AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. November 2011, Volume 13, Number 11: 757-764.

Clinical Cases

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Physician Involvement with Politics—Obligation or Avocation?

Are physicians obligated to advocate for social health in the political sphere?

Commentary by Thomas S. Huddle, MD, PhD, and Kristina (Kiki) L. Maletz, MD

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Dr. Mills and Dr. Ribeira are having a conversation in the hospital break room. Dr. Mills is complaining about another physician, Dr. George, because Dr. George is heavily involved in lobbying his local congressman for patient-centered health reform.

“He’d be doing a lot more good,” Dr. Mills suggests, “if he spent less time following politics and more time reading medical journals. In my opinion, the best way for physicians to provide quality care for their patients is to be competent, careful, compassionate, and spend their extra time learning about the latest treatment recommendations. Not only that,” he adds, “George is so wrapped up in partisan politics, writing and arguing with his congressman. I don’t see how he can remain unbiased and patient-centered in his practice.”

Dr. Ribeira disagrees and, in fact, applauds Dr. George’s patient advocacy, noting that if physicians don’t contribute to an informed discussion of health reform, from whom should legislators obtain information? He expresses a belief that physicians have a duty to advocate for sound health policy. “The Dr. Marcus Welby days are over, my friend,” he says to Dr. Mills. “We have a simple choice today: work to enact policy that will help medicine or have someone else force politically motivated regulations on us.”

Commentary 1

by Thomas S. Huddle, MD, PhD

Dr. Mills finds fault with a colleague, and Dr. Ribeira defends him. As is perhaps typical of conversations in hospital break rooms, each is more concerned with expressing an opinion than with carefully articulating and defending a position. Dr. Mills is overly impatient with Dr. George. Dr. George’s preoccupation with politics need not imply that he neglects the medical literature. Nor does his involvement with politics signify an improper influence affecting his medical practice. Many physicians pursue more or less absorbing avocations alongside professional work, and their professional work is unimpeded. Dr. Mills has offered no particular grounds for supposing that politics is interfering with Dr. George’s practice. Medicine need not, and, likely, ought not to occupy the whole of any physician’s life. Politics is but one of many possible avocations, but there is no reason to think that it is especially incompatible with medicine.

Dr. Ribeira might well take such a view. But his defense of Dr. George goes a step further, suggesting that physicians not only may engage in political advocacy but must do so. What Dr. Ribeira goes on to say does not, however, offer a compelling rationale for mandatory physician advocacy. In support of his position he proposes two possible physician approaches to politics. Physicians may either participate in politics and, thus, have some effect on medicine’s political environment, or they may abstain and take the consequences. How does it follow from these alternatives that political participation is mandatory? If some physicians are content to take the bargain offered them by society, even if that bargain includes “politically motivated regulations,” the more obvious conclusion would be that, if they eschew politics, they must remain content with that bargain.

Might there be a better case for mandatory physician political advocacy than that offered by Dr. Ribeira? Those who defend mandatory advocacy generally begin from the medical profession’s obligations to society [1]. These obligations, we are told, imply that physicians must act to ensure universal access to health care and to further the health not only of individual patients but of the larger community. And the health of the community is in large part determined, of course, by factors that have little to do with patient care. Diet, exercise, levels of violence, and risky behaviors all play important roles in our collective health (or lack thereof). Individual physicians, accordingly, must do their part to bring about improvement in these social determinants of health. Such improvement can be achieved only through political action; political advocacy on behalf of health is therefore necessary [1].

As capsulized above, the argument for mandatory physician advocacy suggests a given content for the medical profession’s normative commitments. Such an argument might be taken in two different ways: it might be contended that the commitments in question just are those held in common by the medical profession—so that we physicians must simply recognize what we are committed to and act accordingly—or it might be contended that these ought to be medicine’s commitments, even if they are not at present. Taken either way, the argument fails.

Begin with the argument taken as an assertion about what medicine’s normative commitments actually are, as physicians, in general, experience them. It is certainly true that medicine has obligations to society. It is simply false, as an empirical matter, that physicians experience these obligations as extending to advocacy either for universal access to care or for measures aimed at improving societal health, at least at present. While professional organizations and programmatic statements have called for the recognition of such obligations in the past 20 years or so, physicians have not so far taken such calls to heart. That is, physicians do not generally engage in political activity specifically related to health care access or health [2, 3]. And the medical profession historically has not enjoined them to do so. The move to graft these particular obligations onto the physician’s professional persona is a recent one [4]. That being the case, it is difficult to maintain that an obligation to advocate is part of what physicians are committed to. Any such claim ignores the history of medical professionalism, in which these obligations simply do not figure.

What about the argument that these obligations should be part of our identity as physicians, even if they have not been so in the past? Such an argument will, of course, appeal to those physicians who have an affinity for seeking social improvement through politics. Such physicians make up a venerable strand in the tradition of the American medical profession. Public health, community medicine, and social medicine have always been important fields in our history, even if they have not attracted the numbers, energy, and funding that we now devote to biomedical research and clinical care [5]. Politically minded physicians will recognize, however, that their own fulfillment in particular nonclinical activities is not a knock-down argument for mandating the pursuit of those same activities by all physicians.

Those who favor mandatory physician advocacy contend that our goal as a profession is societal rather than merely individual health and that, because societal health cannot be achieved without political action, physicians must agitate for measures calculated to increase it. Even if this were granted, it would still remain to be shown why all rather than just some physicians should be politically active on behalf of health. We must, however, reject “the health of society” as the profession’s mission, at least in so far as such a mission is taken to imply a norm directing our activity rather than an ideal to be favored, ceteris paribus. This seems a paradoxical admonition; it would be odd if physicians did not favor societal health. And, of course, as an ideal, they should and, doubtless, do favor it, just as they favor societal prosperity, the defense of society from its enemies, or any other desirable social outcome. But they ought not to be compelled to seek increasing societal health in the political arena. It might seem strange to contend that physicians need not strive for societal health in that way. But consider what is implied by a physician obligation to seek societal health through engagement in politics.

Marshalling the individual members of a profession in the pursuit of societal health through political means is to commit individual physicians not simply to the good health of their patients but to visions of the common good in which communal health is preferred to other goods when other goods compete with it. It is perhaps an obvious objection to any such proceeding to observe that physicians, while they clearly share common approaches to the ill health of their patients, do not, by virtue of that commonality, share a single conception of the common good, even to the extent of identifying a given priority for communal health. To suppose that they should is to posit the desirability not only of a common identity in approach to our work but in our political vision. It is to make of the medical profession by design a political movement on the societal stage. The medical profession has been more or less active in politics at various times in our history, but we have never before defined our profession’s core mission in political terms.

Why ought we to resist the subsumption of medicine into politics as a means to the achievement of communal health? Because there is no single right answer to the question of how far we should devote our energies to attaining more communal health and fewer of other goods necessarily given up on the way to that goal. Consider two political measures that physicians favoring societal health would be likely to advocate: mandatory use of child car seats and bans on cigarette smoking. These measures impose costs on driving parents and on cigarette smokers. Physicians can authoritatively pronounce on the gains in health and safety that result from such measures. They cannot similarly determine the relative value of those gains in comparison with the costs incurred by those who pay. The latter determinations are normative judgments that physicians make with no more authority than any other citizen. Physicians, through the nature of their work and their acquaintance with the harms of accidents and lung cancer, are likely to favor both the mandatory use of car seats and bans on smoking. Their opinions are not on that account dispositive, and physicians who happen to oppose either measure commit no professional sin.

Physicians may, in fact, prefer political quietism to activism and may prefer other goods to communal health on any and all occasions when political choices between health and other goods present themselves—even to the extent of opposing the mandatory use of car seats or smoking bans. They are none the worse as physicians and professionals for such preferences. That is to say, we are called upon as professionals to espouse and adhere to a common approach to our professional work. We are not called to decide upon a given vision of the good life and then to seek the imposition of that vision first on our own membership and then on society through the political process. That is what must inevitably be involved in making societal health part of our professional mission. We must resist the temptation to construe our mission in that way.

The impulse to make political activity integral to professional experience is an instance of a wider phenomenon: the impulse to expand the realm of politics into all of life, as if all of our personal, institutional, social, and economic relations must be made to serve a given political vision. Underlying arguments for mandatory physician advocacy is the wish to give a professional imprimatur to political goals that cannot otherwise speak with professional authority—and that do not warrant such authority. Such sleight of hand will not elevate our professional morality in the public eye; it will diminish it, as has happened recently in Wisconsin [6]. There are many reasons to seek to keep our work life separate (to the extent that we can) from the passions of politics—and from the duplicity and cynicism that too often accompany politics. Seeking a complete separation is doubtless unrealistic, but, on the other hand, we need not bring politics into the center of our professional identity as physicians—something it has never been before and ought not to be.

Of course many physicians, such as Dr. George, will be drawn into political activity on behalf of societal health. That is very right and proper; it would be odd if those physicians with political inclinations did not channel them toward political causes that drew from their daily experience. Dr. Mills is mistaken to find fault with Dr. George on account of his involvement in politics. If he has serious questions about Dr. George’s care of his patients, he ought, in any case, to be bringing those questions either to Dr. George himself or to proper authorities rather than to whoever happens to be in the hospital break room. But Dr. Ribeira goes too far in Dr. George’s defense. What is right for Dr. George is not and ought not to be compulsory for all physicians.



References

  1. Do medical professionalism and medical education involve commitments to political advocacy? Acad Med. 2011;86(9):1061-1065.
  2. Grande D, Armstrong K. Community volunteerism of US physicians. J Gen Intern Med. 2008;23(12):1987-1991.
  3. Grande D, Asch DA, Armstrong K. Do doctors vote? J Gen Intern Med. 2007;22(5):585-589.
  4. Huddle TS. Perspective: medical professionalism and medical education should not involve commitments to political advocacy. Acad Med. 2011;86(3):378-383.
  5. Rosenberg CE. Erwin H. Ackerknecht, social medicine, and the history of medicine. Bull Hist Med. 2007;81(3):511-532.
  6. Vox F. Why doctors protest too much. The Atlantic. October 3, 2011. http://www.theatlantic.com/life/archive/2011/10/why-doctors-protest-too-much/245587/. Accessed October 8, 2011.

Thomas S. Huddle, MD, PhD, is a professor of medicine in the Division of General Internal Medicine at the University of Alabama at Birmingham School of Medicine and the Birmingham VA Medical Center. He is trained in the history of medicine and writes about medical education, medical professionalism, and medical ethics.

Commentary 2

by Kristina L. Maletz, MD

As this case shows, physicians today garner both respect and suspicion when involved in political affairs. A Gallup poll during the height of the health care reform debate showed a high degree of trust in physician involvement. Overall, the poll showed greater public trust in physicians’ ideas for reform than in those of health care academicians, politicians, or commercial groups [1]. Almost three-quarters of Americans expressed confidence in physicians to do the right thing in changing the health care delivery system; only half as many felt that way about congressional leaders.

Physician advocacy is not a new concept. Throughout the history of modern medicine, physicians have acted as political advocates as well as clinicians and scientists. German physician Rudolph Virchow, often referred to as the father of modern pathology, is well remembered by various medical terms named after his work, including Virchow’s Triad, Virchow’s node, Virchow’s psammoma, and Virchow-Robin spaces. In nineteenth-century Germany, Dr. Virchow also ran for and served in political office as a civic reformer, championing the reformation of sewer and water systems, because he recognized that disease did not exist as a pure biological phenomenon, in isolation from its surrounding social context. Noting the similarities between medicine and politics, he said:

Medicine is a social science, and politics is nothing else but medicine on a large scale. Medicine, as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution: the politician, the practical anthropologist, must find the answers for their actual solution…. The physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction [2].

More recently, Dr. Herbert Abrams, a radiologist who received the Nobel Peace Prize for his work with the International Physicians for the Prevention of Nuclear War, termed physician activism “the fourth dimension of biomedicine.” In addressing graduating medical students at Stanford University School of Medicine in 2007, he spoke of patient care, research, and teaching as the first three dimensions linked by physician activism to the greater outside world. “Activism,” as he explained,

means engagement, involvement, sharing a voice or an activity, individual or joint or cooperative action in an area of need…. It represents an understanding that there are areas beyond our professional work and achievements that link to urgent continental or planetary needs. It stems from the connectivity of all humans and the awareness of that great universal community in which hundreds of thousands of smaller ones coexist. It reflects a sense of values that derive partially from the Enlightenment and persist in religious and secular humanism over time [3].

Only 150 years after Virchow, it is unusual to see physicians engaging in political actions to the degree they once did. While 11 percent of the signers of the Declaration of Independence were physicians, only 1 percent of congressional leaders over the past 50 years have been [4].

The medical profession does not have a union to act on important issues. Instead, it relies on the volunteerism of individual physicians to either become politically active themselves or to electively join and contribute to organizations that will advocate on their behalf. But organizing is inherently challenging in such a tremendously diverse field. Medicine is made up of generalists and specialists, rural and urban practitioners, private and academic practices, small practice groups and large hospital staffs. Any single organization attempting to represent the medical profession as a whole needs to appeal to a multitude of different ideologies, backgrounds, and interests. Then it has the monumental task of identifying issues that a majority of members not only agree are important but also agree on what should be done. Consensus is hard to find, and physicians who care about an issue must often go it alone.

Physicians who engage in political advocacy face many obstacles. The time demands of maintaining a medical practice often prohibit political activity and activism. Physicians must keep abreast of growing amounts of clinical and scientific information, leaving little room for following political issues in depth. The unpredictability of a physician’s schedule, dependent on the demands of patients, presents a challenge for meeting with equally busy political officials and staff members.

Some, like Dr. Mills, may have a general feeling that political activism is futile or even unethical. Often, political advocacy is associated with entrenched or extremely partisan views, but physician advocates need not—and should not—be close-minded, biased, or self-serving. Political advocacy is not the championing of one political party, one point of view or one profession. Political advocacy can be the potential leadership and collaboration with government to ensure that decisions and actions are made in the best interest of society.

The skills required for political advocacy are already important for our profession and the betterment of patient health. The ability to identify a problem, construct a legislative solution, work with others (in this case, legislators) to implement the solution and monitor for potential problems or improvements to the solution is as useful when performing an intubation as it is when writing to one’s elected representatives. Both can lead to the saving of hundreds if not thousands of lives. As physicians, we have the ability to speak on behalf of our patients.

Advocacy may also be important for Dr. George himself. Political apathy in medicine may lead to depression and frustration with forces “beyond our control.” Behavioral science has shown that the cumulative effect of chronic stress coupled with helplessness has negative effects on physical and emotional health. One can only suspect the cumulative toll of viewing the environment in which we practice medicine and the adverse forces against our patients’ health as unchangeable. The consequence of this can be seen in physicians’ growing dissatisfaction with their work. Advocacy provides an outlet for that desire to change things, ultimately improving the physician’s sense of well-being and ability to care for patients with complex medical and social problems.

Physician advocacy has historically been of vital importance for the betterment of the medical profession and improvement in public health. Physicians are trained to both diagnose and treat disease. However, disease encompasses more than a series of biological sequelae, and the treatment requires more than prescriptions and procedures. Political advocacy provides physicians the opportunity to educate legislators on positive systemic interventions beyond the realm of encounters with individual patients. Ultimately, patients are the beneficiaries when physicians like Dr. George bring forth issues that adversely affect their health.


References

  1. Saad L. Gallup. On healthcare, Americans trust physicians over politicians. June 17, 2009. http://www.gallup.com/poll/120890/healthcare-americans-trust-physicians-politicians.aspx. Accessed October 21, 2011.
  2. Virchow RLK. Collected essays on public health and epidemiology. Vol 1. Rather LJ, ed. Sagamore Beach, MA: Science History Publications; 1985: 217.
  3. Abrams H. Fourth dimension of biomedicine. Stanford University Dean’s Newsletter. June 18, 2007. http://deansnewsletter.stanford.edu/archive/06_18_07.html#5. Accessed October 21, 2011.
  4. Kraus CK, Suarez TA. Is there a doctor in the House?...Or the Senate? Physicians in US Congress, 1960-2004. JAMA. 2004;292(17):2125-2129.

Kristina (Kiki) L. Maletz, MD, is a first-year resident in radiation oncology at the University of Rochester in New York. She received her MD degree from Columbia University College of Physicians and Surgeons and completed her internship at Scripps Mercy Hospital in San Diego, California.

Physicians and Political Advocacy, October 2011

The Risks of Professional Protest, October 2011

Inside the Senate—A Physician Congressional Fellows’ Experience with Health Care Reform, November 2011

The Affordable Care Act—A New Way Forward, November 2011

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.