Relational Empathy

Abstract

This work explains the practical benefits of a new and pluralistic notion of empathy that I call relational empathy. Rather than defining empathy as a thing or an activity, as most scholars have done, I define empathy as a set of three conceptually distinct though experientially overlapping relations: the relations of feeling into, feeling with, and feeling for. I then turn to historical discourses about empathy from the late 1700s to the present to demonstrate how different conceptualizations and definitions of empathy during this time span are descriptions of one, two or all three of these relations. I then explain how relational empathy has the potential both to dissolve mere verbal disputes about what empathy is and to shift our attention away from narrowly conceived theories about the ‘nature’ of empathy and toward more practical concerns. Finally, I explain how my theory of relational empathy can help to resolve a number of problems throughout the healthcare system.

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International Journal of Philosophical Studies
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Relational Empathy
Mark Fagiano
To cite this article: Mark Fagiano (2019): Relational Empathy, International Journal of
Philosophical Studies, DOI: 10.1080/09672559.2019.1598086
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ARTICLE
Relational Empathy
Mark Fagiano
Philosophy, University of Central Florida, Orlando, FL, USA
ABSTRACT
This work explains the practical benefits of a new and pluralistic notion of
empathy that I call relational empathy. Rather than defining empathy as
a thing or an activity, as most scholars have done, I define empathy as a set
of three conceptually distinct though experientially overlapping relations: the
relations of feeling into, feeling with, and feeling for. I then turn to historical
discourses about empathy from the late 1700s to the present to demonstrate
how different conceptualizations and definitions of empathy during this time
span are descriptions of one, two or all three of these relations. I then explain
how relational empathy has the potential both to dissolve mere verbal dis-
putes about what empathy is and to shift our attention away from narrowly
conceived theories about the ‘nature’of empathy and toward more practical
concerns. Finally, I explain how my theory of relational empathy can help to
resolve a number of problems throughout the healthcare system.
KEYWORDS Empathy; pluralism; relational empathy; ethics; healthcare
1. Empathy and Pluralism
Peering into the wilderness of research that has shaped the study of
empathy, one might experience a sense of bewilderment. Conflicting defini-
tions of the word ‘empathy’abound, and this often causes confusion. Quite
aware of this, contemporary scholars will often begin a work on the subject
of empathy by noting this ambiguity and stipulating precisely what they
mean by the word ‘empathy’.Definition in hand and theoretical framework
in mind, they then demonstrate how their understanding of empathy
addresses an important problem. This is a useful and strategic approach,
but it hasn’t helped us reach a consensus about the meaning of empathy.
1
Since empathy is a social construct, there is no reason a consensus needs to
be reached. Different definitions and theories of empathy serve different
purposes, and their value should be judged by what they do –that is, by
how they explain experience, guide our actions or help create a framework
for a scientific inquiry.
CONTACT Mark Fagiano mfagiano@gmail.com
INTERNATIONAL JOURNAL OF PHILOSOPHICAL STUDIES
https://doi.org/10.1080/09672559.2019.1598086
© 2019 Informa UK Limited, trading as Taylor & Francis Group

Empathy has been and still is often thought to be primarily either a thing or
an activity. As a thing, empathy has been defined as a condition of possible
knowledge of the outside world (Stein 1964 [1917],63);anaturalcapacity to
share, understand and respond with care (Decety 2012, vii); an ability to
identify and to respond (Baron-Cohen 2012,16);asharedaffective state (de
Vignemont and Singer 2006, 435); or a complex form of psychological infer-
ence (Ickes 1997; Danzinger, Prkachin, and Willer 2006). As an activity,
empathy has been defined as perceiving the internal frame of reference within
another (Rogers 1957); recognizing what another may be feeling or thinking
(Baron-Cohen 2005,2012); imagining the narrative of another (Goldie 2002,
195); or responding to another with affect or emotion (Batson and Oleson
1991, 63; Eisenberg and Fabes 1998,702;Hoffman 2000, 4). Given this tangle
of dissenting voices in which even experts disagree, might it be possible to
weave together these and other conflicting perspectives about empathy into
a pluralistic, inclusive and pragmatic theory? In consideration of this question,
I put forth here a new theory of empathy –what I will call relational empathy.
Idefine relational empathy as the convergence of three relations between
things and/or activities, rather than as a given activity or thing, though each of
these relations has been referred to as a type of ‘empathy’.
I refer to three distinct though experientially overlapping relations of
experience as the relations of (1) feeling into, (2) feeling with and (3) feeling
for. By ‘feeling’, I signify the general and broad meaning of the Greek
understanding of pathos as anything experienced (Graver 2002, 79;
Munteanu 2012, 50; Cayuela 2016, 4).
2
Arelation isthemodeormannerbywhichtwoormorethingsareinterrelated
within experience. The term ‘relation’is nothing new in the language games of
philosophy, but the philosopher William James’s articulation and use of it was
revolutionary. Relations, for James, are not simply the mode or manner by which
things are connected. They are these, but they are also the fundamentum of
experience itself or James called ‘pure experience’.
3
Noticing the myriad relations
that connect our thoughts, words and experiences draws out the multiplicity and
complexity of experience itself and directs our attentions toward the functionality
of our descriptions. James’s turn to relations was pragmatic because it helped him
dissolve a number of unnecessary philosophical debates. In the same spirit,
turning to relations for the purpose of reconstructing empathy provides an
opportunity to include conflicting definitions rather than exclude them. It also
allows us to reject a number of unhelpful historically prominent dualisms that
have influenced contemporary empathy research.
1.1. The Relation of ‘feeling into’
We experience this second relation whenever we feel into an object of
perception or reflection. The object can be anything –another person’s
2M. FAGIANO

thoughts, a beautiful sunset, a Kandinsky painting. It might sound odd to
suggest that a characteristic feature of any theory of empathy includes acts
of feeling into inanimate objects. After all, isn’t it the case that empathy
only refers to interpersonal relationships? That might be the case today, but
it wasn’t before the twentieth century. The word ‘empathy’is an historically
young word; it was coined in 1909 by the psychologist Edward Titchener
(1867–1927) based on the German word Einfühlung, which means feeling
into –or feeling one’s way into –an object (see Titchener 1909). Before
Titchener, the German verb sich einfühlen was employed variously to
signify an experience of ‘feeling into’among the romanticists of the late
eighteenth century, medical doctors and aestheticians in the mid- to late
nineteenth century and, more familiarly perhaps, psychologists during the
late nineteenth and early twentieth centuries.
During the late eighteenth century, a number of philosophers, romanti-
cists and Counter-Enlightenment thinkers believed that feeling one’s way
into things could help combat the misgivings and assumptions of overly
systematic and rationalistic interpretations of nature. For example, the poet
Novalis (1772–1801) lamented excessively rigid scientific interpretations of
nature and how they deaden our poetic and spiritual sense of the world.
However, by feeling ourselves into the beauty and magnificence of nature,
we can overcome our feelings of separateness from nature that have arisen
from rigid scientific portrayals of it and instead feel ‘one with nature’.
Johann Gottfried Herder (1744–1803) widened our understanding of this
first relation by defining it as our ability to feel into everything in order to
feel with all things outside of ourselves, including but not limited to feeling
with and understanding others (Herder 1964 [1774],7–8). Feeling into
certain objects, such as the different ideals, goals and ways of life expressed
within cultures and histories other than our own, enhances our ability to
feel with both similar and dissimilar lived experiences of other people (see
Herder 1877–1937, 5: 502–503, 506).
4
Herder’s larger aim for thinking this
way was to convince the historians of his time that empathic projection (i.e.
feeling oneself into an object) ought to be central to the historian’s craft.
Hermann Lotze (1817–1881) adopted Herder and Novalis’s pluralistic view
by thinking of what was later termed ‘empathy’as an act of feeling into any
object. In Lotze’s(1856, I, 584) words, there is ‘no shape so coy that our
fancy cannot . . . enter into it’.
By the middle of nineteenth century, the act of feeling into was seen as
both an object of scientific inquiry and as a technique for perceiving and
understanding aesthetic objects. Friedrich Theodor Vischer (1807–1887)
argued that the so-called essential properties of objects in nature are in
truth the projections of our own bodily perceptions. Feeling into inanimate
objects, on his account, animates matter by infusing it with ‘buoyant life’
through the linear and planar suspension of its parts (Vischer (1922–1923
INTERNATIONAL JOURNAL OF PHILOSOPHICAL STUDIES 3

[1857], 3: 229 [section 559]). Friedrich’s son Robert Vischer (1847–1933), in
his 1873 dissertation, coined the term Einfühlung to signify a process in
which the body and soul are unconsciously projected into the form of an
object, especially those objects we call works of art.
5
Based on changes in
scientific disciplines, Robert Vischer noted that the act of feeling into
objects gives rise to a number of internal bodily processes.
These conceptualizations of empathy gave rise to the notion of empathy
as an interpersonal phenomenon. Karl Groos (1861–1946) and Theodor
Lipps (1851–1914) offered an important contribution to this historical shift.
Each argued that Einfühlung is made possible by our natural ability to
internally mimic or imitate the form, structure and dynamism of external
objects. In addition to this, Lipps argued that Einfühlung is useful for
facilitating aesthetic contemplation as well as to gain knowledge of other
people’s minds. These conceptual shifts that focus on the physical process
of the observer’s body –especially the mental states of the observer –were
one reason psychologists of the late nineteenth and early twentieth centu-
ries either adopted or rejected Einfühlung as a method of psychoanalysis.
1.2. The Relation of ‘feeling with’
We experience this second relation whenever we have a sense of being
united, in concord or in sync with another person or thing. In contempor-
ary discourses, this relation of feeling with is often described as an inter-
personal phenomenon, but we can also experience it as a feeling of unity or
connection with objects, such as when we have a feeling of oneness with
a piece of music. As an interpersonal experience, this relation is noted, most
commonly, when we perceive that we grasp, feel or have adopted the
perspective of another person. This is generally called ‘empathic perspec-
tive-
taking’, but there are two types of perspective-taking, and these are some-
times conflated. For example, you can imagine how you would personally
feel if you held the other person’s perspective about a given situation, or
you can imagine how the other person actually perceives the situation.
C. Daniel Batson refers to this first option as ‘imagine-self perspective’
and the second as ‘imagine-other perspective’(see Batson 2009).
6
Depending upon the context, this relation, and sometimes the relation of
feeling into, is experienced in various ways –e.g. feeling an emotional
connection with another person or thing; believing we understand
another’s point of view; mentally simulating the experience of another
person; ‘catching’another person’s mood; co-experiencing another’s emo-
tional experiences; mimicking the body language of another; and reading
another person’s thoughts. Despite the differences between these
4M. FAGIANO

experiences, they all involve, in one way or another, both the relation of
feeling with and the relation of feeling into.
Returning to my historical narrative, Groos’s focus on imitation and
Lipps’s emphasis on reading other people’s minds engendered a major
paradigmatic shift from thinking of empathy centrally as a technique to
feel one’s way into any object to thinking of empathy as a skill for feeling
with or grasping the experiences of other human beings. Nevertheless, it is
evident among the theories I have explored thus far that the final goal of the
act of feeling into was to feel with some object of perception or reflection.
For instance, feeling one’s way into objects was aimed toward feeling with
them in order to experience a form of sympathetic understanding (Herder),
a feeling of unity with nature (Novalis), an internal resonance with or an
inward mental tracing of aesthetic objects (Lotze, the Vischers), or a process
of inner imitation, mimicry, or aesthetic sympathy (Groos and Lipps).
These all denote some type of fusion or identification with one’s object of
perception or reflection. This is important because it shows that the relation
of feeling into and the relation of feeling with were never conceived as
being independent of one other.
After Lipps, psychologists and sociologists began to explore the useful-
ness of empathy in psychotherapy and social psychology. In his analysis of
humor, Freud (1960 [1905], 186) states that Einfühlung signifies not the act
of feeling into aesthetic inanimate objects but rather an act in which ‘we
take the producing person’s psychical state into consideration, put ourselves
into it and try to understand it by comparing it with our own’. We see
a similar stipulation of the word ‘empathy’in the works of pragmatist
George Herbert Mead, who wrote that social meaning arises through the
individual simulating himself to take the attitude of the other in his reaction
toward the object (Mead 1938, 545). Mead considered the ability to ‘take
the role of the other’to be both a biological and a social process within
which one perceives the internal frame of reference of another with
accuracy.
7
The habit of thinking about empathy as a was reintroduced in
the discipline of psychology in the middle of the twentieth century with the
works of Carl Rogers. Rogers defined empathy also as the accurate under-
standing of or feeling with the other, specifically in situations in which the
therapist is completely at home in the universe of the patient (Rogers et al.
1967). This understanding, sense and feeling with the perspective of the
patient was also central to the approach of Heinz Kohut, who interpreted
empathy as a manifestation of the relation of feeling with, which served as
a method of therapy offered by the psychologist to the patient (Kohut
1981).
Toward the end of the twentieth century and into the beginning of the
twenty-first century, we find a number of attempts to find the biological
mechanisms of the relation of feeling with, most notably with the discovery
INTERNATIONAL JOURNAL OF PHILOSOPHICAL STUDIES 5

of mirror neurons. These neurons are specialized cells in the brain that are
purported to ‘fire’not only when one performs a particular action but also
when one watches or hears another perform the same action. The theory of
mirror neurons was birthed, quite accidentally, during a study of a macaque
monkey in Parma, Italy (see di Pellegrino et al. 1992; Gallese et al. 1996;
Rizzolatti et al. 1996).
8
In other investigations of mirror neurons following
this study, scientists found that a number of auditory neurons also fire in
the F5 region upon hearing the sound of an action. Theorists and practi-
tioners interested in empathy should continue to follow these and other
exciting developments concerning mirror neurons, as well as all other types
of mirroring processes.
9
1.3. The Relation of ‘feeling for’
The third relation occurs whenever we feel for other persons or things by caring
for them and acting primarily for their benefit. Understanding empathy as
consisting simply of the relation of feeling into and/or the relation of feeling
with excludes not only how a number of scholars have operationalized empathy
as feeling for other persons, but also how empathy is used colloquially as a term
denoting one’s response to and concern for another. The validity of defining
empathy simply as empathic projection (feeling into) or empathic perspective-
taking (feeling with) begins to break down when we examine the different
contexts of our experiences and our usages of the word ‘empathy’to describe
them. Is it possible for a psychologist to feel with patients without feeling for
them –that is, without caring? Certainly it is possible, but I suspect that most
people within this profession would think that this way of relating to a patient is
lacking something vital.
Roughly a century after Lipps’s contribution, we find that the concept of
empathyisincreasinglyconjoinedwith–and even defined as –this relation of
feeling for. This seems to have been encouraged by acts of linking the notion of
empathy not only with the experience of feeling with another but also with the act
of responding or reacting to another’s state or condition. The social psychologist
C. Daniel Batson also facilitated this historical transition from the relation of
feeling with (what he calls ‘feeling as’) to the relation of feeling for. Quite
differently from others, Batson is more philosophically careful, in that he is
aware of the multiple and different meanings ascribed to the term ‘empathy’.
For instance, in one of his many famous works, Batson (2011,4–8) lists eight
different experiences that have been called empathy:
(1) Knowledge of another’s internal state, including his or her thoughts
and feelings
(2) Adopting the posture or matching the neural response of an
observed other
6M. FAGIANO

(3) Coming to feel as another person feels
(4) Intuiting or projecting oneself into another’s situation
(5) Imagining how another is thinking and feeling
(6) Imagining how one would think and feel in the other’s place
(7) Feeling distress at witnessing another person’ssuffering
(8) Feeling for another person who is suffering
Number 4 here clearly denotes a concrete experience of the relation of feeling
into; numbers 1–3 and 5–6 signify both the relation of feeling into and the
relation of feeling with; and numbers 7 and 8 might incorporate, in certain
circumstances, all three of these relations I have been outlining. Batson employs
the notion of empathy and empathic concern to indicate the relation of feeling
for in order to analyze both egoism and altruism. Empathic concern, as ‘an
other-oriented emotional response elicited by and congruent with the perceived
welfare of a person in need’(Batson 2011, 11), often produces the motivation to
act for the benefit of others rather than ourselves. Yet helping others can also
produce a number of consequences that benefit us or boost our ego. For
instance, by responding to the needs of another, we may relieve ourselves of
the distress we feel at seeing him/her in need, avoid feelings of guilt and shame
and/or receive praise from others and gain a sense of pride from acting on
another’sbehalf.Batson’s empirical investigations have demonstrated that these
three ego-based reactions to helping a person in need do not generate the same
kind of motivation as do one’s feelings of empathic concern. Empathic concern
for another, according to Batson’s empathy-altruism hypothesis (Batson 1991,
2011; Batson and Oleson 1991), produces altruistic motivation.
Asignificant number of neuroscientists of the early twenty-first century
have incorporated the relation of feeling for into the relation of feeling with.
For example, in relational terms, Jean Decety’s(2012, vii) definition of empa-
thy as ‘the natural capacity to share, understand, and respond with care to the
affective states of others’signifies that one is capable of feeling with (i.e. sharing
and understanding) another’s state, and able to feel for (i.e. responding with
care) the affective states of others. And to do these things well requires that
one correctly observes and identifies these states –in other words, that one
feels into them with perceptual acuity, so that one’s sharing and understanding
of another’s state informs the manner in which one responds with care.
2. Putting Relational Empathy to Work
Relational empathy and all other conceptualizations of empathy are iden-
tical to one another in one important way: they are all social constructs that
aim not only to describe experience but to change the quality of our lived
experiences. The value of any given notion of empathy, then, lies not in its
‘being right’in some silo of truth apart from and unrelated to our lived
INTERNATIONAL JOURNAL OF PHILOSOPHICAL STUDIES 7

experiences, but rather in what the notion does –the manner in which, for
example, it shapes habits, decreases the suffering of sentient beings or
contributes to the flourishing of our lives. Relational empathy does at
least three important things. First, it includes and embraces conflicting
definitions of empathy, and consequently, it has the potential to dissolve
mere verbal disputes about what empathy is. Second, it directs recurring
questions about empathy (e.g. Can empathy be developed? Is empathy
moral?) away from abstract speculations about the ‘nature’of empathy
and toward the variety, contexts and consequences of different experiences.
Lastly, it serves as a conceptual framework for recognizing specific experi-
ences of these general relations, and for collecting and analyzing data for
the purpose of improving the structure and functionality of organizations.
Let us look at these three claims in turn.
2.1. Dissolving Verbal Disputes about What Empathy Is
How might the theory of relational empathy include rather than exclude
conflicting definitions of empathy? It seems to me that the value of any
given concept or definition of empathy lies in its ability to both illuminate
experience and stimulate satisfactory behavioral change. Although exclu-
sionary definitions and narrow conceptualizations of empathy serve
a number of purposes, they limit our ability to conceive empathic experi-
ences as they have been described historically. The words ‘exclusionary’and
‘narrow’are not pejorative here; rather, they signify a pragmatic move in
which one’s stipulation of the meaning of empathy aims to delineate the
parameters of an experience, bring to light particular truths of experience,
and ground inquiry toward some end(s). Narrowing the meaning of empa-
thy is clearly worthwhile when it produces insight; nevertheless, narrow
approaches necessarily exclude what people have meant or could mean by
empathy.
Consider, for instance, three contemporary definitions of ‘empathy’
today. Returning to Frederique de Vignemont and Tania Singer’s work
mentioned at the start of this investigation, empathy is defined as a thing
(i.e. a state) in which ‘there is empathy if (i) one is in an affective state, (ii)
this state is isomorphic to another person’saffective state, (iii) this state is
elicited by the observation or imagination of another’s person’saffective
state, (iv) one knows that the other person is the source of one’s own
affective state’(de Vignemont and Singer 2006, 435). This conceptualization
and definition of empathy greatly limits what others have meant and what
one could mean by ‘empathy’despite the fact that it might serve to help us
eradicate a number of problems within certain contexts of experience. In
other words, this definition states that empathy exists only when one person
observes another and experiences an affective state that is similar to that
8M. FAGIANO

person’s, while noting that the other person is the source of her/his affective
state. Conceived relationally, this definition utilizes the relation of feeling
into and the relation of feeling with by asserting that the state that is
isomorphic to another person’saffective state arises only after observing
or imagining the other’saffective state (feeling into), but there is no
mention of the relation of feeling for. Or think about the definition Derek
Matravers (2017,1–2) provides: ‘Empathy involves using our imaginations
as a tool so as to adopt a different perspective in order to grasp how things
appear (or feel) from there.’If we interpret this conceptualization and
definition of empathy in relational terms, then the use of our imagination
is a manifestation of the relation of feeling into, while the adoption of our
ability to grasp a different perspective is a demonstration of one way that
we feel with others (i.e. by grasping an experience other than our own).
Again, here the relation of feeling for is absent. But if we turn again to
Decety’s(2012, vii) definition of empathy as ‘the natural capacity to share,
understand, and respond with care to the affective states of others’,wefind
an explanation of our capacity to experience all three relations.
The theory of relational empathy avoids –and also has the potential to
resolve –the conflicts between seemingly irreconcilable definitions and
conceptualizations of empathy. It does this by thinking of empathy as
a relation between things, between activities, or between a thing and an
activity, rather than thinking of it as a discrete thing or activity. With the
definitions provided above by de Vignemont and Singer, Matravers, and
Decety, we find two understandings of empathy that define empathy pri-
marily as a thing and a third that defines it as an act. If we were to adopt
one of the above definitions of empathy as either a thing or activity –or
other similar descriptions of empathy –what purpose would such an
understanding serve? If we were to think of empathy as a state, as de
Vignemont and Singer do, or as a capacity (Decety) or as activities of the
imagination and grasping the experiences of others (Matravers), what
would happen in the world? The adoption of relational empathy –con-
ceived as an experience of the intersection of the relations of feeling into,
feeling with and feeling for –could provide a conceptual framework for
thinking about the value of a number of diverse contextualized experiences
relevant to these and other articulations of empathy as a thing or an
activity.
Looking at a pluralistic definition of empathy other than my own, we
find that there is room for including all three of the relations I have
delineated here. For instance, Stephanie Preston and Frans de Waal define
empathy as ‘any process where the attended perception of the object’s state
generates a state in the subject that is more applicable to the object’s state or
situation than to the subject’s own prior state or situation’(Preston and de
Waal 2002, 4; emphasis added). With this pluralistic, broad and general
INTERNATIONAL JOURNAL OF PHILOSOPHICAL STUDIES 9

definition, the ‘attended perception of the object’incorporates the relation
of feeling into, while the ‘state in the subject’could be applied to any
specific experience of the subject, that is, to feeling for and/or feeling with
the ‘object’s state or situation’. Some argue that these and other broad
approaches for understanding empathy are too vague to be helpful.
10
Conceived relationally, however, it is clear that these terms serve as parti-
cular general notions, each of which can refer to a number of nuanced and
contextualized empathic experiences. Appropriately broad definitions of
empathy, then, offer a great deal of conceptual and semantic flexibility in
relation both to the historical dissimilarities about the nature of empathy
and to the plurality of conflicting voices about the meaning of empathic
experiences.
2.2. Directing Questions about Empathy toward the Contexts of
Different Experiences
In addition to its ability to resolve the conflict between rival notions of
empathy, how might relational empathy help us concretize abstract ques-
tions about empathy (e.g. Can empathy be developed? Is empathy moral?)?
First, I think it is crucial to explain what we mean by ‘empathy’,
and second, I think it is essential to unveil the situational experiences to
which answers to these questions point.
Michael Slote and Jesse Prinz (and many others) have addressed this
question in light of what they conceive empathy to be. Empathy, says Slote
(2010, 15), involves having the ‘feelings of another (involuntarily) aroused
in ourselves, as when we see another person in pain’; it is the ‘cement of the
moral universe’because it helps create something like moral approval and
disapproval, which he contends are crucial for understanding what moral
claims, utterances and judgments mean. Following Hume’s account of
sympathy but moving beyond it, Slote sees empathy as a mechanism that
allows our moral approval and disapproval to focus on moral agents rather
than on the consequences of their actions. But is empathy itself moral? Is it
fundamentally moral? Is it ever necessary for morality? Answers to each of
these questions depend on how one conceives and defines empathy as well
as our approach to morality. The philosopher Jesse Prinz, although inspired
by the same tradition of philosophy that Slote adopts (i.e. Humean moral
sentimentalism), defines empathy slightly differently and thus offers
adifferent answer to the question: Is empathy moral? For Prinz (2012,
212), empathy is primarily
a kind of vicarious emotion: it’s feeling what one takes another person to be
feeling. And the ‘taking’here can be a matter of automatic contagion or the
result of a complicated exercise of the imagination
10 M. FAGIANO

Defining empathy in this way, Prinz is skeptical about Slote’s claims that
empathy serves as the cement of the moral universe. A number of studies,
Prinz notes, have shown that, as a vicarious emotion, empathy does not
substantially motivate us to act on behalf of those in need. It is also highly
selective, prone to in-group biases and in some cases results in preferential
treatment for those who are spatially close to us. Even when empathy serves
as a moral guide, our acts of empathizing are often biased and partial, and
we often have more empathy for the suffering and pain of those who are
similar to us (Xu et al. 2009; Gutsell and Inzlicht 2010) than for those
whom we perceive as different. Conclusively for Prinz, empathy is not
necessary for the capacities that make up basic moral competence, and
one can acquire moral values, make moral judgments and act morally
without empathy (Prinz 2011,2012).
Conceptualizing empathy relationally offers a radically different
approach for answering this main question about empathy. If we were to
accept the definition of empathy that Slote provides, then the morality of
empathy would be measured only by those instances in which the feelings
of others are involuntarily aroused in us, and by how such feelings help us
make sense of moral language. But since empathy is then defined so
narrowly, there is no room for assessing the variety of empathic experiences
that may also act as a ‘cement’(or a solvent) of moral experience. And if we
were to accept the definition of empathy that Prinz provides, then empathy
is not necessary in order to acquire any dimension of moral competence.
But if empathy were to be defined more broadly and pluralistically, then the
question of its moral significance would have to address the ways in which
a variety of our capacities and actions function within different circum-
stance and situations to produce moral ends –however those moral ends
are defined. Adopting the pragmatic notion of relational empathy therefore
provides a pluralistic framework for interpreting deeds, action or behavior
as moral, immoral, non-
moral or amoral in the contexts and situations in which they are experi-
enced. Narrow conceptualizations, on the contrary, limit discourses about
morality because they do not offer the breadth of hermeneutical possibilities
that relational empathy can offer. Slote defines empathy as having the
feelings of another (involuntarily) aroused in ourselves, so that empathy
is the ‘cement of the moral universe’and necessary for morality. Prinz
defines empathy as feeling what one takes another person to be feeling, and
hence as unnecessary for morality. If nothing happens as a consequence of
this verbal disagreement, then it is a moot debate, for what work is there to
be done? With relational empathy, however, the question is not whether or
not the act or activity of empathy is moral in and of itself, but instead: How
do contextualized experiences of one, two, or all three of these relations of
feeling into, feeling with and feeling for produce moral satisfaction?
INTERNATIONAL JOURNAL OF PHILOSOPHICAL STUDIES 11

2.3. Relational Empathy as a Conceptual Framework
How might the conceptual framework of relational empathy be helpful for
collecting and analyzing data for the purpose of improving the structure
and functionality of organizations? In the United States, I believe this new
theory of empathy will find an important application in healthcare. One of
the biggest problems in healthcare is that patients don’t feel cared for.
11
Unless we are already inclined to note what exactly is at stake here, this may
seem unimportant for many of us who do not grasp the consequences of
this problem. Gone are the days when successful medical outcomes were
the only criteria used to measure effective treatment in healthcare. Today,
patient perception of care matters –patient satisfaction matters, both
financially and medically.
12
After 2008, administrative focus on patient perception of care and
patient satisfaction greatly increased with the introduction of the Hospital
Consumer Assessment of Healthcare Providers and Systems (HCAHPS),
a government-mandated survey that is used as a tool to measure a patient’s
perception of care. Although the majority of leaders in healthcare provide
additional, more thorough measures of patient satisfaction, the results of
this survey greatly affect a healthcare organization’s ability to exceed its
bottom-line goals, which subsequently influences its overall ability to pro-
vide the best healthcare for its community. The Center of Medicare and
Medicaid Services (CMS), which requires hospitals to report their inpati-
ents’perceptions of care, withholds up to 3% of a hospital’s total costs based
on these interpretations of caregiving. CMS also reduces its payments to
hospitals that have excess readmissions, which are a sign of inadequate care
coordination and follow-up care in the community.
13
In addition to these,
there are other financial losses that works against an organization’s ability
to function and flourish. Compared to physicians with the top satisfaction
survey ratings, physicians in the middle tertile have malpractice lawsuit
rates that are 26% higher, while physicians in the bottom tertile have
malpractice lawsuit rates that are 110% higher (see Stelfox, Gandhi, and
Orav et al. 2015; Jones and Gates 2007).
14
Interestingly, the majority of non-demographic questions on the
HCAHPS survey are easy to analyze if one applies relational empathy to
them; however, they are quite difficult to access if one adopts a narrow
approach for defining empathy. For example, questions 1–3 and 5–7 on this
survey ask patients whether their nurses and doctors treated them with
respect, listened to them carefully and explained things to them in a way
they could understand. If chief nursing officers (CNOs), chief medical
officers (CMOs) and other leaders in healthcare were to adopt an exclu-
sionary and narrow approach to understanding empathy, their ability to
analyze patients’answers to these questions would be severely limited. If
12 M. FAGIANO

empathy were to be defined narrowly as a particular instance of only one of
the first two relations –such as taking another’s perspective (feeling with)
or empathic projection (feeling into) –it is unlikely that discussions about
caregiving would be very practical with such an exclusion of the historical
traditions that have stipulated empathy to be a manifestation of the relation
of feeling for. If we think of the acts of treating others with respect, listening
carefully to others and explaining things carefully to others, each of these
requires us to perceive acutely (feeling into), to grasp accurately (feeling
with) and to care passionately about (feeling for) the well-being of another
person or situation.
Adopting relational empathy as a conceptual framework for our current
healthcare system will help leaders reflect upon and analyze a host of
different relationships that either fuel or foil their attempts to provide
compassionate healthcare. Take, for instance, the following situation:
Imagine a doctor perceiving and observing (feeling into) the condition of
a patient in order to understand accurately (feel with) this patient’s health
condition, but doing so without observing and grasping the safety condi-
tions in the room. Narrow theories of empathy employed only to analyze
interpersonal relationships would exclude thinking about empathy as
between a person and an object (in this case the safety of the room). Or
think about another situation: A small child has broken her arm and is
reticent to speak about it. If we were to think of empathy narrowly (e.g. as
involuntarily catching the emotions of others or as taking the perspective of
another), then we would be limited as interpreters and would miss seeing
that empathic mimicry –acting out the child’s condition –could elicit the
child’s explanation and assist her in describing her situation.
As Press Ganey’s CMO Thomas Lee notes, to drive sustained improve-
ment in healthcare throughout the United States, ‘we need measures, we
need data, and we need wisdom about how to use them’; moreover, Lee
states that in order to increase empathic care throughout the healthcare
industry, ‘we also need a new language’(Lee 2016, 85, 7). In addition to
Lee’s insights, the healthcare industry needs to tap into new technologies
that will allow patient-centered care coordinators to collect data of the
perceptions of both patients and healthcare professionals. A number of
emerging technologies will serve as valuable tools for maximizing patient-
centered care and engendering organizational efficiency, but perhaps the
most relevant current technology useful for driving sustained development
in healthcare is virtual reality. In addition to applying the methodologies of
biometrics, data science and social network science, virtual reality will
become very instrumental for future training and development departments
of healthcare organizations. Eventually, healthcare professionals will be
faced with a choice: They can either adopt a narrow conceptualization of
empathy that will limit both the content of their VR simulations and the
INTERNATIONAL JOURNAL OF PHILOSOPHICAL STUDIES 13

scope of their investigations, or they can embrace and implement the
historically rich interpretive framework of relational empathy that will
expand such content and broaden their empirical approaches.
One can locate the presence of these intersecting relations throughout
different historical traditions, notice how they are manifested within
a variety of experiences and find novel ways of employing them in circum-
stances other than those mentioned here. We can give the co-existence of
these three relations in experience any name we wish. Here, I have chosen
the term ‘relational empathy’in the hope that this neologism and the
pluralistic, pragmatic approach upon which it is based will help us develop
an individual and social ethos and eradicate pressing philosophical and
organizational problems.
Notes
1. I think it is important not only to be clear about what one means by empathy
but also to be informed about –and try to include what –others have meant
by this term historically. In light of this, I have adopted a pluralistic, philo-
sophical and relational perspective on the subject of empathy (Fagiano 2016).
2. See the OED’sd
efinition of pathos, 2a: ‘To have experience of; to meet with;
to feel or undergo.’Margaret Graver describes the ancient Greek under-
standing of this general and neutral sense of pathos as ‘a broad and colorless
term, roughly equivalent to “experience”in English’(Graver, trans and
comm 2002, 79). In Plato’sGorgias,wefind one such example of using
pathos to signify a general experience: ‘Well, Callicles, if human beings
didn’t share common experiences [pathos], some sharing one, others sharing
another, but one of us had some unique experience [pathos] not shared by
others, it wouldn’t be easy for him to communicate what he experienced
[pathema] to the other’(Plato, 481c–d; Cooper 1997, 826). Historically, the
Latin term sensus has been used in a similar fashion, signifying anything
sensed without signifying any sort of ontologically rigid dualism.
3. For a lucid explanation of James’snotion of pure experience, see James 1996
[1912],93–95, and Gavin 2013,44–65.
4. As Isaiah Berlin (1997,253) notes, Herder ‘believed that to understand
anything was to understand it in its individuality and development, and
that this required the capacity of Einfühlung (“feeling into”) the outlook,
the individual character of artistic tradition, a literature, a social organization,
a people, a culture, a period of history. To understand the “organic structure”
of the society in terms of which alone the minds and activities and habits of
its members can be understood.’
5. R. Vischer states that the body ‘unconsciously projects its own . . . form –and
with this also the soul –into the form of the object. From this I derived the
notion of what I call Einfühlung’(Vischer 1994 [1873], 92).
6. See also Batson’searlier collaborative work on this distinction: Batson, Early,
and Salvarini (1997).
7. The twofold process of feeling into for the purpose of feeling with is often
described today as an act of inferring (feeling into) for the purpose of
14 M. FAGIANO

understanding or feeling with another accurately. The social psychologist
William Ickes has conducted a number of studies of empathic inference
and its relation to empathic accuracy (i.e. ‘mindreading’), defining the latter
as the measure of one’s ability to infer accurately the specific content of other
people’s thought and feeling: see Ickes (1997,2–6). For earlier accounts, see
Rogers 1957 and Malcolm 1963, 130–140.
8. During this study, Italian scientists noted that certain neurons in the F5
region of the premotor cortex of the monkey fired both when it picked
a piece of food with its own hand and when it observed another monkey
pick up a piece of food.
9. For a good start on the ongoing discourse surrounding the concepts of
mirror neurons and/or mirroring processes, see Iacoboni 2008; Iacoboni
and Dapretto 2006; Keysers 2011. It is important to note that although
explorations of mirror neurons are attempts to find evidence for the biolo-
gical foundations of a notion of empathy as the relation of feeling with, they
are not examining the perceptual processes (feeling into) and/or the com-
passionate feelings and actions (feeling for) that are connected to the mirror
neuron activity. What would it look like if we were to conduct
a neuroscientific exploration of all three of these relations within
a particular experience?
10. Amy Coplan (2013,5 n. 19), for example, claims that ‘we need more
specificity, not more generality’to grasp what empathy ‘really’is.
11. In a 2011 national survey, when hospitalized patients were asked if com-
passionate care is essential for successful medical care, 80% of these
patients said yes, while only 53% of these patients professed that contem-
porary healthcare in the US provides such care. See Lowen, Rosen, and
Marttila 2011.
12. Discourses about patient-centered care and patient satisfaction in the
US began in the 1980s and were centered on the goal of providing better
‘service’for patients. This turn among healthcare professionals was stimu-
lated initially by a number of shared goals, for instance, to avoid gaining
a bad reputation, to reduce the number of medical malpractice lawsuits
leveled against them, and to avoid losing market share. Also in the 1980s,
it was discovered that if patients believed they were adequately cared for
during their stay in a hospital, then they were less likely to file a lawsuit,
independent of the technical quality of the medical care they received. See
Lee 2016,86–92.
13. For more on this, see Orszag and Emanuel 2010;see also Hines et al. 2014.
14. Beyond these financial losses, hospitals in the top quartile of HCAHPS’s
ratings are noted to have better performance on quality metrics for all four
clinical conditions examined: acute myocardial infarction, congestive heart
failure, pneumonia, and prevention of surgical complications (Lee 2016, 101).
Disclosure statement
No potential conflict of interest was reported by the author.
INTERNATIONAL JOURNAL OF PHILOSOPHICAL STUDIES 15

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