Evaluation and the Health Professions 26: 166–179.

Eikeland, Hanne-Lise, et al. 2014. The physician’s role and empathy—A qualitative study of third year medical students. BMC Medical Education 14: 165–172.

Ekman, Eve, and Jodi Halpern. 2015. Professional distress and meaning in health care: Why professional empathy can help. Social Work in Health Care 54 (7): 633–650.

Flaherty, Lauren. 2016. Empathetic reasoning as an evolution of humankind. Dialogue: 113–121.

Foss, T. D. 2006. Angels of death? Mercy killing? How about murder? British Journal of Nursing 15 (8): 417.

Fox, Renée C. 1959. Experiment Perilous: Physicians and Patients Facing the Unknown. Glencoe, IL: Free Press.

Fox, John. 2006. Notice how you feel”: An alternative to detached concern among hospice volunteers. Qualitative Health Research 16 (7): 944–961.

Gallagher, Shaun. 2001. The practice of mind: Theory, simulation, or interaction? Journal of Consciousness Studies 8 (5–7): 83–107.

Gallagher, Shaun. 2004. Understanding interpersonal problems in autism: Interaction theory as an alternative to theory of mind. Philosophy, Psychiatry, & Psychology 11 (3): 199–217.

Gallagher, Shaun. 2009. Two problems of intersubjectivity. Journal of Consciousness Studies 16 (6–8): 289–308.

Gallagher, Shaun. 2012. Empathy, simulation, and narrative. Science in Context 25 (3): 355–381.

Gallagher, Shaun, and D Hutto Daniel. 2008. Understanding others through primary interaction and narrative practice. In The Shared Mind: Perspectives on Intersubjectivity, eds. J. Zlatev, T. Racine, C. Sinha, and E. Itkonen, 17–38. Amsterdam: John Benjamins.

Gallese, Vittorio. 2001. The “shared manifold” hypothesis from mirror neurons to empathy. Journal of Consciousness Studies 8 (5–7): 33–50.

Gallese, Vittorio. 2003. The roots of empathy: The shared manifold hypothesis and the neural basis of intersubjectivity. Psychopathology 36 (4): 171–180.

Garden, Rebecca. 2007. The problem of empathy: Medicine and the humanities. New Literary History 38 (3): 551–567.

Gelhaus, Petra. 2012a. The desired moral attitude of the physician: (I) Empathy. Medicine, Health Care and Philosophy 15: 103–113.

Gelhaus, Petra. 2012b. The desired moral attitude of the physician: (II) Compassion. Medicine, Health Care and Philosophy 15: 397–410.

Gelhaus, Petra. 2013. The desired moral attitude of the physician: (III) Care. Medicine, Health Care and Philosophy 16: 125–139.

Goldman, Alvin. 2006. Simulating Minds. New York: Oxford University Press.

Goldman and Sripada. 2005. Simulationist models of face-based emotion recognition. Cognition 94 (3): 193–213.

Gopnik, Alison. 1988. Conceptual and semantic development as theory change. Mind and Language 3 (3): 197–216.

Gopnik, Alison. 1993. How we know our minds: The illusion of first-person knowledge of intentionality. Behavioral and Brain Sciences 16 (1): 1–14.

Gopnik, Alison. 1996. The scientist as child. Philosophy of Science 63 (4): 485–514.

Gopnik, Alison, and N Meltzoff Andrew. 1997. Words, Thoughts, and Theories. Cambridge, MA: MIT Press.

Gopnik, Alison and Laura Schulz. 2004. Mechanisms of theory formation in young children. TRENDS in Cognitive Sciences 8 (8): 371–377.

Gopnik, Alison, and Henry M. Wellman. 1992. Why the child’s theory of mind really is a theory. Mind & Language 7 (1–2): 145–171.

Green, Stephen. 2002. Review of Jodi Halpern, From Detached Concern to Empathy: Humanizing Medical Practice. Psychosomatics 43 (3): 255–256.

Guignon, Charles. 2009. The body, bodily feelings, and existential feelings: A Heideggerian perspective. Philosophy, Psychiatry, & Psychology 16 (2): 195–199.

Halpern, Jodi. 2001. From Detached Concern to Empathy: Humanizing Medical Practice. New York: Oxford University Press.

Halpern, Jodi. 2003. What is clinical empathy? Journal of General and Internal Medicine 18: 670–674.

Halpern, Jodi. 2007. Empathy and patient–physician conflicts. Journal of General Internal Medicine 22 (5): 696–700.

Halpern, Jodi. 2011. Clinical empathy. In From Bench to Bedside: Empathy and the Social Brain. ed. Decety Jean. Cambridge, MA: MIT Press.

Halpern, Jodi. 2012. Attending to clinical wisdom. Journal of Clinical Ethics 23 (1): 41–46.

Halpern, Jodi. 2014. From idealized clinical empathy to empathic communication in medical care. Medicine, Health Care and Philosophy 17: 301–311.

Hardy, Carter. 2017. Empathizing with patients: The role of interaction and narratives in providing better patient care. Medicine, Health Care and Philosophy 20 (2): 237–248.

Heidegger, Martin. 1962. Being and Time. Translated by John Macquarrie and Edward Robinson. New York: Harper & Row.

Hojat, Mohammadreza, et al. 2009. The devil is in the third year: A longitudinal study of erosion of empathy in medical school. Academic Medicine 84 (9): 1182–1191.

Hojat, Mohammadreza, et al. 2011. Physicians’ empathy and clinical outcomes for diabetic patients. Academic Medicine 86: 359–364.

Hojat, Mohammadreza, et al. 2013. Empathy and health care quality. American Journal of Medical Quality: The Official Journal of the American College of Medical Quality 28 (1): 6–7.

Hooker, Claire. 2015. Understanding empathy: Why phenomenology and hermeneutics can help medical education and practice. Medicine, Health Care and Philosophy 18: 541–552.

Karmiloff-Smith, Annette. 1988. The child as theoretician, not an inductivist. Mind and Language 3 (3): 183–195.

Khanuja, S., et al. 2011. Empathy and sympathy in the medical profession: Should we stop the desertion? Pravara Medical Review 3 (3): 37–39.

Kitcher, Philip. 1988. The child as parent of the scientist. Mind and Language 3 (3): 217–228.

Lampert, Bettina, and Glaser Jürgen. 2016. Detached concern in client interaction and burnout. International Journal of Stress Management. https://doi.org/10.1037/str0000053. (Advance online publication)CrossRef

Landes, Donald A. 2012. Translator’s introduction. In Phenomenology of Perception, Maurice Merleau-Ponty, Translated by Donald A. Landes: xxx-li. New York: Routledge.

Lanzoni, Susan. 2012. Empathy in translation: Movement and image in the psychological laboratory. Science in Context 25 (3): 301–327.

Larson, Eric B., and Xin Yao. 2005. Clinical empathy as emotional labour in the patient-physician relationship. JAMA 293 (9): 1100–1106.

Lief, Harold, and Fox Renée. 1963. Training for “detached concern” in medical students. In The Psychological Basis of Medical Practice, ed. H. Lief, 12–35. New York: Harper & Row.

Macnaughton, Jane. 2009. The dangerous practice of empathy. The Lancet 373: 1940–1941.

Marcus, E. R. 1999. Empathy, humanism and the professionalisation process of medical education. Academic Medicine 74: 1211–1215.

Meltzoff, Andrew N. 2006. The ‘like me’ framework for recognizing and becoming an intentional agent. Acta Psychologica 124: 26–43.

Merleau-Ponty, Maurice. 2012. Phenomenology of Perception. Translated by Donald A. Landes. New York: Routledge.

Merton, Robert. 1957. The Student-Physician: Introductory Studies in the Sociology of Medical Education. Cambridge: Harvard University Press.

Osler, William. 1899. Address to the students of the Albany Medical College. Albany Medical Ann 20: 307–309.

Osler, William. 1904. Aequanimitas. In Aequanimitas, With Other Addresses to Medical Students, Nurses and Practitioners of Medicine, 1–11. Philadelphia: P. Blakiston’s.

Pedersen, Reidar. 2008. Empathy: A wolf in sheep’s clothing? Medicine, Health Care and Philosophy 11: 325–335.

Pedersen, Reidar. 2010. Empathy development in medical education—A critical review. Medical Teacher 32: 593–600.

Pinotti, Andrea. 2010. Empathy. In Handbook of Phenomenological Aesthetics, ed. Hans Rainer Sepp and Lester Embree, 93–98. Dordrecht: Springer.

Ratcliffe, Matthew. 2005. The feeling of being. Journal of Consciousness Studies 12 (8): 43–60.

Ratcliffe, Matthew. 2008. Feelings of Being: Phenomenology, psychiatry and the sense of reality. Oxford: Oxford University Press.

Ratcliffe, Matthew. 2009a. Belonging to the world through the feeling body. Philosophy, Psychiatry, & Psychology 16 (2): 205–211.

Ratcliffe, Matthew. 2009b. Existential feeling and psychopathology. Philosophy, Psychiatry, & Psychology 16 (2): 179–194.

Ratcliffe, Matthew. 2014. Why mood matters. In The Cambridge Companion to Heidegger’s ‘Being and Time’, ed. Mark A. Wrathall, 157–176, Cambridge: Cambridge University Press

Roter, Debra L., et al. 2006. The expression of emotion through nonverbal behavior in medical visits: Mechanisms and outcomes. Journal of General Internal Medicine 21: S28–S34.

Scheler, Max. 1954. The Nature of Sympathy. Translated by Peter Heath. London: Routledge & Kegan Paul LTD.

Scheler, Max. 1992. On Feeling, Knowing and Valuing. Chicago: University of Chicago Press.

Shanafelt, Tait D., et al. 2005. Relationship between increased personal well-being and enhanced empathy among internal medicine residents. Journal of General Internal Medicine 20: 559–564.

Singh, Sonal. 2005. Empathy: Lost or found in medical education? Medscape General Medicine 7 (3): 74.

Skeff, Kelley M., and Sunita Mutha. 1998. Role models: Guiding the future of medicine. New England Journal of Medicine 339: 2015–2017.

Svenaeus, Fredrik. 2015. The relationship between empathy and sympathy in good health care. Medicine, Health Care and Philosophy 18: 267–277.

Testerman, J. K., K. R. Morton, L. K. Loo, J. S. Worthley, and H. H. Lamberton. 1996. The natural history of cynicism in physicians. Academic Medicine 71 (10): S43–S45.

Underman, Kelly and Laura Hirshfield. 2016. Detached concern? Emotional socialization in twenty-first century medical education. Social Science & Medicine 160: 94–101.

Vandenberghe, Frédéric. 2008. Sociology of the heart: Max Scheler’s epistemology of love. Theory, Culture and Society 25 (3): 17–51.

Wellman, Henry. 1990. The Child’s Theory of Mind. Cambridge, MA: MIT Press.

Wellman, Henry, David Cross, and Julanne Watson. 2001. Meta-analysis of theory-of-mind development: The truth about false belief. Child Development 72 (3): 655–684.

Yagil, Dana, and Moran Shnapper-Cohen. 2016. When authenticity matters most: Physicians’ regulation of emotional display and patient satisfaction. Patient Education and Counseling 99: 1694–1698.

Zahavi, Dan. 2014a. Empathy and other-directed intentionality. Topoi 33: 129–142.

Zahavi, Dan. 2014b. Self and Other: Exploring Subjectivity, Empathy, and Shame. Oxford: Oxford University Press.

Titel: Clinical sympathy: the important role of affectivity in clinical practice
verfasst von: Carter Hardy
Publikationsdatum: 27.03.2019
Verlag: Springer Netherlands
Erschienen in: Medicine, Health Care and Philosophy / Ausgabe 4/2019
Print ISSN: 1386-7423
Elektronische ISSN: 1572-8633
DOI: https://doi.org/10.1007/s11019-018-9872-8

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