AMA Journal of Ethics^®

Case

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 2

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.