It’s a question that every medical student, resident, and physician grapples with at one time or another, and one that became important to me almost as soon as I entered medical school. What role should I have in my patient’s lives? As a physician, what role should I play in my family, my community, and my society?
Few would claim that choosing these roles is easy or intuitive. There are expectations at my institution (and I think generally) that physicians should be: competent clinicians, ethical decision makers, cost controllers, nurturing caretakers, creative researchers and scientists, teachers to students and patients, avid followers of current health-related events, counselors, businessmen and women, and advocates for their patients. Fulfilling any of these roles requires reflection and effort, but the one I find I have the most interest in and the least guidance for is the last. The importance of physician involvement in the local and national community is taught in my classes; indeed, planning and executing a community health project in partnership with an organization in our local community is a required part of the curriculum. However, there seems to be little real consensus among physicians or the public at large that every physician should have a significant public advocacy role beyond the individual patient-physician encounter. When should physicians choose this role?
The central question of this issue of Virtual Mentor is: when does medicine’s social contract with society require an ethical physician to take a public role (defined as a role beyond the patient-physician encounter) in advocating for the health of his or her community? Conversely, are there times when this is inappropriate or ought to be avoided? If physicians take public roles, what ethical values should guide their public involvement?
These questions are of crucial importance for 2 reasons: the public realm is increasingly influencing the individual patient-physician encounter, and physicians are uniquely equipped to advise their communities on pressing public health issues.
Contemporary society influences every aspect of physicians’ lives, whether they choose to participate in public advocacy or not. Patients come with questions about pharmaceuticals they’ve heard about through direct-to-consumer advertising. Medical ethics cases like that of Terri Schiavo permeate the news. Patients can find medical advice that may or may not be sound from a variety of popular media. Insurance companies and employers can impose pressure to keep patient visits short and broadly curtail health care costs. How ought we as individuals and as a profession to respond?
Recent history has given rise to more pressing public health concerns. Society seems to be asking physicians for answers to social problems that lie within their purview: how ought we to prepare for bioterrorism or an infectious epidemic? How should the problem of the uninsured and underinsured in the United States be solved? What are we to do about the epidemics in our midst: obesity, diabetes, and heart disease? Are stem cells going to live up to their promise? Should intelligent design be taught in schools alongside evolution? These are questions individual physicians will be asked in their offices and social settings, and “expert” physicians or professional medical organizations will be asked in a public setting.
Where can one turn for guidance? We looked to members of the President’s Council on Bioethics, the senior health correspondent at CNN, physician members of Congress, medical school deans, bioethicists, medical sociologists, American Medical Association staff, and of course, physicians who struggle to maintain professional and public advocacy roles. I am very grateful for their time and their willingness to share their ideas with me and now with you, the reader. Their ideas are sure to elicit even more questions, but perhaps the best way to try to define our public role as physicians is to begin the dialogue and see where it leads us.