The Experience of Empathy in Medicine

Introduction

The objective of this essay is to reflect on empathy as an existentiary phenomenon in the frame of existentiary philosophy. The fundamental intention is to demonstrate the improper concept of empathy that the traditional clinical method used in medicine proposes. At the same time, we will explore the perspective of the phenomenology that Heidegger proposes by defining empathy as a “temper of the mood” or state of mood and the hypothesis that this search produces that empathy is an existentiary (existenziall) linked to states of the mood like the anguish. From this point of view, empathy is a pre-ontological phenomenon that cannot sleep from preoccupation and taking care of the “being-there.” This text is subdivide in four parts. The first section is an introduction to the subject. In this part I will try to highlight the phenomenological aspect of empathy. The second part explores the impropriety of the traditional “empathic way of being” in the practice of medicine. The third segments orients the reader about the existentiary analysis on the proper Conceptual Paper empathic way of being. Finally I propose some conclusions at the end.

The clinical relationship between the physician and the patient presupposes the continuous existence of the other so long as he remains a patient and that he is stimulated by the idea that his suffering can be learned and turned into experience for the physician. When we see it this way, the physician-patient relationship carries a philosophical problem. The main problem is the way in which the physician tries to capture the phenomenon of the other’s suffering from his clinical skills and what sense does that have in the existence of the physician. Strictly speaking, this is the problem of the alterity or otherness in medicine, if we take the term alterity (alter) from the dictionary’s definition as: the condition of being other.1

1 Real Academia Española, Diccionario. En línea: https://dle.rae.es/ alteridad?m=form. Consultado el 23 de mayo 2021.

Although this problem can be approached from the epistemology of the clinic, in this work I propose to explore it from the perspective of the hermeneutic phenomenology. To alternate in clinic implies a dialogue with the patients and at first glance, this phenomenon pretends to be current in the modern scientific-technologic medicine. However, it seems clear that the main obstacle to the alterity in medicine is the presence of the technique. The intrusion of different techniques in the diagnostic process has taken to oblivion the sense of the nature of sickening (Physics), both for the physician and the patient.

In essence, sickness and health are ways of bearing the heterogeneity of physics: cosmogonic earth and nature. Even though this idea appears as abstract, in reality it is very concrete and factual of the day to day living experience. The biggest sense that life has is understood when it is linked to the dynamics and deployment of the telluric forces of understanding how life is a gift integrated to the origins of the cosmos and its renovation. I believe that this refers us to Heidegger’s idea of Ereignis as an “event coming into view”.2 Whether in health or in sickness, the idea of this Ereignis as an event of the self and the entity. The self-experiences, makes itself present in the world of the entity that each one of us is. For there to be Ereignis the healthy or sick entity must be open to the call of the being. What I have sustained regarding this subject is that many phenomena in health, and above all, in sickness like pain and suffering, is linked to existential moods that allow us to pre-comprehend the essential part of being and existing. It is about, as Heidegger says, pre-ontological events; where the pre-ontologic only indicates what previous, originary, primordial is. That which we comprehend in absence of conceptual representations.

My philosophical research has sought to exemplify the existentiary character of health and sickness, a matter that Heidegger barely insinuated in one of his seminaries.3 What this existentiary analysis shows, is that there are proper and improper ways of facing the saving and pathologic ocurrences. In this essay, I intend to make an analysis of the way of being of the alterity in medicine. In order to achieve this I propose to develop the following question: ¿What is the existentiary way of being of the alterity in the clinical relationship between patient and physician of the modern scientific-technologic medicine? For this question, I put forth the proposition that the physician does not achieve “being the other” because he faces against the disease and the ill patient from an improper way of being in the world.

2 Heidegger M (2009) Aportes a la filosofía. Acerca del evento. Madrid: Editorial Biblos.

3 Heidegger M (2007) Seminarios de Zollikon. Edición de Medard Boss. Morelia: Editorial Jitanjáfora.

Improper Way of Being Empathetic

In this part I would like to examine the phenomenological way of being empathetic in both a proper and improper manner, following for this the concepts of Heidegger. The idea is to manifest the possibility of an “ethos” attached to the proper way of being empathetic. To clarify this point, I will analyze the structure and the sense of the empathetic experience. The idea is to determine if empathy can be a transcendental experience while one is responsible for the other.

How Heidegger proposes that we exist in an already made world. When we are born, the world is already there. Existentially we are thrown in this world. Therefore, we are already situated and compromised, and because of this everything that happens in our world is absent of any sense. It is because of the capacity of our comprehension that we interpret the significance of others and ourselves in an ontological way of speaking. Because of this, to comprehend is primordially, pre-comprehend. This means, there cannot be comprehension from zero or a zero grade of comprehension.4 In this existential context, we can confirm that empathy, being itself a fundamental state of the mood is determined by comprehension. We may part from a thought from Heidegger by which through the existentiary analytic, the fundamental ontological thesis is that the essence of the “being-there” resides in its factual existence.5 The existence is the vent in which the being of the entity reveals and discovers itself as eccentric, or in open state: auto-discovered, exposed, as part of an inner-world, thrown in his “there”; the man himself finds in the world and that determines his affective disposition. To found and comprehend oneself are determinations originated simultaneously with the capacity to speak. These three phenomena are the basis of this state of aperture. And only in this state, “the other” can appear as a similar being. Only under this condition that can empathy for the other can appear.

It would be convenient to accurately define the concept of “temper of the mood”. From the start, Heidegger rejects any psychological idea, just precisely because he wants to escape any definition of traditional metaphysics. In this same manner, he rejects the existence of an illuminated being, originally isolated from the others and the world that with posteriority to his feelings, emotions and passions

4 Crelier A (2011). “El neokantismo heideggeriano en las tensiones de la filosofía trascendental”. En B. Ainbinder (ed.), Studia Heideggeriana, Vol. I Heidegger-Kant, Sociedad Iberoamericana de Estudios Heideggerianos. p.70.

5 Heidegger M (1997). El ser y el tiempo. México: Fondo de Cultura Económica. Traducción José Gaos.

establishes a relationship with them by measurement of the language. On the contrary, Heidegger recognizes that existence happens always and with the others in this world. Any kind of Heideggerian affectivity is linked one way or another to the concept of Anguish, boredom and tediousness; but at the same time, all of these are linked to the temporality of existence, hence, he says: “the comprehension has its founding primarily in the “come to one-self”, in contrast, finding oneself and the affective disposition, have its founding in the having been”.6 We can then conclude saying that empathy is a temper of the mood, and as such, is an experience of living and being in this world with the others. Empathy is a way of being of the “being-there”. The existentiary analysis of this encounter with the others becomes evident in the idea of the everyday nature of the “One” (Man)7. The formulation of this analysis is relayed to the sphere of what is public, the opinions and the hearsay. It is clear that this mode of being with the others everyday is bonded with the hermeneutical comprehension of the factual.

Medical Empathy

There is a mythical thought regarding the idea that physicians must be empathetic towards their patients. This mythology supposes that empathy is a “natural”, spontaneous and rational ability. In this perspective, it is assumed that empathy is based on our capacity to know, comprehend and communicate.8 And there is a whole rhetoric that proliferates in the periodical publications of medicine, insisting in the relevance that it has in the education and development of skills and competence of medical empathy.9 The Greek term “ἐμπαθης-empátheia”, refers to the emotional character of an individual. In Heideggerian language, we would say, a “temper of the mood”. I’ve previously stated that sickness propitiates tempers of the mood like anguish, fear and dreadfulness.10 But the rhetoric speech that medicine supposes is that empathy is there within the medic per se, as a quality, capacity, clinical skill or as a part of his professional personality.

6 Heidegger M (1997). El ser y el tiempo. México: Fondo de Cultura Económica. Traducción José Gaos. p. 368.

7 Heidegger M (2000). Ontología. Hermenéutica de la facticidad, Tr. J Aspiunza, Madrid. p. 68

8 Fernández-Pinto I., López-Pérez B, Márquez M (2008) Empatía: medidas, teorías y aplicaciones en revisión. Annals de Psicología. pp. 284-298.

9 Olge J, Busshnell J, Caputi P (2013) Empathy is related to clinical competence in medical care. Medical Education. 47, pp.824-833.

10 Carranza-Bucio O (2021) Reflexiones sobre dolor, sufrimiento y existencia propia. Medicina y Etica, vol. 22: 443-461.

If as Edith Stein suggests, empathy is the experience that a “me” has from an adjacent “me”11, the phenomenon is not purely emotional or sentimental, although it is neither compassion, sympathy or mercy. Empathy is a much more authentic phenomenon. For Edith Stein, empathy is about “contemplating in internal perception”, a way in which my spiritual self is absorbed in self-observation and I see the other as he sees me. This way I can convert the other into the object of my attention and apprehend him. In this manner, I can occupy myself with the spiritual life of the other that appears through my eyes, not as a simple object, but as a similar being to myself, perceived together with his physical body, and then I can comprehend him as “similar to me”.12 But not everyone agrees about empathy, not even as a psychological phenomenon. Paul Bloom, who defines empathy as the act of coming into this world to experience life in the manner that you think that somebody else does, mentions about empathy that:

….it is a mediocre moral guide that allows poor judgment and frequently motivates indifference and cruelty. It can take us to take irrational decisions and unjust policies; it can wear away important relationships, like the ones that exist between a doctor and his patient and make us bad friends, parents, spouses or companions. I am against empathy, and one of the objectives of this book is to convince you that you should be too.”13 Bloom thinks that empathy is more a problem of moral conscience, and of good reasoning and judgment. If not were like this, he says, the idea of sharing emotions with others might result more harmful than beneficial. According to him, the anatomy of empathy is inherent to impulsiveness. This author shares many examples that seek to illustrate how empathy becomes prejudice and alter transforms into cruelty.

In a phenomenological perspective, the real problem is to elucidate the event that consists in understanding the other’s experience. The analysis from Edith Stein points towards establishing empathy as a temporal phenomenon of the present, which subsequently supposes that the other one similar to me is given to us originally here and now. The other is given to us as a psycho-physical individual: “it is given as a living body, not merely incorporated to my phenomenal world, but on the contrary as the center of orientation itself

11 Stein E.(1989) On the Problem of Empathy. ICS Publications, Washington, D.C. Translated by Waltraud Stein, Ph.D.

12 Stein E Ídem, p. 106.

13 Bloom P (2017) Contra la empatía. Argumentos para una comprensión radical. Editorial Taurus, p.10 of such phenomenal world.”14 Following Edith Stein, empathy is a cognitive phenomenon of the living of my alien self. This is, a sentimental affection that should not be confused with memory or imagination. To her, the empathic event presents three moments: in the first place, the perception of the situation of the other and his living experience; secondly, the interiorization of the other’s living experience happens; and third, the moment comes when the one who perceived the alien living experience perceives it as his or her own. Nevertheless, Stein poses the problem of the origin of the living experience in controversial terms. For her it is not clear that the empathic living experience is originated in first person, but is certain that the living experience of the other one can definitely not be so because it does not belong to the subject, but to the other.

The solution that Stein proposes for this stays within the idea of the inter-subjectivity. In the end, for her empathy is an experience originated in the measure that it is for the subject with whom we become empathetic with. This seems to the condition of possibility. Empathy is, as such, an original phenomenon without which knowledge of our own body or soul would not be possible (because the knowledge of our own body, or of our own soul supposes from the start the empathetic transference). This is: I get know myself as a real me at the same time and proportion I transfer this knowledge to the others and I perceive myself as how they perceive me”.15 Stein knows from her own religious living experiences that to apprehend the other in suffering in an original manner is perhaps the most relevant problem of the alterity, and because of this she insists:

Empathy is understood as living inside the life of the other. This is, empathy seeks the comprehension of the other as “other” and does not disturb the original living experience that he or she has of himself. Hence, having the capacity to live the joyfulness and sadness that the other subject is living in his original experience; feeling the joy and the happiness that he is feeling and living and not because he is living it or feeling it. This way of living the original experience of the other implies a proper mode of the self to approach to the world that is beyond it.16 Without a doubt, the most important trait of the meditations of Edith Stein is his intellectual honesty to recognize the epistemic difficulty in the apprehension of the

14 Stein E (1989) On the Problem of Empathy. ICS Publications, Washington, D.C. p. 21. Translated by Waltraud Stein, Ph.D.

15 Stein E. Idem, p. 106

16 Stein E. Ídem, p. 87

experience of suffering by the others. She has it clear that it is not a psychological or anthropological matter. It is not enough to say: “I understand”, “I put myself in your place, “I know that you’re in pain and I bear that with you”. We know that this jargon is banal and is far from captivating the original phenomenon.

Empathy as a Proper Mode of Being in Medicine

Since several decades ago, in numerous medical publications there exists an intention to associate the phenomenon of empathy with the medical education and formative process, proposing it as a clinical competence of a student or physician.17 Regarding this, there are many affirmations made that mention that the empathetic physician increments the satisfaction of patients18 and that the sick patient has a bigger acquiescence. Other studies say that empathy makes doctors more competent for the diagnosis and treatment of patients.19 It has also been proposed that empathy reduces the complaints and afflictions20 of the patient. As we can observe, there is a whole utilitarianist and pragmatic conception of empathy.

In consideration to this, I’ve found limited philosophical approaches, although there are some very interesting studies.21 As Svenaeus says, after the boom of the “mirror neurons”, the myth that the neuronal circuits of empathy per se could temple de mood in face of the alterity in compassion was generalized, suggesting that it was actually a natural process rather than a cultural one. Svenaeus himself wrote about his multiple research projects in neurosciences that had the objective of establishing the neurophysiological aspects of empathy, an approach that in plain light results in a reductive and insufficient effort to explain it. In this section of my essay, I propose to explore the exercise of empathy from the professional formation of a physician.

In our everyday life, every idea of truth that guides our actions affects at the same time our relationship to the world. This is what I will call “The truth of our life”; there is not only one nor can it be perceived as a single unit. Our daily living

17 Esquerda M, Yuguero O, Viñas J, Pifarré J (2016). La empatía médica, ¿nace o se hace? Evolución de la empatía en estudiantes de medicina. Aten Primaria. 48 (1): 8-14.

18 Gual SA., Oriol BA, Pardell AH, El médico del futuro. Med Clin (Barc).

19 Neuwirth Z (1997) Physician empaty- should we care? The Lancet, vol 350.

20 Beckman HB, Markajis KM., Suchman AL, Frankel RM (1994). The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med 154(12): 1365-70.

21 Svenaeus F (2014) The phenomenology of empathy in medicine: an introduction. Med Health Care y Philos 17: 245-248.

experience is settled in a plurality of certainties that it is not really relevant to verify. Some of those certainties have to do with health and sickness. It is important to state once and for all the meaning of the terms: truth, certainty, health, sickness; these are not assumed here as scientific categories but more as existential experiences. In this sense, the truth of our life has to do with our own being, or in other words, our existence.

The idea that there is a truth of our life, represents knowing that our own life is real, because there cannot exist any being without truth, and vice versa no truth without being. I would say that this is the first certainty: being truth and truth of being. Therefore, the question that is imposed to us is: How do we know about this certainty? Well, let us say that there exists a sort of epistemology of living the everyday nature of life through which this mode of existence is revealed. The objective that we pursue in this work is to come closer to that episteme in the process of teaching medicine. However, we should have clear that the truth of health, is the truth of life itself.

The idea that there is a truth of our life, represents knowing that our own life is real, because there cannot exist any being without truth, and vice versa no truth without being. I would say that this is the first certainty: being truth and truth of being. Therefore, the question that is imposed to us is: How do we know about this certainty? Well, let us say that there exists a sort of epistemology of living the everyday nature of life through which this mode of existence is revealed. The objective that we pursue in this work is to come closer to that episteme in the process of teaching medicine. However, we should have clear that the truth of health, is the truth of life itself.

If we take the noun in Spanish “salud” (health), in his most religious significance, we can glimpse the subject of salvation. This relationship is very clear in the christian tradition where salud (salus, -ūtis), means salvation, safeguarding and a state of grace. But the word is much older. His indo-european etimology refers to the verb saluere that appears to indicate totality or integrity.22 Maybe this totality is already pointing towards the fact that being healthy is not being divided. The person that is healthy is complete, but the one that is sick is lacking something, as it is suggested in a certain way in the dictionary of Vaan.23

22 De Vaan, Michiel. Etymological Dictionary of Latin and the Other Italic Languages. Leiden: Brill, 2008.p. 537.

23 Del protoitálico *salu-, y este del protoindoeuropeo *slH-u- (“entero”).1 Compárese el hitita šalli- (“grande”, “principal”), el sánscrito सर्व (sárva) (“entero”, “todo”), el avéstico clásico hauruua (“intacto”, “entero”), el prusiano antiguo haruva (“entero”, “en total”), el griego antiguo ὅλος (hólos) (“entero”, “completo”) y el tocario A salu (“enteramente”, “totalmente”).

This last idea contrasts with the previous one of health as salvation. Salvation comes to be seen as a negative term. To save (salvāre) is a repairing action. The being is damaged and wants to be freed of danger, to be kept safe.24 And we can ask ourselves, What happened to the totality?, In what way was the being and its totality damaged so that it requires now to be saved?

Heidegger speaks of a state of the original being, a way of existing that is preontologic. This is an ontic mode of being where the entity that in each case is us is not apprehended as being what it is.25 From there that the fundamental ontology starts to propose the relationship between entity and being and I that we can highlight an ontic-ontological difference. The most relevant epistemic that the theory of health and sickness has is that it wants to establish them always from the exterior. To pretend that both health and sickness have to be perceptible to the eyes and senses of the physician in a rational and objective way.

For example, the common protest against the practical physician of the XVIII y XIX century was that they practiced a conjectural discipline.26 Which was attributed to the method of study of sickness and patients inherited since Hippocrates; although by the XIX century, we had perfected the method of auscultation. Nonetheless, observation is a technique originated from the primitive medicine. In fact, there is no disease, if it cannot be observed.

To observe (observāre), means to notice, to repair27. Through observation we try to construct the truth by focusing on the study of details, patterns, differences, marginal characteristics and aspects engulfed in the disease of the patient.

Hippocrates himself is said to have taught his disciples that only with careful observation we could establish the nature of a disease, although the disease in itself is inaccessible.28 In this same sense, Alcmeon of Croton, a known physician contemporary to Pythagoras used to say “of the invisible things and the mortal things, the gods have the immediate certainty, but us men are left to proceed with only

24 Real Academia Española y Asociación de Academias de la Lengua Española (2014) Diccionario de la lengua española (23.ª edición). Madrid: Espasa.

25 Heidegger M (1997). El ser y el tiempo. México: Fondo de Cultura Económica. Traducción José Gaos.

26 Elvira Arquirola, Luis Montiel. (19939. La corona de las ciencias naturales. La medicina en el tránsito del siglo XVIII al XIX. Madrid: Consejo Superior de Investigaciones Científicas

27 Real Academia Española, Diccionario. En línea: https://dle.rae.es/ alteridad?m=form. Consultado el 23 de mayo 2021.

28 Laín-Entralgo, P. (1970). La medicina hipocrática. Madrid: Revista de Occidente.

clues”.29 These clues and hints are the signs and symptoms with which we give the truth of any disease a structure. A truth that must be visible to the physician, without regard to what the sick patient is experiencing.

To convince ourselves of the former proposition we just have to think on the pedagogy of a symptom. The symptom (σύμπτωμα, accident, disgrace) can be any corporal manifestation, internal or external that results invisible to a keen observer. In that sense, it is less consistent that a sign. This last one differences itself for being objective, real and demonstrable. Thus, the students are taught to idenfity the trace, and footprints and hints: the signs. Every future physician learns to describe them, make a history of them, interpret and represent them. But with the symptoms, that is never possible. A symptom is the own experience of the other, what the other one similar to me is going through: the truth of life and the living of truth.

It seems we encounter a link between, clinical knowledge, phenomenology, ontology and hermeneutics of medicine, although this relationship is rarely kept in mind by a teacher of medicine. If we do not assume a symptom as the truth (alétheia)30 that the sick patient is passing through, we will never be able to interpret and make sense of another one’s suffering. Our symptoms are part of our property. This is what Heidegger defines as the concept of alétheia: the truth that happens during our factual living, a true event that we glimpse as evident, although it may seem occult for another.

Conclusion

What makes medicine pretend to be a science that is everyday more similar to physics? An exact, experimental, objective sciences supported only by what is demonstrable

29 Laercio, D. (2007). Vidas y opiniones de los filósofos ilustres. Madrid: Alianza Editorial. Libro VIII.

30 Francisco-Javier. Aletheia. Ontología Hermenéutica Unificada. España: CuantoCaos editorial, Sin fecha de edición. WWW.aletheia.comoj.com.

and evident. There is in all of it a sort of horror vacui with respect towards the symptoms that are not aligned to the scientific canon. Above all, the objective truth. The greater risk that we take, of not listening to science is to be accused of empiricism. It is such the power of positivism that we have to fill the void of truth with whatever resembles it: if we do not know what the patient has, we will submit him to a diagnostic-therapeutic test; if he does not die, at least science will have achieve a triumph.

This other reflections about empathy as an existentiary phenomenon show how medicine, when set apart from any philosophical thinking tries to justify its lack of comprehension of the human. Speeches like the ones provided by the bioethics have obscured even more the way towards a real humanism in medicine.

We maintain the hypothesis about how empathy is an existentiary linked to a temper or state of mood like anguish, an open state of being, to the finding of one-self, the comprehension and the ability to speak, confirming that empathy is a pre-ontological phenomenon that stays awake in worriedness and the caring of the being-there.

Perhaps no one protested with such energy the empirical practice of physicians as Philippe Pinel. According to Pinel, the physicians only offer light conjectures and boasts, interminable disputes and eternal fights of self-love and titles for the mockery and derision.31 As hard as the critique made by Pinel may be, Pinel ended up being convinced that the best treatment for madness, is the moral treatment. Pinel wanted a positivist science, an experimental and evidence based medicine. That was his dream, although, as Francisco de Goya insinuates: the dream of reason produces monsters.32

31 Pinel P (1818) Principios generales sobre el método de estudio y la observación en medicina. París: De L’imprimerie de Crapelet

32 Goya F, Los Caprichos. El sueño de la razón produce monstruos. Gravado núm. 43. Museo del Prado. En línea: https://www.museodelprado. es/coleccion/obra-de-arte/asmodea/1025ddbf-50b6-41ae-bb8a- 006ddde8a791 (consultado mayo 10, 2021)