Clinical Empathy and Narrative Competence: The Relevance of Reading Talmudic Legends as Literary Fiction

摘要

The “curative potential” in almost any clinical setting depends on a caregiver establishing and maintaining an empathic connection with patients so as to achieve “narrative competence” in discerning and acting in accord with their preferences and best interests. The “narrative medicine” model of shared “close reading of literature and reflective writing” among clinicians as a means of fostering a capacity for clinical empathy has gained validation with recent empirical studies demonstrating the enhancement of theory of mind (ToM), broadly conceived as empathy, in readers of literary fiction. Talmudic legends, like that of Rabbi Judah’s death, are under-appreciated, relevant sources of literary fiction for these efforts. The limitations of narrative medicine are readily counterbalanced by simultaneously practiced attention to traditional bioethical principles, including—especially—beneficence, non-maleficence, and autonomy.Keywords: Empathy, literature, narrative medicineOn the day when Rabbi [Judah] died, the rabbis had decreed a public fast and offered prayers for heavenly mercy. They had furthermore announced that whoever said that Rabbi was dead would be stabbed with a sword. Rabbi’s handmaid ascended to the roof and prayed: “The immortals desire Rabbi to join them, and the mortals desire Rabbi to remain with them. May it be the will of God that the mortals may overpower the immortals.” When, however, she saw how often he resorted to the privy, painfully taking off his tefillin and putting them on again, she prayed: “May it be the will of God that the immortals may overpower the mortals.” As the rabbis continued their prayers for heavenly mercy, she took up a jar and threw it down from the roof to the ground. At that moment they ceased praying and the soul of Rabbi departed to its eternal rest.(Babylonian Talmud, Tractate Ketubot 104a)This well-known Talmudic legend is subtly evocative. On the one hand, it may be read as a hackneyed, sentimental tale condemning the strait-jacketed, ritualistic rabbis facing their leader’s imminent death in contrast to the more flexible, attentive handmaid who intentionally ends the prolonged dying process. On the other, it may be read as a complicated story with gaps which invite speculation as to the motivations of the rabbis and the handmaid. To read it in the latter fashion is to allow an evocation of a more nuanced view of the text which has relevance for a caregiver of any century past or present who faces the challenges of acting with clinical empathy and what has been termed narrative competence.CLINICAL EMPATHYA recent consideration of clinical empathy is found in Jamison’s essay collection, The Empathy Exams, where she writes as both a medical actor who helps students learn interviewing techniques and as a patient herself.1 She begins:Empathy comes from the Greek empatheia—em (into) and pathos (feeling)—a penetration, a kind of travel. It suggests you enter another person’s pain as you’d enter another country, through immigration and customs, border crossing by way of query …1Jamison considers empathy to be an intentional state of insight for any clinician with regard to a patient, and more than “Checklist item 31” on the form which she fills out after each student interview. She details the consequence of an absence of empathy when recalling a complicated procedure of her own with an impatient cardiologist. Her implication is that the physician was at least neglectful if not lazy in the work of empathizing. She concludes:Empathy isn’t just something that happens to us—a meteor shower of synapses firing across the brain—it’s also a choice we make: to pay attention, to extend ourselves … The act of choosing … means … “I will listen to his sadness, even when I’m deep in my own.”1Not to listen invites bad medical outcomes.2,3 Groopman and Ofri have documented that medical mistakes result mainly from the interference of emotional factors not addressed during dialogues between clinician