Besides the value of health or wellbeing and the disvalue of disease or illness, as well as besides the normative ethical theories and the four principles that under gird contemporary bioethical principlism, modern medical knowledge and practice are influenced by two chief values that inform the ethical or moral stance or attitude of physicians-emotionally detached concern and empathic care. For the biomedical practitioner, the chief value is emotionally detached concern. "People enter medicine," according to Manish Raiji, "out of concern for the sick and, for the more ambitious of them, the betterment of society as a whole" (2006, p. 295, emphasis added). Certainly the biomedical practitioner is concerned about the patient's diseased state, but from a detached-particularly from the patient's and physician's-emotional state. Emotions are viewed as detrimental to the practice of scientific medicine, just as they are for the practice of natural science. For the humanistic or humane practitioner, however, scientific medicine is embedded within empathic care that includes the patient's and the physician's emotional state.
Warren Reich reconstructs the distinction between emotionally detached concern and empathic care in terms of two radically different meanings of care: "In the context of healthcare, the idea of care has two principal meanings: (1) taking care of the sick person, which emphasizes the delivery of technical care; and (2) caring for or caring about the sick person, which suggests a virtue of devotion and concern for the other as a person" (2004a, p. 361). "Taking care of' refers to the physician's technical competence sans emotional engagement. It is a concern for the objective clinical data pertaining to the patient's diseased state and is often reduced to a legal minimum of "due care" (Reich, 2004a). "Caring for," however, includes an empathic or emotional engagement as a critical component of medical practice. It involves altruistic values and is part of the moral structure that under girds humanistic medical knowledge and practice (Reich, 2004a). In this chapter the emotionally detached concern of the biomedical model ("taking care of') is explored initially followed by contemporary challenges from humanistic practitioners in terms of empathic care ("caring for"), especially with respect to an ethic of care.
14.1 Emotionally Detached Concern
In an essay entitled "From the heart," Rachel Remen recounts the story of a first year medical student who suddenly collapsed and died from a congenital heart defect, while playing basketball. The following year the student's heart was used in a pathology teaching lab at the medical school he attended to illustrate the defect. One of the medical students realized whose heart the students were examining and as she "looked out of the corner of her eye. No one around her seemed to react. All her classmates wore expressions of detached scientific interest" (Remen, 2002, p. 93).
Remen then expounds upon the professional mask or gaze a physician wears in order to practice his or her trade. That gaze is meant to protect the physician from the emotional turmoil that medicine brings on a daily basis. "Medical training instills," concludes Remen, "a certain scientific objectivity or distance... In particular, the perspective of the heart is seen as unprofessional or even dangerous" (2002, p. 93). The biomedical model is predicated upon the value of emotionally detached concern, which has been chiefly responsible for the current quality-of-care crisis in modern medicine.
In the early to mid twentieth century, medical practitioners and educators subscribed to a notion that in order for physicians to apply their trade they must not allow the patient's or their emotions to interfere. A physician's technical competence must be severed from sympathetic care. For example, Richard Cabot (1926) championed this view, arguing that physicians should attend to the body and specifically to the diseased body part. Rather than emotional attachment to the patient, Cabot claimed that the chiefs of medicine model "the `technique' of courtesy to most unpromising old wrecks of humanity" (1926, p. 26).
Cabot illustrated this ethical ideal of courtesy with a clinical encounter between one of his chiefs and a female patient. "He [the chief] brought the atmosphere of a summer garden," as Cabot narrated the encounter, "to meet this miasmic fog [the patient]. The fog did not yield. The women showed no slightest appreciation of his kindness, no melting of her scorn. But," Cabot related triumphally, "he carried through the interview as he had begun it and still bowed and smiled to her oblivious back as she stumbled sullenly away" (1926, p. 32). For Cabot, ethics, if it has any import for the physician's behavior in a clinical encounter, is ruled by an ethical code of conduct.
In the early twentieth century, emotionally detached concern was heralded as a critical component of medicine's social structure, especially in terms of the patientphysician relationship. Lawrence Henderson, Talcott Parson, and Renee Fox each explicated its position within medicine's social structure. Henderson, a well known physiologist, argued that medicine-although an applied science-was still practiced in terms of its social structure as it was from Hippocratic times. He suggested a new theory for the patient-physician relationship based on an analogy to Willard Gibbs' physico-chemical systems. Recognizing the danger of sentiment or emotions in social systems like medicine, Henderson proposed the following "rule of conduct: The physician should see to it that the patient's sentiments do not act upon his sentiments and, above all, do not thereby modify his behavior, and he should endeavor to act upon the patient's sentiments according to a well-considered plan" (1935, p. 821).
Henderson also counseled physicians to beware of their own feelings and emotions, since they are likely to be "harmful" and "irrelevant" to the patient's care. The physician should "try to do as little harm as possible, not only in treatment with drugs, or with the knife, but also in treatment with words, with expression of your own sentiments and emotions. Try at all times," Henderson admonished, "to act upon the patient so as to modify his sentiments to his own advantage, and remember that, to this end, nothing is more effective than arousing in him the belief that you are concerned whole-heartedly and exclusively for his welfare" (1935, p. 823).
Parsons (1951) conducted one of the first modern social analyses of the medical system, especially in terms of a patient's "sick role" and a physician's response to it. That response was structured in terms of four features that guide the physician's behavior in treating the patient. These features constitute a structure that permits the physician to access "the `particular nexus' of his patients to perform his function" (Parsons, 1951, p. 459). They include "universal achievement" (the medical knowledge general applicable to all medical practitioners), "functional specificity" (technical specialties), and "collectively-orientation" (social consensus concerning altruistic behavior) (Parsons, 1951, pp. 454-465).
The final feature, "affective neutrality," was germane to a physician's emotional response. "The physician," according to Parsons, "is expected to treat an objective problem in objective, scientifically justifiable terms. For example," he claimed, "whether he likes or dislikes the particular patient as a person is supposed to be irrelevant, as indeed it is to most purely objective problems of how to handle a particular disease" (1951, p. 435). The emotional needs of the patient should be the patient's responsibility and his or her family's, but not the physician's. The notion of affective neutrality, then, "is a critical distancing reaction which prevents the practitioner from entering too sympathetically into the patient's situation. The doctor is expected to be neutral in judgment and to exercise emotional control" (Ford et al., 1967, p. 3).
Fox employed Parson's notion of affective neutrality to interpret evidence obtained from a sociological study on patient-physician interactions at a research hospital, in which experimental treatment protocols were used to treat patients. She utilized the terms "detachment" and "concern" to describe the tension the physician faces in medical practice. "In the `emotional aspects' of his relationship with the patient," concluded Fox, "the physician is expected to maintain a dynamic balance between attitudes of `detachment' and `concern.' He is expected," she continued, "to be sufficiently detached or objective toward the patient to exercise sound medical judgment and maintain his equanimity. He is also expected to be sufficiently concerned about the welfare of the patient to give him compassionate care" (quoted in Ford et al., 1967, p. 4).
Later, in association with Howard Lief, Fox introduced in a well known article, "Training for `detached concern' in medical students," the phrase "detached concern" and described the program or process by which medical students are taught to detach themselves from emotional involvement with patients (Lief and Fox, 1963). As generally acknowledged, most medical students enter medical school with a deep sense of concern for wanting to help people. During the process of becoming a physician, however, they are taught to distance themselves from normal emotional responses to patient's disease and death.
One of the first steps towards detachment occurs in gross anatomy. There are several mechanisms used during dissection of cadavers, almost unconsciously, to strip students of normal emotional responses in the face of a dead human being. The most profound or interesting one is to name the cadaver. At the time of their study names such as "Elmer" and "Bones" were popular, whereas for a previous generation of medical students "Hitler" and "Mussolini" were popular. The naming of cadavers "helped to reduce guilt derived from unconscious fantasies of defiling the body, albeit a dead one, of a human being" (Lief and Fox, 1963, p. 18). Naming is also an important mechanism for residents and other hospital staff when dealing with patients. For example, older patients who are quite ill and helpless are often referred to as "gomers" (George and Dundes, 1978; Leiderman and Grisso, 1985).
Emotionally detached concern was in response or reaction to the value of sympathy, in which the physicians and their emotions, as well as the patients and their emotions, were an integral part of medical knowledge and practice. The sympathetic physician was the standard from Hippocrates to nineteenth physicians such as Worthington Hooker: "Within the trajectory of medical thought from Hippocrates to Hooker, the physician's special tolerance of emotions enables an emotional understanding of patients that enhances his reliability and effectiveness" (Halpern, 2001, p. 21).
Sympathy was to some extent an occult force that the physician commanded for treating the patient. The underpinning of this force was a blind emotional response to the patient's pain and suffering. Although it was a morally admirable response it was generally ineffectual and often caused more harm than good. In addition, "Victorian culture steadily sentimentalized, feminized, and marginalized sympathy's connotative meaning, while at the same time the term was slowly devalued within medicine's scientific and professional discourse" (More, 1994, p. 20). By the beginning of the twentieth century to be sympathetic was to be unscientific.
In response to the abuse of sympathy, physicians proposed a chastened form of empathy that was stripped of its blind emotivism or at least a form of empathy in which the physician was cognizant of the patient's emotional state and especially the problems associated with it (Halpern, 2001; More, 1994). For example, in a well known and influential 1958 JAMA article Charles Aring distinguished between sympathy, which often hinders the physician's effectiveness in treating a patient, and empathy, which enhances that effectiveness. Drawing on a "good dictionary," Aring defined sympathy as "an affinity, association, or relationship so that whatever affects one, similarly affects the other" (1958, p. 449). He gave the illustration of a "provocative" patient who questions the physician's competence because of deep seated emotional issues, to which the physician unfortunately responds in kind.
In contrast, Aring proposed a notion of empathy, although similar to that of sympathy in terms of the physician's "appreciation" of a patient's emotional state, in which the physician remains detached yet interested. What is at issue for the physician is not to become incapacitated by the problems arising from a patient's emotional state. "The patient," counseled Aring, "should be allowed his own problems without a need to partake of them" (1958, p. 449). In other words, the physician must endeavor to remain separate from these problems in order to be effective in treating the patient. "A subtle and significant feature of a happy medical practice," concluded Aring, "is to remain unencumbered by the patient's problems" (1958, p. 452). The key to empathy is the physician's reflection upon his or her own emotional constitution based on personal experiences and to apply an intellectualized form of that reflective process in addressing the patient's emotional needs or state.
Hermann Blumgart (1964) claimed that Aring's notion for the appreciation of the patient's emotional state is denoted, in medical circles, as "neutral empathy." Blumgart, however, deemed that "compassionate detachment" is a better or more accurate description of Aring's notion. The influence of Aring's notion cannot be understated. For example, Blumgart related a personal encounter during his final year in medical school. He was assigned a patient suffering from Addison's disease and recommended surgical drainage for an abscessed tooth. His instructor, William Smith, pointed out that there is a very good chance that the patient could die from the drainage procedure and asked Blumgart how he felt about a patient dying under such conditions. Blumgart responded he would "feel very bad"
Well then, [Smith said] you ought to leave medical school this instant and abandon the profession of medicine. If after giving all of your time and energy, and to the very best of your ability having weighed the risks and benefits, you grieve over ill fortune, your life will be tormented by the past, and you will be of little use to your patients in the present or to yourself in the future. To each and every patient you must give your best-and, having done so, you must accept with equanimity bad fortune as well as good. Unless you learn this, you had better not be a doctor (1964, p. 451).
The emotional detachment necessary for the practice medicine was a lesson Blumgart never forgot.'
One of the main assumptions of emotionally detached concern is objectivity or neutrality towards the patient's-and physician's-emotional state. "The model of detached concern," according to Halpern, "presupposes that knowing how the patient feels is no different from knowing that the patient is in a certain emotional state" (2003, p. 670). Objectivity in medical practice was a result historically of Osler's model of equanimity: "Osler denied that physicians' effectiveness depends upon emotional engagement with patients" (Halpern, 2001, p. 22).
Osler, in an 1889 valedictory address at the University of Pennsylvania, "Aequanimitas," argued that physicians must detach from their own emotions to the patient's condition in order to evaluate properly the patient. He identified two virtues for clinical success. The first was the physical or bodily virtue of "imperturbability," which he took to mean "coolness and presence of mind under all circumstances, calmness amid the storm, clearness of judgment in moments of grave peril, immobility, impassiveness" (Osler, 1943, p. 4). The mental virtue was equanimity, which allows the physician "to bear with composure the misfortunes of our neighbours" (Osler, 1943, p. 7).2According to Halpern, "Osler's rhetoric promotes the idea that detachment serves rationality... No meaningful way exists to compare emotional perspectives for their accuracy or appropriateness to a person's circumstances, because the only reliable facts about humans are objective facts about bodies as things" (2001, p. 24).
Under the biomedical model of contemporary medical knowledge and practice, the physician's concern for the patient's body and its parts is detached from the emotions of either the patient or physician: "modern medicine has now evolved to the point where diagnostic judgments based on `subjective' evidence-the patient's sensations and the physician's own observations of the patient-are being supplanted by judgments based on `objective' evidence, provided by laboratory procedures and by mechanical and electronic devices" (Reiser, 1978, p. ix). The notion of detached concern satisfies the necessity on the part of physicians to be engaged with the patient's physical needs but only in a concerned fashion. "The model of `detached concern' thus acknowledged the need for effective and compassionate communication," opines Ellen More, "without sacrificing the profession's claims to neutrality and objectivity. Patient and professional remained two `separate' parties" (1994, p. 31).
There are a number of reasons why the medical profession excluded emotions from the practice of medicine, in terms of detached concern or a chastened form of empathy. Halpern (2001) identified four of them. The first is that physicians must often perform difficult and painful procedures that take a toll on the physician's emotions. A mask of emotionally detached concern protects the physician from the emotional pain of these encounters. Another reason is that emotionally detached concern protects the physician from burnout, especially emotional burnout. Next, emotionally detached concern allows the physician to distribute healthcare fairly and equally to patients without preference for one or another based on feelings and especially given the time constraints of managed care. Emotionally detached concern then ensures impartiality.
The most important reason, according to Halpern, is that emotions are too subjective and thereby interfere with the correct or accurate diagnosis or treatment of the patient. The gaze of emotionally detached concern "enables doctors to understand their patients' emotional experiences accurately, free from their own emotional bias" (Halpern, 2001, p. 17). More identified another reason in terms of gender: a chastened empathy provides "an interactive but fundamentally detached relationship that did not threaten the roles, values, or personal security of a male-gendered professionalism" (1994, p. 31).
Finally, how is concern a value? Concern is a powerful basic or primitive value of one human being's apprehension for the state or plight of another. It motivates people to act and often heroically for the better or enhancement of others. As noted already many, if not most, medical students enter medical school with the profound sense of concern for helping patients. Unfortunately, given the age and developmental stage of most medical students this native concern for the welfare of others is underdeveloped and students are unable to sustain it in the face of the medical school's indoctrination process. Instead of fostering and nurturing this native concern, medical school programs strangle its emotive component to reduce it to a bland and scientific concern for curing the patient's disease. For example, "hazing, strange-making, and symbolic inversion" are effective means by which medical students and residents are stripped of their native empathy for a patient's suffering (Davis-Floyd and St. John, 1998, p. 51).
14.2 Empathic Care
As others before her, Halpern palpated an essential tension in the practice of medicine: "On the one hand, doctors strive for detachment to reliably care for all patients regardless of their personal feeling. Yet patients want genuine empathy from doctors and doctors want to provide it" (2003, p. 670). The tension remains unresolved because the medical profession values emotionally detached concern or a chastened or masculinized form of empathy over genuine or authentic empathic care. No single factor is more responsible for the qualityof-care crisis in contemporary medicine than the value of emotionally detached concern.
As Walter Menninger acknowledged some time ago, many physicians are competent in medical technology but incompetent in people skills. "There are numerous examples," according to Menninger, "who are absolutely superb technicians, with all the latest knowledge and skill, but who approach patients in such a cold manner as to prompt doubt and distress" (1975, p. 837). To resolve the problem, he recommended emotional attachment to the patient.
Today, there is a movement, especially with respect to humanistic or humane models of medical knowledge and practice, to establish genuine empathic care in medicine. "Detached concern," according to William McMillan, "doesn't cut it anymore. Patients don't care how much you know until they know how much you care" (1996, p. 223). There are two dimensions to this movement. The first is the introduction and redefining of the notion of empathy, which is discussed in the first section. The second is the development of the ethic of care, especially by feminists and others, which is explored in the final section.
Although emotionally detached concern is a predominate value for the biomedical model, Remen, from her own clinical practice, stresses that it is actually dangerous for clinical medicine: "I found that abandoning my humanity in order to become a service made me vulnerable to burnout, cynicism, numbness, loneliness, and depression"-all of the problems from which detached concern is supposed to protect the physician (2002, p. 93). The mask of professional detachment is not only bad for the physician but also for treating patients and is one of the prevalent reasons for contemporary medicine's quality-of-care crisis. The core of medicine is not emotionally detached concern but an empathic care or compassion for the other. "The heart," according to Remen, "has the power to transform experience" (2002, p. 93). In other words, physicians must connect with rather than detach from their patients, especially their emotional states in order to provide genuine healing-i.e. to transform brokenness and illness into wholeness and healing.
Halpern also questions whether emotionally detached concern or an empathy that is detached or at best simply appreciative of the patient's emotional state is appropriate for clinical medicine. Detached concern leads to errors in medicine from a patient's-or even a physician's-emotional irrationality. These errors result in distortions of the medical worldview for both patient and physician. Halpern cites a clinical case involving a woman who lost all hope after a second amputation from complications associated with diabetes and kidney failure and from her husband's abandonment. The patient refused treatment because of the depression brought on by her situation and her medical team respected her decision. However, in the past the patient experienced depression but through medical intervention overcame it. She died shortly thereafter.
Halpern insists that both the patient and the medical team, in an effort to practice good, ethical medicine, failed to address the patient's-as well as their-irrational fears. "Detachment," opines Halpern, "does not make medicine more rational; rather, it forces irrationality underground, where it poses as certainty about the future and irrational assumptions. Detachment is a poor strategy," she maintains, "either to help patients overcome emotional irrationality or to help physicians detect both their own and their patients' emotional irrationality" (2001, p. 29). She contends that empathy is the cure for these errors of emotional irrationality occasioned or fostered by detachment.
Empathy, indeed, has become a rallying point for some medical professionals to reshape the emotionally detached clinical gaze and to reconnect the patient and physician, especially at an emotional level. The term is derived from Einfuhlung, coined by Robert Vischer (1847-1933) and used by others such as Theodor Lipps (1851-1914) in late nineteenth-century German aesthetics to describe the process of projecting oneself into an object of beauty (Halpern, 2001; Katz, 1963; More, 1994; Peitchinis, 1990; Wispd, 1987). In his 1909 Lectures on the Experimental Psychology of the Though Processes, Edward Titchener (1867-1927) adapted the term for psychology and used the Greek term empatheia to translate it into the English term "empathy"-em for "into" and pathos for "feeling." However, the term changed meanings for Titchener during his career. "In the beginning (1909)," according to Wispe, "it represented an amalgamation of visual and muscular/kinesthetic imagery (after Lipps) by which certain kinds of experiences were possible. Later (1915) it became a feeling, or projecting, of one's self into an object, and its implications were more social. It was a way to `humanize our surrounding' " (1987, p. 23).
Since Titchener there have been a variety of definitions proposed for empathy. For example, Howard Spiro defines empathy as "a feeling that persons or objects arouse in us as projections of our feelings and thoughts. It is evident when `I and you' becomes `I am you,' or at least `I might be you"' (1993a, p. 7). Ervin Staub defines empathy in general terms as "apprehending another's inner world and joining the other in his or her feelings" (1987, p. 104). Mark Barnett defines it as "the vicarious experiencing of an emotion that is congruent with, but not necessarily identical to, the emotion of another individual" (1987, p. 146). David Berger defines it in terms of psychoanalytic therapy as "an intrapsychic process in the therapist by which an understanding of the patient, particularly an emotional understanding, a capacity to feel what the other is feeling, is enhanced" (1987, p. 8). Finally, Robert Katz claims that empathy takes on different dimensions depending on the discipline in which it is used: "[its connotation] in biology as a form of instinctive reverberation, its definition in psychoanalytic theory as a form of identification, its equation in social psychology with experimental roleplaying and in sociology as mutual understanding among members of the same in-group" (1963, p. 2).
Although there are a variety of definitions for empathy, there are common features by which to classify them. For example, Nancy Eisenberg and Janet Strayer (1987) identified two such features. The first and primary feature is affective. Almost all definitions of empathy include sharing of the emotions between the empathizer and the empathizee: "an emotional response that stems from another's emotional state or condition and that is congruent with the other's emotional state or situation" (Eisenberg and Strayer, 1987, p. 5). The second feature is cognitive in nature. They cited Wispe to illustrate this feature, who, in turn, quoted Heinz Kohut: "empathy is the `mode' of cognition which is specifically attuned to the perception of complex psychological configurations"' (Wispe, 1987, p. 30).
Ruth MacKay (1990) distinguished three features or ways to categorize empathy. The first is in terms of behavioral response to the suffering of another, whether observed or perceived. She quoted S.K. Valle: "Empathy is the ability to respond to the feelings and reasons for the feelings the patient is experiencing in a manner that communicates an understanding of the patient" (MacKay, 1990, p. 9). The next way of categorizing empathy is in terms of a person's personality. Here she quoted G.L. Forsyth to illustrate this type of empathy: "Empathic individuals are those who posses keen insight, imaginative perceptiveness and social acuity about other persons" (MacKay, 1990, p. 6). Finally, MacKay (1990) noted those definitions that use "experienced emotion," in which the helper recognizes and responds to the helpee on the level of feeling.
Staub (1987) provided one of the most comprehensive classifications of empathy. The more basic category, in terms of being a precondition for the other categories, is cognitive empathy. According to Staub, cognitive empathy is "an awareness, an understanding, a knowing of another's state or condition or consciousness, or how another might be affected by something that is happening to him or her" (1987, p. 104). The second category is participatory empathy, which is a more general form of empathy in terms of everyday experience. Participatory empathy begins with cognitive empathy but soon transcends it. "A person," claimed Straub, "enters the world of another, tunes in to the other, feels with the other, participates in the other's ongoing experience, but usually without strong emotional or intense feeling of his or her own" (1987, p. 105). The next category, affective empathy, does involve these emotions and feelings. However, the experience of the emotions and feelings is not direct but vicarious. The final category is empathic joining in which the emotions and feelings are not vicarious but mutual. According to Staub, empathic joining is "a sharing of emotion, not in a participatory way, by entering another's experience, but by the other's experience generating the same experience in oneself' (1987, p. 107).
The development of empathy within a person is seen as the outcome of a multi-step process rather than a result from a single event or feeling. For example, Theodore Reik (1948) identified four steps in the process of empathizing with another. The first is identification, in which the empathizer recognizes the need of the empathizee. The next step is incorporation, in which the empathizer internalizes the emotional state of the empathizee and makes it his or her own. The third step is reverberation, in which the empathizer then responds to the empathizee's emotional state. The final step is detachment, in which the empathizer retreats from fusion with the empathizee in order to comprehend fully the empathizee's emotional condition.
Jochanan Benbassat and Reuben Baumal (2004), on the other hand, have recently proposed only three steps. The first is insight into the patient's emotional state. The next step is then engagement, which produces compassion for the patient's situation and a desire to intervene on the behalf of the patient. These three steps are similar to Reik's first three, with the exclusion of Reik's final step of detachment. James Marcia (1987), however, used Reik's steps for appropriating empathy in medicine and keeps the final step in order to maintain a distinction between the emotional state of both the therapist and patient.
In the literature, there has been some confusion over the distinction between sympathy and empathy, given their respective histories, and there have been several attempts to distinguish between them (Eisenberg and Strayer, 1987; Katz, 1963; MacKay, 1990; More, 1994; Spiro, 1993a, b; Wispd, 1986). For example, Katz demarcated between empathy and sympathy based on their respective purposes: "Practitioners of empathy are committed to objective knowledge of other personalities. If we use our own feelings, it is for the purpose of learning more about what actually belongs to the other person. But we do not exercise our own feelings," argued Katz, "to gratify our needs. When we sympathize, we are aware of our own state of mind and much of our attention is still devoted to our own needs. When we empathize we cannot fully escape our own needs but we discipline ourselves to use our feelings as instruments of cognition" (1963, pp. 8-9).
Wispe also distinguished between empathy and sympathy: "In empathy, the empathizer `reaches out' for the other person. In sympathy, the sympathizer is `moved by' the other person... The object of empathy is to `understand' the other person. The object of sympathy is the other person's `well being'... In brief, empathy is a way of `knowing' Sympathy is a way of `relating"' (Wispe, 1986, p. 318). Finally, Spiro noted the following distinction between empathy and sympathy: "Sympathy brings compassion, `I want to help you,' but empathy brings emotion. Without feeling there is no empathy" (1993a, p. 2). In other words, according to Spiro, empathy involves "passion" The role of empathy is to restore this passion that equanimity and its associated technology displaces in favor of emotionally detached concern. "Computer tomographic scans offer no compassion," observed Spiro, "and magnetic resonance imaging has no human face. Only men and women," he concluded, "are capable of empathy" (1993b, p. 14).
Halpern (2001), in particular, has recently argued for a clinical empathy that is based on an emotional reasoning in which the physician "resonates" with and "imagines" the "how" of the patient's emotional state. There is a cognitive dimension to empathy that allows a person to understand the object of empathy. It is "the power of projecting one's personality into the object of contemplation, and so fully understanding it" (Selzer, 1993, p. ix).3
According to Halpern, there are four facets to emotional reasoning. The first is "associational linking," in which "the empathetic physician relies on her capacity to associate in order to link to the patient's images and ideas" (Halpern, 2001, p. 41). The next facet of emotional reasoning is "gut feelings," which are the spontaneous emotions that are pre-cognitive in nature. These feelings serve a heuristic not a confirmatory function in medical knowledge and practice. The third facet is "emotional inertia." Rather than being spontaneous these emotions have a history behind them and serve to help the physician imagine a patient's emotional state. The final facet is "moods and temperament," which provide the background or context in which the physician and patient operate in his or her world. Importantly, this emotional reasoning is "pre-logical" in that it serves a heuristic or strategic function by guiding a physician in obtaining important affective information about a patient, which has a significant impact on a patient's illness experience.
Based on this notion of emotional reasoning, Halpern (2001) proposes an alternative conception of empathy to that of its chastened or masculinized form or affective melting. This type of empathy allows the physician to resonate with the patient's emotional state. "Resonance," Halpern explains, "is extremely helpful for empathy because it provides a coordinated emotional context between speaker and listener" (2001, p. 92). Such a context allows a physician to imagine how or why a patient feels the way he or she does about being ill.
Halpern provides a case illustration of an older male patient who was a successful business person and a family patriarch. The patient was suffering from a neurological disease, which left him a quadriplegic and dependent upon a respirator. In Halpern's first clinical encounter with the patient, she approached him with sympathy and pity. The patient did not respond. In an attempt to resonant with the patient and to imagine what the disease meant to the patient, she suddenly realized the anger, fear, and shame the patient must be experiencing. She then approached the patient from this perspective and found him responsive. "In empathy," concludes Halpern, "emotional resonance can set the tone, but imagination work must be done to unify the details and nuances of the patient's life into an integrated affective experience" (2001, p. 88).4
Empathy then supplements or complements the clinical objective knowledge to yield a complete or holistic picture of the patient: "Empathic communication enables patients to talk about stigmatized issues that relate to their health that might otherwise never be disclosed, thus leading to a fuller understanding of patients' illness experiences, health habits, psychological needs, and social situations" (Halpern, 2001, p. 94).
As noted earlier, More expounds upon the masculinization of empathy during the twentieth century, to fill the gap left by the feminization of sympathy. "Our task," she claims, "is to reclaim the validity of empathy as intersubjective knowledge without simultaneously marginalizing it" (More, 1994, p. 33). To that end she proposes a "relational" model for empathy, especially in terms of hermeneutic practice. This practice involves a "reflexive interpretation" in which there is "a constant oscillation back and forth between observation of the patient, and of ourselves, allying imagination, emotion, memory and cognition in the service of informed understanding" (More, 1996, pp. 244-245). Through this process the physician comes to a "relational knowledge" that is empathic.
"The empathic physician," according to More, "is neither objective nor subjective, neither detached nor identified, but dialogically linked to the patient in a continuing cycle of reflexive interpretation that integrates the objective and subjective" (1996, p. 245). The consequence is that a physician is not distant from a patient but present empathically. For many humanistic or humane practitioners and for a number of feminists, the relational dimensions of genuine and authentic empathy are advanced by modification of traditional notions of caring and by a contemporary ethic of care.
The notion of caring has deep roots within western thought, especially as it relates to medicine and general wellbeing. Reich (2004b) has identified two main trunks to its roots. The first is the "Cora" myth of Greco-Roman origin. Briefly, the deity Cura fashioned human beings from Earth and solicited the deity Jupiter to enliven them. Because Cura and Jupiter could not agree on the appropriate name for these beings, Saturn intervened. Upon death the human spirit returns to Jupiter, while the human body to the Earth. While alive, however, humans are the under the solicitous care of Cura. "The lifelong care of the human that would be undertaken by Cura," according to Reich, "entails both an earthly, bodily element that is pulled down to the ground (worry) and a spirit-element that strives upward to the divine" (2004b, p. 350).
The Cara myth reflects the tension that exists in the traditional meanings of care: care as worry or burden and care as concern over or devotion to the welfare of another. The main lesson of the myth is that the very heart of what it means to be human is to care and to be cared for. "Indeed," notes Reich, "the Myth of Care presents an allegorical image of human kind in which the most notable characteristic of the origins, life, and destiny of humans is that they are cared for" (2004b, p. 350).
The second trunk of the root of caring within western thought is the "care of souls" tradition. According to Reich (2004b), the notion of soul has a variety of meanings in the tradition. Predominantly, however, it refers not simply to any one dimension like the spiritual but to the entire human person or to "the essence of human personality. It is related to the human body, but it is not a mere expression or function of bodily life. It is capable of vast ranges of experience and susceptible to disorder and anguish" (McNeill, 1951, p. vii). The notion of caring is also multidimensional and complex: "The word care in the care of souls refers both to the tasks involved in the care of a person or group and to the inner experience of solicitude or carefulness concerning the object of one's care" (Reich, 2004b, p. 351).
There are then two orientations in the "care of souls" tradition. The first is inward and is concerned about caring for one's individual soul. The second is towards other souls, especially their suffering and relief. The care of souls pertains to those therapeutic interventions that lead to or promote healing and wholeness. "Man is a seeker of health," according to John McNeill, "but not health of the body alone. Health of the body may be contributory to," he added, "but it does not guarantee, health of personality... The health that is ultimately sought is not something to be secured by material means alone; it is the well-being of the soul" (1951, p. vii).
Through the centuries, caring has been a critical element in medical practice. Care and cure were often on opposite sides of the same clinical coin. "Nominally," according to Joel Howell, "health care providers have always been charged with caring for those to whom they minister. For such providers, caring has at times been part of a larger set of professional responsibilities" (2001, p. 77). Often in medical history, caring was all that was available for physicians. Medical knowledge and practice prior to the nineteenth century promoted caring relationships between patients and physicians: "Each person was unique, each person's temperament would play a key role not only in making the diagnosis but also in guiding the hand of the physician in recommending appropriate therapy" (Howell, 2001, p. 83).
Although knowing and caring for the patient originally went hand in hand, during the latter part of the nineteenth and the early part of the twentieth centuries theories of disease causation and medical technology began to equip a physician with more than a caring touch or attitude. Caring became equated with curing, such that the traditional notion of caring was eclipsed by the miraculous cures of scientific medicine. Old fashion caring was now obsolete and eclipsed by scientific curing.
Francis Peabody responded to this trend in the 1927 Gay lecture at Harvard Medical School, claiming that the secret of caring for a patient is to care for a patient. Such caring, according to Peabody, is two dimensional. The first is a technical dimension in that the physician must know the latest scientific advances and techniques applicable for diagnosis and therapy. The second is a humanistic or humane dimension. The physician must attend to the emotional and personal needs or concerns of the patient. "The treatment of a disease may be entirely impersonal;" however for Peabody, "the care of the patient must be completely personal" (1984, p. 814). That humane dimension involves attention to the whole person rather than simply to the patient's diseased part.
"What is spoken as a `clinical picture' is not just a photograph of a man sick in bed;" according to Peabody, "it is an impressionistic painting of the patient surrounded by his home, his work, his relations, his friends, his joys, sorrows, hopes and fears" (1984, p. 814).1 A critical element of that impressionistic picture is the emotional state of the patient. Illness produces considerable angst for the patient and must be attended to in order to heal the whole person. Moreover, for about half of patients Peabody and his colleagues treated there was no organic basis for their disease but only an emotional or a psychological basis. In a final section to his paper-"Importance of personal relationship"-Peabody concluded that "the physician who attempts to take care of a patient while he neglects [the patient's emotional life] is as unscientific as the investigator who neglects to control all the conditions that may affect his experiment... for the secret of the care of the patient is in caring for the patient" (1984, p. 818).
Peabody's influence was considerable but was not wholly appreciated until another generation arose who witnessed the inhumane effects of scientific medicine that resulted in today's quality-of-care crisis. For example, Menninger drew upon Peabody's charge to care for the patient as a supplement for the detached concern of technical medicine, by including the emotional condition of the patient: "caring implies more than perfunctory concern. It implies a broader concern for the whole patient, rather than just the patient's disease" (1975, p. 836).6
Cassell, in particular, has made caring for the patient's suffering one of the chief goals-if not the chief goal-of medicine: "Everything the doctor sees of that person is directly relevant to his or her care of that person-and there is much to be seen that can be seen by those who care. What Francis Peabody said so many years ago as a moral precept for physicians finally becomes a fundamental necessity of medicine: `The secret of the care of the patient is caring for the patient"' (1991, p. 155). In sum, Peabody's approach to care was best articulated accordingly: "This sort of care requires attentiveness and alertness to what kind of person the patient is; sympathy for the patient's total situation; friendliness that elicits trust; and a consideration expressed in `little incidental' actions that assure the patient's confidence" (Reich, 2004a, p. 364).
Gary Benfield (1979) identified two types of caring in medical practice, especially with relationship to critical-care patients. The first is disease-oriented care, which focuses on the care of the patient's diseased part. This type of care is based on a philosophy in which " `life' is all that matters" (Benfield, 1979, p. 509). Death is seen as the enemy and is to be avoided at all costs. Care is wrapped up with technical competence, such that "some physicians may feel that they are trained to treat, to cure at all costs, rather than practice a more humanitarian approach to the art of healing" (Benfield, 1979, p. 509). In contrast, a personoriented care and its humanitarian approach concentrate on "the needs of the individual patient" (Benfield, 1979, p. 508). The basis of this care is a philosophy of the "quality of life."
Benfield contrasted the two types of care in several clinical case histories. Disease-oriented care is illustrated with the case of a middle aged male who was comatose after an automobile accident. The physician did not communicate effectively either with the family or the nursing staff concerning the patient's prognosis, other than it is not good. Person-oriented care is illustrated with a case in which the parents of a dying infant were informed of the infant's status and were present at the infant's death. Benfield identified five factors that hinder person-oriented care: lack of cooperation among the healthcare team, paucity of time, nurses as technicians who take care of machinery, lack of training in caring, and poor communication.
Finally, caring is a general theme and goal of medicine that includes a variety of responses to human illness and the helplessness associated with it. "Caring," according to Leighton Cluff and Robert Binstock, "comprises a wide range of responses to human vulnerability, frailty, pain, and suffering. Many words can be used to describe its elements-compassion, comfort, empathy, sympathy, kindness, tenderness, listening, support, and being there" (2001, p. 1). For Daniel Callahan, caring is a particular type of vulnerability, especially in terms sickness and illness. "Caring is needed," Callahan claims, "in order that we can help each other bear the assaults upon order and rationality that disease brings, destroying, or threatening to destroy, the orderly world of customary good health, so invisible when we have it, so wrenching and all-consuming when it is absent" (2001, p. 14).
Callahan divided the need for caring into two levels. The first is a general need for caring, which is "almost always needed by patients, whatever their condition and whatever the situation of the caregiver" (Callahan, 2001, p. 20). There are four sublevels to general caring, in which cognitive needs, affective needs, value of life needs, and relational needs are met. The second level is particular caring, which is a "critical mode of caring that works to understand this patient and this time in this circumstance, seeking to find what is unique about the patient and his or her needs" (Callahan, 2001, p. 20).
14.2.3 Ethic of Care
Contemporary ethic of care began with the publication, in the early 1980s, of Carol Gilligan's seminal work, In a Different Voice (Jecker and Reich, 2004; Little, 1998; Rudnick, 2001). In it, Gilligan (1982) challenged Lawrence Kohlberg's theory on moral reasoning and development. Kohlberg, who was Gilligan's doctoral mentor, claimed that moral reasoning and development depend upon learning how to use moral principles like justice and rights appropriately. Gilligan, however, alleged that Kohlberg's theory does not represent women's moral reasoning and development since he used exclusively males in his study. She tested female subjects and found a significant difference in the way women reason and develop morally.
Instead for relying upon principles and hierarchical relationships, Gilligan reported that her female subjects are more concerned about the context of a moral dilemma and are more willing to take into consideration the other's best interest, as well as their own. "The ideal of care," according to Gilligan, "is thus an activity of relationship, of seeing and responding to need, taking care of the world by sustaining the web of connection so that no one is left alone" (1982, p. 62). She referred to this moral reasoning as the ethic of care in contrast to an ethic of justice.
Gilligan's work has had a major impact on ethics, especially the development of feminine ethics (Jecker and Reich, 2004). For example, Nel Noddings (1984) contrasted feminine ethics, based on caring and relationships, with masculine ethics based on logic and detachment, and developed a notion of an ethic of care from the general natural caring. The essential ingredient in an ethic of care as compared to a masculine ethic of justice is the natural ethical commitment or duty to act. "Caring," according to Noddings, "requires me to respond to the initial [natural] impulse with an act of commitment: I commit myself either to overt action on behalf of the cared-for... or I commit myself to thinking about what I must do" (1984, p. 81).
Noddings identified two chief requirements for an ethic of care: engrossment and motivational displacement. "Caring," for Noddings, "involves stepping out of one's own personal frame of reference into the other's. When we care, we consider the other's point of view, his objective needs, and what he expects of us. Our attention, our mental engrossment is on the cared-for, not on ourselves. Our reasons for acting [motivational displacement or shift], then, have to do both with the other's wants and desires and with the objective elements of his problematic situation" (1984, p. 24). Caring, then, is based on an ethical ideal of oneself as a good person, especially in relation to others and to their need for care. But Noddings' ethic of care is not duty bound in a dour manner but is girded by the joy caring brings not only to the cared-for but also to the one caring.
Rita Manning (1998) identified five features of an ethic of care. The first is moral attention, which refers to focusing on the various relevant (and at times apparently non-relevant) details that make up a moral or ethical situation. The next is sympathetic understanding. "When I sympathetically understand the situation," according to Manning, "I am open to sympathizing and even identifying with the person in the situation. I try to be aware of what the others in the situation would want me to do, what would most likely be in their best interests and how they would like me to carry out their wishes and interests" (1998, p. 98). The third feature is relationship awareness, which pertains to the relational network that connects people to one another. An important factor in relationships is mutual trust. The final two features are accommodation and response to needs. Physicians in particular, for example, must be willing to accommodate to a patient's needs and to respond to them concretely.
Gilligan's ethic of care came under wide scrutiny and criticism, especially from those defending Kohlberg (Jecker and Reich, 2004; Larrabee, 1993). For example, Iddo Landau (1996) argued that an ethic of justice and an ethic of care are not the result of gender but of socio-economic factors. He claimed that Gilligan did not control for socio-economic factors in her studies. When such factors are controlled for, however, gender is not the determining factor but rather socio-economic ones.' Moreover, he concluded that there are ample ethical theories that already combine justice and care ethics, such as Rawl's theory of justice.
In Gilligan's defense, Susan Mendus (1996) argued that Gilligan is calling for equal footing for an ethic of care vis-n-vis an ethic of justice and that the ontological basis of a care ethic is not exclusively gender but also equality and violence. Indeed, Gilligan did note in the Introduction to her book: "The different voice I describe here is characterized not by gender but theme. Its association with women is an empirical observation, and it is primarily through women's voices that I trace its development. But this association," she warned, "is not absolute, and the contrasts between male and female voices are presented here to highlight a distinction rather than to present a generalization about either sex" (1982, p. 2). Moreover, Mendus claimed that Rawl's theory of justice marginalizes care and that Gilligan wants to make it an equal partner with justice for a comprehensive ethic.
Finally, some feminists have been particularly critical of feminine ethics or ethic of care (Jecker and Reich, 2004). Rosemarie Tong, for example, claimed that Noddings' "ethics is more feminine than feminist" (1998, p. 148). Tong's complaint is that Noddings is ambiguous about whether men are as caring as women or women are more caring than men. She is concerned that this ambiguity may lead to a "moral trap" for women, in which they may become more indentured to men than they already are.
Along a similar line, Hilde Nelson also criticized Noddings' notion of caring as being too unidirectional in that it leads to a "slave-caring" paradigm, since it "teaches those who are cared for to receive without giving" (1992, p. 10). The danger is that the caring person is absorbed or eclipsed by the cared for. Nodding objected, claiming that her notion of caring is not individualistic but relational: "When I maintain my capacity to care, I maintain my self in the deepest sense; I maintain my capacity to participate in caring relations" (1992, p. 16). Caring then is mutual, i.e. a two-way rather than a one-way street.
Instead of a physician being rationally concerned in an emotionally detached manner for a patient, as advocated by proponents of the biomedical model, a humanistic or humane practitioner cares both emotionally and rationally for the health of a patient qua person. "Humanistic medicine," according to Little, "seems to mean a medicine that is rooted in a concern for fellow humans, for their emotions, their suffering, their peace of mind" (2002, p. 319). Whereas the biomedical model brackets the emotions of both the physicians and the patient-that leads to the current quality-of-care crisis-humanistic models embrace them as important components of an ethical structure that composes medical practice-that leads to resolving the crisis. Emotions are incorporated into the care a physician exhibits for a patient's wellbeing. "Competency in the basic sciences provides the tools for care," claims Jeffrey Botkin, "but it cannot be synonymous with care" (1992, p. 276).
Humanistic or humane medicine then does not abandon the scientific cure; rather, it strives to obtain that cure within a caring ethos. "Without very much reflection," observes Golub, "curing replaced caring as the dominant ideology of this new technology-driven medicine. We are slowly realizing that most people want both" (1997, p. 215). Patients expect the physician to cure not only the diseased body but also to heal the sick person: "most patients believe that doctors should do more than simply mechanically intervene in the disease. Rather, they expect the doctor to help them find and remedy the factors that led to the illness, and assist them in returning to their best possible function" (Cassell, 1991, p. 111).
Within an ethos of care, a physician is no longer the locus of supreme authority and power in curing patients but a first-among-equals co-participant with them. The physician then recognizes that the patient's body/mind often cures itself and that the role of both the physician and the patient is to assist in that process and not to hinder it. The patient-physician relationship is one of mutual respect, for the role and contribution of each other in the curing process. And it is to the various models of the patient-physician relationship that we now turn.