Med Health Care and Philos (2014) 17:245–248 DOI 10.1007/s11019-014-9547-z
SCIENTIFIC CONTRIBUTION
The phenomenology of empathy in medicine: an introduction Fredrik Svenaeus
Ó Springer Science+Business Media Dordrecht 2014
Abstract This article is an introduction to a thematic section on the phenomenology of empathy in medicine, attempting to provide an expose of the field. It also provides introductions to the individual articles of the thematic section. Keywords Phenomenology Empathy Social neuroscience Medical ethics Clinical practice Empathy and medicine are connected in at least two ways. Empathy is central to good medical practice, but studies of how our bodies work can also teach us things about empathy. The phenomenon of empathy has attracted increasing attention and interest the last 20 years, not only in medical ethics, but in many different disciplines and fields—psychology, philosophy, sociology, social anthropology, media studies, history of ideas, social work and nursing—and the most important factor behind this attention rise has been the finding and study of so called ‘‘mirror neurons’’ (Iacoboni 2008). Mirror neurons are neurons that fire not only when somebody does something, but also when he sees or hears somebody else doing similar things. This type of neurons thus makes it possible for us to feel and understand the actions and bodily expressions of other persons without forming any explicit hypotheses about their mental states. In the wake of the mirror neuron discovery in the 1990s a new interdisciplinary research field has been formed, so called ‘‘social neuroscience,’’ which
F. Svenaeus (&) Department of Philosophy, Centre for Studies in Practical Knowledge, So¨derto¨rn University, 141 89 Huddinge, Sweden e-mail: [email protected]
investigates the biological underpinnings of our social and moral life in various ways (Decety and Ickes 2009). The brain studies of empathy not only concern mirror neurons; they also take into account other forms of neurological processing belonging to at least ten different areas of the cortex and the limbic system that have been identified in that what Simon Baron-Cohen calls ‘‘the empathy circuit’’ of the human brain (Baron-Cohen 2011, pp. 27–41, see also Engen and Singer 2012). These areas contain not only mirror neurons, but also neural structures initiating feelings in situations that typically call for a quick emotional response (what is called somatic markers) and structures involved in face recognition, thought formation and the expression of language (Damasio 2010). It seems obvious that some of these neurological circuits will not only be engaged in preconscious, automatic functioning, but also in emotional-cognitive processing that includes what the phenomenologist calls intentionality—perceptions and thoughts with a meaning content being formed (Gallese 2009). Empathy is not a reflex (although it might begin as a reflex), but a way of understanding the other person and (in some definitions of the concept) also caring about his well being. As Jan Slaby shows in his contribution to the thematic section of articles devoted to relations between empathy and medicine that you find in this issue of Medicine, Health Care and Philosophy we would do well to adopt a more critical attitude towards the findings and theories following in the footsteps of the mirror neuron hype (Slaby 2014). Mirror neurons—and other parts of the empathy circuit of the brain—do not automatically make us good although the neurological structures in question provide means for engaging in pro-social behavior. Morality and politics have many other dimensions (some of them are natural, but most of them are cultural) that need to be taken into account, and
123
246
the proclamations that we are goodhearted and social from the very start (e.g. Rifkin 2009; de Waal 2009) could easily be exploited. Notwithstanding a portion of healthy skepticism as concerns the results and theories established in social neuroscience, it is interesting to see how the interest for mirror neurons, beginning in the 1990s, has reawakened a century old debate about the nature of empathy—in the German original: ‘‘Einfu¨hlung’’—in philosophy of mind, aesthetics and ethics. The mirror neuron findings provided new resources for answering two old philosophical questions: How do I get to know the experiences of other persons and how do I develop feelings of concern for the persons in question? The empathy researchers attempting to answer the first, so called other-minds problem, question were inspired by the mirror neurons to understand the way we come to know others in terms of a direct perception and simulation of their experiences, instead of in terms of theories being formed about the experiences by way of analogy (Zahavi 2012). I do not understand the other person as minded because I form a theory about his bodily expressions based on an analogy with my own animated bodily condition; but because I feel his expressions directly and by way of these feelings project myself into his predicament. Empathy as this ability of perceiving and imagining the other person’s perspective on the world has a long history that was, so to say, reactivated by the mirror neuron hype and brought back to the philosophy of mind (Agosta 2010; Zahavi 2010). Important philosophers in this tradition of empathy are, for example, Theodor Lipps (1907), Max Scheler (1913/1954), and Edith Stein (1917/ 1989). As Jonna Bornemark shows in her contribution to the present section, the phenomenology of empathy we find at work in philosophers such as Scheler, Stein and, also, Maurice Merleau-Ponty (1945/1962) support the findings in social neuroscience (Bornemark 2014). The phenomenological theories are better equipped to spell out the new neurological version of social selfhood than theories proceeding from the idea that we are fundamentally cut off from each other as human beings and attempt to make contact and establish knowledge about the others through forming ‘‘folk psychology’’ theories about them (Gopnik and Meltzoff 1997). An embodied and attuned understanding of selfhood can explain the way we share a human existence from the very start and in some situations feel and do things synchronized and united with each other in the form of a primordial we. Scheler calls this ‘‘Einsfu¨hlung’’ (feeling at oneness) rather than ‘‘Einfu¨hlung,’’ which is a notion he is more skeptical about because of its association with an alleged Cartesian model of the mind according to which we can project feelings from our own self onto the other (a model we find in Lipps). Bornemark
123
F. Svenaeus
attempts to show that the idea of such a ‘‘feeling at oneness’’ can be utilized to understand the relation between the mother and the infant, and even the experiences of the fetus and of being born. The feeling of empathy (Einfu¨hlung) through which I understand and come to care about others thus rests on a preceding feeling of ‘‘at oneness’’ (Einsfu¨hlung) which actually makes the former possible. I only know the other because I have once been united with him in a feeling that precedes the I and the you. In Slaby’s contribution we find a skepticism, not only regarding the findings (or, perhaps, rather, the application of the findings) of social neuroscience, but also regarding our possibilities to really put ourselves into the position of the other person by way of empathy and thereby coming to understand him (Slaby 2014). Human beings are not only similar but also different from each other in many important ways, and perhaps it would be better to acknowledge and respect these differences and engage in dialogue instead of relying on knowledge being formed about others by way of empathy. A similar criticism could be launched as regards the feelings of ‘‘at oneness’’ that Bornemark employs, with the assistance of Scheler, to underpin the possibilities of empathy. Do we really have any phenomenological accounts of how it feels to be a fetus or an infant? Or of how it feels to be born? Nobody seems to remember (and if they claim to do we are reluctant to trust them). Studies in developmental psychology show a rudimentary bodily self to be at hand at least from birth and onwards, successively joined by more reflective forms of selfhood (Gallagher and Zahavi 2012, pp. 229 ff.). Should we interpret such studies to support or challenge the idea of a primordial we? Bornemark provides her answer by paying attention to the experiential situation of the fetus in the womb, making a rudimentary sense of selfhood gradually possible in a temporal flow of rhythmic sounds and sensations produced by the mother’s body. This primordial selfhood of the fetus is situated in relation to a belonging to the mother, who is, certainly, not thematized as another person (or another body) by the fetus, but nevertheless provides the union that is the starting point of life and our belonging together in the world as separate persons. The primordial we appears to contain a primordial self (and a mother self) from very early on in life. Although we do not remember how it feels to be a fetus, we do seem to have an understanding of what it means to share the world with another person in intimate ways. Not only mothers (and perhaps fathers) and infants do this, but lovers, dancers and other couples or groups of people who are attuned to each other in sharing the same activity. These forms of being attuned to the other person are not necessarily examples of empathy, since I can be focused on the thing we do together, rather than on the other person in performing the activity in question, but they point towards
The phenomenology of empathy in medicine
something that must be in place in order for us to be able to understand the other: a shared pattern of feelings and moods. In his contribution to the section, Matthew Ratcliffe investigates the nature of these shared feelings and how they form a prerequisite for our possibilities to engage in empathic understanding (Ratcliffe 2014). In order to explore this basic feature of our lives that we are not often directly aware of he employs a medical example: depression. Why is it so hard to empathize with depressed people and why do they feel that nobody really understands them? Ratcliffe’s explanation is that depression rips apart our fundamental way of belonging to the world in a homelike mood and leaves the sufferer unable to find any point in engaging in activities or communication with others. The reason why it is so hard to understand what it is like to be depressed, if you are not depressed yourself, is that the basic moods supporting our worldly activities and engagements in life are disarranged, which leads to a feeling of not belonging anywhere and seeing no point in living. This disruption of existential feelings need not be total—there are different degrees and shades of depression—but the example of depression—and of other mental disorders—can make us understand why it is easier or harder to empathize with the people we meet. It is easier or harder because an understanding of the other person’s life depends upon sharing the world with him in moods that tie us together and make us take place in the same space of possibilities, so to say. Empathy is not basically a process of simulation or imagination of the other person’s perspective; it is first and foremost a kind of emotional, perceptual and practical experience of the other person as sharing the world with me. Ratcliffe engages with philosophers such as Edmund Husserl and Jean-Paul Sartre to make his points, but the phenomenologist who has arguably done most to develop a theory of existential and social moods is Martin Heidegger (1927/1996). Lou Agosta takes off from Being and Time, in which Heidegger mentions the possibility of developing a ‘‘hermeneutics of empathy,’’ and tries to fill out the lacunas in Heidegger’s phenomenology of intersubjectivity and authenticity by developing his phenomenology of human being (Dasein) as being-in-the-world further and marrying it to ideas found in various schools of psychotherapy (Agosta 2014). The account Agosta is developing not only attempts to find an alternative to the dualistic version of communicating minds; it also explicitly introduces the normative dimension: what does it mean to be together with the other in a way that takes care of his existence? In his contribution Agosta distinguishes the unified multidimensional process of what he calls empathic receptivity, empathic understanding, empathic interpretation, and empathic speech. This brings us back to the second question I mentioned above as central for
247
the contemporary empathy debate: How do I come to feel concern for the other (and not only understand him)? At this point we arrive at the ways in which empathy is central for our understanding of good medical practice in contrast to the ways in which medical research and practice can influence our understanding of empathy (the mutual influence I started out with above). We arrive in medical ethics and the role that empathy plays in this territory. Empathy is a thing constantly asked for and stressed as a central skill and character trait of the good physician and nurse. To be a good doctor (or other health-care professional) one needs to be empathic—one needs to be able to feel and understand the needs and wishes of patients in order to help them in the best possible way, in a medical, as well as in an ethical sense. The problem with most studies of what role empathy plays in medical practice and ethics is that empathy is poorly defined and tends to overlap with other related things, such as emotional contagion, sympathy, or a caring personality in general (Pedersen 2010). It is far from clear how empathy fits into the general picture of medical ethics and the framework of norms and principles that are most often stressed there, such as respect for autonomy and beneficence. How does empathy attain moral importance in medicine? Fredrik Svenaeus, in his contribution, tries to show that a comparison with the Aristotelian concept of phronesis— practical wisdom—makes it easier to see what empathy in medicine means and how it fits into the general picture of medical ethics (Svenaeus 2014). Empathy, he argues, is a basic condition and source of moral knowledge by being the feeling component of phronesis, and, by the same power, it is also a motivation for acting in an ethical way. Svenaeus’s analysis is phenomenological by picking up on the idea found in the philosophers mentioned above—Scheler, Husserl, Stein, Heidegger, Sartre and Merleau-Ponty— that empathy is basically a way of presenting the other person and his sufferings to me, rather than forming any hypotheses or imaginations about them (Zahavi 2010). Empathy in medicine is an emotional account of the patient that makes it possible to see how and why he is suffering and there by making way for ethical decisions and actions being formed and taken by the doctor or other health-care professionals. Empathy may include explicit hypotheses and attempts to imagine what things are like for the other person, but it starts out in feeling the predicament of the other and presenting it to me as an issue to be dealt with. In accordance with such a model of emotional and cognitive empathy as mutually supportive, Jodi Halpern, in the last of the contributions building up the present thematic section, develops her theory about empathy in medicine as a form of engaged curiosity on part of the health care professional in contrast to a detached concern (Halpern 2001, 2014). Halpern stresses how empathy must be thought about as a mutual engagement of professional and patient. Empathy
123
248
in medicine is sustained through a dialogue which can be developed if there is mutual trust between the parties (and sufficient time to feel, think and talk together). This is also how empathy should be studied in medicine and medical ethics: through paying attention to and investigating real life scenarios, instead of merely filling out empathy questionnaires or doing experiments in the empathy lab with brain scanners. It is hard to define, as well as live up to, a concept that is held in such a high esteem as empathy. In the section of her paper called ‘‘Dispelling myths and misunderstandings to help physicians sustain empathy’’ Halpern gives some practical advice and points out what empathy in fact is not (Halpern 2014). To be empathic is not the same thing as being nice or agreeing with everything that the patient says or wants. Nor does it mean never to feel negative feelings towards patients. The empathic doctor is not necessarily the doctor that always knows how and what to respond. The important thing is that he responds maybe merely by repeating what the patient just has said. Empathy is about seeing, understanding and caring for the other person, but it is also about the feeling of being seen. Patients who feel that their doctors care for them and attempt to understand and help them will often be satisfied even if there is nothing to be done, or even if the doctor does not do the right thing for them. This is a clear proof of how powerful the feelings of empathy (and the lack thereof) and the dialogues between persons that empathy enables (or precludes) in medicine are.
References Agosta, L. 2010. Empathy in the context of philosophy. New York: Palgrave/Macmillan. Agosta, L. 2014. A rumor of empathy: Reconstructing Heidegger’s contribution to empathy and empathic clinical practice. Medicine, Health Care and Philosophy 17(2): 281–292. Baron-Cohen, S. 2011. The science of evil: On empathy and the origins of cruelty. New York: Basic Books. Bornemark, J. 2014. The genesis of empathy in human development: A phenomenological reconstruction, Medicine, Health Care and Philosophy 17(2): 259–268.
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F. Svenaeus Damasio, A. 2010. Self comes to mind: Constructing the conscious brain. New York: Random House. Decety, J. and W. Ickes (eds.) 2009. The social neuroscience of empathy. Cambridge, MA: MIT Press. Engen, H.G., and T. Singer. 2012. Empathy circuits. Current Opinion in Neurobiology 23: 275–282. Gallagher, S., and D. Zahavi. 2012. The phenomenological mind, 2nd ed. London: Routledge. Gallese, V. 2009. Mirror neurons, embodied simulation, and the neural basis of social identification. Psychoanalytic Dialogues 19(5): 519–536. Gopnik, A., and A. Meltzoff. 1997. Words, thoughts, and theories. Cambridge, MA: MIT Press. Halpern, J. 2001. From detached concern to empathy: Humanizing medical practice. New York: Oxford University Press. Halpern, J. 2014. From idealized clinical empathy to empathic communication in medical care. Medicine, Health Care and Philosophy 17(2): 301–311. Heidegger, M. 1996. Being and Time. Trans. J. Stambaugh. New York: SUNY. Iacoboni, M. 2008. Mirroring people: The new science of how we connect with others. New York: Farrar, Straus, & Giroux. Lipps, T. 1907. Das Wissen von fremden Ichen. In Psychologische Untersuchungen 1 (pp. 694–722). Leipzig: Engelmann. Merleau-Ponty, M. 1962. Phenomenology of Perception. Trans. C. Smith, London: Routledge. Pedersen, R. 2010. Empathy in medicine: A philosophical hermeneutic reflection. Oslo: University of Oslo, Faculty of Medicine. Ratcliffe, M. 2014. The phenomenology of depression and the nature of empathy. Medicine, Health Care and Philosophy 17(2): 269–280. Rifkin, J. 2009. The empathic civilization: The race to global consciousness in a world in crisis. New York: Penguin Books. Scheler, M. 1954. The nature of sympathy. Trans. P. Heath. London: Routledge. Slaby, J. 2014. Empathy’s blind spot: Critical theory and the social brain. Medicine, Health Care and Philosophy 17(2): 249–258. Stein, E. 1989. On the Problem of Empathy. Trans. W. Stein. Washington DC: ICS Publications. Svenaeus, F. 2014. Empathy as a necessary condition of phronesis: A line of thought for medical ethics. Medicine, Health Care and Philosophy 17(2): 292–299. de Waal, F.B. 2009. The age of empathy: Nature’s lessons for a kinder society. New York: Crown Publishing Group. Zahavi, D. 2010. Empathy, embodiment and interpersonal understanding: From Lipps to Schutz. Inquiry 53(3): 285–306. Zahavi, D. 2012. Empathy and mirroring: Husserl and Gallese. In Life, subjectivity & art: Essays in honor of Rudolf Bernet, ed. R. Breeur and U. Melle (eds.) (217–254). Dordrecht: Springer.
SCIENTIFIC CONTRIBUTION
The phenomenology of empathy in medicine: an introduction Fredrik Svenaeus
Ó Springer Science+Business Media Dordrecht 2014
Abstract This article is an introduction to a thematic section on the phenomenology of empathy in medicine, attempting to provide an expose of the field. It also provides introductions to the individual articles of the thematic section. Keywords Phenomenology Empathy Social neuroscience Medical ethics Clinical practice Empathy and medicine are connected in at least two ways. Empathy is central to good medical practice, but studies of how our bodies work can also teach us things about empathy. The phenomenon of empathy has attracted increasing attention and interest the last 20 years, not only in medical ethics, but in many different disciplines and fields—psychology, philosophy, sociology, social anthropology, media studies, history of ideas, social work and nursing—and the most important factor behind this attention rise has been the finding and study of so called ‘‘mirror neurons’’ (Iacoboni 2008). Mirror neurons are neurons that fire not only when somebody does something, but also when he sees or hears somebody else doing similar things. This type of neurons thus makes it possible for us to feel and understand the actions and bodily expressions of other persons without forming any explicit hypotheses about their mental states. In the wake of the mirror neuron discovery in the 1990s a new interdisciplinary research field has been formed, so called ‘‘social neuroscience,’’ which
F. Svenaeus (&) Department of Philosophy, Centre for Studies in Practical Knowledge, So¨derto¨rn University, 141 89 Huddinge, Sweden e-mail: [email protected]
investigates the biological underpinnings of our social and moral life in various ways (Decety and Ickes 2009). The brain studies of empathy not only concern mirror neurons; they also take into account other forms of neurological processing belonging to at least ten different areas of the cortex and the limbic system that have been identified in that what Simon Baron-Cohen calls ‘‘the empathy circuit’’ of the human brain (Baron-Cohen 2011, pp. 27–41, see also Engen and Singer 2012). These areas contain not only mirror neurons, but also neural structures initiating feelings in situations that typically call for a quick emotional response (what is called somatic markers) and structures involved in face recognition, thought formation and the expression of language (Damasio 2010). It seems obvious that some of these neurological circuits will not only be engaged in preconscious, automatic functioning, but also in emotional-cognitive processing that includes what the phenomenologist calls intentionality—perceptions and thoughts with a meaning content being formed (Gallese 2009). Empathy is not a reflex (although it might begin as a reflex), but a way of understanding the other person and (in some definitions of the concept) also caring about his well being. As Jan Slaby shows in his contribution to the thematic section of articles devoted to relations between empathy and medicine that you find in this issue of Medicine, Health Care and Philosophy we would do well to adopt a more critical attitude towards the findings and theories following in the footsteps of the mirror neuron hype (Slaby 2014). Mirror neurons—and other parts of the empathy circuit of the brain—do not automatically make us good although the neurological structures in question provide means for engaging in pro-social behavior. Morality and politics have many other dimensions (some of them are natural, but most of them are cultural) that need to be taken into account, and
123
246
the proclamations that we are goodhearted and social from the very start (e.g. Rifkin 2009; de Waal 2009) could easily be exploited. Notwithstanding a portion of healthy skepticism as concerns the results and theories established in social neuroscience, it is interesting to see how the interest for mirror neurons, beginning in the 1990s, has reawakened a century old debate about the nature of empathy—in the German original: ‘‘Einfu¨hlung’’—in philosophy of mind, aesthetics and ethics. The mirror neuron findings provided new resources for answering two old philosophical questions: How do I get to know the experiences of other persons and how do I develop feelings of concern for the persons in question? The empathy researchers attempting to answer the first, so called other-minds problem, question were inspired by the mirror neurons to understand the way we come to know others in terms of a direct perception and simulation of their experiences, instead of in terms of theories being formed about the experiences by way of analogy (Zahavi 2012). I do not understand the other person as minded because I form a theory about his bodily expressions based on an analogy with my own animated bodily condition; but because I feel his expressions directly and by way of these feelings project myself into his predicament. Empathy as this ability of perceiving and imagining the other person’s perspective on the world has a long history that was, so to say, reactivated by the mirror neuron hype and brought back to the philosophy of mind (Agosta 2010; Zahavi 2010). Important philosophers in this tradition of empathy are, for example, Theodor Lipps (1907), Max Scheler (1913/1954), and Edith Stein (1917/ 1989). As Jonna Bornemark shows in her contribution to the present section, the phenomenology of empathy we find at work in philosophers such as Scheler, Stein and, also, Maurice Merleau-Ponty (1945/1962) support the findings in social neuroscience (Bornemark 2014). The phenomenological theories are better equipped to spell out the new neurological version of social selfhood than theories proceeding from the idea that we are fundamentally cut off from each other as human beings and attempt to make contact and establish knowledge about the others through forming ‘‘folk psychology’’ theories about them (Gopnik and Meltzoff 1997). An embodied and attuned understanding of selfhood can explain the way we share a human existence from the very start and in some situations feel and do things synchronized and united with each other in the form of a primordial we. Scheler calls this ‘‘Einsfu¨hlung’’ (feeling at oneness) rather than ‘‘Einfu¨hlung,’’ which is a notion he is more skeptical about because of its association with an alleged Cartesian model of the mind according to which we can project feelings from our own self onto the other (a model we find in Lipps). Bornemark
123
F. Svenaeus
attempts to show that the idea of such a ‘‘feeling at oneness’’ can be utilized to understand the relation between the mother and the infant, and even the experiences of the fetus and of being born. The feeling of empathy (Einfu¨hlung) through which I understand and come to care about others thus rests on a preceding feeling of ‘‘at oneness’’ (Einsfu¨hlung) which actually makes the former possible. I only know the other because I have once been united with him in a feeling that precedes the I and the you. In Slaby’s contribution we find a skepticism, not only regarding the findings (or, perhaps, rather, the application of the findings) of social neuroscience, but also regarding our possibilities to really put ourselves into the position of the other person by way of empathy and thereby coming to understand him (Slaby 2014). Human beings are not only similar but also different from each other in many important ways, and perhaps it would be better to acknowledge and respect these differences and engage in dialogue instead of relying on knowledge being formed about others by way of empathy. A similar criticism could be launched as regards the feelings of ‘‘at oneness’’ that Bornemark employs, with the assistance of Scheler, to underpin the possibilities of empathy. Do we really have any phenomenological accounts of how it feels to be a fetus or an infant? Or of how it feels to be born? Nobody seems to remember (and if they claim to do we are reluctant to trust them). Studies in developmental psychology show a rudimentary bodily self to be at hand at least from birth and onwards, successively joined by more reflective forms of selfhood (Gallagher and Zahavi 2012, pp. 229 ff.). Should we interpret such studies to support or challenge the idea of a primordial we? Bornemark provides her answer by paying attention to the experiential situation of the fetus in the womb, making a rudimentary sense of selfhood gradually possible in a temporal flow of rhythmic sounds and sensations produced by the mother’s body. This primordial selfhood of the fetus is situated in relation to a belonging to the mother, who is, certainly, not thematized as another person (or another body) by the fetus, but nevertheless provides the union that is the starting point of life and our belonging together in the world as separate persons. The primordial we appears to contain a primordial self (and a mother self) from very early on in life. Although we do not remember how it feels to be a fetus, we do seem to have an understanding of what it means to share the world with another person in intimate ways. Not only mothers (and perhaps fathers) and infants do this, but lovers, dancers and other couples or groups of people who are attuned to each other in sharing the same activity. These forms of being attuned to the other person are not necessarily examples of empathy, since I can be focused on the thing we do together, rather than on the other person in performing the activity in question, but they point towards
The phenomenology of empathy in medicine
something that must be in place in order for us to be able to understand the other: a shared pattern of feelings and moods. In his contribution to the section, Matthew Ratcliffe investigates the nature of these shared feelings and how they form a prerequisite for our possibilities to engage in empathic understanding (Ratcliffe 2014). In order to explore this basic feature of our lives that we are not often directly aware of he employs a medical example: depression. Why is it so hard to empathize with depressed people and why do they feel that nobody really understands them? Ratcliffe’s explanation is that depression rips apart our fundamental way of belonging to the world in a homelike mood and leaves the sufferer unable to find any point in engaging in activities or communication with others. The reason why it is so hard to understand what it is like to be depressed, if you are not depressed yourself, is that the basic moods supporting our worldly activities and engagements in life are disarranged, which leads to a feeling of not belonging anywhere and seeing no point in living. This disruption of existential feelings need not be total—there are different degrees and shades of depression—but the example of depression—and of other mental disorders—can make us understand why it is easier or harder to empathize with the people we meet. It is easier or harder because an understanding of the other person’s life depends upon sharing the world with him in moods that tie us together and make us take place in the same space of possibilities, so to say. Empathy is not basically a process of simulation or imagination of the other person’s perspective; it is first and foremost a kind of emotional, perceptual and practical experience of the other person as sharing the world with me. Ratcliffe engages with philosophers such as Edmund Husserl and Jean-Paul Sartre to make his points, but the phenomenologist who has arguably done most to develop a theory of existential and social moods is Martin Heidegger (1927/1996). Lou Agosta takes off from Being and Time, in which Heidegger mentions the possibility of developing a ‘‘hermeneutics of empathy,’’ and tries to fill out the lacunas in Heidegger’s phenomenology of intersubjectivity and authenticity by developing his phenomenology of human being (Dasein) as being-in-the-world further and marrying it to ideas found in various schools of psychotherapy (Agosta 2014). The account Agosta is developing not only attempts to find an alternative to the dualistic version of communicating minds; it also explicitly introduces the normative dimension: what does it mean to be together with the other in a way that takes care of his existence? In his contribution Agosta distinguishes the unified multidimensional process of what he calls empathic receptivity, empathic understanding, empathic interpretation, and empathic speech. This brings us back to the second question I mentioned above as central for
247
the contemporary empathy debate: How do I come to feel concern for the other (and not only understand him)? At this point we arrive at the ways in which empathy is central for our understanding of good medical practice in contrast to the ways in which medical research and practice can influence our understanding of empathy (the mutual influence I started out with above). We arrive in medical ethics and the role that empathy plays in this territory. Empathy is a thing constantly asked for and stressed as a central skill and character trait of the good physician and nurse. To be a good doctor (or other health-care professional) one needs to be empathic—one needs to be able to feel and understand the needs and wishes of patients in order to help them in the best possible way, in a medical, as well as in an ethical sense. The problem with most studies of what role empathy plays in medical practice and ethics is that empathy is poorly defined and tends to overlap with other related things, such as emotional contagion, sympathy, or a caring personality in general (Pedersen 2010). It is far from clear how empathy fits into the general picture of medical ethics and the framework of norms and principles that are most often stressed there, such as respect for autonomy and beneficence. How does empathy attain moral importance in medicine? Fredrik Svenaeus, in his contribution, tries to show that a comparison with the Aristotelian concept of phronesis— practical wisdom—makes it easier to see what empathy in medicine means and how it fits into the general picture of medical ethics (Svenaeus 2014). Empathy, he argues, is a basic condition and source of moral knowledge by being the feeling component of phronesis, and, by the same power, it is also a motivation for acting in an ethical way. Svenaeus’s analysis is phenomenological by picking up on the idea found in the philosophers mentioned above—Scheler, Husserl, Stein, Heidegger, Sartre and Merleau-Ponty— that empathy is basically a way of presenting the other person and his sufferings to me, rather than forming any hypotheses or imaginations about them (Zahavi 2010). Empathy in medicine is an emotional account of the patient that makes it possible to see how and why he is suffering and there by making way for ethical decisions and actions being formed and taken by the doctor or other health-care professionals. Empathy may include explicit hypotheses and attempts to imagine what things are like for the other person, but it starts out in feeling the predicament of the other and presenting it to me as an issue to be dealt with. In accordance with such a model of emotional and cognitive empathy as mutually supportive, Jodi Halpern, in the last of the contributions building up the present thematic section, develops her theory about empathy in medicine as a form of engaged curiosity on part of the health care professional in contrast to a detached concern (Halpern 2001, 2014). Halpern stresses how empathy must be thought about as a mutual engagement of professional and patient. Empathy
123
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in medicine is sustained through a dialogue which can be developed if there is mutual trust between the parties (and sufficient time to feel, think and talk together). This is also how empathy should be studied in medicine and medical ethics: through paying attention to and investigating real life scenarios, instead of merely filling out empathy questionnaires or doing experiments in the empathy lab with brain scanners. It is hard to define, as well as live up to, a concept that is held in such a high esteem as empathy. In the section of her paper called ‘‘Dispelling myths and misunderstandings to help physicians sustain empathy’’ Halpern gives some practical advice and points out what empathy in fact is not (Halpern 2014). To be empathic is not the same thing as being nice or agreeing with everything that the patient says or wants. Nor does it mean never to feel negative feelings towards patients. The empathic doctor is not necessarily the doctor that always knows how and what to respond. The important thing is that he responds maybe merely by repeating what the patient just has said. Empathy is about seeing, understanding and caring for the other person, but it is also about the feeling of being seen. Patients who feel that their doctors care for them and attempt to understand and help them will often be satisfied even if there is nothing to be done, or even if the doctor does not do the right thing for them. This is a clear proof of how powerful the feelings of empathy (and the lack thereof) and the dialogues between persons that empathy enables (or precludes) in medicine are.
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