Abstract
Empathy in physician–patient relationship is widely discussed and debated as a critical input that helps to enhance the effectiveness of a therapeutic process and to improve the well-being of the patient and the physician. This article, based on relevant literature, which includes theoretical insights and conducted studies of empathy, presents a brief thematic review of empathy, with a specific focus on the role played by it in physician–patient relation and the usefulness of a patient-centred approach and empathetic understanding in enhancing positive health outcomes. Further, while examining the challenge to empathy in India’s current health care scenario, this study maintains that, amidst difficult circumstances, instances of empathetic behaviour still prevail and empathy hopefully has a definite role to play in India’s medical care.
Keywords
What Is Empathy?
The word ‘Empathy’ is said to have its origins in the German word ‘Einfulung’ which literally means ‘feeling within’. Tichener coined the term ‘empathy’ from two Greek roots, em and pathos (feeling into). Empathy is a quality, an ability to enter into the life of another person, to be able to accurately perceive his or her current feelings and their meanings. According to theorists of psychological therapy, empathy is vital in any interpersonal process. In medical care, empathy when communicated helps to evolve an effective relationship between a physician 1 and a patient.
Empathy is complex to understand, has umpteen dimensions and the theory of empathy is deeply rooted in philosophy and spans many disciplines like Sociology and Psychology. It is not easy at all for human beings to fully express the essence of their inner being to another, but in empathy such an attempt is made. Macarov summarises the varied uses of the word empathy to make three compact divisions:
Taking the role of the other, viewing the world as he or she sees it, experiencing his or her feelings Being capable of reading non-verbal communication, interpreting the feelings underlying this communication Giving off a feeling of caring, or sincerely trying to understand in a non-judgemental and helping way (Macarov, 1978).
We can view empathy as an aspect of human personality, or as a behaviour, or as an experienced emotion. A component definition of empathy given by Morse (Mercer & Reynolds, 2002) features four important attributes: emotive, moral, cognitive and behavioural. In the emotive component, the physician should be able to subjectively experience and share in patient’s inner feelings and her psychological state. The moral component involves the physician’s internal altruistic force that motivates the practice of empathy. In the cognitive component we see the physician’s intellectual ability to identify and understand patient’s feelings very objectively. And finally, behavioural component involves a communicative response of the physician to convey understanding of patient’s perspective.
Empathy and the Physician–Patient Relationship
Developing Empathy
An empathetic process has to be understood in terms of its critical features. Empathy involves trying to understand immediate, current feelings of the patient. So, for instance, it would be improper on the part of the physician to base his behaviour towards his patient solely on his past experiences as such past experiences can interfere with the current interactive process. The empathy factor attains preciousness at the very moment of encounter between the patient and the physician, or else if timely help is not given, it would be no help. An empathetic understanding requires the physician to go beyond what the patient says, and see and find meaning in what the patient ‘is’.
In empathy, the physician will borrow the patient’s feelings, but he is always a separate self, and throughout knows that the feelings of the patient are not his own feelings. In sympathising lies a fear that a physician may identify so much with the patient that he may actually find himself in the place of his patient (Kalisch, 1973). Such a behaviour may obscure attempts to truly know a patient and her feelings. In empathy, a better process prevails as physician concentrates more on the patient and his viewpoint. This may be no easy feat: how can a physician borrow a patient’s feelings, and yet remain a separate self?
Pemberton’s (1972) elaborate interpretations on different types of physician–patient relationships can be insightful in developing a context for empathy. Her first view defines the doctor–patient relationship as an ‘I–It’ relationship. Here, the doctor is active and independent and the patient is passive and dependent. The doctor needs to be objective in his encounter and the patient fully depends on him to get a proper diagnosis. But in reality, we know that the patient is not an ‘It’ and is a ‘Thou’, As much as the physician’s objectivity is important, the person-hood of the patient is also important. So the first view is rejected. The second view considers both these factors, and tries to include the ‘I–It’ component and the ‘I–Thou’ component. The ‘I–It’ relationship is the impersonal and objective component of the relation and the ‘I–Thou’ component is the personal, subjective component. This sort of view entails dual feature. In one, the physician alternates between treating the patient as an ‘It’ (objective) and as a ‘Thou’ (subjective). The other type results in an arbitrary separation of the patient into soul (subject) and body (object). But even here, there is a fear that in these dual states, the ‘I–It’ relationship can predominate and prevail over the ‘I–Thou’ relationship; thus giving a small insignificant place to the latter. Therefore, the third refined and inclusive view describes the doctor–patient relationship as fundamentally an ‘I–Thou’ relationship (the personal and subjective component), but the only constant challenge here is to maintain the physician’s objectivity. This problem is solved by understanding the ‘I’ both as a person who relates to his fellow-man and as a person who is the soul of his body. Here, ‘I’ has a comprehensive interpretation which allows for the objective stance of the doctor to be a part of the I–Thou relationship, without treating the patient as an ‘It’. Pemberton feels that any doctor–patient relationship is truly to be seen as a ‘person-to-person encounter’ in which both doctor and patient remain ‘I’s’.
The Role of Empathy in physician--patient relationship
Till the twentieth century, for a physician, compassion in thinking was considered an essential input for understanding human nature and through compassion, a physician would be expected to get motivated enough to take care of patient and become a good effective healer. Osler (Pembroke, 2007) later argued that such a practice may interfere with objective judgement and suggested ‘detached concern’ or what we call ‘equanimity’ to understand patient’s physical and emotional needs. Detached concern is also a form of empathy, but here physician’s or patient’s emotions do not interfere with the objective judgement of the physician.
Empathy plays a crucial supplementary role along with the other process of objective judgement, and the use of technology in medical care. How can empathy help the process of objective judgement? Empathy actually can help the physician not to overlook certain critical features of the patient which might never get deciphered if we use detached concern. In the words of Halpern (2001), ‘the pursuit of a correct diagnosis requires a full, as well as accurate understanding of patient’s problems. Empathy involves discerning aspects of a patient’s emotional experiences that might otherwise go unrecognised...’.
Another very important use of empathy according to Halpern is to help a patient regain ‘psychological autonomy’. Empathy gives a patient the needed support to process difficult information. For instance, if empathy is provided, a patient can better cope up with the news that she suffers from say a severe illness, and she can be more enabled to participate in the process of her recovery.
When we conceptualise empathy as a detached concern, we view it mainly as a cognitive understanding of the subjective experience of the patient. But empathy involves both cognitive and affective elements. Pembroke opines that genuine empathy involves not just feeling and recognising what the suffering of the patient feels like, but genuinely reaching out to the other. Succinctly put, ‘It is an imaginative projection into her inner world of experience’. In the Western religious traditions, ‘going out of the self’ has been referred to as ‘Ekstasis’ 2 (Pembroke, 2007). So the goal of empathy is to imaginatively understand ‘what it feels like to be in the patient’s actual, individual life, feeling what the patient is feeling’, rather than what one would feel in her situation, and this requires the physician to distinguish between oneself and the patient.
Does empathy interfere with an objective and scientific assessment of a physician? On this Halpern strongly puts it that in understanding a patient, partly cognitive and partly emotional aspects are involved, and the physicians must have or rather develop the proper skills to effectively use their emotional responses in any good medical therapy or care. Every illness episode is an experience for a patient; it has a meaning for the patient. So the physician needs to have ‘emotional resonance’ to connect to the patient and provide holistic healing care.
As medical technology expands and new advances take place in diagnostic procedures and the treatments, ‘dehumanisation of medical encounter’ takes place and the relationship between the doctor and the patient becomes less and less humane and impersonal. Technologies like CT scan, MRI, X-rays increase the wedge between the physician and the patient, as the physician at times need not even have a personal encounter with the patient, as he has access to these tools to get a feel of the patient’s illness. Pembroke feels that such diagnostic procedures reduce a human being to an X-ray film or any image and ‘abstract a disease from its living context’ (Pembroke, 2007). In this sense, we could view empathy as playing a gap filling role, to reduce this newly created wedge between technology and the person.
Arguments for empathy are often seen as a counter to views of the current biomedical approach. Whereas the biomedical approach is based on diseasecentred care, the empathetic understanding underscores the relevance of a patient-centred approach. It revolves around the issue of whether disease and pathogens are more important in care, or whether along with these, the patient’s illness experience should be also taken into consideration. But in reality, can one ever deny the ever expanding role that technology plays in current diagnostics/modern medical care? It emerges then that what we actually need is a synthesising approach which embraces empathy and patient-centred care, along with an acceptable role which technology plays and deserves to play in a patient’s life.
In the meantime, new theoretical formulations and reformulations in the application of clinical empathy in physician–patient relation evolve. The recent focus of thinking is a kind of patient-centred approach in which the physician makes a collaborative sort of effort with his patient to be empathic. Current theories base empathy on an imagined experience of patient’s illness, and they stress on the need for a collaborative experience of illness. Garden (2007) warns that such approaches must not get influenced by power relations. For instance, in a collaborative effort, a physician should not let his superior power position (he is more knowledgeable than the patient) obstruct his empathetic understanding and he should still keep in mind that no matter how powerful he is as a ‘knowledgeable person’, a patient is still an authority in his or her illness experience.
Empathy, Patient-centred Approach and Health Outcomes
The patient-centred approach draws from a thinking which includes the interpersonal and social aspects of patients’ lives along with biological processes. Studies on empathy are primarily meant to understand its effects on health outcomes and often they explore physician patient communication and understand in what way empathy either singularly or together with other positive attributes helps not just to evolve a better therapeutic relation, but to improve patient and physician well-being.
A lot of research has gone into evolving various measures of empathy. Defining empathy as a predominantly cognitive attribute that involves an understanding of experiences, concerns and perspectives of another person combined with a capacity to communicate this understanding, Hojat (2009) believes that clinical empathy can lead to positive patient outcomes, greater patient satisfaction, lower costs of medical care and lower rate of medical errors and even helps to improve well-being of the physician. Hojat advocates the use of empathy education to train all kinds of health care providers and has prescribed 10 approaches for enhancing empathy in the health care environment some of which include improving interpersonal skills, exposure to role models, role playing, studying literature and the arts, improving narrative skills, among others.
Hojat and his research team at Jefferson Medical College developed the Jefferson Scale of Physician Empathy (JSPE), 3 an instrument to measure empathy in medical care, which specifically targets medical students, physicians and other health professionals. In a significant study which tries to validate this scale on two cohorts of medical students, scores on JSPE declined during the medical school, the decline in empathy was observed to be highest for the later years of medical schooling. In every year, women scored significantly higher over men in the measure of empathy. Hojat’s team conducted two more cross sectional studies, one on Italian physicians and the other on Japanese medical students to confirm the psychometrics of the JPSE scale, and to see if there are differences between empathy scores of men and women. Women scored higher over men for both these studies, resulting in an observation that there could be differences among gender in displaying an attribute like empathy (Crandall & Marion, 2009).
In a clinical encounter, the word ‘enablement’ describes the effect of a clinical encounter on a patient’s ability to cope with and understand his or her illnesses. Mercer et al. (2001) collected 200 valid questionnaires from 230 consecutive outpatients attending the Glasgow Homoeopathic Hospital, an NHS facility that integrates complementary and orthodox approaches. Measures included three aspects, a patient enablement instrument, perception of the doctor’s empathy and knowing the doctor well.
Enablement was not directly related to the length of consultation, but correlated with the patient’s perception of the doctor’s empathy. When this was done, empathy emerged as a critical input in enablement. No patient reported a high enablement score with low empathy score. 4 A recent study on empathy by Michigan State University demonstrated that trust and empathy shown in a physician patient relationship is good not just to make patients comfortable, but helps the patients to relieve stress and even increase pain tolerance. Patients were randomly assigned to one of two types of interviews with a physician before they underwent an MRI scan. In the patient-centred approach, doctors addressed all types of concerns about their patients and also listened to them about their personal, social life and their illness. The other set of patients were asked limited questions about their medical history and drugs. Post-interview questionnaires revealed that the former patients reported better confidence and greater satisfaction levels. Even when the patients were later exposed to an MRI scanner, the former patients showed greater pain tolerance, 5 indicating that an empathetic encounter was much more fruitful.
Is Empathy Possible in India’s Health Care?
Having accepted the importance of ideological construct of empathy in practice of health care, one needs to see if empathy can be best utilised to get better health outcomes and bring about systemic transformation in our society. Though no one shot solution to empathetic provision exists, in real world of health care, examples of empathetic behaviour do exist, and so do challenges to its application. We examine these by considering the following notions of empathy, as applied to India’s health care scenario.
Individual v/s Collective Dimension of Empathy
The Micro (Individual) Dimension of Empathy
To better understand empathy and the challenge in its application to India’s health care, one needs to separate the micro dimension of empathy which pertains to the relationship between a physician and a patient, from the macro dimension of empathy which pertains to the larger context of provision of overall empathetic health care. At individual level, empathy can be viewed at best as a cognitive attribute of a person (physician) that benefits both the physician and the patient towards a better health outcome. In the larger macro context, it matters whether the collective conscious of Indian health system, with its vast levels of organisational networks and providers can deliver truly empathetic care in a society. The micro dimension is the sole individual responsibility of the physician; whereas the efforts at macro level can lead to a systemic transformation in society, a task which faces challenges.
Francis Weld Peabody once stated,
The treatment of a disease may be entirely impersonal; the care of a patient must be completely personal. The significance of the intimate relationship between the physician and the patient cannot be too strongly emphasized, for in extraordinarily large number of cases, both diagnosis and treatment are dependent on it, and the failure of the young physician to establish this relationship accounts for much of his ineffectiveness in the care of his patients. (1927)
Health care is essentially a market like any other. There is a provider (physician, the seller) and there is a receiver (patient, the buyer). But health care is a market like no other—it has peculiar characteristics, one such being the informational asymmetry between the seller and the buyer. The physician knows information about the patient which the patient knows little about or does not know at all (diagnosis of illness, treatment). In such a circumstance, when a physician in a specialist position has scope to bid up his price or reduce the time given to a patient, how would he be motivated to go out of his way to provide empathy? Keeping his moral dilemma aside, there is every reason for him to fear that a market can hardly offer him a material compensation for the provision of empathetic care, or offer him additional monetary incentives for the additional time he needs to spend for empathetic encounter. A major hindrance is the length of consultation to provide for ‘empathetic’ clinical encounter which may make it just impossible for the lone physician take care for all kinds of patients, each with their own individual expectation, behaviour traits, needs (Toop, 1998). Again, how does the physician strike a right balance between the personal goals of self-actualisation, prestige, monetary returns, on the one hand and service towards his patient or patient’s emotional needs, on the other? A physician can often refuse the notion of empathy, on grounds that she is not adequately trained to provide it or she may feel it is her prime duty to focus only on acute medical problem of her patient, or she may feel too exhausted to provide empathy.
The Macro (Collective) Dimension of Empathy
At the macro level, in true economic sense, empathy in health care creates positive externalities and happier patients and physicians together add up to the society’s welfare, besides leading to a culturally caring and enriched state with better citizens. Often, our real world of medical care with overcrowded wards, clinics and hospitals presents a big disconnect to the world of debates, writing and research on empathy and its useful application, and this prompts a question—is empathy-based delivery of healing holistic care a mere idealistic notion? In rural India, where the physician–population ratio is low, how do the physicians cope up with the workload and to what extent can they survive and strike a balance between their own private lives on one hand and delivery of empathetic care to the patients? Based on their own survey findings on resident surgeons in India’s four medical colleges, Agarwal et al. (2011) point out to the lack of effective communication and very little conversation time spent by surgeons with the patients to highlight the need for effective physician patient communication. They see patient contact with a physician as a step towards ‘reconnection’ as an ill patient disconnects from society, and a need for a physician to provide for listening and healing comfort. Pointing out that empathy and effective doctor patient communication forms a part of training curricula in medical and nursing colleges in many parts of the world, they urge for a need to imbibe this practice in Indian medical schools to foster a better therapeutic relationship. ‘Empathy is sincere and successful when a patient acknowledges that he or she has been seen, heard, and accepted as a person’ (Agarwal et al., 2011). The larger macro application of empathy necessitates that empathy is formally accepted as a value in medical education and that learners of medicine practice the value while they serve care.
The Sectoral Challenges to Empathy
Srinivasan (2000) suggested the following four criteria, in his vision for health care (Vision 2020):
Universal access and access to an adequate level, and access without excessive burden. Fair distribution of financial costs for access and fair distribution of burden in rationing care and capacity, and a constant search for improvement to a more just system. Training providers for competence, empathy and accountability; pursuit of quality care and cost-effective use of the results of relevant research. Special attention to vulnerable groups such as children, women, disabled and the aged.
For the first time, the third criterion stated above on training concretely formulated empathy as a factor in the provision of quality health care. But how this was to be achieved has been far kept aside in agendas on health care.
India’s health sector is fast advancing with modern technology, public–private partnerships, different delivery models, increasing infusion of internal and external capital, while at the same time the sector is marked by unevenness in access and utilisation of health care, inadequacy of health spending and major personnel and workforce issues that grip India’s health delivery systems. Health systems with a proper mix of quality and distribution of medical personnel that includes physicians, nurses, paramedics, public health workers, are the need of the hour. The application of empathy is desirable at the level of health personnel, both in public sector and the private sector.
Baru et al. (2010) have highlighted three forms of inequities that characterise India’s health sector. Historical inequities that have their roots in the policies and practices of British colonial India, many of which continue till date; socio-economic inequities which manifest in caste, class and gender differentials; and inequities in the availability, utilisation and affordability of health services. Of these, quite critical they feel is the need to address inequities in provisioning of health services and assurance of quality care. And empathy is a key input in quality health care.
India’s focus on biomedical model has been responsible for a health care delivery system that prioritises curative health care, at times even at the expense of preventive care. Curative care by its very nature has an element of emergency, is urgent and rushed care. Indian health sector is besotted by unlimited patients in queues and for the states and as a whole India has low doctor–population ratio. In public sector, the preventive health network is largely crowded. A high premium is placed on the time factor. Holistic care and empathy is very much at the periphery.
The epidemiological transition that India currently witnesses is marked by increasing presence of non-communicable and lifestyle-related diseases, that do not just require medical cure, but prevention and management. Such diseases do not necessarily lead to mortality, but do increase morbidity levels, thereby increasing inpatient and outpatient care. Along with medical care, they necessitate the services of primary providers who help to prevent and manage the disease. This requires a patient-centred approach with high levels of listening to the patient and many empathetic encounters. The ‘cure-oriented’ public sector has not been able to adapt itself to this role necessitated by our epidemiological transition.
Verma (2013) critically points out that though the High Level Expert Group on Universal Health Coverage (HLEG 2010) recognised the role of patientcentred care, merely increasing the inputs in terms of nurses and doctors, as well as greater financial allocations devoted to health care as suggested by HLEG may not help as much as giving a thrust to patient-oriented care, and a personalised approach to medical care. Verma suggests the need to ‘reposition the role of a general practitioner’ in the context of primary health care in India. He recommends that primary physicians be provided with market incentives, as they alone are better suited to offer ‘patient-oriented holistic care’, and that a transformative change in primary health delivery can happen if the primary physician is restored in her role, as a first consultant to the patient.
The Private Sector/Corporate Sector
The structural adjustment programmes of the 1990s led to many changes in the health sector. Along with the cuts in budgetary spending, there began an entry of private sector in medical care, opening up of public health institutions to private investments and introduction of all sorts of user fees. Imrana Qadeer (2007) observes that the quality of a clinical service, does not only depend on diagnostics and curative potentials of a service, but also depends on patient satisfaction, social skills of physicians, individual practitioner support and team work at the hospital level. If each has to perform well, it needs the right mix of manpower and proper referral facility. The majority of private practitioners operate quiet independently of each other, while the public sector has provisions for referral. Many a times Qadeer laments that the patients face expensive informal linkages in the private sector and this finally makes them turn to the public sector. She observes that the private sector can provide facilities, but may not provide referrals and universal coverage to patients. The private sector is disaggregated, scattered and highly unregulated. There is no direct way by which the government can regulate private practitioners and their practices. The private entities such as nursing homes run by doctors are unregulated in standards of quality, accountability, medical records. The need to make more money in less time can lead to deterioration of standards, and empathy may be overlooked as a standard for healing holistic care by individual private practitioners.
Corporatisation of health care in India increased hospital care which was being largely facilitated by provisions of concessional land, tax breaks but there are no proper procedures to ensure that the poor get free beds in these hospitals. In absence of transparency and poor grievance redressal systems for patients, the goals of empathy can be far beyond reach. The secondary and the tertiary levels of India’s health care have gone through phases of corporatisation. The presence of competitive element in health services provision leads to innovative search for newer and better ways of selling care, and this is achieved by two ways; one by cost cutting and the other, by giving innovative, faster, efficient and better care. At the level of the corporate sector, the word empathy is often a seller’s way of enticing the buyer better health care. Huge corporates, often with the mediation of health providers like insurance authorities can use ‘empathy’ as a selling proposition to attract patients who can afford to pay for more for better health care. Corporates have doctors themselves as their major stakeholders, who in their drive for greater profits, may be forced to compromise on ethical care, by indulging in practices like over investigations and supply of excessive care to patients.
So the notion of empathy with a wider holistic and deeper meaning often runs a danger of getting narrowed down to a small supply-side saleable idea, meant to generate higher demand from the patients. The moot question is—how far will a corporate with a business objective be motivated to push the ideological construct of empathy in imparting actual health care to its people? In a market economy, health care is said to have three links: the link between state and citizens’ entitlement for health, the link between the consumer and provider of health services and the link between the physician and patient. The link between the physician and the patient in corporate health care is more based on the idea of profit, and here, the ‘disease’ rather than the ‘experience of illness’ attains importance. And empathy becomes a business idea rather than a tool to forge better health outcomes. Sadly, no such studies exist in India, which enhance our understanding of the exclusive role of empathy in health care. In essence, it becomes difficult to measure levels of empathy in macro health scenario of India.
Is Empathy beyond Sectors?
However, empathetic care need not confine itself to the realm of a specific sector at all times. At the macro level, a systemic transformation can take place and goals like equity and access to health care can be achieved by service providers, as these become a closest approximation of holistic health care with an empathetic understanding. Umpteen examples exist where health care has been characterised by empathetic provisions, at the level of NGOs, or hospitals, or individual service providers in India. Health schemes have tried to incorporate the notion of empathy, like in case of Yeshaswini Micro Health Insurance Scheme in Karnataka which has a huge coverage and which provides world class health care facilities to poor farmers with country’s lowest premiums in health insurance (Nagaraj, 2010). Several attempts have been made by NGOs in the health sector, to bring health care to the millions of poor in India, like in case of tribal health care provided by practitioners like Dr Abhay Bhang and Dr Rani Bhang, whose collective efforts to provide health and well-being to the tribals in Gadchiroli speak volumes about empathy and holistic care. Dr Devi Shetty and his pioneering efforts in the field of health care are an exemplary evidence of real life approximation of empathetic health care in India. The business model of health care of Narayana Hridayalaya of Dr Shetty is largely based on numbers, but aims to provide low cost, affordable, holistic and accessible care to people, many times the poor and thus combines the goals of equity and efficiency in health care.
A recent piece of news on India’s medical care shows how empathy and care may well be a part of healing culture in nursing for patients. A dozen students of Linfield Nursing College visited health care network in many parts of India and observed that despite the most basic issues in health that India grappled with (like clean drinking water, basic infrastructure), there was ‘healing care’. 6
Remarked a nursing student on India’s health care, ‘Buildings are sometimes open to the weather, nurses sleep onsite on metal bunks, and clinics have older equipment than U.S. facilities. But the care of the staff is still there, the dedication nurses have to their patients is inspiring, and many clinics provide primary care to rural populations at little to no cost’.
All this could not have been envisaged without an innate construct of empathy in the mind of the health service provider. Thus the Indian health care experiences empathy not through a formulated organised network, but through the altruistic efforts of such scattered dedicated providers of health care, especially for the poor.
The Importance of ‘Criticality of Illness’ in Empathy
To a considerable extent, the application of empathy in health care has to do with the type of illness, and a patient-centred approach becomes all the more crucial when certain critical illnesses threaten to increase morbidity and mortality levels for patients. Critical illnesses, some of which are also associated with stigma like cancers and AIDS, need greater levels of empathy. Arora’s (2009) narrative as a cancer survivor for 14 years spells out the need for an approach which blends high quality technical care with patient-centred care, which alone can reduce suffering for a patient and enhance his well-being. Patient-centred measures focus on high interpersonal quality, view a patient as a whole and provide care that would include the medical and the psychosocial needs of the patient. In sum, both the ‘medical’ and the ‘care’ aspect of ‘medical care’ are a must. The same is true for mental illnesses. Based on his personal experiences and study reviews, Swaminath (2007) urges for a critical need for effective doctor patient communication in general medicine, and to the field of psychotherapy. Highlighting that an empathic relationship is primary, he remarks that without a sense of connection and mutual understanding, physician–patient relation becomes ‘an exchange of medical information divorced from the context and complexities of the patient’s life’. The above studies are a pointer towards understanding the challenge of giving healing care with intense flow of empathy to diseases which are particularly threatening or disturbing to individuals, and which create their own scars and scares in patients.
What follows is that different disease types would require different levels of empathetic understanding. States a WHO (2008) report,
People want to know that their health worker understands them, their suffering and the constraints they face. Unfortunately, many providers neglect this aspect of the therapeutic relation, particularly when they are dealing with disadvantaged groups. In many health services, responsiveness and person centredness are treated as luxury goods to be handed out only to a selected few.
The report goes on to state that in many countries including the developing ones, efforts are on to ‘put people first’ in the health agenda for HIV, and many other disease control programmes.
India’s epidemiological transition over the last few decades shows a disease profile with predominance of non-communicable diseases and lifestyle diseases like cancers, mental illnesses, accidents and trauma. Though there is no formula for empathy provision, there surely exists a need to imbibe the culture of empathy to India’s growing health problems. Slowly India’s health care is adapting to these challenges. For instance, in the new Mental Health Care Bill 7 (2013) which seeks to replace the Mental health Act of 1987, the government for the first time has come up with a rights-based approach in the mental health law which now seeks to decriminalise suicide and make access to affordable mental health care a right for all. The Bill clarifies that the act of suicide and the mental health of the person committing the act are inseparably linked and have to be seen together and not in isolation. It seeks not only to provide for mental health care for persons with mental illnesses and to protect, promote and fulfil the rights of such persons during the delivery of mental health care and services, but guarantees several rights to the mentally ill—from the right to privacy in mental health establishments to the right to dignity. It bars inhuman practices such as electro-convulsive therapy without anaesthesia, sterilisation as a treatment for illness, chaining in any form of the mentally ill, and has strict punishment for offenses done in this manner. This is a welcome step in healing care which incorporates empathy. But such efforts are few and far in between, and more needs to be done to make empathy truly felt in India’s health care.
Concluding Remarks
Empathy, when communicated, helps to evolve an effective therapeutic relation and enhances positive health outcomes. The emergence of theoretical construct on empathy points out to a patient-centred approach wherein both the physician and the patient make a collaborative effort to have an empathic encounter. Studies on empathy too tend to emphasise effective physician–patient communication and patient-centred care. Often, due to its very nature, empathy cannot be isolated as the single most critical factor to positively affect health outcomes and this remains a limitation of some of the studies on empathy. Which is why, perhaps, despite attempts to understand empathy, it does remain, only partly explained, only partly understood. India’s excessive dependence on biomedical model and curative approach to health care often poses challenges to application of empathy in health care. But efforts at the level of individual health practitioners, business models which incorporate empathy, as well as innovative government steps like the Mental Health Bill are a testimony to a hope that even with challenges, India’s health care can look up to higher levels of empathy.
Footnotes
Notes
Acknowledgements
I wish to convey my sincere gratitude to anonymous referee of this article for helpful comments and suggestions.