Virtue Ethics in a Value-driven World: When Empathy Clouds Clinical Judgment

After giving an ethics talk recently, I was approached by a surgeon who described an interaction with a patient who had an abscess on her arm caused by intravenous drug use. The patient refused a bedside débridement using local anesthesia and insisted on general anesthesia instead.

The surgeon asked me about the ethics of the case. Shouldn’t scarce operative resources be reserved for those who truly need the operating room? Didn’t the patient, in some way, deserve to feel pain as a result of her illicit drug use?

I was troubled by the suggestion of punitive justice, but instead of critiquing the surgeon, I suggested he use empathy as a proxy for morality, that is, to consider the situation from the patient’s perspective. I believed the surgeon’s obvious stereotyping of an intravenous drug user could be combatted by empathy [3]. Imagine this patient’s life, her own self-hatred causing or arising from her self-destructive behavior; isn’t this patient especially deserving of greater care, given the sad results of her tragic life choices?

The surgeon responded that I truly am a softy, a self-deprecating term I had used earlier in the day. The psychologist Paul Bloom would have a different assessment. He would say that empathy is biased, and because of that, should not be used as the foundation of good medical decision-making.

In his book Against Empathy [1], Bloom explores the unreliability of empathy as a moral foundation. He argues that rather than basing moral decisions on empathy, we should use rational compassion, because using empathy as a moral compass is tricky at best. Bloom defines compassion as “simply caring for people, wanting them to thrive,” and in his work he advocates for “rational compassion,” that is, caring that is cognitive rather than emotional [1]. Whereas empathy might lead us to spend inordinate sums to save the baby who fell down a well, rational compassion may lead us to cure rotavirus and save many babies. Importantly, both empathy and compassion involve caring for others. However, empathy generally involves potential suffering not only by the victim but also by the empathic individual who feels the pain of the sufferer.

When I think of the ideal physician, I envision someone who empathizes with patients in the manner described by Atticus Finch in To Kill a Mockingbird: “You never really understand a person until you consider things from his point of view … until you climb in his skin and walk around in it” [9]. The challenge, according to Bloom, is that human beings are not particularly adept at feeling empathy for those different from us; we have trouble walking around in the skin of others. Functional MRI scanners have shown that our neural responses to other people’s pain depend on our relationship to the individual in pain [8]. We have an increased neural response when we observe someone of our same social group or race in pain versus someone of a different social group or race [13]. When I recommended the surgeon consider the perspective of the patient with the abscess, it is líkely the surgeon’s brain hit a mental roadblock, with the patient seen as the “other,” someone from a different social group, and this resulted in his bias and resultant impaired decision-making. These calculations about pain and suffering are subconscious. Therefore, physicians are unlikely to recognize how such calculations may cloud clinical judgment.

Empathy also has a dark side with respect to punishment [2]. Psychological studies have shown that subjects’ empathy can drive aggression and increased punishment in theoretical, laboratory-based situations [5]. In these studies, an increase in empathy for a victim created aggression toward another (blameless) individual whom the subjects had encountered after their interaction with the victim. A misapplication of empathy may have caused the surgeon in the case above to feel that the patient deserved to feel pain, and the surgeon’s empathic investment didn’t lead to fair judgment.

The fact that empathy can cloud judgment is not surprising when one considers that applying rules fairly often requires neutrality. Empathy can lead us astray when we need to allocate scarce resources. This has been described as the rule of rescue [7], which is not always fair. For example, society often mobilizes tremendous resources to save identifiable individuals in peril [6]. This empathic approach was vividly demonstrated by the rescue of 12 Thai soccer players and their coach in July 2018. The costly rescue effort mobilized thousands of individuals for more than a 2-week operation, ultimately leading to the death of one rescue diver and the rescue of all 13 stranded individuals [4]. During that same period, nearly 1000 individuals died from vehicular accidents in Thailand, which has the second highest road traffic-fatality rate in the world [12]. If the resources spent on the cave rescue had been applied to road safety, many more lives may have been saved. Yet, those lives represent individuals who are unknown and unidentifiable, in contrast to the boys trapped in the cave.

The philosopher John Rawls famously argued for the use of a “veil of ignorance” as the basis of his consequentialist moral philosophy [10]. The concept is fairly simple: The moral action should be based on the known consequences of a potential decision, without knowing whom within a society will benefit. As such, decisions would not be based on self-interest.

The “veil of ignorance” can be useful in clinical medicine. Returning to the woman with the abscess in her arm: What anesthetic approach would a surgeon choose when operating on a patient’s abscess if the surgeon did not know whether the patient was a heroin user or a CEO with no history of drug abuse? Assuming no medical contraindications to general anesthesia, or at least conscious sedation, in either situation (and the surgeon did not suggest there was any medical rationale for his choice), the right choice of anesthetic has nothing to do with the patient’s social circumstances; it is a medical decision. This approach avoids using empathy to drive decision making, given that empathy is an unreliable guide for moral judgment. The “veil of ignorance” relies purely on reason, without the influence of clinically irrelevant information.

Using reason is clearly important, but when patients think of a “good doctor” they likely envision someone with a caring side, a merging of the humanity of a Captain Kirk with the rationality of a Mr. Spock. Does this require empathy? Bloom and others would argue that compassion, rather than empathy, is required.

A neuroscience experiment showed that when individuals are trained to experience empathy or compassion, the empathy-trained group experienced discomfort and distress while the compassion-trained group ultimately felt kinder and more eager to help others [11]. Based on this neuroscience research, I believe physicians should work to be compassionate rather than empathic, both to prevent their own distress and to provide the best medical care.

Looking back on my short conversation with the surgeon described in this essay, I wish I had reminded him that there is no justification in our profession for administering treatment punitively. After addressing the surgeon’s odious behavior (and if he still wanted my advice), I would suggest that he follow Bloom’s approach and function within the cognitive realm of compassion. The patient is suffering. The surgeon does not need to walk in the patient’s shoes to understand this. Here, the clinically best treatment is also the morally best treatment: adequate débridement with some type of sedation, in the emergency department or operating room. The patient’s responsibility for the abscess is clinically and morally irrelevant to her treatment.