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01-12-2019 | Editorial

Clinical sympathy: the important role of affectivity in clinical practice

Author: Carter Hardy

Published in: Medicine, Health Care and Philosophy | Issue 4/2019

Abstract

Bioethics has begun to see the revaluation of affects in medical practice, but not all of them, and not necessarily in the sense of affects as we know them. Empathy has been accepted as important for good medical practice, but only in a way that strips it of its affectivity and thus prevents other affects, like sympathy, from being accepted. As part of a larger project that aims at revaluing the importance of affectivity in medical practice, the purpose of this paper is to develop a clinical sympathy that can serve as a trainable skill for medical professionals. While everyday sympathy may be problematic as a professional skill for physicians, this does not imply that sympathy should be entirely rejected. As a natural part of our moral psychology, sympathy is an intersubjective affect that aids in our interactions with others and our decision-making abilities. I present here a theory of clinical sympathy as an affective response to patients, in which physicians are both attuned to their affective response and understand how their affects are influencing their beliefs and judgments. In this way, clinical sympathy serves as a trainable skill that can aid physicians in their interactions with their patients.

I prefer to use the term affectivity when talking about individual affects since I do not think there is a clear divide between an experience being an emotion, feeling, and mood. Rather, individual affects, like happiness, tend to be experienced as emotions, feelings, and/or moods. Especially when it comes to empathy, which has many competing definitions and explanations, identifying it with one type of affect—such as an emotion—would oversimplify the experience of empathy. To make things more complicated, there are different theories of emotions, feelings, and moods, and empathy could be fit into any one of these. However, this paper is about sympathy, not empathy, so arguing for a specific theory of emotion and how empathy either does or does not fit this theory, is outside of the scope of this paper. Especially since empathy is now more associated with a cognitive skill/faculty than and affective experience, it may even be fruitless to provide such an argument. Instead, in this paper, I am accepting the current theory of empathy as a cognitive understanding of the other, and approaching sympathy considering this interpretation of empathy.

This is elsewhere called merely the simulation theory of empathy. It will be explained further in later sections of this paper.

These include theory (Baron-Cohen 1993, 1995; Gopnik 1988, 1993, 1996; Gopnik and Meltzoff 1997; Gopnik and Schulz 2004; Gopnik and Wellman 1992; Karmiloff-Smith 1988; Kitcher 1988; Wellman 1990; Wellman et al. 2001), and interaction theory (Gallagher 2001, 2004, 2009, 2012; Gallagher and Hutto 2008).

I phrase this as such since, even with the way empathy is being defined, it is still possible to understand parts of the other’s situation without empathy. Empathy allows for a more holistic understanding, but there is still an understanding of some aspects of the other’s situation without empathy.

Similarly, “empathy” has different meanings in English than simply the imaginative, projective empathy that Titchener and others discussed. For now, it is worth noting—as both Lanzoni and Andrea Pinotti note—that “there was never one simple psychological depiction of Einfühlung or empathy: projection, transfer, association, animation, personification, vivification, fusion, identification, among others were all possibilities” (Lanzoni 2012, p. 306; Pinotti 2010, p. 94). Philosophers and psychologists have been unable to agree to one use for the term. This has led to the debate concerning the true nature of empathy.

While many like to think that the experience of most (if not all) affects is independent of the existence of other subjects. For Scheler, most affects are made possible by our primordial intersubjectivity, and we experience them with others. That is, we are always, already being with others in the world, and it is only within this context the we experience affects. As such, he sees love and sympathy as fundamental features of the lives of persons. Affects are perceptions of values, and they can be divided into levels based on the things in which they perceive value, as well as how such value is perceived. Intersubjective affects—especially sympathy—allow us to experience affects with and for others, sometimes to the extent that we merge back into our primary intersubjectivity by achieving a feeling of oneness with each other. In this way, our affective lives are an important aspect of our intersubjective lives because they allow us to experience a valued world with others.

Genuine sympathy is sympathy guided by love—when it is “embedded in, and sublated by, love” (Vandenberghe 2008, p. 39). This is important to the development of clinical sympathy.

Aside from the intersubjective importance of sympathy and empathy, emotional sharing allows us to genuinely share an emotion with the other. It is our ability to enter into the same situation as the other in the world—to literally “be with” others in an affect. Additionally, emotional contagion has a special role in the way that it bonds us to the world with others. It shows how we are pulled into the same affective world with others, even if we do not realize it happening. Finally, a feeling of oneness brings us back to our primary intersubjectivity.

Lief and Fox list: “exploring, examining, and cutting into the human body; dealing with the fears, anger, sense of helplessness, and despair of patients; meeting emergency situations; accepting the limitations of medical science in dealing with chronic and incurable disease; being confronted with death itself.” (Lief and Fox 1963, p. 13).

As Halpern says, it is “detachment with a veneer of generic tenderness” (Halpern 2001).

Detachment is trained to assist with emotional experiences, such as death and dying (Fox 2006, p. 945; Lief and Fox 1963, p. 13; Underman and Hirshfield 2016, p. 95). And it is argued that it taken on partly due to the examination of cadavers during autopsies (Underman and Hirshfield 2016, p. 95).

This is understood to be a useful coping technique for students to learn. (Fox 2006, p. 945).

These authors also note that students “made jokes or blamed the patient to reduce their anxiety. This kind of emotional socialization led to dehumanizing and objectifying patients” (Underman and Hirshfield 2016, p. 95). In these ways, students foster detached concern as way to cope with emotion-laden experiences.

Halpern warns against situations like this where there is a risk that “one person’s irrational emotions are transmitted to others” (Halpern 2001, p. 9). This can happen when the patient is experiencing a strong emotion that is transmitted to the physician, but it can also happen when a physician transmits a strong emotion to the patient. It is the latter that is particularly troubling here.

I address one option for this in another paper (Hardy 2017). I argue that Shaun Gallagher’s interaction theory is a promising alternative theory for clinical empathy. This theory explains the physician’s understanding of patients from diverse backgrounds as an ability to learn and apply narratives. I find this to be a better theory of empathy because it provides a more holistic understanding of the patient and the patient’s situation, in the sense that it incorporates both what the physician perceives of the patient and the patient’s point of view on the patient. I do not explain this distinction here, since this paper is more concerned with sympathy than empathy. In other words, this paper is focused on the role that sympathy should play in medical practice if we continue to accept the current theory of empathy (rather than trying to redefine it). We could either redefine empathy to provide a more holistic understanding of the patient, or we can accept the current theory of empathy and incorporate a theory of sympathy to aid in the holistic understanding.

Some even argue that empathy serves as the foundation upon which all other intersubjective affective engagements are established, such as “pity, sympathy, affective matching, perspective taking etc., [which] arise at the secondary level” (Daly 2014, p. 231).

Paralleling and directly connected to the feeling/cognitive divide in the philosophy of emotion, this dichotomy between subjective feelings and objective cognitions can be shown to be both untrue and problematic. There is a need to overcome this divide and see both empathy and sympathy as affective phenomena that are important in and of themselves.

This is similar to how Halpern talks about the emotional resonance that she argues is an aspect of empathy. She says that emotional resonance is the physician’s first clue to understanding the patient’s “emotional point of view” (Halpern 2001, p. 16). It is the physician’s attunement to the patient’s relationship to the world It immediately established the patient’s affects “as presences, rather than as mere possibilities” (Halpern 2001, 74). However, many physician’s pass over and ignore the opportunity to explore this clue because they focus too narrowly on facts, rather than to “the emotional meanings of patients’ words” (Halpern 2007, 697).

It is also worth noting that Gelhaus defines sympathy in the way that Scheler defines emotional contagion—“sharing the same feelings with the other” (Gelhaus 2012b, p. 399).

These are also identified by Gelhaus in her discussion of compassion as a professional attitude.

This goes back to the divide between detached concern and sympathy. These are established as extremes in medicine, where sympathy is an overly strong emotional engagement with the patient and detached concern is devoid of emotional engagement. Detached concern can easily lead to unwarranted paternalism, whereas sympathy risks leading to either paternalism or avoidance, based on the physician’s affective response to the other.

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Title: Clinical sympathy: the important role of affectivity in clinical practice
Author: Carter Hardy
Publication date: 01-12-2019
Publisher: Springer Netherlands
Published in: Medicine, Health Care and Philosophy / Issue 4/2019
Print ISSN: 1386-7423
Electronic ISSN: 1572-8633
DOI: https://doi.org/10.1007/s11019-018-9872-8

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Clinical sympathy: the important role of affectivity in clinical practice

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