Doctors Should be Political, but not Political as Doctors

The idea that medicine and politics inevitably blend together confuses the nature of both medicine and politics

As seems to be the norm on Sensible Medicine these days, whenever John, Vinay, or I publicly disagree with one another, one of our readers chimes in to explain how all of us are off the mark. Today I am happy to post the latest comeuppance, this one by Dr. Thomas Huddle.

Adam Cifu

The ringleaders of Sensible Medicine had a lively back and forth over the proper relation between medicine and political advocacy. John Mandrola advises against physician involvement in politics, at least some of the time. Vinay Prasad disagrees, somewhat mutedly, as he seems to find much political commentary by physicians to be platitudinous and unhelpful. Finally, Adam Cifu weighs in in favor of physician political involvement but cautions that academic medical centers should not take political stances and that physicians should be careful not to allow politics to interfere with the doctor patient relationship. 

The case for mandatory physician political activity generally involves several lines of argument; one is that physicians are inevitably politically situated; whether they like it or not they act through either political activism or political quietism. It is therefore incumbent upon them to identify political ramifications of professional identity and act accordingly. Another suggestion is that medicine’s social contract with society includes a physician obligation to seek improvement in societal health. A third recruits medical ethics to the cause of mandatory advocacy through the suggestion that the bioethical imperative of physician benevolence extends to public health. 

It is often suggested that medicine and politics inevitably blend together, and that political means are necessary in the pursuit of medical ends. I suggest that this view of medicine and politics confuses the nature of both. Some conceptual analysis of medical work and political activity may illuminate the difficulty. In practice, whether it be in emergency room bays or patient hospital rooms or operating suites, competent physicians know what to do next—whether that is conversation, examination, technical intervention, or prescription. In so acting, physicians are guided by norms of technical excellence and of clinical ethics. Professional settings make this practice possible and (ideally) as straightforward as possible. Most importantly for present purposes, medical practice is individual; it proceeds patient by patient. While physicians seek health, it is their patient’s health rather than the health of a group. Medical work is distinct from the work of a public health officer. 

The activist objection to this account of physician work is that it describes part but not the whole of what physicians ought to do. Physicians, it will be said, are just as responsible for public health as for individual patient health. My suggestion is that this claim is a fallacy; public health implicates politics in ways that medical work does not and should not. This conclusion follows from the nature of politics, in contrast to medicine. Many commentators would define politics as the process of determining relationships of power in a community. Others would add that the political is opposed to the despotic; politics involves not only determining power relationships, but doing so peacefully through mutual accommodation of disagreement by use of procedures such as voting. At stake in political conflict are competing visions of the societal good.  Political authority, in contemporary democracies, stems from consent of the governed won by political authorities that have successfully persuaded citizens to vote them in (or their opponents out). 

Such platitudes about politics indicate a contrast of politics to medicine. The doctor is not tasked with bringing about a societal vision of good, but to the optimal resolution of illness. The demands of the work are exacting and the work done well is the professional task.  Professional authority, as recognized by professionals and by the public that grants privileges to professionals, is an authority of expertise, of an ability to do and to judge professional work through the possession of expert knowledge and skill. 

The difficulty with incorporating public health into the ends of medicine is that public health is a political end, competing with other political ends. Social policies may achieve more or less public health at the expense of other political ends such as freedom or prosperity. Money spent on public health is money unspent on highways or police or education. It can be a matter of medical expertise to determine how much public health a given policy will gain, although such calculations are often more complex than is assumed. What is not a matter of medical expertise is an assessment of the tradeoff between public health and other goods forgone by directing wealth and labor toward that political end and not others. Such tradeoffs are political judgments. Physicians may campaign against nuclear weapons or fossil fuels or for motorcycle helmet laws and gun control. Their standing as physicians may give them special insight into what one side of the tradeoff may be for a given policies but none into whether the tradeoff is worth making. On that political matter physician judgment is on the same plane as that of any other citizen. 

The contrast between the means and ends of politics and professional work implies a need to keep the two activities distinct, on pain of professionals asserting an authority they do not possess on political matters.  Accordingly, the proper relation between medicine and politics ought to be one of scrupulous separation.  Physicians are, of course, citizens, and should participate in politics as such.  What they should not do is insert their professional standing into their political stances, implying that their professional standing confers special political heft to their policy prescriptions.  It does not, and improper assertions of professional authority in the political realm will inevitably erode professional authority where it belongs in the professional realm. 

John, Vinay, and Adam are all correct.  Physicians should take political stances as they see fit; but they should do so without implying that professional authority informs those stances.  Doctors should be political, but not political as doctors. 

Thomas Huddle is a Professor of Medicine, Emeritus in the Division of General Internal Medicine at the UAB Heersink School of Medicine.

Photo By Melany Rochester