AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. January 2004, Volume 6, Number 1.

Clinical Cases

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Campaign Posters in the Clinic

Expressing political views in a professional setting can be detrimental to the patient-physician relationship.

Commentary by Marion Danis, MD, and Leonard M. Fleck, PhD

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

by Marion Danis, MD

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.

The views expressed here are those of the author and do not reflect the policies of the National Institutes of Health or the Department of Health and Human Services.

Marion Danis, MD, is head of the Section on Ethics and Health Policy in the Department of Clinical Bioethics and chief of the Bioethics Consultation Service at the National Institutes of Health. She is also on medical staff at the National Naval Medical Center.

Commentary 2

by Leonard M. Fleck, PhD

Undoubtedly Dr. Harper does have his free speech rights, but professional ethics requires that he exercise those rights away from his office practice. Considerations related to both his patients and his colleagues would seem to require this.

Dr. Robert suggests that patients might be made uncomfortable by a sign endorsing a prolife candidate. If a bit of psychological discomfort was the whole story, then it would not raise any serious ethical concerns. Should we say, then, that the sign is "offensive"? That might be too strong a description. If the candidate were known to have racist views, for example, and if a Confederate flag were part of the sign, then the sign would be offensive in a morally significant sense. The patients' discomfort is not the only issue of concern, however; there is a risk that patient trust might be undermined perhaps without Dr. Harper's knowledge. This is morally significant enough to warrant removal of the sign.

Trust is an essential part of the patient-physician relationship. Patients need to be confident that their physicians will render medical judgments on the basis of medical science and the best interests of the patient (as an informed and autonomous patient would judge those interests). A reasonable expectation is that physicians will not allow their personal values (eg, religious or political) to contaminate the professional and objective medical judgments patients seek.

Dr. Harper may in fact be quite attentive to this professional norm, never raising partisan political issues with his patients in the office setting. Still, his political sign could undermine patient trust. Many of the women in the waiting room will be pregnant. It is natural that some of them will have anxieties about the status of the pregnancy. His patients might wonder, for example, whether he would fail to suggest prenatal genetic testing when their fetuses might have a significantly increased risks of serious genetic disorders because he does not want to encourage abortions. Many, perhaps most, women would feel uncomfortable raising this issue with Dr. Harper, perhaps because they would feel as if they would be questioning his integrity and clinical judgment. These tensions may result in the patient's losing trust in her physician and being unnecessarily anxious for at least the duration of the pregnancy. This loss of trust can have corrosive effects on the patient-physician relationship, which are difficult to recognize and remedy. Dr. Harper may not even realize if this becomes an issue that he should address.

A defender of Dr. Harper could say that patients who have these concerns can always leave the practice and find another physician. This will be true for some patients; however, for others this is only a theoretical option because either insurance or geographic restrictions make leaving the practice nonviable. Apart from that, leaving a physician imposes additional costs on a patient.

Academics, for example, are in a similar position. If we have partisan political posters all over our offices that relate to issues that we must necessarily discuss in our classes, students will justifiably wonder whether they will be fairly graded if they voice contrary political views. Although the university campus is a place where free expression, especially political expression no matter how controversial, ought to be protected, the classroom and by extension an academic's office are not appropriate places for political campaigning. A political science professor could express her views on the Medicare prescription drug bill in the classroom, but she also has an obligation to present fairly the best arguments of her critics. She must be an educator in the classroom, not a political activist. This is not a threat to academic freedom but a way of protecting the integrity of that value.

Given my analysis, someone could raise the question of whether Dr. Harper must desist from all partisan political activities in public, thereby significantly squelching his political rights as a citizen. The argument would be that this sort of activity could make his patients just as uncomfortable and distrusting as having signs in his office. It seems to me that there is a real and ethically significant difference between these situations. In a public setting, women who are his patients can confront him more directly and comfortably. In that setting they are not "his patients"; they are his fellow citizens. In a well-functioning democracy this distinction is meaningful. There would not be sufficient reason, then, to have abstinence from all political activity as a professional norm.

We need to return to one other issue: this is a group practice. Though the sign is in "Dr. Harper's window," most passers-by would have no sense of that. The conclusion can be drawn that the sign reflects the political sentiments of the group as a whole. This is unfair to the other members of the group who do not agree with those sentiments or support this candidate. Of course, other members could post their own signs, which could correct the misimpressions of passers-by but would only worsen the problem we discussed above. It creates an impression in the public mind that physicians in their professional role as clinicians are politicized. Prudent patients would be more circumspect about discussing medical problems that have become a focus of political controversy with their physicians. This would be potentially subversive of the best interests of some patients, not to mention the professional comity required to serve patients well.

Finally, we have addressed this case as if it were about only physicians. Yet nurses, other health professionals, and office staff in general would all be part of this practice. Would all of these individuals have an equal right to hang partisan political signs in their office space? Would Dr. Harper comfortably approve their equal right to exhibit their political views in this way? We are fortunate, as a society, to have ample political space for engaging in political work in our role as citizens. There is no need for medical offices to be included in that space. How many of us would like to see medical offices become the clone of "talk radio"?

Leonard M. Fleck, PhD, is a professor of philosophy and medical ethics in the College of Arts and Letters' Philosophy Department and the College of Human Medicine's Center for Ethics and Humanities in the Life Sciences at Michigan State University.

The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.