Big Ideas That Percolate into Clinical Ethics

Abstract

I. INTRODUCTION

Hope, culture, death, society, empathy—these words convey multifaceted, diverse, ideas and phenomena that inspire, intrigue, and capture our imagination. Like water emanating from faraway sources that percolate into unexpected nooks and crevices carrying residue from their journeys, these types of ideas seep into diverse contexts, shaping terrain and being shaped by the residue of their diverse manifestations as they stimulate reflection and raise deep and profound questions. Philosophers throughout history have long been drawn to big, important ideas that bubble up to the surface in interesting ways in myriads of disparate contexts. In this issue of the Journal of Medicine and Philosophy dedicated to clinical ethics, the authors continue that time honored tradition and consider a host of diverse topics, including the importance of hope in healthcare understood through the lens of project theory, the WEIRDness of Western cultural assumptions in clinical ethics, the appropriate aims of hospice and palliative medicine (HPM) for those dying, the proper role of society in pharmacovigilance, and the epistemic role of empathy in genetic counseling.

Despite the wide diversity of topics, perhaps what unites these essays is that each, in some way, focuses on a big, age-old, multifaceted idea that has seeped into the particular crannies of clinical ethics. Hope and empathy are intellectually interesting concepts both inside and outside clinical contexts. Likewise, reflection on what constitutes a good death, which is important for both hospice and palliative care medicine, is also an important question for any person to consider. The assumptions in the background of Western culture are important for clinical ethics but can also help illuminate widespread ethical disagreement outside the clinical context. Finally, as modern technology allows for unprecedented data collection from the public, how best to incorporate society into scientific data collection is an important question both inside and outside of clinical settings. In what follows, I will briefly interact with each of this issue’s essays by reconstructing central claims, offering critiques, and raising questions.

II. AN INTRODUCTION TO THIS ISSUE’S ARTICLES

Where There’s Hope, There’s Life: On the Importance of Hope in Healthcare

Steve Clark and Justin Oakley (2024) present an insightful and thought-provoking essay on the nature and importance of hope in medicine using prospect theory as an illuminating lens. In the first part of the essay, the authors compare and contrast different conceptual analyses of hope and settle on the following account: “To hope for an outcome is to desire (be attracted to) it, to assign a probability somewhere between 0 and 1 to it, and, in situations in which it is possible to influence the probability of it occurring, to judge that there are sufficient reasons to engage in certain feelings and activities directed toward it” (Clark and Oakley, 2024, 15). They then discuss a less commonly recognized reason for why hope is important in clinical medicine: “...hope has a further consequence that often benefits patients, which is that it tends to change patient attitudes to risk, making them more willing than they would otherwise be to accept risks in order to try to attain states of good health” (Clark and Oakley, 2024, 16).

To explain how these changes in attitude occur, Clark and Oakley engage prospect theory.¹ As they explain, prospect theory involves three core claims:

1. We evaluate risks in comparison to a “reference point.” Outcomes understood as being superior to this reference point are regarded as gains. Outcomes understood as being inferior to this reference point are regarded as losses.

2. We are loss averse. Losing hurts us psychologically more than winning benefits us psychologically.

3. We experience diminishing sensitivity to gains and losses in proportion to their relative distance from a reference point. (Clark and Oakley, 2024, 17)

These core claims lead to an observation that people tend to be “risk averse in regard to risky opportunities that may take them above their reference point, and risk seeking in regard to threats to take them below their reference point” (Clark and Oakley, 2024, 17). The reference point for individuals can be shifted, however, by goal setting: People tend to “regard a result that falls short of a goal as a loss, and a result that meets the goal or exceeds it as a gain” (Clark and Oakley, 2024, 18).

In the healthcare setting, this means that patients tend to be “risk-seeking when making attempts to prevent further deterioration of their health, and risk averse with respect to attempts to improve their health from its current state” (Clark and Oakley, 2024, 18) which can create barriers to their successful treatment. These barriers can be overcome, however, if healthcare professionals are able “to persuade a patient to adopt a particular goal, such as the goal of returning to a former state of health” (Clark and Oakley, 2024, 19) because in doing so the patient’s “reference point shifts and they will tend to be risk seeking in regard to any outcome that falls short of that goal” (Clark and Oakley, 2024, 19). Healthcare professionals can persuade patients to adopt particular goals by imbuing the patient “with the hope of regaining a previous state of health” (Clark and Oakley, 2024, 19). As Clark and Oakley note, “when a patient embraces a particular hope, they also embrace the goal of realizing that hope and their adoption of this goal shifts their reference point, changing their attitude to risk” (2024, 19). At the end of their essay, the authors focus attention on the importance of responsibly imbuing hope. They argue that physicians should avoid imbuing patients with false hope² which is “epistemically unjustified hope” (Clark and Oakley, 2024, 20) and involves deceptively inducing the patient “to take on an attitude to risk that she does not endorse” (Clark and Oakley, 2024, 20) or inducing the patient “to take on an attitude to risk that is irrational” (Clark and Oakley, 2024, 20). They note that “if a doctor knowingly attempts to instill hope in a patient by targeting a decision-making weakness which the patient prefers not to influence their decisions, and the patient is thereby led to become risk-seeking due to their newfound hope shifting their goal and hence their refence point, the doctor is unjustifiably manipulating this patient” (Clark and Oakley, 2024, 21).

Clark and Oakley provide a helpful framework through which to understand various aspects of patient and physician decision-making. If we begin by examining the account of hope they ultimately adopt, some interesting questions emerge. Recall that on their account hope involves (1) desiring an outcome, (2) assigning a probability to that outcome, and (3) “in situations in which it is possible to influence the probability of it occurring, to judge that there are sufficient reasons to engage in certain feelings and activities directed toward it” (Clark and Oakley, 2024, 15). Consider now the following case:

Case #1

Dan is a 50-year-old man with cancer and advanced chronic kidney disease. He is married to his wife of 25 years, Sheila, and they have three young girls, Tammy (12), Evelyn (10), and Cindy (6). His oncologist tells him that there is an ~ 30% chance of living five years or longer with aggressive treatment of his cancer but that there is a high likelihood that during the process his kidneys will fail. If his kidney’s do fail, he would need to start dialysis to continue the cancer treatment. If he decides to do nothing, he will likely die from the cancer in six months. Dan’s father had been on dialysis at the end of his life, and Dan had always told himself that he would rather die than do dialysis. When faced with the decision as to whether to pursue the aggressive cancer treatment, Dan desires to live another five years with his wife and children and understands the probability of achieving this outcome is 0.3. He also understands that he could influence the probability by engaging in the cancer treatment and submitting himself to dialysis treatment if needed. When he considers the prospect of a 70% chance of dying despite the aggressive therapy and likely having to undergo dialysis in the process; however, he judges that these reasons are not sufficient to agree to the treatment. He is not hopeful for a five-year survival, and if he just considered himself, he would say no and pursue hospice. However, he also loves his wife and his daughters, and he feels an obligation to continue to be in their lives as long as possible to support and provide for them. Despite the aggressive treatment he would still be able to work to provide for his family and could even do dialysis at home at night if that were required. His wife has told him that she loves him and does not want him to die. His children have also told him that they need him and that they want him to be a part of their lives as long as possible as they grow up. Dan judges that it is his moral obligation to try to stay alive for his family even if that chance is low, and it involves a life that he would otherwise not have chosen. He does not feel hopeful, but he does steel himself with resolve and determines to do everything he can to survive the cancer.

In this case, Dan desires to live for another five years and does not think it is impossible, just unlikely and associated with unwanted aspects. It is possible for him to influence the probability of achieving it through his actions, and he has judged “that there are sufficient reasons to engage in certain feelings and activities directed toward it” (Clark and Oakley, 2024, 15). However, it does not seem like Dan has hope. He has courage and resolve in spite of not having hope and has determined to act in ways to achieve the outcome, but these are not flowing from hope but from a judgment regarding duty. If this intuition is correct, Dan meets the definition of hope presented by Clark and Oakley but does not have hope. Why? It seems that the problem with Dan’s case is that even though he judges that there are sufficient reasons to engage in feelings and activities towards the outcome he desires that may, in fact, be identical to feelings and activities someone with hope would have and pursue, Dan’s reasons don’t seem to be the right type of reasons to give hope. And it is hard to pinpoint exactly why that is the case.

Perhaps it has to do with Dan’s desires. They seem to be complex in a situation like this. The “outcome” involves a state of affairs in which some aspects are things Dan really desires—being with his wife and children—and other aspects are things Dan really wants to avoid—being on dialysis. Maybe the desires are of equal intensity. When coupled with a relatively high five-year mortality rate, it seems reasonable that Dan might judge that all-things-being equal it would not be worth it to pursue aggressive cancer therapy. However, all things are not equal. Dan has a family and as such he has obligations that he recognizes to his family. These moral reasons are what ultimately tip him over to pursuing the treatment—not an overwhelming desire for the outcome itself. Practical rationality can be divided into prudential rationality having to with self-interest and moral rationality, having to with moral obligations and values. Does hope only involve the former? Perhaps not. Perhaps Dan has hope but hope in something different than previously thought. Perhaps the outcome that Dan has hope for is not for his own flourishing but for the flourishing of his family and to fulfill his duty to his family. If that were the case, then it would be true that Dan would be attracted to that outcome, that he could assign a probability to it occurring between zero and one and judge that there are sufficient reasons to engage in certain feelings and activities directed toward it.

If this is the case, then it may help to explain certain end-of-life situations that are common and possibly misinterpreted by healthcare professionals. In clinical ethics consultation, it is not uncommon to be consulted when there are disagreements between a primary team and family regarding the continuation of life-sustaining treatment at the end of life. These cases are often presented as if the family has an irrational hope that their family member will survive, and it is the outcome for which they are hoping. Certainly, this might be the case in some or even many of these circumstances, but there also might be something else going on, something different. Perhaps what the family is hoping for is not that their loved one will survive but that they will act in a way that is faithful to that loved one while they die.³ That is, the outcome that is desired may be different than what is thought. I can certainly imagine situations in which the family desires for their loved one to recover and thinks that there is a very small probability for recovery, which would continue to be present if they continued life-sustaining treatment, but also judge that these reasons alone are not enough to continue life-sustaining treatment. However, they might also hope that they act in a way that is faithful and loyal to their loved one and, rightly or wrongly, judge that this would involve giving their loved one every opportunity to survive—even an opportunity with a very low likelihood of success. They might also judge that in this outcome—being faithful—they can succeed, and they might also judge that there are sufficient reasons to engage in activities and feelings toward achieving this outcome. These activities might look very similar to activities that they would pursue if the outcome was the patient’s survival itself. Interestingly, in these types of situations, the outcome is self-directed rather than patient-directed, while in Dan’s case, the outcome is other-directed rather than patient-directed.

The Weird Trio: Examining Physician Ethics in Pluralistic Societies

Lester Liao argues that “a people’s ethics reflects its culture” and that most medical students in North America reflect a WEIRD culture—western, educated, industrialized, rich and democratic (2024, 25). This WEIRD culture gives rise to the WEIRD trio—three orienting ideas through which ethics is framed and interpreted: secularism, individualism, and existentialism. Liao points out that the background worldviews of patients, however, may be radically different and offers a brief description of how these orienting ideas are themselves particular ways of viewing the world:

I want to show that the weird trio is a very particular way of understanding the world. It is not a default position, and it is not shared by many cultures. This is crucial to recognize in a multicultural world where many patients do not subscribe to the intellectual history of the West. The inability to see how our positions are not immediately evident to those around us is a serious defect. (2024, 26)

Liao’s project is primarily descriptive, presenting and probing the potential epistemic pitfalls in interactions between patients and their WEIRD providers; however, Liao also briefly points out potential strategies that may move the patient and the WEIRD provider toward mutual understanding. First, Liao suggests that we should look for shared moral intuitions and learn to “identify and communicate them in a language that is mutually understood” (2024, 33). Second, we should deliberately expose ourselves to different ways of thinking—what he calls “cognitive contamination” (Liao, 2024, 30).

Liao makes important points in his essay. Physicians should not assume that they share the same ontological, metaphysical, epistemological, political, metaethical, and ethical background beliefs as their patients. While most of the time, patients and physicians agree and work together toward common ends, these background beliefs matter and can lead to radical disagreement, turning physician and patient into “moral strangers” who simply see morality differently and who struggle to find ways to reach agreement.⁴ In this point, Liao echoes the judgement of diverse and influential thinkers in bioethics, such as Edmund Pellegrino and H. Tristram Engelhardt, Jr.

After arguing that the unique nature of illness and the patient–physician relationship creates an environment in which agreement between patient and physician is common, Edmund Pellegrino notes:

Even with this agreement there remains broad areas in which there is no consensus. A philosophy of the physician-patient relationship is not the whole of medical morality. One cannot have a complete medical morality unless one has taken a stand on several levels of medical-moral discourse. First, the one I have been talking about: What are the obligations of a professed healer, simply in virtue of making that profession? We can come to a common agreement at this level because the phenomena of illness, medicine, and the act of medicine have foundations we can observe. This will not tell us how we should act in the face of specific medical moral dilemmas—what to do in the case of abortion, euthanasia, the prolongation of life, the care of the infant with multiple deformities, behavior control, genetic engineering, and all the other medical-moral problems of the day. On these important issues we are not likely to agree unless we are in agreement at two deeper levels. One level has to do with what we think man is, what his nature is—our philosophy of man....The other level has to with our opinions about a source of morality outside of man, a transcendental source, that stands over and beyond man (2006, 70)

Tristram Engelhardt often pointed out that differing background worldviews can lead to differing ethical beliefs. In his last major work, Engelhardt noted the wide gulf that exists between traditional Christian bioethical beliefs and secular bioethical beliefs:

Moral strangers are persons with whom one has no common way to resolve moral and bioethical disputes either through sound rational argument and/or by an appeal to a commonly recognized authority. Such a gulf separates traditional Christians (and for that matter Kantians) from the secularists of the now-dominate secular culture. Each experiences and understands reality in a fundamentally different fashion. Because all is seen with different frameworks of meaning, there will inevitably be conflicts between traditional Christianity’s and the dominant secular culture’s understanding of proper conduct and bioethics... (2017, 262-263).

Liao’s suggestions for ameliorating potential disagreement are also instructive. We often do share moral intuitions with others, and this can be a starting point for discussion and dialogue. Also, it is important to first focus on mutual understanding rather than using dialogue to debate or diminish differing opinions. Intellectual honesty and generosity are virtues. It is exhibited and developed when we habitually seek to understand and reconstruct the beliefs and arguments of our interlocutors in ways that are both accurate and fair. To do this, however, we must understand the terms that are being used. In our current modern moment, it is especially important to carefully define our terms. Many disagreements involve complex, normatively loaded concepts that share a common name but differ widely in meaning and extension. As tedious as it might sound to some, it is important to define terms and to try to identify how we disagree as the conceptual prolegomena to debates about particular positions. Finally, it is important to test our beliefs by engaging with others who disagree with us. This reflects another epistemic virtue—intellectual humility. If our ultimate aim is truth and we can acknowledge that we sometimes make mistakes, then we will want to test our beliefs to better understand the reasons we hold them and how they fit into our greater web of beliefs.

The Role of Hospice and Palliative Medicine in the Ars Moriendi

Levi Durham (2024) argues that Hospice and Palliative Medicine (HPM) should not simply be organized around mitigating suffering but should rather pursue a broader goal of promoting health. Durham first affirms an Aristotelian understanding of medicine: “medicine is a practice that aims at health...” (2024, 37). Durham then argues that HPM is a subdiscipline of medicine and as such, shares the same general aim of medicine in promoting health. This aim applies also at the end of life and is vital to the art of dying—the ars moriendi. While relieving suffering is part of promoting health at the end of life, it is not the only or even most important end to be pursued. To promote health at the end of life involves “empowering patients to die well by lessening their suffering in order to allow them to engage during their own death” (Durham, 2024, 37) while focusing solely on relief of suffering potentially leads to a usurpation of “the patient’s role in engaging during the death” (2024, 39). Drawing on the Roman Catholic tradition, Durham (2024) notes that the art of dying well involves not just relief of suffering but also active engagement within a community that helps the patient prepare for death and set her life in order. Durham notes, however, that “dying well is both a gift and a task, the patient must take it up voluntarily. It cannot be forced” (2024, 41). At the end of life, some patients may only wish to be made comfortable, and Durham (2024) affirms that HPM should honor those wishes. Durham presents two cases illustrating how, depending on the case, HPM aiming at promoting health may look very different or very similar to HPM that aims only at preventing suffering.

Durham’s essay raises an interesting question about dying a good death. The central claim in the essay is that dying well involves more than the relief of suffering. On Durham’s account, during the dying process, relief from suffering is itself an intrinsic good, but it is not the only intrinsic good and not necessarily the most important intrinsic good. Relief of suffering also operates as an extrinsic good allowing the pursuit of other goods, such as sustaining agency at the end of life to pursue activities that promote a good ending to one’s life. For Durham, these activities usually involve communal interactions such as pursuing closure, attempting restoration of relationships, and helping loved ones prepare for the transition into a life in which one is no longer present.

However, what if someone has a radically different view of what activities are involved in a good death? Is a “good” death, defined in terms of broadly pursuing good ends at the end of life, possible without some objective standard of goodness that determines what counts as a “good” end? At some points, Durham seems to indicate that the goods at the end of life are primarily subjective in nature.

If HPM seeks to alleviate all forms of suffering, it runs the risk of diminishing the patients’ role: it can overstep into the realm that patients themselves should oversee. On the view that HPM aims at health, it promotes the dying patient’s ability to participate in the goods that are important to the patient. The patient’s own activity is paramount.... By not seeking to address the other aspects of the dying patient’s suffering, HPM creates space for patients, supported by their community, to exercise their agency and play the dying role by pursuing the goods that are the most important at the end of one’s life (2024, 40).

There is likely to be widespread agreement that all-things-being-equal pain at the end of life is bad, and pain relief is good. Pain, however, can be justified if it leads to some greater good—but that seems to be the rub. What counts as a greater good that justifies not totally eliminating the pain if that is possible? For Durham, agency at the end of life is very important. Over-aggressive pain control can eliminate agency. But does any autonomous exercise of agency at the end-of-life count as a good death? Durham, in the case of Jasmine Claude, envisions a person who chooses to tolerate a certain degree of pain in order to exercise her agency at the end of life to organize her funeral, write her obituary, and have final conversations with family and friends. These seem like good or at least normatively neutral ends to pursue at the end of life. Consider the following case, however:

Case #2

Mr. Alloway is a 75-year-old male with metastatic pancreatic cancer with metastases to the bones. He is currently in inpatient hospice and reports a great deal of pain. He tells his physician, Dr. Pippin, that despite his pain, he wants to remain lucid to be able to interact with his family, but his resolve is wavering. Mr. Alloway likely only has a few days to live, and Dr. Pippin realizes that Mr. Alloway could easily be persuaded to take IV pain medication that would leave him comfortable but unable to exercise his agency. Dr. Pippin has noticed that when his family comes to his room Mr. Alloway is abusive, insulting, and belittles them constantly. He constantly threatens to leave them without any inheritance, and he enjoys making them afraid and exerting control over them. In fact, Mr. Alloway seems to get a disturbing amount of pleasure in emotionally torturing his family. One day after an especially egregious episode which Dr. Pippin witnessed, Dr. Pippin spoke to Mr. Alloway’s daughter, Ann. Ann tells Dr. Pippin that her father has always been physically and emotionally abusive to his family. She reports that her mother has lived in constant fear of him and under his control for 30 years. All of her income was kept in a bank account controlled by Mr. Alloway, and Mr. Alloway has run up quite a bit of debt due to his gambling habits. She worries that her father will make good on his threat to withdraw the money and give it away for spite in order to inflict a final bit of pain on the family before he dies, leaving their mother with his unpaid debts.

What would a “good” death for Mr. Alloway look like? Or perhaps, alternatively, what would the “least bad” death for Mr. Alloway look like? Should Dr. Pippin persuade Mr. Alloway to simply take the IV pain medication and drift off to sleep so that he cannot exercise his agency to continue to abuse and abandon his family, or should he encourage Mr. Alloway to bear some pain so that he can maintain his agency and pursue the ends that he has chosen to prioritize at the end of his life, even if those ends are morally bad? If your intuition is that Dr. Pippin would be helping everyone, including Mr. Alloway, by persuading him to take the IV pain medication, thereby diminishing his agency and rescuing his family from his vicious behavior and that this would be a better death not only for Mr. Alloway’s family but for Mr. Alloway as well, then that implies that the ability to exercise agency and pursue one’s preferences is not sufficient for a good death. The exercise of agency at the end of life must be directed at good ends, and those good ends are not simply ends that one desires but rather ends that are good according to some objective standard of goodness. Using one’s agency to emotionally manipulate, control, and inflict harm on others simply aren’t good ends, even if that is what Mr. Alloway prefers. It seems that more than the mere exercise of agency is needed at the end of life to die well. Agency in the pursuit of objectively good ends is also required.⁵

Is There a “Best” Way for Patients to Participate in Pharmacovigilance?

Austin Due (2024) tackles an important issue in the pharmacological care of patients—postmarket pharmacovigilance. He writes, “A cornerstone of pharmacovigilance is the ‘spontaneous reporting’ of suspected adverse drug reactions (SADRs) to regulatory databases. From these reports, signals can be detected that prompt studies into drugs’ side effects that may not have been known in the pre-market trial process. However, it is estimated that over 90% of SADRs go unreported...” (Due, 2024, 46). One way to increase the reporting of SADRs is to involve patients in the process. Due lays out multiple models of public-engaged research and ultimately argues that the most appropriate kind of public participation in the process of reporting is “contributory participation where members of the public donate or volunteer data to a project initiated and carried out by professional researchers” (2024, 48). He then turns to developing a framework for different models of contributory participation in the reporting of SADRs. Due argues that each model should balance three broad sets of goals: bioethical, social epistemic, and pragmatic. He then looks at three different models: patient-dominant, “where patients actively report their SADRs, largely removed from clinician interactions and directly to databases,” industry led, “where patients do not initially seek out amongst themselves to report but are spurred on by private industry,” and patient-physician, “where patients are prescribed drugs, and the patient’s SADRs are tracked by the patient in consultation with their physician” (Due, 2024, 50). Due then looks at each model and reflects on how well they would be able to meet bioethical, social epistemic, and pragmatic goals. Through this reflection, Due arrives at three principles that should guide the ultimate choice of model to be implemented. First, “undue or preventable harms ought not befall patients/reporters” (Due, 2024, 52). These harms may arise from nocebo effects or from a failure to protect patient privacy. Second, “the social epistemic aims of pharmacovigilance should not be hindered in collection, analysis, or distribution” (Due, 2024, 52). Whichever model is used should try to minimize reporting nocebo effects that aren’t causally related to the drug and not reporting actual bad effects that are causally related to the drug. Finally, “proposals ought to account for existing practical constraints in clinical practice (Due, 2024, 52). These constraints include over-burdening physicians who are already struggling to meet the demands necessitated by modern clinical medicine.

Due’s analysis provides a cogent and carefully considered approach to the problem of pharmacovigilance. With technological and informatics advances, postmarket pharmacovigilance with active patient participation on a large scale has moved from the realm of wishful thinking to that of real possibility. Due provides a broad but still helpful normative framework to evaluate different concrete programs to improve postmarket reporting of SADRs. As with any framework that comprises multiple principles, questions will inevitably arise regarding balancing the principles. Due affirms that the bioethical criterion is most important, but does that mean that this criterion operates as a constraint on action or just carries more normative weight than other principles? Should the possibility of any patient harm be allowed? If so, how much? Is there a threshold of probability of harm that would disqualify a program? In addition, are there absolute thresholds for the other criteria as well? And once any absolute thresholds have been met, is there a common metric that can be used to judge the aggregate value of a proposed program, or are we simply left with different programs reflecting different valuations of the various criteria?

Another question that arises is how should we think about proposals that seemingly meet all three criteria? Due notes that deciding between proposals in this type of situation might require “knowing to what degree each criterion is met, or the degree of probable success the two suggested approaches will have in meeting the criteria” (2024, 53). Another possible approach, however, is to admit that there may be more than one approach that is normatively acceptable and, in these cases, accept that other factors may be determinative in whether to implement one type of program rather than another. I see no reason why there would have to be a one-size-fits-all solution to collecting SADR data, and multiple normatively acceptable programs might provide flexibility to better meet the exigencies of particular needs in particular contexts. In this way, Due’s framework provides a useful “floor” that any proposed program would want to meet, but once met, it would not preclude other criteria from being used to judge among alternative options.

Communicating Genetic Information: An Empathy-Based Framework

In a fascinating and timely essay, Betzler and Roberts (2024) argue for an empathy-based framework for communicating genetic information. They begin by exploring the two main models currently used in genetic counseling—the teaching model and counseling model—each with its advantages and disadvantages. Betzler and Roberts then go on to develop an empathy model that purports to combine both standard models. First, however, they explore the multifaceted concept of empathy and choose to emphasize its epistemic function:

When thinking about empathy in the context of genetic counseling, then, we need to start with the question: For what empathy? What should it help us to do? Starting here helps us not only to create the right theoretical framework for genetic counseling practice, but also to formulate the right measures for that practice. To this end, we provide a model of empathy that serves the heavy informational demands of genetic counseling. The view that we outline here emphasizes the epistemic functions of empathy—the potential for empathy to facilitate understanding and provide the clinicians with deeper knowledge of their client (Betzler and Roberts, 2024, 64).

How does empathy enhance the epistemic faculties of the genetic counselor? Betzler and Roberts point to how empathy aids in active listening by illuminating both facts that are being conveyed and the feelings behind the fact which in turn serves an epistemic function for both the clinician and client: “Active listening—and the empathy that is part and parcel of this process—therefore produces two kinds of knowledge. The clinician, on the one hand, gains knowledge of the client’s situation and perspective—both factual and feeling dimensions....The client too, however, gains a form of self-knowledge...They better understand the meanings that facts hold for them and how to respond to those meanings” (2024, 64).

Betzler and Roberts go on to distinguish between two types of empathy—cognitive empathy that involves “understanding what people are thinking and feeling but without feeling those feelings oneself” and emotional empathy that involves “feeling what the other individual is feeling, or what one takes another to be feeling” (2024, 66). They argue that their epistemically oriented account of empathy includes both dimensions and that the emotional component aids in obtaining a deeper understanding. Finally, in an important addendum to their framework, they acknowledge that humility is an essential part of the process: “Engaging in the dynamic process of empathy involves knowing that you do not know; empathy does not provide you with a full picture of the other person, but rather functions as a bridge for further inquiry” (Betzler and Roberts, 2024, 67).

Betzler and Roberts put forth an intriguing framework that deserves attention. One question that arises from their account involves the concept of empathy they are employing. It has both a cognitive component—understanding what someone else is feeling—and an emotional component—feeling what one takes another to be feeling. Both of these components are supposed to serve the same end—a certain type of knowledge attainment. But is the emotional component necessary for this type of knowledge attainment? Consider a typical science fiction example: a robot with an advanced artificial intelligence program that is trained on the emotional, behavioral responses of billions of human interactions and is also able to accurately perceive subtle physiological changes in human beings such as increases in heart rate, respiratory rate, pitch of voice, etc. when human beings are experiencing particular emotional states. As a result, the robot is able to accurately recognize the emotional responses of human beings and able to predict the “emotional weight” or attitude that accompanies a human being’s perception of an experience. In fact, it is more accurate than most human beings at doing this sort of thing. Does the robot have empathy? It seems that it is able to obtain the knowledge that Betzler and Roberts are after, but it does not feel anything. So, is empathy simply any process that leads to the attainment of the particular knowledge that Betzler and Roberts are interested in or is empathy necessarily tied up with feeling particular ways? Is the emotional element simply a way of increasing the accuracy of one’s epistemic faculties to better attain knowledge acquisition, but it is not really necessary for empathy, or without it, does empathy simply not exist anymore? Would the robot’s ability to recognize subtle physiological cues serve the same epistemic function as a human being’s ability to feel emotions—simply enhancing the ability to attain the right kind of knowledge?

Another important question that arises from Betzler and Roberts’ account is whether empathy is, in fact, epistemically illuminating—especially if one takes empathy to include emotional elements. It seems possible that trying to feel what one takes another to be feeling might be just as likely to lead one into error as it is to lead one into a better understanding of that person. For example, when one feels sad because one believes another is feeling sad the sadness one feels is modulated by one’s own background experiences, memories, beliefs, etc. All of the particularities that make a person who they are are in the background of these feelings and create the danger of projecting something of ourselves, potentially foreign and distorting, onto the other person. Perhaps attempts at emotional sympathy would be epistemically illuminating, but perhaps not. Perhaps it could lead us to form false beliefs. Admittedly, Betzler and Roberts note the importance of combining humility with empathy in the counseling process. This seems wise. If one can recognize one’s attempts at common feeling are moving one away from better understanding, then perhaps humility would involve giving up the attempt and pursuing a more cognitive approach through careful questioning and listening.

III. CONCLUSION

Big ideas resonate widely and can percolate into unexpected places both within and outside clinical medicine. In this issue of the Journal of Medicine and Philosophy our authors explore big ideas and arguments in the context of clinical ethics. Their analyses and arguments reverberate not only within the particular contexts of clinical medicine but also in other broad and diverse areas of life.

REFERENCES

Footnotes