In healthcare, clinical empathy is rarely analyzed from the perspective of its moral role, even within bioethics. Instead, empathy is usually examined from its benefits to patients, health professionals, and even institutions. we propose moral roles of clinical empathy. It is noteworthy that the moral roles offered by the authors consist of original formulations from research developed over time in clinical empathy and ethics in healthcare. This is a theoretical study whose goal is to create theoretical contributions that aim to add to the scarce investigations on the articulations between clinical empathy and morality in healthcare. Clinical empathy should not be the only moral construct within health care ethics, as it is limited and does not account for the complexity of the moral phenomenon. Yet, considering that the current care model advocates patient centrality and participation and patient respect as subjects of rights, it is concluded that clinical empathy is a non-negotiable moral construct to implement the contemporary model of care.

Keywords: empathy, clinical empathy, patient, patient rights

There are various opinions regarding the role of empathy in morality. Slote claims that actions are right or wrong depending on “whether, or on the extent to which, they exhibit or reflect normally or fully empathic caring motivation”.¹ Others, including Prinz² and Bloom,³ don’t deny that empathy has a moral role, but they claim it is negative. For example, they claim that a jury’s ruling in a Court could be influenced by the emotions expressed by the victims and their defenders. Empathy could also lead to selectivity and generate a pro-group bias.⁴ Between these two extremes are intermediate positions, such as Maibom, who argues that perspective, emotional empathy, and sympathy contribute to moral concern but are not required.⁵ Similarly, Oxley states that empathy should be at the core of the action, motivation, and moral deliberation, but it is insufficient as a moral guide.⁶

In healthcare, clinical empathy is rarely analyzed from the perspective of its moral role, even within bioethics.¹ Instead, empathy is usually examined from its benefits to patients, health professionals, and even institutions. However, specifically in the Ethics of Care field, especially from a feminist bioethics perspective, Slote, Hamington, Held, and Meyers highlight the moral role of empathy in healthcare and argue that empathy is essential for morality.⁷ On the other hand, it is necessary to recognize that the moral role of clinical empathy in judgment and motivation has significant controversies, which reflect those present in the literature on empathy and morality in general. An intermediate position is that clinical empathy has a relevant moral role in healthcare. However, it is not sufficient to guide the ethical behavior of health professionals, given that empathy is not always the best guide for moral behaviors since it generates social preferences and favoritism.⁸ Thus, it is advocated based on Hoffman that despite empathy being associated with prosocial behaviors, a comprehensive ethical theory requires the adoption of principles or other prescriptive constructs.⁹ Clinical empathy is not enough for professionals to respect the patients as agents of their health and lives and to act to empower them in this regard.¹⁰

With the above in mind, we propose moral roles of clinical empathy. It is noteworthy that the moral roles offered by the authors consist of original formulations from research developed over time in clinical empathy and ethics in healthcare. This is a theoretical study whose goal is to create theoretical contributions that aim to add to the scarce investigations on the articulations between clinical empathy and morality in healthcare, especially regarding patient centrality. The theoretical framework we propose is divided along four axes: (i) the concept of clinical empathy; (ii) the benefits of clinical empathy; (iii) the epistemic function of clinical empathy; (iv) clinical empathy and patients’ rights. The concept of clinical empathy was based on the studies by Howick^11–14 and Halpern.^15,16 The epistemic function of clinical empathy was based on the research by Oxley¹⁷ and, finally, on patients’ rights in the studies developed by Guidi and Traversa.¹⁸ In this paper, we will argue that empathy is required for ethical medical practice and to respect patient rights. We will make this argument in four parts. First, we will define clinical empathy. Next, we will explain why empathy is a moral value. Third, we deal with the epistemic function of clinical empathy. Finally, we will argue that empathy is required to implement patients’ rights.

¹There are authors who emphasize the prominence that contemporary Bioethics gives to empathy in healthcare. However, we do not agree with this position, since there is scarce literature on Bioethics on the subject. Likewise, Principialism, a theory that still predominates in Clinical Bioethics, does not consider empathy as a relevant moral category.

Following Mercer and Reynolds, many define clinical empathy as: (a) understanding the patients’ situation, feelings, and perspectives and recognizing the difficulties of putting oneself in the patient’s shoes; (b) communicating this understanding and checking its accuracy, and (c) acting according to this understanding to help the patient.¹⁹ To this end, studies on the subject indicate that health professionals must display the following behaviors as guides of empathic care: (a) set aside sufficient time to understand the patient’s story; (b) talk about general issues; (c) offer encouragement; (d) give verbal signals that the patient is being understood (hmm, ahh, etc.); (e) be physically engaged (adopting specific postures, gestures, eye contact, appropriate touch, and others); (f) be welcoming during the consultation, from the beginning until the end.²⁰ Defined as such, clinical empathy is essential for good care. Indeed, courses for developing empathy and compassion as professional skills have been developed.²¹ The National Institute for Health and Care Excellence in the United Kingdom establishes that empathy is one of the pillars of quality of care in the mental health field. Relatedly, a lack of empathy can cause harm.²² The Mid Staffordshire NHS Foundation Trust Report entitled “Dying Without Dignity,” prepared by the Health Ombudsman Service on end-of-life care, and the Leadership Alliance for the Care of Dying People Report shed light on the empathy deficit in healthcare.²³ Clinical empathy is considered decisive in healthcare quality, contributing to better clinical results.²⁴ In sum, clinical empathy is a capacity with three dimensions; a cognitive one, in which professionals understand the patients’ perspective; an emotional one, in which the professionals are attuned to the patient’s emotions; and another, active, which involves the professionals acting therapeutically.

Evidence that clinical empathy is beneficial to patients is becoming abundant. Empathic healthcare positively impacts patient stress and anxiety, decreases pain and depression, and even reduces the risk of heart disease.²⁵ In addition, it improves emotional health, symptom resolution, and psychological measures.²⁶ Empathy improves diagnosis accuracy²⁷ because patients feel more comfortable revealing embarrassing personal information.²⁸ Patient adherence is one of the main factors for better health outcomes, and nearly half of the medical recommendations, including prescriptions, are not followed by patients. Indeed, empathy contributes to increased adherence and self-efficacy.²⁹ A high number of trials have shown that increased professional empathy can reduce pain and anxiety and contribute to the quality of healthcare.³⁰ Likewise, empathic care positively impacts patient safety and decreases mortality. According to observational studies, there is a 50% decrease in patients with diabetes.³¹ In sum, it is noted that when patients perceive a high level of clinical empathy, they experience better long-term results and feel more motivated and empowered.³² This provides an improvement in psychological response, a decrease in hospitalization, and increased therapeutic effectiveness.³³ Empathic care increases patient satisfaction, better outcomes such as proper management of chronic conditions, and less post-traumatic stress after severe medical emergencies.³⁴ Also, empathic care reduces morbidity³⁵ and may benefit many patients with multimorbid conditions.³⁶

Concerning health professionals, empathy in care increases their well-being while reducing stress and burnout,³⁷ and litigation risks.³⁸ Thus, evidence shows that empathic care increases job satisfaction,³⁹ which provides better communication with patients.⁴⁰ It is also important to highlight that, commonly, physicians perceive those empathic relationships with patients are significant interpersonal connections, which is a mechanism to diminish dissatisfaction with both the job and the health system, as well as burnout.⁴¹ Considering that clinical empathy benefits patients and health providers, it has a moral value⁴² in the light of a consequentialist perspective and because the doctors’ duty of beneficence requires it. Clinical empathy is a capacity that contributes to increasing the well-being of the patient and health providers, so it is morally right because of its good consequences in the healthcare field.

The epistemic function of clinical empathy in patient healthcare

The epistemic function of clinical empathy is to understand as a competency that identifies the patient’s mental state. This knowledge helps in the deliberation process on how to act, considering the mental states comprehended. Thus, the epistemic function is one of the essential derivatives of cognitive empathy, as it allows one to have information about the other person and awareness of their mental state. As such, it forms the substratum of empathy’s moral value, so we include this epistemic facet as a moral one. According to Oxley, the epistemic function of empathy develops in three stages: (a) the comprehension stage, (b) the simulation stage, and (c) the attribution stage.⁴³ In the first stage, the person who seeks to empathize opens to comprehend different beliefs, perceptions, and understandings emanating from the other, aiming to recreate the other person’s perspective of the world. In the second stage, once the other’s perspective is adopted, they begin to think of the world from this new perspective and to consider reasons that justify actions. Finally, in the attribution stage, the other’s perspective understands their reasons for acting. Based on these stages, Oxley proposes two functions of empathy: gathering information and acquiring knowledge about the other person to promote deeper understanding.⁴⁴

There are two conditions for epistemic functions to be performed in healthcare: the intelligibility of the patient’s emotions; and prima facie approval of these emotions. If health professionals cannot understand the meaning of the patient’s perspectives and emotions, that is, if these do not make sense, this hinders response to these emotions or perspectives, affecting the possibility of transforming them into knowledge that can be used. Prima facie approval means that the professionals must consider that the patient’s emotional state is appropriate for that context. If the practitioner expresses disapproval rather than acceptance, this impedes empathy by preventing emotional resonance. Although it is possible to understand from a rational point of view why the patient feels a certain way, it is difficult to tune in to an emotion that is disapproved of. It should be noted that this approval does not have an element of moral judgment but rather an initial perception that the emotion is applicable in each context. For example, when a parent feels happy when his/her child dies, it is difficult to accept this emotion and resonate with the emotion of happiness in this context.⁴⁵

The epistemic function of clinical empathy can contribute to the health professional’s approach to the patient’s experiential knowledge, a central element of the patients’ participation and engagement in healthcare. Because clinical empathy makes it possible to gather knowledge about the needs, will, and preferences of the patient and to understand them, it has a central epistemic function in Shared Decision-Making, which implies decision-making based on informed choices, which means giving prominence to what matters to patients and family members.⁴⁵ Recent research evaluating Shared Decision-Making in clinical practice highlights the low integration of patients’ preferences when discussing treatment options. Indeed, information related to patients’ preferences, values, and contexts potentially relevant to decision-making is still scarce in clinical practice.⁴⁶ Therefore, integrating clinical empathy into Shared Decision-Making can be a tool for discovering and understanding the patient’s world, helping increase its importance in Shared Decision-Making, notably when discussing options.

The role of clinical empathy in the realization of patients’ rights

Particularly, when it comes to patients’ rights, it begins with the right to participate in decision-making (established in Article 4 of the 1978 Declaration of Alma-Ata on Primary Health Care). Thus, this right relates to Shared Decision-Making, as it is how decisions are made collaboratively in healthcare, based on the provision of accessible information regarding options, typically in situations in which the concerns, personal circumstances, and background of patients and families play a central role in decisions.⁴⁷ It is noted that empathy is considered a dimension of Shared Decision-Making⁴⁸ or a prerequisite,⁴⁹ which presupposes health professionals’ active listening and the integration of the patient’s needs, wills, and preferences⁵⁰ into the decision-making process. Indeed, if the physician does not explore the patient’s values, a key element of Shared Decision-Making is lost.⁵¹

The empathetic relationship between professionals and patients is reinforced by elaborating a care plan and adopting personalized interventions.⁵² The right to participate in decision-making encompasses communication with patients and a more accurate understanding of what the disease means for them.⁵³ Therefore, the epistemic function of clinical empathy can enable the comprehension of the patient’s perspective and experience, establishing an atmosphere in which the patients feel that their view on treatment options is valued and necessary to conduct the decision-making process.⁵⁴

The patient’s right to be informed is related to the epistemic function of clinical empathy since information presupposes understanding what the patient wants to know and how to explain it. The right to be heard relates to the right to be informed and the right to informed consent. In the informed consent process, patients must have time to tell their stories and feel heard.⁵⁵ Therefore, the empathy shown by professionals can create a connection with patients, which creates a relationship that facilitates open communication based on attentive listening. The patient has the right to refuse treatment and procedures, which means establishing that an adult and a capable patient have the right to refuse treatment and procedure for any reason. Empathy in healthcare presupposes connecting with patients, understanding their mental state and situation, and providing detailed responses. Thus, clinical empathy can help health professionals respect the patients’ refusal, even when they disagree with it. In this case, being empathic will help professionals understand the patients’ choice of refusal and respect their rights.

Empathy can help to take care of others, overcoming stereotypes and categories, allowing us to move away from our beliefs and values and imagine the mental and emotional states of the other, trying to understand them.⁵⁶ Clinical empathy favors health professionals’ self-regulation, considering its function of mitigating self-interest and modulating selfishness⁵⁷ from the perspective of patient well-being.⁵⁸

The right not to be discriminated against means that the patient’s rights must be exercised without discrimination. Empathy is a powerful means to mobilize concern towards marginalized social groups and to give weight to their suffering.⁵⁹ Indeed, accepting patients without prejudice is fundamental to the empathic approach.⁶⁰ The right to information about their health condition involves the communication process between professionals and patients. The information about treatment and options must be explained to understand the patient. It is up to the professional to check if the patient has effectively understood what was transmitted to them. Likewise, the lack of empathy and connection with the patient’s emotional state can cause the health professional to provide too much information, worsening the patient’s condition or hindering their understanding of the information necessary for their decision-making. Research on the subject has shown clear communication and effectiveness in transmitting information to patients about adverse effects, and the reasons for tests and treatment are relevant in meeting the patient’s need for information.⁶¹

This paper outlined some moral roles of clinical empathy that show its importance for healthcare. Clinical empathy is the ability of health professionals to understand patients and is required for moral practice. The patient and practitioner benefits of empathy have been empirically demonstrated; together with the moral duty of beneficence, it makes empathic care a duty. Furthermore, clinical empathy has a unique epistemic function (which is required for its moral function) by allowing professionals to comprehend the patient’s mental states, emotions, and the situation in a singular way, given that it modulates their listening, understanding, and emotional attunement, making these professionals connected to the patient’s condition. Moreover, empathic practitioners tend to adopt behaviors that respect patients’ self-determination and seek to alleviate their suffering and anguish. Clinical empathy should not be the only moral construct within health care ethics, as it is limited and does not account for the complexity of the moral phenomenon. Yet, considering that the current care model advocates patient centrality and participation and patient respect as subjects of rights, it is concluded that clinical empathy is a non-negotiable moral construct to implement the contemporary model of care.

None.

The author declares there is no conflict of interest.

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