Remember the classic definition formulated by Rogers (1959), empathy is defined as the ability

to perceive the internal frame of reference of another with accuracy and with the emotional components and meanings which pertain thereto as if one were the person, but without ever losing the ‘as if’ condition. Thus, it means to sense the hurt or the pleasure of another as he senses it and to perceive the causes thereof as he perceives them, but without ever losing the recognition that it is as if I were hurt or pleased and so forth.

The “as if” condition is important: If this condition is absent, feeling another person’s emotions is not empathy but sympathy (i.e., emotional identification). The distinction between empathy and sympathy was clarified by Wispé (1986) as follows:

To know what it would be like if I were the other person is empathy. To know what it would be like to be that other person is sympathy . In empathy I act ‘as if’ I were the other person. In sympathy I am the other person. The object of empathy is to ‘understand’ the other person. The object of sympathy is the other person’s ‘well-being.’

This explains why empathy, and not sympathy , has been privileged in the patient -doctor relationship. According to Wispé , sympathy is not the mode for therapeutic interaction:

Sympathy does not facilitate accurate assessments. One cannot be sympathetic and objective. Sympathy lends itself to emotional distortions. Sympathy can lead to closer emotional identification and to peremptory rescue actions in the patient ’s behalf […] Compassionate understanding is one thing in therapy; sympathy is another.

Similarly, Mohammadreza Hojat proposed that the relationship with patient outcomes is positive and linear for empathy but curvilinear (having an inverted U-shape) for sympathy . In other words, only a small dose of sympathy may be beneficial (Hojat 2007).

Clearly, if one refers to these definitions of empathy and sympathy , we can conclude that both of them can lead to clinical inertia . Let us say that a Doctor D sees a patient , Ms P who is psychologically resistant to the idea of starting insulin, giving priority to her fear of insulin and refusing to accept the fact that insulin may preserve her health . Doctor D considers empathetically Ms P’s concern. Even without forgetting the “as if” condition, Doctor D understands Ms P’s fear about insulin and acts accordingly: She does not prescribe insulin and will therefore be clinically inert. If, on the other hand, Doctor D forgets the “as if condition,” she expresses sympathy for Ms P (emotional identification) and, of course, does not prescribe insulin either, which also leads to clinical inertia.

We therefore arrive at a paradox of empathy in medical care : While empathy is presented as a cornerstone in the doctor -patient relationship, Doctor D will actually prescribe insulin to Ms P (i.e., will not be clinically inert) if (i) she does not express empathy at all (paternalism) or (ii) if she behaves empathetically, but with a definition of the “as if” condition of empathy which implies that she remembers that she is a doctor, and that to be a doctor means giving priority to the patient’s future well-being and not to the patient’s own concern. In other words, clinical inertia can be avoided if the doctor either does not express empathy or expresses empathy but does not act accordingly, which is not impossible: Philosopher Stephen Darwall (2002), using the example of a child on the verge of falling into a well, remarked that “empathy consists in feeling what one imagines he feels, or perhaps should feel (fear , say), or in some imagined copy of these feelings, whether one comes thereby to be concerned for the child—or not.” He added: “Empathy can be consistent with the indifference of pure observation or even the cruelty of sadism. It all depends on why one is interested in the other’s perspective.” Of course, coming from a doctor, such behavior would be recognized as an aberrant response, and probably as pathological.

Darwall , in his book, Welfare and Rational Care, proposed another definition of sympathy , which may be relevant in the context of the psychological relationship between doctor and patient . He calls sympathetic concern or sympathy

a feeling or emotion that (i) responds to some apparent obstacle to an individual’s welfare, (ii) has that individual himself as object, and (iii) involves concern for him, and thus for his welfare, for his sake. Seeing a child on the verge of falling [into a well], one is concerned for his safety, not just for its (his safety’s) sake, but for his sake. One is concerned for him. Sympathy for the child is a way of caring for (and about) him (Darwall 2002, 50–72).

Sympathy , in this Darwallian sense, is clearly different from empathy:

empathy is the imaginative occupying of another’s point of view, seeing and feeling things as we imagine her to see and feel them. Sympathy for someone, on the other hand, is felt not as from her standpoint but as from the perspective of someone (anyone) caring for her. Empathizing with someone in a deep depression, we imagine how things feel to her, for example, how worthless she feels. When, however, we view her situation with sympathy (a sympathy she perhaps cannot muster for herself), she and her welfare seem important, not worthless.

Similarly, psychoanalyst David Black observed that there are two senses of the word sympathy . First, sympathy refers to “a spontaneous capacity to be directly affected by the feeling state of others”. Let us say that this form of sympathy is “a capacity”, like empathy, and it is by and large empathy from which the “as if” condition was removed. It represents the sympathy in the sense of Wispé (emotional identification). Second, sympathy can refer to another concept, according to Black:

a warm concern for the feelings of others. Sympathy in this sense, also called compassion, is an emotion, or a range of emotions , akin to sorrow and belonging with the depressive position group, and like other emotions, it can be highly developed, repressed, split off, etc. (Black 2004).

Here, sympathy is an emotion, and this meaning of the word sympathy represents actually the sympathy in the sense of Darwall , who described it also as an emotion.

The word “care ” comes from old English word, caru, ċearu: care, concern, anxiety , sorrow, grief, trouble; this old English word was derived from the proto-Germanic word, *karō: care, sorrow, cry; that proto-Germanic word, in turn, came from the proto-Indo-European word, *ǵār-, *gÀr-, voice, exclamation. Thus, etymologically at least, care seems to be the emotional answer to a cry: Is not care the innate answer of the mother, when she hears, for the first time , the cry of her child? Therefore, the words care, sympathy , and beneficence may have a synonymous meaning.

One thinks also to the Aristotelian concept of philia, one of the Greek words for love , often translated as friendly feeling :

We may describe friendly feeling towards any one as wishing for him what you believe to be good things, not for your own sake but for his, and being inclined, so far as you can, to bring these things about. (Aristotle 1381)

However, something more is needed. Take again Doctor D and Ms P. Even if Doctor D exercises this form of sympathy , this does not mean that she will prescribe insulin. Indeed, she may consider that Ms P’s fear of insulin represents something that jeopardizes her welfare. Caring for her patient , Doctor D may want to improve her welfare and decide not to prescribe insulin. Again, she manifests clinical inertia .

However, Doctor D may also manifest this kind of sympathy for her patient by defining her welfare, but not just any welfare: Her future welfare. For instance, having to decide between the patient’s immediate feelings (the fear of insulin) and what she, as a doctor , considers to be the patient’s future welfare (what is enshrined in evidence-based guidelines ), she would decide in favor of the guidelines, thus avoiding the pitfall of clinical inertia .

We propose therefore that to avoid clinical inertia , the doctor should practice not only empathy, appreciating the feelings of her patient , but also a new form of sympathy , defined as an emotion that takes the three criteria defined by Darwall : “(i) Responds to some apparent obstacle to an individual’s welfare, (ii) has that individual himself as object, (iii) involves concern for him, and thus for his welfare,” and adds a fourth condition, (iv) specifying clearly that the emotion involves concern for the patient’s future .

This conclusion (that doctors are concerned with the future of their patients) may be considered as a truism. It takes its real meaning here, at the end of a book aimed to explain patients’ adherence: If clinical inertia , at least in some cases, is due to the doctor failing to consider the future of her patient , in that case, doctor’s clinical inertia shares with patient’s nonadherence the fact to be a case of “clinical myopia ” (Reach 2008).

In Darwall ’s definition, sympathy is “an emotion which has for its object the person herself, involving concern for her, and thus for her welfare, for her sake”. Including this fourth condition in the definition of sympathy entails accepting that, in the doctor -patient relationship, the concept of a person encompasses the idea of the future . Interestingly, an emphasis on prognosis had been recommended by Hippocrates (Hippocrates 1978):

It seems to be highly desirable that a physician should pay much attention to prognosis. If he is able to tell his patients when he visits them not only about their past and present symptoms, but also to tell them what is going to happen, as well as to fill in the details they have omitted, he will increase his reputation as a medical practitioner and people will have no qualms in putting themselves under his care . Moreover, he will the better be able to effect a cure if he can foretell, from the present symptoms, the future course of the disease (Hippocrates , Prognosis).

When I introduced the hypothesis of a role for certain emotions in the phenomenon of clinical inertia , I quoted the suggestion by Tappolet (2003) that emotions are the perception of values. In Darwall ’s definition, the sympathy that the doctor feels for the patient is the emotion that has “the patient herself” for object. The doctor sympathizing with the patient has to decide between the value of the patient’s emotions which are often essentially present-oriented, and the value of the person herself (i.e., her future ). According to the Construal Level Theory developed by Trope and Liberman (2003), concepts related to the future are categorized in our mind as having a higher level than immediate ones. However, they are also more abstract. This may explain why they are difficult to apply, both for the patient and for the physician, and why patient nonadherence and doctor clinical inertia are so frequent.

Harry Frankfurt , in his essay “The importance of what we care about” (Frankfurt 1988), observed “that the outlook of a person who cares about something is inherently prospective; that is, he necessarily considers himself as having a future .” The interesting point here is that if we transpose this definition of care to health care, we are in a situation where the doctor who takes care of the patient considers not only herself (the subject who cares) but also her patient (the object of care) as having a future.

The key point in Darwall ’s argument is that a person’s well-being is defined not only by the person herself but also by “someone (anyone) caring for her”. Anyone caring for her, because she cares for her, is entitled to help shape the contours of what is good for her, in order to ensure her welfare. Of course, as already mentioned, the patient can reject the doctor ’s definition of what is good, in favor of her own definition.

Let’s come back to the four models of the doctor -patient relationship proposed by Emanuel and Emanuel: (i) the paternalistic model where the doctor decides for the patient, (ii) the informative model where the doctor gives information to the patient, (iii) the interpretative model , in which the goal of the therapeutic relationship is to help the patient elucidate her preferences, as they may not be explicit, and then to help her act by explaining which therapeutic option is the most appropriate, taking into account the preferences expressed during the therapeutic interaction (significantly, the physician does not influence the revelation of the preference), and (iv) the deliberative model, in which the goal of the physician-patient relationship is to help the patient determine and choose what seems best for her health . Here, contrary to the interpretative model, the physician indicates which options she finds preferable for the patient’s health (Emanuel and Emanuel 1992).

I suggest that these four models can be described as an ethical pathway. First, introducing empathy in her relationship with the patient , the doctor proceeds from the informative to the interpretative model : indeed empathy, the aim of which is to understand the patient, is the very attitude which will help the patient elucidate her own preferences. Secondly, I suggest that sympathy , according to our four-point definition, is the hallmark of the deliberative model. Here the doctor expresses her own preferences, after having heard the patient’s, and doctor and patient move forward to craft a treatment plan. Although the deliberative model calls for the doctor to express her preference as in paternalism, it differs from paternalism by the fact that the expression of the doctor’s preference occurs at the end of a process, described here as an “ethical pathway” shown on Fig. 9.2. Therefore, I propose that clinical inertia can be seen, at least sometimes, as an unintended consequence of empathy. This is not to deny that empathy is essential in the doctor-patient relationship. Certainly, it is a way to practice the biopsychosocial model of medicine (Engel 1977), which aims to counterbalance the coldness of a purely factual medicine. Indeed, applying empathy in the doctor-patient relationship represents a transition from the second (informative) to the third (interpretative) model. However, remaining at the interpretative stage may be dangerous: As shown herein, when the “as if” condition of empathy is misused (taking into consideration only the immediate interest of the patient) or missed (emotional identification—a primitive form of sympathy, where the doctor takes for herself the patient’s immediate concern), there is a risk of clinical inertia (Fig. 9.2). This risk may be avoided if the doctor proceeds to the fourth, deliberative, model, expressing her own preferences, i.e. sympathy as it is defined herein.