The Cost of Caring: Why Empathy Might Be Breaking Healthcare

‘You never really understand a person until you consider things from his point of view… until you climb into his skin and walk around in it.’ — Harper Lee, To Kill a Mockingbird

This timeless line from Atticus Finch has always resonated with me. It challenges us to embrace empathy, urging us to understand others deeply. But a recent discussion with third-year medical students made me question whether Atticus’ advice is entirely helpful — particularly in the context of moral suffering in healthcare.

The conversation began with a story I shared about an HIV clinician seeking guidance for what she described as “compassion fatigue.” She confessed to feeling increasingly “unsympathetic and angry” toward patients who failed to adhere to treatment plans. Having witnessed the harrowing deaths of countless patients in the pre-ARV era, she struggled to reconcile their “ungratefulness” with the life-saving therapies now available.

Initially, the students predictably analysed the case through the lens of autonomy versus paternalism — a staple of their ethical training. However, their suggestions soon became more nuanced. Some proposed counselling, noting potential trauma underlying the clinician’s feelings. Others pointed to burnout, suggesting a restorative break. Many emphasized the importance of understanding why patients struggled with adherence, positing that empathy could bridge the gap.

Then, one student — boldly breaking rank — posed a provocative question: “Is not caring always a bad thing?” Her argument was striking. She proposed that if excessive caring leads to burnout, perhaps cultivating “healthy detachment” could help clinicians build resilience, cope better, and stay in the profession longer.

This suggestion sparked a fresh wave of reflection on empathy, compassion, and their roles in moral suffering. It also led me to revisit the work of researchers like Tania Singer and Olga Klimecki[1], who differentiate empathy from compassion.

According to Singer and Klimecki, empathy involves sharing another’s suffering, whereas compassion centres on feelings of warmth, care, and a desire to alleviate suffering. Empathy can lead to what they call “empathetic distress” — a self-related emotion marked by negative feelings like stress, which can precipitate burnout. Compassion, on the other hand, is other-focused, promoting positive emotions and prosocial behaviour.

This distinction is echoed by Mihalache and Zăgrean[2], who argue that empathy is about stepping into someone else’s state, while compassion is about acknowledging suffering and striving to improve it. Crucially, they suggest that understanding this difference might help unravel the neural and psychological roots of occupational burnout[3].

Nowhere is this distinction more vital than in environments like South Africa, where healthcare is shaped by profound inequality and systemic challenges. Budget cuts and austerity measures only add to the strain. According to a 2023 Medical Protection Society survey[4], more than a third of South African healthcare professionals report that their mental health is worse now than during the pandemic. Alarmingly, nearly 40% link burnout to compromised patient safety.

In this fraught landscape, asking healthcare workers to “walk in their patients’ shoes” risks deepening the crisis. After all, if everyone is walking in borrowed shoes, it’s only a matter of time before blisters form. Instead, we need to empower clinicians to walk with their patients, shoulder to shoulder, forging paths toward shared wellbeing.

Empathy is valuable, but compassion is sustainable. By prioritizing the latter, we might not only preserve the mental health of our healthcare workforce but also build a system where care flourishes — not in spite of adversity but because we choose to approach it differently.