Politics in the clinics (2)

In last week’s column, I talked about some recent heated debates about the political lives of physicians. I talked about how the profession of medicine is inherently political because of the sociopolitical determinants of health that drive patient outcomes. I also talked about how it is acknowledged that this political engagement should not affect our ability or desire to render care. The remaining point seems to be whether physicians can, or should, campaign for their candidates and parties in their clinics, or whether they may initiate political conversations in such situations.

The Philippine Medical Association’s Code of Ethics does not specifically dissuade such discussions; it emphasizes service regardless of political affiliation and refers the physician to the standards of behavior of the International Code of Medical Ethics. The latter also does not discuss the topic in specifics, though it states that the physician shall respect the rights and preferences of patients.

The American Medical Association or AMA’s Code of Ethics lauds political engagement but encourages physicians to avoid initiating political conversations during the clinical encounter. As mentioned in last week’s column, physicians must always be sensitive to a power imbalance. In cases where such discussions are necessary, the code encourages physicians to use their judgment to assess the situation, including the intrusiveness of such discussions and their patients’ level of comfort, and to avoid such topics in tense or emotional situations.

The UK General Medical Council’s guide for Good Medical Practice states that the physician must not express personal beliefs to patients in ways that exploit the latter’s vulnerability, or are likely to cause them distress. After heated or tense discussions we risk alienating patients or making them less likely to follow sound medical advice. We also can’t dismiss the fact that some people have commented on the social media posts I have mentioned and shared that they were made uncomfortable by MDs “imposing” their opinions.

However, these codes appear to leave some room open for situations where patient comfort and physician-patient rapport are sufficient to accommodate such discussions. We return to the obligation to educate patients on the health ramifications of political decisions; physicians are in a unique position to assist patients to connect the dots between science and matters of policy, in a venue that should be more trustworthy than unregulated social media. Writing for the AMA Journal of Ethics, Dr. Jack Freer wrote, “Physicians have a broader role to share their unique perspective and knowledge with the public. Certainly, physicians have an inside track about health policy and health care reform.”

Doubtless I will be missing out on other societies’ codes of ethics. What I aim to say for now is that there is no single well-defined standard of behavior on the matter. What is clear is that no doctor should use their position to shame, intimidate, or coerce patients or families due to the latter’s political positions. However, medical opinion on whether or not we can talk politics in the clinics is not unanimous.

It also seems to be an evolving and dynamic issue. Some health issues are now more politicized. The increasingly tense issue of gun safety laws in the US is one example, with more doctors finding it important to discuss such concerns in clinics. The pandemic also has thrown into stark relief how health care delivery and national politics are inextricably intertwined. Masks, face shields, vaccines, and ivermectin, are topics that will surface, and physicians will doubtless feel obliged to guide their patients accordingly, while still doing their best to avoid putting a strain on the clinical relationship.

We also cannot avoid talking about health care costs. These are constantly impacted by health system inefficiencies, resource misallocation, and corruption. It is easy to remain “neutral” in the face of patients and families who can easily afford treatment. It is less easy to be so stoic when we face patients who cannot, or when we think of those who couldn’t even make it into the clinic due to a daunting number of health access barriers. We are hard-pressed to blame physicians who thus feel strongly about the matter and wish to speak accordingly, knowing that the intention is not to intimidate or abuse, but to advocate. The point is that it is a sensitive matter either way. The physician will need to balance two moral obligations: the need to advocate and educate, versus the need to provide a positive and conducive environment for patients regardless of political affiliation. It should go without saying that it is also the duty of the physician to be well-educated on the matter, and to look at existing science and evidence first. In this as in other parts of the “Art of medicine,” sensitivity to nuance may be needed, as well as cultural humility and understanding.

kchuarivera@gmail.com