Beyond Empathy: Teaching Alterity

Clinical empathy has been increasingly recognized as an important component of both professionalism and good patient care. It is generally understood as identifying commonality between patient and provider and responding to this shared experience with appropriate care and concern. However, many clinical encounters are between strangers with little shared experience, which seems to present a challenge for both empathy and a sense of responsibility toward the patient. Physicians can also develop a deep sense of caring and responsibility by learning to appreciate the alterity, the otherness, of the patient, and this skill, like clinical empathy can be modeled and taught. Philosopher Emmanuel Levinas described respect for alterity as foundational to human relationships. That is, my primary experience in meeting other people is one of difference, not an immediate sense empathy can be modeled and taught. Philosopher Emmanuel Levinas described respect for alterity as foundational to human relationships. That is, my primary experience in meeting other people is one of difference, not an immediate sense of similarity. This sense of difference is both superficial and profound, although in most cases we will recognize only the superficial. Recognizing the profundity of difference opens one up to a radical sense of alterity that is the source of ethics, including our responsibility to the other. By exploring Levinas’ descriptions of human responsibility, humans as infinite and unique, and the consequences of this philosophy for the clinical encounter, it is evident that respect for alterity represents an underappreciated source of human caring, accessible in clinical relationships, even between a patient and physician with radically different life experiences. The implications of this for medical education are that we must help students appreciate and respect both the commonality we share with our patients, and the differences that makes them special and worthy of our care and attention.


Article abstract
Clinical empathy has been increasingly recognized as an important component of both professionalism and good patient care. It is generally understood as identifying commonality between patient and provider and responding to this shared experience with appropriate care and concern. However, many clinical encounters are between strangers with little shared experience, which seems to present a challenge for both empathy and a sense of responsibility toward the patient. Physicians can also develop a deep sense of caring and responsibility by learning to appreciate the alterity, the otherness, of the patient, and this skill, like clinical empathy can be modeled and taught. Philosopher Emmanuel Levinas described respect for alterity as foundational to human relationships. That is, my primary experience in meeting other people is one of difference, not an immediate sense of similarity. This sense of difference is both superficial and profound, although in most cases we will recognize only the superficial. Recognizing the profundity of difference opens one up to a radical sense of alterity that is the source of ethics, including our responsibility to the other. By exploring Levinas' descriptions of human responsibility, humans as infinite and unique, and the consequences of this philosophy for the clinical encounter, it is evident that respect for alterity represents an underappreciated source of human caring, accessible in clinical relationships, even between a patient and physician with radically different life experiences. The implications of this for medical education are that we must help students appreciate and respect both the commonality we share with our patients, and the differences that makes them special and worthy of our care and attention.
Les éditeurs suivront les recommandations et les procédures décrites dans le Code of Conduct and Best Practice Guidelines for Journal Editors de COPE. Plus précisément, ils travaillent pour s'assurer des plus hautes normes éthiques de la publication, y compris l'identification et la gestion des conflits d'intérêts (pour les éditeurs et pour les auteurs), la juste évaluation des manuscrits et la publication de manuscrits qui répondent aux normes d'excellence de la revue.
The editors follow the recommendations and procedures outlined in the COPE Code of Conduct and Best Practice Guidelines for Journal Editors. Specifically, the editors will work to ensure the highest ethical standards of publication, including: the identification and management of conflicts of interest (for editors and for authors), the fair evaluation of manuscripts, and the publication of manuscripts that meet the journal's standards of excellence.
Clinical empathy has been increasingly recognized as an important component of both professionalism and good patient care. It is generally understood as identifying commonality between patient and provider and responding to this shared experience with appropriate care and concern. However, many clinical encounters are between strangers with little shared experience, which seems to present a challenge for both empathy and a sense of responsibility toward the patient. Physicians can also develop a deep sense of caring and responsibility by learning to appreciate the alterity, the otherness, of the patient, and this skill, like clinical empathy can be modeled and taught. Philosopher Emmanuel Levinas described respect for alterity as foundational to human relationships. That is, my primary experience in meeting other people is one of difference, not an immediate sense of similarity. This sense of difference is both superficial and profound, although in most cases we will recognize only the superficial. Recognizing the profundity of difference opens one up to a radical sense of alterity that is the source of ethics, including our responsibility to the other. By exploring Levinas' descriptions of human responsibility, humans as infinite and unique, and the consequences of this philosophy for the clinical encounter, it is evident that respect for alterity represents an underappreciated source of human caring, accessible in clinical relationships, even between a patient and physician with radically different life experiences. The implications of this for medical education are that we must help students appreciate and respect both the commonality we share with our patients, and the differences that makes them special and worthy of our care and attention.

Introduction
While I recognize that empathy as resonance with shared emotion, shared experience, and mirror neurons is all the rage, there is a problem for the clinical encounter if we identify this pathway as the sole or even primary source of clinical caring. Literature on clinical empathy emphasizes the ability to see from another person's perspective, to sense, and even "resonate" with their emotions [1][2][3]. The problematic implication is that clinicians can care best, or perhaps only really care at all, when patient and physician share enough commonality to form a therapeutic bond grounded in seeing the other as we see ourselves.
I acknowledge that commonality is an easy pathway to empathy and shared investment in a clinical relationship, and I support medical schools seeking to diversify their classes so that patients can seek out doctors who share their life worlds, look like them, and understand their language and idiom. But as a clinician-educator with more than 20 years of experience working with largely underserved populations, I believe there is another inherent pathway to care that is not grounded in recognition of sameness or even similarity, but rather appreciation, even awe, at the incommensurability of the life of a patient with my own. Listening to a patient and finding her story absolutely inconceivable within my experience, I may find that this profound sense of difference, even alterity, is a powerful source of human caring. This respect, even reverence for alterity may come more naturally to some than to others, but it can certainly be cultivated, and educators of medical students would do well to remember and teach both sources of human and clinical caring. Recognizing and respecting alterity is as important to human relationships as empathy, but unlike empathy, medical schools have not yet developed strategies for cultivating or re-awakening this fundamental human ability.
The twentieth century philosopher, Emmanuel Levinas, spent his career elucidating a concept of care grounded in the recognition of alterity. Although the radical difference, or alterity, that Levinas is describing is present in every encounter, Levinas's writing often seems to suggest that we see this difference best when confronted with an other who strikes us as different in the more mundane sense of the word, particularly when we identify a need in the other (a common occurrence in the clinical encounter): "The Other is what I myself am not. The Other is, for example, the weak, the poor, 'the widow and the orphan.'" [4] The relative difference I may encounter with a patient from a different class, or race, or gender, which may be an impediment to empathy, might actually be an opening onto this sense of alterity.
My intention is not to replace empathy with a Levinasian sense of alterity and care, but rather to place the two beside each other as equally valuable tools in a clinical encounter, and therefore as concepts that both merit attention in medical education. The philosophy of Levinas does not preclude clinical empathy, a resonance grounded in a sense of likeness that allows clinicians to bond with patients and exhibit profound caring. However, this need not be the only avenue available to us as clinicians for caring deeply or feeling responsible for others. My claim is that physicians, and by extension medical training, must recognize both pathways, and their differences, to truly live up to the ideal set by Dr. Francis Peabodycaring for all of humanity. 1 I will begin by briefly explaining the philosophy of alterity presented by Levinas, and then discuss its implications for the clinical encounter and medical education. His thought runs counter, or at least presents an alternative viewpoint, to the prevalent ideology of empathy taught today, that care for the other arises in recognition of patterns of sameness. Again, without denying the truth of this, our first reaction to meeting other people is not always a sense of similarity, but often of difference, and we do not always see this as a negative. Perhaps we are no longer small tribal cultures precisely because we have an innate capacity to respect, even embrace, difference. 2 This capacity may have increased over historical time from an acceptance of difference to actively enjoying seeing how different cultures, and different people, live in our shared world. Certainly, the great religions of the world have been teaching for more than two millennia that strangers are to be treated well, even honored in their foreignness. Levinas argues that recognition of difference in other people opens me to a world infinitely larger than my own selfish needs, and that this is the ground of my sense of responsibility.

Responsibility for the Other
My thinking on this subject was recently rekindled by a patient encounter I had while working in our prenatal clinic. I saw a young couple, refugees from Nepal, for a follow-up visit in the third trimester for her pregnancy. I noted that she had been diagnosed with latent syphilis at her first prenatal visit and had received the standard three-weekly doses of antibiotics to treat it. The treatments had ended one month prior to this visit, so I asked the husband whether he had yet received testing and treatment. His English was better than his wife's, but it soon became evident that he did not know that the disease was something he likely shared, and that he also needed to be treated. Furthermore, since he had not been treated, and did not understand that this was a communicable sexually transmitted infection, he had had unprotected intercourse with his wife since her treatment had ended, potentially re-infecting her and the fetus. This all unfolded in a slow, difficult conversation with them. A treatment plan took additional time and involved calls to the health department and additional nursing support. By the time the visit was done my clinic was running behind, but I made sure that their next visit was also with me so that I could ensure that the plan had been fully executed.
One could explain my response to this couple as a mere instance of a physician fulfilling his duty to beneficence. However, this characterization does not adequately capture my experience responding to the needs of this couple. Certainly, the feeling that we had failed them in earlier visits increased my sense of the need to make things right, but even greater was the palpable sentiment that these were strangers who needed help, and that to fail them again was to fail in a more ancient duty of hospitality. As I continued to reflect on this couple, the sense of responsibility I felt to them loomed large as the reason I did more than simply arrange partner treatment and move on. I felt responsible beyond simply my role a physician: I felt responsible to them as one person to another in the very primal way one responds to a child crying or a hungry stranger begging for food. This responsibility to the stranger is a central focus of the ethics of Levinas. The claim here is that rather than a duty to beneficence grounded in my role as a physician, I have a deeper duty founded in my humanity that gives rise to a desire to care for others when I sense their need, even though I sense this need as grounded in difference rather than something shared. This is responsibility with an emotive component, motivated by a deep sense of care rather than a detached obligation engendered by the physician role. If we accept that there is a second pathway to human caring that is triggered differently than the familiar pathway of empathy, we should acknowledge that, like empathy, it is valuable to teach and preserve this sense of respect for alterity in medical education.
In seeing the other as different from myself, I must acknowledge someone I may not fully understand, and in fact, who may have needs and a worldview I do not share. Levinas writes that the encounter with another person produces an imperative from the start -I see her need, and I feel responsible [4].
It is not Levinas's claim that I see or feel this responsibility to an other in each encounter, but rather that it is there, and it is the ground or the condition for my relationship with others [4]. But perhaps the clinical encounter, where physician responsibility is encoded in the nature and goals of the encounter, opens us to seeing this fundamental responsibility to the other. This is then a "teachable" moment, where the physician has perhaps greater awareness of the ground for the more specific clinical ethics of beneficence and nonmaleficence. That is, we may be uniquely open to feeling the responsibility that Levinas believes grounds all authentic human relationships because the role of physician has this duty explicitly enumerated. Or, beginning from the other side, this basic human response may be the source of the duty to the patient that physicians have accepted since the time of Hippocrates. Modeling this openness and responsibility is something clinical educators need to demonstrate and encourage. This must include showing interest and respect for the lives of our marginalized patients, not just tolerance or a neutral "non-judgmental" stance.
But is it fair to ask whether this responsibility to the other necessarily implies alterity? Perhaps responsibility is engendered by a feeling of commonality when we can see the other as a being who, like us, is imperfect and has needs. What is it about seeing a starving child from the developing world that pulls at usthe similarity we feel or the fact that we are not hungry, and we cannot help but care for someone who lacks what we do not? But this still a repetition of the question regarding whether the care is arising from a sense of shared-ness rather than an encounter with someone who shatters the comfortable world that appears to serve only us. To fully grasp Levinas's perspective it is important to examine why he claims that encountering the other is an encounter with infinity, because the alterity of other people is not just the kind of difference between blue and red. It is a difference of kinds.

The Other as Infinite
Levinas's argument for the infinite nature of the other is both phenomenological and a critique of Western philosophy. The history of philosophy, he writes, is the project of reducing the other to the same [5]. To become an object of knowledge, or the aim of one's consciousness, is to be reduced to an object of intentionality, and thus to be placed into a relation with the self where the self has now fully claimed the other as its own, that is, fully knowable. Levinas describes knowing as a grasping and "assimilation." [6] But intentionality, a phenomenological term for the way in which consciousness is directed at something, the object of consciousness, breaks down when consciousness is directed at another person. The other cannot be "encompassed" by thought, cannot become a mere idea or object for us: "A face is pure experience, conceptless experience. The conception according to which the data of our senses are put together in the ego ends, before the other, with de-ception, the dispossession which characterizes all our attempts to encompass this real." [6] The "conception" ends because we cannot simply make others into things in our world; we are "dispossess(ed)" in that the world belongs to us, but other people do not. We cannot even fully perceive them in the same sense as the rest of the world which lies bare to our perception, and thus they are a "de-ception" an absence, a hole, in our perceiving consciousness. While Levinas's language here is poetic, and also somewhat theological, his point is clear: if I am open to it, the other person confronts me and challenges me in a way wholly different than the rest of the familiar world.
The object of consciousness that cannot be satisfactorily assimilated by consciousness is the Cartesian definition of the infinite, and so Levinas concludes that I experience the infinite, or experience the unexperienceable, when I meet an other, and truly see the other as other. If the other person is my entry point to the infinite, a break from the sameness of the world, it is not surprising that Levinas writes that I experience "height" when I am in relation to another [5]. By "height" he is gesturing both toward the sense of something greater than myself, and also to an asymmetry that I will soon describe. Only in the presence, or as Levinas describes, in "proximity" to another do I have access to someone who shows me the limits of my own world and has the power to truly surprise me. This notion of "height" has, I believe, implications for the clinical encounter if the physician appreciates it. Paul Ricoeur, a colleague and interlocutor of Levinas, recognized that the patient-physician relationship begins in an asymmetrical power relation with the physician firmly in control [7]. But, he argued, as a patient tells her story, the physician can become drawn into the other, and find herself seeking to serve the person now seen through their story. While Levinas was much less sanguine about our ability to truly or fully "see" another even in dialogue or narrative, he would concur that appreciating the radical exposure to someone truly different from ourselves can neutralize the asymmetry of the clinical encounter. Even in their need, the patient presents a striking opening into a someone who is not us, is not for us, and who is ultimately beyond our control in a way non-human things are not. Levinas's point here has important implications for how we, as clinicians, should understand the "noncompliant patient," which is a theme I have developed previously [8]. Teaching students that we can guide and make recommendations, but to accept that we cannot, and should not, seek to control our patients, is a lesson made easier when we have taught them to respect, not fear, the otherness of our patients.

A New Source of Care
Levinas's philosophy may offer a challenge to commonplace thinking regarding clinical empathy. The too familiar other, the other who we see as a reiteration of ourselves, will not necessarily allow a sense of awe that the true stranger may engender. My suggestion is not that the teaching of empathy as finding resonance with another is wrong, but rather that it is incomplete. We need not despair that physicians must fall back on a specific sense of beneficence when treating patients who are "foreign" to them. As David Hume taught, ethics without emotional engagement lacks motivation [9]. Levinas answers this problem by showing us a pre-socialized sociality that relies on respect and response to alterity, rather than an appreciation of likeness. If this claim is correct, then medical students can be shown that the kind of emotional caring for the other that we have to date ascribed only to empathy, may arise either from seeing the other as similar to ourselves, or by seeing the other as truly and remarkably other in a way that makes our world larger and shows us a new and different way of living. Teaching this begins in seeing it.