Compassion: an evolutionary analysis and empirical review

What is compassion? And how did it evolve? In this review, we integrate 3 evolutionary arguments that converge on the hypothesis that compassion evolved as a distinct affective experience whose primary function is to facilitate cooperation and protection of the weak and those who suffer. Our empirical review reveals compassion to have distinct appraisal processes attuned to undeserved suffering; distinct signaling behavior related to caregiving patterns of touch, posture, and vocalization; and a phenomenological experience and physiological response that orients the individual to social approach. This response profile of compassion differs from those of distress, sadness, and love, suggesting that compassion is indeed a distinct emotion. We conclude by considering how compassion shapes moral judgment and action, how it varies across different cultures, and how it may engage specific patterns of neural activation, as well as emerging directions of research.

Empathy-related Responding: Associations with Prosocial Behavior, Aggression, and Intergroup Relations

Empathy-related responding, including empathy, sympathy, and personal distress, has been implicated in conceptual models and theories about prosocial behavior and altruism, aggression and antisocial behavior, and intergroup relationships. Conceptual arguments and empirical findings related to each of these topics are reviewed. In general, there is evidence that empathy and/or sympathy are important correlates of, and likely contributors to, other-oriented prosocial behavior, the inhibition of aggression and antisocial behavior, and the quality of intergroup relationships. Applied implications of these findings, including preventative studies, are discussed, as are possible future directions.

Empathy Is a Protective Factor of Burnout in Physicians: New Neuro-Phenomenological Hypotheses Regarding Empathy and Sympathy in Care Relationship

Burnout is a multidimensional work-related syndrome that is characterized by emotional exhaustion, depersonalization-or cynicism-and diminution of personal accomplishment. Burnout particularly affects physicians. In medicine as well as other professions, burnout occurrence depends on personal, developmental-psychodynamic, professional, and environmental factors. Recently, it has been proposed to specifically define burnout in physicians as "pathology of care relationship." That is, burnout would arise, among the above-mentioned factors, from the specificity of the care relationship as it develops between the physician and the patient. Accordingly, experimental studies and theoretical approaches have suggested that burnout and empathy, which is one of the most important skills in physicians, are closely linked. However, the nature of the relation between burnout and empathy remains not yet understood, as reflected in the variety of theoretical and contradictory hypotheses attempting to causally relate these two phenomena. Firstly, we here question the epistemological problem concerning the modality of the burnout-empathy link. Secondly, we hypothesize that considering the multidimensional features of both burnout and empathy, on one hand, and on the other hand, the distinction between empathy and sympathy enables to overcome these contradictions and, consequently, gives a better understanding of the relationship between burnout and empathy in physicians. Thirdly, we propose that clarifying the link between burnout, empathy and sympathy would enable developing specific training in medical students and continuous professional formation in senior physicians and would potentially contribute to the prevention of burnout in medical care.

Should Machines Express Sympathy and Empathy? Experiments with a Health Advice Chatbot

When we ask a chatbot for advice about a personal problem, should it simply provide informational support and refrain from offering emotional support? Or, should it show sympathy and empathize with our situation? Although expression of caring and understanding is valued in supportive human communications, do we want the same from a chatbot, or do we simply reject it due to its artificiality and uncanniness? To answer this question, we conducted two experiments with a chatbot providing online medical information advice about a sensitive personal issue. In Study 1, participants (N = 158) simply read a dialogue between a chatbot and a human user. In Study 2, participants (N = 88) interacted with a real chatbot. We tested the effect of three types of empathic expression-sympathy, cognitive empathy, and affective empathy-on individuals' perceptions of the service and the chatbot. Data reveal that expression of sympathy and empathy is favored over unemotional provision of advice, in support of the Computers are Social Actors (CASA) paradigm. This is particularly true for users who are initially skeptical about machines possessing social cognitive capabilities. Theoretical, methodological, and practical implications are discussed.

Emotion understanding, theory of mind, and prosocial orientation: Relations over time in early childhood

Data were collected when children were 42, 54, and 72 months of age (Ns=210, 191, and 172 for T1, T2, and T3, respectively). Children's emotion understanding (EU) and theory of mind (ToM) were examined as predictors of children's prosocial orientation within and across time. EU positively related to children's sympathy across 2.5 years, and T1 EU positively related to parent-reported prosocial orientation concurrently and across 1 year (T2). T2 ToM positively related to parents' reports of sympathy and prosocial orientation concurrently and 18 months later (T3); in contrast, T3 ToM did not relate to sympathy or prosocial orientation. T2 ToM accounted for marginally significant variance (p<0.058) in T3 mother-reported prosocial orientation over and above that accounted for by T2 prosocial orientation. Fostering the development of EU and ToM may contribute to children's prosocial orientation.

Empathic Concern Is Part of a More General Communal Emotion

Seeing someone in need may evoke a particular kind of closeness that has been conceptualized as sympathy or empathic concern (which is distinct from other empathy constructs). In other contexts, when people suddenly feel close to others, or observe others suddenly feeling closer to each other, this sudden closeness tends to evoke an emotion often labeled in vernacular English as being moved, touched, or heart-warming feelings. Recent theory and empirical work indicates that this is a distinct emotion; the construct is named kama muta. Is empathic concern for people in need simply an expression of the much broader tendency to respond with kama muta to all kinds of situations that afford closeness, such as reunions, kindness, and expressions of love? Across 16 studies sampling 2918 participants, we explored whether empathic concern is associated with kama muta. Meta-analyzing the association between ratings of state being moved and trait empathic concern revealed an effect size of, r(3631) = 0.35 [95% CI: 0.29, 0.41]. In addition, trait empathic concern was also associated with self-reports of the three sensations that have been shown to be reliably indicative of kama muta: weeping, chills, and bodily feelings of warmth. We conclude that empathic concern might actually be a part of the kama muta construct.

Respiratory sinus arrhythmia, effortful control, and parenting as predictors of children's sympathy across early childhood

The goal of this study was to examine physiological and environmental predictors of children's sympathy (an emotional response consisting of feelings of concern or sorrow for others who are distressed or in need) and whether temperamental effortful control mediated these relations. Specifically, in a study of 192 children (23% Hispanic; 54% male), respiratory sinus arrhythmia (RSA), a measure thought to reflect physiological regulation, and observed authoritative parenting (both at 42 months) were examined as predictors of children's effortful control (at 54 months) and, in turn, children's sympathy (at 72 and 84 months). Measures of both baseline RSA and RSA suppression were examined. In a structural equation model, observed parenting was positively related to children's subsequent sympathy through its positive relation to effortful control. Furthermore, the indirect path from baseline RSA to higher sympathy through effortful control was marginally significant. Authoritative parenting and baseline RSA uniquely predicted individual differences in children's effortful control. Findings highlight the potential role of both authoritative parenting and physiological regulation in the development of children's sympathy.

Routine, empathic and compassionate patient care: definitions, development, obstacles, education and beneficiaries

RATIONALE

We believe that this study represents an innovative approach to clarifying the definitions of routine, empathic and compassionate health care, as well as of sympathy. We emphasize the importance of affective empathy and its intensification in the context of patient suffering (compassion), without abandoning the ideal of clinical equanimity.

METHODS

We develop a pedagogical model for clinicians and trainees who are weaker in their empathic skills that includes four levels of growth. We clarify representative obstacles to empathic and compassionate care in education and clinical practice. We summarize the four beneficiaries of empathic and compassionate care (clinicians, patients, trainees, institutions). We suggest areas for future research, including the development of a compassion scale and conclude with a statement on how the conceptual and professional confusion we address adversely impacts patients and trainees. The article represents the consensus work of a group of health care professionals and students at Stony Brook University Hospital and School of Medicine who have been engaged in this project for several years through the Center for Medical Humanities, Compassionate Care, and Bioethics, established in August of 2008.

CONCLUSIONS

We discern a shift away from concepts of clinical empathy and compassionate care that deny a significant place for an affective component and that idealize 'detachment'.

Nonrandom Acts of Kindness: Parasympathetic and Subjective Empathic Responses to Sadness Predict Children's Prosociality

How does empathic physiology unfold as a dynamic process, and which aspect of empathy predicts children's kindness? In response to empathy induction videos, 4- to 6-year-old children (N = 180) showed an average pattern of dynamic respiratory sinus arrhythmia (RSA) change characterized by early RSA suppression, followed by RSA recovery, and modest subsequent suppression during positive resolution of the empathic event. Children's capacity for this pattern of flexible RSA change was associated with their subjective empathic feelings, which were concurrently associated with more sympathetic and prosocial responses to others. Conversely, only children's dynamic RSA change longitudinally predicted prosocial behavior 2 years later. These findings have implications for understanding the dynamic and multifaceted nature of empathy, and its relation with prosocial development.

Giving versus acting: Using latent profile analysis to distinguish between benevolent and activist support for global poverty reduction

There are a variety of ways that people can respond to inequality. This article considers the distinction between collective giving and collective acting, but also adopts a focus on the people who engage in those behaviours. Benevolent supporters engage in efforts to alleviate suffering through the transfer of money or provision of goods ('giving'), while activist supporters engage in actions that aim to challenging an underlying injustice or exploitation ('acting'). Using samples obtained through anti-poverty non-governmental organizations (N = 2,340), latent profile analysis suggested two qualitatively different forms of support for global poverty reduction: a benevolent supporter profile (defined by moderate levels of charitable support) and an activist supporter profile (defined by engagement in a suite of socio-political actions). The two forms of support are predicted by different appraisals for, emotional reactions to (outrage v sympathy), and social change beliefs about, global injustice. Results highlight the theoretical and practical importance of considering subgroup differences in how social justice is pursued.

From Empathy to Apathy: The Bystander Effect Revisited

The bystander effect, the reduction in helping behavior in the presence of other people, has been explained predominantly by situational influences on decision making. Diverging from this view, we highlight recent evidence on the neural mechanisms and dispositional factors that determine apathy in bystanders. We put forward a new theoretical perspective that integrates emotional, motivational, and dispositional aspects. In the presence of other bystanders, personal distress is enhanced, and fixed action patterns of avoidance and freezing dominate. This new perspective suggests that bystander apathy results from a reflexive emotional reaction dependent on the personality of the bystander.

Patient autonomy in chronic care: solving a paradox

The application of the principle of autonomy, which is considered a cornerstone of contemporary bioethics, is sometimes in obvious contradiction with the principle of beneficence. Indeed, it may happen in chronic care that the preferences of the health care provider (HCP), who is largely focused on the prevention of long term complications of diseases, differ from those, more present oriented, preferences of the patient. The aims of this narrative review are as follows: 1) to show that the exercise of autonomy by the patient is not always possible; 2) where the latter is not possible, to examine how, in the context of the autonomy principle, someone (a HCP) can decide what is good (a treatment) for someone else (a patient) without falling into paternalism. Actually this analysis leads to a paradox: not only is the principle of beneficence sometimes conflicting with the principle of autonomy, but physician's beneficence may enter into conflict with the mere respect of the patient; and 3) to propose a solution to this paradox by revisiting the very concepts of the autonomous person, patient education, and trust in the patient-physician relationship: this article provides an ethical definition of patient education.

Roses by other names? Empathy, sympathy, and compassion in mental health nursing

Empathy and related concepts such as sympathy and compassion are considered fundamental to mental health nurses' work with consumers. However, there is often little consensus on the relationship between these interpersonal interaction factors and their similarities and differences. In this paper, these three concepts are discussed. Theoretical frameworks of empathy, sympathy, and compassion are presented with a social psychological model of empathy focused upon. From this, discussion is undertaken of how the mental health nursing process may be explained by such frameworks, as well as what unique aspects of the nursing relationship need to be considered. It is contended that precise definitions and understandings of empathy, sympathy, and compassion are vital, and the use of models allows researchers to consider where gaps are in current knowledge, and to identify what might be important to consider from a nurse education perspective.

Optimus Primed: Media Cultivation of Robot Mental Models and Social Judgments

Media influence people's perceptions of reality broadly and of technology in particular. Robot villains and heroes-from Ultron to Wall-E-have been shown to serve a specific cultivation function, shaping people's perceptions of those embodied social technologies, especially when individuals do not have direct experience with them. To date, however, little is understood about the nature of the conceptions people hold for what robots are, how they work, and how they may function in society, as well as the media antecedents and relational effects of those cognitive structures. This study takes a step toward bridging that gap by exploring relationships among individuals' recall of robot characters from popular media, their mental models for actual robots, and social evaluations of an actual robot. Findings indicate that mental models consist of a small set of common and tightly linked components (beyond which there is a good deal of individual difference), but robot character recall and evaluation have little association with whether people hold any of those components. Instead, data are interpreted to suggest that cumulative sympathetic evaluations of robot media characters may form heuristics that are primed by and engaged in social evaluations of actual robots, while technical content in mental models is associated with a more utilitarian approach to actual robots.

Compassionate goals, prosocial emotions, and prosocial behaviours during the COVID-19 pandemic

During the COVID-19 pandemic, it is important for people to engage in prosocial behaviours to support one another. The aim of this research is to answer a key question: in a social crisis, what motivates Americans to help others? Guided by research on appraisal theories and ecosystem theory, we examined the role of compassionate goals and prosocial emotions in promoting prosocial behaviours towards either out-group or in-group members. Study 1 (N = 943) was conducted in February 2020, before the widespread transmission of COVID-19 began in the United States. Results show that people with high compassionate goals are more likely to experience sympathy, which in turn makes them more willing to help people suffering from COVID-19 in China. Study 2 (N = 1,009) was conducted with a nationally representative sample after COVID-19 became more prevalent in the United States. Although people with high compassionate goals still experience more sympathy and solidarity, sympathy does not predict donation intention. Instead, solidarity mediates the relationship between compassionate goals and donation intention. Please refer to the Supplementary Material section to find this article's Community and Social Impact Statement.

The development of sympathy from 5 to 7 years: increase, decline or stability? A longitudinal study

In the present study the development of sympathy in a group of 85 children (43 girls) was investigated over a 3-year period, starting with the last year of child care, when the children were 5 years-old. Sympathy was measured via different measures: two standardized observations, where the children were observed as they witnessed the distress of a puppet in two different situations; two follow-up interviews with the children immediately after the observations; a self-report questionnaire and two other-report questionnaires by parents and teachers. At all three periods the observations and the children’s self-reports (interviews, questionnaire) were intercorrelated. The teachers’ and the parents’ reports were not significantly correlated with any of the other measures at time 1. At times 2 and 3, a few low but significant correlations emerged. As a consequence, the other reports were dropped from further analyses and a composed sympathy measure consisting of observations and self-reports was created. Rank-order stability of this composed measure over the course of the 3 years proved to be high; suggesting that interindividual differences maintained stability. Mean-level differences showed a significant increase over the course of the study with the highest increase in the initial 2 years. Neither gender nor the interaction between gender and time were significant. In conclusion, the measurement of sympathy has proven valid for the childrens’ observations and self-reports. To the question of age-correlated development, stability in sympathy is firstly high and secondly sympathy increases mainly during the time between the last year in child care and the first year in elementary school.

What determines forgiveness in close relationships? The role of post-transgression trust

Relationship closeness is one of the best predictors of forgiveness. But what is the process by which closeness encourages forgiveness? Across three studies, we employed a mix of experimental and correlational designs with prospective (N = 108), scenario (N = 71), and recall (N = 184) paradigms to test a multiple mediation model. We found consistent evidence that the positive association between relationship closeness and forgiveness may be explained by levels of post-transgression trust in the offender. Moreover, trust always played the main mediating role in the forgiveness process, even when taking into account several transgression-specific variables associated with both trust and forgiveness (e.g., apology). We discuss the theoretical and practical implications of trust as a key indicator of forgiveness in close relationships.

Burnout in nursing staff caring for patients with dementia: role of empathy and impact of empathy-based training program

OBJECTIVES

Although relationships between empathy and burnout have been reported, it remains unclear whether empathy should be considered as a predictive or a protective factor. A multidimensional approach towards empathy was selected to determine whether cognitive and emotional aspects might differently contribute to the burnout (first study). In a second study, we aimed at investigating the effect of empathy-based training program on empathic skills and burnout.

METHODS

The first survey was conducted among 124 nursing staff from 10 geriatric residential facilities. They filled out (i) the Maslach burnout inventory (assessing emotional exhaustion, depersonalization and personal accomplishment); (ii) two empathy questionnaires assessing both cognitive (perspective-taking, i.e. the tendency to adopt another person's point of view) and emotional empathy (compassionate care, i.e. the propensity to take patients' feelings into account; and personal distress, i.e. feelings of discomfort in relationships). In the second study, questionnaires were filled out by 41 caregivers before and after an empathy-based training program (Validation®).

RESULTS

results showed that higher personal distress predicted higher burnout scores while higher compassionate care predicted lower emotional exhaustion and higher perspective-taking predicted lower depersonalization as well as higher accomplishment. Results from the second study showed that personal distress decreased after the Validation training and nursing staffs reported lower depersonalization and higher accomplishment.

CONCLUSION

The first study suggests that, in predicting the decrease of burnout symptomatology, perspective-taking and the propensity for compassionate care should be considered as protective factors, whereas personal distress can be considered as a predictive factor. Moreover, empathy-based training programs such as Validation® could contribute to the prevention of burnout by decreasing signs of personal distress. The nature of this component (empathy or sympathy) is discussed.

Left Amygdala and Putamen Activation Modulate Emotion Driven Decisions in the Iterated Prisoner's Dilemma Game

Although economic decision-making is commonly characterized as a purely rational phenomenon, it is clear that real-world decision-making is influenced by emotions. Yet, relatively little is known about the neural correlates of this process. To explore this issue, 20 participants underwent fMRI scanning while engaged in the Prisoner's Dilemma game under partner-directed sympathy, anger and neutral emotion conditions. Participants were most and least likely to cooperate after sympathy and anger induction, respectively, with the neutral condition eliciting intermediate cooperation rates. Moreover, the sympathy condition elicited quicker responses for cooperation than defection choices, whereas this pattern was reversed in the anger and neutral conditions. Left amygdala activation showed a positive correlation with cooperation rates and self-reports of partner directed sympathy in the sympathy condition. In the anger condition, left putamen activation was positively correlated with cooperation rates and negatively correlated with self-reports of partner directed anger strength. These findings indicate that while the left amygdala activation may be indicative of emotion enhancement and increase of cooperative behavior, the left putamen may help to suppress an emotion to overcome anger and engage in cooperation.

The ethology of empathy: a taxonomy of real-world targets of need and their effect on observers

Empathy is inherently interpersonal, but the majority of research has only examined observers. Targets of need have been largely held constant through hypothetical and fictionalized depictions of sympathetic distress and need. In the real world, people's response to life stressors varies widely-from stoicism to resilience to complete breakdown-variations that should profoundly influence the prosocial exchange. The current study examined naturally-varying affect in real hospital patients with serious chronic or terminal illness during videotaped interviews about quality of life. Participants viewed each video while psychophysiological data were recorded and then rated each patient's and their own emotion. Patients displayed three major emotion factors (disturbed, softhearted, and amused) that were used to classify them into five basic types (distraught, resilient, sanguine, reticent, wistful). These types elicited four major emotions in observers [personal distress (PD), empathic concern (EC), horror, pleasure], two of which were never discovered previously with fictionalized targets. Across studies and measures, distraught targets usually received the greatest aid, but approximately as many observers preferred the positive and likeable resilient patients or the quietly sad wistful targets, with multiple observers even giving their greatest aid to sanguine or reticent targets who did not display distress or need. Trait empathy motivated aid toward more emotive targets while perspective taking (PT) motivated aid for those who did not overtly display distress. A second study replicated key results without even providing the content of patients' speech. Through an ecological examination of real need we discovered variation and commonality in the emotional response to need that interacts strongly with the preferences of observers. Social interactions need to be studied in ethological contexts that retain the complex interplay between senders and receivers.

The effect of partner-directed emotion in social exchange decision-making

Despite the prevalence of studies examining economic decision-making as a purely rational phenomenon, common sense suggests that emotions affect our decision-making particularly in a social context. To explore the influence of emotions on economic decision-making, we manipulated opponent-directed emotions prior to engaging participants in two social exchange decision-making games (the Trust Game and the Prisoner's Dilemma). Participants played both games with three different (fictional) partners and their tendency to defect was measured. Prior to playing each game, participants exchanged handwritten "essays" with their partners, and subsequently exchanged evaluations of each essay. The essays and evaluations, read by the participant, were designed to induce either anger, sympathy, or a neutral emotional response toward the confederate with whom they would then play the social exchange games. Galvanic skin conductance level (SCL) showed enhanced physiological arousal during anger induction compared to both the neutral and sympathy conditions. In both social exchange games, participants were most likely to defect against their partner after anger induction and least likely to defect after sympathy induction, with the neutral condition eliciting intermediate defection rates. This pattern was found to be strongest in participants exhibiting low cognitive control (as measured by a Go/no-Go task). The findings indicate that emotions felt toward another individual alter how one chooses to interact with them, and that this influence depends both on the specific emotion induced and the cognitive control of the individual.

The effect of sympathy on discriminatory attitudes toward persons living with HIV/AIDS in Puerto Rico: a hierarchical analysis of women living in public housing

As the number of persons living with HIV/AIDS (PLWHA) continues to increase in Puerto Rico, it becomes increasingly important to address the issues of stigma and other discriminatory attitudes. Therefore, the objective of the present study is to examine the attitudes toward PLWHA of a large sample of women living in public housing in Puerto Rico, including sympathy and support for PLWHA in the workplace and in school. A total of 1138 women completed a self-administered 218-item survey made up of questions that measured HIV-related knowledge, attitudes and behaviors. Levels of sympathy varied depending upon the target group, with HIV-infected drug users receiving the least sympathy. Most women reported that HIV-positive teachers should be allowed to teach and that HIV-positive children should be allowed to attend school. However, a significantly lower percentage reported that HIV-infected nurses should be allowed to continue working. Women who were more sympathetic toward PLWHA were more tolerant of PLWHA in the workplace and school, while those with inaccurate knowledge concerning HIV transmission were less tolerant. Also, those who knew a PLWHA were more tolerant. Levels of discriminatory attitudes in Puerto Rico are high and warrant both individual- and societal-level interventions.

Respiratory sinus arrhythmia and prosociality in childhood: Evidence for a quadratic effect

Research investigating the link between the parasympathetic nervous system (PNS) and prosociality in childhood has yielded inconsistent findings. This relation has mainly been conceptualized as linear, however, the broader physiological literature suggests that children's physiological arousal and task performance may be related in an inverted U-shaped fashion-with peak performance at moderate levels of arousal. Therefore, we tested whether resting respiratory sinus arrhythmia (RSA)-a dispositional indicator of PNS activity-was quadratically related to child- and caregiver-reported sympathy and prosocial behaviors in an ethnically diverse sample of 4- and 8-year-olds (N = 300). We found a quadratic inverted U-shaped association between resting RSA and child-reported sympathy and prosocial behavior in 8-year-olds, whereas no consistent findings emerged for 4-year-olds. Therefore, moderate resting RSA in middle childhood may facilitate sympathy and prosocial behaviors. Dispositional over- or under-arousal of the PNS may impair children's ability to attend and respond to the distress of others by middle childhood.

Empathy's purity, sympathy's complexities; De Waal, Darwin and Adam Smith

Frans de Waal's view that empathy is at the basis of morality directly seems to build on Darwin, who considered sympathy as the crucial instinct. Yet when we look closer, their understanding of the central social instinct differs considerably. De Waal sees our deeply ingrained tendency to sympathize (or rather: empathize) with others as the good side of our morally dualistic nature. For Darwin, sympathizing was not the whole story of the "workings of sympathy"; the (selfish) need to receive sympathy played just as central a role in the complex roads from sympathy to morality. Darwin's understanding of sympathy stems from Adam Smith, who argued that the presence of morally impure motives should not be a reason for cynicism about morality. I suggest that De Waal's approach could benefit from a more thorough alignment with the analysis of the workings of sympathy in the work of Darwin and Adam Smith.

Community Reaction to Older-age Parental AIDS Caregivers and their Families: Evidence from Cambodia

Accounts of community reaction to persons with HIV/AIDS and their families typically focus only on negative reactions stemming from stigmatization with little acknowledgement of variation over time and across settings. To usefully guide local interventions, a broader view is needed that also encompasses attitudes and actions stemming from sympathy and friendship. We examine community reaction in Cambodia to families from the perspective of parents of adults who died of AIDS or currently receive antiretroviral therapy. Survey evidence and open-ended interviews reveal a mixture of reactions with respect to social relations, interactions with local officials, gossip, business patronage, funeral participation, and orphaned grandchildren. Positive support is often dominant and reactions typically improve substantially over time. Misplaced fears of contagion through casual contact underlie most negative reactions. Moral condemnation or blame is not evident as a source of negative reactions. Overall a sufficiently supportive atmosphere likely exists in many localities to facilitate community based efforts to mitigate the epidemic's impact on affected families.