AMA Journal of Ethics^®

Case

Dr. William Harper is an obstetrician-gynecologist in a suburban group practice. He spends much of his time providing prenatal and reproductive health care to young women. Dr. Harper also has a strong interest in public policy and local politics. He has served twice on the city council and is also very active in the local chapter of his political party.

Dr. Harper's colleagues often do not agree with him, but they acknowledge his right to his own political stances and activities. They don't think he attempts to influence his patients' views, but they are sometimes concerned that his highly visible involvement in politics might make patients uncomfortable.

The state in which Dr. Harper practices is likely to have one of the closest races in the upcoming presidential election. He wants to do everything he can to support his party's nominee. His office is located on a busy street in the community, so he decides to place a sign supporting the candidate in his window.

His colleague, Dr. Marsha Robert, first sees the sign upon pulling into the practice's parking lot the next morning. Appalled, she marches directly into Dr. Harper's office to ask him about the sign. "It's going to be a close race, Marsha, and my candidate needs all the support he can get," says Dr. Harper.

"That's fine," says Dr. Robert, "But a physician's office is no place for a political advertisement."

"What do you mean, there's no place for it? Being a physician doesn't preclude me from having political views and making them known. I have a right to free speech too, you know," says Dr. Harper.

"You're right, William, you do have a right to free speech. But don't you think that knowing that you support this candidate—one of the most vocal opponents of a woman's right to choose—will make your patients feel uncomfortable? Don't you think that they'll be less likely to ask you about their different options and more likely to think that you agree with this candidate about women's reproductive rights?" says Dr. Robert.

"Listen, Marsha. My patients know me, and I know them. They know that they can talk to me about anything and that I won't judge them for the choices they make. Just because I support a candidate doesn't mean that I agree with him about every issue," retorts Dr. Harper.

Frustrated and concerned about the sign, Dr. Robert ends the conversation and goes to her office to start the day.

Commentary 1

Given that a patient comes to the doctor to address health concerns, one can plausibly argue that the relationship between them should be confined to this agenda. A physician should exercise influence on a patient only to promote health-related goals such as encouraging healthy behavior and compliance with a medical regimen. So, while physicians, like all citizens, have the prerogative of endorsing political candidates and demonstrating this endorsement, I would suggest that political activities be separated from professional activities in some ways. Inside the walls of the clinic, it seems to me that it would be wrong to endorse a political candidate. This is so for several reasons largely connected to the special nature of the patient-doctor relationship and the role a physician plays in his or her workplace.

No matter how well a patient and physician know each other or how comfortable they are with one another, the unequal and privileged nature of the relationship obliges the physician to restrain the expression of personal views. Otherwise a patient may sense an expectation, even in the absence of overt stated pressure, to adhere to the physician's point of view. She may feel that she is expected to endorse the candidate that her physician endorses, and this would be an inappropriate expectation. Alternatively, the patient may strongly disagree with her physician's political point of view, and this may alienate her to the point of straining the therapeutic relationship. If the patient happens to support a different candidate than the physician, the patient may feel intimidated about acknowledging this, which may subtly inhibit her from expressing other unrelated but important issues to avoid alienating her physician. This pressure can distort the patient and physician's therapeutic alliance.

Outside of the clinical setting it is appropriate for an individual to campaign for a candidate in the course of his or her civic activities. This is simply an expression of a citizen's right. Physicians may contribute money to campaigns, help to raise funds, speak on behalf of a candidate, and participate in political rallies because they share a politician's point of view and want to support the candidate's election. There are, however, better ways for a medical professional to combine professional and political activities than putting campaign posters in the office. For instance, a physician might advocate that a professional organization endorse a candidate because he or she has a campaign platform that furthers the goals of the profession from the clinician's point of view.

Let's turn back to the case at hand, which focuses particularly on an obstetrician-gynecologist who endorses and wishes to use his office to advertise a candidate who opposes abortion. Abortion is among the most divisive political and moral issues in the United States today and has direct consequences for the practice of obstetrics and gynecology. Given the contentiousness of the debate, the need to separate politics and practice is particularly compelling.

Even if a gynecologist does not hang a sign endorsing a political candidate, it may well be that the doctor's views about termination of pregnancy cannot be avoided in the day-to-day conduct of his practice. Here, Dr. Harper's comment is quite apt when he says, "My patients know me and I know them. They know that they can talk to me about anything and that I won't judge them for the choices they make." It requires careful and explicit discussion to make sure this nonjudgmental attitude is plainly evident to patients.

Aside from the patient-doctor relationship, a physician's relationships with his coworkers are also important. His coworkers may or may not agree with his political perspective. If it were acceptable for one physician to endorse a candidate by hanging a campaign poster, it should be acceptable for anyone else in the office to do the same. So, while one solution to the question might be to allow any and all clinic or office staff to hang political posters in the office, this does not seem advisable or practical. When a patient comes to a medical office with health concerns, it should be a safe place where she can be sheltered from outside pressures in sorting out what is best for her health and well-being. An office filled with competing political slogans hardly seems like the haven one would want.