Empathy in Medicine

“You’ll h-h-h-have to… excuse m-m-m-me. I’m a little slow because I had a stroooooke,” he told us before we explained to him what his wife’s treatment would be.
His voice was nasal and his speech deliberate as he slowly and poorly enunciated each word. He wore sweatpants and a long-sleeved shirt with a
blue and white hat pulled down over his eyes. Stubbornly refusing to stay tucked away, gray hairs peeked out the sides of his chapeau and covered
his ears. He looked to be in his seventies. His wife lay on the bed in a hospital gown, slippers still on. She wore a winter hat that
concealed a bald scalp, one of the many side effects of potent cancer medications. Her eyebrows were gone and her sinewy frame was exaggerated as cachexia set in. She needed extra rounds of chemotherapy for metastatic cancer.

Image via Flickr: Tim Hamilton (CC)

That afternoon, I ran into the husband in the hospital lobby. He had just bought food and was going to bring it back to his wife, but he was heading the
wrong way. He asked a fellow student and me (he recognized both of us) how he could get back to his wife’s room and we pointed him in the right direction.
We watched him shuffle tow
ards his wife in the cancer ward. This couple was neither wealthy nor well-educated; they were suffering and attempting to
navigate the healthcare system as well as the overwhelming size of an academic hospital. They seemed helpless together.

It’s in such moments, as in many others, when empathy wells up in medical practice. I
could clearly imagine myself or my family members in their position. Their emotions became all too familiar and upsetting to me. I wanted to do everything
in my power to help them and to fix their situation. But this strong sense of identification seemed odd given how brief my interaction with them had been.

In reality, however, such a feeling is not so unusual. Robert Louis Stevenson, the famous nineteenth-century Scottish writer, co-authored a short story called The Ebb-Tide. It is an account of three criminals who steal a ship and the deeply
troubling moral situation they subsequently encounter. When one of them falls sick, Stevenson describes the healthy comrades’ feelings:

A profound commiseration filled them, and contended with and conquered their abhorrence. The disgust attendant on so ugly a sickness magnified this
dislike; at the same time, and with more than compensating strength, shame for a sentiment so inhuman bound them the more straitly to his service; and even
the evil they knew of him swelled their solicitude, for the thought of death is always the least supportable when it draws near to the merely sensual and
selfish.

Image via Shutterstock

Given the power of this selfless commiseration shouldn’t we cultivate it in medicine? No doubt
it will help us to act altruistically even when we see the worst in patients or colleagues, thus leading to a better bedside manner and better patient
care. Jean-Jacques Rousseau, the Genevan philosopher, saw such feelings differently,
however. In

Emile, or On Education
, Rousseau points out that empathy is really an outlet for selfish passions, even if its effects can be positive. Rousseau writes that,

if the enthusiasm of an overflowing heart identifies me with my fellow-creature, if I feel, so to speak, that I will not let him suffer lest I should suffer too, I care for him because I care for myself, and the reason of the precept is found in nature herself, which inspires me with the desire for my own welfare wherever I may be.

Such cynicism about the underlying nature of empathy still has its advocates today. In the September 2014 Boston Review, Yale psychology professor Paul Bloom questions our high regard for empathy. I recommend reading his essay and his
exchange with other scholars, including Peter Singer, Sam Harris, and Leslie Jamison.
Bloom points out the dangers of unchecked empathy: “Strong inclination toward empathy comes with costs. Individuals scoring high in unmitigated communion
report asymmetrical relationships, where they support others but don’t get support themselves. They also are more prone to suffer depression and anxiety.”
And this is especially the case, Bloom points out, in the medical field in which a doctor can lose a sense of objectivity and a cool head in an emergency.
Bloom distinguishes between cognitive empathy, which is empathy tempered by rational feeling, and emotional empathy, which can be dangerous. Bloom writes
of an older relative of his in the hospital:

He values doctors who take the time to listen to him and develop an understanding of his situation; he benefits from this sort of cognitive empathy. But
emotional empathy is more complicated. He gets the most from doctors who don’t feel as he does, who are calm when he is anxious, confident when he
is uncertain. And he particularly appreciates certain virtues that have little directly to do with empathy, virtues such as competence, honesty,
professionalism, and respect.

This makes sense. I can imagine how exhausting it must be to feel so strongly about every patient. It would cause burnout and depression. But the
psychologists Lynn O’Connor and Jack Berry respond to Bloom in the
following way: “We can’t feel compassion without first feeling emotional empathy. Indeed compassion is the extension of emotional empathy by means of
cognitive processes. Only if we have the capacity to feel empathy toward loved ones can this sentiment be generalized by the imagination and extended to
strangers.” This addition to Bloom’s argument is absolutely vital. Both types of empathy are important.

Such balanced empathy keeps the physician honest. There are many times when, in a rush to complete the work of the day or under the pressure to see every patient,
physicians take their frustrations out on patients. Empathy tames our impulsivity and gives us pause. It forces us to consider the actions we
are about to take. And we can project empathy using reason and emotion. If an elderly woman is being difficult, instead of reacting with frustration and
annoyance we can step back and ask ourselves, “What if is this were my grandmother or my mother? How would I want her physician to behave?” To do this is
not easy, but it can make an immense difference in how one interacts with a patient.

Empathy may or may not spring from selfishness, and too much of one aspect of it (like too much of any emotion) can be a bad thing. But physicians do need
empathy, both the emotional empathy that we feel towards some and the cognitive empathy that we can extend toward all. In the cogs of an impersonal
medical system, it leads to the dignified treatment of a suffering patient.

Forcing People to Be Good

[Editor’s Note: We are pleased to introduce Brendan Foht, the new assistant editor of The New Atlantis. He holds degrees in political science from the University of Calgary and in biology from the University of Alberta. This is his first post for Futurisms, to which he will be a regular contributor.]

Peter Singer, along with researcher Agata Sagan, recently made an appearance on the philosophy blog of the New York Times. Suggesting the need for a “morality pill” that could boost human ethical behavior, Singer reminds us why he is the king of crass consequentialism:

Might governments begin screening people to discover those most likely to commit crimes? Those who are at much greater risk of committing a crime might be offered the morality pill; if they refused, they might be required to wear a tracking device that would show where they had been at any given time, so that they would know that if they did commit a crime, they would be detected.

As long as we’re asking people to take morality pills, we might as well preemptively implant those we deem pre-criminals with tracking devices, right?
Singer’s ideas about moral enhancement, however, pale in comparison to those of Julian Savulescu, who drops even the rhetorical semblance of doubt as to whether moral enhancements ought to be compulsory. Indeed, he seems to believe that without the development of genetic or other biomedical methods for moral enhancement, the human race is doomed to extinction.
Savulescu, a professor at the Oxford Uehiro Centre for Practical Ethics, and one of the most prominent academic advocates of human biological enhancement, has argued that the human race is “unfit for the future,” and is heading into a “Bermuda Triangle of Extinction.” The three points of this triangle (representing the three factors pulling us toward extinction) consist of our rapidly advancing technological and scientific power, the evolutionary origins of our moral nature, and our commitment to liberal democracy.
The moral nature we received from our ancestors is far from perfect, rooted as it is in a world of supposedly violent and xenophobic cavemen. With the development and dispersal of powerful new technologies, it is becoming increasingly likely that powerful weapons, like genetically engineered super-plagues, might end up in the hands of people whose moral nature disposes them to violent, possibly catastrophic acts. Liberal democracy is represented in the triangle because it prevents us from taking the measures necessary to ensure the survival of the human race — measures like compulsory moral enhancement.

The idea of using genetic engineering as a measure to secure global security or peace is, hopefully needless to say, totally removed from medical, scientific, and political realities — not to mention from basic ethical and practical concerns. The idea of actually implementing such a scheme, effectively and successfully, is laughable.
Since facts don’t play much of a role in these proposals, consider just one small bit of relevant data. In Afghanistan — a country that would be high on the list as a potential source of troublesome weapons or people — the infant mortality rate in 2009 was over 13%, and one in five children died before the age of five. Even from a purely practical standpoint, are we to take seriously the idea of going into country that lags a century behind today’s medical standards, and undertaking a massive program of chemical or genetic manipulation, using techniques that are as of now barely hypothetical, targeting genes that we have barely begun to identify, on “patients” who are unlikely to understand the procedures, and in any case will almost certainly be coerced into them?
While it is true that our moral dispositions are to some extent rooted in our biology, our moral and political actions are rooted at least as much in our beliefs about justice and injustice as in our innate dispositions. And one would think that just about any society would not take kindly to an attempt to violate its members’ bodily autonomy. Even if the technical and medical problems were somehow miraculously solved, the fact that some state or international agency would have to force people to take these “moral enhancements” — as Savulescu notes, those who most “need” them would be the least likely to take them voluntarily — would create a backlash that would almost surely inspire more violence than the intervention could possibly prevent.

The apparent failure of transhumanists to recognize the basic political problems with such a scheme makes plain some of the lapses in their understanding of human nature. Savulescu’s argument that human beings are “unfit for the future” reflects an anxiety common among many people — not just transhumanists — who think about how messy and imperfect our biological nature can be. Evolutionary biology seems to show us that our bodies were designed to compete in a vicious, pre-historical struggle, burdening us with desires and vices that conflict with our higher longings and our moral values.
But this insight is of course not new; Plato and the authors of Genesis seemed to have some notion that human nature is prone to bad as much as good, and common sense shows that we are not always as good as we would like to be.
The difference between transhumanists and more serious ethical traditions is that transhumanists think that because nature is not perfectly designed, it is completely up for grabs — while others acknowledge that ethics is about learning the best way to live with our natural imperfections. In this sense, trying to eliminate the aspects of our nature we don’t like would not be a moral “enhancement,” but would rather be a profound change in the meaning of a moral human life.

Rudolph, the Racism Reindeer

My apologies if this puts some coal in your stocking on Christmas Eve, but among the many wonderful tunes sung and played at Christmastime (the beautiful, transportive instrumental album Dulcimer Christmas comes highly recommended by yours truly), there is one that has never sat well with me: the story of Rudolph the Red-Nosed Reindeer. There have been various versions of it over the years — most notably the original 1939 booklet produced by Robert L. May for Montgomery Ward, and the 1964 stop-motion animation film (Snopes has a great overview of the history) — but if you recall, the most famous version of all is of course the 1949 Johnny Marks song, sung since by millions and millions of children.
The song leaves a lot of important questions unanswered, but what is there paints a pretty unsettling picture. Rudolph is a physically deformed young buck who is mocked and ostracized by his reindeer peers for looking different. They never let him join in any of their reindeer games; alack, poor Rudolph.
Eventually, it turns out that Rudolph’s deformity, a shiny red nose — so shiny, in fact, that one could even describe it as luminous — comes in handy (nosey?) during a particularly low-visibility Christmas Eve. Santa calls upon our snubbed protagonist, who, owing to his unique feature, is able to save the day. It is then (only then!) that all the reindeer love him.
I ask you, gentle reader: what kind of message is this sending to our children?
Rudolph’s predicament of feeling different, excluded, and unable to fit in is something many kids must be able to relate to — and I think many parents assume the story has a positive message to tell them. But what are we to take away from the way Rudolph’s predicament is resolved?
The conclusion to the story is ostensibly redemptive; but is it because the young reindeer come to empathize with the suffering they have inflicted on Rudolph, accepting him into society when they realize the inherent wrongness of their bigotry? No. At least in the song — I understand that the 1964 movie version tells the story quite differently — things only turn around for Rudolph when the thing that makes him abnormal happens to be also very valuable, and moreover, valuable in a way that is recognized as valuable by others.
Rudolph, in other words, becomes accepted because he is lucky. There is an optimistic way we can read the story: Rudolph’s shiny nose stands for the inner light that shines in each of us, through each of our unique and special attributes, waiting for the proper opportunity to finally become visible to others. Rudolph gains acceptance when his fellows realize not only that he is excellent in spite of being different, but excellent because of his difference. So, too, can each of us find ways to make the things that make us different become recognizable to others as displaying our unique worth. Perhaps there is even an excellence — a process of, in the parlance of our times, actualization or of finding the self — in learning how to make our unique worth recognizable to others.
This question about the wisdom of the message of “Rudolph” points to a larger tension in our culture — one that was probably at its most apparent at the height of the P.C. era of the 1980s and 1990s, but that has been with us as long as we have been struggling to achieve civil rights and secure liberal democracy: are we supposed to rally around the motto that “everybody’s equal,” or is it that “everybody’s different”? Égalité or diversity? The former is very easily warped into the ludicrous and harmful “everybody’s the same” (a suggestion that has been brilliantly spoofed by Stephen Colbert’s repeated insistence that he literally “can’t see race”). And the latter is a notoriously tricky, somewhat fuzzy, and often challenged concept.
One problem with the notion that “everybody’s the same” is that it papers over the great diversity of ways that people can be excellent and valuable. There is a potential wisdom in the message of “Rudolph” worth underlining: it teaches us that excellence often must be demonstrated in deeds. It celebrates that there are many ways we can be remarkable, and teaches us the virtue in striving to find them and show them. In other words, it tells kids that if they are different and don’t fit in, then they just need to find ways to prove everyone wrong by showing just how great they can be in their difference.
But the problem with this message is that many of the things that make us different from each other are not easily recognizable as great, particularly by the people we want to accept us. When the next mutant reindeer comes along, perhaps with a lump of coal for a nose instead of a light bulb, will the other reindeer have learned their lesson about acceptance and immediately let him join their reindeer games? I suspect that the coal-nosed reindeer too will have to struggle to show the specialness of his difference, and may well never find a way to fit in as well as Rudolph has.

For better or worse, the “Rudolph” song paints an honest picture of how equality and acceptance tends to be won in our own society. Black civil rights probably gained as much from the achievements of jazz, Ralph Ellison, Langston Hughes, and Jackie Robinson as from philosophical appeals to inherent human equality — as much, even, from the personages and deeds of Frederick Douglass and Martin Luther King, Jr., who were making those philosophical appeals, as from their words.
Of course, the notions of diversity and equality are bound up with one another. Our acceptance of people’s differences is tied to our expansion of equality — the realization that a person who is different from us is still equally a human being, and equally deserving of the rights and respect accorded to human beings. We still, that is, believe that equality comes not from what a person can do but from what he or she is.

And this is where the transhumanists come in. Transhumanists call for the proliferation of new posthuman forms; they celebrate diversity and tolerance; and they seek to smash such “-isms” as “speciesism,” acting, as we have noted, as if they are in fact the modern successors to the civil rights movement. But in avowedly rejecting the human, the transhumanists also reject, at least implicitly, our underlying human equality. And once we refuse to recognize our underlying equality, as poor Rudolph discovered, the best way we have left to get at what we are is through what we do.
Yet there are many people who already cannot do as much as most — the very young, the very old, the sick, and the disabled — who thus cannot easily demonstrate their worth in deeds. Consequently, philosophers like Peter Singer already declare that many of these groups should not be treated or defended as people at all. (It is not an accident or a quirky footnote of utilitarian belief that Singer defends killing infants and Alzheimer’s patients — including perhaps even his own mother.) And transhumanists, for all of their self-congratulatory tolerance, are either indifferent to or repulsed by these groups. (Or perhaps, charitably, they are repulsed for them, on their behalf.)
If these obviously human groups are already having trouble being recognized as people, how will they — and the rest of us — fare in the posthuman age? For while Rudolph was lucky to have his difference make him excellent in a way that was recognizable to others, the posthuman age will be defined by the dissolution of any shared notions of who we are and what is valuable about us. One of the new sorts of beings may be great in some way that is totally unrecognizable to the many other new sorts of beings. It may no longer be just the weakest human beings who will have trouble making the case for their worth in a way that others will understand.
“Rights,” “equality,” and “tolerance” may well lose their meaning in such a world. If that happens, you’d better make sure your bright-red nose can shoot lasers beams too.
[Images: The 1964 stop-motion film; diversity according to Fairfax County; Frederick Douglass; “speciesism” according to Flickr user thinkvegan; the 1998 animated film.]

Transhumanist Resentment Watch II: Breathing, Ctd.

[A continuation of our Resentment Watch series.]
In my last post, I described the anti-humanism of utilitarian philosophers like Peter Singer, who more than rhetorically ask the question of whether humans should exist. While I don’t believe (as, say, Wesley J. Smith does) that Singer’s anti-humanism is now characteristic of the West in general, Singer’s apparent loathing of human existence in all of its supposed misery is at least shared by many transhumanists.
The discussion thread for a recent post here exploring the full human phenomenon of breathing illuminates the point. Commenter IronKlara says,

You sound like you actually *like* being trapped in these meat cages. And like you think it’s bad to want to escape a cage that does pretty much nothing except find new ways to hurt and malfunction.

It’s hard to see how we could contrive new good things outside our “cages” if all we know is inside them and all that’s inside them is bad.

Similarly, commenter Jonathan is concerned about “the loss of life (particularly infant life) that cerebral hypoxia causes each year,” invoking a utilitarian calculus to claim that “the good of preventing an infant death outweighs the good of those joys of breathing to which Schulman refers.” Commenter tlcraig, whose comments on this thread are smart and funny, aptly asks, “How does this help me to decide whether being without breathing would be a better way for me to be?” Not only does it evade the central question, but if you tease out Jonathan’s comment, it amounts to claiming that if I like breathing, I support allowing infants to die, which veers into South Park farcical political ad territory (“If you support this, you hate children. You don’t hate children … do you?”).
To put it mildly, of course, the “breathing versus dead infants” idea is what they call a “false choice,” and one that, aside from its odiousness, manages to put the problem precisely backwards. If there are infants with cerebral hypoxia, or anyone with any sort of hypoxia for that matter, the problem is that they have a fundamental need they are unable to meet, and that we should focus our medical efforts on helping them meet it. The commenter seems to be saying, however, that if someone has trouble breathing, then instead of eliminating the trouble, we should eliminate the breathing.
Okay, but what’s left over once we do — particularly if we consistently apply this standard of eliminating rather than fulfilling needs? One would have to say we should do away with arms because some babies are born without them, and do away with sight to accommodate the blind. For that matter, if this idea is really fully and consistently applied, one would have to say we should eliminate all needs, and do away with life, because so much death results from it. And so at the root of this utilitarian transhumanist argument we find the same anti-humanism as we did at the core of Singer’s: the ostensible concern for eliminating suffering hollows out our understanding for why we should even be alive. Rather than maintaining aspects of our humanity like breathing, it’s the whittling away of everything that is essentially human from our self-understanding that poses the real threat to our existence.

Peter Singer’s utilitarianism increases human suffering

They told you life is hard, Misery from the start, It’s dull, it’s slow, it’s painful. But I tell you life is sweet In spite of the misery There’s so much more, be grateful. -Natalie Merchant
Peter Singer recently published a New York Times blog post seriously posing the question of whether the human race should allow itself to go extinct. Most of the post is built around the arguments of philosophy professor David Benatar, author of the book Better Never to Have Been: The Harm of Coming Into Existence. Singer writes:

We spend most of our lives with unfulfilled desires, and the occasional satisfactions that are all most of us can achieve are insufficient to outweigh these prolonged negative states. If we think that this is a tolerable state of affairs it is because we are, in Benatar’s view, victims of the illusion of pollyannaism. This illusion may have evolved because it helped our ancestors survive, but it is an illusion nonetheless. If we could see our lives objectively, we would see that they are not something we should inflict on anyone.

There is a simple riposte, of course, to anyone seriously claiming we should not exist: one simply need note that no rational being is capable of posing such a claim, for once he believes it, if he is fully consistent in his conclusions and convictions, he should immediately kill himself, and so never have the opportunity to communicate the argument. Of course, I’m not suggesting that extreme utilitarian philosophers should kill themselves (though one could consider their existence as a special sort of suffering), and the fact that they don’t do so should be the first indication that something is amiss in their arguments. They live, like the rest of us, based on the notion that their lives are worth living, even though they are uniquely incapable of understanding that they are and why.
Even the most hardcore of evolutionary psychologists can agree with the notion that an organism that has lost the will and drive to continue its own existence is deeply sick — indeed, not just sick, but suffering from sickness. And it is a sickness of the highest degree, overwhelming as it does the most fundamental imperative of any organism or rational being: to exist, to maintain the prior condition for any state of goodness, joy, or wellbeing. We consider this true for animals so ill they have ceased to eat; and we consider it even truer for human beings who are suicidal: over and above whatever suffering has caused their state, we understand the state of not wanting to live to be itself a profound form of suffering — literally, the deepest form of existential despair.

Nietzsche said, “He who has a why to live can bear with almost any how.” So, also, he who has no why to live cannot bear with almost any how. Walker Percy claims that postmodern man “has forgotten his bad memories and conquered his present ills and … finds himself in the victorious secular city. His only problem now is to keep from blowing his brains out.” Singer et al. turn this problem into the explicit question of why we shouldn’t, and when it exposes the gaping vortex of nihilism at the center of their philosophy, they attempt to divert our gaze with posturing of bold discovery and heroic honesty.

What we risk suffering from most deeply is not the physical anguish that concerns the utilitarians, but the very existential despair they so eagerly prescribe. By defining the value of our lives as simply the absence of physical suffering, philosophers like Singer may actually markedly increase human suffering. Not only does their philosophy provide an active reason for people to be suicidal, but it commits extreme utilitarians to arguing that the profound suffering of being suicidal is itself good reason for the suicidal to go ahead and commit suicide. (Notably, I know of no utilitarian philosophers who have had sufficient confidence in their convictions to openly advance such an argument.)

It is indeed a profound loathing for most of human existence that undergirds Singer’s philosophy. At the end of his post, he poses the question to the readers, “Is life worth living, for most people in developed nations today?” Though Singer allows, both here and in the conclusion to his post, that life is under the right circumstances worth living — presumably, under circumstances similar to his own — it is apparently taken for granted in this question that life is not worth living for people in undeveloped nations. And it must be even more taken for granted that life was not worth living for the thousands of generations of ancestors to whom we owe our own (at last potentially worthwhile) existences. Posterity, then — the accumulated infliction of the suffering of existence by each generation on the next — must be an injustice of unthinkable proportions.

It is in this understanding of the meaning of posterity, of course, that Singer most profoundly misses the worth of life, as available to today’s poor and to our impoverished ancestors as it is to affluent college professors. As a commenter on the Singer post, Pierce Moffett, puts it:

Maybe most normal people enjoy their lives to a greater extent than the typical philosopher does. It wouldn’t surprise me. I don’t know about you, but I’m glad I’m here. I have unfulfilled desires, but I have also had a great deal of enjoyment. I experience a few minutes of profound joy every morning when my 5 year old gets out of bed, comes to my office, and crawls up into my lap for a still-sleepy hug — and by having her, I’ve made it possible for her to have that joy herself someday if she has a child of her own. This sort of utilitarian, weigh-everything-on-the-scales approach is the worst sort of academic pseudo-philosophical nonsense.

As a philosopher, Dr. Singer is surely aware that the notion that [the] world is getting worse every year has been around among philosophers for a very long time. But out in the real world, people do the millions of things they like to do — from roller skating to playing computer games to solving differential equations to flying hang-gliders … and many of these things we love to do involve our children.