The desired moral attitude of the physician: (I) empathy

In the following, I will use the terms „moral“, „good“ (respectively „inherently good“) and „right“ in the meaning of referring to the idea of a special type of normativity that is not easily defined in other terms as it belongs to some basic categories (Moore 1903). Sometimes, „good“ might also appear in the sense of „instrumentally good“ or „useful“. Whenever this happens, it should be clear from the context. I will not take position in these articles between moral objectivism and relativism (though I tend to the first). For my purposes, it suffices to refer to the historical and cultural practice of medicine and its internal values. Like Alasdair MacIntyre (2007), I see however reasons to take medical practice for an excellent example of an objectively good practice. I will not defend that here. Ethics is understood as the philosophy of morals.

Moral emotions (or sentiments) are a wide field. In this series, I am not dealing with those emotions that refer to moral judgments, such as guilt and remorse, and I abstain from a stance on the role of emotions in ethics in general. I do, however, take position by regarding morals not exclusively as a means to restrict emotions. I take for granted that there are morally adequate emotions, and indeed that it is an impoverished view on ethics reserving it to purely rationalistic judgments.

In his later work, Slote tries to found morals generally on empathy. That is a very different project from mine (Slote 2007).

That is the reason why physicians are warned to treat close relatives, friends, or even themselves.

In the concept of empathy in medical practice, the borderline between epistemology and ethics becomes diffuse. Being defined as a mainly (not thoroughly) cognitive way of understanding, empathy appears to be a merely epistemic tool. As a necessary part of medical practice, it is at the same time subjected to moral analysis and judgment.

The use of the term “feelings” and “emotions” is varying: sometimes they are used synonymously; often feelings are understood as a broader category that includes emotions as specifically directed feelings; or emotions are taken for the objectively observable phenomena of which feelings are the subjective experience (Damasio 1995), etc. For my purposes a clear distinction is not necessary, but as I focus on directed, conscious affective states that can be influenced in a desired way, I usually prefer the term “emotion”, as including the subjective experience of it.

A thorough deliberation about rational emotions in medical practice can be found in Maier and Shibles (2010), pp. 137–160.

Howard Spiro illustrates it this way: “We doctors are selected by victories: We reached college because we were bright and competitive in high-school, and we reached medical school through competition and hard-edged achievements. (…) No wonder we have little empathy for the defeated, the humble, the dying, those who have not made it to the top of the heap, and even for the sick.” p. 844.

Aring is one of the authors who support an attitude of „detached concern“ for doctors; he warns of losing the objectivity and capacity to act by indulging in emotions. Jodie Halpern recommends empathy as a remedy for too much distance which is, according to her, the more common problem of physicians. Nonetheless also Halpern recommends a balance between nearness and distance (Halpern 2001).

In fact, there is much more for Cassell in understanding the patient as a person than empathy alone. He reminds us of many different aspects in which a person can be inflicted by an illness (Cassell 1982), he emphasizes the meaning of the patient’s narratives and the importance of his values (Cassell 1991). But he always describes the attention to the emotional and subjective side of the patient as competing with the scientific, medical knowledge and technical know-how, and the main task of a physician as a person to unite two opposite poles.

This goes very well with the current neuropsychological findings about psychopathic delinquents where different brain areas are brought into connection with cognitive and emotional aspects of empathy as a precondition to really understanding the implications of the own deeds for others. (Damasio 1995) In a useful review Grit Hein and Tania Singer summarize: “Accumulating evidence has put forward the view that there are at least two different ways to put us in the shoes (the mind) of the other person. One route is to share the other person’s feelings in an embodied manner, known as empathy (…). The other route is to cognitively infer about the state of the other person, known as ‘theory of mind’, ‘mentalizing’, ‘mind-reading’, or ‘cognitive perspective-taking’. Although often occurring in concert, findings from functional magnetic resonance imaging (fMRI) studies suggest that understanding others on the basis of cognitive perspective taking and empathy recruit different neural networks”. (Hein and Singer 2008, p. 153) Mark that the ‘empathy’ concept in this article is different from our definition which encompasses both emotional as well as cognitive aspects, i.e. the full capacity to “put us in the shoes of another person”. (See also Bauer 2005) In fact the difference between empathy and emotional contagion (which is made by Hein and Singer) is not easily to detect if awareness and cognitive modulation (see Lamm et al. 2007) are taken out of the concept of empathy.

It is important to keep in mind that this special meaning of empathy is directed on the clinical encounter between physician and patient, in order to safeguard the capacity of the physician to help efficiently and not to lose himself in pity and compassion. In other contexts, the adequate extent of empathy may be much more emotional and nearer to “feeling-with”, of emotional resonance.

As the psychiatrist deals with very special inner states, namely pathological ones, he also may need a qualitatively different kind of empathy. But the transfer from normal over exceptional to unequivocally sick mental states is even more fluent than in somatic contexts. So the qualitative step in psychiatry might also result from the overlarge quantity. Another example for the context-sensitivity and necessity of empathy is veterinary medicine. Here empathy must work beyond species limits and without help of language. The life of a veterinary surgeon who lacks this capacity is short, and his successes will be few.

This means in no way that empathy is only an inborn talent that cannot be taught or learned; on the contrary (Platt and Keller 1994). According to Aristotle, virtues that are important elements of character can and should be learned and fostered, and habituation to right behaviour will lead to a better character on the longer run (Aristotle 2002).

In chapter II of his „Theory of Moral Sentiments“, Adam Smith emphasizes the „pleasures of mutual sympathy“ (sympathy in a meaning very close to contemporary „empathy“). Though at first view it seems to be the sharing of the same emotions, it becomes clearer and clearer that it is the combination of understanding and the kind attitude that is the source of the pleasure (Smith 1759, pp. 12–18).

„While empathy is believed to have high social value, in actuality it is a neutral human facility whose value is derived from the manner in which it is used“ (Zinn 1993, p. 309).

In order to be precise, I must admit that it depends on the theory of morality: a strictly consequentialist approach implies that the bad result does make the helpfulness in this case a part of bad agency. But even a consequentialist, if he scrutinises the general attitude of helpfulness, probably would come to the conclusion that, generally, helpfulness leads to morally good results. So it is not the attitude that makes the act of helping bad, and as it normally leads to good consequences, it is rather a good attitude, though it is not decisive for judging the whole act.