Prejudice has been with us as long as anyone can remember and seems to be part of the human condition. In 1593, when William Harvey won a scholarship to Gonville and Caius College at Cambridge University, the College criteria were that students be ‘neither deformed, dumb, lame, maimed, mutilated, sick, invalid or Welsh’.[1] The word prejudice means to form a pre-judgement, usually an unfavourable one, towards a person or persons because of differences. Is there then a survival advantage to prejudice? One can imagine that to mistrust persons from another tribe or culture might protect you if they are warlike or bent on other mischief. In these days of multiculturalism, however, there are many disadvantages in persisting with ancient notions of stranger-danger.

Use of language is an important weapon in promulgating prejudice. The first step of oppression is to dehumanise opponents in order to legitimise your own inhuman behaviour. During the apartheid era in South Africa, those in power refused to use the word ‘people’ for non-whites, calling them ‘blacks’ and ‘coloureds’, but referring to ‘white people’. The persistent use by some Australians of the term ‘illegals’ when referring to asylum seekers, even though there is nothing illegal in international law about seeking asylum from danger and oppression, is a similar attempt to dehumanise people. The most potent way of overcoming prejudice against others is meeting people.[2] The Truth and Reconciliation Commission, started in 1995 post-apartheid and chaired by Archbishop Desmond Tutu, is an extraordinary example of a brave and generous attempt to achieve resolution of some of the grossest human rights violations through communication, thereby avoiding racial conflict that seemed almost inevitable. Similarly, anyone with the time to listen to asylum seekers' terrifying stories of pain, fear, grief and loss cannot help but be moved by their suffering and their courage and will have more sympathy for their plight.

While examining in a clinical examination, I was presented with a 16-year-old young man with marked chorea. I started to take a history from his parents, then paused and said, ‘Oh I am sorry, does P understand?’ ‘Everything’, they said. I turned to P and apologised profusely. ‘Happens all the time’, he said, clearly understandable despite his dysarthric speech. When the candidates arrived we asked them to examine his gait. The first three candidates all assumed he was intellectually impaired, even though he obeyed all their requests to walk, for example on tiptoe. Happily, the fourth candidate introduced herself to P and talked to him as if he understood her perfectly. I have made a similar mistake before, of assuming a patient with cerebral palsy cannot comprehend me, and I am still embarrassed by the memory. We are all extremely susceptible to having prejudices but should struggle to acknowledge and if necessary correct them. Prejudice based on physical appearance is very common and something that paediatricians should try to avoid.

When I was a medical student doing experimental psychology, we were given two groups of rats: the ‘maze-wise’ group had seen the experimental maze many times before, but the ‘maze-naïve’ group had never seen it. We had to time the rats through the maze, then analyse the results to see if we found a statistically significant difference. We all did. Afterwards we were told that none of the rats had seen the maze before and the experiment was about bias. It was a humbling but important lesson. Bias is a form of prejudice: someone who is biased only sees one side of an argument or situation. The word bias is mainly used in reference to human temperament. However, bias is also used in statistics: for example, selection bias occurs when a group of persons selected for a scientific study is inadvertently different from the norm. Scientific bias is problematic, because if we have already made up our mind what we are going to find, we may constrain the data to comply, like the medical students testing the rats. This is why trials should include controls whenever possible and be randomised and double-blind in every effort to avoid scientific bias.

Evidence-based clinical guidelines: the very name makes it sound as if they are immune to prejudice. But a recent paper points out that important clinical guidelines, including those based on Cochrane systematic reviews of evidence, are susceptible to prejudice or bias.[3] This is particularly likely to happen when one or more of the people writing the guidelines have a stated or unstated conflict of interest.[4] If biased guidelines are published or endorsed by highly respected professional societies, it can put clinicians in an impossible position. The clinicians feel that the guideline recommendations might be construed as a standard of care and failure to follow them as being negligent. The best solution is to continue to advocate for open disclosure about potential conflicts of interest. Clinical guidelines committees must be composed of persons without conflicts of interest, particularly in the case of the Chair, or else there must be strict rules in place and enforced regarding the committee's handling of situations where members are potentially conflicted.

Doctors like to think they are immune from influence, yet pharmaceutical companies spend millions advertising their wares to doctors. Who do you think is being naïve? Prejudice thrives perniciously because we do not recognise it in ourselves or others and do not fight against it. Social researcher and author Hugh Mackay defines human goodness in terms of our ability to empathise with others and behave to them as we would wish them to behave to us. We need to be honest with ourselves about our own prejudices, and we need to be vigilant about how the prejudices of others can have unwanted effects on how we treat children.



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