From Detached Concern to Empathy: Humanizing Medical Practice (review)

Rarely do I finish a book feeling humbled. In her book, From Detached Concern to Empathy, Halpern offers an original way of thinking about the doctor-patient relationship that is so satisfying that one wonders why it took until now. The thesis is simple: promoting patient autonomy must not be understood merely in the negative sense of not interfering in patient decision-making, but rather, it must be understood as a positive obligation to help patients use or regain mental freedom such that they can set and pursue future goals. Only with such mental freedom does one act fully autonomously. Physicians help patients achieve mental freedom not by detached concern, but by engaging empathically with them.

What is empathy and how can it be cultivated? Halpern's central claim is that "empathy requires experiential, not just theoretical, knowing" (p. 72). It incorporates both cognitive and affective capacities and requires that the physician be open to feedback and correction. It is based on emotional reasoning, in which the "empathizer is able to resonate emotionally with, yet stay aware of, what is distinct about the patient's experience" (p. 85). It requires that physicians "imagine how it feels to experience something, in contrast to imagining that something is the case" (p. 85). In some situations with some patients, a physician's empathy will resonate spontaneously; otherwise, a physician can promote empathy by cultivating curiosity about what it feels like to be in the patient's distinct situation (p. 93).

The book opens with the case of Ms. G, a middle-aged woman with diabetes who has just had her second above-the-knee amputation and is refusing dialysis, even though she knows that she will die without it. Her refusal follows on the heels of her husband's attestation post-operatively that he had found another woman and was leaving her. My reaction to the case was that she would be declared mentally incompetent on the basis of her acute depression. But to my surprise, Halpern explains that Ms. G's primary physician, the surgeon, the supervising psychiatrist, and the consulting ethicist all agreed that Ms. G's decision needed to be respected. Halpern suggests that the physicians reached this conclusion because of their difficulty in addressing patients in emotionally wrenching situations. Some took a detached concern and concluded that respect for patient autonomy required them to do so, while others sympathized and projected their own viewpoints. Halpern is disturbed by the course of events and returns to this case throughout the book to explain how it happened and to explore how such events can be transformed by empathy into positive therapeutic opportunities.

The book offers four important contributions. First, Halpern explains how the cultivation of empathy incorporates both the emotions of the patient and the health care providers, and how it can contribute to more effective medical care. Second, Halpern explains how the concepts of empathy and autonomy are not two distinct ways of addressing patient's needs, but rather how empathy helps promote a richer conception of patient autonomy. Third, Halpern shows how clinicians, whether practicing physicians, nurses, or clinical ethicists, can improve their clinical care and achieve self-discovery by developing their emotional reasoning and empathy skills. Fourth, Halpern provides suggestions for cultivating empathy. While some may have hoped for a cookbook solution, Halpern's suggestions are more of a homework assignment. And although the attainment process sounds simple, empathy is a skill that needs to be practiced and developed.

The book is well-written and should be accessible to a wide audience. Readers with a philosophical background will be amazed at the numerous philosophers whose ideas are raised and referenced, but Halpern's clear style permits those with less of a theoretical background to easily grasp these diverse philosophical ideas. Readers who have a clinical background and take Halpern's message...