Medical Matters: How much empathy is too much empathy?

How important is it that your doctor is empathetic? Until recently I would have responded with an emphatic “very”. After all, teaching narrative medicine to medical students is driven, in part, by my wish to encourage them to practice empathetically.

Empathy is the ability to share and understand the emotions of others. Research suggests it is a construct of multiple components, each of which is associated with its own brain network. Affective empathy is the ability to share the emotions of others. People who score high on affective empathy are those who, for example, feel others’ pain strongly within themselves when seeing others in pain.

Cognitive empathy, on the other hand, is the ability to understand the emotions of others. Cognitive empathy is demonstrated by the healthcare professional who understands the emotions of a patient in a rational way, but does not necessarily share their emotions in a visceral sense.

Empathy is also different from sympathy, which involves feeling concern for the suffering of another person and a desire to help.

I believe empathy is important in medicine for a number of reasons: when a doctor expresses empathy patients are more likely to feel understood and validated. In turn, this creates a “team approach” to dealing with the person’s illness, leading to a balanced consideration of the medical advice being offered and a commitment to whatever plan of action is agreed by patient and doctor.

Hard facts

How do you know when your doctor is expressing empathy? She will be listening attentively and will summarise your illness story back to you. Crucially she will summarise not just the hard facts of your story but also the emotions you are experiencing due to the illness. And you will be aware that the doctor is working to integrate your agenda.

However, a couple of articles and a book have recently challenged my thinking on the absolute goodness of empathy. Writing in the online magazine Aeon, ethicist Karin Jongsma and psychologist Verena Klar ask if empathy is an overrated skill when dispensing medical care? Many physicians are now trained to be empathetic, but still struggle with showing empathy all day, every day, they note.

“We’ve long assumed that the empathising doctor is the better doctor, but both aspects of empathy – the cognitive and the emotional – can malfunction. From the cognitive end, our ability to walk in someone else’s shoes is biased and not-neutral; we walk easier in shoes that fit us . . . And from the emotional end, we underestimate the influence of affective states such as anxiety or depression on other people’s behaviour when we are not affectively aroused ourselves.”

Non-empathetic compassion

Their solution? “We want our doctors to acknowledge our needs and act accordingly, yet we don’t actually need them to mirror our pain. In fact, this final requirement is most closely related not to empathy but to compassion – defined among emotion researchers as the feeling that arises when you are confronted with another’s suffering, including the desire to help. This non-empathetic compassion . . . might act as a bridge between recognising the other’s feelings and providing care without the detriments of empathy.”

Writing in a recent issue of the Medical Independent, Tipperary GP, Dr Lucia Gannon, says that climbing into someone else's skin isn't easy. " The continuous sharing of other people's pain is not good for doctors. Recent scientific studies have shown that doctors with high levels of empathy . . . are at higher risk of burnout than those who score lower on [an empathy scale]."

And in his just published book, Against Empathy, Yale psychology professor Paul Bloom, comes out strongly against emotional empathy. He is not dying about cognitive empathy either, but is on the side of compassion. In fact, the title flatters to deceive, and the book is more an argument for rational compassion.

It’s no harm to have ones certainties challenged.