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Academy News: July 2004 Mixing politics and medicine The Zanzibar school district has a bond issue on the ballot at the next election. Dr. A lives in Zanzibar and feels very strongly that the school district needs the money to operate. In the waiting room of his office, he puts up a big sign showing his support for the bond issue and in his exam rooms he includes literature on the necessity of the bonds. After each patient visit, he makes an effort to remind his patients to vote. When Dr. A is confronted by his partner, who also supports the bond issue, about the appropriateness of his actions, Dr. A explains that he is simply expressing his views, and he reminds his partner that he only encourages his patients to vote—he doesn’t tell them how to vote. As we approach the election season, it is important to visit the issue of mixing politics and medicine. This is a difficult issue, as it involves free speech, coercion and paternalism, and poor interactions can severely damage the doctor-patient relationship. The American Medical Association (AMA) Code of Medical Ethics makes it very clear that the “rights and privileges of free political speech” do not end when one becomes a physician1. Three of the nine Principles of Medical Ethics broadly encourage physician involvement in the community to push for changes to laws that are “contrary to the best interests of the patient” (III), to “support access to medical care for all people” (IX), and “to participate in activities contributing to the improvement of the community and the betterment of public health” (VII)2. Thus the Code makes it very clear that physicians may participate in the political process and make their voice heard, “individually or through involvement with organizations such as professional societies and political action committees.” These statements deal with physician involvement in the political process away from the physician-patient interaction, but what about expressing political views during the patient visit? Perhaps somewhat surprisingly, the Code allows for this, but with a warning that “conversations about political matters are not appropriate at times when patients or families are emotionally pressured by significant medical circumstances.” So political discussions during routine visits would be acceptable. In fact, the Code goes so far as to explicitly state that political discourse “may be appropriate” whenever “conversation…concerning social, civic or recreational matters is acceptable….” However, there is a caveat that differences in beliefs should never be allowed to interfere with the delivery of “high-quality professional care.”2 As in any ethical discussion, there is more than one view to this issue. Lawrence White, MD, in a recent ethical forum article from the AMA Medical News, argues against the introduction of any political discourse in the patient encounter3. He states that patients come to see a physician for medical care and, in general, do not expect a political discussion. It would be akin to visiting a psychotherapist for “emotional problems…and [they] suddenly tell us…how we should vote.” White feels that these situations take advantage of the power imbalance inherent in the patient encounter. The great risk is that differences in political attitudes would lead to damage of the patient-doctor relationship. As we have previously discussed, the doctor-patient relationship is of prime importance in the delivery of ethical medical care. Anything that might disrupt this relationship should be avoided, if at all possible. Further, because of this power imbalance, we must also be concerned that the patient will feel coerced into agreeing with the physician. In addition, because the physician is relating his/her view to the patient, he/she may be putting his/her needs ahead of the patient’s needs. This violates the primary rule that the “patient’s welfare must come before any other agenda.” White concludes that, nonetheless, “it is indeed appropriate for physicians to advocate for political positions, parties or candidates, and to fully exercise their political rights away from the office or hospital.” This brings us back to our vignette. What is appropriate for Dr. A to do? Clearly it is not a violation of the Code of Medical Ethics to display his support for the bond issue. However, we must ask if the sign or the literature in the examination rooms interferes or in some other way affects the doctor-patient relationship. Could this be construed as coercion? Is it even appropriate for Dr. A to encourage his patients to vote? Would it be better if Dr. A directed all of his support to activities outside of the office arena? There are no right or wrong answers to these questions. This is a situation where a physician needs to feel comfortable with what he/she decides to do. The important issue is to be aware of the various concerns related to expressing one’s political views in the office. References
The Ethics Committee provides these discussions as a way to open a dialogue on the various ethical issues that confront our specialty on a daily basis. These issues are often quite complex and do not have simple “right” or “wrong” solutions. The articles are meant as a way to highlight the various issues that are involved in these ethical dilemmas, they should not be viewed as the Ethics Committee or the AAAAI’s particular stance on an issue. |
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