Empathy is about knowing or understanding how another person feels. Unlike sympathy (feeling badly for another), or emotional sharing (sharing in an emotion with another), they key is that we come to some understanding of how another person feels in their own shoes (i.e. NOT how you would feel in another person’s shoes aka “perspective taking”).
Empathy is controversial. Some argue it isn’t possible or that it requires too much of us (e.g. is overburdensome in the clinical context). Others worry about its tendency to rely on stereotypes (e.g. greater accuracy with ‘in-groups’) or the potential for false/paternalistic empathy (e.g. a failure to ask another but just assume to know how they feel). However, the medical profession also relies on empathy for two important reasons:
- When appropriately sensitive and responsive, it can lead to knowledge about how a patient feels that can be critical to medical care.
- When appropriately sensitive and responsive, empathic engagement, on its own, manifests respect for the patient and can be critical to building a trusting relationship.
The term ‘value’ distinguishes descriptive statements/beliefs (e.g. the world is spherical) from normative statements (e.g. clinicians ought/should be compassionate). In the latter case we are making evaluative judgments or calling something good/bad.
Sometimes we take value to be intrinsic (e.g. we might say happiness is valuable in itself, not for some other goal), and sometimes we take value to be extrinsic (e.g. when we say x job is good because it pays well, or e.g. empathy is good because it helps patients heal more quickly).
We can also say that value is subjective or objective. For instance, wealth may be a subjective value that one person holds but not another (the value is relative to the subject/person). Whereas, we might say that compassion is objectively valuable because we all agree to its value, or because there is evidence that it makes persons and communities live well/ flourish, or because it is dictated by religious text, etc. (though some might disagree about whether compassion is an objective value, or whether anything can have objective value).
Virtue Ethics can be traced back to Mencius and Confucius, as well as Plato and Aristotle. In this course, we will be primarily using an Aristotelian framework for understanding virtue. The virtues are defined as excellent traits of character. Though there is disagreement over what it means for a trait of character to be excellent, most agree that it is the sort of trait that is fundamental to flourishing or living well (what Aristotle calls eudaemonia). For instance, courage, compassion/sympathy, truthfulness, trustworthiness, humility, empathy, respectfulness, these are all traits that are taken to be critical to flourishing as individuals and as a society.
The key for Aristotle is that our traits of character depend on excellent habitualization (we learn from others and practice habits with others). So, virtues are significantly dependent on social support. This can mean that being trustworthy is something that comes easily to you in part because you were raised to be trustworthy, but it also means choosing to be trustworthy because it is an excellent trait as you develop greater capacity to make choices. Some contemporary interpretations of Aristotle add that virtue can be dependent on sociality in another sense, virtue requires normative structures and systems that encourage and support it. For instance, when hospitals place higher value on numbers of patients than time with patients, it could be at the cost of empathy. Likewise, oppressive -isms (racism, chauvinism, ablism, etc.) can hamper virtue (e.g. being respectful of someone when social norms tell us that a feature of their identity is not worthy of equal respect, or e.g. being trustworthy when no one trusts me).
Some key virtues in the medical profession include (but are not limited to): empathy, sympathy, compassion, beneficence, respectfulness, justice, curiosity, humility, courageousness, trustworthiness, truthfulness, etc.
Some object to prenatal diagnosis on the basis that it ‘expresses’ a discriminatory attitude towards those with (dis)ability. Namely, the act of screening for genetic information that might demonstrate risk for certain forms of (dis)ability (e.g. developmental (dis)ability associated with Down Syndrome) so that one might then choose to terminate the pregnancy endorses normative assumptions that treat those with (dis)ability negatively or as unequal in moral worth.
It is important in weighing this objection against other considerations to consider the perspective of those who have a screened for or similar genetic trait. Likewise, you might consider how you would feel if any genetic trait that you have were screened for regularly and pregnancies were regularly terminated because of it.
For further reading…
Boardman, FK. (2014). The expressionist objection to prenatal testing: the experiences of families living with genetic disease. Social Science & Med, 107:18-25.
Edwards SD. (2004). Disability, identity and the “expressivist objection”, J Med Ethics, 30(4):418.
Kittay, E. and Carlson, L. (2010) Cognitive Disability and its Challenge to Moral Philosophy, Wiley-Blackwell: Oxford.
Though we often talk about a patient’s right to be informed about the risks and benefits of treatment options or about prognosis, there is a correlative right not to be so informed (or not to know).
This right has become particularly prevalent in the field of genetics, where patients could come to know that they are at risk for a serious disease for which there is no effective treatment (e.g. Huntington’s disease). Under such circumstances, some patients may decide that they do not want to know their risk and respecting that choice may be both a matter of respecting autonomy and ensuring beneficence.
However, the existence of this right is contested. And even for those who agree that there is such a right, what that right entails is complicated by risk to the patient (e.g. some patients may ask not to know even when there are potentially effective treatments) and by risk to others (e.g. when genetic testing reveals genetic information that would affect family members).
For further reading…
Berkman and Hull (2014). The “Right Not to Know” in the Genomic Era: time to Break From Tradition? Am J Bioeth, 14(3):28-31.
Gilwa et al (2015) Institutional review board perspectives on obligations to disclose genetic incidental findings to research participants. Genetics in Medicine, Nov 2015. https://www.nature.com/gim/journal/vaop/ncurrent/pdf/gim2015149a.pdf
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“Paternalism is the interference of a state or an individual with another person, against their will, and defended or motivated by a claim that the person interfered with will be better off or protected from harm. The issue of paternalism arises with respect to restrictions by the law such as anti-drug legislation, the compulsory wearing of seatbelts, and in medical contexts by the withholding of relevant information concerning a patient’s condition by physicians.” (https://plato.stanford.edu/entries/paternalism/)
There is disagreement over classification of paternalism in practice and the ethical justification for it in any given case. One of the classic cases of paternalism that occurred at the birth of bioethics as it is known today is the case of Dax Cowart (see BH website: https://depts.washington.edu/bioethx/tools/ceintro.html). Dax was a patient with severe burns over 65% of his body who was assessed as having decision making capacity and refused care, but care was provided over his objections for the purpose of benefiting Dax (by saving life and restoring significant quality in his life).
“The term beneficence connotes acts of mercy, kindness, and charity. It is suggestive of altruism, love, humanity, and promoting the good of others. In ordinary language, the notion is broad, but it is understood even more broadly in ethical theory to include effectively all forms of action intended to benefit or promote the good of other persons. The language of a principle or rule of beneficence refers to a normative statement of a moral obligation to act for the others’ benefit, helping them to further their important and legitimate interests, often by preventing or removing possible harms. Many dimensions of applied ethics appear to incorporate such appeals to obligatory beneficence, even if only implicitly. For example, when apparel manufacturers are criticized for not having good labor practices in factories, the ultimate goal of the criticisms is usually to obtain better working conditions, wages, and benefits for workers.” (https://plato.stanford.edu/entries/principle-beneficence/)
When thinking about beneficence as a principle in case analysis we are typically considering the consequences, specifically how to bring about the most good and the least harm. One should consider all perspectives (e.g. patient, family, clinicians, community, etc.), and all forms of harms and benefits (e.g. physical, spiritual, social, etc.), and as questions like: Which course of action is likely to produce the greatest benefit (e.g. quantity or quality of life) over harm (e.g. bio-psycho-social pain and suffering) for the patient? For everyone involved?
Key Ethics Terms for this session:
For a broad overview of bioethics watch Maggie Little’s Introduction to Bioethics: Bioethics at the Bedside. After watching the video read the following two articles:
1. The Seattle God Committee: A Cautionary Tale. While reading the article think about the following points.
- What was surprising about what you learned about the Seattle God Committee’?
- What criteria were being used to make judgements about organ allocation in the Seattle God Committee’?
- What moral obligations, principles, or virtues (e.g. beneficence, empathy, trustworthiness, respectfulness) were/were not displayed in the process of this deliberation?
- What do you think are the key obligations or virtues missed here?
2. Read Race, Racism and Access to Renal Transplantation Among African Americans. Your focus when reading this article should be on the highlighted passages. While reading:
- Consider how to connect these contemporary issues to the historical case above.
- What moral obligations, principles, or virtues (e.g. beneficence, empathy, trustworthiness, respectfulness) continue to/ continue to not be displayed in the process of organ allocation?
- How does social context impinge on the process of renal transplantation?
For Further Reading:
The original 1962 LIFE magazine article by Shana Alexander, “They Decide Who Lives, Who Dies” begins on page 102.