It is clear that shame can get in the way of the successful delivery of healthcare and can clearly impact on health outcomes. People who are anxious about shameful exposure may avoid seeking help in the first place, may regularly miss appointments, may avoid disclosing honest details about lifestyle or circumstances, may fail to follow through with treatments, may conceal diagnoses and coping behaviours from friends, family and professionals. Chronic shame can erode physical health and contribute to negative health outcomes. For these reasons, it can be useful to consider shame an affective determinant of health.
In addition, interactions with care professionals can compound feelings of shame, as these interactions often involve unequal power relationships, a fear of being judged, the scrutiny and exposure of one’s potentially ‘shameful’ past, circumstances, lifestyle, coping behaviours, body, illnesses, along with other vulnerabilities. As Allison J. Pugh notes: “Shame can stifle patients, causing them to keep their incompetence and unhealthy behaviours hidden.”
To address the problem of shame and shaming in medicine, some recent research has suggested that shame can be lessened or eliminated simply through replacing doctors and clinicians with technology (e.g., an app, a zoom call, an AI bot, or a robot). In the New Yorker article, Automated healthcare offers freedom from shame, but is it what patients need?, Allison J. Pugh discusses an Artificial Intelligence programme that was developed at Northeastern University to help low-income patients at the Boston Medical Centre prepare for discharge. The patients interacted with a virtual nurse, which is an animated figure on a screen. The ‘nurse’ asked them questions and talked them through what they needed to do after they were discharged, for instance what medications to take, how often, when to return for check-ups, etc. Pugh notes that “Human health-care providers spend an average of seven minutes with patients at discharge… but low-literacy patients need more like an hour. With the virtual nurse, his subjects could proceed at their own pace, digesting the information without the embarrassment of doing so too slowly.”
While acknowledging that most writing and commentary about AI is concerned with its negative potential, namely that it might take away jobs from humans, and concerns around bias in the algorithms and privacy, Pugh concludes: “There is an … important conversation to be had about shame and vulnerability. We often respond more frankly to computers and robots than we do to our fellow-humans. In online surveys, for example, people admit to financial stress and illegal or unethical acts more readily than they do over the phone, and potential blood donors report riskier behaviors.”
When considering the clinical encounter through a ‘shame lens’ and acknowledging that for certain populations shame may be a serious hinderance to the successful delivery of healthcare, Pugh, argues: “AI is not just ‘better than nothing’ but, indeed, better than humans.”
Other recent literature points to the potential of keeping the real-life human in the clinical encounter, but using technology to mediate their presence such that the positive effect of reducing shame or self-consciousness is still in effect. Some very recent publications in philosophical phenomenology, have pointed to this affective benefit of using basic telepresence.
For example, in her article, Healing Online: Social Anxiety and Emotion Regulation in Pandemic Experience, Anna Bortolan discusses how “certain experiential dynamics that are particularly prominent in social anxiety can be weakened when communicating with others via video calls.” Social anxiety is lessened in Zoom calls “due to the reduced level of exposure of the body in communication and interaction,” and this happens “alongside a greater controllability of one’s experiences overall,” where people can turn off cameras, conceal parts of their bodies and control how visible others are.
In her article, Body Objectified? Phenomenological perspective on patient objectification in teleconsultation, Māra Grīnfelde focuses specifically on teleconsultations, or clinical encounters that take place via a video call. Addressing common concerns and assumptions that these sorts of consultations will result in a diminished experience for patients, through focusing on the lens of phenomenology of embodiment, what Grīnfelde found is in fact that patients found these encounters to be overall positive. Patients experienced more control, agency and intimacy in their relationship with their healthcare provider. Interestingly, what Grīnfelde concludes is that patients reported less objectification through teleconsultations, and experienced their relationship with their healthcare provider as less hierarchical, less objectifying and less judgemental. In short, “the objectifying attitude of the health care professional is diminished in a teleconsultation.”
What these studies indicate is that, when considering the negative impacts of shame in clinical encounters, it may at times be beneficial to distance or even replace human contact from some healthcare interactions. Telemedicine may in fact afford opportunities for patients to feel more dignity, control and less fear of negative judgement, in some cases enhancing patient engagement and health.
Luna Dolezal, Professor in Philosophy and Medical Humanities, Co-Director of the Wellcome Centre for Cultures and Environments of Health, University of Exeter
5th June 2023