From the Editor
Sep 2014

Treating Presymptomatically

Audiey C. Kao, MD, PhD
Virtual Mentor. 2014;16(9):691-693. doi: 10.1001/virtualmentor.2014.16.9.fred1-1409.


On April 4, 1967, Dr. Martin Luther King, Jr., delivered his “Beyond Vietnam” speech at New York’s Riverside Church. In this controversial address, Dr. King made the moral argument that the war on poverty was being threatened by the Vietnam War.

There is at the outset a very obvious and almost facile connection between the war in Vietnam and the struggle I, and others, have been waging in America. A few years ago there was a shining moment in that struggle. It seemed as if there was a real promise of hope for the poor—both black and white—through the poverty program. There were experiments, hopes, new beginnings. Then came the buildup in Vietnam and I watched the program broken and eviscerated as if it were some idle political plaything of a society gone mad on war, and I knew that America would never invest the necessary funds or energies in rehabilitation of its poor so long as adventures like Vietnam continued to draw men and skills and money like some demonic destructive suction tube. So I was increasingly compelled to see the war as an enemy of the poor and to attack it as such [1].

Some closest to Dr. King questioned the wisdom of making such a link, concerned that it would undermine his role as a civil rights leader. Lifemagazine called the speech “demagogic slander that sounded like a script for Radio Hanoi” [2], and the Washington Post declared that King had “diminished his usefulness to his cause, his country, and to his people” [3]. For many commentators at the time and most likely even today, a preacher simply has no place in the world of foreign policy.

In this month’s issue of Virtual Mentor (VM) we explore the ethical landscape that shapes our understanding of physicians’ role in addressing the myriad nonmedical factors that affect human health, such as poverty and economic justice, climate change and environmental stewardship, and marriage equality and human rights. Like the critics of Dr. King’s anti-Vietnam War fight, there are some who think physicians have no obligation to address nonmedical factors that may negatively affect the health of their patients. With little authority or expertise to speak or act on such “non-bedside” matters, there is the danger that well-intentioned physicians may overreach. On the other hand, these social, economic, and environmental ills threaten the health and welfare of the public. Ignoring them would be like treating the symptoms of a disease and not its root causes, and that is not an ideal way of practicing medicine.

In this VM issue, authors examine the responsibilities and limitations of physicians’ acting as agents of change in matters that go beyond the bedside but have profound impacts on the public’s health.

What considerations should physicians take into account when deciding whether to speak out on a health-related matter on which they may have little or no expertise? Reflecting on a personal situation that raised this exact dilemma, Matthew Wynia provides some practical insights on what physicians should weigh before deciding to speak up. In the same vein, what kind of on-site rules and policies should medical schools and residency programs have for students and housestaff who want to voice their views on social policy debates like same-sex marriage? Mark Kuczewski offers ethical guidance for medical faculty and administrators that is grounded in the role of physicians and the medical profession in educating the public about the health consequences of laws and regulations. Martin Donohoe and Gordon Schiff explore the tension that arises between patients and physicians when they have different stances on social policy, and they suggest how to minimize the possible adverse effects of those differences on the therapeutic relationship.

Can a propensity for activism among physicians be taught? Joshua Freeman examines the importance of physician social activism and the need for physicians to acquire the relevant knowledge and skills to be more effective advocates. While there is no accreditation standard requiring medical educators to impart various “activism” competencies, Bharat Kumar recounts how the Robert Wood Johnson Clinical Scholars program served for four decades as an educational springboard for physicians who sought to be agents of change in their communities. Rebecca Lunstroth and Eugene Boisaubin share insights on using team-based learning to teach medical students about topics such as social justice, resource allocation in health care, and social determinants of health.

Several articles in the issue discuss health-care-related social advocacy by physicians. Joseph Gregorio examines the legal landscape in which physicians who recommend medicinal marijuana to patients find themselves. Cristina Richie explores the relatively short history of efforts to quantify and reduce the environmental impact of health care through the lens of seminal publications on the topic. Philip Perry highlights current efforts by hospitals and other medical organizations to reduce their carbon footprints.

Other articles discuss physician activism and service outside the world of medicine. Ira Helfand, Antti Junkkari, and Ogebe Onazi discuss physician efforts to end the use of nuclear weapons and remind our readers of the devastating impact their use would have on humanity and the environment. In this month’s podcast, Rajiv Shah reflects on how being a physician informs his role as the administrator of the United States Agency for International Development. John Dittmer provides a historical account of physicians who volunteered to care for civil rights advocates who braved the segregated South during “Freedom Summer” in 1964. Finally, Catherine Thomasson argues that the only way for physicians to really address the causes of their patients’ conditions is to serve as agents of social change.


  1. King ML. Beyond Vietnam: A time to break silence. Accessed January 22, 2014.

  2. Dr. King’s disservice to his cause. Life. April 21, 1967:4.

  3. A tragedy. Washington Post. April 6, 1967:A20.


Virtual Mentor. 2014;16(9):691-693.



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