Nov 2011

Physician Involvement with Politics: Obligation or Avocation? Commentary 1

Thomas S. Huddle, MD, PhD
Virtual Mentor. 2011;13(11):757-761. doi: 10.1001/virtualmentor.2011.13.11.ccas2-1111.

Case

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

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. Kuo AA, Arcilla L, Castro A, et al. 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.

Citation

Virtual Mentor. 2011;13(11):757-761.

DOI

10.1001/virtualmentor.2011.13.11.ccas2-1111.

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.