Abstract
Artificial intelligence (AI) is increasingly embedded in clinical medicine. In palliative care (PC), its presence is evident in autogenerated documentation, predictive algorithms that identify patients for earlier consultation, communication tools capable of producing empathic-sounding language, and emerging applications that attempt to anticipate patient preferences to support surrogate decision-making.1–4 Even in this edition of the Journal of Palliative Medicine, many of the articles comment on AI and its potential in PC practice. These developments promise efficiency, scalability, and more consistent access to supportive care. Yet as these systems become more integrated into clinical workflows, they raise deeper questions that are not merely technical but moral and relational: What is preserved, and what may be altered, as elements of care become increasingly optimized?
The concept of the “uncanny valley,” originally described in robotics, refers to the discomfort that arises when something appears nearly human but falls short in subtle ways, producing unease rather than connection or trust. 5 Many people recognize this sensation when interacting with a customer service chatbot. The language may be polished and polite, yet the system fails to grasp the underlying concern. Frustration arises from a mismatch between the appearance of understanding and the true presence of it. The exchange feels hollow, as though responsiveness is being simulated rather than experienced, leaving the person feeling unrecognized.
Similarly, the “uncanny valley” experience can occur in clinical communication as well. A clinician might say, “I can only imagine how difficult this must feel, and we are here with you through this,” drawing on language consistent with established communication frameworks. The statement reflects best practices and appears empathic. Yet a patient or family member may still experience the interaction as distant when the words are delivered without pause or responsiveness to what has been shared. Communication can be structurally correct but feel emotionally thin.
PC offers an important context for examining this phenomenon. Conversations in PC involve uncertainty, suffering, mortality, and questions of meaning, identity, and value. As in most parts of medicine but often intensified in PC, communication does more than just convey clinical information; it is part of the care itself. Patients and families often rely on clinicians for both medical expertise and accompaniment during moments of vulnerability. Small shifts in tone, pacing, and responsiveness can shape how communication is experienced. Because relational aspects of care are so central in PC, moments of discordance between language and presence may be especially perceptible.
Further, experiences of uncanniness in medicine are not limited to technologically mediated encounters. Novice clinicians learning communication frameworks may produce interactions that feel awkward or detached as they integrate new skills under cognitive strain. Experienced clinicians practicing within time-pressured environments may rely more heavily on structured language to manage competing demands. In such contexts, structure can function as a stabilizing tool but runs the risk of decontextualized application.
That said, communication frameworks appropriately remain an essential part of PC training and practice. Structured approaches help clinicians enter difficult conversations, provide language for emotionally charged encounters, and support development of core skills. These frameworks work best as flexible guides. Structure can provide scaffolding for relational work, but the quality of communication depends on how that structure is enacted in context. When frameworks are used with sensitivity to the person and situation, they can deepen connection. When enacted mechanically, they can produce language that appears empathic without fully functioning as such.
Attunement helps explain this distinction. Attunement refers to the clinician’s ability to perceive and respond to the emotional, interpersonal, and contextual features of an encounter as they unfold. It involves timing, interpretation, restraint, and sensitivity to verbal and nonverbal cues. 6 Attunement is often subtle, perhaps recognized by a patient’s willingness to continue speaking, a family member’s posture softening, or a clinician’s sense that the emotional tone of the room has shifted. Attunement may also involve tolerating small moments of uncertainty, hesitation, or imperfect phrasing, which can signal genuine engagement and allow space for authentic human connection to develop. These elements rarely appear in documentation or performance metrics, yet they are widely recognized as central to skillful PC communication. 7 Attunement requires attention and flexibility, both of which may be challenged within systems shaped by time pressure, administrative burden, and increasing standardization.
AI technologies intensify this tension because they are a process designed to generate language that appears fluent, coherent, and emotionally calibrated. Fluency can give communication the appearance of empathy without necessarily functioning as accompaniment or attunement. When communication becomes optimized primarily for efficiency, the balance between structure and responsiveness becomes more difficult to sustain.
The clinical encounter demonstrates the importance of relational engagement, as it involves more than a simple exchange of information. In the clinical setting, communication is a form of solidarity. The clinician is present as a person who recognizes suffering and is entrusted to respond to it. Presence and responsibility together give clinical care much of its meaning. These dimensions cannot be fully reproduced through information sharing alone. Patients seek more than just accurate explanations; they seek acknowledgment of the significance of what they are experiencing. Expertise combined with presence and responsibility gives the clinical encounter its unique weight and meaning—something that AI alone cannot provide.
In clinical practice, the uncanny valley may signal relational misalignment rather than a consequence of technological advancement. Moments that feel slightly “off” may indicate that communication has become overly procedural or insufficiently responsive to the interpersonal context in which it occurs. A patient’s hesitation, a sense of disconnection in the room, or a clinician’s own discomfort may reflect diminished attunement. Such moments create opportunities for recalibration. The experience of uncanniness does not identify a single cause, but it can highlight areas where relational aspects of care require renewed attention.
Recognizing the uncanny valley as a signal rather than as a threat allows for a more balanced view of AI. AI may reduce clerical burden, improve access to PC expertise, and create conditions that allow clinicians to devote more attention to complex relational work; these are desirable outcomes. Technology may support attunement when it expands the cognitive and temporal space available for presence. For these reasons, the discussion is not about whether AI should be incorporated into PC practice. Rather, the better question is how its use shapes the clinical encounter and what ends it ultimately serves. Efficiency can support patient-centered care when it functions as a means rather than an endpoint.
As AI continues to evolve, its role in PCs will likely expand. Maintaining the integrity of the clinical encounter will require intention about how these tools are integrated and which aspects of care are prioritized. Patients remain sensitive to the difference between communication that simply appears empathic and communication that feels attuned. The uncanny valley offers a useful name for the discomfort that arises when the form of empathy is present without its full relational substance. Efficiency may support the work of medicine, but interpersonal presence continues to shape its meaning. Presence, like suffering, cannot be automated. It must be practiced, protected, and, at times, imperfectly expressed.