Shakespeare’s empathy: enhancing connection in the patient–doctor relationship in times of crisis

Speak what we feel, not what we ought to say.

King Lear Act V Scene iii

Doctors sometimes distance themselves from patients, avoiding emotions by focusing on biomedical facts, a process described as ‘detached concern’. ¹ Marcum maintains that the concept of a patient as a unique person disappears before this biomedical gaze. ² An empathic approach includes emotional, cognitive and moral dimensions of a relationship. ³ The recent COVID-19 pandemic, with the need for personal protection, social distancing and video consultations, has created challenges to establishing empathic relationships between patients and doctors.

The conversation surrounding the relevance of medical humanities in enhancing empathy has moved towards considering how a study of the humanities might be introduced into the medical undergraduate curriculum.^4,5 This article argues that a study of Shakespeare’s plays may be a creative way of enhancing empathic approaches in medical students.

Hazlitt claimed that Shakespeare displayed the ‘greatest knowledge of humanity with the greatest fellow-feeling for it’. ⁶ McCrum asks, ‘What is the secret of Shakespeare’s empathy?’ ⁷ This paper addresses this question, investigating how the playwright’s empathic approach can enhance the patient–doctor relationship.

The relevance of Shakespeare’s empathy: emphasising the psychosocial

It is remarkable that Shakespeare’s work remains relevant today. It seems that he had an ability to anticipate our thoughts, particularly in times of crisis. His sensitivity to psychological and social concerns relates to the fact that he was writing before the Scientific Revolution in times of plague and religious upheaval. ⁸ It may be that working in the prescientific era was an advantage to Shakespeare as he could develop his empathic approach without having to view the mind through a mechanistic scientific lens. ⁸ The strong biomedical emphasis in medicine is thought to be one factor in distancing doctors from patients. ¹ Unencumbered by these scientific biases, Shakespeare portrays human relationships identifiable in today’s world, which can inspire emotional connections in clinical practice. ⁹

The mystery of Shakespeare’s empathy

Human relationships are constrained by the inaccessibility of other minds, any conclusions about another’s mind must rely on human interpretation. Shakespeare’s defining gift is his empathic approach: each of his characters speaks in their own voice, generating a narrative composed of multiple individual perspectives, while suppressing his own ego. ¹⁰ Shakespeare depicts the world from the other person’s point of view, not just their understanding, but their emotions and their moral perspectives, encouraging the audience to empathise with both heroes and villains. Shakespeare’s approach creates a space for interpretation and reflection, to experience empathy. Creating such a space for reflection is a central part of clinical practice and medical education.

Shakespeare was familiar with the plague, spending time in ‘lockdown’, when the theatres were closed. He possessed ‘negative capability’, a term coined by Keats to describe an ability of living with uncertainty. ¹¹ Doctors also require ‘negative capability’, particularly in the current pandemic. Shakespeare’s empathic sensitivity was enhanced by his willingness to collaborate with colleagues in the theatre, his classical education, a love of the countryside and his openness to the views of others. In the overcrowded medical curriculum emotional issues may be neglected, collaborative teamworking threatened, in a competitive culture fostering individual achievement.

Empathic imagination

O, I have suffer’d with those that I saw suffer.

The Tempest Act I Scene ii

To see things from another’s point of view demands imagination, requiring both practice and effort. Imagination in Shakespeare does not refer to make-believe, but interrogating a situation creatively. ¹² Shakespeare could see a situation from multiple points of view. His understanding of empathic feeling was deepened by his grief for his son, who died in 1596. Shakespeare’s suffering increased the depth of his emotional expression as shown in his later plays and explored in O’Farrell’s novel Hamnet. ¹³

In King Lear, Kent urges Lear to ‘see better’. This is not simply advice to a king making poor moral choices but a call to explore the reasons behind another’s behaviour, not just to react to things at face value. ¹² Shakespeare shows us that empathy can develop, at the outset of The Tempest, Prospero lacks empathic feelings in his harsh treatment of Ariel and Caliban, but as time passes he comes close to identifying with his enemies.

Shakespeare adopts the other-orientated perspective, imagining undergoing the other’s experience. An other-orientated perspective prevents the doctor from losing sight of the patient as another person, despite having a deep engagement with them.

Empathy and the theatrical self

All the world’s a stage,

And all the men and women merely players:

As You Like It Act 11 Scene vii

Shakespeare was intimately involved in all aspects of the theatre as an actor, playwright and director. He knew that theatre reflects reality, comparing the world to a stage and people as actors, creating a theatrical self. ⁸ In her modern interpretation of The Tempest, Margaret Atwood describes the production of the play by a cast of prisoners, creating powerful bonds between the actors, such empathic teamworking being a feature of modern clinical care. ¹⁴

Empathic relationships may also be described in theatrical terms. Medical students describe ‘fake’ empathy in exams, where they show empathic behaviours without trying to understand the patient’s view. ¹⁵ Fake empathy has been compared to ‘surface acting’ in which empathetic expressions are adopted without any change in the student’s emotions or understanding of the patient. ¹⁶ In contrast, authentic empathy is related to ‘deep acting’ where the actor feels the emotions. ¹⁶ Empathy conceptualised at this deep level recognises the patient as a fellow human being, developing a sense of fraternity. This feeling of a shared humanity can create a sense of security in situations of great uncertainty, for instance, in end-of-life care and in promoting effective teamworking.

Empathy and morality

Poor naked wretches, wheresoe’er you are,

That bide the pelting of this pitiless night,

King Lear Act III scene iii

Shakespeare’s plays are concerned with the ethical dilemmas of everyday living. In empathic relationships each person respects the other as being of equal moral worth. ¹⁷ Shakespeare leaves moral judgements to his audience, involving them without supplying any of his ethical views. ⁸ Empathy-based ethics extends the ethical importance of empathy from a desirable moral disposition in a doctor to a capacity, which is fundamental to ethical functioning. ¹⁸

Empathy and emotions

Expose thyself to feel what wretches feel,

King Lear Act III scene iii

The idea that emotions are disruptive and need to be controlled is deeply ingrained in medical education and practice, contributing to doctors distancing from patients. ¹⁹ Shakespeare would have been aware of Cicero’s belief that to inspire emotion in his audience the orator must first feel the emotion himself, emotional identification being integral to his classical education. ¹⁰ Experiencing emotions enables a doctor to focus on their work and can be used to guide their responses in a particular context. ²⁰ In such a trusting partnership, the doctor feels the pain of the patient while remaining aware of a self-other boundary. ²¹ This subtle connection between listening, reflection and interpretation is an appropriate form of ‘distancing’, or pausing, as part of an empathic experience.

Language of empathy: starting a conversation

Shakespeare, like all writers, retold existing stories and gave them new life. Nowadays academics consider plagiarism a sin, yet in Shakespeare’s time adapting earlier works would have been considered praiseworthy, for example, his lifting of parts of Ovid’s Metamorphoses in The Tempest. ²² This ‘lively tuning of familiar material’ was rather a mark of artistic excellence which he would have been taught in school. ²² No-one starts with a blank sheet, I draw on the wisdom of Shakespeare scholars, adapting and applying their ideas to the patient–doctor relationship. ²³ A positive role model inspires imitation in the student in their progress to acquire clinical skills.

Doctors need ‘narrative competency’ to allow them to interact with the patient in a joint process of making sense of their stories of suffering. ²⁴ Frank suggests that it is at precisely the moment when two people share feelings of uncertainty, vulnerability and loneliness that dialogue is most possible between them. ²⁵ The moral demand of a dialogue is that each participant grants equal authority to the other’s voice, speaking with the other rather that speaking about them. ²⁵

Introducing medical students to Shakespeare

I’ll teach you differences

King Lear Act I scene iv

The humanities have been used in a variety of ways in medical education, including poetry, literature music and paintings.^24,26,27 Drama has been used effectively in teaching medical students to explore empathic relationships in their clinical work.^17,28 Studying Shakespeare disturbs our assumptions and prejudices and to opens us to possibilities. ²⁹ He shows us how to live with uncertainty, to accept that often there is no single right answer. Shakespeare’s work enforces an ethical pause in which a person can step back and think deeply about other people and their lives. His plays encourage students and doctors to engage a psychosocial perspective when thinking about the patient’s story, stimulating their ability to see the world through the other’s eyes. Shakespeare’s plays can extend understanding of patients’ suffering by developing imaginative reflective practice and extending clinical curiosity. ³⁰ Such reflective practice can supplement the contact between students and real patients rather than the simulation with actors which forms part of their communication skills training.

Medical humanities are often on the fringes of medical education, but should be central to medicine culture change. ⁴ A special study module would be one way of introducing Shakespeare studies to the undergraduate curriculum. ²⁸ Students attending such a course would be mirroring the availability of the empathic clinician to emotional connection. In such a supportive environment the student would have an opportunity to rehearse their natural spontaneous empathy, developing their imagination, curiosity and self-reflection in the process of experiencing empathy. A module focusing on empathy and the nature of suffering would offer students ways of transcending themselves and connecting with the inner world of others.

Conclusion

Shakespeare speaks through times of crisis, underlining the centrality of empathic human relationships. Weatherall reflects on the need for doctors and students to achieve a balance between retaining competence and fostering a curiosity of the patient’s experience of their illness. ³¹

This commentary contributes to the conversation about how best to incorporate the humanities into the medical undergraduate curriculum. I describe the analogy of the playwright and his plays to the everyday drama of empathic clinical relationships. I suggest that the current imbalance between biomedical and psycho-social care can be addressed by incorporating Shakespeare studies into the undergraduate medical curriculum. Antony Burgess summarises the playwright’s contribution, ‘To see his (Shakespeare’s) face we need only look in a mirror. He is ourselves, ordinary suffering humanity, fired by moderate ambitions, concerned with money, the victim of desire, all too mortal.’ ³²

Supplemental Material

sj-pdf-1-jrs-10.1177_0141076821996005 - Supplemental material for Shakespeare’s empathy: enhancing connection in the patient–doctor relationship in times of crisis

Supplemental material, sj-pdf-1-jrs-10.1177_0141076821996005 for Shakespeare’s empathy: enhancing connection in the patient–doctor relationship in times of crisis by David Ian Jeffrey in Journal of the Royal Society of Medicine