Restoring humanism in healthcare

Abstract

Restoring humanism in medical care
Throughout history, medicine has been considered a moral profession exercised under ethical values and principles [1], hence the basis of its practice is considered to be humanism [2].  Humanistic attention and care brings the patient closer to the physician and confers trust in him/her, which is necessary to have a punctual and certain history of health and disease, as a guarantee of compliance with the measures recommended to maintain or recover his/her health.  This necessary relationship between the patient and the physician is not built by laboratories or X-rays or technology, not even by prescriptions; it is achieved through attentive listening, empathizing with respect for the patient's emotions and beliefs, recognizing his or her emotional needs and establishing an enriching dialogue for both, through a clear and sincere interaction with respect to human values [3].
 
Humanism in medical practice is learned or cultivated by approaching and studying art, literature, exploring the narrative of the patient and the physician, observing the behavior around us, that of the human person in the face of illness, without the imposition or superiority of the physician.  Humanistic ethics emanates from that humanism that grows from social roots and from understanding that illness diminishes the patient's capacity to have a full life. But illness and burn-out also diminish the physician's capacity to attend patients with attention and warmth [4].
 
Medical dilemmas in daily practice occur with unusual frequency.  We learn from every situation and, for this reason, the codes of ethics of the medical profession are built around lasting values and the multiple experiences that are accumulated in the course of practice. One of the mainstays at this time, when anti-vaccine groups easily disseminate their arguments without even certainty or precision, is the management in pediatric practice of the family and the child of parents who are anxious, rather than opposed, to vaccination and vaccines. In the Saxon literature, the term for them is hesitant.  Its approximate translation is anxious, uncertain. 
 
Faced with the degree of uncertainty that is always the scenario in medical practice, where we are asked not to make mistakes even when we do not have sufficient, perfect or truthful information [5], this issue is a dilemma.  And if medicine is uncertain, so is science, which is why it continually seeks the truth.  However, the patient expects from us and waits for us. Are we prepared?

 
Despite the title of this paper, I am not going to present or discuss how to restore humanism in medical education or practice.  Rather, I bring a situation magnified in these last 3 years of pandemic and based on several ethical discussions of Pediatric Collections, of the American Academy of Pediatrics [6], which, without hesitation, touches the title promptly.  I refer to how the pediatrician should deal with the frequent situation of providing care to children of parents with uncertainties about vaccines and vaccination.
 
Situations where parents disobey pediatricians' recommendations are not limited to the issue of vaccination and do not indicate parents' distrust of their pediatricians.  As John D. Lantos rightly points out, they indulge their children with junk food, give them screens at a very young age to distract them from their care, allow them to ride bicycles or scooters without head or limb protection, buy them vehicles like 4-wheelers at a very young age, and start them on antibiotics for any febrile illness, all despite the pediatrician's advice not to do so.  The argument of the risk of becoming infected with pathogenic organisms in the waiting room fades with the knowledge that the concentration of these organisms is very small and that for an asymptomatic unvaccinated child there is a greater risk of becoming ill there because of the presence of other children whose parents do not vaccinate them against influenza.  These unvaccinated children in waiting rooms should wear face masks to protect those children vulnerable to infection.
 
It is not uncommon today for pediatricians to encounter parents in their office who refuse to vaccinate their children.  It is popularized that caring for unvaccinated children constitutes a serious risk for unvaccinated and immunocompromised children.  And, in that line of thought, of course it is unacceptable for unvaccinated children to put other children at risk and the principle of non-maleficence is observed.  On the other hand, some pediatricians, sometimes more often than we think, take personally the decision contrary to their advice and consider that this is an indicator of mistrust of the child's parents towards them.  The third concern is that the pediatricians' waiting room is already a high risk of infection. In any situation the principle remains "Primun non nocere" ("First do no harm"), which is the pillar of one of the 4 bioethical principles: the value of "non-maleficence".

Waiting rooms are not a greater risk of infection than not being vaccinated.  The risk is that children are not protected annually against seasonal flu because their parents refuse to vaccinate them. Immunocompromised children who go to the pediatric clinic are safe if they attend the consultation with a face mask.  Another way to reassure parents and protect these children is to make it easier for them to wait in their cars until they are called to come to the clinic.  It is well known that the frequency of vaccine-preventable diseases occurring in immunocompromised children is very rare, and even rarer for infections for which vaccines are available.  Pediatricians can check the vaccination status of parents to get them vaccinated.  They, the unvaccinated parents, can transmit infectious diseases in waiting rooms more than anyone else sharing those rooms.
 
The pediatrician, surely the medical professional who most enjoys the practice of his profession, does not only vaccinate, he is not only a vaccinator.  The pediatrician does preventive medicine and education about hygiene, health, disease, growth, development.  The pediatrician talks about the risks of accidents at home or in the practice of sports or even in children's fun activities.  He also discusses why children and adolescents are at greater risk of poisoning, vehicular accidents, substance use and consumption, addictions, decision and planning to take their own lives, human sexual behavior, unprotected sexual intercourse.  We all also talk about early and unwanted pregnancy, sexually transmitted diseases.  This multiple role of the pediatrician should make us realize that it is not a good idea to refuse care to unvaccinated children in our offices, that we are not complying with the principle of beneficence.  By doing so, we would be depriving him/her of all the other functions that we perform to monitor the growth and development of children.

 
This duality or opposition of principles, that of non-medicine and that of beneficence, to exclude non-immunized patients and families and to offer another series of benefits to the growth and development of children does not clarify the position we should take.  It is time then, as Kenneth Alexander and Tomas Lacy comment, to apply the principle of double effect, whereby, when an act with positive intent has a very small or minimal negative effect, the act is still positive.  For this the positive act must be the primary intention and it is not the intention, the negative component. In the case under discussion, given that the risk of transmitting a vaccine-preventable disease to a vulnerable child in the pediatric office is very low, it is assertive to consider that the care provided to non-immunized children in the same pediatric practice creates more positive effects than the unintended negative consequences of increased risk to vulnerable children [7].
 
It is true that physicians are often more and better informed than parents and are in a position to educate them, but there are times when parents know more about a condition than the pediatrician.  This is particularly true with rare diseases. Prudence and humility must accompany us in the relationship with the patient or his parents so that the relationship of trust prospers.  In the presence of parents who refuse to vaccinate their children, the pediatrician should approach them to learn about their values and fears, what the parents know and do not know about vaccines, and as often as necessary, in subsequent visits, return to the issue.  This is a morally and ethically superior action to that of closing the office doors to these families with well-founded or unfounded fears about vaccines and vaccination. 

Referencias/References

[1] Miles JL: Humanistic medicine or values-based medicine…what’s in a name? Med J Aust. 2002; 177(6(:319-321

[2] Hulail M: Humanism in medica practice: what, why and how? MedCrave. Hospice & Palliative Medicine International Journal. 2018. Volume 2 Issue 6. November 2018

[3] Pellegrino ED. Toward a reconstruction of medical morality. Am J Bioeth. 2006; 6(2):65-71

[4] Rushton CH: To Restore Humanity in Health Care, Address Clinician Burnout. The Hasting Center.  Bioethics Forum Essay. January 16, 2020.

[5] Siddhartha Mukherjee: The Laws of Medicine. Field Notes from An Uncertain Science. A TED original. TED Books: Small books, big ideas.  Sss.ted.com/books

[6] American Academy of Pediatrics. Ethics Rounds: A Casebook in Pediatric Bioethics.  Pediatric Collections. Edited by John D. Lantos, MD. AAP, 2019

[7] Alexander K, Lacy TA, Myers AL & Lantos JD: Should Pediatric Practices Have Policies to Not Care for Children With Vaccine-Hesitant Parents? Ethics Rounds: A Casebook in Pediatric Bioethics.  Pediatric Collections. Edited by John D. Lantos, MD. AAP, 2019. pp 74-79