1428 Journal of Pain and Symptom Management
5 May 2018
Humanities: Art, Language, and Spirituality in Health Care
Series Editors: Christina M. Puchalski, MD, MS, and Charles G. Sasser, MD
In Defense of Sympathy, in Consideration of Empathy,
and in Praise of Compassion: A History of the Present
Ana Soto-Rubio, MSc, and Shane Sinclair, PhD
Faculty of Psychology (A.S.-R.), University of Valencia, Valencia, Spain; Compassion Research Lab (A.S.-R., S.S.), Faculty of Nursing (S.S.),
University of Calgary, Calgary, Alberta, Canada
History is the best medicine for a sick mind, for in
history you have a record of the infinite variety of
human experience plainly set out for all to see,
and in that record you can find for yourself and
your country both examples and warnings: fine
things to take as models, base things rotten through
and through to avoid.
Livy, Roman Historian.
Introduction
Beyond Semantics
Sympathy, empathy, and compassion are frequently
invoked concepts in contemporary health care,
particularly in incidences when we find ourselves at
a loss for words or curative interventions. Linguistic
epistemologists remind us that words are powerfuld
they shape our thoughts, determine what is truth, in-
fluence our actions, and can instil healing or harm in
the patients in our care.1 But are sympathy, empathy,
and compassion words that everyone uses, but no one
understands?dbeing treated dichotomously on the
one hand and conflated on the other.1e4 Although
the perspectives of current patients, practitioners,
policy makers, researchers, and contemporary
thinkers are an invaluable source of knowledge in
helping to disentangle these terms,1,4e6 the human-
ities remind us that contemporary thoughts on the
nature and differences of these concepts may not
be as novel, revolutionary, and enduring as we might
think. The purpose of this article was to provide an
account of the evolution of these terms within history
and health care to provide clarity and to understand
the clinical implications associated with them in
contemporary practice.
Address correspondence to: Shane Sinclair, PhD, Faculty of
Nursing, University of Calgary, 2500 University Drive NW,
Calgary, Alberta, Canada T2N1N4. E-mail: sinclair@
ucalgary.ca
Ó 2018 American Academy of Hospice and Palliative Medicine.
Published by Elsevier Inc. All rights reserved.
Vol. 55 No.
The Historical Roots of Sympathy
Amid the shock of so many passions that oppress
the weak or marginalize the unfortunate, from
the bottom of its heart humanity secretly pleads
the cause of sympathy and avenges it from the
injustice of fate by arousing the sentiment of natu-
ral equality.
Sophie de Grouchy.
The word sympathy comes from the ancient Greek
sympάqεia, sympatheia, which literally means ‘‘to suf-
fer with.’’ Since antiquity, its core meaning implied
involuntary co-affection of a physiological nature to-
ward different kinds of physical phenomenadthe
interconnectedness of all things. The nature of this
interconnectedness typically referred to things that
were not visible to the naked eye, a metaphysical
connection, or energetic bond between two objects
such as the sympathetic resonance between two
strings or the effect on one tuning fork when a sepa-
rate tuning fork is struck from across the room. As
Giuseppe Gerbino comments, ‘‘The term sympa-
thetic resonance [in antiquity] reveals a different
worldview, one that postulated the existence of a hid-
den force, sympathy, operating throughout nature
and binding the universe in all its parts. In such a
world, the two strings respond to each other’s mo-
tion because of a mysterious affinity that can be
conceived by the mind but cannot be directly
perceived by the senses.’’7,8
Within health care, one of the first known uses of
the term sympathy or sympathetic affection was in
Galen’s second-century commentary on Hippocrates,9
Accepted for publication: December 14, 2017.
0885-3924/$ - see front matter
https://doi.org/10.1016/j.jpainsymman.2017.12.478
Vol. 55 No. 5 May 2018 A History of Sympathy, Empathy and Compassion
in describing how symptoms in a distinct region of the
body are effected by illness/pathology within a seem-
ingly separate region of the body. As Holmes sum-
mates, ‘‘‘Sympathy’ is overwhelmingly used by Galen
to express what must have been an existing technical
notion within the learned medical tradition, accord-
ing to which, diseases, or more properly, ‘affections’
(path
e ) are trafficked from one part of the body to
another.’’9
The term sympathy retained a largely biophysical
meaning until the end of the 16th century when it
began to be used to explain the ability of one indi-
vidual to attune to the feelings of another. As a
result of this expanded understanding of sympathy
to the affective realm, sympathy enjoyed exemplary
status within Western society so much so that the
18th century has been coined the ‘‘age of sympa-
thy.’’10 As Hume lauds,11 ‘‘No quality of human na-
ture is more remarkable . than the propensity we
have to sympathise with others, to receive by
communication their inclinations and sentiments,
however different from or contrary to our own.’’
The realization of the ability to emotionally reso-
nate with others was considered a mechanism for
prosocial behavior and social reform by philoso-
phers, educators, and ethicists and was readily incor-
porated into discourses on child rearing, morality,
and human relations.11e14 As a result, by the end
of the 18th century, sympathy was largely synony-
mous with our contemporary understanding of
compassion. According to Adam Smith, the famous
18th-century philosopher and economist, sympathy
involved putting ourselves through our imagination
in the place of someone else and feeling what they
feel, be it joy or sorrow; and thus enlivening joy
and alleviating grief through shared feelings.14
The close affinity between this historical under-
standing of sympathy and contemporary under-
standing of compassion is further evident in the
fact that the Greek word sympatheia was increasingly
translated as compassio in Latin, Italian, Frenchd
eventually resulting in the original meaning of
sympatheia being literally lost in translation.
The Fall of Sympathy: Contemporary Insights
Sympathy’s demise was a slow and gradual one.
While throughout the 20th century ‘‘sympathy’’ was
still used to describe the ability to feel what others
feel, its potential for societal reform was increasingly
dismissed and replaced with a growing sentiment of
cynicism.1,15,16 Twentieth-century definitions of sym-
pathy by social and developmental psychologists were
increasingly denuded from its etymological roots of
‘‘fellow feeling,’’ taking on a more pejorative meaning
1429
of feeling sorrow or pity for the emotional state of an
‘‘other.’’1,17e21
The devolution of sympathy within health care to
what was recently described as a pity-based response
that was unwelcomed and in some incidences
despised by patients4 is due in part to the emergence
of the more objective, scientific, and apparently more
complex construct of empathy within the 20th
century.1,22
The Historical Roots of Empathy
Don’t judge a man until you have walked a mile in
his shoes.
Cherokee Proverb
The English word empathy has its etymological
roots in the late-19th-century German term Einf€ u h-
lung, which literally means ‘‘in feeling,’’ with its first
known usage being attributed to the German psychol-
ogist Robert Vischer in 1873, to describe the ability to
project the self into a viewed object such as a piece of
art or into another person’s situation.23,24 Another
German psychologist, Theodore Lipps, described
empathy as ‘‘objectified self-enjoyment,’’25e27 whereas
his colleague E.B. Titchener defined empathy as the
process of humanizing objects, of feeling ourselves
or reading ourselves into them.28 The legacy and
impact of empathy within psychoanalytic schools of
the 20th century can be traced through the translation
of Freud’s works into English, with empathy being
used to translate Freud’s use of Einf€ u hlung.24 In this
way, empathy implied a psychological projection but
not specifically esthetic,24 through object relations
theorists and the self-psychology of Heinz Kohut who
defined empathy as ‘‘vicarious introspection.’’29
Following his theory, ‘‘We see a person who is unusu-
ally tall. It is not to be disputed that this person’s un-
usual size is an important fact for our psychological
assessmentdwithout introspection and empathy, how-
ever, his size remains simply a physical attribute .
Only when we think ourselves into his place, only
when we, by vicarious introspection, begin to feel his
unusual size as if it were our own and thus revive
inner experience in which we had been unusual or
conspicuous, only then begins there for us an appreci-
ation of the meaning that the unusual size may have
for this person and only then have we observed a psy-
chological fact.’’29). As a result, empathy, in its original
usage, attempted to avoid the messiness and vulnera-
bility of ‘‘feeling with’’ a fellow human being associ-
ated with sympathy, in favor of a more objective and
emotionally detached stance that was dependent on
the ability to literally ‘‘put oneself in the shoes of
another.’’
1430 Soto-Rubio and Sinclair
The Rise of Empathy: Contemporary Insights
Over the course of the late 20th century and early 21st
century, empathy began to develop a softer side, affec-
tive empathydthe ability to not only understand what
it would be like to be in a persons’ situation but also reso-
nate or attune to the persons’ feelings30,31dthereby re-
turning and reinserting sympathetic resonance into the
vernacular of 20th-century empathetic discourses.
Based on this new understanding, contemporary re-
searchers with the aid of scientific progress and technol-
ogy began to identify ‘‘the empathy circuit,’’ a series of
neural circuits within the cortex and limbic system that
are activated when observing another person’s feel-
ings.32-34 In addition to identifying a neurological basis
for emotional resonance, researchers noted the activity
of mirror neurons in regions of the brain associated with
thought and language formation, suggesting that a
more detailed understanding of the situation was also
occurring.35 Thus, whereas cognitive empathy facilitates
an understanding of the emotions of another person by
discerning body language, perspective taking, and re-
flecting this objective understanding back to the person
in need, affective empathy involves understanding the
experiences of another person by sharing their emo-
tionsddirectly attuning to the feelings of the other
person.36
Although the majority of researchers acknowledge the
cognitive and affective domains of empathy, the proso-
cial aspect of empathy, such as having concern or its
orientation toward action, is contested.37 Some
researchers18,38e41 depict empathy as a series of evolving
concentric circles, moving from cognitive perspective
taking, emotional resonance, developing feelings of
concern, and a motivation to address suffering. A second
group of researchers42e45 postulate that although
empathy allows us to know what the other person is
feeling or thinking, it does not necessarily include any
warm feelings of concern or the desire to help. In fact,
some researchers have even suggested that there is a po-
tential ‘‘dark side’’ to empathy involving attuning to the
feelings of another person to take advantage of their
vulnerability, to manipulate them, or even to exacerbate
their suffering.46,47 Increasingly, however, researchers
and patients themselves associate empathy with the abil-
ity to acknowledge, understand, and emotionally reso-
nate with a person’s feelings and situation, reserving
the prosocial desire to help and action aimed at the alle-
viation of suffering to compassion.4
The Historical Roots of Compassion
We aspire to heal suffering because we are all con-
nected in some way.48
Vol. 55 No. 5 May 2018
Although the Latin root for the term compassion
(compassio) was often used interchangeably when
translating sympatheia from ancient Greek in the
16th century, the concept originally held a deeper
meaning and religious connotation that was rooted
in love and the spiritual connection of living beings
through a Higher Power, God, the Universe, Nature
or a Life Force.49e51 The higher purpose and deeper
meaning of compassion is evident in the words of
the 16th-century Christian mystic Teresa of Avila,

‘‘You are the eyes through which to look out Christ’s
compassion to the world’’52; the Dalai Lama,
‘‘Whether one believes in a religion or not and
whether one believes in rebirth or not, there isn’t
anyone who doesn’t appreciate kindness or compas-
sion . Our prime purpose in life is to help others’’53;
and Albert Einstein, ‘‘A human being is a part of the
whole, called by us ‘Universe,’ a part limited in time
and space. He experiences himself, his thoughts,
and feelings as something separate from the restda
kind of optical delusion of his consciousness. The
striving to free oneself from this delusion is the one
issue of true religion. Not to nourish it but to try to
overcome it is the way to reach the attainable measure
of peace of mind.’’54 Whereas the emotional resonance
of sympathy and empathy was limited to the connection
between human beings, compassion, both in terms of
its motivation and source, added a transpersonal
dimension to the interconnectedness between pro-
viders and recipients of compassion.49,55 Although
compassion seemed to have more esoteric origins,
a further defining feature of compassion through-
out history is that it was inherently pragmaticd
involving not simply attuning to the emotional state
or suffering of another, but to do something to actively
alleviate another person’s suffering, often with some
personal expense for the respondent.4,6,55,56
Compassion: Back to the Future
In the latter part of the 19th and much of the 20th
century, the importance of compassion within health
care was especially emphasized within the field of
nursing, which was strongly influenced by the reli-
gious orders within which many schools of nursing
found their origins.57 In fact, for early nurse leaders
such as Nightingale, Dock, Goodrich, and Wald,
compassion was esteemed as the essence of nursing56
occupying a prominent place in nursing textbooks
and training programs for much of the 20th century.57
By the end of the 20th century, however, nursing re-
searchers began to recognize that compassion was
receding from the prominent position that it once
occupied within the discipline, a phenomenon that
has been attributed to a variety of factors including
Vol. 55 No. 5 May 2018 A History of Sympathy, Empathy and Compassion
the professionalization, medicalization, consumeriza-
tion, and secularization of nursing and health care
in general.57e60 Ironically, recent high-profile reviews
of health care failures in the U.K. not only identified
a lack of compassion as a significant systemic cause
but also unfairly implicated nurses in the process, call-
ing for the renewal of compassion training for future
and practicing nurses.61e66
Contemporary researchers on compassion recognize
that a further distinctive feature and challenge of
compassion is its deeply personal naturedinvoking
health care providers’ personal qualities or character
and not simply their professional qualities. As William
Osler attests, ‘‘The practice of medicine is an art, not
a trade; a calling, not a business; a calling in which
your heart will be exercised as much as your head.’’67
Thus, compassion requires a willingness on the part
of health care providers to be vulnerable, to not only
‘‘feel with’’ their patient, but also ‘‘suffer with’’
them,68 being professionally and personally impacted
in the process.59,69,70 Although this has raised many
questions about the potential negative impact of
providing compassion,71,72 other researchers argue
that providing compassion actually has a sustaining ef-
fect that disentangles health care providers from
emotional contagion to action.4,46,73 For example, Ta-
nia Singer, a neuroscientist, recently discovered that
empathy activated regions of the brain in the observer
associated with pain, while the loving kindness and pro-
social aspects of compassion extend beyond this mirror-
ing state, activating regions of the brain associated with
love, warmth, reward, and affiliation.73 As a result,
although researchers acknowledge that health care
providers are susceptible to burnout, vicarious
suffering, and occupational stress, attributing these
conditions to compassion may be misguided and harm-
ful for both health care providers and patients.48,74
Clinical ReflectionsdThe 3Rs for Assessing and
Enhancing Compassion in Practice
Based on this historical overview, patient research,
and our clinical experience as a psychologist and spiri-
tual care provider working with palliative patients and
their families, we suggest that there are three essential
questions that health care providers consider in assess-
ing and enhancing compassion in their patient care: 1)
Relate: How do I relate to the person in my care? 2)
Respond: What is my response to suffering? 3) Role:
What are my beliefs about my role in this process?
Relate
Compassion requires health care providers to
reflect not only on how they see the patient but also
on how they see themselves in relation to them. The
1431
language we use in referring to individuals in our
care can be a powerful indicator and influencer of
these underlying attitudes. Whether we refer to
them as a client, a resident, a health care consumer,
the 63 year old with metastatic pancreatic cancer in
Room 463, a patient, a person, or by their first name
not only tells us how we see them but also tells them
how they are seen by us. Compassion also implores
us as health care providers to consider how we see our-
selves in relation to the person in our caredis our
relationship based on shared humanity, mutual
suffering, interrelatedness on a spiritual level or a
strict physician/patient relationship, deservedness, or
based on a socioeconomic, cultural, or religious simi-
larities. While on the surface these may seem like
simplistic or esoteric questions, in our experience,
they have a profound and tangible effect on patients’
experiences of compassion and are often a distin-
guishing feature of colleagues we esteem as exemplary
compassionate health care providers.
Response
How we as health care providers respond to suffering
is the second demarcating feature of compassion.
Although sympathetic resonance is an important start-
ing point for compassion, as an end point, it is largely
ineffective in alleviating suffering. Although sympa-
thetic resonance may have a cathartic effect for patients
knowing that their health care provider commiserates
in their suffering, it may have the opposite effect on
health care providers whose only option is to absorb
their patients’ suffering, making them susceptible to
vicarious suffering. Similarly, while empathetic concern
adds an element of cognitive and emotional under-
standing to health care providers’ response to a pa-
tient’s suffering, historically, it entails a more
objective response that, while making patients feel un-
derstood, does not necessarily translate to them feeling
cared for or having their suffering addressed through
action. A compassionate response to suffering extends
sympathetic resonance and empathetic concern by
engaging the virtues of health care providers and the
addition of action. Although compassion requires
more from health care providers, both on a personal
and professional level, contrary to popular opinion,
this does not necessarily make them more susceptible
to burnout.75 In fact, true compassion may have a sus-
taining effect on health care providers by allowing
them to practice in a self-congruent manner and by
providing an outlet for sufferingdaction that protects
against emotional contagion on the one hand and help-
lessness on the other.
Role
Cultivating compassion as health care providers also
requires us to reflect on our beliefs about our role in
1432 Soto-Rubio and Sinclair
addressing suffering. While compassion requires
health care providers to engage and attempt to
ameliorate the suffering of our patients, this does
not mean that we are responsible for finding answers
or annihilating suffering altogether. History and clin-
ical practice teaches us that in regard to compas-
sionate care, while health care providers play an
instrumental role in the healing process, their role is
not fundamental to this process. The latter leads to
chronic caring that places the onus for alleviating
suffering on the health care provider, whereas the
former allows health care providers to fully engage
suffering knowing that they are but one medium of
healing within a broader team or a greater source of
healing.
Conclusion
Compassion is a verb.
Thich Nhat Hanh.
Understanding the history of the concepts of
compassion, empathy, and sympathy can provide
important insights that can optimize the care that we
provide to patients and protect health care providers
in the process. History teaches us that although these
terms share a common lineage, they also evolved,
devolved, and borrowed from each other over time.
Thus, although history can teach us about the original
meaning of these terms, patients can teach us about
their contemporary meaning and how they distinguish
between these interrelated terms. Sympathy has come
to be understood by patients as an unhelpful, pity-
based response that often exacerbates their suffering,
whereas empathy involves acknowledgment, attune-
ment, and understanding of a person’s situation and
feelings through emotional resonance.69 As for
compassion, history and patients largely agreed
compassion is a virtuous response that seeks to address
the suffering and needs of a person through relational
understanding and action.69 This understanding has
not only stood the test of time but also is a form of
care that patients prefer and hope is a more prominent
feature of their health care experience in the future.4
Disclosures and Acknowledgments
Ana Soto-Rubio is supported by a VALiþd program
scholarship from the government of Valencia, Spain.
While the aim of this article was to provide clarity
regarding these three terms by investigating and dis-
entangling each of their etymological roots, we discov-
ered that these words were not static but morphed
over time and were often used interchangeably. As
Vol. 55 No. 5 May 2018
such, while we have exercised diligence and rigor in
delineating between them, we acknowledge that there
is always a degree of interpretation when writing about
history, including the historical writers referenced
herein.
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