Your pain is not mine: A critique of clinical empathy

Abstract Both in mainstream culture and in bioethical literature, there is a general agreement on the absolute positive value assigned to empathy in healthcare settings. Thanks to its two components—affective and cognitive—clinical empathy should allow physicians to be emotionally affected by the experiences of their patients, and at the same time, to imagine their situations in order to gain a deeper understanding and implement a ‘tailored’ approach to care. So, it seems that good physician has become synonymous with empathetic physician. However, while acknowledging its numerous benefits, I will argue that clinical empathy seems to harbour some dark sides. First, the affective component of clinical empathy (i.e. emotional resonance) is responsible for its partial nature and can lead to cognitive and moral distortions. Moreover, it can lead healthcare providers to negative psychological states, such as burnout and personal distress. Second, the cognitive component of empathy can be problematic as well: perspective‐taking is a far more difficult task than it is ordinarily thought to be. I will also try to demonstrate that accessing the inner world of others is neither possible nor desirable since this operation can result in undermining the patient's agency. Third, clinical empathy can become a tool that disguises the power imbalance between patients and doctors, and this can reinforce an elitist and paternalistic conception of the clinical encounter. Furthermore, the disregard for the influence that the sociocultural context has on the clinical relationship can amplify and promote instances of epistemic injustice perpetuating discriminatory and unfair dynamics.


| TWO SIDES OF THE SAME COIN: AFFECTIVE AND COGNITIVE EMPATHY
In the last 20 years, clinical empathy has slowly but steadily replaced detached concern as the core value in medical care: 'physicians must connect with rather than detach from their patients, especially their emotional states in order to provide genuine healing'. 8 This paradigm shift has forced healthcare professionals and bioethicists to reflect on the nature of empathy.
The definition of empathy in general and clinical empathy in particular is a thorny issue. Nevertheless, there is a general consensus on the existence of two components of empathy that are not only conceptually and phenomenally distinct but also involve different neural networks: 9 affective empathy and cognitive empathy. Notably, even though it is possible to identify these two components, it does not mean that they do not interrelate or cannot operate simultaneously.
Affective empathy encompasses different phenomena with various degrees of complexity, such as affective empathy proper, sympathy, emotional contagion or personal distress, and generally consists of 'a range of emotional responses we can have to what others feel or the situation they are in'. 10 By contrast, cognitive empathy is usually regarded as 'the capacity to understand another person's state of mind from her perspective'. 11 Here, the empathizer consciously shifts her perspective to ascribe mental states or emotional experiences to the other person.
The bioethical reflection on clinical empathy has embraced this taxonomy and consequently developed a variety of accounts considering both components of empathy. In particular, Jodi Halpern has provided a nuanced and rich definition of clinical empathy in which its hybrid nature is perfectly highlighted: it is 'the ability to resonate [that] allows the curious physician to use her imagination.
The imaginative use of the physician's affects provides a 1 spect, it proves to be an extremely useful heuristic tool since it stimulates patients to provide crucial information that would otherwise have been unavailable to the doctor. 13 A deeper understanding of the condition of patients should enable healthcare professionals to create a stronger and more trustworthy clinical relationship. This, in turn, should lead to an increase in patient satisfaction and consequently, to a higher adherence rate to the doctor's therapeutic guidelines. 14 So, clinical empathy appears to be particularly appealing as it helps clinicians implement a 'tailored' approach to care. By recognizing and valuing the uniqueness of each patient's existential perspective, the empathic doctor should be able to develop a highly specific therapeutic plan. Yet, in order for doctors to properly imagine how their patients feel and therefore have a better understanding of their patients' conditions, they must experience, to some extent at least, the same emotional states.
A certain level of emotional isomorphism between doctors and patients is required, and it can be achieved through emotional resonance, which is defined as the 'spontaneous affect that is similar to another's affect, such as feeling anxious around an anxious person'. 15 Although Halpern assigns a preliminary role to emotional resonance, I believe that its involvement in clinical empathy raises some issues: as I will try to show below, the fact that physicians are required to share the same emotional states as their patients, even if just at the beginning of the process, can be harmful both to the patient and the healthcare professionals.
At the same time, I think that advocating for a purely cognitive form of clinical empathy is not an effective solution either; on the contrary, it can be as problematic as affective resonance-based empathy. Finally, even without these concerns, clinical empathy can still have troubling consequences on the already asymmetrical distribution of power and the unequal level of epistemic credibility in the doctor-patient relationship. In the next sections, I will try to articulate and discuss these criticisms.

| THE DARK SIDE OF EMPATHY
Far from being the panacea for all problems, clinical empathy seems to harbour some dark sides. In order to demonstrate this, I will use a threefold argument: the first argument is of a neuroethical nature and addresses the problems of affective empathy, the second discusses epistemological questions related to cognitive empathy and the third investigates moral issues arising from clinical empathy in general. It seems that the degree of empathy experienced by the tested subject is directly proportional to the degree of emotional proximity, spatial proximity and temporal proximity. These findings reflect and explain some aspects of our behaviour that are rather common, if not universally shared. It is because of this emotional proximity that we empathize more with our friends and family, people that are usually near and dear to us. The element of spatial proximity is also very important and may explain why we usually care significantly more about the fate of people who are from our neighbourhoods, our cities and our countries, despite the fact that we do not know them personally. Lastly, temporal proximity is a key feature in the ability to empathize with others. Consider, for example, how difficult it is to imagine and care about future generations-human beings that are not even born yet-in regard to the catastrophic effects of the climate emergency. from the fact that our empathic responses are strongly modulated by group membership, and the parameters that draw the boundaries of the group can vary considerably ranging from race, gender and political affiliation to football team preference. 19 In this respect, one could object that we have developed strategies to mitigate these biased mechanisms. The problem is that these strategies seem unable to overcome the fact that 'we can empathize with members of the out-group but only by making their similarities salient'. 20 The 'local' character of empathy seems inescapable, and the only way to reduce its negative effects would be to minimize-if not eliminatethe peculiarities of the other that must become, at any cost, similar to us. So, the only way by which empathy could work would be via the reduction of the differences between the empathizer and the subject of empathy. These findings are strongly in contrast with the assumption that morality requires empathy, which is a position largely endorsed by both the mainstream culture and within the academic debate. 23 The premise for this argument is that human beings are intrinsically selfish. The only way through which these selfish tendencies can be overcome is by making the condition of others relevant to one's individual situation. Only empathy, since it is able to connect with the emotional experiences of others, can 'guide us to treat others as we treat ourselves and hence expands our selfish concerns to encompass other people'. 24 The problem with this perspective is that it is absolutely necessary to feel the emotional states of others in order to make their situations relevant to us.

| The neuroethical argument
However, feeling what others are feeling is extremely taxing and demanding for any empathizer, especially for healthcare providers who are exposed to incredible amounts of suffering, pain and death on a daily basis.
This leads us to the second issue: the emotional resonance element in clinical empathy can cause states of psychological distress in doctors, among which the most serious is burnout. Its consequences can be very dangerous: 'deterioration in patient care, medical errors, substance abuse, interpersonal difficulties, depression and suicide'. 25 In this respect, Lamothe et al. have found that 'affective sharing without emotion regulation skills may be associated with personal distress, compassion fatigue and burnout, which would turn into decreasing empathic concern and pro-social helping behaviour'. 26 Gleichgerrcht and Decety have also found similar results: 'it is possible that physicians who are most vulnerable to emotional distress and compassion fatigue, which may lead to emotional exhaustion, and a low sense of accomplishment, are those who have difficulties regulating their negative arousal'. 27 Therefore, clinical empathy has to be regulated through a cognitive intervention. However, even with this cognitive regulation, 'it is important to note that a modicum of negative arousal is necessary to help physicians attune to and empathically understand patients' emotions'. 28 So, it seems that some level of emotional fatigue is inevitable for the doctor who wants to be empathic.

| The epistemological argument
One might say that since emotional resonance causes all of these problems, perhaps a purely cognitive concept of clinical empathy might be the answer we are looking for. Note that this position implicitly assumes that it is possible for healthcare professionals to switch one of the two components of clinical empathy on and off as if they were completely independent of one another, which in itself, is a controversial thesis to argue. Despite this, supporters of cognitive empathy claim that the desired benefits of clinical empathy, such as engaged communication and personalized care, can be achieved solely with perspective-taking without having to deal with the downsides of emotional resonance. 29 However, I am not convinced that perspective-taking poses fewer challenges than emotional resonance, and I think that the attempt to understand and have access to the inner world of others is an extremely complicated process. When we discuss understanding others, we often seem to forget how baffling the complexity of our minds is: 'another person's mind is one of the most complicated systems that any person will ever think about'. 30 In fact, 'neuroscientists calculate that a human brain could be in more possible brain states than there are elementary particles in the universe'. 31 Clearly, the complexity itself does not impede the feasibility of this operation. Yet, when we engage in perspective-taking, we are satisfied only if the understanding we have acquired is accurate. Most importantly, when others are trying to grasp our perspective, we want them to understand us as accurately as possible. This desire is even stronger if we are suffering physically, emotionally and mentally as occurs during an illness. In this regard, given how inherently So, given its importance, is perspective-taking the right strategy to attain accuracy? According to empirical evidence, not really. The widespread idea behind the benefits of perspective-taking is fairly straightforward: putting oneself in the other's shoes seems to be an effective way to contrast our egotistical inclinations and at the same time, our tendencies to stereotypically categorize others' experiences. However, little attention has been directed at verifying that accuracy is truly attained through perspective-taking. In this respect, strong notion of agency is involved, the characteristics of the subject

| The moral argument
Leaving aside the obstacles that we have encountered so far, I think that the majority of accounts of clinical empathy still fail to discuss how empathy can affect the power balance within the patient-doctor relationship. As Rebecca Garden says, even Halpern's comprehensive account tends to obscure the unequal distribution of power between the doctor and the patient: "where some might caution physicians against assuming that they can fully understand the experience of patients, Halpern argues that physicians should imagine 'how it feels to have a certain illness, disability, or psychological injury'". 41 It seems that it is always possible for the doctor to penetrate and master the understanding of the existential world of the patient. While it is certainly true that sometimes this can be difficult and require more effort and time for the doctor, the difficulty of empathic labour does not imply its impossibility. Hence, for Halpern, the ability to empathically understand the patient simply becomes another skill that doctors are required to have. However, this way of defining empathy has an important consequence: it 'situates the patient's experience squarely within the realm of the physicians' expertise'. 42 So, the interpretative work of empathy seems to become an issue that is beyond the interest of the patient and becomes a concern exclusively for the doctor. Conversely, 'in regards to the experience of pain and illness, the patient rather than the physician is the expert '. 43 Recognizing that patients have a greater degree of knowledge and experience than their doctors about their own conditions, has the ability to return the power to the patients themselves. If doctors fail to understand that the inner world of the patient will always remain, in some respects, beyond their cognitive reach, we will face what can be called 'the colonization problem'. When the patient's experience is seen as a sort of 'territory to be conquered', empathy becomes a tool that disguises the exercise of the doctor's power. Those who empathize have, quite literally, the experiences of others at their disposal, and they always have the power to modify and mystify them.  45 On the contrary, the doctor-patient relationship should be understood as horizontal and active, and the asymmetry between the two subjects-which will never be completely overcome-should be rebalanced as much as possible.
If it is true that patients are not 'lands of conquest' and that they will always remain in some aspects an unknowable otherness, it is equally important to point out that they are not atomized entities and that clinical encounters never take place in a vacuum. On the contrary, patients are always members of a community whose cultural and social background has a critical impact on their overall medical condition. For this precise reason, the empathetic physician needs not only to recognize the influence that the sociocultural context has on the doctor-patient relationship but also should develop Epistemic injustice, defined by Miranda Fricker as 'a wrong done to someone specifically in their capacity as a knower', 47 is 'integrally related to social injustice' 48 because it arises from biases, negative stereotypes and prejudices that can result in discriminatory behaviours. If we fail to acknowledge the ubiquity of negative stereotypes and prejudices, we might consequently fail to remove them as well as to grant the deserved epistemic credibility to other people's testimonies and experiences.
In this respect, it has been argued that epistemic injustice is particularly pervasive in healthcare settings for at least two reasons: on the one hand, patients 'are often regarded as cognitively unreliable, emotionally compromised, or existentially unstable in ways that render their testimonies and interpretations suspect'. 49 This suspicion can result in low or non-existent epistemic credibility. In this sense, the lack of credibility depends on the onto- Similarly, the epistemic dignity of patients who suffer from stigmatized pathologies can be denied because of the prejudice that illness is 'an expression of morality', 51 and therefore, these patients are not worthy of epistemic credibility and must be, in some sense, punished for their 'moral failures'. This vicious circle between social injustice, prejudices and epistemic injustice proves how critical it is for all clinical empathy accounts to recognize not only the unequal level of epistemic privilege but also the importance of situating the doctor-patient relationship within the sociocultural context of patients in order to recognize and potentially reduce the harm of negative prejudices that perpetuate the dynamics of epistemic injustice. At the same time, physicians must always bear in mind that the cultural and social differences between them and their patients are not simply some temporary obstacles that they are sooner or later going to overcome or some sort of empirical data that they can factor in during the decision-making process. Instead, they need to find the right balance between the required understanding of the context and the awareness that this distance is never going to be completely bridged. Undoubtedly, achieving this balance is an onerous process whose difficulty directly depends on the ambiguous nature of empathy itself, which 'is always perched precariously between gift and invasion'. 52 However, it is important to clarify that the point of discussing the perils of epistemic injustice is to unearth and reflect on 'certain policies, practices and cultural norms within modern healthcare practice [which] are liable to generate epistemic injustice' 53 and not to imply that every healthcare professional will unavoidably perpetrate epistemically unjust behaviours.
In conclusion, the suffering of others, their inner worlds and their existential experiences are undoubtedly important to clinical practice and to the therapeutic process itself. Nevertheless, healthcare professionals must be aware of the ethical problems that clinical empathy poses especially regarding the concealment of the power imbalance and the influence of the sociocultural context.

| CONCLUSION
Empathy is considered essential to clinical practice today more than ever. For this reason, healthcare professionals are always encouraged to develop and enhance their empathic skills. However, I have tried to demonstrate that this stance can be extremely problematic both from a theoretical and practical point of view. Clinical empathy is a multifaceted phenomenon with positive and negative sides, and ignoring the latter can be counterproductive both for healthcare professionals and patients.
By pointing out these difficulties, I do not aim to imply that empathy must be disregarded completely; on the contrary, I have tried to argue that, precisely because of its relevance, a critical and comprehensive approach is required. Clinical empathy deserves to be discussed in a way that takes into account its complexity, and this 46 Garden, R. (2008). Expanding clinical empathy: An activist perspective. Journal of General