AMA Journal of Ethics^®

Case

Dr. Molleur is a family doctor in a state that accepts federal funding for abstinence-only sex education in its public schools. She believes that abstinence-only sex education is harmful to adolescents and to society because it results in unplanned pregnancies, the spread of STDs, psychological harm to those who don’t conform to the norms of the curriculum, and reversal of decades of progress in the social status of women and gay people.

Dr. Molleur submits a resolution for consideration at her state medical society’s annual meeting entreating the society to adopt a position urging the state’s governor to reject federal funding for abstinence-only education programs and to replace them with comprehensive sex ed, which would include abstinence but also cover such topics as correct use of condoms. Her resolution discusses not only what she views as problems with the factual information in the abstinence-only curriculum (for example, the assertion that HIV can get through pores in condoms) but also her objections to the sexual mores promulgated in the abstinence-only curriculum (for example, that nonmarital, nonheterosexual sexual activity is likely to have harmful psychological and physical effects and that abstaining from sexual activity outside of marriage is the expected standard). “This,” her proposal concludes, “is misinformation, and, as highly educated professionals devoted to promoting the health and welfare of the public, we have a responsibility to combat the teaching of inaccurate and problematic beliefs.”

Getting a cup of coffee before the meeting begins, she runs into her friend Dr. Baxter in line and asks him, “Did you see the resolution I submitted?”

Dr. Baxter hesitates. Eventually he says, “I did see it. But I’m not sure I’m with you on this. Is it appropriate for a physician group to be making judgments about what constitutes healthy or normal—or moral—sexual behavior? Who are we to prescribe sexual norms for society?”

Commentary

The difference of opinion between Drs. Molleur and Baxter illustrates the complex nature of physician engagement with public issues related to health. Sex education can have important health implications, but it is a topic not easily separated from the social and moral dimensions of sexuality—opinions on which vary widely in society [1]. Dr. Molleur is rightly concerned that young people could be misled and acquire preventable health problems because her state’s sex education program does not accurately and fully reflect the knowledge that medicine has worked to discover and make available. Dr. Baxter presents an equally valid concern: that the resolution may exceed the physician group’s mandate by championing certain social or moral viewpoints over others. To resolve these issues, the medical society will have to consider its public engagement in the context of two ethical duties: the stewardship of medical knowledge and an unbiased presentation of health information in the public domain.

Medical Knowledge and the Duty of Stewardship

Given their unique education, training, and experience, physicians acquire specialized knowledge and privileges. Along with this, physicians incur responsibilities. Among them is a duty to steward medical knowledge to inform society as it decides public issues of health importance [2, 3].

The concept of stewardship in medicine is often used in the context of the responsible allocation of limited health-related resources. However, stewardship—the notion of safeguarding the valuables of others—can apply more broadly in medicine. Medical knowledge, for example, is a public good that is advanced, preserved, and promulgated primarily by the medical profession. If medical knowledge is to retain its public value, physicians must work collectively to ensure the integrity of this knowledge, speak candidly about its limitations, and communicate it willingly when appropriate. Stewardship of medical knowledge is critical to meriting public trust in the collective voice of medicine as the authority on questions of health. It is this trust that ultimately allows physicians the opportunity to influence public debate.

However, physicians must humbly accept that society may need to weigh the interests of health against other concerns and in so doing may adopt policies that do not promote health per se. If physicians as a profession advocate for specific policies they run the risk of being seen as narrow-minded or mischaracterized as yet another interest group competing in the political arena. Such a perception could jeopardize the public trust upon which the real opportunity for physicians’ impact is predicated—that of a neutral and objective voice that merits the public’s attention and respect.

Championing a specific policy presumes the capability to perform the economic, cultural, and moral—among other—calculations necessary to determine if the policy is a wise way forward for society. Despite profound knowledge about health, the medical community may not be equipped to make these calculations. Moreover, while physicians might achieve consensus regarding a policy’s implications for health, diversity of opinion concerning the relative merits of nonhealth considerations make policy advocacy by the medical community a challenging, if not divisive, proposition.

Public Trust and Physician Neutrality

It is appropriate to examine physicians’ roles and responsibilities in the context of the physician-patient relationship as an entry point into a discussion of an ethical framework for physicians’ broader engagement with society. In the clinic, a physician’s advocacy of healthy choices and behaviors should be neither coercive nor manipulative but, rather, take place in the context of a conversation that is forthright, scientifically informed, and considerate of patient values and goals. In short, the physician must act with due regard for the autonomy of the patient, informing him or her and letting him or her make decisions based on that information [4]. Truly respecting autonomy requires that the physician honor a duty to render therapeutic care no matter the patient’s choices.

Similarly, the profession of medicine should focus on providing relevant and objective information to the public and public servants about the consequences of policies so as to aid democratic decision making. Medicine’s duty to promote health is balanced by a duty to uphold the autonomy of those whom medicine seeks to help. By the nature of the specialized knowledge it stewards, the medical profession exerts significant social authority. This authority must be wielded cautiously; it offers the opportunity to bring important health issues to the public’s attention, but it may also permit manipulation of the public discourse at the expense of other viable concerns. Moreover, certain policies (e.g., prohibitions on the consumption and sale of certain foods or beverages or behaviors perceived as personal health risks) may be proscriptive—in effect limiting the autonomy of individuals or segments of society to make choices [5]. While it may be appropriate for society to affirm such proscriptions in the context of public debate, I posit that direct support of proscriptive measures conflicts with physicians’ duty to uphold autonomy. Rather than advocate for specific policies, physicians should educate the public and public decision makers about the health implications of policy choices.

Resolving These Concerns

Dr. Molleur’s proposal presents an apparent conflict between the two principles outlined above for physician engagement of public issues: stewardship of medical knowledge and political neutrality. When speaking out in their professional capacity, physicians should willingly provide full and accurate medical knowledge to inform public deliberation but avoid advocating for proscriptive policy positions to give due regard to social dialogue on such issues.

Dr. Molleur’s resolution is intimately tied to the idea of stewardship of medical knowledge. Observing misinformation and incompleteness in the current sex education program, she calls upon her colleagues to unite and fulfill their duty to “combat inaccuracies and problematic beliefs.” However, Dr. Molleur’s resolution does not merely call decision makers’ attention to the inadequacy of the current system and initiate a public dialogue. Instead, she specifies and supports a new education paradigm that fulfills health-related goals. The scenario highlights the important distinction between disseminating knowledge and advocating for a particular policy.

But the scenario is complicated by the informational component of sex education: the prevailing policy provides information to young people inconsistent with medical knowledge. If physicians do not speak out on this issue, they risk violating their duty to inform and bring accurate medical knowledge into the public sphere. In determining the extent of their involvement, physicians will need to engage the question of young people’s right to access the best available medical knowledge [6]. However, going so far as to prescribe a new educational paradigm may conflict with other nonhealth-related concerns that society may be compelled to consider regarding how sexual education is pursued. These may include the rights of parents or local sociocultural mores. Although nonhealth concerns may conflict with physicians’ perspectives on health promotion, an attempt to bypass the broader debate in society by putting the profession’s weight behind a particular measure may initiate an adversarial relationship between medicine and other interests in society, generate social and political resentment of the medical profession, and undermine future efforts to inform the public.

Conclusion

To resolve the conundrum of how physicians should fulfill their duty to steward medical knowledge without overstepping their role, the physician group should educate lawmakers and the public on the factual inconsistencies in the current sex education program and the potential negative health consequences of this failure to properly inform young people. In the end, it is the purview of the legislature to take this information conveyed by physicians into account and weigh the health issues against other concerns.