AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. January 2004, Volume 6, Number 1.

Op-Ed

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Physician Activism--An Obligation or Filler for Spare Time?

A past president of the AMA discusses the obligations of physicians to participate in health and social activism.

Nancy W. Dickey, MD

According to Webster's dictionary, an obligation is a "moral or legal duty, the act of obligating oneself or a debt of gratitude." As I pondered those words, I wondered if concurring that membership in medical organizations is an "obligation" was too strong a word. I decided that obligation is indeed just the right word. Physicians—and physicians in training—should feel an obligation to support and to be a member of those organizations that are committed to advancing and enhancing medical education, representing physicians, and establishing and upholding the ethical framework of the profession as a whole.

Medical organizations have been formed for many purposes but most often to advance the science, ethics, or educational standards of the profession or some subset of the profession. More than 150 years ago, the American Medical Association (AMA) was formed in an attempt to bring physicians' collective voices together to speak out for improvement in educational quality and standards. Organizers of the AMA also sought to establish an ethical framework that would assure patients that the profession stood for commitment to patients and quality of care. In more recent years, representation and advocacy for physicians and patients has been an increasingly predominate activity of the AMA.

The ethical code written as a result of that first meeting spoke vehemently to the importance of putting patient welfare first, caring for the poor, and identifying the incompetent (ie, the "quacks") within the ranks of medicine. Since then, the AMA's Code of Medical Ethics has been continually revised and expanded. It has become the standard in court rooms, state medical licensing boards, and other civic arenas, as well as the foundation for ethical norms within virtually all medical organizations. The creation and maintenance of ethical standards is one of the characteristics that initially set medicine apart as a profession, rather than merely a career.

Physicians have responsibilities to themselves, their profession, their patients, and their communities. To fully meet their obligations to any or all of these groups, participation in organizations that represent them is virtually obligatory. The standards by which physicians judge whether or not they have satisfied their obligations cannot be established individually but must be created by a group—preferably the whole group. This process requires an organization. Webster defines standards as "measures used as the basis for judging value, quality, or extent of." During a time when the medical profession and the public are concentrating on quality and variations of care, it is important to have guidelines not only for beta blockers after an MI, but also for physician relationships with pharmaceutical companies, HMOs, and patients. Just as we turn to evidence-based medicine to help patients select among therapeutic options, there should be some standard for weighing ethical stance—a standard that is generally recognized and authoritative.

It takes more than a single voice to create the standard for the profession. Indeed, it takes many voices finding a basis for agreement, and then creating an expectation of adherence to that standard. Defining the medical profession's collective voice is the job of the AMA's House of Delegates (HOD). The HOD is a representative body whose members are selected by the principal governing body or the memberships of state and specialty medical societies and the corps of military physicians. As with representatives in the US House, the number of representatives from each association is based on its physician membership in the AMA. And, again, as in the US Congress, representatives generally vote in accord with the wishes of their constituencies. If non AMA members think that the AMA resolutions and advocacy agenda do not reflect the interests and concerns of the majority of today's physicians, there is a reason for that: the majority of today's physicians are not AMA members. And there is a solution to the problem: those US physicians who do not feel represented by the AMA should join and have their voices heard because the AMA is still the national organization of physicians with both the largest and the broadest membership, and, hence, the profession's strongest voice.

Like legislative groups in all representative forms of government, the AMA House of Delegates experiences tension between enacting resolutions that reflect current membership opinion and attempting to lead its constituency to higher standards of professional and ethical conduct. This tension and the sometimes rancorous deliberation it produces are the essence of the democratic process, though not the most direct or efficient path to change and improvement. As Winston Churchill said, "No one pretends that democracy is perfect or wise. Indeed, it has been said that democracy is the worst form of government except for all others that have been tried." For the deliberative process to work effectively in the best interest of those represented, everyone—or at the least, a sizable majority of the represented—must participate. What AMA's detractors often allege about the association's advocacy positions is similar to what disgruntled voters describe when their candidates or issues fail to win majority support because, unfortunately, the majority did not vote. The process can be slow and frustrating but its ability to succeed is demonstrated by students changing the investment policies of the AMA toward socially sensitive investment and the addition of a ninth principle to the 156-year-old "Principles of Medical Ethics" in June 2001 that declares, "A physician shall support access to medical care for all people."

Though medicine today often seems to be a conglomeration of multiple professions rather than a single profession, in reality we share the same obligations to our patients and society and the same challenges in meeting those obligations. We must have a process and a place where we can discuss—vociferously if necessary—our differences, seek common solutions, and resolve conflicts, and it should occur within the family. The American Medical Association is the best resource for all of the above that is currently available to us. If the organization is not what we wish it were, or if it is not all that it could be, the fault lies with us, with the profession. Our patients deserve a strong profession with a strong voice to advance their care. Our colleagues—and we as physicians and physicians-in-training—deserve a strong profession with a strong voice to represent both our ideals and our needs. Having taken advantage of the stature, the better-than-average income, and the respect that comes with being a physician, it is our obligation to give back. And one of the most important and effective ways to give back is to help assure a strong profession speaking to the right issues, with the right perspective and the right priorities. This situation is perhaps possible by working as individuals, but it is more likely to occur when we combine our efforts as a group that works together through an organization. That organization will best serve its purposes for both the profession and the patient if many perspectives are present to be honed into collective, representative, and articulate positions.

Nancy W. Dickey, MD, is president of the Texas A&M Health Science Center and Vice Chancellor for Health Affairs for The Texas A&M University System. She is founding program director of the Family Practice Residency of the Brazos Valley, professor of family and community medicine at the A&M Health Science Center College of Medicine, and a past president of the American Medical Association.

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