Dr. Clarke is president, Psychophysiologic Disorders Association (www.ppdassociation.org), and assistant director, Center for Ethics, Oregon Health & Science University, Portland, Oregon; e-mail: DrDave@stressillness.com.
Empathy is a criticall–y important skill for resolving many clinical and ethical dilemmas. It was defined by psychologist Carl Rogers as the ability “to perceive the internal frame of reference of another with accuracy, … as if one were the other person, but without ever losing the ‘as if’ condition.”1
In The Scarlet Letter (1850), Nathaniel Hawthorne describes the physician Roger Chillingworth as he evaluates his patient, the Reverend Arthur Dimmesdale. Chillingworth’s approach is a model for health care professionals who seek to help patients understand and cope with life stresses they don’t fully recognize. Ironically and shockingly, Chillingworth is seeking revenge, using his seemingly compassionate technique to uncover a secret that tortures both him and his patient. His cold, calculating nature is reflected in the surname the author chose for him. This reminds us that skills developed for noble ends can be exploited for evil by some individuals.
However, when coupled with beneficent intent, Chillingworth’s approach is worthy of emulation. When lab tests and imaging studies fail to explain an illness, empathic skill is often essential to uncovering the source of the problem. I recall treating a 24-year-old woman in the seventh month of her second pregnancy who was hospitalized for uncontrollable vomiting. Diagnostic studies were normal, but I learned she had strong Christian views that caused her extreme guilt for giving up her first baby for adoption when she was 17. It was through empathy rather than diagnostic tests that I was able to uncover her fear of divine retribution in the form of harm to her fetus. We discussed the parallels between giving her first child to another family and her belief that God gave His son to humanity, and she found relief from much of her guilt. This lessened her fear enough for the symptoms to resolve. Fortunately for all concerned, her pregnancy concluded with delivery of a healthy child.
Empathy is also valuable in resolving ethical dilemmas. As Hampshire2 noted, “the practical need is often for sensitive observation of the easily missed features of the situation, not clear application of principles….” Because ethical dilemmas often arise when there is a conflict in values among patients, families, and health care professionals, a fundamental goal is achieving an expeditious understanding of the mindsets of the stakeholders. One of my most experienced colleagues refers to this process as “reading the room.” Ability in this area can significantly improve outcomes and reduce the time needed to achieve them.
Unfortunately, development of empathic skill is not emphasized in medical training. Perhaps one source of this problem is that medical school admissions criteria are based on achievement in quantitative sciences where empathy is of little importance. This focus continues during professional training. Also consistent with the objectivity of quantitative science is the tradition of maintaining a demeanor of emotional separation from patients. As Halpern3 has written, “The ideal of detached concern is justified by the argument that only an unemotional physician is free to discern and meet patients’ emotional needs without imposing his own.”
Halpern goes on to point out how this attitude increases the risk of diagnostic errors. For example, a “physician whose father was alcoholic might minimize her contact with alcoholic patients because of her resentment” or a “physician who just lost a patient to cancer may judge that a new patient with weight loss and lethargy is likely to have a cancer, despite the patient having given a history more suggestive of depression.”3
Halpern’s most compelling example is an ethical dilemma.3 A 56-year-old woman’s husband leaves her for another woman while she is recovering from her second above-knee leg amputation. She decides to stop hemodialysis. Empathy was essential for comprehending the many complex issues that factored into her decision and for providing support so she could transition from irrational acute grief to true autonomy. Unfortunately, her clinicians failed to demonstrate empathy, accepting the patient’s decision that her life was not worth living despite evidence to the contrary. She was allowed to die quickly. Much of the remainder of Halpern’s book describes the knowledge and skills that could have produced a better outcome.
Empathic skill can be learned.3 During evaluation of patients with medically unexplained symptoms, attention to past and present life stresses may clarify the source of an illness. During ethics committee deliberations, including a discussion of the mindsets of key stakeholders (patient, family, staff) will encourage participants to attend to these issues. Over time, professionals will see their skill in “reading the room” grow and, with it, their ability to solve medical mysteries or bring conflicts in values to a successful conclusion. We can learn from Chillingworth’s approach even as we deplore his malign intentions.
David D. Clarke, MD
1. Shea SC Psychiatric Interviewing: The Art of Understanding. 1998 Philadelphia, PA WB Saunders
2. Hampshire S Morality and Conflict. 1987 Cambridge, MA Harvard University Press
3. Halpern J From Detached Concern to Empathy. 2001 New York, NY Oxford University Press