Dr Paulina Taboada
Profesor Centro de Bioetica
Pontificia Universidad Catolica de Chile
Alameda 340 Correo Central 1
Illness and suffering are first and foremost subjective experiences. Since one cannot have direct access to another's person consciousness, the question about the possibility of gaining an access to another person's conscious experiences rises especially in the context of the care for terminally ill patients.
To provide a proper account for intersubjectivity has been a major philosophical problem. The diverse philosophical answers proposed throughout history have had an impact on medical practice and ethics. So, for instance in the 18th. Century, Hume's conception of 'sympathy' was applied to the task of developing a medical ethics by one of Hume's friends -- the Scottish physician and medical ethicist John Gregory (1724 - 1773). Gregory was concerned about the practice of medicine in his time. He thought that physicians were putting their own monetary interests first, focusing on themselves, and neglecting the needs of their patients. He found in Hume's concept of sympathy a basis for a more humanitarian practice of medicine and made this concept the core of his medical ethics (Gregory, 1770; McCullough 1999). Gregory's conception gave origin to the image of the 'sympathetic physician.' Sympathy gave a basis for a more humanitarian practice of medicine and made this concept the core of his medical ethics.
The Humean conception of 'sympathy' demands that one suffers the same that another is suffering: "I come now to mention the moral qualities peculiarly required in the character of a physician. The chief of these is humanity; that sensibility of heart which makes us feel for the distresses of our fellow-creatures, and which, of consequence, incites us in the most powerful manner to relief them. Sympathy produces an anxious attention to a thousand little circumstances that may tend to relief the patient; an attention which money can never purchase. (Gregory, in McCullough 1998, p.38).
Following Hume, Gregory uses 'humanity' and sympathy' interchangeably. His views gave origin to the image of the 'sympathetic physician'. Sympathy is what binds people together in society. However, this kind of 'emotional conversion' would prevent us from understanding the other in his 'otherness'. Moreover, the application of Hume's concept of sympathy to medical ethics may paradoxically result in the defense of selfish motivations. For, if it is my own uneasiness in the face of suffering which moves me to action, then, by relieving the other person's suffering, I am really relieving my own suffering. Thus, a critical analysis of Hume's account on sympathy shows that rather than establishing the feasibility of intersubjectivity, this account paradoxically undermines it (Welie 1998, Mc Cullough 1999).
Alternative understandings of sympathy and its role in ethics have been developed by some 20th. Century phenomenologists (e.g. Scheler, Stein). I think that their views can shed light on the current search for a 'more compassionate medical ethics' (Singer, 1994). Indeed, an attempt to show the fruitfulness of Scheler's analysis of sympathy to providing a cogent foundation for medical ethics has been recently undertaken by Welie (1998). Further contemporary efforts to clarify the role of compassion in medical ethics have been undertaken by Pellegrino & Thomasma (1988), Thomasma & Kushner (1995), Dougherty & Purtilo (1995), and others. Nevertheless, the question is far from being settled. Indeed, at the bottom of the current bioethical debate on the need for a 'more compassionate medical ethics' a fundamental ambiguity about the precise nature of compassion still persists.
In this context, Edith Stein's (1980) understanding of 'empathy' as the capacity to grasp the object of another person's conscious experiences, offers interesting perspectives. Stein notes that the possibility of attaining intersubjective knowledge seems self-evident, at least to a certain extent. But on the other hand, it is also evident that we do not have an immediate apprehension of another person's thoughts and conscious activity. It is only through bodily events (e.g. blushing, smiling), body movements, or communication through language that we gain an access to the other person's inner world.
Hence, it should be noted that when we perceive the 'other', we perceive always his body as a totality. Moreover, we perceive the 'other' always as being in a given situation. We do not perceive, by itself, frowns and redness in the face. We perceive a person who in a certain situation becomes red. It is this totality - the 'body in situation'- that allows us to grasp, for instance, that this other person is angry. In isolation, the gesture would mean nothing. We perceive the other person's body as a totality and his gesture as having practical significance. We may refer to this as a 'body language', a language that at times communicates more eloquently than speech. Moreover, each person develops a certain corporeal 'style', a certain bodily bearing which identifies the lived body as own.
Health care personnel in general - and particularly those working in palliative care - should pay special attention to the 'body language' of their patients. Moreover, they should make an effort to learn the unique 'style' of each patient. This effort will certainly result in a better care.
Dr. Paulina Taboada, MD, PhD Palliative Care and Bioethics