Virtual Mentor

Virtual Mentor. October 2011, Volume 13, Number 10: 690-696.

Clinical Cases

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Physicians and Political Advocacy

Physicians may involve themselves in political advocacy as long as it does not damage patient relationships or erode access to health care. They may, in fact, have an obligation to do so.

Commentary by Thomas A. Bledsoe, MD, and Grayson W. Armstrong

It is October in the American Southwest, and Mrs. Feldman is watching playoff baseball on TV. Between innings, she notices her gynecologist, a well-respected professional who delivered both of her children as well as those of her sister, in a political advertisement.

This is an election year, and, in the 30-second spot, the physician speaks on behalf of a state proposition that would curtail public services, including education benefits, to illegal immigrants and their noncitizen dependents. His name appears under the image of a graying man dressed in a sharp polo shirt and khakis.

“Hi, I’m Dr. Seligman. I’m a lifelong resident who has been practicing medicine in this state for 20 years, and we need your support in saving American tax dollars,” he says.

Mrs. Feldman, who strongly disagrees with the proposition, is upset to see the doctor she likes and respects taking this view. The next week, she goes to Dr. Seligman’s office for a routine exam. The office’s walls are decorated with artistic renditions of the fetal stages of pregnancy; there are no posters or campaign literature visible. After she grumbles her protests of the doctor’s television appearance to the admitting nurse, who commiserates, Dr. Seligman arrives. There is no discussion of political topics, but she remains disconcerted by Dr. Seligman’s using his position and the respect people have for him to promote this political action.

Commentary 1

by Thomas A. Bledsoe, MD

This case raises questions about the public activities of physicians outside of the practice of medicine. When and how is it appropriate to use one’s status as a physician in nonmedical affairs?

In this case, Dr. Seligman is presented as a “well-respected professional” and his patient is disturbed by his use of that respect (presumably both for him as an individual and for the profession to which he belongs) to further aims not related to the practice of medicine. I would like to start analyzing the case by considering why he is well-respected. What has Dr. Seligman (or his profession) done to earn that respect? The code of professionalism endorsed by the American Board of Internal Medicine, the American College of Physicians and the European Federation of Internal Medicine defines professionalism as

the basis of medicine’s contract with society. It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health [1].

The profession earns respect as a result of the knowledge base accumulated by members of the profession over time and its commitment to use it for the good of society. The “well-earned respect” may stem from Dr. Seligman’s scientific approach to the practice of medicine, to his contributions to the field or to his ability to put the interests of his patients before his own interests.

While one could certainly imagine the good doctor having applied the scientific method to his personal study of the issues around funding education and other services to illegal immigrants and his having made significant contributions to our understanding of these issues, none of this is presented in the vignette. By contrast, Dr. Seligman seems to be simply trading off his well-earned high standing in the community in the practice of medicine to attempt to speak with authority in areas outside of medicine. His use of the honorific “doctor” in his self-introduction appears to be an attempt to present himself as an authority figure in this area as well, perhaps fraudulently.

In this respect, Mrs. Feldman would be right to question the authority of the physician as spokesperson for a political cause. At the same time, a desire to view him with skepticism as a physician would be misplaced. Why should his desire to speak outside of his area of highest expertise and credibility call into question the respect she has for him within his scope of practice? It certainly would be within her rights to accept care only from physicians with whom she shares political opinions, but this would be foolhardy.

The second issue in this case relates to a possible obligation, arising from the precepts of professionalism, to speak out, even on topics not directly related to the practice of medicine. In addition to the privileges granted to members of the profession, there are also responsibilities and obligations. As physicians, we have privileged access to information, both at a personal level and at a systems or societal level. With that privilege comes responsibility, and sometimes that responsibility involves actions not traditionally related to the practice of medicine, even in the broader “professional” sense. Dr. Seligman may be aware, to an extent that few others in his community might be, of the degree to which services to various groups of legal residents are being curtailed as a result of efforts to provide these or other services to residents who are not in the community legally. Dr. Seligman may think it is wrong to keep silent in the face of his knowledge of these situations. (In the words of James Dwyer, “primum non tacere”—first, be not silent [2].)

In sum, there are many perspectives to consider. Dr. Seligman must first consider whether his experience as a physician gives him some insight on policy that others do not have. If so, it would seem defensible at least to mention his experience as part of his credentials. If not, then it would seem inappropriate and perhaps even paternalistic in the old-fashioned sense, now generally seen as negative, to try to make the case that “doctor knows best,” especially if the issue is not related to the profession.

Finally, if he considers himself an expert, then he must weigh carefully the positive and negative effects his political activity will have on his relations with his patients. Some, like Mrs. Feldman, may find that the therapeutic relationship she has had with her physicians over the years is compromised by his advocacy. Others may seek out this doctor because of his political positions. Either way, the relationship becomes more complicated and perhaps less therapeutic.

In the end, I am reassured by Dr. Seligman’s apparent separation of practice and political positions—no pamphlets in the office—but am discomfited by his presenting himself as both an expert and maybe even as a representative of the profession in the political advertisement, especially as the issue seems distinct from medicine.



References

  1. American Board of Internal Medicine; American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136(3):243-246.
  2. Dwyer J. Primum non tacere. An ethics of speaking up. Hastings Cent Rep. 1994;24(1):13-18.

Thomas A. Bledsoe, MD, is a clinical associate professor of medicine at Warren Alpert Medical School of Brown University in Providence, Rhode Island. He is also a primary care internist with University Medicine, the chair of the Rhode Island Hospital Ethics Committee, the governor of the American College of Physicians’ Rhode Island chapter, and co-chair of the steering committee of the Chronic Care Sustainability Initiative, Rhode Island’s multipayor patient-centered medical home pilot program.

Commentary 2

by Grayson W. Armstrong

Should a physician use his credentials as a doctor to support explicit political viewpoints even though this may generate ill feelings among his patients? Physicians have a long history of involvement in politics. Doctors were a part of the push against socialized medicine in the 1940s just as they are currently voicing their diverse opinions on health care reform. Mrs. Feldman’s negative reaction to Dr. Seligman’s ad illustrates the importance of paying attention to political involvement by physicians.

There are many points to consider: whether or not it is acceptable for physicians to publicly support legislation; whether or not the content of the legislation plays a role in that acceptability; when, if ever, physicians should discuss political matters with their patients; who, if anybody, should be responsible for deciding whether legislation is appropriate for physicians to support; whether anyone should intervene if physicians’ political stances are perceived to exceed boundaries for professional involvement; and whether the legislation in this case falls in line with Dr. Seligman’s ethical responsibilities.

Physicians’ Civic and Professional Rights and Responsibilities

Dr. Seligman explicitly supports the measure he speaks out for, and, as a citizen of the United States, he enjoys the rights and privileges of political free speech that allow him to do so. Political free speech includes, but is not limited to, lobbying public officials, running for political office, and supporting political candidates and legislation. Political stances of any kind may take the form of public endorsements, such as Dr. Seligman’s appearance in the television ad, or private endorsements. Physicians may exercise these political rights as individuals, through political action committees, or through local, state, or national medical and non-medical associations. In light of this, Dr. Seligman’s support of political legislation is well within his constitutional rights as a citizen.

According to the American Medical Association Code of Medical Ethics, Dr. Seligman as a physician also has a professional responsibility to improve his community, advance public health, and encourage access to medical care for all individuals [1]. So, while, as a citizen, Dr. Seligman has the right to support any legislative mandate he chooses, as a professional, he also has the obligation to ensure that the legislation he supports does not infringe upon the advancement of public health, the betterment of community, or access to medical care for all.

Individual physicians often have differing views about whether or not specific legislation meets these professional guidelines, and, indeed, they are entitled to their own political viewpoints. One timely example is the debate over whether legislation mandating that individual Americans buy health insurance will increase patient access to health care services. Who, then, is responsible for deciding whether legislation satisfies a physician’s professional responsibilities? Ultimately, Dr. Seligman is. In order to form an educated political opinion, however, he must keep up to date on political and health care issues. He may also seek input from his colleagues, professional medical societies at the local, state, and national level, or from legal and political professionals.

Is anyone besides Dr. Seligman responsible for judging whether or not his political stance accords with his professional imperatives? In general, physicians should be cognizant of the views of patients, co-workers, colleagues, and medical and non-medical organizations in order to enhance their ability to make an informed decision. At the same time, physicians must weigh their political rights with their ethical responsibility when deciding on political stances and, ultimately, make this decision for themselves. Once Dr. Seligman is convinced that his stance is aligned with his professional ethics, he has the right to free political speech and should not succumb to undue pressure by any party, nor should he accept punishment for his stance.

Analysis of Legislation

Is the legislation supported by Dr. Seligman, which limits educational resources provided to illegal immigrants and their dependents, concordant with his ethical responsibility as a physician? Specifically, does the legislation limit or promote access to medical care, negatively or positively impact public health, or disrupt or enhance community?

It could be argued that the legislation does not directly limit access to heath care, as no mention is made about specifically limiting health care resources to illegal immigrants or their dependents. However, one could also argue that illegal immigrants and their dependents indirectly lose access to health care through the restriction of educational resources. Not having access to education limits both employment opportunities and earning potential and would make it less likely that those affected would obtain either employer-offered health insurance or sufficient earnings to purchase their own health care services. Conversely, this decrease in resources for the illegal immigrant population could translate into more available health care resources for documented residents.

The legislation’s impact on both public health and community are also important points to address. One could argue that restricted educational resources may result in a decline in the education of the illegal immigrant population on public health issues. Those affected may need more urgent or emergency health and social interventions for preventable problems, which ultimately require more community resources.

It can also be argued that the legislation disempowers illegal immigrants and sets up a divide between this population and documented residents, which could encourage discrimination. Conversely, limiting illegal immigrant educational resources may release funds that could then be devoted specifically to public health issues or to education of the entire community, leading to a positive public health impact. The resources freed up might also be reallocated to legal residents for education, health care, or other means of building community.

Despite the multitude of conflicting arguments about the appropriateness of this legislation, one hopes that Dr. Seligman weighed all of the potential consequences, keeping in mind his ethical responsibility as a physician and subsequently came to his conclusion that the legislation was appropriate. After coming to such a conclusion, Dr. Seligman could have publicly justified his political stance using such arguments in the television ad, but it appears from the information provided in the case that this did not take place. Outlining health care-related arguments should not be a requirement of physicians when publicly supporting legislation.

Politics and Patient Care

Irrespective of the content of the legislation, ethical dilemmas are bound to arise when politics comes into the medical context. Mrs. Feldman, as a patient, may worry that the quality of care Dr. Seligman offers her could be diminished if she argues with him, making her less likely to bring up her concerns about his politics. Medical students and residents may feel that their grades or training will suffer if they voice disagreement with a senior physician’s political views. (Physicians can make an effort to refer vulnerable parties to forums, such as public sessions sponsored by independent institutions, where they can voice dissent without fear of retribution).

Physicians should be mindful to discuss political matters with patients only in settings where patients and families are not emotionally pressured by health care concerns. The television ad featuring Dr. Seligman airs in nonmedical settings. Additionally, Dr. Seligman does not touch on political topics during his patient’s medical visit. Political discussions should not occur during the clinical portion of a medical visit. If patients introduce such discussions after the clinical encounter has concluded and the patient is not in emotional distress, the physician can state his views. He must, however, keep political discussions with patients respectful and reassure them that their political beliefs will have no effect on their treatment. Physicians should use their best judgment in deciding when medical issues or concerns make such political discussion inappropriate.

Is it possible that Dr. Seligman’s political advocacy will compromise patient care? When physicians consider political advocacy methods, they should avoid collective actions such as strikes, which may limit access to care or delay imperative care. Additionally, formal unionization or workplace alliances may tether the physician to other workers who do not share in the physician’s professional responsibility to treat patients. Dr. Seligman’s television ad, however, does not limit his patients’ access to care, does not align him with workers who don’t share his professional responsibility to treat patients, nor does it by any direct mechanism compromise the delivery of high-quality patient care.

Conclusion

Physicians have the same political rights and freedoms as every other U.S. citizen, but they must balance these freedoms with their ethical responsibilities to patients. Physicians should make every effort to arrive at educated decisions and should remain open to new ideas. Ultimately physicians are responsible for choosing their own political stances. Physicians should make sure to formulate and communicate political opinions without compromising their responsibility to care for their patients.


References

  1. American Medical Association. Code of Medical Ethics. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics.page. Accessed July 31, 2011.

Grayson W. Armstrong is the vice-speaker of the AMA-MSS Governing Council. He is a second-year medical student in the scholarly concentration program in medical education at Warren Alpert Medical School of Brown University in Providence, Rhode Island. He received his undergraduate degree in music from the University of North Carolina at Chapel Hill in 2009 and has interests in music, medical artwork, health care policy, and medical ethics.

Acknowledgment

The author would like to thank Herbert Rakatansky, MD, for his support and guidance throughout the process of writing this article.

The Risks of Professional Protest, October 2011

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 on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.