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Fall 2006
Volume 06, Number 1

Newsletter on Philosophy and Medicine

Articles

The Role of Compassion in Medicine

Lee M. Brown
Howard University

Recent research from varied disciplines indicates that medical patients receive better quality medical care and are more likely to recover completely from an illness, disease, or injury when medical and ethical decisions concerning their care are informed by information realized through empathy and when their care is compassionate or at least tempered by compassion.1 If that is correct, the implementation of compassion-based medicine as a standard of healthcare poses significant challenges. Modern medical care is driven primarily by science and the treatment of symptoms, and it has had tremendous success. In efforts to address the merits and the viability of incorporating compassion-based medicine into healthcare, practical concerns about the role of compassion in the treatment of patients have evoked theoretical concerns about the implications for relying on compassion for improving patient well being.

Practical Concerns Raised by Compassion

With respect to the more notable practical concerns, foremost is whether significant improvements in medical care can be realized by attending to patients with medical perspectives informed through empathy. The research of Cassell, Halpern, Spiro, and others alleges that healthcare is significantly improved when medical perspectives are informed through empathy. It seems obvious that, in many circumstances, the more a physician knows about a patient the more informed decisions she can make about what is best to do for the patient. Empathy provides a vehicle for accessing information about the patient’s feelings that are difficult or nearly impossible to realize through ordinary interviews. In addition, the patient tends to feel safer and less vulnerable when his physician takes a sincere personal interest in what and how the patient feels. This tends to normalize blood pressure and to firm up the immune system.

Another practical concern is whether ethical decisions about patient care would be improved were they informed from empathetic perspectives. When making ethical decisions, all aspects of the patient’s well being must be considered. Determining what is most important to the patient is often an obstacle. There are occasions when the patient is not in touch with his or her own feelings about such matters. There are also occasions when the patient lacks the verbal skills or the presence of mind to convey accurately what is felt. The more pertinent information had by the treating physician about what is felt and wanted and not wanted by the patient, a more informed decision can be made about what is best for the patient. Given patient autonomy, having insight into the emotional state of the patient avails a physician of the opportunity to discern what the patient sees as best and right. Empathy provides a viable avenue into the psychological makeup of the patient. Thus, the treating physician is better able to make decisions consistent with the patient’s psychological and spiritual makeup. It can also be the case that such information permits the physician to justify a decision that is counter to what the patient claims he wants.

Another is whether components of medical education should be changed in efforts to foster the development of empathetic dispositions toward patients.2 Medical education is extremely rigorous and disciplined. In some respects it can be considered cruel. Moreover, during students’ formal medical education, little attention is given to how to behave caringly and with professional integrity. Because of the culture of medical school,3 students quickly develop survival skills for protecting their careers, and by so doing they tend to develop insensitivities to professional indiscretions that challenge the potentials for patients to realize maximum recovery and a return to full health, and they subsequently develop insensitivities to patient distresses. In addition, little attention is given to how to treat patients in a genuinely humane manner while protecting oneself from becoming emotionally involved in patient concerns. Becoming too involved can cloud professional judgment and can put the physician at risk of internalizing the feelings of patients. Detached concern becomes the norm.4 The current culture of medical education needs to be changed in efforts to enable physicians to develop the required skills to attend to patients in a caring manner without having concerns about over-extending themselves emotionally. Moreover, were medical students treated in a more humane manner they would more likely attend to patients in a more humane manner, and perhaps the former would help reduce depression among medical students.

That said, it is not wholly obvious that current medical education can foster the development of empathic dispositions toward patients. Still medical education can be more humane,5 and medical education can be adjusted so that students receive skills that will enable them to provide humane treatment of their patients. The medical schools of the University of California–Davis and Howard University are revising their curricula and their student evaluation protocols to attend better to such matters.

Philosophical Concerns Raised by Compassion

A concern of another sort is whether physicians should be required professionally to have compassion for their patients. The answer to this question is no, and the reasons require considerable explication. Compassion can perhaps best be characterized as "an empathy driven desire to enhance the fortune or reduce the misfortune of the person for whom empathy is had."6 In other words, "compassion," for another is "the having of a firm desire to do all within one’s reach to enhance the well being of the person for whom empathy is had." Unlike sympathy, an empathetic response is not to the condition or state that precipitated the feelings of the other. It is instead an involuntary emotional identification with the feelings of another. Loosely speaking, one empathizes when one feels the feelings of another, when one has the other’s feelings. However, such loose talk is problematic, since it is not obvious that a person can literally experience another person’s feelings.7

My recognizing that someone is in pain is not the same as my experiencing that person’s pain. Also, feeling pain that one believes another is feeling is not the same as experiencing the other person’s pain. That instead constitutes, at most, feeling a pain like the other’s. However, within current African-American culture the idiomatic expression, "I’m feeling you" seems to capture well the alleged relationship between an empath and the person to whom the empath is emotionally connected. Implied is a felt understanding and appreciation of the other’s intentions, reasons, motives, attitudes, desires, and dispositions during a specific moment. Still, the notion of two persons having the same feelings whereby one possesses the feelings of the other seems to be impossible, except in the case where each person is experiencing sentiments of the same kind. But, here, the sentiment of each is her own and not the other’s. They can be alike and perhaps identical with respect to content, but the feelings of one are hers and not the other’s. To claim otherwise seems to be metaphorical. By analogy, "You can walk a mile in my shoes, but you can’t take a step in my feet."8 Your feet are as your feelings, something only you can experience when a part of you.

Although many may have feelings with identical content, received wisdom has it that feelings which are another’s are only another’s—that only the person having some particular feelings can possess those feelings. My "feeling you" implies no dual ownership of feelings. It implies instead only my understanding and appreciation of your feelings and your emotional state of being. One can be empathetic without understanding or appreciating the relevant feelings, and one can understand and appreciate another’s feelings without being empathetic―without, in the relevant sense, feeling the feelings of the other. The point here is that the identification required for empathy cannot be one whereby another literally experiences the feelings that you are having both as her feelings and as your feelings.

Another characterization has empathy as the taking away of another’s feelings. As your feelings become mine you lose your feelings to me. My having your feelings then amounts to my having feelings that were once yours. But that characterization is not amenable to the work that is intended for empathy and compassion in medical environments. An original Star Trek episode featured this characterization of empathy, whereby an empathic individual began healing a terminally ill person by taking on the other’s illness. The exchange was linear and opposite. As the empathic one took on the feelings of the other, the other became well, and, of course, the empathic one became correspondingly ill. The episode was fantasy, and there is no known empirical evidence to suggest that such a transfer can or should take place.

A secondary use of "empathy" is to refer to the projecting onto another the feelings believed to be had by the other. Such a usage in medicine opens the floodgates to paternalism. Believing oneself to have knowledge of another’s feelings via projecting one’s feelings onto another sidesteps the gathering of potentially critical information about one’s patient. Furthermore, one can be mistaken in one’s assessment.9 To make informed decisions, physicians need to know what the patient actually thinks and feels.

It makes more sense to characterize empathy as a profound awareness of one’s own emergent feelings with an associated awareness that another has feelings of the same kind and quality. In the absence of empirical studies to clarify what occurs during empathy, we can speculate that the quality of the awareness also prompts a feeling that one is experiencing the feelings of the other. Loosely speaking, the feelings had by an empath are identical to those of the person whose feelings he experiences as his own. Concerning the onset of compassion, the empath’s experience of the other’s feelings as the same as his prompts a desire to rectify the misfortune or to otherwise enhance the fortune for the person for whom empathy is had.

The emergent desire to help the other mirrors one's desire to help oneself. That is to say, just as it is rational to want one's own misfortunes to be reduced, and just as it is rational to do what is appropriate to reduce one's own misfortunes, it is rational to want to reduce the misfortunes of those for whom compassion is felt―those with whom one identifies. Although there is some discrepancy over what counts precisely as identity in this context, a common thread is the requirement that the perceived misfortune is experienced as one's own. (Empathy, unlike sympathy, requires identification.) It is out of this felt experience that a desire to reduce the perceived misfortune emerges. Hence, assisting the other is analogous to assisting oneself, and since it is rational to want to enhance one's own well-being, when the opportunity arises, it is rational to want to enhance the well-being of the person with whom one identifies.

However, mitigating conditions may arise that thwart the emergence of compassion. 10

Because compassion emerges from empathy and because empathy is an involuntary response to the feelings of another, no one can be justifiably required to be compassionate. One can decide not to act on a desire to help another, and, in that sense, being compassionate can be resisted. However, few have the ability to will themselves to be compassionate. Except in extraordinary circumstances, one cannot make oneself have feelings for another. Just as we cannot will ourselves to love someone whom we do not love, we cannot will ourselves to have caring feelings for someone about whom we do not care. Perhaps after extensive time and efforts sentiments can change, but sentiments do not change immediately by merely willing them to change. Physicians can be compelled to give care, but they cannot be compelled to have caring feelings. Moreover, requiring physicians to behave in a manner that is not true to their feelings promotes insincerity, and that is not healthy for the physician. Also, patients can usually discern when a physician’s concerns are genuine or mere affectation, and the latter is not appreciated. Empathy and compassion are grounded upon feelings for others, and the having of those feelings is not something that is in the control of the person having them.11 It is common wisdom that we have little choice about what we like and feel, but we have tremendous choice about how we act. That said, a physician cannot be required to be compassionate or generally held responsible for not being compassionate. It would be unethical to hold a person responsible for what is not in the person’s ability to control.

Compassion in Medical Education

In keeping with the spirit of the research of Cassell, Halpern, Spiro, and others that laud the contributions of empathetic and compassionate medical care, a more viable alternative would be enriching medical education to enable students to develop a more humane sensitivity to others and a more humane practice of medicine. This can be viewed as having a compassion-like sensitivity to patients―a commitment to do all within one’s reach to foster and nurture the well being of patients. With that, having compassion is not necessary. Furthermore, one can be a competent physician without being a compassionate person. I was attended by a surgeon who had terrible people skills but was wise enough to have a physician’s assistant with wonderful people skills who did all but the required surgical procedures. The surgeon’s having a "front-man" showed his awareness of a need to be humanely sensitive to patients for realizing the best medical outcome. Our seeing the humanity in others involves reference to the humanity in ourselves, and as in the case of having a desire to assist those with whom we identify via empathy, we similarly have a desire to assist those whose humanity we recognize as our own.

Properly directed, the discipline inherent in medical training can nurture students’ abilities to be more humanely sensitive to others.12 Observation and assessment during medical education provide opportunities for medical schools to identify and remediate students who have limited empathic dispositions or challenged humane sensitivities toward patients. Developing such sensitivities can be made a requirement for graduation. So, medical students would not be unfairly discriminated against by being denied permission to practice medicine when failing to pass the humane sensitivity standard.

Conclusion

There are circumstances when the most effective healing can be achieved only by "taking all the tears away."13 Merely providing means for absorbing the tears is not the same as taking the tears away. There can be underlying concerns that can inhibit regaining health. Desired, in the relevant context, is a recognition that will remove the need for crying―that will rectify the cause of the tears. Attending to another on that level requires a profound humane or empathic sensitivity―an ability to enter the emotional space of another and to facilitate healing the emotions that foster or enable physical pain, illness, and suffering. Many patients are in need of that level of sensitivity, while few physicians are prepared to embrace it. Experiences teaching healthcare ethics to medical students inform me that many physicians and medical students believe that attending to patients with the mentioned level of sensitivity is outside of the purview of medicine. They propose that it is the duty of nurses, psychologists, and social workers to attend to patients on that level. Nonetheless, when a physician has an opportunity to intervene on that level, it seems that a professional and humane duty arises to do all that can be done to attend appropriately to the patient’s needs.14 Moreover, doing so is in keeping with the modern Hippocratic Oath that most medical students embrace at graduation.15 With respect to the Hippocratic/ethical foundations that ground medicine, I suggest that medical education better prepare students to intervene on such a level. Effectively treating patients often requires more than prescribing medicines, repairing fractures, or performing surgical procedures.

Seeing the humanity in others and treating others in humane ways requires neither compassion nor empathy. The emotional component that grounds empathy and compassion is not required for treating patients humanely, and having it cannot be mandated, since having it is not readily within one’s control. Both compassion and empathy contribute enormously to the well being of others, and a humane sensitivity to others can approach the quality of intimacy realized through empathic sensitivity. Moreover, the quality of intimacy often required for attending well to patient needs can be achieved through humane sensitivity. Unlike the compassionate treatment of others, the humane treatment of others can be mandated, and treating others humanely yields healthy outcomes in arenas where empathy and compassion are missing.

Acknowledgments

I thank Dr. David R. Kurtzman for assisting me in editing this essay, and I thank Angelo Volandes, Ben Rich, Gordon Greene, Howard Spiro, Jodi Halpern, Laura Ekstrom, and Sandra Shapshay for sharing their perspective on the role of compassion in medicine and for providing me the impetus to write this essay.

Endnotes

1. Jodi Halpern. From Detached Concern to Empathy (New York: Oxford University Press, 2001).

2. An empathetic disposition is an emotional openness to experiencing or to otherwise psychically coming to know in depth what is felt by others.

3. See Ben Rich’s "Breeding Cynicism: The Re-Education of Medical Students" in this issue of the APA Newsletter on Philosophy and Medicine.

4. Halpern, 2001.

5. Rich, in this issue.

6. See Aristotle’s Politics (1252a24-1253b22), and Rhetoric (1385b12-1386b8). See also L. A. Blum, "Compassion," in Virtues: Contemporary Essays in Moral Character, edited by Robert B. Kruschwitz and Robert C. Roberts (Belmont, CA: Wadsworth, 1987), 229-36. See N. E. Snow, "Compassion," American Philosophical Quarterly, 28 (1991): 195-205. See Lee Brown, "Compassion and Societal Well-Being," Pacific Philosophical Quarterly, 77 (1996): 216-24.

7. For example, let us suppose that two coins are flawlessly fashioned from the same mold. Let’s also suppose that all of their physical characteristics are the same and that each coin is possessed by a different person. Either person recognizing the other’s coin as identical to hers or either otherwise feeling it to be the same evokes no implication for having possession of the other’s coin. Although the coins are identical, experiencing one’s own coin would not count in and of itself as experiencing the other’s coin. It seems apparent that I would have to experience the other’s coin for it to be appropriate to say that I have experienced the other’s coin. My not having contact with the other coin, but knowing that the two coins are identical, is not the same as experiencing both coins.

8. George Clinton’s Parliament/Funkadelics. "Can’t take a step in my feet" is a lyric in a song in a recording whose name I cannot recall. The recording was made between 1970 and 1980.

9. One can be mistaken about the existence of an object that one believes oneself to be experiencing. For example, neural stimulation within the brain can bring to consciousness experiences had years past, but are experienced as current. My having the experience of eating pistachio ice cream does not imply the existence of pistachio ice cream or that I am eating. The phantom limb syndrome is another example of having an experience for which there is no corresponding object.

10. Lee, 1996.

11. Ibid.

12. According to Dr. Gordon Greene, a Rinzai Zen Master and the Director of the Program for Medical Education in East Asia at the University of Hawaii at Manoa, "Zen Buddhist monasteries make use of rigorous discipline to foster within monks the development of compassionate dispositions, and that discipline, though different in content, is similar in kind to that found in medical school environments." 2006 APA Central Division meeting session: "The Role of Compassion in Medical Education and the Practice of Medicine."

13. Al Green, "Let’s Get Married," Greatest Hits. Hollywood: Hi Records, 1972.

14. See Immanuel Kant’s Metaphysics of Morals, (239-241) and (448-453), trans. Mary Gregor (New York: Cambridge University Press, 1991), 65 & 241-47. See Immanuel Kant’s Groundwork of the Metaphysics of Morals, trans. H. J. Paton (New York: Harper and Row, 1964), 67.

15. "I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of over treatment and therapeutic nihilism. I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug. I will not be ashamed to say ‘I know not’, nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery." Excerpt from the 1964 adaptation of the original Hippocratic Oath by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University. See http://www.pbs.org/wgbh/nova/doctors/oath_modern.html for a discussion of Lasagna’s "Modern Version of the Hippocratic Oath."

Bibliography

Cassell, Eric J. The Nature of Suffering and The Goals of Medicine. New York: Oxford University Press, 1991.

Davis, Mark H. Empathy: A Social Psychological Approach. Boulder, CO: Westview Press, 1994.

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

Spiro, Howard. The Power of Hope: A Doctor’s Perspective. New Haven, CT: Yale University Press, 1998.

Spiro, Howard, Mary Curnen, Enid Peschel, and Deborah St. James. Empathy and the Practice of Medicine. New Haven, CT: Yale University Press, 1993.

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APA Newsletters

Fall 2006 Volume 06, Number 1

Fall 2006
Volume 06, Number 1