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Detached Concern": the Cognitive and Ethical Function of Emotions in Medical Practice Jodi Lauren Halpern Yale University

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Detached Concern Yale University EliScholar – A Digital Platform for Scholarly Publishing at Yale Yale Medicine Thesis Digital Library School of Medicine 11-1993 Beyond "Detached Concern": the cognitive and ethical function of emotions in medical practice Jodi Lauren Halpern Yale University Follow this and additional works at: http://elischolar.library.yale.edu/ymtdl Part of the Medicine and Health Sciences Commons Recommended Citation Halpern, Jodi Lauren, "Beyond "Detached Concern": the cognitive and ethical function of emotions in medical practice" (1993). Yale Medicine Thesis Digital Library. 3360. http://elischolar.library.yale.edu/ymtdl/3360 This Open Access Dissertation is brought to you for free and open access by the School of Medicine at EliScholar – A Digital Platform for Scholarly Publishing at Yale. It has been accepted for inclusion in Yale Medicine Thesis Digital Library by an authorized administrator of EliScholar – A Digital Platform for Scholarly Publishing at Yale. For more information, please contact [email protected]. B e y o n d "D eta c h ed C o n c e r n": T h e C o g n itiv e a n d E th ic a l F u n ctio n o f E m o tio ns in M ed ic a l P r a c tic e A Dissertation Presented to the Faculty of the Graduate School of Yale University in Candidacy for the Degree of Doctor of Philosophy by Jodi Lauren Halpern November. , 1993 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ABSTRACT Beyond "Detached Concern": The Cognitive and Ethical Function of Emotions in Medical Practice Jodi Lauren Halpem Yale University 1993 This dissertation analyzes the ideal of "detached concern" in medical practice. This ideal arises as an attempt to bridge the gap in medicine between managing diseases and recognizing patients "as persons." First, physicians take their emotions to interfere with making objective diagnoses and making every aspect of their practice "scientific." Second, physicians idealize detachment as the stance of the impartial moral agent who is able to care for all types of patients out of a sense of duty. Third, physicians also recognize the need to be empathic; however they conceive of empathy as a purely cognitive capacity that is compatible with detachment. Chapter one analyzes the features of emotions that contribute to and also threaten rational agency. Chapter two analyzes Descartes' theory of the emotions, which is the outcome of his "scientific" method for understanding reality. Descartes' legacy to physicians is not only the capacity to build powerful mechanistic models of diseases, but the failure to account for human experience via such models. Chapter three considers the turn to Kantian ethics to restore respect for patients "as persons" to the practice of medicine. Kantian impartiality is shown not Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. to require detachment. Further, the practice of Kantian ethics in medicine is impoverished when physicians are not affectively engaged. Whereas chapters two and three show the limitations of the arguments for emotional detachment, chapters four and five give positive arguments for the role of emotions in medical practice. Chapter four examines the cognitive and affective aspects of clinical empathy, and argues that emotions are essential for directing the empathizer to imagine what the patient is experiencing. The final chapter argues that given the importance of emotional engagement and the fact that emotions can obstruct rational and moral agency, physicians need to regulate their emotions without detaching themselves from patients. Physicians can best meet the goals of medicine by cultivating overarching emotional attitudes like curiosity and courage to effectively move themselves towards a more realistic and respectful appreciation of patients. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Acknowledgments First, I want to thank my dissertation advisor, Karsten Harries, whose curiosity has inspired me, and whose encouragement and guidance have been essential for sustaining the creative spirit. Second, I thank Judith Wilson Ross for carefully reading drafts of several chapters and for encouraging the writer in me. I thank Judith Broder for deepening my understanding of clinical empathy. For kindling my initial interest in philosophy I thank my teachers, George Schrader and Maurice Natanson. For teaching me to believe in my own thinking, I thank my mother Francine Halpem, and my grandmother, Rhea Slominsky. For teaching me how to listen to people's stories, I thank Phillip Krey. Finally, I want to thank my husband Philip Sager, whose support and companionship have sustained me during the years of thinking and writing that went into this work. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CONTENTS ACKNOWLEDGMENTS............................................iii INTRODUCTION.................................................1 I The Ideal of Objectivity.............................5 II The Ideal of Impartiality...........................16 III Emotional Engagement and Self-Regulation.......... 20 CHAPTER ONE: THE INTENTIONAL CHARACTER OF EMOTIONS.......... 24 I The Cognitive Aspects of Emotion................... 24 II The Volitional Aspects of Emotion.................. 36 III Emotions Determine Salience........................ 40 CHAPTER TWO: DESCARTES AND THE RATIONALITY OF THE EMOTIONS. .46 I The Problem of Irrationality: Emotions as Pathogens..............................49 II Rethinking the Pathogenicity of Emotions.......... 55 III The Problem of Arationality: Do Emotions Disclose Reality?...................... 64 IV The Essential Role of Emotions in Rational Agency................................... 71 CHAPTER THREE: ON KANTIAN IMPARTIALITY...................... 89 I The Conflation of Impartiality and Impersonality in Medicine........................................91 II The Conflation of Impartiality and Impersonality in a Traditional Reading of Kant................... 96 III Current Arguments Against the Claim that Moral Agency Requires Impartiality .......... 103 IV The Core Kantian Ideal of Impartiality as Residing in the Autonomy of the Will.............. 107 V A Revisionist Reading of Kant that Does Not Equate Impartiality with Detachment......115 CHAPTER FOUR: THE CONCEPT OF CLINICAL EMPATHY.............. 131 I The Conception of Empathy as Detached Insight.....135 II The Original Meaning of the Concept of Empathy. .147 III Three Models of Clinical Empathy as Affective Understanding...........................151 IV A Non-Inferential Model of Clinical Empathy.......168 V Some Limitations of Clinical Empathy.............. 180 CHAPTER FIVE: REGULATING EMOTIONS IN CARING FOR PATIENTS...183 I Emotional Transitions in a Clinical Encounter.....187 II Emotional Regulation Involves Self-Persuasion.....192 III Curiosity and the Freedom to Imaginatively Reconstrue One's Situation........................200 IV What Affective Standpoint is Needed for Physicians to Maintain their Integrity Over Time?............ 214 V Prospective Conclusions for Future Work on the Physician-Patient Relationship................226 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1 Introduction The increasing interest in medical ethics in the United States over the past twenty years arises in the context of widespread public dissatisfaction with physicians. The effective treatments that are the fruits of medical science do not assuage patients' unprecedented concern that physicians will not talk to or listen to them. Patients fear that their suffering will go unrecognized and their dignity will not be respected. The prevalent ideal that guides physicians in their conduct towards patients is the ideal of "detached concern." "Detached concern" is a complex concept that posits that physicians can detach themselves from their personal emotions, while maintaining a professional concern for patients.1 Physicians believe that detaching themselves emotionally best meets the special cognitive and moral demands that distinguish medicine from other helping professions. Twentieth century physicians take the ideals of scientific objectivity and technological reliability as overarching principles for every aspect of medical practice. The current AMA Code of Ethics emphasizes science as the basis of appropriate medical conduct: "A physician should practice a method of healing founded on a scientific basis; and he should not voluntarily associate professionally with anyone who violates this principle."2 Physicians have interpreted the goal of practicing medicine "scientifically" to require that they turn themselves into reliable Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. instruments for diagnosing and treating disease, by purifying themselves from the influence of any personal emotions.3 In contrast, therapists, social workers and nurses, who rarely view themselves as applied scientists or technicians, have models of professional conduct that allow an important place for sympathetic emotions. Yet the goal of medicine is the same as the goal of these other professions — to alleviate the suffering of human beings. In the current environment of medicine, physicians translate this obligation to understand and care for the patient as a sufferer into an obligation to have an impartial
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