AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

AMA Journal of Ethics. December 2017, Volume 19, Number 12: 1174-1182.
doi: 10.1001/journalofethics.2017.19.12.ecas3-1712.

Ethics Case

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How Should Clinicians Weigh the Benefits and Harms of Discussing Politicized Topics that Influence Their Individual Patients’ Health?

The adverse health effects of climate change should be the focus of physician advocacy efforts and of conversations between physicians and their patients.

Commentary by Diana Alame, MD, MBE, and Robert D. Truog, MD

Abstract

Health implications of politically charged phenomena are particularly difficult for physicians to discuss with their patients and communities. Addressing climate change and its associated health effects involves trade-offs between health and economic prosperity, necessitating that physicians weigh the potential benefits and risks of discussing climate change health effects. We argue that the potential benefits of physician communication and advocacy ultimately outweigh the potential risks. Therefore, physicians should be supported in their efforts to educate their patients and communities about climate change health effects. Furthermore, democratic deliberation could prove helpful in addressing disagreements among physicians within a practice about such politicized health topics.

Case

Dr. Schwartz is one of four family medicine physicians at a rural, private group practice. He has been part of the practice for more than three decades and has developed strong relationships with many local families. One of his major areas of interest is preventative medicine, and he is viewed as a local expert. He has been instrumental in many community health initiatives, including the creation of smoking cessation and weight loss programs for patients in his practice.

One of Dr. Schwartz’s biggest concerns in his community is a large coal-burning power plant located about a mile outside of the town center. Generally, other community members don’t seem to mind the power plant, and many are grateful for the employment it brings to their remote region. However, Dr. Schwartz has recently been concerned by rising rates of respiratory illnesses, such as asthma, among his patients. He is aware that living in a zip code containing a fossil fuel-fired power plant is associated with higher rates of respiratory disease including asthma, chronic obstructive pulmonary disease, and acute respiratory infection [1]. Moreover, he knows that coal-fired power plants are the largest source of toxic substances in the air in the United States and that exposure to pollutants from power plants is associated with asthma, low infant birth weight, and premature mortality in adults [2]. Dr. Schwartz is worried about how his town’s power plant is contributing to his patients’ poor health as well as the plant’s contribution to climate change, which harms human health worldwide.

In the past, Dr. Schwartz has avoided educating patients on the detrimental health effects of the power plant, because he knows that many local families rely on its employment. However, the incidence of respiratory disease among his adult and pediatric patients has reached a level at which he feels he must speak up. He hopes that, by raising awareness, he might influence community members to advocate for pollution-reducing measures at the power plant, such as the installation of additional filters that reduce toxins released into the air by burning coal. The filters could reduce pollution-related illness in the short term and might even benefit his patients’ health in the long term by reducing the plant’s impact on climate change.

During the clinic’s monthly business meeting, in which all physicians gather to discuss best practices and the clinic’s finances, Dr. Schwartz announces that respiratory illnesses have risen enough among his adult and pediatric patients that he intends to start briefly counseling them on the potential impact of the power plant on their health, both directly through local pollution and indirectly through the plant’s contribution to climate change.

His announcement receives mixed responses from the other physicians, including some nods of approval and scattered grumbling. Dr. Rizzo, in particular, appears opposed. “I’m not comfortable with that,” she replies. “These topics are too political in our community. There’s risk for us if we’re perceived as fighting the coal plant, particularly if our patients who work there lose their jobs.”

“I understand your hesitation,” Dr. Schwartz replies, “but our patients’ health is at risk. I feel that, as physicians, we have an obligation to educate our patients on serious dangers to their health, particularly when patients could reduce or avoid risk by pressing that plant to change how it generates power in this community. Patients here are in a position to advocate for changes that can benefit them now and in the future, and we should help them do that.”

Dr. Rizzo sighs. “We also have obligations to provide a nonjudgmental setting in which patients trust that we are giving them unbiased advice. I could maybe get on board with advising patients about pollution from the power plant, but talking about its impact on climate change and health is going too far. If you bring such a politicized topic into the conversation with a patient, particularly when its impact on that particular patient’s health is uncertain, you overstep your role as a physician.”

There is murmuring around the table as the physicians continue to discuss the issues.

Commentary

Physicians are experienced in discussing sensitive issues with their patients. However, some topics are particularly difficult to discuss when they are politically charged or involve broad matters outside the scope of an individual physician’s area of expertise. In the case presented here, a group of physicians comes together to decide how best to approach the influence of climate change on human health. The physicians are aware of the health risks of working and living near the local coal-burning power plant but are also sensitive to the larger economic and political forces at play. In the US, opinions about the scientific consensus regarding climate change and whether to legislate a solution fall along a marked partisan divide [3, 4], potentially posing difficulty for physicians attempting to provide patient education and community advocacy.

The case presented here illustrates how the tension between health and economic prosperity, in addition to the partisan divide, necessitates that physicians weigh the potential benefits and risks of discussing the health effects of climate change with their patients and communities. In this article, we will examine these potential benefits and risks, arguing that despite the politicized nature of climate change and the trade-offs in addressing it, the potential benefits of discussion outweigh potential risks. Physicians should thus work to educate their patients and advocate for ways to mitigate the effects of climate change on health and be supported in such efforts by their colleagues and professional societies. In situations in which disagreements arise within a practice regarding how to approach the health effects of climate change, democratic deliberation could prove helpful and will be briefly described.

Risks and Benefits of Discussing the Health Risks of Climate Change

Because addressing climate change involves a substantial trade-off between health and economic prosperity, discussing the topic creates an ethical dilemma for physicians. On the one hand, physicians such as Dr. Schwartz feel compelled to speak out about the adverse health effects of climate change. Indeed, one of the most compelling drivers in physician advocacy is the duty to promote public health and safety [5]. Physicians witness the downstream effects of social and environmental factors on the health of their patients and, by extension, should seek to mitigate those upstream determinants for the benefit of the broader population. On the other hand, some might feel, as expressed by Dr. Rizzo, a deep sense of unease at being perceived as biased, politically motivated, or judgmental—and hence as overstepping their role as physicians—if they speak out. Negative impressions of this nature could be detrimental to the therapeutic relationship between the physician and patient or to the community’s view of the trustworthiness and objectivity of the physician-advocate.

In contrast to this worry, however, are the benefits of discussing the health risks of the coal plant in this case and of climate change generally. These benefits include fostering transparency and patient education, which serve to promote knowledge and empowerment; upholding the physician’s broader role in both prevention and treatment; and, in some cases, enhancing a sense of social responsibility and motivating advocacy for population health. Discussions between patients and physicians of politicized topics such as climate change thus can serve to strengthen the therapeutic relationship and inform the public debate about these critically important issues.

Nevertheless, the nature of acceptable advocacy is limited by the roles that individuals play within society. When acting in the role of a health care professional, physicians must limit their advocacy to matters clearly related to promoting the health and well-being of their patients and communities. In certain circumstances it might be possible for physicians to step outside of their role as health care professionals and engage in advocacy as a private citizen—a role that would not fall under the constraints of acting as a member of the medical profession. Clear boundaries between these two forms of advocacy would help to diminish potential risks identified by Dr. Rizzo.

The Role of the Physician-Advocate

One of Dr. Rizzo’s chief concerns is whether physicians would be overstepping their role should they begin counseling patients and informing the community about the health effects of climate change. While in some ways the topic of climate change health effects is distinct, it nonetheless shares certain qualities with other public health and safety concerns, such as vaccine hesitancy or firearm safety, for which political viewpoints sometimes overtake health concerns. In these contentious and politicized public health areas, physicians must contend not only with whether but also how to communicate and advocate. Especially in politically volatile arenas, how should physicians delimit their role as patient and public health advocates?

Dr. Rizzo, presumably, is not questioning the appropriateness of physician advocacy in general, nor has she taken issue with other community health initiatives conducted by Dr. Schwartz. Rather, she appears to be concerned about the highly political nature of climate change and physicians’ subsequent political entanglement in the course of their clinical work, which she sees as a threat to maintaining the trust of community members who rightly expect medical professionals to be objective and politically neutral. One scholar, Thomas Huddle, is sympathetic to this view [6], stating that “traditional norms of scholarship: accuracy, objectivity, and truth” are “often, if not always, incompatible” with political advocacy [7], which encompasses “advocacy on behalf of societal goals, even those goals as unexceptionable as the betterment of human health” [8]. Furthermore, he insists that “the medical profession has no special authority or insight into … how far societal resources should support communal health rather than other priorities” [9].

Nevertheless, insofar as physicians are in fact experts on matters of health, Mark Earnest and colleagues [10] argue that physicians are “uniquely positioned” and “understand the medical aspects of issues better than any sector of society” [11]. They define physician advocacy as “action by a physician to promote those social, economic, educational, and political changes that ameliorate the suffering and threats to human health and well-being that he or she identifies through his or her professional work and expertise” [11]. This definition of advocacy recognizes that while the scope of acceptable actions to be taken by physicians might be broad, the focus is necessarily limited to those topics relevant to health and well-being and that are within the realm of the given physician-advocate’s area of expertise.

On such matters pertaining to health, therefore, physicians should be supported by their colleagues and professional societies in their efforts to inform their patients and communities about the health effects of even politicized phenomena such as climate change. As advocates, physicians can strive to shed light on the health effects of climate change while acknowledging that greenhouse gas-emitting activities involve a trade-off between values—economic prosperity versus health—that are to be ultimately weighed collectively by society as a whole. We agree with Huddle that physicians’ health expertise does not necessarily “privilege their assessment of those [health care] needs in relation to other societal needs” [12]. Yet it is well within the duties of the medical profession to ensure their knowledge enters the public domain where weighing of values can properly take place and the debate can be better informed.

Of course, physicians, like other citizens, have a right to be civically engaged within their communities and to hold political views. Notwithstanding, they have a professional obligation to give unbiased medical advice that is both in the best interest of their patients and based on sound evidence. Therefore, it is important to be clear when a physician is acting as an expert on health matters or as a citizen on general civic matters. This distinction earns and protects the trust given to physicians by society and reduces the threat of personal bias that undermines neutrality and objectivity.

Dr. Schwartz demonstrates medical expertise about respiratory disorders and specifically limits his professional expression of concern to such health impacts of climate change, whether his concerns regarding climate change as a private citizen might be broader. Therefore, Dr. Schwartz, in this case, models the appropriate scope of physician advocacy.

Benefits of Physician Advocacy

Physician values such as trustworthiness, integrity, honesty, and transparency, while intrinsically valuable, also serve to reduce unnecessary paternalism and promote patient knowledge and self-advocacy. Dr. Schwartz and his colleagues hesitated in the past to discuss the health effects of the coal-burning power plant for fear of influencing the politics and economy of the community, especially because the power plant is a major employer. However, physicians are unable to predict what decisions patients and communities will make based on such information. It is safe to assume that everyone wants clean air and water and good health, although no assumptions can be made regarding people’s awareness of health issues related to pollution and climate change. Ultimately, avoidance of important topics does not serve patients or the community. Withholding health information for nonhealth reasons disempowers patients and hampers them from making their own value choices. Even if well intentioned, physicians should not decide what trade-offs are acceptable to patients and the community when health and economics conflict. Howard Koh gives compelling reasons why physician communication about the health effects of climate change is vital to both individuals and communities [13]. Such communication can help communities develop adaptation and preparedness strategies to reduce vulnerabilities in the presence of climate change, lead to mitigation strategies to reduce greenhouse gas emissions and other pollutants, help educate those with cardiopulmonary disease to look for indicators of poor air quality and environmental triggers, and identify those vulnerable to heat waves and other extreme weather events and help them find ways to manage the risks [13].

Some have framed the issue of climate change mitigation as one of “climate justice” and cite rurality and socioeconomic status as additional vulnerabilities [14]. Climate change is predicted to drastically worsen regional and international health inequities [14-16]. Rural physicians, like Dr. Schwartz and Dr. Rizzo, are crucial in mobilizing their knowledge of health disparities and health needs of their communities to help mitigate climate change, and all physicians are well positioned to understand the health effects of climate change related to their area of expertise, to raise awareness, and to advocate for their patients.

When Disagreements Exist within a Practice

In addition to raising concerns about how individual physicians should manage issues like health effects of climate change, this case also presents the challenge of how a physician group practice should respond when there is disagreement among members of the group. One view would be that group practices are simply composed of individuals who cooperate primarily in terms of financial and administrative matters and that each member should be free to respond to issues like health effects of climate change in whatever way is most consistent with his or her values. Another view would hold that group practices ideally reflect a shared approach to the practice of medicine overall and that patients should be able to expect the same general philosophical approach to care regardless of which physician they happen to see. In reality, most group practices probably adopt an approach that is somewhere between these two extremes. In this way, they have an opportunity to model the principles of “deliberative democracy,” a strategy endorsed by many political scientists for society as a whole [17-19]. This approach emphasizes the importance of authentic deliberation on areas of disagreement rather than more mechanistic approaches to conflict resolution such as voting and majority rule [17, 18].

In adopting this approach, the physicians in the group practice might augment their personal conversations with patients with either a letter that could be sent to all of their patients or a pamphlet that could be placed in the office waiting room that mirrored the principles of deliberative democracy by describing the known medical facts about climate change and health while acknowledging that ultimate decisions about the trade-offs between community health and economic viability are questions that need to be determined by the community at large. Such a letter or pamphlet would indicate that while the practice was speaking with “one voice” about the medical aspects of climate change, it was not taking a stand with regard to the broader questions of how best to manage the trade-off between economic, cultural, and health-related risks and benefits.

Conclusion

Although difficult, discussion of the health implications of certain politicized topics, such as climate change, has potential benefits that outweigh potential risks. Potential benefits include the promotion of knowledge and empowerment of individuals and communities to make their own value choices, as well as advancement of public health initiatives such as preparedness and climate change mitigation strategies. However, there is a distinction between physician advocacy and civic engagement as a private citizen. Maintaining a clear boundary between these two roles serves to diminish threats to neutrality and objectivity that would undermine patient and community trust. Physician-advocates should remain focused on areas directly relevant to health and well-being and acknowledge that value trade-offs are to be weighed by society. Because physician-advocates benefit patients and communities, they should be supported by their colleagues and professional societies. When disagreements exist within group practices regarding how to approach politicized health topics, the principles of deliberative democracy could prove especially useful for resolution.



References

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Diana Alame, MD, MBE, is an assistant professor of pathology and the medical director of the clinical microbiology laboratory at Thomas Jefferson University in Philadelphia. She is a clinical pathologist and a bioethicist trained at the Harvard Medical School’s Center for Bioethics.

Robert D. Truog, MD, is the Frances Glessner Lee Professor of Medical Ethics, Anaesthesia, & Pediatrics at Harvard Medical School in Boston, where he directs the Center for Bioethics. He is also a senior attending physician in the Medical/Surgical Intensive Care Unit at Boston Children’s Hospital, where he has practiced for more than 30 years.

Are Physicians Obliged to Lead Environmental Sustainability Efforts in Health Care Organizations?, December 2017

The “Buy One, Get One Free” Ethics of Investing Public and Philanthropic Funds in Health and Climate, December 2017

Climate Change and Human Health 101, June 2009

Greener Clinics, Better Care, September 2014

The Importance of Physician Climate Advocacy in the Face of Political Denial, December 2017

Medicine’s Role in Mitigating the Effects of Climate Change, June 2009

Should Health Professionals Speak Up to Reduce the Health Risks of Climate Change?, December 2017

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 in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.