Against Empathy: The Case for Rational Compassion, by Paul Bloom, Penguin Random House, 285 pp, £14.99, ISBN: 978-1847923158
The Empathy Instinct: How to Create a More Civil Society, by Peter Bazalgette, John Murray, 375 pp, £16.99, ISBN: 978-1473637511
Mirror Touch: Notes from a Doctor Who Can Feel Your Pain, by Joel Salinas, HarperCollins, 307 pp, $26.99, ISBN: 978-0062458667
Phrenology was the bizarre belief that one could determine personality and intellectual ability by examination of the contours of the skull. The idea had a remarkable hold on the public imagination in the nineteenth century, but eventually died out, mainly because it had no plausible biological basis and because it was used to give a bogus scientific credibility to racism. The contemporary equivalent of phrenology is functional Magnetic Resonance Imaging (fMRI). “Functional” MRI differs from standard MRI scanning by mapping the differential rate of oxygen consumption in different parts of the brain: this is thought to measure metabolic, and hence, neuronal activity. Functional MRI scans display impressive colour changes which reflect these differences in oxygen consumption. If an area of the brain “lights up” during a specific activity, it is assumed that this activity “takes place” in that location. Academic psychologists, who had hitherto been low in the pecking order of neuroscience, thought fMRI might give them scientific credibility, and even recognition by the general public.
The sociologist Scott Vrecko listed fMRI-based neurobiological accounts of altruism, borderline personality disorder, criminal behaviour, decision-making, fear, gut feelings, hope, impulsivity, judgement, love, motivation, neuroticism, problem gambling, racial bias, suicide, trust, violence, wisdom and zeal. “Neurobollocks”− as this new phrenology came to be labelled by its detractors − has infiltrated economics, criminology, theology, literary criticism, education, sociology and politics: the American writer Matthew Crawford described fMRI as “a fast-acting solvent of the critical faculties”. Many cautious, reticent neuroscientists, however, are painfully aware of its limitations. The neuroscientist David Poeppel observed that “we still don’t understand how the brain recognizes something as basic as a straight line”.
Empathy is the latest target of this neo-phrenology. As well as the obligatory fMRI-based neuroanatomy, all contemporary meditations on empathy contain earnest accounts of mirror neurons, described as “the most hyped concept in neuroscience”. These cells were first described in the 1990s by the Italian neuroscientist Giacomo Rizzolatti, who studied macaque monkeys. He found that some motor cells (involved in the control of movement) are activated by the sight of the same movement in others (humans and monkeys). Since then, outlandish claims have been made for these neurons, particularly by the Indian-American neuroscientist VS Ramachandran, who believes these mirror neurons are responsible for empathy, language, even civilisation. A sobering review of mirror neurones written by British neuroscientists JM. Kilner and RN Lemon, published in Current Biology in 2013, concluded that we can’t extrapolate findings from monkey studies to humans, and furthermore, we’re not absolutely sure that these cells exist in humans, and even if they do, we’re not sure what their function is. These doubts haven’t remotely impeded the establishment of the new popular science orthodoxy that mirror neurons are what make us human and empathetic. Neurobollocks has escaped from the laboratory and is now the rickety foundation for popular, and populist, books by writers such as Jonah Lehrer, Malcolm Gladwell and many others. Writing in the New Statesman in 2012, Stephen Poole described this phenomenon as “an intellectual pestilence”, and observed how putting the prefix “neuro” to whatever you are talking about gives a pseudo-scientific respectability to all sorts of meretricious rubbish.
Paul Bloom, author of Against Empathy: The Case for Rational Compassion, notes that there are currently 1,500 books listed on Amazon with “Empathy” in the title. From government to health care to education, empathy is the putative fix for all our societal woes. Bloom takes us through the standard exposition of neuroanatomy and fMRI. Teasing out the difference between empathy and compassion, he describes an experiment by the German neuroscientist Tania Singer using as her subject the celebrity French Buddhist monk Matthieu Ricard (“the happiest man in the world”):
While in the scanner, Ricard was asked to engage in various types of compassion meditation directed toward people who are suffering. To the surprise of the investigators, his meditative states did not activate those parts of the brain associated with empathic distress – those that are normally activated by nonmeditators when they think about others’ pain … He was then asked to put himself in an empathic state and was scanned while doing so. Now the appropriate empathy circuits were activated: His brain looked the same as those of nonmeditators who were asked to think about the pain of the others.
Singer trained nonmeditators (“normal people”) to experience either empathy or compassion, and then scanned them: “Empathy training led to increased activation in the insula and anterior cingulated cortex … Compassion training led to activation in other parts of the brain, such as the medial orbitofrontal cortex and ventral striatum [my italics].”
If one can ignore the neuroflapdoodle, his thesis, namely that compassion trumps empathy any day, is refreshing and well-argued: “ … what really matters for kindness in our everyday interactions is not empathy but capacities such as self-control and intelligence and a more diffuse compassion”. He shows how empathy can clash with other moral considerations, and sways us towards the needs of the few over the many:
C. Daniel Batson and his colleagues did an experiment in which they told subjects about a ten-year-old girl named Sheri Summers who had a fatal disease and was waiting in line for treatment that would relieve her pain. Subjects were told that they could move her to the front of the line. When simply asked what to do, they acknowledged that she had to wait because other more needy children were ahead of her. But if they were first asked to imagine what she felt, they tended to choose to move her up, putting her ahead of children who were presumably more deserving. Here empathy was more powerful than fairness, leading to a decision that most of us would see as immoral.
We see this phenomenon in action in contemporary healthcare. A recent opinion piece in The Irish Times by the health economist Anthony McDonnell took the example of the government’s decision to fund the cystic fibrosis drug Orkambi, which costs €100,000 to treat a single patient for a year:
After 10 years of underinvestment, the Irish health system is deeply short of new medical equipment, we are short on doctors, on nurses and we do not have enough hospital beds. At a time when our health system is struggling to stay afloat we should refocus the resources we have, where they can achieve the most good for the greatest number of people possible, rather than cherry-picking people based on how sad their story appears.
Peter Bazalgette, author of The Empathy Instinct: How to Create a More Civil Society, is another new contributor to the empathy book mountain. Bazalgette, a former chairman of the Arts Council, and most famous for the dubious distinction of bringing the vulgar and exploitative Big Brother to British television, is one those panjandrums who run cultural life in Britain. He, too, is entranced by the magic of fMRI:
In the 1990s, fMRI sparked a revolution in brain mapping. The technology has not only changed how we understand our bodies, it’s also given us profound insights into the human mind. The mapping of our emotions using functional brain imaging, now well underway and revealing more every year, is leading to startling discoveries that are changing our understanding of human nature itself.
Citing the work of Tania Singer and the Cambridge-based developmental psychologist Simon Baron-Cohen, he explains the anatomy of empathy:
In 1994, Baron-Cohen identified another region of the empathy circuit – the orbitofrontal cortex … And in 2013, Tania Singer and colleagues at the Max Planck Institute in Germany hit on another piece of the jigsaw. The right supramarginal gyrus helps us to separate our own feelings about a situation from those of the subject of our empathy.
Bazagette’s sketchy understanding of how scientific inquiry works doesn’t inhibit him in the least, and he concludes that therapeutic applications for this neuroanatomical knowledge are just around the corner: “Routine fMRI scans will identify psychopaths and others with an empathy deficit as people requiring special attention. There will be programmes to repair the parts of their brains which malfunction.” Bazalgette might have paid more attention to the behaviour of the “house-mates” in Big Brother: psychopaths and bullies tend to be very skilled in working out the emotions of others.
Citing the scandal at Stafford Hospital, Bazalgette believes that healthcare professionals (and doctors in particular) are in dire need of an empathy injection. He laments the “tendency in doctors towards grandiosity and omnipotence”, taking as his example of this tendency the fictional surgeon Sir Lancelot Spratt, played by the great James Robertson Justice in the Doctor in the House films, seven of which were made between 1954 and 1970. Spratt, writes Bazalgette was “the bombastic, aggressive, megalomaniacal surgeon … [who] harassed the nurses, terrified the junior doctors and treated the patients like unfortunate serfs”. This lazy stereotype of medical consultants as pinstriped bullies has proved remarkably enduring, and impervious to the intrusion of the grim realities faced by contemporary hospital doctors. The answer, Bazalgette suggests, is to get them young, when they are malleable medical students, and re-educate all those embryonic Spratts with “theatre-based” empathy training. Better still, get to them before they even enter medical school: “There is an argument for the screening of all of those in the front line of patient care. This would require the development of new emotional intelligence and empathy tests.” In the near future, he seems to hint, would-be doctors will undergo fMRI scanning to ensure they are empathetic enough.
Paul Bloom correctly argues that empathy can be a hindrance to doctors in their work. He interviewed a doctor:
Christine Montross, a surgeon, weighs in on the risks of empathy: “If, while listening to the grieving mother’s raw and unbearable description of her son’s body in the morgue, I were to imagine my own son in his place, I would be incapacitated. My ability to attend to my patient’s psychiatric needs would be derailed by my own devastating sorrow. Similarly, if I were brought in by ambulance to the trauma bay of my local emergency department and required immediate surgery to save my life, I would not want the trauma surgeon on call to pause to empathize with my pain and suffering.”
Bloom recounts the experience of his elderly uncle, who was treated for cancer:
He seemed to get the most from doctors who didn’t feel as he did, who were calm when he was anxious, confident when he was uncertain. And he was particularly appreciative of certain virtues that have little directly to do with empathy, such as competence, honesty, professionalism, and certainly respect.
Empathy is nevertheless doing a brisk trade in the big business which is now medical education, and the academic journals regularly feature earnest articles claiming that it can be taught to trainee doctors and students. A systematic review published in 2014 in the journal BMC Medical Education identified over 1,400 papers on the subject. One study “sought to build medical student empathy for patients receiving intramuscular or subcutaneous injection by asking medical students to take turns injecting each other with saline solution”. Others used “role playing” and “reflective writing”. Although the authors were keen to promote such toe-curling endeavours, they conceded that “the majority of studies (84%) lacked highly rigorous study designs”.
Dr Helen Riess is a psychiatrist at Harvard Medical School who has come up with a tremendous wheeze. She developed a shaky, unpersuasive scaffolding of neuroscience (the standard stuff about fMRI and mirror neurons) around empathy training for medical students, nurses and doctors, and then set up a for-profit company called EmpatheticsTM, which offers courses in empathy training. (The word “empathetics” gives the impression that this is a new branch of medicine, sounding, as it does, vaguely like “anaesthetics”.) Dr Riess did a TED talk in 2013 called “The Power of Empathy”. After the obligatory opening salvo of neuroflapdoodle, it turns out that her recipe for empathetic dealings with patients consists of the tried and tested manoeuvres of old: eye contact, facial expression, posture, tone of voice and so on. It’s the standard stuff medical schools have been teaching for years. The company’s website advertises a three module course called “Empathetics: Neuroscience of Emotions”, all for $400. Module 1 is “Introduction to the Neuroscience of Empathy”, Module 2 is “Managing Difficult Medical Interactions”, and Module 3 is “Delivering Bad News”. Modules 2 and 3 are the traditional fare of courses provided by medical schools: they are merely given a new gloss by the neurobollocks of Module 1. Riess has even produced a study showing that doctors who had been through her course were rated by patients as being “more empathetic”.
Empathetics is closely related to another American medical movement called narrative medicine, whose high priestess is Dr Rita Charon of Columbia University. It is no coincidence that both narrative medicine and empathetics took root and flourished in the US, where the dominant ethos in medicine is commercial. Both feed into the new consumerism in medicine: what was once a profession is now a service industry. Empathy is now one of the accredited “skills” required by the American Council for Graduate Education in Medicine. Doctors can be trained to simulate the outward expressions of empathy – maintaining eye-contact, giving the “correct” verbal prompts and so on – in this regard the process is similar to acting; indeed, out-of-work actors often find employment as “patients” in such exercises. The title essay of the writer Leslie Jamison’s 2014 collection The Empathy Exams recounts her experience as a medical actor, a “standardised patient” for the training of medical students. These “patients” have to give an evaluation of the students’ performance:
Checklist item 31 is generally acknowledged as the most important category: ‘Voiced empathy for my situation/problem.’ We are instructed about the importance of this first word, voiced. It’s not enough for someone to have a sympathetic manner or use a caring tone of voice. The students have to say the right words to get credit for compassion.
Jamison observed that the students cynically game this po-faced charade:
I grow accustomed to comments that feel aggressive in their formulaic insistence: that must really be hard [to have a dying baby], that must really be hard [to be afraid you’ll have another seizure in the middle of the grocery store], that must really be hard [to carry in your uterus the bacterial evidence of cheating on your husband.] Why not say, I couldn’t even imagine?
Given contemporary medicine’s obsession with empathy, it was inevitable that super-empathisers would emerge. Which brings me to Dr Joel Salinas. Salinas is thirty-four, and part of the new generation of American doctor-memoirists who are driven to pen profundities on life, death and medicine when they are barely out of residency training. He is a Boston-based neurologist, and claims to suffer from a condition called “polysynesthesia”. Chromosynesthesia – where some experience sounds as colours − is well recognised. Salinas, however, has multiple forms of synesthesia, including “mirror-touch” synesthesia, which causes him to feel the pain others experience. His memoir, Mirror Touch: Notes from a Doctor Who Can Feel Your Pain, is a good example of the new genre of medical quest. The protagonist feels different from others, but can’t quite understand why. Childhood and adolescence are lonely and confusing. He meets another person who is just like him: he knows he is not alone. A sympathetic expert doctor takes him in hand, and after a series of tests, finds an explanation for our hero’s difference: it could be Asperger’s syndrome, or ADHD, or gluten sensitivity. The important conclusion is that he is special and different. Our hero finally realises that this difference, this specialness, is not a handicap: it is a gift. In an unintentionally comic aside, Salinas muses on his brother’s colour-blindness: “Rainier embraces his colour blindness as a gift that reminds him, time and time again, that he comes with a distinct experience, a unique perspective.” (Eight per cent of all men are colour-blind: that’s a lot of special and unique people.)
In Wes Anderson’s wonderful film The Royal Tenenbaums, Margot Tenenbaum (Gwyneth Paltrow) is married to the dreary and obsessive neurologist and author Raleigh St Clair (Bill Murray), clearly based on Oliver Sacks. St Clair studies a pre-adolescent boy called Dudley Heinsbergen, who has a rare neurological syndrome characterised by “amnesia, dyslexia and colour blindness, with an acute sense of hearing”. St Clair tours medical schools and hospitals with Dudley, and writes a bestselling book about the boy called Dudley’s World. Joel Salinas is the Dudley Heisbergen of empathy. His memoir has all the key components of the contemporary medical quest memoir: “I knew at an early age I was different, even though I didn’t know why or how I was different … I remember asking my mother why no one seemed to like me.” He visits the laboratory of the famous neuroscientist VS Ramachandran in San Diego (he of mirror neuron fame), where one of the graduate students, David Brang, takes a keen interest: “Within a day of my arrival, David began taking me through a battery of psychometric tests to objectively quantify as many facets of my synesthetic experience as possible in a controlled lab setting.” Inevitably, our hero’s data are “way off the chart”: “Turns out, I was an outlier. My reaction time was not only faster than nonsynesthetes, but also easily at least three times faster than the average synesthete.” After an exhaustive series of tests in the lab, Brang has a moment of inspiration: “Finally, David asked, ‘Do you happen to have mirror-touch synesthesia?’”
The Dudley Heinsbergens of this world like to hold gatherings to celebrate their specialness. In a scene that Wes Anderson might have choreographed, Salinas attends a symposium at the Tate Modern in London “on mirror-touch synesthesia and the trait’s relationship with art”. James Wannerton, the president of the UK Synesthesia Association, is a lexical-gustatory synesthete: “James associates written words and letters with distinct flavours, sometimes as specific as malt vinegar, warm semolina, hair spray.” Salinas meets Fiona, another mirror-touch synesthete, who addresses the group:
I had this experience in America. I was sitting in a car and there was this fury going on between two men over a parking space. One man punched the other, and that was it. I felt it. I felt punched. I passed out. All I had seen was the punch. That was it. The medical team couldn’t place it. They thought I had perhaps had a seizure of some sort. It was only when I returned to the UK that I learned of my mirror-touch synesthesia. I felt validated.
Her fellow-synesthetes are deeply moved: “I looked across audience members and felt the flickering of their wonder at Fiona’s mirror touch, wide-spread wonder and an unmistakable pity.” While in London, Salinas visits the laboratory of the neuroscientist Michael Banissey at University College London, and undergoes yet another round of neuro-psychological tests: “The results were validating. ‘Your results clearly indicate that you are a mirror-touch synesthete,’ the graduate student performing the tests told me.” Salinas and Fiona meet on Skype (the best way for synesthetes to communicate is online), and she confesses:
I often wonder, when you’ve got somebody with something that makes them as sensitive as what I am, or you are, and they’re exposed to conditioning, whether that leads to having no empathy at all or having empathy for everything. I find that, no matter what I’ve been through, empathy prevails. It’s there all the time.
You would think that medicine would be an eccentric career choice for a polysynesthete. As an undergraduate at Cornell, Salinas encounters “the Kayapo, an indigenous tribe in a remote part of the Amazon rainforest”. (I was reminded here of one of the many spoof books in The Royal Tenenbaums, Raleigh St Clair’s The Peculiar Neurodegenerative Inhabitants of the Kazawa Atoll):
… the Kayapo, whom I worked with during my junior year in college as part of an ecological research trip, also translate their emotions into physical pain. A mother mourning the loss of her child, for instance, expressed her sorrow by slicing two-inch crevices in her scalp with a machete. When I met her, it had been years since her son’s death, but her grief was still apparent. Her head was covered with long, ridged scars, which felt like dried wild reeds lying against my own head. A dull ache radiated and draped over my head like a funeral veil.
This experience, he claims, led to his decision to become a doctor:
My experience with the Kayapo helped me realize how empathy – noticing, interpreting, and experiencing – works and how I personally interpreted and experienced the world in a heightened, nearly constant state of empathy … following this trip, I decided to become a healer . . .
He enrols in the University of Miami medical school, and spends some time in Gujarat in India, where he gets his first exposure to obstetrics:
As I watched the obstetricians perform an episiotomy, slicing their surgical scissors across a woman’s flesh, I felt my pelvic diaphragm stretching and nearly shred … I felt desecrated. I felt powerless. Yet no one seemed to notice or care, not even the woman who had just given birth …
During his first week as an internal medicine clerk, he is called to a cardiac arrest:
The sensations in my body mirrored the sensations in his. Compression after compression on his chest and on mine. I felt my own vocal cords tighten as doctors slid a tube down his throat – a sharp object shoved down the back of my throat … I was dying, but I was not … The absence of sensations in my own body, the absence of movement, the absence of breath, a pulse, any and all feeling. In my body, nothing but a deafening absence. I had to step away. I had to will myself to breathe.
The book is full of these self-serving reminiscences: when a patient is undergoing a lumbar puncture (spinal tap), Salinas feels the needle going into his own back; when a trauma patient undergoes an abdominal surgical exploration, he feels the knife going in; dealing with a manic patient, he “had the physical sensation, as if I had just drunk several shots of espresso”. No senior doctor, teacher or mentor, however, had the courage, or common sense, to take Salinas aside and advise him that clinical medicine might not be for him. A wiser head might have advised him to pursue a career as a pathologist, biochemist or laboratory-based researcher. But no, for Salinas, this specialness is a gift, which sets him apart. After all, in an era when doctors are supposed to be empathetic, a super-empathiser like Salinas is surely what we doctors should all aim to be? Salinas found himself “gravitating toward the study of empathy”, and Mirror Touch recites the standard ráméis on mirror neurons: “Today, in the wake of a growing body of evidence, the mirror neuron system is a generally accepted theory about how the brain works.”
Like a modern Charon (the ferryman, not Rita), he guides souls from this life to the next:
… whenever a patient died, I felt as if I had died, too. The feeling never waned. In this regard, I have died many times. Watching patients pass away, I realized in my body the final moments before fading into death … Like Lazarus, I stand regularly at the threshold and behold in the distance an altar with enough space for a new sense of the divine …
Were Raleigh St Clair to write Joel’s World, he might describe Salinas’s syndrome as a rare neurological syndrome characterised by solipsism, humbug and relentless self-promotion.
The moral philosopher Robin Downie has called empathy “the Japanese knot-weed of palliative care”, and many commentators within medicine have questioned whether it is either desirable or teachable. Jane Macnaughton, who teaches medical humanities at Durham University, spoke for many in her 2009 Lancet essay called “The dangerous practice of empathy”:
It is potentially dangerous and certainly unrealistic to suggest that we can really feel what someone else is feeling. It is dangerous because, outside the literary context, where we are allowed direct experience of what a fictional patient is feeling, we cannot gain direct access to what is going on in our patient’s head … Any mirroring of feeling will always differ quantitatively and qualitatively from that patient’s experience. A doctor who responds to a patient’s distress with “I understand how you feel” is likely, therefore, to be both resented by the patient and self-deceiving.
One can be empathetic without being compassionate, just as one can be compassionate without being empathetic. Compassion is not easy, because it is composed of more than just simple human kindness. Compassion also requires courage, competence and that mysterious quality which some call “bottom”. Empathetics and the Narrative Medicine Program at Columbia may be able to teach medical students and doctors glib customer service skills and a superficial carapace of “caringness”, but the regeneration of compassion in our hospitals will require a more fundamental shift in the culture of contemporary healthcare. And neuroscience isn’t going to guide us: whether compassion is located in the head or the heart really doesn’t matter.
Seamus O’Mahony is a consultant physician and a regular contributor to the Dublin Review of Books. His book The Way We Die Now was published this year by Head of Zeus in London and in the United States by Thomas Dunne Books (St Martin’s Press), an imprint of Macmillan New York. The Way We Die Now picked up the British Medical Council Chair’s Choice Award for 2017.