Edinburgh, United Kingdom
|Bradley by David Jeffrey|
“Do you think I needed anticoagulants for my atrial fibrillation?” I asked the general practitioner.
He stared at his computer screen, and answered without looking at me. “No-one knows for sure. I will print out a recent article which you can read at home and then decide what you would like to do,” he replied. “Oh, by the way, I see on the screen that you need to see the practice nurse for a blood pressure check.”
After he handed me a sheaf of papers, I left his surgery feeling that I had wasted his time. Foucault elegantly described “the medical gaze,” by which doctors focus on the physical condition of the patient, objectifying the body and neglecting psychosocial dimensions of the individual patient, the very reverse of empathy.1
In contrast, I had an outpatient appointment with a cardiologist, who was pioneering laser ablation surgery in the UK, to assess whether I would benefit from such treatment. As I sat in his office, he looked at me and said, “I am a bit obsessed with atrial fibrillation. I would like to know how this has affected you. Can you help me to understand what it’s like to have this condition?”
I was surprised. Here was a national expert interested to hear about my experience and how it affected my life; he cared about my extreme fatigue, fear during episodes, breathlessness, and inability to walk uphill. It was so supportive to experience such empathy and to be able to express my feelings to an interested professional. I trusted him and later took his advice when he offered me the operation.
At the heart of the patient-doctor relationship, empathy is an experience by which a person tries to see the world from another’s point of view.2 Empathy requires both cognitive sensitivity and emotional involvement to experience, to some degree, the suffering of the other person.3 Authentic empathy begins with eye contact as two individuals come together face-to-face. Empathy may also be enhanced by other non-verbal methods, including touch and presence. Verbal communication skills are also integral to the flourishing of relational empathy.
Kim Carnes celebrated the connecting power of “Bette Davis’ eyes” in a Billboard chart-topping single in 1981.4 While eye contact may play a part in romantic attraction or “love at first sight,” in clinical practice it is a gateway to empathy.
A video-based study of eye movements found a relationship between empathic capacity and eye contact.5 The authors noted that individuals with autism who have an empathy deficit also exhibit reduced ability to maintain eye contact. It appears that eye to eye exchanges are vital to establishing social relationships. Individuals who show deeper empathic responses may motivate people to use a gaze pattern that searches for emotional cues from the eyes of the other person, an interaction described as the “empathic gaze.”5 Conversely, in people with lower empathic relationships, their gaze pattern falls away from the eyes.5
While making eye contact facilitates empathy and a trusting relationship, people also need space. It is appropriate sometimes to pause and to drop eye contact, providing privacy. Eye contact is a subtle form of non-verbal communication, vulnerable to misuse, which paradoxically may be threatened by modern communication technology.
In Toxic Childhood, Palmer describes how eye contact is critical for mother-baby bonding, a shared gaze inducing a shared pleasure in connecting.6 However, many babies are denied this vital attachment when their mothers gaze at screens on mobile phones or delegate their care to nannies, nurseries, or siblings.
As children grow up and acquire mobile phones and laptops, they communicate widely with friends while missing face-to-face eye contact. The “selfie” is the antithesis of empathy, which is outward looking and directed at connecting emotionally with the other person. Nowadays much of the communication between patients and doctors is by phone, e-mail, or video consultation, none of which facilitate empathy.
Eye contact may be used in ways to intimidate or interrogate the other person. An elderly patient described being discomforted by the “beady eyes” of an examining psychiatrist. His fixed eye contact was interpreted by the patient as a hostile glare. William Yeams’ painting And when did you last see your father? explores this use of eye contact. It depicts a young Royalist boy being questioned by Parliamentarians during the English Civil War. The picture examines the moral dilemma of whether lying is ever justified. If the boy tells the truth his father’s life is endangered, if he lies his father may escape detection. The boy gazes at his interrogator, maintaining eye contact and so appearing honest and trustworthy, while his inquisitor leans forward with his chin resting on his hands staring at the boy in what he hopes is a sympathetic pose.
It is hard to maintain a conversation with someone who does not have eye contact. It feels humiliating, as if one’s own story is boring. Indeed, discontinuing eye contact may be used as an effective way of terminating a conversation. I am aware of colleagues at conferences who gaze over my shoulder, losing eye contact, to find someone more impressive with whom to “network.”
Losing eye contact may be a sign of shame, a common emotion among patients who have embarrassing symptoms or guilty feelings about an unhealthy lifestyle or addictive behavior. Classically people who are telling the truth are able to look another person in the eye, loss of eye contact may be a sign that a patient is being evasive.
Cultural variations exist with regard to eye contact. Chinese and Japanese cultures generally regard direct eye contact with a stranger rude and will avert their gaze as a sign of respect.7
Empathy and eye contact has been investigated in animals and, more recently, even in robots. As Elif Shafak points out, for people to connect with something other than themselves they need to interact with a face.8 She argues that the more visible an animal’s eyes, the more sympathy it will receive from humans. Bradley, my black Labrador puppy, is highly responsive to my grieving for my wife. Recent research suggests that this emotional connection is common in dogs and indeed some dogs respond to their owner’s distress with helping behaviors.9 One of the first lessons in dog training is to establish and reward eye contact with the puppy as this is central to bonding.
In a study of human-robot interactions (HRI), researchers found that participants felt more engaged with a robot when it established eye contact.10 Kazuo Ishiguro explores the emotional world of androids in Klara and the Sun.11 The story is narrated by Klara, an Artificial Friend, a robot, whose perspectives on human relationships increases our understanding of the complexities of empathy.
Empathy is a relational experience between individuals. While one may feel compassion or sympathy for a group of suffering people, empathy is experienced between two individuals. Making eye contact is not time consuming or expensive but this simple step opens the door to deeper empathy, gaining both an understanding of the real concerns of the other person and greater self-awareness. In order to connect with another, we look into their eyes. It is a humbling thought that empathy may be dependent on the way we look at another person’s face.5
- Foucault M. The Birth of the Clinic : An Archeology of Medical Perception. Routledge; 2003.
- Jeffrey D. Empathy, sympathy and compassion in healthcare:is there a problem?Is there a difference?does it matter? Journal Royal Society Medicine. 2016;109:446-452.
- Jeffrey D. Empathy -Based Ethics: A way to practice humane medicine. Palgrave Macmillan; 2021.
- Carnes K. Bette Davis Eyes. Accessed 9th September 2021, AZLyrics.com
- Cowan DG, Vanman LJ, Nielsen M. Motivated empathy:The mechanics of the empathic gaze. Cognition and Emotion. 2014;28:1522-1530.
- Palmer S. Toxic Childhood. Orion Books; 2006.
- Blais C, Jack RE, Scheppes C, et al. Culture shapes how we look at faces. Plos One. 2008. Accessed 12th September 2021. Culture Shapes How We Look at Faces (plos.org)
- Shafak E. The Island of Missing Trees. Viking; 2021.
- Sanford EM, Burt ER, Meyers-Manor JE. Timmy’s in the well: Empathy and prosocial helping in dogs. Learning and Behaviour. 2018;46:374-386.
- Kompatsiasi K, Ciardo F, Tikhanoff V, et al. It’s in the Eyes:The Engaging Role of Eye Contact in HRI. International Journal of Social Robotics. 2021;13:525-535.
- Ishiguro K. Klara and the Sun. Faber; 2021.
DAVID JEFFREY was awarded a PhD from Edinburgh University in 2018 for a qualitative study exploring empathy in medical students. He was formerly a general practitioner and latterly a consultant in palliative medicine in Cheltenham UK and an academic mentor in Dundee Medical School. His most recent book is Empathy-Based Ethics published by Palgrave Macmillan in 2020.
Acknowledgement: In memory of Pru Jeffrey.