AMA Journal of Ethics^®

Case

Dr. Molleur is a family doctor in a state that accepts federal funding for abstinence-only sex education in its public schools. She believes that abstinence-only sex education is harmful to adolescents and to society because it results in unplanned pregnancies, the spread of STDs, psychological harm to those who don’t conform to the norms of the curriculum, and reversal of decades of progress in the social status of women and gay people.

Dr. Molleur submits a resolution for consideration at her state medical society’s annual meeting entreating the society to adopt a position urging the state’s governor to reject federal funding for abstinence-only education programs and to replace them with comprehensive sex ed, which would include abstinence but also cover such topics as correct use of condoms. Her resolution discusses not only what she views as problems with the factual information in the abstinence-only curriculum (for example, the assertion that HIV can get through pores in condoms) but also her objections to the sexual mores promulgated in the abstinence-only curriculum (for example, that nonmarital, nonheterosexual sexual activity is likely to have harmful psychological and physical effects and that abstaining from sexual activity outside of marriage is the expected standard). “This,” her proposal concludes, “is misinformation, and, as highly educated professionals devoted to promoting the health and welfare of the public, we have a responsibility to combat the teaching of inaccurate and problematic beliefs.”

Getting a cup of coffee before the meeting begins, she runs into her friend Dr. Baxter in line and asks him, “Did you see the resolution I submitted?”

Dr. Baxter hesitates. Eventually he says, “I did see it. But I’m not sure I’m with you on this. Is it appropriate for a physician group to be making judgments about what constitutes healthy or normal—or moral—sexual behavior? Who are we to prescribe sexual norms for society?”

Commentary

Dr. Molleur’s proposal brings to the forefront questions about the rights and responsibilities that physicians have—especially when acting through a professional organization—in the realm of public discourse. If doctors choose not to address factual assertions that they know to be scientifically inaccurate, both people’s health and the public’s respect for and trust in the medical profession are at risk. Physicians are uniquely equipped, by both their training and their experience, to promote public health and welfare by challenging improper, deceptive, and unprofessional practices of medicine. However, they must recognize that their position in society is not a soapbox from which they should preach their own beliefs. Therefore, medical professional organizations should address topics that are circumscribed by what is, and what ought to be, considered “medicine.” In the specific case of Dr. Molleur’s resolution the organization’s rights and responsibilities, as well as its limits, are brought to bear.

The Authority to Speak

Physicians have the right to speak publicly on issues within the proper scope of medicine as a consequence of their being especially well informed on medical topics. By and large, doctors are very well educated. Even after considerable training in medical school and residency, physicians in nearly every state are required to take continuing medical education classes with the purpose of learning the most current scientific research and techniques [1]. The field of medicine is constantly incorporating new research and reevaluating old knowledge. Thus, doctors are accustomed to keeping themselves up to date on recent literature. And of course, physicians learn from what they experience in their own practices. This ongoing medical education, both formal and informal, not only gives physicians a solid grounding in medical knowledge, but helps them to be more aware of recent developments than the general public. This entitles physicians to comment on health-related matters. Since they are often the most aware of the most accurate information, their expert opinions hold value.

Beyond their specialized knowledge, physicians share a culture of respect and professionalism that makes their collective voice a welcome one in public discourse. Whether it is through deliberate effort or exposure-based desensitization, physicians must learn to address issues that most people may find uncomfortable, including the body, sexuality, disability, and death. This makes doctors even better equipped to contribute to broad public conversations that may implicate these topics.

The Duty to Advise

Doctors, acting individually or as a group, are well positioned to offer information to benefit people’s health. One can even argue that they have an obligation to do so. Historically, the role of the physician has been to advise patients on health-related matters, providing treatment when necessary [2]. At the beginning of their careers, medical students undergo a rite of passage by reciting a version of the Hippocratic Oath, which describes the duty of a physician not only to patients, but to the profession and to society [3]. Physicians hold a privileged social status, and in return, they are expected to use their specialized training and experience both to treat and to educate their patients and the public. The missions and guiding principles of professional medical associations, including the American Medical Association, recognize the importance of physicians’ leadership in appropriate contexts, and the need for ethical standards delineating when to exercise it. Section 9.012 of the AMA’s Code of Medical Ethics notes the obligation physicians have to examine and reform laws related to health care and stresses that physicians should keep themselves informed about political changes affecting it [4, 5]. When health-related issues arise in public discourse, people want and expect doctors to weigh in with an opinion based on their expert knowledge. It is part of the profession’s ethical mandate to offer that information [4, 5]. If doctors remain silent on medical issues, they jeopardize the medical profession’s standing in society. Just as patients depend upon their doctors’ remaining up to date on education and practice, so also does the public trust the medical field to make its voice heard on health-related concerns.

In the case of the resolution against abstinence-only sexual education programs, Dr. Molleur is correct in asserting that physicians have an obligation to contest some of the propaganda presented by the program. Specifically, physicians should challenge the scientifically inaccurate information, such as HIV transmission through condoms [6]. The CDC reports that research has demonstrated that consistent and correct use of condoms is highly effective in preventing the spread of STD pathogens, including HIV [6]. The general public is unlikely to have a more reliable source for this information, and it falls within the purview of physicians: it is directly health-related and based on the kind of scientific research that regularly informs a doctor’s work. That condom use is a prophylactic measure rather than a treatment does not make it any less appropriate for a doctor to address. Ethical guidance is quite clear on this point [7]. Therefore, Dr. Molleur’s resolution asking the group to combat this misinformation is in line with her responsibilities as a physician to protect her community from improper, scientifically unsound information.

Appropriate Limits

Physicians have a broad social privilege to speak and be heard on matters of health, but they must recognize the limits of that privilege. Dr. Baxter brings up an important point about Dr. Molleur’s resolution. In particular, he asks whether physicians have the right to dictate societal norms about sexual behavior. It’s a fair question. Part of Dr. Molleur’s objection is to the sexual mores propagated by the abstinence-only curriculum, such as that nonmarital, nonheterosexual sexual activity can have harmful psychological effects. Though she believes that this is also misinformation, it is on much less sure footing, both in terms of its scientific grounding [8, 9] and also its falling within the proper sphere of medical opinion. She is asking the organization to overstep its role by opining about sexual norms for society. Dr. Baxter questions Dr. Molleur’s resolution because he is aware that a physician’s role does not include prescribing social standards.

Doctors are trained to promote, maintain, and ameliorate patients’ health through advice, study, and treatment. Of course, there are many aspects of a patient’s life that a physician is neither equipped nor entitled to treat. Due to their position in society, physicians should combat scientifically inaccurate information, but they may not dictate what should be considered sexually normal. To offer a comparison, few would contend that it is a physician’s role to decide which people are fit to raise children. This is a decision that implicates health-related concerns, but it relies on so many variables outside of a doctor’s expertise that we leave it up to society (in this case, more qualified institutions such as Child Protective Services and the courts) or individuals (putative parents). Questions about sexual norms and mores are similar—best left to society, if not individuals themselves.

Shaping Social Behavior

It should be noted that doctors’ opinions may indirectly influence social norms. To the extent that norms develop in social environments partly comprising a body of shared knowledge, any contribution to that body of knowledge may, in a roundabout way, serve as a contribution to the norm. To make an example of the present case, as medicine discovers and publicizes ways to make sex less risky (e.g., condoms to prevent the spread of sexually transmitted infections, birth control to reduce the chance of pregnancy), individuals may choose to engage more readily in sex outside of marriage. As this behavior becomes widespread, society may determine that sex outside of marriage is normal and healthy. This is not an invalidation of (or even an exception to) the limitation on physicians described above. Instead, it is an illustration of a process of how society’s norms may change organically, drawing, in part, on the contributions physicians make to society within their area of competence.

Conclusion

This situation presents a debate surrounding physicians’ role in society and their obligation to monitor social behaviors that affect the health of the public. The training, experience, and professional culture of the medical field allow doctors to address medical issues. That allowance may even grow to an ethical responsibility to speak out against scientifically inaccurate information that can cause harm to the safety and welfare of the public. But that responsibility is limited to health-related matters, and physicians must recognize the line between health-related matters and strongly held beliefs that fall outside the realm of health. In this specific case, Dr. Molleur believes she is acting within these limits by submitting her resolution. Dr. Baxter points out that Dr. Molleur’s resolution goes too far; it oversteps the bounds of the medical profession’s role. Even though doctors do hold a high position within society, they should not use that position to make judgments about societal norms.