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IN CONCLUSION | MOSKOVITZ<br />
empathy evolved together, in their primal forms, as essential for<br />
mammalian nurturing. The capacity for empathy requires the<br />
capacity for suffering.<br />
PREMISE 6<br />
The capacity for suffering is the experiential<br />
precursor of empathy and altruism, which are<br />
the components of values and natural morality.<br />
MOST OBSERVERS AGREE that empathy is the antecedent of<br />
altruism (29). Explanations of altruism that rely on self-interest,<br />
enlightened self-interest, kin or group advantage, or strategic<br />
decision-making are either irrational or fail empirical validation.<br />
I propose that the survival and reproductive advantages of suffering,<br />
empathy, and altruism are inextricably related.<br />
Suffering, Empathy, and Mirror Neurons<br />
THE THEORY OF EMPATHY—and, arguably, a theory of suffering—took<br />
an important turn with the discovery by Giacomo<br />
Rizzolatti and colleagues (29) of “mirror neurons” in primates.<br />
The current understanding of mirror neurons was recently summarized<br />
by Rizzolatti and Craighero (30). Mirror neurons are<br />
specialized nerve cells that form systems in several areas of the<br />
brain that are involved in motor functions. According to the<br />
theory, when a person observes the face of another, mirror neurons<br />
appear to evoke in the observer the sensation that the<br />
observed facial muscle activity would evoke. They do not stimulate<br />
the observer to duplicate the activity, only to feel as<br />
though it had. We know that the feeling of the facial muscle<br />
activity that is characteristic of an emotion evokes the feeling of<br />
the emotion. Ekman demonstrated that a person who naively<br />
“makes the face” of sadness by practicing specific facial muscle<br />
activity in a pattern that is characteristic of grief, will feel sad<br />
(31). It follows that when a person observes another in grief,<br />
mirror neurons evoke the feeling of the observed facial expression.<br />
According to Damasio’s somatic marker theory, and<br />
Ekman’s observations, the feeling of sensations from the body<br />
proper (even if the body is observing at rest) that are concordant<br />
with a grieving face is an “emotionally competent stimulus”:<br />
the feelings evoke the experience of grief. 15 The operation<br />
of mirror neurons in humans has been well demonstrated for<br />
simple motor activity. The theory linking mirror neurons to<br />
suffering, empathy, and values is well on the way to validation,<br />
and, validation not withstanding, it makes wonderful sense.<br />
Thus far I have proposed that there is a relationship<br />
between suffering, the capacity for empathy and altruism, and<br />
that the relationship establishes a neural basis for natural morality.<br />
When I refer to altruism, I mean that which consists of fairness,<br />
generosity and regard for others—social emotions and<br />
values. 16 I use the term natural morality to distinguish it from<br />
imposed morality, which is commonly associated with belief<br />
systems and mythology. 17 I believe that altruism is fragile while<br />
exploitation is robust. Cooperation between evolving individuals<br />
did not come easily. The longest period of evolution, as<br />
much as 2.9 billion years, 18 passed while avaricious, self-protective,<br />
single-celled organisms “learned” how to tolerate each<br />
other and cooperate in order to form more efficient and adaptable<br />
multi-celled creatures. 19<br />
Conclusions<br />
IN THIS PAPER I proposed that suffering is the feeling of bodily<br />
disturbance that is evoked by fear or grief primarily, or as a<br />
response to (a) unresolved drives (thirst, hunger, oxygenation,<br />
lust, attachment, etc.) or (b) the experience of pain as it threatens<br />
the integrity of the existential domains of the autobiographical<br />
self. The disability of illness (as opposed to the impairment<br />
of disease) is the effect of suffering as an awareness of the bodily<br />
effects of grief and fear, particularly (but not exclusively) when<br />
evoked by pain.<br />
I offer this theory of suffering in an effort to make suffering<br />
more than just “the story of pain,” the “language of pain,”<br />
or the “emotional aspects of pain.” I have proposed that the<br />
neural substrate of suffering is as real as that of nociception or<br />
fear. Similarly, the burden of suffering is real, even though our<br />
patients use words to describe the experience that are variable<br />
to the point of idiosyncrasy. It is a fatuous conceit to say, “I<br />
feel your pain (or suffering).” No one, neither practitioner<br />
nor patient, can experience the pain or suffering of the other.<br />
That is the interior nature of consciousness and the inherent<br />
15 One aspect of the science of mirror neurons is important for the pain<br />
practitioner who is trying to comprehend the suffering of a patient who<br />
sits with a stooped posture, rocking aimlessly, protecting a withdrawn,<br />
deformed extremity, with the facial expression of fear and grief. Mirror<br />
neurons do not appear to evoke mimicry, only the feeling of mimicry.<br />
Mirror neurons, therefore, do not put practitioners at risk of identification,<br />
a state of mind in which the observer is motivated to behave like the<br />
patient. This is, no doubt, extending limited knowledge too far, but the<br />
ethical distinction between empathy and identification in clinical practice<br />
cannot be overstated. Some practitioners may fear empathy, lest they identify<br />
with the patient and lose clinical perspective in formulating a cogent<br />
diagnosis and appropriate plan of care. The advancing science of mirror<br />
neurons does not eliminate the risk of identification, but it doesn’t<br />
make it inevitable either.<br />
16 This is often referred to by the outmoded term psychological altruism, to distinguish<br />
it from biological altruism, cooperation that promotes survival of the<br />
species but not the individual. Biological altruism is observed in organisms<br />
lacking a central nervous system.<br />
17 In this context I define natural morality as the predisposition to good (as<br />
opposed to right) behavior that does not require, or is independent of, the<br />
existence of a supernatural power or intelligence. For a discussion of natural<br />
law and morality, I refer the reader to Alfonso Gomez-Lobo (32).<br />
18 For those who are interested, a representative evolutionary time-line includes:<br />
Earth cools, water and atmosphere form, 4.1 BYA (billion years ago); singlecelled<br />
organisms appear, 3.9 BYA; sexual reproduction appears, 1.2 BYA;<br />
multi-celled organisms appear, 1.0 BYA; the Cambrian explosion occurs,<br />
0.55 BYA.<br />
19 We share half of our genome with the common yeast whose cooperative skills<br />
go no further than forming colonies. The rest of evolution seems easy in<br />
comparison.<br />
80 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6