One of the many appealing aspects of practising medicine is the constant impulse to challenge simplistic thinking around widely held tenets. A classic example is the hugely important school of anti-psychiatry, where pioneers such as Thomas Szasz and RD Laing forced a rethink on the degree to which psychiatric diagnoses represent social constructs.
While few would support their radical platform as the main basis for providing support and help for those with psychiatric illness, their analysis allowed for a fuller understanding of how we practice and the need to consider carefully the language and terms h we use. Indeed, Szasz pointed, in particular, to the power of the language and definition, noting that the one who defines dominates, and the one who is defined is subjugated.
An interesting recent turn is a critical focus on empathy. This may be surprising to the lay public – surely empathy is an unqualified good, no more amenable to criticism than kittens or rainbows?
My own interest stemmed from a misguided enthusiasm among some engaged in the medical humanities that its primary purpose was to engender empathy among medical students. Their lack of clamour for extending this to other professions was surprising, given that studies show no substantive difference in empathy profiles between physicians and nurses.
Equally questionable is the uncritical acceptance that aesthetic experiences are in some way redemptive in professional terms. One study showed that more aesthetic activity among university students was related to higher personality scores on openness but to lower scores on agreeableness and conscientiousness, hardly attributes that we hope to foster in professional development.
Critique
A powerful critique of empathy arises from a recent book by Paul Bloom, an American psychologist – iti.ms/2qsshEt. His use of a quote from Leslie Jamison's insightful The Empathy Exams provides a foretaste for what is to come: "empathy is always perched precariously between gift and invasion", neatly balanced by Martha Nussbaum's dictum that: "human beings are above all reasoning beings".
It is not that Prof Bloom is against kindness, sympathy or compassion: at the heart of his criticism is the possibility that empathy – the act of feeling what you believe other people feel – may cloud our moral reasoning. The challenge is that empathy focuses on specific people in front of us, prompting us to care more about them but leaving us insensitive to the long-term consequences of our acts and blind to the suffering of those with whom we do not or cannot empathise.
This was illustrated in a research study where participants were told about a 10-year old girl named Sheri Summers with a fatal disease. When asked simply what to do, they placed her in a queue with more needy children ahead of her: when imagined to ask what she felt, they moved her up the queue.
That empathy can trump fairness is troubling and finds echo in the debate and discourse around the negotiations for the new drugs for cystic fibrosis – iti.ms/2rr65HI – and notably the pressure put on during the process by Micheál Martin who, as a former Minister for Health with responsibility for the health of all, should have known better.
Society’s needs
Empathy sways us towards the needs of the one rather than the many and, coupled with its vulnerability to our biases and prejudices (such as those against ageing, disability and mental health), can blinker us in meeting the broad range of needs of our society. In clinical settings, we can be challenged by marshalling emotional identification with an articulate carer and an inarticulate patient.
Some of this dynamic can be more easily understood in the family setting where avoiding short-term suffering can lead to pain in the longer term. Promoting actions that might involve short-term unhappiness – homework, eating vegetables, going to bed – clearly assist in healthy development. Supporting this temporary hardship is tempered by love, intelligence, prudence and compassion but can be impeded by empathy focusing on feelings.
What Bloom supports is the cognitive aspects of empathy, the process of understanding what the other person is thinking as opposed to feeling what they feel, and how this supports the more effective if more distanced feelings of compassion and care.
In an era of sound-bites and immediacy, we need health professionals who understand that rational compassion and and care are long-distance races rather than sprints: they must also learn to articulate and defend this complex and considered vision of healthcare.