2. • Besides the value of health or wellbeing and the disvalue of disease or illness, as well as besides the normative
ethical theories and the four principles that under gird contemporary bioethical principlism, modern medical
knowledge and practice are influenced by two chief values that inform the ethical or moral stance or attitude of
physicians—emotionally detached concern and empathic care
People enter medicine,” according to Manish Raiji, “out of concern for the
sick and, for the more ambitious of them, the betterment of society as a
whole”
3. Warren Reich reconstructs the distinction between emotionally detached concern and empathic care in terms of two
radically different meanings of care:
“In the context of healthcare, the idea of care has two principal meanings: (1) taking care of the sick person,
which emphasizes the delivery of technical care; and (2) caring for or caring about the sick person, which suggests
a virtue of devotion and concern for the other as a person” (2004a, p. 361).
Taking care of” refers to the physician’s technical competence sans emotional engagement. It is a concern for the
objective clinical data pertaining to the patient’s diseased state and is often reduced to a legal minimum of “due
care” (Reich, 2004a)
Caring for,” however, includes an empathic or emotional engagement as a critical component of medical practice.
It involves altruistic values and is part of the moral structure that under girds humanistic medical knowledge and
practice (Reich, 2004a)
4. In this chapter the emotionally detached concern of the biomedical model (“taking care of”) is explored
initially followed by contemporary challenges from humanistic practitioners in terms of empathic care (“caring
for”), especially with respect to an ethic of care.
5. EMOTIONALLY DETACHED CONCERN
• In the early to mid twentieth century, medical practitioners and educators subscribed to a notion that in order for
physicians to apply their trade they must not allow the patient’s or their emotions to interfere.
For example, Richard Cabot (1926) championed this view, arguing that physicians should attend to the body and
specifically to the diseased body part. Rather than emotional attachment to the patient, Cabot claimed that the
chiefs of medicine model “the ‘technique’ of courtesy to most unpromising old wrecks of humanity” (1926, p. 26).
Caring for,” however, includes an empathic or emotional engagement as a critical component of medical practice. It
involves altruistic values and is part of the moral structure that under girds humanistic medical knowledge and
practice (Reich, 2004a).
6. In this chapter the emotionally detached concern of the biomedical model (“taking care of”) is explored initially
followed by contemporary challenges from humanistic practitioners in terms of empathic care (“caring for”),
especially with respect to an ethic of care.
In the early twentieth century, emotionally detached concern was heralded as a critical component of medicine’s
social structure, especially in terms of the patient- physician relationship. Lawrence Henderson, Talcott Parson,
and Renée Fox each explicated its position within medicine’s social structure. Henderson, a well known
physiologist, argued that medicine—although an applied science—was still practiced in terms of its social
structure as it was from Hippocratic times
Henderson also counseled physicians to beware of their own feelings and emotions, since they are likely to be
“harmful” and “irrelevant” to the patient’s care. The physician should “try to do as little harm as possible, not
only in treatment with drugs, or with the knife, but also in treatment with words, with expression of your own
sentiments and emotions
Parsons (1951) conducted one of the first modern social analyses of the medical system, especially in terms of a
patient’s “sick role” and a physician’s response to it. That response was structured in terms of four features that
guide the physician’s behavior in treating the patient.
7. One of the first steps towards detachment occurs in gross anatomy. There are several mechanisms used during
dissection of cadavers, almost unconsciously, to strip students of normal emotional responses in the face of a
dead human being.
The naming of cadavers “helped to reduce guilt derived from unconscious fantasies of defiling the body, albeit a
dead one, of a human being” (Lief and Fox, 1963, p. 18).
Naming is also an important mechanism for residents and other hospital staff when dealing with patients. For
example, older patients who are quite ill and helpless are often referred to as “gomers” (George and Dundes,
1978; Leiderman and Grisso, 1985).
Emotionally detached concern was in response or reaction to the value of sympathy, in which the physicians and
their emotions, as well as the patients and their emotions, were an integral part of medical knowledge and
practice.
8. One of the first steps towards detachment occurs in gross anatomy. There are several mechanisms used during
dissection of cadavers, almost unconsciously, to strip students of normal emotional responses in the face of a
dead human being.
The naming of cadavers “helped to reduce guilt derived from unconscious fantasies of defiling the body, albeit a
dead one, of a human being” (Lief and Fox, 1963, p. 18).
Naming is also an important mechanism for residents and other hospital staff when dealing with patients. For
example, older patients who are quite ill and helpless are often referred to as “gomers” (George and Dundes,
1978; Leiderman and Grisso, 1985).
Sympathy was to some extent an occult force that the physician commanded for treating the patient. The
underpinning of this force was a blind emotional response to the patient’s pain and suffering
9. In response to the abuse of sympathy, physicians proposed a chastened form of empathy that was stripped of its
blind emotivism or at least a form of empathy in which the physician was cognizant of the patient’s emotional
state and especially the problems associated with it (Halpern, 2001; More, 1994)
Under the biomedical model of contemporary medical knowledge and practice, the physician’s concern for the
patient’s body and its parts is detached from the emotions of either the patient or physician: “modern
medicine has now evolved to the point where diagnostic judgments based on ‘subjective’ evidence—the
patient’s sensations and the physician’s own observations of the patient—are being supplanted by judgments
based on ‘objective’ evidence, provided by laboratory procedures and by mechanical and electronic devices”
There are a number of reasons why the medical profession excluded emotions from the practice of
medicine, in terms of detached concern or a chastened form of empathy. Halpern (2001) identified four of
them. The first is that physicians must often perform difficult and painful procedures that take a toll on the
physician’s emotions. A mask of emotionally detached concern protects the physician from the emotional
pain of these encounters. Another reason is that emotionally detached concern protects the physician from
burnout, especially emotional burnout
10. The most important reason, according to Halpern, is that emotions are too subjective and thereby interfere
with the correct or accurate diagnosis or treat- ment of the patient. The gaze of emotionally detached
concern “enables doctors to understand their patients’ emotional experiences accurately, free from their
own emotional bias” (Halpern, 2001, p. 17)
Finally, how is concern a value? Concern is a powerful basic or primitive value of one human being’s
apprehension for the state or plight of another. It motivates people to act and often heroically for the
better or enhancement of others. As noted already many, if not most, medical students enter medical
school with the profound sense of concern for helping patients.
11. CARING ETHICS
Ideal caring," according to Gilligan, "is thus a relationship activity, see and respond to needs, take care of the
world by sustaining network of connections so no one is left alone
Contemporary care ethics began with publication, in the early 1980s Noddings identifies two main
requirements for care ethics: pleasure and motivation
12. SEVERAL FEATURES OF THE ETHICS OF CARE
(RITA MANNING 1998)
• The first is moral concern, which refers to focusing on relevant things
• Next is sympathetic understanding. “When I sympathetically understand the
situation
• The third is relationship awareness, which is concerned with the relational
networks that connect people to one another. An important factor in a
relationship is mutual trust
• The final feature is accommodation and response to needs. Physicians in
particular, for example, must be willing to accommodate the needs of patients
and to respond to them in a concrete way.
