AMA Journal of Ethics^®

Just as a significant proportion of the American public is deliberately disengaged from current events and elections, many physicians and medical students find politics repugnant. At a recent lecture on effective lobbying techniques for physicians, for example, a good number of my colleagues left the talk even less inclined to participate in advocacy than they had been an hour earlier. Many were incensed to hear about the importance of becoming skilled at executing "elevator talks" and the value of making donations to local candidates' campaigns. Some remarked that the talk only bolstered their view of politics as "the dirty way of getting things done." They left the lecture seeing no role for a competent and compassionate clinician in public affairs.

These remarks are distressing and represent the views of all too many medical professionals and students. Part of this attitude is derived from the general public's skepticism of politicians, but some of it stems from the primacy that our profession assigns medical services in the lives of patients. We often believe that the opportunity for restoration to baseline health is the most important thing that can be done. In reality, however, there are other issues in patients' lives that are at least as important to them as any remedy clinical medicine can offer. The antibiotic prescribed for a 30-year-old single mother's urinary tract infection, for example, may be less important to her than finding a job that pays a living wage, her inability to secure affordable day care for her 2 children, and her wish that she lived in a safer neighborhood. The hernia repair operation performed on a 45-year-old laid-off factory worker may be less important to him than his lack of health insurance, his need to acquire skills in order to find a new job, and his concern about retaining affordable housing while unemployed.

These concerns—and the countless other social, economic, and public health issues that medical professionals ought to be concerned about—are not problems that physicians can solve through the conventional means of writing a script or executing a well-crafted treatment plan. They are, however, problems that significantly affect our patients' well-being perhaps more than the ones we treat within the walls of our clinics and hospitals. If we are truly dedicated to improving the lives and well-being of our patients, and if we honestly care enough about the vulnerable persons that have trusted us to care for them, we have an obligation not only to provide health care of the highest quality, but also in some way, shape, or form to be active in public policy changes needed to better their lives.

In addition to the obligation to advocate for our patients, we also have rights as professionals to advocate for ourselves and our own best interests. Indeed, many physicians' main venue for participation in advocacy is through membership in one of many professional organizations such as the American Medical Association, a state medical society, or a specialty association. This type of activism differs from public health activism and advocacy on behalf of disadvantaged patients but is just as necessary. In fact, the current malpractice insurance crises in many states demonstrate that if physicians do not advocate for themselves, they and their families may be left devoid of the livelihoods that they have worked hard to attain.

While a necessary part of medicine, physician activism is rife with ethical conflicts. Dilemmas can arise when either advocating for patient health or professional self-interests infringes on physicians' other ethical duties. Sometimes these 2 motivations are even in direct opposition to one another. Physicians also have a responsibility to maintain high ethical standards in the practice of activism inasmuch as they often wield substantial influence in the public policy process by virtue of their professional status. Polls of the general public consistently show that physicians constitute one of the most trusted professions, and policymakers' views generally seem to coincide. When advocating on behalf of patients, physicians are often seen as providing first-hand expert knowledge. When advocating on their own behalf, physician activism is very well-funded, an unsavory but important factor in today's political environment. Indeed, in both national and state political arenas, physician associations represent some of the most powerful advocacy groups in existence. This significant credibility and power offer enormous opportunities for impact but demand restraint if ethical standards are to be upheld.

This issue of Virtual Mentor seeks to address these opportunities and conflicts by exploring what activism should look like, where its ethical boundaries should be drawn, and how medical students and young physicians might appropriately participate. A special question-and-answer feature with 2 prominent physician-policymakers Dr. Antonia C. Novello, the Commissioner of Health for the State of New York, and Dr. Mark McClellan, FDA Commissioner, provides insight into the lives and thoughts of physicians who are making significant impact in both clinical medicine and public policy. Commentaries by ethicists and physicians on 3 clinical cases consider and seek to further define the appropriate roles and limits of physicians ' participation in civil disobedience, work stoppages, and political pursuits. In complementary opinion pieces, Drs Howard Brody and Nancy Dickey take opposite sides in response to the question "do physicians have an obligation to participate in the profession's national organization?"

In a special feature, our professional colleagues from the Korean Medical Association share a frank and disturbing—yet hopeful—account of the results of collective physician activism in their country in 2001. And a Policy Forum essay explores the ways in which civil disobedience both threatens and strengthens the fabric of civil society. Finally, 2 pieces specifically address the next generation of physician-activists—medical students. A review by Braden Hexom of the American Medical Student Association examines the roots of medical student activism as well as contemporary movements in which students are involved. Dr. Peter Lurie and colleagues describe an innovative approach currently being used at several medical schools to educate and nurture the next generation of physician activists.

In spite of the aversion of many physicians and medical students to politics, there are countless physicians who are making public policy an important—and even a central—part of their careers. Dr. Bill Frist, a transplant surgeon, is now the Senate majority leader. Dr. Howard Dean, an internist, is currently campaigning to become president of the United States. Dozens of physicians hold elected office in the United States House of Representatives and the nation's 50 statehouses. Hundreds more in private practice have captured the attention of national media and policymakers through highly publicized work stoppages to protest the malpractice insurance crisis.

Clearly not every physician can or should be expected to seek the public policy influence and visibility of Drs Frist or Dean. But certainly there are gradations of activism that we should all aspire to and on which the futures of our patients and our profession depend. It is my hope that these role models and the articles contained in this issue can offer new perspectives on physician activism as well as inspire readers to envision ways that they can effectively contribute to both medicine and public policy.

The learning objectives for this issue are:

• Understand physicians' obligations to engage in advocacy.
• Recognize conflicts between physicians' rights as private citizens and responsibilities as clinicians.
• Understand ethical boundaries of physician participation in the public policy process.
• Identify appropriate ways in which physicians can participate in activism and advocacy.