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Empathy as an ethical principle for environmental health
Science of the Total Environment 705 (2020) 135922
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Science of the Total Environment journal homepage: www.elsevier.com/locate/scitotenv
Empathy as an ethical principle for environmental health Friedo Zölzer a,⁎, Neysan Zölzer b a b
Institute of Radiology, Toxicology and Civil Protection, Faculty of Health and Social Sciences, University of South Bohemia in České Budějovice, Czech Republic Mensch Innovation, Oxford, United Kingdom
H I G H L I G H T S • • • • •
Environmental Health is a matter not only of scientific fact, but also of ethics. Basic principles include respect for autonomy, justice, solidarity, and precaution. Practice requires procedural principles such as accountability and transparency. We suggest to add empathy to the set – “taking the perspective of those affected”. Empathy is gaining importance in many other areas from urban design to health care.
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Article history: Received 7 August 2019 Received in revised form 27 November 2019 Accepted 2 December 2019 Available online 05 December 2019 Editor: Lotfi Aleya Keywords: Moral values Ethical principles Applied ethics Environmental health and safety Occupational health Radiation protection
a b s t r a c t Purpose: Environmental health ethics is a relatively young field of study, drawing on experience from medical ethics, public health ethics, and the ethics of radiological protection. Fundamental to all of these in one way or another are the four “principles of biomedical ethics”, originally proposed by Beauchamp and Childress (1979) as a guide for decision making in clinical practice. Suggestions have been made of various other principles which should be added to address the specifics of the individual disciplines under consideration. Here we are exploring empathy as a principle complementing those hitherto applied in environmental health practice. Results and conclusions: Empathy can be defined as the “capability (or disposition) to immerse oneself in and to reflect upon the experiences, perspectives and contexts of others”. It is often understood as a skill that one either has or has not, but research has shown it can be taught and therefore can be required as an attitude of those working in health care, education, design, and even politics. We suggest to consider it a procedural principle on a par with inclusiveness, accountability, and transparency. It should drive the assessment of any environmental situation and the health problems accruing from it. © 2019 Elsevier B.V. All rights reserved.
1. Introduction Ethical questions in environmental health have received increasing attention over the last 15 to 20 years. The journal Environmental Health Perspectives in 2003 featured a “Mini Monograph – Ethics and Environmental Health”, (Parascandola, 2003) which addressed a whole range of issues, primarily research ethics. This was also the focus of Lavery et al. (2003) as well as Merlo et al. (2007). The first comprehensive monograph on “Environmental Health Ethics” was the one by Resnik (2012), which suggests a method of making ethical decisions by weighing alternative values applicable to key questions in the field. Around the same time began a series of “International Symposia on
⁎ Corresponding author at: J. Boreckého 1167/27, 370 11 České Budějovice, Czech Republic. E-mail address: [email protected] (F. Zölzer).
https://doi.org/10.1016/j.scitotenv.2019.135922 0048-9697/© 2019 Elsevier B.V. All rights reserved.
Ethics of Environmental Health” which covered a similarly broad range of issues. Some of the papers presented have been published in Oughton and Hansson (2013), and in Zölzer and Meskens (2017, 2018). During the same period, there has also been some discussion on public health ethics. Much of it has focused on the question whether the “principles of biomedical ethics” proposed by Beauchamp and Childress (1979) as a guide for decision making in the clinical situation, are more generally applicable. Several authors have argued that the approach itself is useful, but additional principles are needed if it is to help address questions of public health. Concrete suggestions have been made, as also referred to below, by Coughlin (2008) and SchröderBäck et al. (2014). All this ties in very well with efforts made more recently in the area of radiological protection. Realising that it had long-since based its recommendations on ethical values, but had mostly refrained from addressing them explicitly, the International Commission on Radiological Protection initiated a number of workshops around the world to discuss
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relevant questions, and in 2013 established a Task Group to draft recommendations on the topic. The final version was approved by the Commission in 2017 and published in 2018 under the title of “Ethical Foundations of the System of Radiological Protection” (ICRP, 2018). The “core values” identified therein are very similar, though not identical with the “principles of biomedical ethics”, and again reflect the specifics of the field which were felt to be insufficiently covered by the Beauchamp and Childress set. The ICRP recommendations, of course, cover much more than questions arising in the medical context, but rather extend to environmental and occupational issues. As concerns environmental health, it seems best to us to explicitly proceed from the well-known “principles of biomedical ethics”, but then take account of other principles, or values, which have been proposed in neighbouring fields and see if they apply to environmental health ethics as well. This is the approach taken by Zölzer (2017). In addition to the four basic principles of “respect for autonomy, nonmaleficence, beneficence, and justice”, four “correlated” principles were identified as relevant: “human dignity, precaution, solidarity, and sustainability”, and for the practical application of all these, four “procedural” principles were suggested: “inclusiveness, accountability, empathy, and transparency”. Of these, three are taken into account in most pertinent discussions, sometimes under different names, but empathy is not usually included, and may need some more argument to be understood and to qualify as a principle for ethical decision making in environmental health.
2. The concept of empathy The term “empathy” is not much older than a century. It was first used in 1909 by the British-American psychologist Edward Bradford Titchener (1867–1927) (Titchener, 1909) when he referred to a concept developed by the German philosopher Theodor Lipps (1851–1914). The original German was “Einfühlung”, meaning “in-feeling” or “feelinginto”, and Lipps was the first to propagate it as a fundamental concept of perception psychology (Lipps, 1900, 1903, 1907). The coining of the term in the context of aesthetics, i.e. as an aspect of the perception of art, is often attributed to the German art historian and philosopher Robert Vischer (1847–1933). Vischer did use the word (in noun form) in his doctoral dissertation 1872 (Vischer, 1872), but his father, the philosopher Friedrich Theodor Vischer (1807–1887) had already applied “einfühlen” in verb form (Vischer, 1846–1854). The verb is actually found in much earlier writings, such as those of the Enlightenment philosopher Johann Gottfried Herder (1744–1803) who used it in 1774 (von Herder, 1774) to describe how an understanding can be gained of foreign cultures and past epochs. The first use of the noun “Einfühlung” can be traced back to the German philosopher Rudolf Hermann Lotze (1817–1881) who in 1858 applied it to the aesthetic process in a similar way as Robert Vischer a few years later (Lotze, 1858). Apparently, Vischer was not aware of this work before he developed his concept. “Empathy” has been variously defined as “the projection of one's own personality into the personality of another in order to understand the person better” (Webster's New World College Dictionary, 2014); “allowing one to see another person's context, needs and aspirations” (de Vignemont and Singer, 2006); “the identification with or vicarious experiencing of the feelings, thoughts, etc., of another” (Webster's College Dictionary, 2010); “the ability to understand and share the feelings of another” (Oxford Dictionary, 2016); or “the capacity to understand what another person is experiencing from within the other person's frame of reference, i.e., the capacity to place oneself in another's shoes” (Bellet and Maloney, 1991). All these definitions appear to relate primarily to the relationship between two individuals. However, empathy can also be understood to encompass the relationship between an individual and a larger group, a community, or a population, and may thus be defined more broadly as “the capability (or
disposition) to immerse oneself in and to reflect upon the experiences, perspectives and contexts of others” (Zölzer, 2014). Some authors distinguish different kinds of empathy, in particular emotional and cognitive empathy. Emotional empathy again may take different forms, or occur with different intensities: emotional contagion, which consists in actually taking over the feelings of another; personal distress, in which one is afflicted by another's plight, but does not necessarily feel exactly the same anxiety, sorrow and pain; and empathic concern, which involves feeling for another and can be equated to sympathy, or compassion (see our brief discussion below). Cognitive empathy, by contrast, does not imply that one's emotions are affected, but that one is aware of, or successfully guessing, someone else's thoughts and feelings. A mental process facilitating this kind of empathy is perspective taking, i.e. imagining oneself in the situation of the other, with the realisation that the other person's thought and feelings may well be different from one's own (Hodges and Myers, 2007). Somewhat more broadly, one might say that empathy engenders an opportunity to immerse oneself in the experience of the other, while remaining distant enough to reflect upon it (Zölzer, 2014). The terms empathy, sympathy and compassion are often used interchangeably, and of course are not defined by everyone in exactly the same way. Kouprie and Visser (2009) suggest the following distinction: “When you feel sympathy for someone your concern is for the other person's well-being; you feel like you are the other. When you have empathy with someone your concern is to understand the other person; you feel as if you are the other.” They refer to Wispé (1986), who summarised his understanding like this: “Sympathy is a way of ‘relating’. Empathy is a way of ‘knowing’”. Here, the focus is obviously on cognitive empathy. If a broader understanding of empathy is preferred, including both cognitive and emotional aspects, one might see sympathy and compassion as synonyms of empathetic concern, a form of emotional empathy (as mentioned above). Actually, Latin “compassion” is a loan-translation of Greek “sympatheia”, both meaning “fellow-suffering”. Some dictionaries claim that while sympathy describes feeling for somebody else, compassion includes the desire to help (e.g. Merriam-Webster's Dictionary of Synonyms 1984). 3. Empathy – a character trait or an ethical principle? Given the common definitions of empathy, many of which start with “the ability to”, or “the capacity to”, one might think that we are talking about a character trait, or a personal quality – something that one either possesses, or not. But to call it an ethical principle seems to suggest that empathy can be demanded of anyone, it can be consciously applied, and it can be taught. It is still conceivable, of course, that some people may find it easier than others to be empathetic, but then - some may find it easier than others to act according to transparency, accountability, inclusiveness, or any of the more fundamental principles mentioned above. That empathy can be learned is evident from quite a number of studies. Empathy training has been developed and tested for medical doctors (Wündrich et al., 2017), nurses (Bas-Sarmiento et al., 2017), social workers (Dupper, 2017), and teachers (Bouton, 2016). Here we mention only a few recent examples. Positive experience has actually accumulated over the past 40 years. A meta-analysis of 18 randomised controlled trials including participants from different professions came to the conclusion that empathy training is indeed effective, although further research is recommended to understand the influence of certain factors such as different types of trainees, training conditions, and types of assessment (Teding van Berkhout and Malouff, 2016). If it is possible to train empathy, it can be included in the catalogue of ethical principles which at least certain people would be expected to follow, such as the ones mentioned above (medical doctors, nurses, social workers, and teachers). Accordingly, empathy has been called a “moral concept” (Schapiro, 2011); a “normative value” (Zanetti, 2011); a “guiding principle” (Ferrara, 2018); or an “ethical imperative” (Adams, 2018).
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Other authors disagree, and prefer to speak of a “skill” (FernándezOlano et al., 2008; Cunico et al., 2012; Walther et al., 2017), but even that has a connotation of desirability or goodness. In her “Handbook of Philosophy of Empathy”, nevertheless, Maiboom (2017) points out that such a positive appraisal is by no means universal. Quite often, empathy has been seen as biased, focusing on the good for an individual, and neglecting the common good. Yet again that is not necessarily so, and Maiboom states that a number of her co-authors “are pretty stout defenders of the importance of empathy to morality, and so empathy may be making a comeback.” Our portrayal of empathy as a “procedural principle” seems to be in tune with its somewhat ambivalent character evident from this short discussion. Procedural principles are those that facilitate the implementation of more fundamental principles in practice. They can therefore on the one hand be seen as behavioural standards, on the other hand they call for the acquisition of certain skills without which their practical application would be impossible. Neither skills nor behavioural standards can be applied in isolation. Beauchamp and Childress emphasize that in a particular situation several principles may have to be considered and may all have validity prima facie – at first sight. In such a case, balancing is needed: sometimes one principle taking precedence, sometimes another. The principles may also have to be specified differently for each context in which they are going to be applied. All this was originally suggested for the set of four principles proposed by Beauchamp and Childress, which were supposed to help decision making in a clinical context, but it is certainly applicable as well for a model in which further principles, “correlated” and “procedural” ones, are taken into consideration. In the case of empathy, it seems most natural to see it as the procedural principle closely akin to the fundamental principle of beneficence, and the correlated principle of solidarity. Beneficence usually focuses on the individual, but solidarity reminds the decision maker of the need to factor in the good of a larger group, or indeed the whole of society. Empathy, we might say, provides the means and process to achieve and exercise beneficence and solidarity. There are, of course, kinships with other principles as well, such as with non-maleficence, or with human dignity. For a somewhat more detailed discussion of these relationships, we have to refer the reader to earlier publications (Zölzer, 2016; Zölzer, 2017; Malone et al., 2018). 4. An operational approach to empathy Further to our discussion on empathy as a “procedural principle”, we would like to offer here a short exploration of how the principle comes to life in practice. Empathy is actually applied across various disciplines and sectors. In design practices, such as architecture, product design, urban planning, service design, and digital design, it is now consciously used to produce work that correlates more closely to the needs of the user or consumer. Applying empathy in this context means “leaving the design office and becoming immersed in the lives, environments, attitudes, experiences and dreams of the future users” (Battarbee et al., 2002). This helps practitioners to “communicate effectively [and] make accurate decisions” (King, 2011). It must be emphasised, however, that this practice is not primarily aimed at higher effectiveness or productivity. The designer should have the good of the user or consumer in mind for its own sake. To the extent that his or her interest in the counterpart is genuine, higher effectivity and productivity can be expected as a secondary outcome. While ‘design’ is popularly understood to be concerned with the form or style of physical and digital objects, designers see themselves primarily involved in problem-solving. Over the last decade, in particular, terms such as ‘empathy-driven design’, ‘participatory design’, and ‘human-centred design’ have emerged to define an iterative process by which a practitioner (a ‘designer’ of whichever design discipline) can understand the user, challenge assumptions, redefine problems, and iteratively test solutions. Empathy is operationalised throughout
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the process by various methods that enable the practitioner to see, feel, and do what the ‘user’ sees, feels, or does. These methods may include classical research methods such as observation, focus groups, or interviews, but may also embrace more creative and interactive methods with users, enabling them to become ‘co-designers’. These practices can allow practitioners of any discipline in any field to actively develop the capability of empathy (Kouprie and Visser, 2009). One example is the Singapore government's long-term relationship with design firm IDEO, a proponent of empathy-focused design practice. In a project for the Ministry of Health, a multifunctional team of civil servants and design practitioners created tools to help patients better understand and predict healthcare costs, including government subsidies. The work was undertaken in close collaboration with doctors who had significant experience in speaking with patients, and with patients themselves (IDEO, 2015). Design teams working to improve accessibility in public spaces systematically employ empathy as a tool. For example, to understand limitations in public spaces for the elderly, design practitioners (such as architects or urban designers) may be too young to have deep knowledge of the elderly's experience and use a blend of methods, including observation, interviews, and walk-throughs, to enrich their understanding. To design workspaces or digital experiences for those blind or severely visually impaired, designers may choose to wear blindfolds for limited exercises to educate themselves on others' experiences (Fulton Suri et al., 2003). Such tools tap into the notion of the ‘empathic horizon’, developed by McDonagh-Philp and Denton (1999). It defines the limits of an individual's empathy at any given moment as his or her unique experiences and characteristics, such as history, background, gender, culture, and education. Practitioners, then, must recognise their own unique empathic horizon and endeavour to gain experience beyond that horizon to design more appropriate results. In quite a different context, that of jurisdiction, empathy has been described as essential for decision making in court. Deigh (2011) argues that “to interpret a law soundly, one must be sensitive to the perspective of the different people whose interests the law affects or is liable to affect if applied to their situation. Sound interpretation of the law, in other words, requires empathy.” This is so, he says, because the purpose of the law is to serve the interests of justice. From his discussion of a particular case decided by the U.S. Supreme Court, it becomes obvious that a formal application of precedent cases can lead to unfair decisions, and that “one cannot see this unfairness without taking the plaintiff's perspective.” Empathy has also begun to appear in political discourse. The former Czech president, Vaclav Havel, opened a NATO conference in 2002 with these words: “I believe that the first requisite, above all else, is a quest for better knowledge of each other, better mutual understanding and a greater capacity for empathy with one another's positions and one another's dilemmas” (Havel, 2002). In 2006, the former US president Barack Obama in a speech delivered at the University of Massachusetts at Boston said, “Empathy is a quality of character that can change the world - one that makes you understand that your obligations to others extend beyond people who look like you and act like you and live in your neighbourhood” (Obama, 2006). More recently, the re-elected president of Ireland, Michael D. Higgins, included the following in his acceptance speech: “We are in a time of transformation and there is a momentum for empathy, compassion, inclusion and solidarity which must be recognised and celebrated” (Irish Times, 2018). And Jacinda Ardern, New Zealand's prime minister, stated in a widely broadcast interview: “It takes courage and strength to be empathetic. And I'm very proudly an empathetic, compassionatelydriven politician” (BBC, 2018). These are indications of how empathy is perceived in the wider community. If politicians are beginning to advocate for it, one might argue, it is high time for health professionals to do so too. They should be leading rather than following in this respect.
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5. Conclusion and recommendation Clearly, then, empathy is called for in a broad spectrum of situations, ranging from the conversation of a doctor with his or her patient to the assessment and management of public health problems, and way beyond. As concerns decision-making in environmental health specifically, our idea of the place of empathy and the other procedural values mentioned above – transparency, accountability, and inclusiveness – is as follows: - The assessment of an environmental situation and the health problems accruing from it, must be driven mainly by empathy. - For the communication about what has been ascertained, transparency is most crucial. - In the consultation process about what should be done, inclusiveness (making sure that all stakeholders are involved) takes precedence. - When decisions are taken and their effectiveness is evaluated, accountability is key.
In other words, we suggest that people's concerns, their needs and wishes need to be taken seriously from the very beginning of any decision-making process, even if they are considered unfounded or exaggerated. Everybody involved should make an effort to “immerse oneself in and to reflect upon the experiences, perspectives and contexts of others.” Without empathy, our practice of beneficence and solidarity would be oddly limited. Declaration of competing interest The authors declare they have no actual or potential competing financial interests. Acknowledgement The authors thank Jacques Lochard, Jim Malone and Maryam ZölzerYazdani for critically reading an earlier draft of this paper and for making valuable suggestions. References Adams, S.B., 2018. Empathy as an ethical imperative. Creat Nurs 24 (3), 166–172 PMID: 30567759. https://doi.org/10.1891/1946-6560.24.3.166. Bas-Sarmiento, P., Fernández-Gutiérrez, M., Baena-Baños, M., Romero-Sánchez, J.M., 2017. Efficacy of empathy training in nursing students: a quasi-experimental study. Nurse Educ. Today 59 (12), 59–65 PMID: 28945994. https://doi.org/10.1016/j. nedt.2017.08.012. Battarbee, K., Baerten, N., Hinfelaar, M., 2002. Pools and satellites: intimacy in the city. Proceedings of the Conference on Designing Interactive Systems DIS'00. ACM Press, New York, NY, pp. 237–245. https://doi.org/10.1145/778712.778746. BBC, 2018. Jacinda Ardern: ‘It takes strength to be an empathetic leader’. https://www. bbc.co.uk/news/av/world-asia-46207254/jacinda-ardern-it-takes-strength-to-be-anempathetic-leader, Accessed date: 31 May 2019. Beauchamp, T.L., Childress, J.F., 1979. Principles of Biomedical Ethics. University Press, Oxford. Bellet, P.S., Maloney, M.J., 1991. The importance of empathy as an interviewing skill in medicine. JAMA 266 (13), 1831–1832 (PMID: 1909761). Bouton, B., 2016. Empathy research and teacher preparation: benefits and obstacles. SRATE Journal 25 (2), 16–25 (ERIC Number: EJ1113829). Coughlin, S.S., 2008. How many principles for public health ethics. Open Public Health J 1, 8–16 (PMID: 20072707). Cunico, L., Sartori, R., Marognolli, O., Meneghini, A.M., 2012. Developing empathy in nursing students: a cohort longitudinal study. J. Clin. Nurs. 21 (13–14), 2016–2025 PMID: 22672461. https://doi.org/10.1111/j.1365-2702.2012.04105.x. de Vignemont, F., Singer, T., 2006. The empathic brain: how, when, and why? Trends Cogn. Sci. 10 (10), 435–441 (16949331). Deigh, J., 2011. Empathy, justice, and jurisprudence. South. J. Philos. 49 (Suppl), 73–90. https://doi.org/10.1111/j.2041-6962.2011.00058.x. Dupper, D., 2017. Strengthening empathy training programs for undergraduate social work students. J Baccal Social Work 22, 31–41. https://doi.org/10.18084/10847219.22.1.31.
Fernández-Olano, C., Montoya-Fernández, J., Salinas-Sánchez, A.S., 2008. Impact of clinical interview training on the empathy level of medical students and medical residents. Med Teacher 30 (3), 322–324. https://doi.org/10.1080/01421590701802299. Ferrara, N., 2018. Pursuit of Impact: Trauma- and Resilience-informed Policy Development (Lanham, MD: Lexington). Fulton Suri, J., Battarbee, K., Koskinen, I., 2003. Designing in the Dark — Empathic Exercises to Inspire Design for our Non-visual Senses. http://www2.uiah.fi/~ikoskine/ idmi05/designinginthedark.pdf (accessed 31 May 2019). Havel, V., 2002. The Transformation of NATO. Opening Speech at the Prague Summit. https://www.nato.int/docu/speech/2002/s021120c.htm (accessed 31 May 2019). Hodges, S.D., Myers, M.W., 2007. Empathy. In: Baumeister, R.F., Vohs, K.D. (Eds.), Encyclopedia of Social Psychology. SAGE Publications, Thousand Oaks, CA, pp. 296–298. ICRP (International Commission on Radiological Protection), 2018. Ethical Foundations of the System of Radiological Protection. ICRP Publication, p. 138 (Ann ICRP 47). IDEO, 2015. Singapore's road to a human-centered government. https://www.ideo.com/ case-study/singapores-road-to-a-human-centered-government, Accessed date: 31 May 2019. Irish Times, 2018. ‘Words matter. Words can hurt’ - Michael D Higgins's acceptance speech in full. https://www.irishtimes.com/news/politics/words-matter-words-canhurt-michael-d-higgins-s-acceptance-speech-in-full-1.3678585, Accessed date: 31 May 2019. King, S.H., 2011. The structure of empathy in social work practice. J Hum Beh Soc Envir 21 (6), 679–695. https://doi.org/10.1080/10911359.2011.583516. Kouprie, M., Visser, F., 2009. A framework for empathy in design: stepping into and out of the user's life. J Engin Des 20 (5), 437–448. Lavery, J.V., Upshur, R.E., Sharp, R.R., Hofman, K.J., 2003. Ethical issues in international environmental health research. Int. J. Hyg. Environ. Health 206 (4–5), 453–463 (12971701). Lipps, T., 1900. Aesthetische Einfühlung. Zeitsch Psych Phys Sinnesorg 22, 415–450. Lipps, T., 1903. Einfühlung, innere Nachahmung, und Organempfindungen. Arch ges Psych 1, 185–204. Lipps, T., 1907. Das Wissen von fremden Ichen. In: Lipps, T. (Ed.), Psychologische Untersuchungen. vol. I. Wilhelm Engelmann, Leipzig, pp. 694–722. Lotze, H., 1858. Mikrokosmus: Ideen zur Naturgeschichte und Geschichte der Menschheit. Versuch einer Anthropologie. Zweiter Band. Leipzig: Hirzel. Maiboom, H. (Ed.), 2017. The Routledge Handbook of Philosophy of Empathy. Routledge, Oxford. Malone, J., Zölzer, F., Meskens, G., Skourou, C., 2018. Ethics for Radiation Protection in Medicine. CRC Press, Boca Raton. McDonagh-Philp, D., Denton, H., 1999. Using focus groups to support the designer in the evaluation of existing products: a case study. Des. J. 2 (2), 20–31. https://doi.org/ 10.2752/146069299790303570. Merriam-Webster’'s Dictionary of Synonyms, 1984. Merriam-Webster, Springfield, MA. Merlo, D.F., Knudsen, L.E., Matusiewicz, K., Niebrój, L., Vähäkangas, K.H., 2007. Ethics in studies on children and environmental health. J. Med. Ethics 33 (7), 408–413 (17601869). Obama, B., 2006. University of Massachusetts at Boston commencement speech. http:// obamaspeeches.com/074-University-of-Massachusetts-at-Boston-CommencementAddress-Obama-Speech.htm. Oughton, D., Hansson, S.O. (Eds.), 2013. Social and Ethical Aspects of Radiation Risk Management. Elsevier Science, Isle of Seil, Argyll. Oxford Dictionary. University Press, Oxford. Parascandola, M., 2003. Ethics in environmental health: a mini-monograph. Environ Health Persp 111 (14), A774–A775. Resnik, D.B., 2012. Environmental Health Ethics. Cambridge University Press, New York, NY. Schapiro, T., 2011. Empathy as a moral concept: comments on John Deigh's “empathy, justice and jurisprudence”. South J Phil 49 (S1), 91–98. Schröder-Bäck, P., Duncan, P., Sherlaw, W., Brall, C., Czabanowska, K., 2014. Teaching seven principles for public health ethics: towards a curriculum for a short course on ethics in public health programmes. BMC Medical Ethics 15, 73–82 2014. PMID: 25288039. https://doi.org/10.1186/1472-6939-15-73. Teding van Berkhout, E., Malouff, J.M., 2016. The efficacy of empathy training: a metaanalysis of randomized controlled trials. J. Couns. Psychol. 63 (1), 32–41 PMID: 26191979. https://doi.org/10.1037/cou0000093. Titchener, E.B., 1909. Lectures on the Experimental Psychology of Thought-processes. Macmillan, New York. Vischer, F.T., 1846–1854. Aesthetik, oder Wissenschaft des Schönen. 3 Vols. Reuttlingen, Leipzig. Vischer, R., 1872. Über das optische Formgefühl – ein Beitrag zur Ästhetik. Dissertation. Eberhard Karls Universität, Tübingen. von Herder, J.G., 1774. Auch eine Philosophie der Geschichte zur Bildung der Menschheit. Hartknoch, Riga. Walther, J., Miller, S.E., Sochacka, N.W., 2017. A model of empathy in engineering as a core skill, practice orientation, and professional way of being. Australas. J. Eng. Educ. 106 (1), 123–148. https://doi.org/10.1002/jee.20159. Webster's College Dictionary. Random House, New York, NY. Webster's New World College Dictionary. Houghton Mifflin Harcourt, Boston, MA. Wispé, L., 1986. The distinction between sympathy and empathy: to call forth a concept, a word is needed. J Pers Soc Psych 50 (2), 314–321. Wündrich, M., Schwartz, C., Feige, B., Lemper, D., Nissen, C., Voderholzer, U., 2017. Empathy training in medical students - a randomized controlled trial. Med Teach 39 (10), 1096–1098 PMID: 28749198. https://doi.org/10.1080/0142159X.2017.1355451. Zanetti, L.A., 2011. Cultivating and sustaining empathy as a normative value in public administration. In: King, C.S. (Ed.), Government is Us 2.0. M.E. Sharpe, New York, NY, pp. 76–85.
F. Zölzer, N. Zölzer / Science of the Total Environment 705 (2020) 135922 Zölzer, N., 2014. Beyond Pragmatic Reductionism: Towards Empathy-driven Refugee Camp Design. Master Thesis. University College, London. Zölzer, F., 2016. Are the core values of the radiological protection system shared across cultures? Ann. ICRP 45 (S1), 358–372 PMID: 26984903. https://doi.org/10.1177/ 0146645316630169.
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Zölzer, F., 2017. A common morality approach to environmental health ethics. In: Zölzer, F., Meskens, G. (Eds.), Ethics of Environmental Health. Routledge, Oxford, pp. 51–68. Zölzer, F., Meskens, G. (Eds.), 2017. Ethics of Environmental Health. Routledge, Oxford. Zölzer, F., Meskens, G. (Eds.), 2018. Environmental Health Risks – Ethical Aspects. Routledge, Oxford.
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Science of the Total Environment journal homepage: www.elsevier.com/locate/scitotenv
Empathy as an ethical principle for environmental health Friedo Zölzer a,⁎, Neysan Zölzer b a b
Institute of Radiology, Toxicology and Civil Protection, Faculty of Health and Social Sciences, University of South Bohemia in České Budějovice, Czech Republic Mensch Innovation, Oxford, United Kingdom
H I G H L I G H T S • • • • •
Environmental Health is a matter not only of scientific fact, but also of ethics. Basic principles include respect for autonomy, justice, solidarity, and precaution. Practice requires procedural principles such as accountability and transparency. We suggest to add empathy to the set – “taking the perspective of those affected”. Empathy is gaining importance in many other areas from urban design to health care.
a r t i c l e
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Article history: Received 7 August 2019 Received in revised form 27 November 2019 Accepted 2 December 2019 Available online 05 December 2019 Editor: Lotfi Aleya Keywords: Moral values Ethical principles Applied ethics Environmental health and safety Occupational health Radiation protection
a b s t r a c t Purpose: Environmental health ethics is a relatively young field of study, drawing on experience from medical ethics, public health ethics, and the ethics of radiological protection. Fundamental to all of these in one way or another are the four “principles of biomedical ethics”, originally proposed by Beauchamp and Childress (1979) as a guide for decision making in clinical practice. Suggestions have been made of various other principles which should be added to address the specifics of the individual disciplines under consideration. Here we are exploring empathy as a principle complementing those hitherto applied in environmental health practice. Results and conclusions: Empathy can be defined as the “capability (or disposition) to immerse oneself in and to reflect upon the experiences, perspectives and contexts of others”. It is often understood as a skill that one either has or has not, but research has shown it can be taught and therefore can be required as an attitude of those working in health care, education, design, and even politics. We suggest to consider it a procedural principle on a par with inclusiveness, accountability, and transparency. It should drive the assessment of any environmental situation and the health problems accruing from it. © 2019 Elsevier B.V. All rights reserved.
1. Introduction Ethical questions in environmental health have received increasing attention over the last 15 to 20 years. The journal Environmental Health Perspectives in 2003 featured a “Mini Monograph – Ethics and Environmental Health”, (Parascandola, 2003) which addressed a whole range of issues, primarily research ethics. This was also the focus of Lavery et al. (2003) as well as Merlo et al. (2007). The first comprehensive monograph on “Environmental Health Ethics” was the one by Resnik (2012), which suggests a method of making ethical decisions by weighing alternative values applicable to key questions in the field. Around the same time began a series of “International Symposia on
⁎ Corresponding author at: J. Boreckého 1167/27, 370 11 České Budějovice, Czech Republic. E-mail address: [email protected] (F. Zölzer).
https://doi.org/10.1016/j.scitotenv.2019.135922 0048-9697/© 2019 Elsevier B.V. All rights reserved.
Ethics of Environmental Health” which covered a similarly broad range of issues. Some of the papers presented have been published in Oughton and Hansson (2013), and in Zölzer and Meskens (2017, 2018). During the same period, there has also been some discussion on public health ethics. Much of it has focused on the question whether the “principles of biomedical ethics” proposed by Beauchamp and Childress (1979) as a guide for decision making in the clinical situation, are more generally applicable. Several authors have argued that the approach itself is useful, but additional principles are needed if it is to help address questions of public health. Concrete suggestions have been made, as also referred to below, by Coughlin (2008) and SchröderBäck et al. (2014). All this ties in very well with efforts made more recently in the area of radiological protection. Realising that it had long-since based its recommendations on ethical values, but had mostly refrained from addressing them explicitly, the International Commission on Radiological Protection initiated a number of workshops around the world to discuss
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relevant questions, and in 2013 established a Task Group to draft recommendations on the topic. The final version was approved by the Commission in 2017 and published in 2018 under the title of “Ethical Foundations of the System of Radiological Protection” (ICRP, 2018). The “core values” identified therein are very similar, though not identical with the “principles of biomedical ethics”, and again reflect the specifics of the field which were felt to be insufficiently covered by the Beauchamp and Childress set. The ICRP recommendations, of course, cover much more than questions arising in the medical context, but rather extend to environmental and occupational issues. As concerns environmental health, it seems best to us to explicitly proceed from the well-known “principles of biomedical ethics”, but then take account of other principles, or values, which have been proposed in neighbouring fields and see if they apply to environmental health ethics as well. This is the approach taken by Zölzer (2017). In addition to the four basic principles of “respect for autonomy, nonmaleficence, beneficence, and justice”, four “correlated” principles were identified as relevant: “human dignity, precaution, solidarity, and sustainability”, and for the practical application of all these, four “procedural” principles were suggested: “inclusiveness, accountability, empathy, and transparency”. Of these, three are taken into account in most pertinent discussions, sometimes under different names, but empathy is not usually included, and may need some more argument to be understood and to qualify as a principle for ethical decision making in environmental health.
2. The concept of empathy The term “empathy” is not much older than a century. It was first used in 1909 by the British-American psychologist Edward Bradford Titchener (1867–1927) (Titchener, 1909) when he referred to a concept developed by the German philosopher Theodor Lipps (1851–1914). The original German was “Einfühlung”, meaning “in-feeling” or “feelinginto”, and Lipps was the first to propagate it as a fundamental concept of perception psychology (Lipps, 1900, 1903, 1907). The coining of the term in the context of aesthetics, i.e. as an aspect of the perception of art, is often attributed to the German art historian and philosopher Robert Vischer (1847–1933). Vischer did use the word (in noun form) in his doctoral dissertation 1872 (Vischer, 1872), but his father, the philosopher Friedrich Theodor Vischer (1807–1887) had already applied “einfühlen” in verb form (Vischer, 1846–1854). The verb is actually found in much earlier writings, such as those of the Enlightenment philosopher Johann Gottfried Herder (1744–1803) who used it in 1774 (von Herder, 1774) to describe how an understanding can be gained of foreign cultures and past epochs. The first use of the noun “Einfühlung” can be traced back to the German philosopher Rudolf Hermann Lotze (1817–1881) who in 1858 applied it to the aesthetic process in a similar way as Robert Vischer a few years later (Lotze, 1858). Apparently, Vischer was not aware of this work before he developed his concept. “Empathy” has been variously defined as “the projection of one's own personality into the personality of another in order to understand the person better” (Webster's New World College Dictionary, 2014); “allowing one to see another person's context, needs and aspirations” (de Vignemont and Singer, 2006); “the identification with or vicarious experiencing of the feelings, thoughts, etc., of another” (Webster's College Dictionary, 2010); “the ability to understand and share the feelings of another” (Oxford Dictionary, 2016); or “the capacity to understand what another person is experiencing from within the other person's frame of reference, i.e., the capacity to place oneself in another's shoes” (Bellet and Maloney, 1991). All these definitions appear to relate primarily to the relationship between two individuals. However, empathy can also be understood to encompass the relationship between an individual and a larger group, a community, or a population, and may thus be defined more broadly as “the capability (or
disposition) to immerse oneself in and to reflect upon the experiences, perspectives and contexts of others” (Zölzer, 2014). Some authors distinguish different kinds of empathy, in particular emotional and cognitive empathy. Emotional empathy again may take different forms, or occur with different intensities: emotional contagion, which consists in actually taking over the feelings of another; personal distress, in which one is afflicted by another's plight, but does not necessarily feel exactly the same anxiety, sorrow and pain; and empathic concern, which involves feeling for another and can be equated to sympathy, or compassion (see our brief discussion below). Cognitive empathy, by contrast, does not imply that one's emotions are affected, but that one is aware of, or successfully guessing, someone else's thoughts and feelings. A mental process facilitating this kind of empathy is perspective taking, i.e. imagining oneself in the situation of the other, with the realisation that the other person's thought and feelings may well be different from one's own (Hodges and Myers, 2007). Somewhat more broadly, one might say that empathy engenders an opportunity to immerse oneself in the experience of the other, while remaining distant enough to reflect upon it (Zölzer, 2014). The terms empathy, sympathy and compassion are often used interchangeably, and of course are not defined by everyone in exactly the same way. Kouprie and Visser (2009) suggest the following distinction: “When you feel sympathy for someone your concern is for the other person's well-being; you feel like you are the other. When you have empathy with someone your concern is to understand the other person; you feel as if you are the other.” They refer to Wispé (1986), who summarised his understanding like this: “Sympathy is a way of ‘relating’. Empathy is a way of ‘knowing’”. Here, the focus is obviously on cognitive empathy. If a broader understanding of empathy is preferred, including both cognitive and emotional aspects, one might see sympathy and compassion as synonyms of empathetic concern, a form of emotional empathy (as mentioned above). Actually, Latin “compassion” is a loan-translation of Greek “sympatheia”, both meaning “fellow-suffering”. Some dictionaries claim that while sympathy describes feeling for somebody else, compassion includes the desire to help (e.g. Merriam-Webster's Dictionary of Synonyms 1984). 3. Empathy – a character trait or an ethical principle? Given the common definitions of empathy, many of which start with “the ability to”, or “the capacity to”, one might think that we are talking about a character trait, or a personal quality – something that one either possesses, or not. But to call it an ethical principle seems to suggest that empathy can be demanded of anyone, it can be consciously applied, and it can be taught. It is still conceivable, of course, that some people may find it easier than others to be empathetic, but then - some may find it easier than others to act according to transparency, accountability, inclusiveness, or any of the more fundamental principles mentioned above. That empathy can be learned is evident from quite a number of studies. Empathy training has been developed and tested for medical doctors (Wündrich et al., 2017), nurses (Bas-Sarmiento et al., 2017), social workers (Dupper, 2017), and teachers (Bouton, 2016). Here we mention only a few recent examples. Positive experience has actually accumulated over the past 40 years. A meta-analysis of 18 randomised controlled trials including participants from different professions came to the conclusion that empathy training is indeed effective, although further research is recommended to understand the influence of certain factors such as different types of trainees, training conditions, and types of assessment (Teding van Berkhout and Malouff, 2016). If it is possible to train empathy, it can be included in the catalogue of ethical principles which at least certain people would be expected to follow, such as the ones mentioned above (medical doctors, nurses, social workers, and teachers). Accordingly, empathy has been called a “moral concept” (Schapiro, 2011); a “normative value” (Zanetti, 2011); a “guiding principle” (Ferrara, 2018); or an “ethical imperative” (Adams, 2018).
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Other authors disagree, and prefer to speak of a “skill” (FernándezOlano et al., 2008; Cunico et al., 2012; Walther et al., 2017), but even that has a connotation of desirability or goodness. In her “Handbook of Philosophy of Empathy”, nevertheless, Maiboom (2017) points out that such a positive appraisal is by no means universal. Quite often, empathy has been seen as biased, focusing on the good for an individual, and neglecting the common good. Yet again that is not necessarily so, and Maiboom states that a number of her co-authors “are pretty stout defenders of the importance of empathy to morality, and so empathy may be making a comeback.” Our portrayal of empathy as a “procedural principle” seems to be in tune with its somewhat ambivalent character evident from this short discussion. Procedural principles are those that facilitate the implementation of more fundamental principles in practice. They can therefore on the one hand be seen as behavioural standards, on the other hand they call for the acquisition of certain skills without which their practical application would be impossible. Neither skills nor behavioural standards can be applied in isolation. Beauchamp and Childress emphasize that in a particular situation several principles may have to be considered and may all have validity prima facie – at first sight. In such a case, balancing is needed: sometimes one principle taking precedence, sometimes another. The principles may also have to be specified differently for each context in which they are going to be applied. All this was originally suggested for the set of four principles proposed by Beauchamp and Childress, which were supposed to help decision making in a clinical context, but it is certainly applicable as well for a model in which further principles, “correlated” and “procedural” ones, are taken into consideration. In the case of empathy, it seems most natural to see it as the procedural principle closely akin to the fundamental principle of beneficence, and the correlated principle of solidarity. Beneficence usually focuses on the individual, but solidarity reminds the decision maker of the need to factor in the good of a larger group, or indeed the whole of society. Empathy, we might say, provides the means and process to achieve and exercise beneficence and solidarity. There are, of course, kinships with other principles as well, such as with non-maleficence, or with human dignity. For a somewhat more detailed discussion of these relationships, we have to refer the reader to earlier publications (Zölzer, 2016; Zölzer, 2017; Malone et al., 2018). 4. An operational approach to empathy Further to our discussion on empathy as a “procedural principle”, we would like to offer here a short exploration of how the principle comes to life in practice. Empathy is actually applied across various disciplines and sectors. In design practices, such as architecture, product design, urban planning, service design, and digital design, it is now consciously used to produce work that correlates more closely to the needs of the user or consumer. Applying empathy in this context means “leaving the design office and becoming immersed in the lives, environments, attitudes, experiences and dreams of the future users” (Battarbee et al., 2002). This helps practitioners to “communicate effectively [and] make accurate decisions” (King, 2011). It must be emphasised, however, that this practice is not primarily aimed at higher effectiveness or productivity. The designer should have the good of the user or consumer in mind for its own sake. To the extent that his or her interest in the counterpart is genuine, higher effectivity and productivity can be expected as a secondary outcome. While ‘design’ is popularly understood to be concerned with the form or style of physical and digital objects, designers see themselves primarily involved in problem-solving. Over the last decade, in particular, terms such as ‘empathy-driven design’, ‘participatory design’, and ‘human-centred design’ have emerged to define an iterative process by which a practitioner (a ‘designer’ of whichever design discipline) can understand the user, challenge assumptions, redefine problems, and iteratively test solutions. Empathy is operationalised throughout
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the process by various methods that enable the practitioner to see, feel, and do what the ‘user’ sees, feels, or does. These methods may include classical research methods such as observation, focus groups, or interviews, but may also embrace more creative and interactive methods with users, enabling them to become ‘co-designers’. These practices can allow practitioners of any discipline in any field to actively develop the capability of empathy (Kouprie and Visser, 2009). One example is the Singapore government's long-term relationship with design firm IDEO, a proponent of empathy-focused design practice. In a project for the Ministry of Health, a multifunctional team of civil servants and design practitioners created tools to help patients better understand and predict healthcare costs, including government subsidies. The work was undertaken in close collaboration with doctors who had significant experience in speaking with patients, and with patients themselves (IDEO, 2015). Design teams working to improve accessibility in public spaces systematically employ empathy as a tool. For example, to understand limitations in public spaces for the elderly, design practitioners (such as architects or urban designers) may be too young to have deep knowledge of the elderly's experience and use a blend of methods, including observation, interviews, and walk-throughs, to enrich their understanding. To design workspaces or digital experiences for those blind or severely visually impaired, designers may choose to wear blindfolds for limited exercises to educate themselves on others' experiences (Fulton Suri et al., 2003). Such tools tap into the notion of the ‘empathic horizon’, developed by McDonagh-Philp and Denton (1999). It defines the limits of an individual's empathy at any given moment as his or her unique experiences and characteristics, such as history, background, gender, culture, and education. Practitioners, then, must recognise their own unique empathic horizon and endeavour to gain experience beyond that horizon to design more appropriate results. In quite a different context, that of jurisdiction, empathy has been described as essential for decision making in court. Deigh (2011) argues that “to interpret a law soundly, one must be sensitive to the perspective of the different people whose interests the law affects or is liable to affect if applied to their situation. Sound interpretation of the law, in other words, requires empathy.” This is so, he says, because the purpose of the law is to serve the interests of justice. From his discussion of a particular case decided by the U.S. Supreme Court, it becomes obvious that a formal application of precedent cases can lead to unfair decisions, and that “one cannot see this unfairness without taking the plaintiff's perspective.” Empathy has also begun to appear in political discourse. The former Czech president, Vaclav Havel, opened a NATO conference in 2002 with these words: “I believe that the first requisite, above all else, is a quest for better knowledge of each other, better mutual understanding and a greater capacity for empathy with one another's positions and one another's dilemmas” (Havel, 2002). In 2006, the former US president Barack Obama in a speech delivered at the University of Massachusetts at Boston said, “Empathy is a quality of character that can change the world - one that makes you understand that your obligations to others extend beyond people who look like you and act like you and live in your neighbourhood” (Obama, 2006). More recently, the re-elected president of Ireland, Michael D. Higgins, included the following in his acceptance speech: “We are in a time of transformation and there is a momentum for empathy, compassion, inclusion and solidarity which must be recognised and celebrated” (Irish Times, 2018). And Jacinda Ardern, New Zealand's prime minister, stated in a widely broadcast interview: “It takes courage and strength to be empathetic. And I'm very proudly an empathetic, compassionatelydriven politician” (BBC, 2018). These are indications of how empathy is perceived in the wider community. If politicians are beginning to advocate for it, one might argue, it is high time for health professionals to do so too. They should be leading rather than following in this respect.
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5. Conclusion and recommendation Clearly, then, empathy is called for in a broad spectrum of situations, ranging from the conversation of a doctor with his or her patient to the assessment and management of public health problems, and way beyond. As concerns decision-making in environmental health specifically, our idea of the place of empathy and the other procedural values mentioned above – transparency, accountability, and inclusiveness – is as follows: - The assessment of an environmental situation and the health problems accruing from it, must be driven mainly by empathy. - For the communication about what has been ascertained, transparency is most crucial. - In the consultation process about what should be done, inclusiveness (making sure that all stakeholders are involved) takes precedence. - When decisions are taken and their effectiveness is evaluated, accountability is key.
In other words, we suggest that people's concerns, their needs and wishes need to be taken seriously from the very beginning of any decision-making process, even if they are considered unfounded or exaggerated. Everybody involved should make an effort to “immerse oneself in and to reflect upon the experiences, perspectives and contexts of others.” Without empathy, our practice of beneficence and solidarity would be oddly limited. Declaration of competing interest The authors declare they have no actual or potential competing financial interests. Acknowledgement The authors thank Jacques Lochard, Jim Malone and Maryam ZölzerYazdani for critically reading an earlier draft of this paper and for making valuable suggestions. References Adams, S.B., 2018. Empathy as an ethical imperative. Creat Nurs 24 (3), 166–172 PMID: 30567759. https://doi.org/10.1891/1946-6560.24.3.166. Bas-Sarmiento, P., Fernández-Gutiérrez, M., Baena-Baños, M., Romero-Sánchez, J.M., 2017. Efficacy of empathy training in nursing students: a quasi-experimental study. Nurse Educ. Today 59 (12), 59–65 PMID: 28945994. https://doi.org/10.1016/j. nedt.2017.08.012. Battarbee, K., Baerten, N., Hinfelaar, M., 2002. Pools and satellites: intimacy in the city. Proceedings of the Conference on Designing Interactive Systems DIS'00. ACM Press, New York, NY, pp. 237–245. https://doi.org/10.1145/778712.778746. BBC, 2018. Jacinda Ardern: ‘It takes strength to be an empathetic leader’. https://www. bbc.co.uk/news/av/world-asia-46207254/jacinda-ardern-it-takes-strength-to-be-anempathetic-leader, Accessed date: 31 May 2019. Beauchamp, T.L., Childress, J.F., 1979. Principles of Biomedical Ethics. University Press, Oxford. Bellet, P.S., Maloney, M.J., 1991. The importance of empathy as an interviewing skill in medicine. JAMA 266 (13), 1831–1832 (PMID: 1909761). Bouton, B., 2016. Empathy research and teacher preparation: benefits and obstacles. SRATE Journal 25 (2), 16–25 (ERIC Number: EJ1113829). Coughlin, S.S., 2008. How many principles for public health ethics. Open Public Health J 1, 8–16 (PMID: 20072707). Cunico, L., Sartori, R., Marognolli, O., Meneghini, A.M., 2012. Developing empathy in nursing students: a cohort longitudinal study. J. Clin. Nurs. 21 (13–14), 2016–2025 PMID: 22672461. https://doi.org/10.1111/j.1365-2702.2012.04105.x. de Vignemont, F., Singer, T., 2006. The empathic brain: how, when, and why? Trends Cogn. Sci. 10 (10), 435–441 (16949331). Deigh, J., 2011. Empathy, justice, and jurisprudence. South. J. Philos. 49 (Suppl), 73–90. https://doi.org/10.1111/j.2041-6962.2011.00058.x. Dupper, D., 2017. Strengthening empathy training programs for undergraduate social work students. J Baccal Social Work 22, 31–41. https://doi.org/10.18084/10847219.22.1.31.
Fernández-Olano, C., Montoya-Fernández, J., Salinas-Sánchez, A.S., 2008. Impact of clinical interview training on the empathy level of medical students and medical residents. Med Teacher 30 (3), 322–324. https://doi.org/10.1080/01421590701802299. Ferrara, N., 2018. Pursuit of Impact: Trauma- and Resilience-informed Policy Development (Lanham, MD: Lexington). Fulton Suri, J., Battarbee, K., Koskinen, I., 2003. Designing in the Dark — Empathic Exercises to Inspire Design for our Non-visual Senses. http://www2.uiah.fi/~ikoskine/ idmi05/designinginthedark.pdf (accessed 31 May 2019). Havel, V., 2002. The Transformation of NATO. Opening Speech at the Prague Summit. https://www.nato.int/docu/speech/2002/s021120c.htm (accessed 31 May 2019). Hodges, S.D., Myers, M.W., 2007. Empathy. In: Baumeister, R.F., Vohs, K.D. (Eds.), Encyclopedia of Social Psychology. SAGE Publications, Thousand Oaks, CA, pp. 296–298. ICRP (International Commission on Radiological Protection), 2018. Ethical Foundations of the System of Radiological Protection. ICRP Publication, p. 138 (Ann ICRP 47). IDEO, 2015. Singapore's road to a human-centered government. https://www.ideo.com/ case-study/singapores-road-to-a-human-centered-government, Accessed date: 31 May 2019. Irish Times, 2018. ‘Words matter. Words can hurt’ - Michael D Higgins's acceptance speech in full. https://www.irishtimes.com/news/politics/words-matter-words-canhurt-michael-d-higgins-s-acceptance-speech-in-full-1.3678585, Accessed date: 31 May 2019. King, S.H., 2011. The structure of empathy in social work practice. J Hum Beh Soc Envir 21 (6), 679–695. https://doi.org/10.1080/10911359.2011.583516. Kouprie, M., Visser, F., 2009. A framework for empathy in design: stepping into and out of the user's life. J Engin Des 20 (5), 437–448. Lavery, J.V., Upshur, R.E., Sharp, R.R., Hofman, K.J., 2003. Ethical issues in international environmental health research. Int. J. Hyg. Environ. Health 206 (4–5), 453–463 (12971701). Lipps, T., 1900. Aesthetische Einfühlung. Zeitsch Psych Phys Sinnesorg 22, 415–450. Lipps, T., 1903. Einfühlung, innere Nachahmung, und Organempfindungen. Arch ges Psych 1, 185–204. Lipps, T., 1907. Das Wissen von fremden Ichen. In: Lipps, T. (Ed.), Psychologische Untersuchungen. vol. I. Wilhelm Engelmann, Leipzig, pp. 694–722. Lotze, H., 1858. Mikrokosmus: Ideen zur Naturgeschichte und Geschichte der Menschheit. Versuch einer Anthropologie. Zweiter Band. Leipzig: Hirzel. Maiboom, H. (Ed.), 2017. The Routledge Handbook of Philosophy of Empathy. Routledge, Oxford. Malone, J., Zölzer, F., Meskens, G., Skourou, C., 2018. Ethics for Radiation Protection in Medicine. CRC Press, Boca Raton. McDonagh-Philp, D., Denton, H., 1999. Using focus groups to support the designer in the evaluation of existing products: a case study. Des. J. 2 (2), 20–31. https://doi.org/ 10.2752/146069299790303570. Merriam-Webster’'s Dictionary of Synonyms, 1984. Merriam-Webster, Springfield, MA. Merlo, D.F., Knudsen, L.E., Matusiewicz, K., Niebrój, L., Vähäkangas, K.H., 2007. Ethics in studies on children and environmental health. J. Med. Ethics 33 (7), 408–413 (17601869). Obama, B., 2006. University of Massachusetts at Boston commencement speech. http:// obamaspeeches.com/074-University-of-Massachusetts-at-Boston-CommencementAddress-Obama-Speech.htm. Oughton, D., Hansson, S.O. (Eds.), 2013. Social and Ethical Aspects of Radiation Risk Management. Elsevier Science, Isle of Seil, Argyll. Oxford Dictionary. University Press, Oxford. Parascandola, M., 2003. Ethics in environmental health: a mini-monograph. Environ Health Persp 111 (14), A774–A775. Resnik, D.B., 2012. Environmental Health Ethics. Cambridge University Press, New York, NY. Schapiro, T., 2011. Empathy as a moral concept: comments on John Deigh's “empathy, justice and jurisprudence”. South J Phil 49 (S1), 91–98. Schröder-Bäck, P., Duncan, P., Sherlaw, W., Brall, C., Czabanowska, K., 2014. Teaching seven principles for public health ethics: towards a curriculum for a short course on ethics in public health programmes. BMC Medical Ethics 15, 73–82 2014. PMID: 25288039. https://doi.org/10.1186/1472-6939-15-73. Teding van Berkhout, E., Malouff, J.M., 2016. The efficacy of empathy training: a metaanalysis of randomized controlled trials. J. Couns. Psychol. 63 (1), 32–41 PMID: 26191979. https://doi.org/10.1037/cou0000093. Titchener, E.B., 1909. Lectures on the Experimental Psychology of Thought-processes. Macmillan, New York. Vischer, F.T., 1846–1854. Aesthetik, oder Wissenschaft des Schönen. 3 Vols. Reuttlingen, Leipzig. Vischer, R., 1872. Über das optische Formgefühl – ein Beitrag zur Ästhetik. Dissertation. Eberhard Karls Universität, Tübingen. von Herder, J.G., 1774. Auch eine Philosophie der Geschichte zur Bildung der Menschheit. Hartknoch, Riga. Walther, J., Miller, S.E., Sochacka, N.W., 2017. A model of empathy in engineering as a core skill, practice orientation, and professional way of being. Australas. J. Eng. Educ. 106 (1), 123–148. https://doi.org/10.1002/jee.20159. Webster's College Dictionary. Random House, New York, NY. Webster's New World College Dictionary. Houghton Mifflin Harcourt, Boston, MA. Wispé, L., 1986. The distinction between sympathy and empathy: to call forth a concept, a word is needed. J Pers Soc Psych 50 (2), 314–321. Wündrich, M., Schwartz, C., Feige, B., Lemper, D., Nissen, C., Voderholzer, U., 2017. Empathy training in medical students - a randomized controlled trial. Med Teach 39 (10), 1096–1098 PMID: 28749198. https://doi.org/10.1080/0142159X.2017.1355451. Zanetti, L.A., 2011. Cultivating and sustaining empathy as a normative value in public administration. In: King, C.S. (Ed.), Government is Us 2.0. M.E. Sharpe, New York, NY, pp. 76–85.
F. Zölzer, N. Zölzer / Science of the Total Environment 705 (2020) 135922 Zölzer, N., 2014. Beyond Pragmatic Reductionism: Towards Empathy-driven Refugee Camp Design. Master Thesis. University College, London. Zölzer, F., 2016. Are the core values of the radiological protection system shared across cultures? Ann. ICRP 45 (S1), 358–372 PMID: 26984903. https://doi.org/10.1177/ 0146645316630169.
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Zölzer, F., 2017. A common morality approach to environmental health ethics. In: Zölzer, F., Meskens, G. (Eds.), Ethics of Environmental Health. Routledge, Oxford, pp. 51–68. Zölzer, F., Meskens, G. (Eds.), 2017. Ethics of Environmental Health. Routledge, Oxford. Zölzer, F., Meskens, G. (Eds.), 2018. Environmental Health Risks – Ethical Aspects. Routledge, Oxford.