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IN CONCLUSION | MOSKOVITZ
empathy evolved together, in their primal forms, as essential for
mammalian nurturing. The capacity for empathy requires the
capacity for suffering.
PREMISE 6
The capacity for suffering is the experiential
precursor of empathy and altruism, which are
the components of values and natural morality.
MOST OBSERVERS AGREE that empathy is the antecedent of
altruism (29). Explanations of altruism that rely on self-interest,
enlightened self-interest, kin or group advantage, or strategic
decision-making are either irrational or fail empirical validation.
I propose that the survival and reproductive advantages of suffering,
empathy, and altruism are inextricably related.
Suffering, Empathy, and Mirror Neurons
THE THEORY OF EMPATHY—and, arguably, a theory of suffering—took
an important turn with the discovery by Giacomo
Rizzolatti and colleagues (29) of “mirror neurons” in primates.
The current understanding of mirror neurons was recently summarized
by Rizzolatti and Craighero (30). Mirror neurons are
specialized nerve cells that form systems in several areas of the
brain that are involved in motor functions. According to the
theory, when a person observes the face of another, mirror neurons
appear to evoke in the observer the sensation that the
observed facial muscle activity would evoke. They do not stimulate
the observer to duplicate the activity, only to feel as
though it had. We know that the feeling of the facial muscle
activity that is characteristic of an emotion evokes the feeling of
the emotion. Ekman demonstrated that a person who naively
“makes the face” of sadness by practicing specific facial muscle
activity in a pattern that is characteristic of grief, will feel sad
(31). It follows that when a person observes another in grief,
mirror neurons evoke the feeling of the observed facial expression.
According to Damasio’s somatic marker theory, and
Ekman’s observations, the feeling of sensations from the body
proper (even if the body is observing at rest) that are concordant
with a grieving face is an “emotionally competent stimulus”:
the feelings evoke the experience of grief. 15 The operation
of mirror neurons in humans has been well demonstrated for
simple motor activity. The theory linking mirror neurons to
suffering, empathy, and values is well on the way to validation,
and, validation not withstanding, it makes wonderful sense.
Thus far I have proposed that there is a relationship
between suffering, the capacity for empathy and altruism, and
that the relationship establishes a neural basis for natural morality.
When I refer to altruism, I mean that which consists of fairness,
generosity and regard for others—social emotions and
values. 16 I use the term natural morality to distinguish it from
imposed morality, which is commonly associated with belief
systems and mythology. 17 I believe that altruism is fragile while
exploitation is robust. Cooperation between evolving individuals
did not come easily. The longest period of evolution, as
much as 2.9 billion years, 18 passed while avaricious, self-protective,
single-celled organisms “learned” how to tolerate each
other and cooperate in order to form more efficient and adaptable
multi-celled creatures. 19
Conclusions
IN THIS PAPER I proposed that suffering is the feeling of bodily
disturbance that is evoked by fear or grief primarily, or as a
response to (a) unresolved drives (thirst, hunger, oxygenation,
lust, attachment, etc.) or (b) the experience of pain as it threatens
the integrity of the existential domains of the autobiographical
self. The disability of illness (as opposed to the impairment
of disease) is the effect of suffering as an awareness of the bodily
effects of grief and fear, particularly (but not exclusively) when
evoked by pain.
I offer this theory of suffering in an effort to make suffering
more than just “the story of pain,” the “language of pain,”
or the “emotional aspects of pain.” I have proposed that the
neural substrate of suffering is as real as that of nociception or
fear. Similarly, the burden of suffering is real, even though our
patients use words to describe the experience that are variable
to the point of idiosyncrasy. It is a fatuous conceit to say, “I
feel your pain (or suffering).” No one, neither practitioner
nor patient, can experience the pain or suffering of the other.
That is the interior nature of consciousness and the inherent
15 One aspect of the science of mirror neurons is important for the pain
practitioner who is trying to comprehend the suffering of a patient who
sits with a stooped posture, rocking aimlessly, protecting a withdrawn,
deformed extremity, with the facial expression of fear and grief. Mirror
neurons do not appear to evoke mimicry, only the feeling of mimicry.
Mirror neurons, therefore, do not put practitioners at risk of identification,
a state of mind in which the observer is motivated to behave like the
patient. This is, no doubt, extending limited knowledge too far, but the
ethical distinction between empathy and identification in clinical practice
cannot be overstated. Some practitioners may fear empathy, lest they identify
with the patient and lose clinical perspective in formulating a cogent
diagnosis and appropriate plan of care. The advancing science of mirror
neurons does not eliminate the risk of identification, but it doesn’t
make it inevitable either.
16 This is often referred to by the outmoded term psychological altruism, to distinguish
it from biological altruism, cooperation that promotes survival of the
species but not the individual. Biological altruism is observed in organisms
lacking a central nervous system.
17 In this context I define natural morality as the predisposition to good (as
opposed to right) behavior that does not require, or is independent of, the
existence of a supernatural power or intelligence. For a discussion of natural
law and morality, I refer the reader to Alfonso Gomez-Lobo (32).
18 For those who are interested, a representative evolutionary time-line includes:
Earth cools, water and atmosphere form, 4.1 BYA (billion years ago); singlecelled
organisms appear, 3.9 BYA; sexual reproduction appears, 1.2 BYA;
multi-celled organisms appear, 1.0 BYA; the Cambrian explosion occurs,
0.55 BYA.
19 We share half of our genome with the common yeast whose cooperative skills
go no further than forming colonies. The rest of evolution seems easy in
comparison.
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