Empathy, sympathy and compassion in healthcare: Is there a problem? Is there a difference? Does it matter?

Introduction

Empathy, sympathy and compassion are defined and conceptualised in many different ways in the literature and the terms are used interchangeably in research reports and in everyday speech.¹ This conceptual and semantic confusion has practical implications for clinical practice, research and medical education. Empathy, sympathy and compassion also share elements with other forms of pro-social behaviour such as generosity, kindness and patient-centredness.² There is a need for conceptual clarity if doctors are to respond to the calls to provide more ‘compassionate care’.³ This paper argues that there is currently a problem in the balance between scientific–technical and psychosocial elements of patient care. A broad model of empathy is suggested which could replace the vaguer concepts of sympathy and compassion and so enable improvements in patient care, psycho-social research and medical education.

Is there a problem?

Since the Francis Report which revealed severe failings in patient care in the Mid Staffordshire NHS Foundation Trust, there has been a resurgence of interest in the humanisation of medical care.³ Francis called for a culture change in the NHS to include more compassionate care and this was echoed by the Chief Nursing Officer's recommendation to nurses.^3–5 The essence of dehumanisation is the denial of another person's mental life and dignity.⁶

The question arises as to why people in caring professions cease to show care?⁶ Among the contributory factors identified in the Francis report were: compassion fatigue, overwork, excess demand, lack of continuity and a failure to see the patient as a fellow human being.^3,6 Medicine's positivist view prioritises technical progress, evidence-based medicine, targets and efficiency, so risking a view of patients solely as objects of intellectual interest.⁷ Healthcare professionals may distance themselves from patients, avoiding emotions and focusing on biomedical facts: a process described as ‘existential neglect’.^8,9 The blame culture prevalent in the NHS leads to a punitive climate where a lack of tolerance leads to a loss of learning and the generation of fear.⁹ In such a social environment, the dynamics of power conformity may influence good people to act thoughtlessly.⁹ Mechanistic organisational healthcare systems create a risk of dehumanisation, with a loss of empathy, which can alienate clinicians from patients.^5,9–11 Commercialisation of healthcare leaves people vulnerable to being treated instrumentally, not as ends in themselves in a culture which fosters competition rather than collaboration.⁹ Zulueta¹⁰ identifies the overemphasis of the biomedical model in medicine as another factor threatening the delivery of good psycho-social care.¹⁰

Although the lapses in care reported by Francis and others are not entirely due to a ‘compassion deficit’, the general consensus is that there is a problem in the provision of psycho-social care in all settings and an urgent need to address the balance between scientific and psycho-social care.¹⁰ Concern about a deficit of empathy in clinical practice is mirrored in medical undergraduate education, where there is conflicting evidence of a decline in empathy as students move through their training.^12–15

Is there a difference?

Words that describe human social relationships and subjective emotions may be difficult to define. Empathy, sympathy and compassion are often confused with each other and with a number of other processes involving sharing in another person's feelings especially of distress or suffering.^10,16 Compassion and empathy are often used interchangeably and the close link between them is reflected in Maxwell's term ‘compassionate empathy’ which represents his attempt to clarify the confusion by adopting the broadest term.¹⁶

Empathy

Empathy is a complex, multifaceted, dynamic concept which has been described in the literature in many different ways. So it appears that empathy means different things to different people. The conceptualisation of empathy has evolved in different ways relating to differing disciplines such as medicine, nursing, philosophy, psychology and counselling. This evolution can be best illustrated by addressing four dimensions of empathy: affective, cognitive, behavioural and moral. However, in practice, these four dimensions interact and overlap to differing extents in differing contexts in different clinical situations.

Affective (emotional) empathy

Theodor Lipps (1851–1914) used the term Einfuhlung (feeling into) to explain how people become aware of each other's mental states.¹⁷ Einfuhlung was a process of inner resonance with the other, an ‘emotional contagion’, a state in which the observer takes on the emotion of the other person.¹⁷ Affective empathy is the ability to subjectively experience and share in another's psychological state or feelings.¹⁸ Sharing the emotion (affective matching) may lead to empathic distress or concern which precedes and contributes to helping behaviour.¹⁹ In affective matching, the doctor experiences the same type of emotion as the patient; this process also involves cognitive evaluation and imagination.²⁰ Our emotional lives inevitably are linked to our actions so there cannot be a rigid distinction between action and attitude. As perception is context-specific, empathy can be conceptualised as a form of perception where people can literally feel the emotional states of others as their own.²¹

Cognitive empathy

Cognitive empathy is the ability to identify and understand another person's feelings and perspective from an objective stance.¹⁸ This cognitive requirement differentiates empathy from sympathy and compassion. Cognitive empathy has been described as ‘detached concern’ or the ability of one individual to understand the experiences of another without evoking a personal emotional response.²² Cognitive empathy has been conceptualised as an active skill that is acquired and is amenable to nurturing.^23–26

Edward Tichener used the Greek word empatheia to translate Einfuhlung and was first, in 1909, to coin the term ‘empathy’.²⁷ Stein emphasised the intersubjective and relational aspect of empathy and claimed that empathy enabled us to understand others and also to understand ourselves as others experience us. This relational component was another important development of the construct of empathy.²⁸

Carl Rogers, the founder of humanistic psychology, placed empathy at the heart of his patient-centred psychotherapy.²⁹ For Rogers, when we empathise, we enter the world of the other and become at home in it, regarding empathy, like Stein, as a relational process. Rogers felt that there was a risk of over-identifying with the patient which then may distort understanding and threaten the therapeutic process.²⁹

It is necessary here to distinguish between self- and other-orientated perspective taking. In self-orientated perspective taking, I imagine what it is like for me to be in your situation, a form of identification.³⁰ This assumption of similarity leads people to conclude that others will think and feel as they do. So we do not just fail to understand the patient's experience, we assume we do and this can lead to a new set of problems: mistakes in prediction, false assumptions and personal distress in the observer.²⁰ This self-orientated perspective, exemplified in sympathy rather than empathy is shown by the doctor who says ‘I know how you feel’. Another of the many problems with a self-orientated perspective is that the doctor focuses on his/her own distress and this may result in them distancing themselves from the patient as a way of relieving their distress.²⁰ Doctors who take a self-orientated perspective are at risk not only of personal distress but eventually burnout.³¹

In contrast, an other-orientated perspective avoids the false assumptions, prediction errors and the personal distress experienced by those taking a self-orientated perspective.²⁰ Empathy starts with curiosity and imagination.³² I imagine being the patient undergoing the patient's experience rather than imagining being myself undergoing the patient's experience. This more sophisticated approach requires mental flexibility, an ability to regulate one's emotions and to suppress one's own perspective in the patient's interests. To adopt the patient's perspective, one has to have some background knowledge of the patient and the context in which she suffers. Halpern describes the need to ‘decentre’ rather than detach, stepping aside from one's own emotional perspective and imaginatively viewing the situation from the patient's position while not submerging in identification with the patient by retaining a sense of the self–other boundary.³²

Behavioural empathy

Irving's three-dimensional model of empathy proposes that the doctor has to understand the patient's world (cognitive), feel with the patient (affective) and communicate this understanding with the patient (behavioural)³³ Derksen et al.³⁴ conceptualise the three-dimensional model of empathy as comprising attitude (affective), competency (cognitive) and skill (behaviour). Coplan defines empathy as: ‘Empathy is a complex imaginative process in which an observer simulates another person's situated psychological state (both cognitive and affective) while maintaining a clear self-other differentiation’. For Coplan, empathy involves the following steps: affective matching, other-orientated rather than self-orientated perspective taking and self–other differentiation.²⁰ Decety extends the definition of empathy to include helping the patient.³⁵ Mercer's definition also includes action; empathy in a clinical situation includes an ability to: (a) understand the patient's situation, perspective and feelings (and their attached meanings); (b) to communicate that understanding and check its accuracy; and (c) to act on that understanding with the patient in a helpful (therapeutic) way.³⁶ Halpern also claims that empathy needs action, ‘empathy without action is not empathy’.³² Bondi³⁷ emphasises the maintenance of the self–other boundary: Empathy is a process in which one person imaginatively enters the experiential world of another without losing an awareness of its difference from one's own.

Moral empathy

Morse identifies a moral component as a fourth dimension of empathy; an internal motivation of concern for the other and a desire to act to relieve their suffering by caring and driving acts of altruism.¹⁸ There is evidence to support the claim that empathy increases motivation to perform pro-social and altruistic acts so overlapping with notions of compassion.^38,39

Feminist care ethics maintains that moral thought and action require both reasons and emotions as well as attention to the needs of particular others^40–42 From a care ethics perspective, the practice of caring is integral to the moral life and empathy is an important element of caring. Noddings thought that empathy was an essential tool for developing our understanding of others and enabling us to decide what is the best course of action in practice⁴¹ For Noddings, care closely relates to empathy since caring depends upon attending to the specific needs of particular patients and attempting to understand the situation from the patient's point of view.⁴¹ Slote adds that empathy maintains the motivation to care.⁴³ A moral issue of authenticity also arises in connection with empathy. In everyday experience, we instantly recognise the ‘have a nice day’ approach of fake empathy. It is not sufficient to mimic the patterns of speech or behaviours which appear empathic, there must also be authentic concern.^44,45

Maxwell¹⁶ proposes that empathy can be conceived as a competence or disposition which plays a role in enabling moral judgement and so is basic to moral functioning. Hilifker argues that a fundamental goal of teaching ethics in medicine should be to foster a sense of empathy.⁴⁶

Sympathy

Sympathy is the broadest of these terms, signifying a general fellow feeling, no matter of what kind. Sympathy is an emotion caused by the realisation that something bad has happened to another person.¹ The triggers of sympathy can be mild discomfort to serious suffering. In defining empathy, some authors contrast the concept with sympathy, which has been defined as experiencing another's emotions, as opposed to imagining those emotions.⁴⁷ It has also been described as concern for the welfare of others.⁴⁸ Some authors feel sympathy is a wholly distinct concept from empathy, while others maintain that sympathy overlaps with the emotional component of empathy.^32,36,49 Sympathy may slide into a feeling of pity or feeling sorry for the other person.⁵⁰ Sympathy takes a ‘self-orientated’ perspective which may arise from an egoistic motivation to help the other person in order to relieve one's own distress. In taking such a self-orientated perspective, the doctor risks being distressed or overwhelmed.⁵¹

Compassion

Compassion, a word derived from the Latin meaning ‘to suffer with’ has, like empathy, varied and confusing definitions in the literature. Chochinov's definition describes compassion as a deep awareness of the suffering of another coupled with the wish to relieve it.⁵² Charlton, reflecting the conceptual confusion surrounding compassion concludes that it is almost indefinable.⁵³

Compassion, like sympathy, is evoked when something bad happens to another person, but compassion is generated by more serious states. It implies a desire to help but does not necessarily result in a helping action.¹ Compassion highlights engagement and commitment to relieve suffering reflecting our need for social relationships.⁵⁴ Tronto⁵⁵ emphasises the two-way relationship involved as the healthcare professional has needs as well as the patient. Compassion in its drive to alleviate suffering also shares elements of altruism. However, one can feel compassionate concern for another without making any attempt to understand their feelings and point of view. Nussbaum⁵⁶ argues that compassion is more intense and involves a greater degree of suffering in the patient and the doctor than empathy.

The differences

For some, empathy is a part of compassion, while others feel compassion is a result of empathy.^9,53 Some authors view compassion as having cognitive components which makes the differentiation from empathy even more unclear.^9,10,57 Smajdor⁵⁰ conflates compassion with emotional empathy and links it with distress and burnout. Contemporary social psychology admits a distinction between empathy, sympathy and compassion but then treats them as variations of the broad affective phenomena they wish to consider.⁵⁸ This constellation of constructs are often then collectively referred to as empathy.⁵⁸ Maxwell¹⁶ summarises this confusing situation: ‘When it comes to “empathy” the waters of terminological confusion run deep indeed” I argue, however, that despite this complexity, empathy is the preferable term to replace ‘sympathy’ or ‘compassion’ in clinical care.²

Empathy does include elements of sympathy and compassion, but it also carries pertinent connotations that both sympathy and compassion lack.¹⁶ Empathy clearly involves imaginative involvement and although it is possible for both sympathy and compassion to be mediated by imaginative involvement, these terms typically refer to reactive and unreflective responses whose features require no great psychological acumen to appreciate. Empathy seems to suggest a response to situations whose features are more subtle, imperceptible and complex which require both affective and cognitive skills to perceive, share, understand and put into action.

Empathy is a skilled response, while sympathy and compassion are reactive responses, which is why developing the skill of empathy is a more realistic goal for medical education, whereas teaching compassion seems counterintuitive.¹⁶ For Maxwell,¹⁶ empathy involves capacities of moral sensitivity, both opening oneself to the other's subjective experience and getting judgements about the others’ subjective experience right (empathic accuracy). Maxwell proposes the term ‘compassionate empathy’ to resolve this conceptual confusion but I argue that a less confusing solution is to develop a broad conceptualisation of empathy which is of particular relevance in a medical setting. Here, we are concerned with empathy in the sense of feeling distress in solidarity with a suffering person so that we might respond appropriately in order to help.^2,16 Empathy is the preferred term because empathy, more than sympathy and compassion, connotes not just reactive distress at another's suffering but considered, justified and hence rational distress.¹⁶ The empathiser is able to resonate with the patient's emotions yet remain aware of what is distinct in that patient's experience. Empathy is a form of engagement that seeks both cognitively and affectively to make sense of another's experience while preserving and respecting difference. This is in contrast to compassion which does not necessarily involve cognitive understanding of the others’ views.

However, the current use of the term empathy in healthcare is at risk of being equated with empathy in the narrower cognitive sense.^59,60 The ‘detached concern’, cognitive model of empathy, has characterised a narrow conceptualisation of empathy in medicine. This makes little of the affective component of empathy, whereas the word compassion puts the emotional affective element of empathy at its core. However, compassion then crucially lacks the cognitive elements of empathy.³² Motivation in compassion may be misguided, unlike the case in empathy which requires understanding of the other's view and so forms a part of phronesis or practical wisdom. Some authors argue that a motivation to help creates a distinction between compassion and empathy, but this paper argues that a motivation to help others is integral to empathy.¹⁰

The empirical nature of compassion is not well understood, it involves the presence of suffering and a desire to relieve it in a dynamic relationship which may change over time. There is a debate as to whether it can be nurtured or is simply an innate quality of the person. There is an inherent tension in linking the intangible nature of compassion to concrete institutional initiatives mandating compassion as a right.^3,4 Research into compassion and its influences in medical is less developed than that into empathy providing a pragmatic reason for preferring empathy as the construct of choice.¹³

A broad model of empathy with clear components encourages researchers and medical educators to study and teach the construct, whereas the vaguer notions of compassion are much more difficult to research or to teach.¹⁶

Does it matter?

Empathy is generally regarded an essential component of the doctor––patient relationship but doctors have always struggled to achieve a balance between empathy and clinical distance.^16,20,32 Doctors can choose between a narrow technical approach based on their competence or a broader more humanistic approach which is more ambiguous and less reductionist.³² The central question seems to be how to empathise without becoming overwhelmed and burning out? However, it appears that detachment is not necessary for sound medical judgement because emotional insights can and should inform clinical decision-making.^32,61 Empathy is critical for diagnosis and for effective treatment, doctors need empathy to learn more of the patient's situation. So empathy supplements objective knowledge and technology. By allowing the patient to participate more fully in decision-making, empathy supports patient's autonomy.

There is some evidence that doctors with high empathy scores have more job satisfaction and less burnout.^62,63 Despite the literature in support of empathy in medical training and practice, this has not been translated into effective actions and attitudes.³⁵ Empathy has been linked to improved patient satisfaction,³⁴ better concordance with medical advice,⁶⁴ decrease of anxiety and distress,⁶⁵ improved diagnosis⁶⁶ and clinical outcomes.^34,67 Perhaps the best understood pathway by which empathy improves health outcomes is in the generation of trust between the patient and doctor.^68–70

Empathy is a way of seeing the world from a patient's point of view. Empathy is involved in perspective-taking capabilities which enable students and doctors to gain insight into the ethical aspects of clinical problems.¹⁶ Empathy is person-focused not condition-focused, i.e. it relates to a particular person in a particular condition. The other-regarding of empathy involves empathic distress or a healthy concern for others who are suffering. Empathic distress motivates the action to help and must be differentiated from the personal distress arising from a self-orientated perspective of sympathy which can result in burnout. ^71,72

Conclusion

This paper argues that a broad concept of empathy, being more complex and nuanced than compassion, is a more relevant and useful construct for clinical practice, medical research and education.⁷³ A review of the literature reveals a broad concept of empathy, which is appropriate in the medical setting, which combines affective, cognitive, behavioural and moral dimensions.² These dimensions vary in expression according to the individual patient, healthcare professional and to their clinical situation.⁷⁴ Empathy is a dynamic process which is dependent on the clinical context and occurs in a reciprocal relationship with a patient. It comprises the following features:²

• Connection: involving emotional sharing with the patient in a two-way relationship.

• Clinical curiosity: to gain insight into the patient's concerns, feelings and distress, giving patients a sense that they matter.

• Another-orientated perspective: the doctor tries to imagine what it is like to be the patient and to see the world from the patient's perspective.

• Self–other differentiation: this respects the patient as an individual with dignity.

• Care: acting appropriately on the understanding gained to help the patient.

A benefit of this model of empathy is that it focuses on developing skills, attitudes and moral concern rather than just urging medical students and doctors to be more compassionate.³² By accepting rather than resisting their own emotions, doctors can stay involved in care without despair.³² Caring involves some degree of identification of a person as a human being with the same needs and deserving the same respect as oneself this is part of the moral force of empathy.⁷⁵ Empathy, unlike compassion or sympathy, is not something that just happens to us, it is a choice to make to pay attention to extend ourselves. It requires an effort.⁴⁴

Declarations

Competing Interests

None declared.

Funding

I am grateful for a Myre Sim Bursary from the Royal College of Physicians of Edinburgh in 2013.

Ethics approval

No research on human subjects so approval was not needed.

Guarantor

DJ

Contributorship

Sole authorship

Acknowledgements

I am grateful to Marilyn Kendall, Marie Fallon and Michael Ross for their wise supervision of my PhD research.

Provenance

Not commissioned; peer-reviewed by Hazel Thornton.