I've suggested before that Sam's sense of empathy toward Dean's experience in hell ebbs and flows with the amount of demon blood Sam has consumed, but I also think there's something to be said for 4.11 "Family Remains" and 4.12 "Criss Angel Is A Douchebag" (where Sam starts drinking demon blood again) being back to back.
In 4.11, Dean tells Sam in shame that he liked torturing souls.
DEAN
You know, I felt for those sons of bitches back there. Lifelong torture turns you into something like that.
SAM
You were in hell, Dean. Look, maybe you did what you did there, but you're not them. They were barely human.
DEAN
Yeah, you're right. I wasn't like them. I was worse. They were animals, Sam, defending territory. Me? I did it for the sheer pleasure.
SAM
What?
DEAN
I enjoyed it, Sam. They took me off the rack, and I tortured souls, and I liked it. All those years, all that pain. Finally getting to deal some out yourself. I didn't care who they put in front of me. Because that pain I felt, it just slipped away.
In the following episode, Ruby tells Sam he should just admit that he likes drinking demon blood:
RUBY
Cut the head off the snake. You're the only one who can stop her, Sam. So step up and kill the little bitch.
SAM
Oh, I'm game, believe me. It's not the psychic thing I got a problem with.
RUBY
Yeah, I know what you got a problem with, but tough. It's the only way.
SAM
No.
RUBY
You know, this would all be so much easier if you'd just admit to yourself that you like it. That feeling that it gives you.
We know Ruby isn't just lying, because we can see Sam likes the power the blood gives him in the episodes like 4.15, 4.16, 4.20. He tells us outright in 5.02. Sam has moral reservations about drinking demon blood also, but part of crushing those reservations is refusing to admit that he likes the power the demon blood gives him. He has to tell himself he's just doing what he has to do. The truth though is that from the very beginning though (flashbacks in 4.09), Sam's chief motivation has been, in the face of all that pain, finally getting to deal some out himself.
RUBY
I can't bring Dean back. But I can get you something else that you want.
SAM
And, uh... what's that?
RUBY
Lilith.
SAM
You want me to use my psychic whatever.
RUBY
Look, I know that it spooks you --
SAM
Skip the speech. I'm ready. Let's go.
RUBY
Slow down there, cowboy.
SAM
Just tell me what I have to do.
Sam ends up rejecting Dean's experience so thoroughly because Dean acknowledged something dark inside himself that Sam can't and won't acknowledge within his own experience—that he likes what he's doing even though he knows it's wrong.
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she may as well have called him a slur
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