This is the introductory essay in our series on understanding others’ feelings. In it we will examine empathy, including what it is, whether our doctors need more of it, and when too much may not be a good thing.
Empathy is the ability to share and understand the emotions of others. It is a construct of multiple components, each of which is associated with its own brain network. There are three ways of looking at empathy.
First there is affective empathy. This is the ability to share the emotions of others. People who score high on affective empathy are those who, for example, show a strong visceral reaction when watching a scary movie.
They feel scared or feel others’ pain strongly within themselves when seeing others scared or in pain.
Cognitive empathy, on the other hand, is the ability to understand the emotions of others. A good example is the psychologist who understands the emotions of the client in a rational way, but does not necessarily share the emotions of the client in a visceral sense.
Finally, there’s emotional regulation. This refers to the ability to regulate one’s emotions. For example, surgeons need to control their emotions when operating on a patient.
Another way to understand empathy is to distinguish it from other related constructs. For example, empathy involves self-awareness, as well as distinction between the self and the other. In that sense it is different from mimicry, or imitation.
Many animals might show signs of mimicry or emotional contagion to another animal in pain. But without some level of self-awareness, and distinction between the self and the other, it is not empathy in a strict sense. Empathy is also different from sympathy, which involves feeling concern for the suffering of another person and a desire to help.
That said, empathy is not a unique human experience. It has been observed in many non-human primates and even rats.
People often say psychopaths lack empathy but this is not always the case. In fact, psychopathy is enabled by good cognitive empathic abilities - you need to understand what your victim is feeling when you are torturing them. What psychopaths typically lack is sympathy. They know the other person is suffering but they just don’t care.
Research has also shown those with psychopathic traits are often very good at regulating their emotions.
Why do we need it?
Empathy is important because it helps us understand how others are feeling so we can respond appropriately to the situation. It is typically associated with social behaviour and there is lots of research showing that greater empathy leads to more helping behaviour.
However, this is not always the case. Empathy can also inhibit social actions, or even lead to amoral behaviour. For example, someone who sees a car accident and is overwhelmed by emotions witnessing the victim in severe pain might be less likely to help that person.
Similarly, strong empathetic feelings for members of our own family or our own social or racial group might lead to hate or aggression towards those we perceive as a threat. Think about a mother or father protecting their baby or a nationalist protecting their country.
People who are good at reading others’ emotions, such as manipulators, fortune-tellers or psychics, might also use their excellent empathetic skills for their own benefit by deceiving others.
Interestingly, people with higher psychopathic traits typically show more utilitarian responses in moral dilemmas such as the footbridge problem. In this thought experiment, people have to decide whether to push a person off a bridge to stop a train about to kill five others laying on the track.
The psychopath would more often than not choose to push the person off the bridge. This is following the utilitarian philosophy that holds saving the life of five people by killing one person is a good thing. So one could argue those with psychopathic tendencies are more moral than normal people – who probably wouldn’t push the person off the bridge – as they are less influenced by emotions when making moral decisions.
How is empathy measured?
Empathy is often measured with self-report questionnaires such as the Interpersonal Reactivity Index (IRI) or Questionnaire for Cognitive and Affective Empathy (QCAE).
These typically ask people to indicate how much they agree with statements that measure different types of empathy.
The QCAE, for instance, has statements such as, “It affects me very much when one of my friends is upset”, which is a measure of affective empathy.
Cognitive empathy is determined by the QCAE by putting value on a statement such as, “I try to look at everybody’s side of a disagreement before I make a decision.”
Using the QCAE, we recently found people who score higher on affective empathy have more grey matter, which is a collection of different types of nerve cells, in an area of the brain called the anterior insula.
This area is often involved in regulating positive and negative emotions by integrating environmental stimulants – such as seeing a car accident - with visceral and automatic bodily sensations.
We also found people who score higher on cognitive empathy had more grey matter in the dorsomedial prefrontal cortex.
This area is typically activated during more cognitive processes, such as Theory of Mind, which is the ability to attribute mental beliefs to yourself and another person. It also involves understanding that others have beliefs, desires, intentions, and perspectives different from one’s own.
Can empathy be selective?
Research shows we typically feel more empathy for members of our own group, such as those from our ethnic group. For example, one study scanned the brains of Chinese and Caucasian participants while they watched videos of members of their own ethnic group in pain. They also observed people from a different ethnic group in pain.
The researchers found that a brain area called the anterior cingulate cortex, which is often active when we see others in pain, was less active when participants saw members of ethnic groups different from their own in pain.
Other studies have found brain areas involved in empathy are less active when watching people in pain who act unfairly. We even see activation in brain areas involved in subjective pleasure, such as the ventral striatum, when watching a rival sport team fail.
Yet, we do not always feel less empathy for those who aren’t members of our own group. In our recent study, students had to give monetary rewards or painful electrical shocks to students from the same or a different university. We scanned their brain responses when this happened.
Brain areas involved in rewarding others were more active when people rewarded members of their own group, but areas involved in harming others were equally active for both groups.
These results correspond to observations in daily life. We generally feel happier if our own group members win something, but we’re unlikely to harm others just because they belong to a different group, culture or race. In general, ingroup bias is more about ingroup love rather than outgroup hate.
Yet in some situations, it could be helpful to feel less empathy for a particular group of people. For example, in war it might be beneficial to feel less empathy for people you are trying to kill, especially if they are also trying to harm you.
To investigate, we conducted another brain imaging study. We asked people to watch videos from a violent video game in which a person was shooting innocent civilians (unjustified violence) or enemy soldiers (justified violence).
While watching the videos, people had to pretend they were killing real people. We found the lateral orbitofrontal cortex, typically active when people harm others, was active when people shot innocent civilians. The more guilt participants felt about shooting civilians, the greater the response in this region.
However, the same area was not activated when people shot the soldier that was trying to kill them.
The results provide insight into how people regulate their emotions. They also show the brain mechanisms typically implicated when harming others become less active when the violence against a particular group is seen as justified.
This might provide future insights into how people become desensitised to violence or why some people feel more or less guilty about harming others.
Our empathetic brain has evolved to be highly adaptive to different types of situations. Having empathy is very useful as it often helps to understand others so we can help or deceive them, but sometimes we need to be able to switch off our empathetic feelings to protect our own lives, and those of others.
Tomorrow’s article will look at whether art can cultivate empathy.
Empathy is generally defined as the identification with, and understanding of another person’s situation, feelings and motives. While empathy and sympathy are two closely related notions, I believe that the subtle difference between them can be found in the idea of “identification”. For, while sympathy says “I understand how you feel and commiserate with you,” empathy goes a step further and says “I feel what you feel”. Such an ability to project oneself into another’s experience can only be rooted in a love for humanity.
Is it possible for a physician to be scientifically proficient and objective while also being empathetic? Theoretically, yes; but practically, it depends on the physician’s motives for being in the profession. It all goes back to this love for humanity, which Plato associates with a love for the art of medicine. I do not take this “love” to necessarily mean a warm, fuzzy feeling toward patients, nor a wallowing in commiseration with them. Rather, I see it as an ability to suffer long, to be kind, to not parade oneself, and not behave rudely. Most importantly, I take that love to mean seeking the highest good of the patient. Such a love, coupled with the understanding that the art of medicine, as Blumgart puts it, is “the skillful application of scientific knowledge to a particular person,” can be a strong motivation to continually seek both scientific proficiency and a deeper understanding of a patient. This is all the more important that about half of the patients who consult a physician reportedly have no organic disease or only minor disorders. Objectivity and empathy are not mutually exclusive notions in patient care, as long as the highest good of the patient remains the primary goal.
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