Flat White

The danger of hubris

7 March 2022

9:00 AM

7 March 2022

9:00 AM

As the apocryphal tale of King Cnut goes, he commanded the sea:

‘You are subject to me, as the land on which I am sitting is mine, and no one has resisted my overlordship with impunity. I command you, therefore, not to rise on to my land, nor to presume to wet the clothing or limbs of your master.’

First recorded by Henry of Huntingdon – contrary to popular misconception – the story is in praise of the 11th century king, who used the tide as a demonstration of his humility and powerlessness before God, knowing that the forces of nature could not be stopped by his command.

The approach of Western leaders towards the pandemic over the last two years has been a striking contrast to this. It is a contrast echoed in our own views towards the pandemic, and in our sometimes-contradictory beliefs about what should be done. As with any challenge, we often make the mistake of believing we can stop a tide, rather than focusing on how we manage it, or deal with its consequences. Aside from vaccines which appear to dramatically decrease mortality and morbidity in high-risk populations, evidence for other interventions such as masks, lockdowns, and social distancing appears more equivocal.

As doctors and as people, in the face of a crisis, we have an inbuilt desire to do something, to act. This is understandable, especially in exceptional circumstances, as humans don’t feel able to stand by. However, as with a drowning man, the impulse to help must be cautious, for an intervention may cause more harm than good, for instance if their panic causes both to drown.

This desire to act is something we feel as medical professionals. A lot of what we do stems from this impulse. The examples are myriad. When patients present, we often provide treatments we know are (at best) equivocal in order to meet patient expectation. This is exemplified by prescribing antibiotics or pain medication when we feel neither is justified. Yet we sometimes do this, partially to cover ourselves, partly to meet patient expectation, and partially out of the biases we have to act. We investigate and treat to make us feel we are doing something, and ‘facilitating the patient journey’. We know we are more likely to get complaints from inaction even when we feel intervention is not in the best interest of the patient, therefore we act. In a respect politicians may share this human flaw.

Yet, as medical professionals, we know the trend towards inaction has good evidence, as interventions we once thought useful are shown to have no mortality benefit. In the aforementioned manner, this is why we have restricted our practice of prescribing both antibiotics and opiates. In the latter case, although there may be short term benefits in terms of pain relief, the longer consequences of addiction and polypharmacy relating to chronic pain have been shown to outweigh that in many circumstances.

Despite concerns about the damaging side-effects of restrictions, the public outcry for action in many countries exemplified the urge to act. We acted under the precautionary principle, that the disease was uncharacterised, and it was better to act rather than not, even though we were unsure of the efficacy of such policies. To a certain extent it’s something we are still doing now.

Our hospital and city are experiencing their first real wave of Covid cases, and therefore all staff are required to wear N95 masks, visors, and other PPE. This intervention has gone a long way to immiserating the workforce, many of whom are less than happy at the prospect. Yet despite this, many staff are sick with Covid. This is not a call to stop wearing PPE, but rather a reflection of the fact that there are limitations to our interventions, and regardless of our best intent and fastidious care, people still get sick. This is mirrored around the world where divisions of ‘Covid’ and ‘non-Covid’ areas of facilities have been shown to be arbitrary as infections spread, and, despite the best PPE, staff in these hospitals are still contracting the disease.

Similarly on the issue of vaccination, many of us had hoped this would be a sterilising vaccine, where receiving it reduces an individual’s ability to transmit the virus in a meaningful way. Sadly, this doesn’t appear to be the case. Although the vaccines go a long way to reducing morbidity and mortality in certain populations, they achieve less than we had hoped. With this in mind, the value of denying individuals entry to the public realm on the basis of vaccination status seems less pragmatic, and more moralistic. Similarly for healthcare professionals.

On issues such as border closures, Australia and New Zealand have demonstrated that it is possible to keep a pandemic from the shores for a period of time, but at escalating costs. We must ask ourselves if this is worth the price. Those who are foreign-born feel this most acutely – being unable to see friends and family, including unwell relatives and attending important life events. A great deal of suffering has been caused and now we open our borders millions will catch Covid anyway, and many will die. In defence of the government measures, hopefully many fewer than would have without the vaccines. Ultimately, border closures are not a sustainable policy, and do not allow us to avoid a pandemic.

Of all these interventions, some have more merit than others, indeed, some are more justifiable than others. However, we should be honest about their limitations.

One casualty of the pandemic has been our attitude towards science and the interrogation of ideas. Sadly, it may be that the medical profession has done this to itself. By our compulsion to act, and our hubristic attitude to what we can achieve, we have perhaps been blind to our limitations. Indeed, the fact we have acted to dismiss and belittle people with concerns (some valid, some less so) about our interventions, makes us even less able to impartially appraise our recommendations. The lack of humility not only fails to reflect our limitations, but undermines the basis upon which we practice. I fear this has only been exacerbated by making certain interventions mandatory, as it will be much harder to admit to ourselves either their limitations or side-effects, if they emerge. This will have damaging consequences to the enquiring scepticism necessary for scientific improvement.

Ultimately, after two years of aggressive interventions, it does not appear that we have a clear panacea. There has been no way to avert mass infections, no way to categorically protect ourselves, and, except for vaccinations, very few interventions with clear-cut efficacy. As health professionals, none of us truly believe that wearing masks and visors will prevent us getting Covid, and experiences from the rest of the world corroborate this.

Yet hubris is a powerful force, especially when mixed with fear of an external threat. Despite knowing in our hearts, and from the evidence presented, that some of our interventions have limited efficacy, we pursue some of them with disproportionate zeal, reluctant to admit our impotence in the face of a threat. This being so, we should be wary of our impulse to act, both on an individual level and on a societal level, being aware that interventions may achieve little, and may sometimes cause more harm than good. As much as anything, our own experience teaches us this, and it is a humbling revelation.

As the tale goes, when – as Cnut predicted – the tide failed to abate, he proclaimed, ‘Let all the world know that the power of kings is empty and worthless, and there is no king worthy of the name save Him by whose will heaven, earth and sea obey eternal laws.’

The Covid virus is here to stay. We do not know how it will affect us in the long-run, but we should perhaps have the humility to appreciate that some of our interventions do not work as well as we would like.

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