|Sailing for the Holy Mountain from Ouranoupolis, Greece|
A few years ago the fear of ‘pandemic flu’ was spread widely all over the world, causing what has been termed an “emotional epidemic.”1 The disease itself, its social dimensions, and the ways it was publicly handled could form the subject for an academic thesis. Those events led me to a series of thoughts, which I subsequently tried to put into some kind of order. What sparked the process was the question addressed to me by an experienced nursing sister in my workplace:
“So, doctor, should we get the flu vaccine?”
“Yes,” I answered.
‘”But last week you said no!” she protested.
“I have been thinking more philosophically about it,” was my own response.
What were my ‘philosophical’ considerations?
Back in the times of Jenner, Pasteur, Koch, and also more recently of Salk, Sabin and their contemporaries, the discovery of a new vaccine was hailed as a scientific revolution, a victory against infections that lurked in every corner and were a major cause of human mortality. Not only vaccines, but every new medicinal product was enthusiastically accepted by the medical community, and also by the patients who rushed to reap the benefits of its use. Widespread use often tempered the initial elation, but side effects, even deaths caused by inadequately tested drugs, were an accepted part of medical reality. Knowledge was limited, the obligation of doctors for detailed patient information was rather loose, even nonexistent, and patient expectations and demands were correspondingly modest.
This situation gradually changed. First with the detailed Summaries of Product Characteristics (those reams of paper with the minuscule print), and subsequently with the advent of digital technology, data on drug safety and efficacy moved from the inner sanctum of laboratories to the center stage of everyday life. Nowadays anybody who can read can find everything with a quick Internet search. The rule of transparency has gradually dominated medical practice, inevitably removing the element of ‘magic’ or ‘wonder’ from medicine, and thus probably curbing its overall effectiveness.
Is transparency a bad thing? I will tackle the question indirectly. Transparency means that all available data are open for public scrutiny. So the next question is, who will judge and decide? Anybody who has the appropriate knowledge, is the correct answer. In older but not so distant times judgment was the remit of experts, who balanced the expected benefits against the potential risks from both the target disease and the weapon-drug, reached a verdict, and acted accordingly. Any doubts were voiced only between colleagues, and scientific deliberations and debates were held behind closed doors, not leaked to the public. This was the established practice, and there was literally blind trust in prestigious scientists who proclaimed that “Everybody must be vaccinated against X.”
Transparency brought to light other issues apart from scientific knowledge. Thus the world at large gradually realized that many things, even in the sensitive domain of healthcare, are done for the purpose of profit and not based on the best balance of benefit and risk. Given the wide commercialization of all products and services, the person in the street came to suspect that there is a hidden and sinister purpose behind everything. Moreover, digital information is amply provided not only by specialists and experts, but also by journalists, patients, well-wishers, or plain gossipmongers who for various reasons try to promote their own personal views or weave conspiracy theories. When all these different opinions reach the wide public, confusion and doubt flourishes.
A typical example in medical practice is the kind of questions we get from patients who scrutinize the small print of drug sheets. For instance: “Doctor, it says here that steroids can raise your blood pressure!” We have to explain to the patient that this is true for steroids in general, but the doses contained in their asthma inhaler or skin cream are so low that this will practically never happen. “Then why do they print such things?” is the usual reaction. Because that’s what the rule of transparency dictates: everything must come to light, and let others separate the wheat from the chaff.
We live in the era of information, which is not synonymous with knowledge.2 Medical information is quantum knowledge, an individual ‘byte,’ which may be true for specific individuals, in a specific time frame, but not necessarily valid in any other place, time, or population. However, information spreads with digital speed, and constitutes the daily bread of news bulletins that do not wait until it passes the test of time and becomes established knowledge. The piecemeal nature of information often leads to conflicting opinions. Thus too much information breeds ambiguity, leading to uncertainty and insecurity.
Even doctors are not immune to these phenomena, and this is the reason for so many different views and opinions. Our knowledge is incomplete: in the words of the Apostle Paul, “we see through a glass darkly” [1 Corinthians 13:12]. We know that answers to our persistent questions and to our many daily medical dilemmas will only come with time. McCue has written that uncertainty is one of the daily sources of stress in the medical profession.3 Every medical decision is seasoned with a varying dose of it. Is this a simple viral cold, or should I prescribe an antibiotic? Does a negative ELISA rule out AIDS? Will this operation cure the patient’s cancer? Does the new hot dot on the scan represent a metastasis? Without adequate time we cannot be certain. The trouble is that during epidemics time is not always on our side, and every step forward sprouts new queries.
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So, is transparency in medicine a good or a bad thing, a blessing or a blight?
I will approach the question metaphysically, using an example from the Bible. The forbidden fruit Adam and Eve tasted came from the tree of knowledge of good and evil [Genesis 2:17]. Knowledge (even in the incomplete form of information) provides us (or so we think) with a wider range of choice, but also creates personal responsibility for our actions. We have more options, but some of them may prove wrong or even dangerous. We cannot feel absolutely certain and safe unless we trust something or somebody as a solid point of reference and final arbiter. Thus a child blindly trusts a parent; monks and ascetics abide by the rule of obedience, which means a complete faith that the abbot, master or elder knows best and will order the novice only what is good for him or her. This approach, naive though it may seem, is also notable for its innocence. A pupil cannot imagine that the teacher will ask him to do something wrong or harmful, and the same is true for the child and parent (if the opposite happens, this is the end of innocence, the collapse of the ‘idol’ the pupil or child previously adored and admired). Every so often we encounter a similar attitude in patients who say: “Doctor, what is your personal opinion? I do not want to know what Professor X or Committee Y proclaims. I want your view. If you say so, it’s good enough for me.” The ball of responsibility is now on our lap. The patient awaits the advice of his or her ‘Elder’ in order to act accordingly.
There is an interesting episode in the life of Alexander the Great, when he fell seriously ill after bathing in an ice-cold river. His friends wrote to him that his physician, Philip of Acarnania, had been bribed to poison him. When the physician entered his tent with a cup of medicine, Alexander took the proffered potion and gave Philip the accusing letter. While the physician was reading it, he toasted him with the medicine cup and drank it down, thus showing his complete trust in him, which led to a quick recovery.4
Happy indeed is the physician who can accept, with sagacity, humility, and awareness of the limitations of knowledge, the burden of responsibility to inspire such confidence in his patients.
And what about my own change of mind regarding the flu vaccine? I wish I could honestly say this was purely due to trust and faith. It is equally likely that I was more swayed by the number of flu-related fatalities reported that year.
- Ofri D. The emotional epidemiology of H1N1 influenza vaccination.N Engl J Med2009; 361: 2594-5.
- Papagiannis Α. Eliot’s triad: information, knowledge and wisdom in medicine. Hektoen International, Spring 2014. [http://hekint.org/index.php?id=1164].
- McCue JD. The effects of stress on physicians and their medical practice.N Engl J Med1982; 306: 458-63.
ANTHONY PAPAGIANNIS, M.D., MRCP(UK), DipPallMed, FCCP, is a practicing pulmonologist in Thessaloniki, Greece. He received his MD degree from the Aristotle University of Thessaloniki Medical School. He trained in Internal Medicine in Greece and subsequently in the United Kingdom, and specialized in Pulmonary Medicine. He also holds a postgraduate Diploma in Palliative Medicine from the University of Cardiff, Wales, United Kingdom. He is a postgraduate instructor in palliative medicine in the University of Thessaly, Larissa, Greece. He edits the journal of the Thessaloniki Medical Association, and blogs regularly.