Son I’ve made a life out of readin’ people’s faces
And knowin’ what their cards were by the way they held their eyes

The Gambler, words and music by Don Schlitz and sung (most famously) by Kenny Rogers on The Muppet Show

THESE words well describe the art of communication in medical practice. Indeed, I think of The Gambler as the theme song for palliative care practice and for many years I have had a framed copy of the Kenny Rogers album cover on the wall of my office.

Botulinum toxin: the paralysis of empathy - Featured Image


Our ability to read people’s faces is at the core of our work. However, while we may think we are pretty smart, neither doctors nor any other humans have a monopoly on the ability to understand emotions by reading the subtleties of facial expression and body language.

Its origins are found in both the anatomy and the behaviour of our animal relatives, near and distant. I suggest you read de Waal’s Mama’s last hug: animal emotions and what they teach us about ourselves. This fascinating book explores the sophistication and importance of non-verbal communication in primates, particularly chimpanzees.

Research by de Waal and many others has revealed how the involuntary physical expression of emotions and the capacity of observers to read those messages as reflecting underlying feelings, and the ability to read them, are central to the day-to-day lives of many species. These similarities reinforce our understanding of the evolutionary origins of our common inherited and instinctive patterns of behaviour.

Mechanisms for the communication of emotions and empathy are integrated into the evolved structure and function of social animals. They are a measure of the underrated importance of non-verbal communication for the normal functioning of groups of social organisms such as ourselves. The perpetuation of the genes that generate this behaviour is driven by the survival benefits of cooperation for small groups in countless of our genetic predecessors, starting a very long way back in our evolutionary past.

However, it should also be said that this power is somewhat, but not fully, matched by our ability to mislead by the manipulation of our posture and expression (think of the lyrics “lied straight-faced while I cried”). Apart from the notable exception of con artists, or actors who are playing a role, most of us give ourselves away eventually by our failure to maintain all components of a facial expression and the posture of honesty.

The success and stability of a community could be diminished if most or all individuals were too good at barefaced deceit or if truth had no survival value. As doctors, we must accept at face value what our patients tell us in the first instance, even while remaining alert for incongruities.

Perhaps our uncontrollable tendency to blush (a complex behaviour discussed in detail by Charles Darwin in his final major work, The expression of emotions in man and animals) exists in part because it delivers a survival advantage. However, a discussion of how genetic evolution to take advantage of the upside of blushing could be driven at the level of community failure or success is a conversation for another day.

Many of you will have observed the ability of some clinicians to sit with their patients and to engage with them through channels that seem invisible, effortlessly asking questions that go to the centre of their concerns. They facilitate their patients’ becoming conscious of that which they had been unaware of feeling, and then explore the consequences of that discovery while addressing the distress the patient may experience from their newfound insights.

While these skills may at times seem magical, given what we now know about our origins, they are simply a part of what we are and without them we would not be here. Our rigorously selected genes build us as collaborating social organisms.

I would now like to introduce a new thread to this conversation. Perhaps, like me and a number of my colleagues, you have observed on the faces of television celebrities, and some of our acquaintances, the phenomenon of foreheads that have become frozen in time. The eyebrows never arch in astonishment, brows do not wrinkle with concern, and these people seem aloof and detached, if not perhaps sometimes even disdainful of the conversations in which they are engaged. We then speculate that this smooth, bland skin is the consequence of the injection of botulinum toxin with cosmetic intent (all references in this article are to the cosmetic use of botulinum toxin).

I had not given much thought to the consequences of this recent phenomenon until it was raised by de Waal in Mama’s last hug. He described work from the 1990s by Dimberg and colleagues who found that when we see an expression on a human face we unconsciously mimic what we see. Even though we may not be aware of our motor responses, our mimicry feeds back into our emotional state and helps to generate our sense of empathy and all the benefits that this brings to our participation in the community.

In The expression of emotions in man and animals, Darwin too wrote of his belief that the facial expressions we adopt could feed back into our emotions.

“The free expression by outward signs of an emotion intensifies it. On the other hand, the repression, as far as this is possible, of all outward signs softens our emotions … Even the simulation of an emotion tends to arouse it in our mind.”

William James, the American psychologist and philosopher of the 19th century also explored this theme with his suggestion that the physical changes (such as facial expression and physiological responses) associated with the emotions must be manifest for the emotions to be experienced – that the emotions were synonymous with the physical changes and without them there was no emotion.

The cosmetic use of botulinum toxin and the invention of functional magnetic resonance imaging (fMRI) have made it possible to undertake experiments to clarify the relationship between facial expression (the activation of the muscles of facial expression has both motor and sensory components) and the experience of emotion.

fMRI studies by Hennenlotter and colleagues:

“demonstrate that facial feedback modulates neural activity within central circuitries of emotion during intentional imitation of facial expressions. Given that people tend to mimic the emotional expressions of others, this could provide a potential physiological basis for the social transfer of emotion”

Subsequently, Havas and colleagues found that injection of botulinum toxin into the forehead slowed reading speed and inhibited the emotional responses of subjects to emotional passages of text. This is thought to be because engaging with the emotional component of text requires activation of the mechanisms (muscles of facial expression) for experiencing the emotions, supporting the views of Charles Darwin and William James in the 19th century.

Further research by Neal and Chartrand has confirmed that botulinum toxin blocks the perception of, and empathy for, the emotions expressed in the facial expressions of others.

Needless to say, nothing about animal behaviour is uniform. Jospe et al found that the interindividual variability of natural human emotional intelligence has an impact on how well individuals are able to interpret facial expressions.

Most of us who look at the face of another human who is distressed have an empathetic response, in part because our imitation of their expression feeds back into our brain to generate a state of empathy. At the same time, our experience of the emotions of others activates the muscles that generate expressions that can be understood by them as the supportive response of empathy. These evolved responses are hardwired.

I suspect that the most astute medical communicators are those who are able to tune in to their unconscious empathic responses, bringing them closer to the surface. This allows them to use their understanding to good effect to help patients to a greater appreciation of their own state, and to make more informed choices. For gamblers, reading opponents can lead to a better understanding of the odds.

It seems to me vital and in both our own interests and those of our patients, that as doctors, we continue to be able to “[make] a life out of readin’ people’s faces”. However, the growing use of botulinum toxin to block the muscles of facial expression with the goal of suppressing frown lines and/or disguising our age suggests a number of unintended consequences for individuals and their medical practitioners.

First, people who receive cosmetic botulinum toxin in the hope of being more attractive to potential partners may find it backfires if it comes at the price of being less able to experience the empathy that is necessary for the maintenance of long-term relationships.

The interpersonal communication of emotions that is vital to the success of families and other small groups could be impaired by a diminished capacity to experience and communicate normal emotional responses of day-to-day life. Hampering of a patient’s ability to express their emotional state to health workers, and to perceive the empathetic responses they induce, may diminish the quality of the care that they receive.

Doctors (and other health workers) who receive botulinum toxin may be less able to experience or generate empathic responses to their patients (who have not had botulinum toxin injections), less able to understand the emotions of their patient, and become incapable of communicating their empathic responses.

Such consequences could challenge our ability to deliver the whole-person care that is at the core of an effective health care system. Consideration might be given to including those consequences as part of informed consent for the cosmetic use of botulinum toxin.

As individuals and as members of small communities, we function most effectively with a finely tuned balance between the benefits to the community of truthfulness and our individual need to be able to hide our thoughts and motives in our own interests. Low-level deception and lying are probably necessary for a small community to function effectively, but only if they are not so successful that they threaten the success of the community as a whole. Here in the 21st century, and after a mere few hundred years of large communities, we are experiencing how the exercise of deceit in the pursuit of short-term self-interest (usually power and money) has become almost the norm for many powerful individuals and organisations. This poses interesting challenges for us as individuals who evolved as members of small groups dependent on one another for reciprocal benefits.

I imagine that Charles Darwin and William James would have understood that the expression of emotions including empathy, along with the ability to receive and integrate such communication, (and a modicum of deception to support our need to pursue our individual interests) is at the core of the success of humanity. Indeed, even the word humanity invokes an emotional sense of empathy. The superficial short-term deceptions of cosmetic botulinum toxin come at the potential cost of much deeper and disruptive consequences for the success of interpersonal relationships, just as lying and cheating can destabilise communities when exercised on an industrial scale.

Encouraged by some purveyors of botulinum toxin, over a mere couple of decades, our community has come to accept as normal the neuromuscular blockade of deeply embedded and hardwired facial expressions, the product of many, many tens of millions of years of evolutionary trial-and-error testing for survival advantage.

What could possibly go wrong?

Dr Will Cairns OAM is on the verge of retirement from his medical career, first as a GP, and subsequently as a specialist in palliative medicine.


The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.

2 thoughts on “Botulinum toxin: the paralysis of empathy

  1. Ian Hargreaves says:

    I nearly caused a lawsuit against our cosmetic colleague by asking the patient preoperatively about her general medical history, and was about to ask “when did you have your stroke?” when I realised that her facial expression was due to Botox, not CVA. A misleading cue indeed!

  2. Sian Pritchard says:

    Great article. Thought provoking and has covered much of my angst with the use of this product in altering our ability to not only express emotion but to be able to feel emotion.

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