1 Introduction

One of the most unexpected effects of the epidemic on our society was the closure of hospitals and other health facilities to outside visitors, including friends and family of inpatients. Said closure was accepted by everyone during the acute phase of the infection’s propagation which coincided with the lockdown periods. This incident occurred among many other unfathomable events, such as the restriction of personal freedom or the cessation of various work or commercial activities, all of which were simply unthinkable just a few months before. During these months of widespread anxiety and fear, everyone was prepared to accept any compromise so as to prevent infection. The ban on visitors, along with other restrictions, were then deemed as necessary and unavoidable. This passive acceptance may seem questionable, but nonetheless transpired. Nevertheless, given the consequences of such a decision on the lives of millions of people, and especially given that “no-visitors policies” are still in place in many health units today, when the spread of infection is minimal and most people are vaccinated, it is time to better analyze how and, above all, why it happened.

The aim of this paper is to analyze the following three questions: first, why this decision was adopted at the start of the pandemic; second, the consequences of the “no-visitor policies” for patients and their relatives, as well as for doctors and nurses; and third, why these policies are still so prevalent in our Italian health system. Finally, given the evidence that the epidemic has shattered a relationship that had taken nearly half a century to build, to explore the hypothesis that a potential underlying reason could be that something has gone wrong in the training of health professionals over the last thirty years. If this hypothesis is correct, it is our duty as pedagogists, to understand how this happened and how subsequent recruitment can become possible.

2 The reasons why the decision was taken

Caution about the spread of infection was the main reason why “no-visitor policies” were implemented everywhere during the early days of the pandemic, when there was no clarity or certainty about the means of transmission and the origin of the virus, and it seemed best to avoid any contact between infected people and healthy people. However, as numerous scholars have argued, there is no scientific proof, either then or now, that these measures achieved the intended effects. (Jefferson et al., 2020; Munshi et al., 2021). Moreover, many hospitals and health services in Italy, as in many other countries, implemented such decisions without reference to any specific state regulation (Sudai, 2021). In Italy, there is no specific mention of the absolute ban on hospital visitors in the several laws and decrees enacted by the Prime Minister and the Government throughout the two years of the pandemic.¹ In every DPM (Decree of the Prime Minister) or LD (Legislative Decree) issued during those months, the only words used are “specific limitation”, not “ban”, and even when the word “ban” is used, it only refers to the carers of infected patients on first access to emergency rooms or relatives and friends who would have access to retirement homes. Yet visitors, whether or not in possession of a green certificate, have been banned everywhere and are still banned from far too many places.

Beyond an excess of caution, it would be interesting to attempt to understand why it happened: perhaps one of the hypotheses underlying these decisions could be rooted in the defensive approach that medicine has taken in recent years. Defensive medicine, according to Tancredi and Barondess (1978) is “the use of diagnostic and end-treatment measures explicitly for the purposes of averting malpractice suits”; thus, clinical choices, before curing patients, would have the aim of safeguarding the clinician against litigation arising from some adverse outcomes of their decisions (Bester, 2020). Tancredi and Barondess claim that defensive medicine is responsible not only for the increased costs of the healthcare systems, but also for a human cost to patients, who are often subjected to unnecessary procedures with significant and avoidable risks and discomforts. Since, according to Bester, a particular kind of defensive medicine known as Negative Defensive Medicine (NDM) is oriented towards avoiding “patients or clinical situations to reduce the risk of such lawsuits or complaints”, it could be argued that the overuse of restrictive measures in relation to family access to wards and care rooms during and after the pandemic is the result of an original, previously overlooked, expression of NDM. Restricting family members’ access might reduce the risk of infection and, thus reduce risk of additional deaths being attributed to errors or medical malpractice. In fact, the fear of death affects not only “the patient, but also the doctor, because if the former sees it as a threat to his/her own life, the latter cannot fail to see it as a threat to his knowledge and skills” (Galimberti, 1987, p. 99).

One final argument for the “no-visitor policies” could be the necessity to reduce healthcare costs by providing visitors with the necessary PPE (Personal Protective Equipment, such as ffp2 masks, etc.) in order to prevent contagion, which results in a considerable cost for healthcare organizations.

In any case, the access restriction policies were accepted by patients and families because they were persuaded that it was and still is necessary in the service of a greater good (Sudai, 2021). And yet that is not the case: whether the reason for the “no-visitor policies” lies in caution, defensive medicine or the reduction of costs, these measures are nowadays completely out of place. If the lack of scientific evidence of its efficacy does not suffice, consider the implications it has had and continues to have on patients and families, as well as doctors and nurses.

3 The consequences

4 Exploring the reasons why the no-entry policies are still applied

None of the above justifications can explain why the no-entry regulations remain in place. Few people appear to consider the detrimental effects that such practices have on those directly affected by the disease, even to the point of violating the fundamental precept of the medical and nursing professions, non-maleficere. There must therefore be something more, something that goes beyond prudence, beyond ethics, beyond everything. Something that has to do with a psychological, but also cultural dimension of illness and care, and which could be better understood by stepping back in time.

Fifty years ago, a letter published in the Corriere della Sera wrote,

I am the mother of a two-and-a-half-year-old boy, and I had the misfortune of having to admit my son to a hospital in a northern Italian city. I was struck by the fact that, despite being preschool-aged, hospitalized children are not permitted to have any family members near them except during visiting hours. Thus, children left alone exhibit clear hysterical reactions: the only remedy is to tie them to their beds until they have become accustomed to this state of abandonment. This attitude reveals a tendency to consider the child only from a physical point of view with no regard at all for the possible psychic trauma.

This was just one of the numerous expressions of disappointment and dissatisfaction that in the mid-1970s of the 20^th century, drove a number of doctors and researchers, such as Giulio Maccacaro, Giorgio Bert, and Massimo Gallio, among others, to establish the Democratic Medicine Movement, whose main goal was to change the relationship between patients and physicians hitherto based on a power dynamic. The various contributions collected in the book series “Medicine and Power”, edited by Maccacaro, attempted to analyze this type of dynamic and the worst consequences on patients it brought about in different fields of medical practice, such as paediatrics, psychiatry, and so on. The findings of these studies were very interesting: firstly, they demonstrated that a “hospital regulates its operation and the provision of its services in order to optimise the management of itself as a moment of a larger enterprise … and not in order to optimise the actual care of the infirmities and needs of the patient” (Maccacaro, 1976, p. XV); moreover, hospital rules place patients in an unfamiliar environment, so that the sick person has to face a process of adaptation (Bert, 1975, p. 90) accepting a mental habit of dependency (Bert, 1975, p. 94). Secondly, the study highlighted that doctors attempt to carry out a process of reducing patients into things, so that they can treat patients as mere objects of scientific interest (Maccacaro, 1976, p. 37). Thirdly, according to those authors, this reduction enables the doctor to assume, according to tradition, the role of the affectionate or perhaps gently severe father (Bert, 1975, p. 43). Fourthly, according to Pollack (1972), family members represent the only link the sick person has with the real world, with his/her world, and can contribute towards making the institution more tolerable by bringing food, drink and linen. They are, however, considered disturbing elements and are removed as soon as possible (Pollack, 1972, p. 142).

Perhaps, it may be too much to speak of an exercise of power in the case of the “no-visitor policies” since the rationale behind their setup is clear and perhaps understandable, but when trying to understand why they persist, the concepts evidenced by these authors can be useful. What is happening now becomes clear if it is hypothesized that during the pandemic period, doctors and nurses had the opportunity to savor in some ways how much easier it is to work only with the patient, as if turning back time fifty years was possible: working only with a weak and defenceless human being, often unable to fully express his or her feelings and needs, unable to oppose any kind of decision made by others, debilitated not only in physical strength but also in his or her identity as an autonomous and self-determined person, is indubitably easier than working with a healthy person in full possession of all physical, psychological and cognitive faculties. The ill person’s self-efficacy can be compromised especially when hospitalisation coincides with a new serious or chronic diagnosis when patients may experience a sense of “loss of self” (Charmaz, 1997, p. 11), which results in losing any ability to be an authoritative defender of his/her own rights. As a result of the loss of self that the alienating experience of hospitalization fosters, patients are unable to significantly influence the definition of the meanings inherent in the relationship between themselves and the medical staff, allowing others to decide who and what they should be in every moment of the hospitalization: a person or a thing, or even simply a diagnosis (Bert, 2007). Left alone, they became passive observers of the therapeutic process they underwent. Sporadic contacts (a few minutes that seem infinitely insufficient) with one’s loved ones are of no use, especially if they occur in virtual mode. Some of the comforts which today’s hospitals come equipped with (though not all of them and not entirely) appear to be of no use as well.

Once the devastating moment of the pandemic had passed, once the months when deaths were no longer countable and work shifts appeared exhausting and unbearable ended, seeing routines restored, doctors and nurses may have realised that the absence of families and friends could be an essential corollary, not necessary but convenient to making their work easier and, perhaps, even compensating them for the fatigue of those days: a way to clear their spaces, to avoid having to face someone who, being healthy and worried, constantly demands accountability for every decision, action or word they may express. So why not continue as such, in the name of an ostensible prudence, even when this is nowadays no longer justifiable?

The pandemic has taken many lives and caused much suffering, but it risks leaving a very serious legacy: the undoing of fifty years of struggles for the rights of the sick and for the claim of a subjectivity of the suffering person who has the right to have beside him/her those who not only confirm his/her identity as a person, but also support him/her in facing what is completely unmissable for him/her in those moments. The hypothesis put forward in this paper is that the continuation of the policies of not allowing visitors is the result of an unspoken decision, rather than the result of an explicit negotiation with the patients or of a clinical or scientific evaluation. Namely, it appears to be the effect of an inertia stemming from the unacceptable desire to be able to work more easily, to regain the authority and freedom to act, to regain the solitude of a weak patient who is simply incapable of attacking, refusing or withdrawing any therapeutic choices, all things and actions that his/her relatives can do and often do. If this means reducing or abolishing the policy of democratisation and the ethical imperative of humanising the hospitals, it makes little difference. No one has explicitly said that prohibition on visits is still necessary, and no one has explained why, even in the face of a state laws that explicitly authorizes visits, they are nevertheless restricted if not prohibited; things continue simply as before…

We are aware that this is an appalling hypothesis, yet it is difficult to find another explanation for what is happening. It looks as if we had suddenly gone back a hundred years and recovered the Cartesian idea of a total distinction between body and mind, as if it were possible to distinguish between a sentient, lived body and an object body, a materiality that can be handled and known:

the doctor’s gaze does not meet the patient but his/her disease, and in his body he/she does not read a biography but a pathology, where the patient’s subjectivity disappears behind the objectivity of symptomatic signs that do not refer to an environment, to a way of life, to a set of contracted habits, but only to a clinical picture (Galimberti, 2010, p. 95).

According to Bruzzone (2015), doctors and nurses are led to deny their own emotions in order to defend themselves, to hide those that drive them from the depths in order to see and pity the suffering of others (p. 133), but as the same author points out, emotional superficiality corresponds to inauthenticity, to the emptiness of any ethical value of the profession (p. 139). Therefore, the defence seems worse than the evil it is supposed to eliminate. The arid coldness, the technological ideology that dominates the character of modern medicine seems to be oblivious to the fragility of others, who instead cry out for attention (Borgna, 2011, p. 135). The spreading individualism can erode the social bond which dissolves under the blows of a fierce defence of the ego’s well-being, even losing all empathic bonds with others (Bruzzone, 2022, pp. 41–42). However, as educators, we know that the self can be understood as becoming human in relation to others, and that the self can only remain human by living for others (Frank, 2013, p. 15).

5 Some implication for the work of pedagogists

If the above hypothesis is correct, it is conceivable that the pandemic has exacerbated an already existing malaise among the operators, who are increasingly overworked and less and less respected for their competence. The numerous cases of aggression, violence, if not outright murder, against doctors and nurses by patients and their families represents perhaps the real crux of the matter. Indeed, doctors and nurses were already under pressure before the pandemic and still remain squeezed today (little has changed…) between the demands of the company they work for on the one hand and the demands of being constantly kind, listening, sensitive, and humane towards patients and their families on the other; squeezed in this impasse, they simply decided, if not consciously and certainly not rationally calculating the consequences of these decisions, that that they could no longer go on like this. And when one cannot go on, one tends to retreat. To return to old habits. Perhaps we also made a mistake as educators, asking before, during the basic university training, to acquire the most complex and updated technical competences, and after, as professionals, to do something completely different and which they could not afford: to be doctors and nurses of humanity in an organisational environment governed by the market laws, cost efficiency, the cutback of everything that managers and economists say can be reduced, including operators. Perhaps, once again, we have acted as academics unable to keep in touch with the reality of the facts and places of care. This is a criticism of the system, specifically of our health and education systems. Trained and sensitized by people who perhaps did not really listen to their difficulties, perhaps being themselves incapable of articulating them, exhausted by a profession that has replaced an ethic of solidarity with a market ethic, they made themselves insensitive to any request and sought every means to protect themselves from any suffering that was not necessary to carry out their technical work, to save and cure sick patients. The deep and vital need to feel and be respected by others has led them to decide, once again irrationally, to push away those who had the strength not to respect them, leaving only those who, weakened by disease, no longer have this strength.

What can we do as educators to remedy this and rebuild a relationship that has been forged over fifty years of battling for patients’ rights and training for the humanization of care? Medicine can no longer be a mode of power; we have the awareness and the knowledge to prevent it. Yet we are living in a period when institutions are being questioned rather than simply accepted because they have lost their authority, a time when the social covenant is being broken because the ethic of individualism is stronger than anything else (Ritchie, 1891). Thus, as educators, we should strive towards forging a new alliance, and in order to do this we must convene all the actors of this human set: doctors need patients as much as patients need doctors, and both cannot make sense of their wounded existences without the help of the other.

Perhaps, this is what pedagogy is called to do, to create the conditions for rebuilding an alliance, not in the same way as in the past, but in a new way. It is up to the actors to decide because the new alliance between patients and health operators cannot be built on the rule of the dynamics of power and obedience between those who decide and those who execute these decisions: patients are no longer willing to relinquish their rights in exchange for a competent but only technical performance. Their access to education, to information, their knowledge of their rights as human beings beyond being purely ill individuals prevents them from being the same kind of patients who in the last century were willing to submit to the doctors’ wishes. What they can understand are the rights that other people have and their obligation to respect them, including the rights of doctors and nurses. But in order to do this, they need to know what being a healthcare worker means in these times, to know that the myth of our healthcare system as a perfect system, the envy of all, is simply an illusion, because it does not correspond to the truth. To understand, also, that the scientific myth of medicine which can care for any kind of disease is another illusion, because it sometimes fails. Patients, especially the suffering ones, cannot be emphatic with the operators, but even in that case, they can comprehend their predicament. Physicians and nurses, on the other hand, need a time-space to express all their malaise having lost the sense of their profession (Bobbo & Ius, 2021), having seen their own vocation eroded little by little by continuous requests of efficiency in every aspect of their work. The new alliance can be based on the opportunity for both parties to get to know each other and their needs and wishes. This hypothesis is fully consistent with the paradigm of critical pedagogy, according to which everyone has the right to speak, to express his or her point of view, to exercise a power of action and choice within his or her community of life, in order to transform that community into a place of empowerment of the self through help and sharing with others (Giroux, 2017, p. 93; McLaren, 2007, pp. 301–302). According to this paradigm, in order to overcome the distance that separates two actors who have ended up on opposite sides and who can now only see each other as a possible threat, a maieutic group must be created, which Danilo Dolci has described as a small research community: a group of people where everyone has the opportunity to talk to and listen to someone else, because the mask of the role is taken off and new ways of being with others can be discovered; when the conflicts and mistreatments of current social relations are suspended, re-establishing authentic social bonds, person to person becomes possible (Vigilante, 2011, p. 105).

To do this, what we as pedagogues can do is to make these encounters possible and moderate them because in order to start talking to each other, physicians, nurses, patients and caregivers need someone who knows that it is possible to grow as a human being through an encounter with the other, however different that other may be from us (Buber, 1970). A pedagogue, moreover, recognizes the patients’ discomfort, and what physicians and nurses are trained for. First, he/she is aware of the biographical disruption (Bury, 1982) that patients face after diagnosis and the limbo of despair they can fall into, as well as the erosion that compassion fatigue can cause in the carer’s life of a health care professional; secondly, he/she knows how doctors and nurses have been trained to be perfect technicians, shielding them from any emotions that might impair their judgment. As a result, they frequently lack the knowledge and abilities necessary to handle any situation pertaining to the vulnerable human relationship. In addition to teaching them how to achieve greater self-aware and understanding of others, the pedagogue can also help them establish the practical framework needed for conversation.

The maieutic group, that is according to Habermas the first, concrete realization of his theorical public sphere (Mayo, 2017; Vigilante, 2011, p. 103), represents the best context for this dialogue, as it is described as a meeting of different human beings needing to solve common problems, through discussion and negotiation, where everyone can express their needs and difficulties and propose and negotiate potential solutions. Several examples can be found in Italy, often carried out by a pedagogist, as the COS² of Aldo Capitini and the School of Barbiana of Don Lorenzo Milani (Catarci, 2012; Scuola di Barbiana, 1967). In these groups of people, the person whose opinion might carry more weight has to speak last. Each member then assists the others in seeking the truth, which arises from the dialogue itself and does not fully exist in each individual (Vigilante, 2011, p. 102).

6 Conclusion

Pedagogists should organize and oversee numerous small-scale maieutic groups that could be formed in various hospital contexts or continuing education settings as opportunities for change and learning: these small communities of research can start by reflecting on relational dynamics and, in particular, on the forms of violence, explicit and implicit, direct and structural, that characterise them, establishing themselves as a single body capable of mobilising for change (Vigilante, 2011, p. 86; McLaren, 2007).

Just as after a war, peace must be restored and people must learn again to embrace the other: it is not through domination and imposition, but only through cooperation, development, and transformation of the mutual perspective that it becomes possible to create a new sociality, so that the enemy can become an ally again (Capitini, 1971). Pedagogists could and should play an important role in this rebirth.