AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. September 2014, Volume 16, Number 9: 694-698.

Ethics Case

  • Print
  • |
  • View PDF

Advocate as a Doctor or Advocate as a Citizen?

If one presents oneself as a physician in the context of activism, one’s remarks can be taken not just as the views of a thoughtful citizen but as those of someone who has expertise relevant to the situation.

Commentary by Matthew Wynia, MD, MPH

Dr. Gonzales, an orthopedic surgeon, enjoys mentoring medical students who are contemplating a career in his specialty. He is also involved in trying to get more students from minority backgrounds interested in becoming physicians and is frequently invited to speak at the local high school near the academic center where he is on staff.

On a recent “Doctors Back to School” event at Riverside High, Dr. Gonzales learned from several teachers that the school board was contemplating closing the school at the end of the academic year because of poor student performance on statewide tests.

“I can’t believe the school board thinks closing down this school is a good thing for our students,” said Mrs. Winters, a science teacher. “You’ve been coming here for several years now, Dr. Gonzales. You know how challenging it’s been for us to build a safe learning environment for these kids. We’re just starting to turn the corner, and we may have the rug pulled out from under us. Look—many of us think of you as one of us. There’s going to be a school board meeting in a few weeks, and many of the teachers are planning to attend. Given your position as a respected physician in this community, I think it would be extremely helpful if you came to this meeting and spoke on our behalf.” Dr. Gonzales gave a slight nod, but said nothing, not quite sure how to respond to Mrs. Winters’s invitation.

By the time Dr. Gonzales was telling his wife about the invitation that evening, he had come pretty close to a decision. “At first, I wasn’t sure if I should attend this school board meeting,” he said. “But the more I think about what those teachers are doing… Many of the students come from families whose primary language is Spanish, and it’s important that many of the teachers there are bilingual. Those state test grades can’t be the most important part of school, and it can’t be good for these kids to be bused to another school and a neighborhood that is unfamiliar to them.”

His wife was concerned. “Honey,” she said, “You should think twice about attending this meeting. I know that you have a positive impression of the school, but you’re not an education expert.”

Commentary

When commenting on social issues, physicians trade on the honor of our profession, benefiting from the public’s assumption that the wisdom won of caring for so many at their most vulnerable imbues us with some privileged understanding of collective need.
Ford Vox, MD
[1]

It has been more than a decade since the summer of 2004, when I decided to testify in front of the Evanston, Illinois, city council in a grassroots effort to close the local hospital’s incinerator.

We had recently moved to a home just three blocks from a hospital with a stubby smokestack connected to an incinerator and boiler. Sometimes we could smell it, and it was worrisome to us as the parents of three young boys. I knew what went into the incinerator—essentially everything, including plastics, metals, and all manner of medical detritus. Even before doing any in-depth research on the issue, I knew medical waste incinerators produce dioxins, mercury, small particulates, and many other potentially harmful toxins. It might have been a state-of-the-art system, but there are no safe levels of exposure to some of these emissions, and operating an incinerator in the heart of a busy residential area, surrounded by schools and homes, seemed ill-advised at best.

A new friend who had been trying to get the hospital’s attention about this for years approached me, and we called together a neighborhood meeting. We invited an expert from a local school of public health who described the issues, informed us that the vast majority of hospital-based medical waste incinerators nationwide had already closed due to concerns like ours, and encouraged us to get organized.

So we did. We formed an ad hoc group, named it “No Burn Evanston,” and started to plot strategy. In only ten days, we gathered more than 2,000 signatures in support of a proposed ordinance to close the incinerator. We submitted the resolution to the city council. When we hit resistance, we started making lawn signs.

Like me, Dr. Gonzalez has every right, as a citizen and an individual working with the staff and students at Riverside High, to testify in front of the local school board. Being a physician doesn’t mean giving up basic first amendment rights of free speech and protest. But his wife is also right to be concerned that Dr. Gonzalez is at risk of using his medical credentials inappropriately.

I certainly worried about this when deciding whether to take a public stance on closing the waste incinerator. I had no special expertise in hospital management or in the regulatory and logistical issues hospital leaders raised when they objected to the proposed timeline for closure. Yet I knew that, in presenting myself as a physician, my remarks would probably be taken by the city council and public not just as the views of a thoughtful citizen, but as an assertion that I had expertise relevant to the situation at hand.

This raises the first question any physician should consider when contemplating whether and how to engage in public advocacy. Is the issue one to which my training and experience as a physician might be directly relevant?

If the answer is no, then invoking one’s medical training when presenting an opinion is simply cloaking one’s personal views in the mantle of respectability that being a doctor provides. When this is the case, it would be better to speak out simply as a concerned citizen, avoiding mention of medical training that isn’t relevant to the issue, or not to engage the issue publicly at all.

On the other hand, if medical expertise is relevant, then taking a public stand as a physician comes with an obligation to deliver medical information as one would in any other professional encounter—with deliberate reason, truthfulness, and care. Speaking in public as a physician is, in essence, serving as a medical expert. It is the public policy equivalent of taking the stand as an expert in a trial. There is an obligation to uphold our profession’s honor, integrity, and decorum when speaking out as a medical expert.

In particular, policy debates can be emotional (not unlike some medical decisions). Physicians can and should present information in ways that will be conducive to reasoned decision making. Physicians should always avoid overheated rhetoric when presenting medical information, and this includes occasions when they are doing so as an act of political advocacy.

It also bears mention that it’s not always straightforward to determine the extent to which specific aspects of medical expertise matter to an advocacy issue. I, for example, acknowledged that I don’t know much about medical waste management, loading dock design, or engineering, but I have training in medicine and public health. I have a basic understanding of toxicology, and I could (and did) read, understand, and translate some of the relevant medical and public health literature for my neighbors and for the city council. In this regard, it isn’t necessary to have specific expertise about all aspects of an issue to make a meaningful contribution to a political debate—in this case, sufficient education to read the public health literature and gather information was what was needed. When presenting as an expert, it’s best to stick to areas where, in fact, you have some expertise.

Dr. Gonzalez, as his wife rightly notes, does not have expertise in public policy or school reform. But he does have direct experience working with students at this school around medical issues. He could limit his advocacy to a careful description of these experiences and how they might bear on the school board’s decision. Within these limits, presenting his views as those of a concerned local physician seems not only appropriate but unavoidable, since he could not talk about his firsthand experiences in the school without mentioning his profession.

The second question I asked myself in considering whether to speak out on the incinerator was whether taking a public stand on the issue could backfire or could even harm my ability to provide quality care to patients or otherwise carry out my regular work.

These might seem like unlikely outcomes, but the reality is that whenever physicians speak out in public there is a chance they will have to cede control of the narrative they’d like to present. What if the press becomes more interested in the local doctor and his or her motivations for speaking out, perhaps to the detriment of the cause? What if the doctor’s patients are divided on the issue—will they continue to view him or her in the same way or with the same level of trust? What if the story becomes about the doctor’s level of expertise, or lack thereof, on the issue?

These concerns are heightened when doctors speak out on issues that do not bear directly on health and medicine. Even if a protestor doesn’t call specific attention to being a doctor, medicine has such a strong presence in society that reporters might focus on the medical angle, or they might try to add one. As the physician Ford Vox has written, “the public, and the reporters who keep them informed, will always attempt to comprehend [physicians’] actions in the context of the greater medical narrative” [2].

Again, these considerations can be nuanced. In my situation, for example, I felt my medical and public health training was relevant to some of the issues under discussion, so I introduced myself to the city council as a physician. But I did not call attention to my role at the American Medical Association, and when one reporter asked I told him not to use my AMA position in his story (despite that fact that the AMA had policy on environmental stewardship and safe disposal of medical waste [3-5]) because I was not acting on its behalf. Calling attention to my AMA position might have raised the profile of the story, but it also wasn’t directly relevant and could easily have become distracting and counterproductive.

Dr. Gonzalez should consider whether his patients might be divided on the closure of the school and whether his taking a public stand might alienate some of them. He should also consider whether any other affiliations he has might pose a risk of confusing or distracting the school board or the public. If present, these considerations might cause him to avoid providing testimony or to frame it more carefully.

After 3 months—during which time I spoke to the council 3 times—the governor got wind of our efforts and made a visit to Evanston to back us up. He pushed the Illinois Environmental Protection Agency to work with all hospitals in Illinois to shut their medical waste incinerators and he threatened a legislative solution if this didn’t work. In August, the council voted (8-1) to ban medical waste incineration in Evanston by the end of October [6]. The hospital wasn’t happy with the short timeline, but they complied.



References

  1. Vox F. Wisconsin’s real doctors and their fake sick notes for protestors. The Atlantic. February 2011. http://www.theatlantic.com/national/archive/2011/02/ wisconsins-real-doctors-and-their-fake-sick-notes -for-protesters/71500/. Accessed June 6, 2014.
  2. Vox F. The risks of professional protest. Virtual Mentor. 2011;13(10):726-730. http://virtualmentor.ama-assn.org/2011/ 10/oped1-1110.html. Accessed June 9, 2014.
  3. American Medical Association. H-135.973 Stewardship of the environment. https://ssl3.ama-assn.org/apps/ecomm/Policy FinderForm.pl?site=www.ama-assn.org&uri=%2fresources%2 fhtml%2fPolicyFinder%2fpolicyfiles%2fHnE%2fH-135.973.HTM. Accessed July 31, 2014.
  4. American Medical Association. D-95.994 Safe disposal of used syringes, needles, and other sharps in the community. https://ssl3.ama-assn.org/apps/ecomm/PolicyFinderForm. pl?site=www.ama-assn.org&uri=%2fresources%2fhtml%2f PolicyFinder%2fpolicyfiles%2fDIR%2fD-95.994.HTM. Accessed July 31, 2014.
  5. American Medical Association. H-135.939 Green initiatives and the health care community. https://ssl3.ama-assn.org/apps/ecomm/ PolicyFinderForm.pl?site=www.ama-assn.org&uri=%2fresources% 2fhtml%2fPolicyFinder%2fpolicyfiles%2fHnE%2fH-135.939.HTM. Accessed July 31, 2014.
  6. Evanston Hospital to shut incinerator. Chicago Tribune. October 13, 2004. http://articles.chicagotribune.com/2004-10-13/ news/0410130340_1_incinerator-medical-waste-shut. Accessed June 7, 2014.

Matthew Wynia, MD, MPH, is the director of patient and physician engagement for improving health outcomes at the American Medical Association in Chicago, a clinical assistant professor of infectious diseases at the University of Chicago, and the director of the Center for Bioethics and Humanities at the University of Colorado Anschutz Medical Campus.

Physicians and Political Advocacy, October 2011

A Call to Service: Social Justice Is a Public Health Issue, September 2014

Physicians’ Social Responsibility, September 2014

Advocacy by Physicians for Patients and for Social Change, September 2014

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.