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Empathy is an emotional faculty that has joint cognitive and affective components. It is important in bioethics because it shapes the attitudes and sensitivities that are important in clinical care. Empathy is important in moral perception and judgment and gives access to other persons’ experiences and emotions as well as the moral domain, understood as the weal and woe of other persons. It is crucial to the foundations of medicine and healthcare practices. This research paper focuses on the normative issues associated with empathy in the healthcare context and their importance in clinical bioethics.
There is a fundamental core of all ethical behavior that consists in being aware of the other person as a human subject. The fundamental lesson is that another person is an individual with the same capacity for emotion, experience, pain, and pleasure as oneself. In ethics, generally, this insight is crucial. Notably, dominant ethical theories consider impartial and non-biased reasoning as the central core of ethics, whereas moral perception and understanding the individual as a subject are placed in the domain of moral epistemology, that is, the sphere of acquiring the necessary knowledge for normative judgments.
However, attention to the ethical subject (a person) generates substantial normative and relational reasons that on occasion can trump impartial reasons (Williams 1981). Moreover, to disregard the importance of ethical subjectivity runs the danger of overlooking some of the most essential normative questions in our time. The normative perspectives that follow from a focus upon empathy run into questions about what is morally good and evil. A central question is: Given our enlightened moral norms and given our common humanity and shared empathy and vulnerability, why do humans kill, molest, and offend each other to the extent that is being done (Glover 2012)? On the other hand, why do we care, why do we struggle with conscience, with guilt, why does the faith of strangers concern us in the ﬁrst place? One way to answer these question is phenomenological and psychological and by understanding the role of empathy in moral perception. Moreover, one answer to questions about good and evil is that lack of attention to the suffering of others is a prominent gate opener to all kinds of immoral behavior. Consequently, how to cultivate a human capacity to empathize with others is one of the most crucial questions of morality today (Vetlesen 1994).
The emotional faculty that is most crucial in getting access to understanding the minds of other people is empathy. This research paper will give an overview of the concept and faculty of empathy and its psychological and philosophical connotations as well as its normative signiﬁcance and importance in clinical bioethics.
The Conceptual And Philosophical Meaning Of Empathy
In the phenomenological tradition following Edmund Husserl, empathy was coined as “einfuhlung,” as an epistemological faculty of understanding the minds of other persons (Zahavi 1999). Empathy is commonly regarded as a combined cognitive and affective capacity of understanding the experiences, feelings, and thoughts of other persons. Later, in moral psychology (Hoffman 2000) as well as in medicine (Halpern 2001; Pedersen 2010), what has been essential to clinical communication and medical therapy is the centrality of “reading” the minds and experiences of other persons.
Now, two problems immediately spring to mind. The ﬁrst is this: When one intends to understand the experiences, feelings, and thoughts of other persons, do we speak of merely copying their feelings? Can we and should we at all feel the same pain, sorrow, or happiness as our fellow human beings do? Can we copy another person’s thoughts and their human experiences by imaginative projection, by analogous inferences? Obviously, mature empathy is a conscious and imaginative project of identifying with and sharing the experiences of another person. However, this does not tell the whole story about empathy. Empathy is also a more sophisticated form of direct social perception, with no deliberate inferences being made in the ﬁrst place. The ﬁrst part of this research paper will deﬁne empathy and specify different aspects of empathy as a joint affective and cognitive faculty, including the phenomenon of what is named “direct empathic perception” (Zahavi 2011).
Then a focus will be on the normative aspects of empathy. Empathy is not a mere hermeneutic and epistemological capacity. Empathy is also a moral capacity of relating to the weal and woe of others. Finally, this research paper will show how empathy is clinically important, both as a moral and epistemological capacity.
A Definition Of Empathy: Empathy As A Joint Affective And Cognitive Capacity
In the psychological and philosophical traditions as well as in medicine, there are a host of deﬁnitions and ways of understanding empathy (Pedersen 2010). The most common and plausible way of understanding empathy is to see it as a joint affective and cognitive capacity of understanding the feelings and experiences of another person. Hoffman in his book on empathy and moral development deﬁnes empathy as a “vicarious affective response to another person.” Extant literature also conceives empathy as “a cognitive awareness of another person’s internal states, his thoughts, feelings, perceptions and intentions” (Hoffman 2000).
Empathy has two distinct and equally valuable features. First, empathy is about an intuitive and spontaneous emotional identiﬁcation with another person, what is called affective empathy. Affective empathy is the immediate and involuntary sensory experience of emotional arousal in witnessing the pain or suffering of another person.
Affective empathy is a direct sensory response to another person’s affective state, an emotional and spontaneous identiﬁcation with another person’s weal and woe. It occurs many times in clinical work, e.g., when healthcare providers are emotionally touched by seeing the patient in pain or when they worry about the psychological state of mourning with regard to a relative of a seriously ill child. Affective empathy is as if you feel discomfort with the pain of another without copying his feelings or feeling the same kind of pain as he or she does. And you do not come to this experience by way of analogous inference or imaginative projection. As such, affective empathy is the ﬁrst intake to a more full-ﬂedged understanding of another person.
Affective empathy or empathic arousal (Hoffman 2000) is the spontaneous emotional state of compassion, of feeling revolt, emotional pain, anger, or disgust by a particular human incident. Affective empathy is what makes debrieﬁng necessary for paramedics after tragic accidents. Affective empathy is what makes it important to protect personnel from visual images of trauma, and, allegedly, it is why the surgeon operates not in the perceptual ﬁeld of the whole body but only envisages part of the body, the part in which he is cutting his knife. Affective empathy is what makes professional detachment and distance necessary and therapeutically signiﬁcant. Affective empathy is also morally signiﬁcant, as will be explained later.
Cognitive empathy is not a spontaneous feeling, but a form of projective imagination. Cognitive empathy is the ability deliberately as well as non-deliberately to take another person’s perspective, to put oneself in the shoes of another, and to try to imagine what it is like for this person to have a particular experience or to be in a particular situation. Thinking in analogies is important in cognitive empathy; “it is like when I had my surgery, or what I felt when my child was acute and seriously ill.” In short, one’s own earlier experiences are brought imaginatively to bear on other persons’ experiences and help us to understand these. This kind of projective imagination is signiﬁcant in empathy because it can be taught and cultivated. Other stories, illness narratives, and role taking can help us empathize with others. Also, cognitive empathy is objective because it maintains a distance, emotionally and cognitively, between yourself and the other. In cognitive empathy, one can still maintain that one understands the pain of another person and what he or she is enduring. Still, it is not one’s own misery; it is not your pain. You are in a different situation than the other.
While affective empathy runs the danger of emotional contamination and empathic overarousal, cognitive empathy maintains a necessary distance between self and others. This kind of distance is important in professional theory and care, in particular in order to keep necessary professional distance in situations with great emotional stress and affective overload. However, it is also important to envision no deliberate processes of empathic cognition, of directly understanding the other’s situation.
Some philosophers argue that it is possible to have direct access to other minds without theoretically inferring their mental states or by analogous inference. The Danish phenomenologist Dan Zahavi, for instance, argues that “rather, the claim has been that we need to take the embodied and environmentally embedded nature of psychological life seriously and acknowledge a more immediate experiential access to the minds of others which is prior to and more fundamental than any imaginative projection or theoretical inference. Whereas some have talked of this access in terms of empathic understanding, others have referred to it in terms of a form of direct social perception” (Zahavi 2011).
In “direct” empathy, the perceptual object is directly given in the sense that another person’s state is my primary and immediate intentional object (Zahavi 2011). The instance is “experienced as actually present to me, thereby making the experience in question very different from, say, reasoning that the other is upset, because the letter she has received has been torn up, or inferring that the person is drunk, because he is surrounded by a dozen empty bottles, or concluding that the other must be furious because I would be furious if I had been subjected to the same treatment as he has” (Zahavi 2011, p. 548).
This kind of direct empathic (or social) perception is a joint affective/cognitive affair. It is notoriously difﬁcult to separate one’s own emotional reaction upon an incident from the direct interpretation of its signiﬁcance. When getting upset about witnessing an incident of a person being harassed, it is impossible to separate this emotional reaction upon the incident of harassment from the evaluative assessment of the incident. This shows an old lesson about emotional understanding, that emotions also are cognitive and evaluative in their nature, that they are subjective judgments (Nussbaum 2001; Solomon 1988). This shows that the kind of direct perception Zahavi discusses is nothing else than mere emotional cognition. This kind of emotional cognition is what empathy and empathic understanding is about sui generis.
An additional point is to emphasize that empathy is a particular kind of other-oriented understanding (Vetlesen 1994). As stated, it is an understanding with joint affective and cognitive components. It is about identifying with the other person, as well as it is about emotional distance and of being aware of the otherness of the other. Hence, empathy is a particular kind of other-directed knowledge; it is directed not at one’s own interests, but at the interests and states of another human being. It is a response upon and an understanding of another person’s weal and woe. It is then not a morally neutral form of understanding, but an understanding that is concerned. We can say that it is a caring understanding.
Empathy And The Normative
In research and debates about empathy over the years, several conceptual and philosophical trends have been dominant. In particular, there have been various emphases on the different natures of empathy and on its cognitive and affective components (Pedersen 2010). Still, the most controversial issue in bioethics about the role of empathy is not whether it is a particular type of understanding, affective or cognitive, but to what extent it can be said to be normative: Is empathy just a morally neutral way of understanding the minds of other persons or is it a particular way of understanding and relating to the other person that is inherently normative? If it is a moral faculty, how can it be a mode of understanding that at the same time has impact upon moral motivation? Two issues are important in this respect: First, if empathy, and in particular affective empathy, is a source of moral value and moral motivation, how can this be given a plausible philosophical explanation? Secondly, can empathy be normatively action guiding? Can it be the tool from which we measure right from wrong, or is its functions merely epistemological, i.e., that it is central in moral perception, providing information of moral relevance?
That we can experience another human being’s pain and suffering is an existential fact; it is intrinsic to our human condition, so to say. And one basis for moral concerns is how the other’s condition emulates our own understanding and emotions. Affective empathy is our bodily sympathy, how another person’s pain and suffering are reﬂected in our own immediate feeling of sympathetic concern. To feel some discomfort and sympathy as a reﬂection upon another person’s pain is in many ways what morality is about. Hence, to argue that empathy is a morally neutral way of understanding the mental state of another person tends to overlook the signiﬁcance of affective empathy, how one through emotion directly identiﬁes with the weal and woe of another person. Affective empathy is the basis for sympathetic concern and for compassion; in fact, affective empathy orchestrates our basic ethical concerns for the weal and woe of others (Vetlesen 1994).
In this manner, psychologist Richard Lazarus talks about hot cognition as opposed to cold cognition (Lazarus 1989). Cold cognition is how one understands another being’s human condition while still being in a detached and disinterested mood. Hot cognition, on the other hand, means that perception and understanding is also affective; it is compassionate. Some kind of concern is so to speak internal to an inescapable part of understanding the other person’s state of affairs. Hot and affective cognition is very different from cold cognition. For instance, a torturist must have the ability to imagine and understand the condition of his victim, but he most likely cannot relate to the condition of his victim in an affective way; he cannot feel affective empathy. Empathic understanding is a kind of “pained awareness” which gives reason to relieve the other’s condition (Nagel 1978; Nortvedt 2012). When saying so, two questions come to one’s mind: What is this kind of “pained awareness” and why is it normative? The other question is about motivation: Why does this kind of awareness or feeling affective empathy motivate morally? Why is the other’s pain a reason to help him or her, and why is it not just a reason to run away, to free oneself from the painful experience, rather than elevating one’s moral conscience? These are tricky questions but some answers can be alluded to. One way would be to argue for some kind of substantive moral realism; that to see another person in pain and suffering is to experience moral value in a direct and immediate way (Korsgaard 1996), and that this kind of seeing reﬂects a person’s motivational disposition. The other way is to argue in a more Levinasian way, that empathic seeing is a perception of epiphanies, something that springs to a person’s immediate experience and alerts human sensitivities. The ethics of Levinas elucidates how the vulnerability of the Other signiﬁes moral responsibility. The central idea in Levinas’, as we also can see in Husserl’s theory of empathy, is that experiencing the minds of other persons is something that we really cannot comprehend in the full epistemological sense. If we through empathy could fully grasp another person’s feelings and intentions, there would be no difference between the other and I (Zahavi 1999). Instead it is important to preserve the idea that to understand and identify with another person is also at the same time and always to be confronted with that which exceeds our understanding. A human encounter is to encounter something that we cannot fully comprehend. It is in this incomprehensibility of capturing the other within our cognitive schemes that an ethics, according to Levinas, is possible. It is not by cognition, but through re-cognition that we can fully do justice to the other person, by respecting his or her as another, as different from us (Levinas 1996). Respect for difference is crucial in ethics, in the same way as fear of the other as different, as the Jew or the Sunni, as the poor and the beggar, may be a source of oppression and immorality. Empathy makes us understand the other, but the other also transcends our empathy. And it is in this encounter with otherness, what Levinas calls alterity, that ethics is possible. Consciousness and the Ego are put into question, put in a condition of receptivity. It is also central in the ethics of Levinas that to see the other in an affective emotional way is in some sense to be addressed morally, to be responsible. Responsibility is possible because its origin is a response. The other cast a spell on you, so to speak, in which the Ego loses its epistemological control. Recall in the following how Levinas illustrates this in his phenomenological descriptions of the Face: The ﬁrst word of the face is the ‘Thou shalt not kill’. It is an order. There is a commandment in the appearance of the face, as if a master spoke to me. However, at the same time, the face of the Other is destitute; it is the poor from whom I can do all and to whom I owe all (Levinas 1992).
Levinas himself never used the word empathy, but in his analysis of ethical sensibility and the face, we can ﬁnd much that reminds us of the kind of being addressed by the suffering of someone that we also ﬁnd when we analyze empathic affectivity/arousal. There is a notion of positive interestedness, of primary concern and sympathy for another human we meet that springs to mind in these analyses of human empathy and in the confrontation with otherness we see illustrated in the ethics of Levinas. To empathize is an other-oriented activity in a most fundamental and primordial way. But interestingly, in spite of all the different accounts of the sources of normativity we see in the Kantian, in the consequentialist, and in virtue ethical traditions in morality, we also ﬁnd some imaginary conceptions of the Good. In Kantianism it is the unconditionally Good Will; in consequentialism, it is maximization of the overall Good; in Aristotelian virtue theory, it is human fulﬁllment, and in Plato and Levinas, it is in the Good that is beyond being. Uniting all these various conceptions of the sources of morality is a basic concern for the weal and woe of others (Vetlesen 1994). One cares about morality because one basically cares about the well-being of other persons. One cares about justice, because justice is all in the end a concern for the overall human good. Empathy seen in this meta-ethical context can never be a neutral epistemological activity, as it were. Empathy is intrinsically also sympathetic concern, some kind of sharing the human condition of the other person. A central question that follows from this outline of empathic normativity is the extent to which it is a universal human capacity of concern for others. This question cannot be fully addressed here, but it sufﬁces to say that empathy is universal and primordial capacity of human concern that has an important place in any understanding of bioethics globally. The problem is not the general relevance and existence of empathy and its importance in clinical bioethics. The problem is the precariousness of such a disposition of kindness and human concern in a global context of increasing suffering, war, and poverty. It is too little of global concern for the poor. The afﬂuent societies care too little and it is rarely a topic in debates about healthcare priorities in the Western societies.
Empathy And Clinical Care
In both its cognitive and affective connotations, empathy is crucial in clinical work with patients. It is obvious that good care has to be empathic care. Empathy makes it possible to understand what it means for a patient to be ill and to experience suffering and loss. Similarly, empathy makes the human sharing of joy, happiness, relief, and coping possible. Finally, empathy is purely emotional, the ability of being spontaneously affected by the weal and woe of others. Given its joint cognitive and affective dimension, there is an interesting clinical aspect of empathy that elucidates its real signiﬁcance in healthcare and not only in the context of moral perception.
Several authors have recently drawn attention to the kind of tacit dimension in empathic concern, in which there are some hunches, signs, and intuitions that are closely associated with affective empathy. These empathic cues fuel clinical cognition and observation and give us access to a better understanding of the clinical condition of patients (Halpern 2002). Consider this example: As a nurse anesthetist or anesthesiologist, you are well acquainted with persons in respiratory distress and in need of ventilator treatment. These professionals all know much about pulmonary physiology, arterial saturation of oxygen, the technological sophistication of ventilation machinery, etc. Imagine that such a patient which is in an unconscious state deteriorates. The ﬁrst way of seeing this can be signs of human stress and of human discomfort envisioned in the patient’s patterns of breathing. Empathic attentiveness and receptivity alerts our clinical knowledge and fortiﬁes observational proﬁciency. At the same time, empathic affect makes a clinician worried and concerned on behalf of the patient. This concerned worry is motivationally signiﬁcant as it arouses clinical knowledge, a sense of taking better care and of alarming the staff to speciﬁc courses of actions such as the need to take more tests, adjust the medication, etc.
Jodi Halpern discusses the role of gut feelings as part of empathy and quotes a psychoanalyst, Michael Basch, arguing that “gut feelings are a necessary basis for social recognition of others’ emotional states, including the kind of recognition needed for empathy” (Halpern 2001). The empathic physician may additionally proﬁt from increased diagnostic accuracy, more meaningful work, an increased sense of well-being, and reduced symptoms of burnout.
The lesson to be learned here is not the pure fact that empathy is signiﬁcant in moral perception, judgment, and motivation. Clinical empathy is also a signiﬁcant source of knowledge about the patients’ clinical condition, giving important information about pathological signs and so forth. On the other hand, empathy also constrains manipulations and makes the clinician careful in his or her manipulation of a wounded and vulnerable body. An empathic clinician can experience bodily cues in a way that makes him or her better in handling the patient in a way that minimizes pain and protects the patient at being too exposed. This is easy to see when the good nurse is about to turn the patient in the bed, helping him to shift to a better and less painful position. Bodily cues of pain and discomfort immediately make the nurse stop or be more careful in her manipulations and movements of the body (Nortvedt 2012).
Of course, empathy in itself does not give us the full answer to normative questions and challenges. Sometimes, it can be too much empathy, and clinicians’ judgments can be blinded by emotional involvement. Also, empathy as a precondition for caring and caring responses make persons and clinicians exposed to harms and vulnerabilities. However, this is not a limitation of empathy, but a general feature of our human condition, as we are living in relationships with others.
Empathy is one of the central sources of human morality. Empathy is the emotional faculty that gives us access to the weal and woe of other persons (Vetlesen 1994). Hence, it gives access to the moral domain and is crucial in moral perception. This is not to say that cognition, knowledge about ethical principles and theories or moral and professional experience, and results from clinical research are insigniﬁcant as sources of moral perception and judgments. It is only to say that empathy is crucial because it gives us reasons for concern and care for patients that are result of emotional understanding and involvement and which at the same time express an emotional attitude of care that is indispensable in healthcare. Empathy combines emotional involvement with moral imagination and is motivationally important because it encompasses an attitude of concern and involvement that is personal and authentic. Finally, empathy is epistemologically signiﬁcant in clinical care because it often opens up knowledge that is relevant for determining the patients’ clinical conditions.
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