Health care institutions and medical educators assert that empathy is essential to optimum patient care, yet medical education and the practice of medicine often neglect empathy in favor of biomedical approaches to disease and injury. This essay discusses the development in medical literature of the concept of "clinical empathy"—which attempts to reorient a biomedical, disease-centered approach to treating illness by accounting for an increasing fluency within the interpersonal relations between physician and patient—and examines arguments for supplementing medical training with the study of literature and the practice of reflective writing as a means of developing empathy in physicians. In order to interrogate the problems as well as the possibilities of clinical empathy, I turn to theories of sympathy produced in the eighteenth century, when innovations in medical technology and knowledge had only begun to create separate categories that would ultimately untwine the body from mind and culture. The eighteenth century was also a time when philosophy and literature, rather than being compartmentalized from medicine as distinct disciplines, informed medical understandings before medicine became specialized as a "science." A critical approach to the theory and literature of the eighteenth century can help to formulate a productive critique of clinical empathy in contemporary medicine and to suggest possibilities for a reconfigured and strengthened understanding of empathy within the larger social context of institutions, systems, and access to care.
I. The Contemporary Debate
The ongoing debate in medical education and in clinical practice about the importance of empathy illustrates a divided approach to patient care. Those who argue for empathy (or at least for concern for the patient's sociocultural and personal experience of illness) are countering what is [End Page 551] seen as a predominantly biomedical approach. This divide is often characterized as disease-centered care versus patient-centered care. The debate about whether disease and pathology are alone responsible for illness and disability or whether (and how much) physicians should focus on the patient's experience of illness unfolds on different levels of discourse and learning. While medical schools, professional organizations, and journal articles advocate empathy in patient care, the practice in hospital wards and clinics often contradicts or undercuts that commitment, emphasizing scientific knowledge at the expense of symbolic and affective aspects of illness. (It is widely acknowledged that the role modeling of senior physicians in clinics and wards has far more influence on trainees than does institutional advocacy or classroom instruction.)1
Those physicians and medical educators who advocate empathy in the patient-physician encounter often cite studies suggesting that physicians who engage empathically with patients increase not only the patient's sense of "satisfaction" but also patient compliance with therapeutic regimens and increased physiological well-being.2 Physician Howard Spiro echoes both psychological studies and anecdotal perceptions suggesting that medical students begin their training with "a cargo of empathy" that is then displaced when "we teach them to see themselves as experts, to fix what is damaged, and to 'rule out' disease in their field."3 Spiro views cadaver dissection, the emphasis on basic science, and the primacy of medical imaging as dangerously objectifying the patient.4
While many in medicine agree that empathy needs to be taught and practiced, there is not yet consistency and clarity in the medical literature about what empathy is and how it works. Some physicians discuss empathy casually, without clearly defining it, as in Jerome Lowenstein's essay "Can You Teach Compassion?"5 Others define it haphazardly, making use of aesthetic and psychological definitions interchangeably. For example, Spiro supplements a definition from Scribner's Dictionary of the History of Ideas with brief mentions of Freud, Buber, Jung, and even John Donne.6 Still others cite psychology, psychoanalysis, and aesthetic theory to historicize and deepen their definitions of clinical empathy. All too often, discussions of empathy in the clinic do not engage with earlier formulations of it in the medical literature. However, some of its proponents have made good use of psychological studies of empathy. The most rigorous of these approaches address empathy as a faculty that involves both feeling and reason. For example, in describing the language physicians...