by Mark Mikhly
A version of this post was originally submitted to the AMA’s Conley Ethics Essay competition – check out last year’s winners!
An AMA sponsored essay-contest prompt asked medical students to consider the case of a physician who chose to advocate against state sponsored abstinence-only sexual education to her state AMA chapter. The question, in brief, was whether physicians’ education, training, and standing in society entitle or obligate them to speak out on issues that, while they affect the health of the public, are not directly related to physician training or the care of patients? This question applies not only to individual physicians but also to the profession as a whole.
To consider whether physicians should take positions on sex education, we will explore the nature of the relationship between the medical profession and society, the role of physicians in public health, and the concept of Social Medicine. After such discussion, as well as an examination of abstinence-only sex education, it should become evident that physicians have an imperative, rather than an option, to be actively involved on this important topic.
Paul Starr’s “The Social Transformation of American Medicine,” winner of the 1984 Pulitzer prize for non-fiction, is a comprehensive history of medicine in the United States that establishes a sociologic framework as a foundation toward understanding how physicians interact with society today and how this situation arose. This foundation may serve when thinking about the entitlements and obligations medical professionals have acquired in society.
Foundations of Physician Authority: Legitimacy and Dependence
Medicine in the U.S. crystallized after two centuries of bitter infighting among a fractured scene of quackery, medical sectarianism, and pre-scientific revolution medical practice, during which the esteem of the physician was not the same valued image we take for granted today. As an example, the father of J. Marion Sims, one of the pioneers of 19th century surgery reacted quite negatively when informed of his son’s choice of profession: “If I had known this, I certainly should not have sent you to college… it is a profession for which I have the utmost contempt. There is no science in it. There is no honor to be achieved in it…”
Ultimately, the professional institution of “allopathic” medicine as we know it was able to secure a claim on legitimacy in a three-fold manner: through a commitment to practice based on scientific evidence, through a rigorous certification system that polices itself to create a body of competent practitioners, and through a value-orientation that elevates the public health at the expense of personal economics. Training, self-regulation, and service-orientation thus serve to define medicine as a profession.
Legitimacy, however, does not imply authority. Physicians may be legitimate in their practice but are unable to “make” the public do anything at all. Authority is realized through dependence; the public depends on the medical profession for official duties that doctors perform and which patients rely on, such as writing sick notes, prescribing medications, performing clearance physicals, and so on. Many of these roles are granted through legal regulation but the professional authority of the physician is ultimately drawn from public trust.
The publics’ dependence on the physician can also be understood as a dependence on physicians’ knowledge. For many in society, of all levels of education, the medical profession is an interface to the biologic sciences. Physicians may, in fact, be the only people with scientific training most people will ever interact with. Medicine’s complexity and the gap in understanding between the laity and medical profession was already evident by 1882, well before the modern era of medicine, when the Supreme Court, while justifying states’ rights to provide medical certification, asserted that “comparatively few can judge of the qualifications of learning and skill which [a doctor] possesses.”[i]
This gap in scientific training is an integral part of the underlying dynamic between doctors and their patients. Even an educated individual cannot be an expert in everything. Patients must thus trust that conclusions arrived at by physicians represent those that they would themselves reach if similarly exposed to the accumulated wealth of medical evidence and years of training of the medical professional. The doctor is a “shortcut to rationality,”[ii] an extension of the patient and public’s own mind into scientific and medical matters.
This relationship of professional legitimacy and patient dependency engenders a great deal of authority. The physician’s authority, however, is only asserted through persuasion. Except in rare circumstance, such as quarantine and psychiatric commitment, a physician holds no power of compulsion over a patient. Doctors furnish advice, not commands, and patients autonomously decide whether to heed advice or suffer the consequences. This dynamic demands the medical profession to rely heavily on evidence to provide assertions and furnish materials of persuasion.
A feasible conclusion is that physicians should have no role in creating laws that force patients into any specific action. Such mandates may impact patient autonomy and undermine the established role of trust and evidence in providing a physician’s authority. Perhaps the physician’s authority is meant to be applied only in case-by-case circumstances, privately, and to individual patients.
This is not the case. The origins and nature of a physicians’ authority provide a license for public advocacy in that it is not a function of legislation but of scientific and professional legitimacy. Further, the dependent relationship of the public on physicians empowers and deputizes the profession into advocacy on their behalf.
Professional Responsibility and Public Health
The American Medical Association, American medicine’s oldest professional society, has attempted to enshrine a professional code of ethics. Founded in 1847, the AMA was medicine’s first successful attempt at creating a professional society in the United States and remains the country’s preeminent professional medical body. The code of ethics is extensive and handles the particulars of many issues. It begins with a statement of principles, three of which are particularly relevant to the question of how physicians should interact with public policy.
Principle III imparts a responsibility to seek changes in law that run counter to “the best interests of the patient,” presumably in terms of their health. Principle V demands a commitment to education, including that of the patient. Principle VII requires a commitment to public health.[iii] Additional published opinion in the code concerns advocacy for change in law and policy, permitting physicians freedom to decide on participation in whatever legally permissible activities they feel need to be done to exact change, as long as the motivation maintains the priority of the patients’ best interest.
In the traditional narrative, physicians passively await a patient – the client – to seek them out before taking action on a particular problem. By assuming the prerogative to act in line with the service orientation of their profession, especially in circumstances that demand their training and education, organized medicine, in the form of the AMA, has accepted the professional responsibility of creating public policy in the name of public health. While this seems to be a significant addition to the mission of the physician, it is manifest naturally in the role of physicians in public and preventive health.
Medicine and public health haven’t always been unified. The division separating prevention through public health and treatment through medicine was somewhat artificial and a product of history – as an example, when departments of public health took up screening for tuberculosis, measles, and trachoma in public schools at the beginning of the 20th century, they would refer the patients to private doctors for treatment.3 Today, vaccination and preventative health screens and interventions are an everyday occurrence in all primary care settings.
Rather then strict sequestration of issues of pathologic processes, the physician’s domain has expanded to include the mission of public health. Conceptually, this is an acceptance that the practice of medicine cannot be defined narrowly to exclude actions that would bring broad benefits to society rather then to specific individuals. In as much, social issues that have public health impacts must be brought into the fold. It is imperative to reject the notion that there exist issues that affect the health of the public that do not pertain to the training of the physician or the care of the patient.
Social Medicine: Extending the domain of Public Health
During the mid-nineteenth century, Marx and other social theorists impacted greatly on the medical establishment, leading to a stress on the importance of social conditions in the origination of disease. The rise and success of germ theory and evidence-based medicine swept such ideas into the realm of politics and “social medicine,” a field seemingly separate than that of clinical medicine. Explaining his work’s mission, Dr. Jack Geiger, the great community health pioneer of the 1960’s, stated, “the determinants of health lie in the social order, not in the medical process.”[iv] Many of the maladies the medical field fights are rooted in social determinants—race, class and gender have significant impacts on medical outcomes. The doctor’s aim is to improve health outcomes using evidence-based intervention; if evidence shows social ills creating clinical ones, how can those topics lie outside the realm of medicine?
Take, for example, the case of former prisoners. In the two weeks immediately following their release, the adjusted death rate for this population is 12 times that of the general population. The greatest causes of death are drug overdose, suicide, cardiovascular disease, and homicide.[v] Considering the disproportionately high rate of African American incarceration (1 in 13 between the ages of 30 and 34), the picture of health disparity as a function of social disparity becomes clear. If an identifiable virus were the cause of death, this would surely be considered a national epidemic necessitating urgent government action. As it stands, for some, prison policy can never serve as the proverbial contaminated water pump and will always remain outside the realm of medicine. Where there exists an explicit line between social policy and public health, the physician’s public health imperative must be transitively applied to social issues.
At what point should the line be drawn? Racial laws and human experimentation were products of physician groups hoping to enact social change within the past century. Only in 2012 did German physicians apologize for their role in the Holocaust.[vi] Until 1973, the DSM of American psychiatry continued to list homosexuality as a medical illness; many psychiatrists actively promoted and practiced conversion therapy, now widely discouraged. Looking back, these ‘medical’ issues would obviously fall outside the accepted AMA ethics guidelines. What strongly held understandings and beliefs of ours of today will one day be looked at in shock? Do we take a risk in taking stances on “value-laden” topics?
While overstepping is a risk of physician advocacy, the greater hazard is in silence. In a 2008 address, the AMA apologized to the National Medical Association (the preeminent group of African American physicians in the U.S.) for the organization’s long history of racism and exclusion of African Americans. During the fight for the passage of the Civil Rights Act of 1964, the AMA remained notably silent. Only in 1968 did the AMA amend its constitution to exclude segregation.[vii] The issue of segregation may have seemed out of the profession’s purview at the time, but upon reflection this unfortunate history of America’s most important professional medical society is a testament to physicians that they must be professionally active in combating laws and policies that promote inequality and injustice, whether or not they are explicitly health-related.
Speaking up on Sexual Education
If the primary goals for including sexual education in public schools are the prevention of sexually transmitted illness and of adolescent pregnancy, it is difficult to argue that sexual education does not fall under the category of public health. Prevention of medically unwanted outcomes through education of the public is a widely accepted goal of public health. Presumably, sexual education is such a preventative measure.
Much research has been done to examine the truth of that presumption. In 2009, SIECUS (Sexuality Information and Education Council of the United States, a preeminent national organization devoted to the topic of sexual education) reviewed federal, state, and private studies concerning the efficacy of federally-funded abstinence-only programs. They found that these programs had been repeatedly found to be ineffective, not demonstrating improvement in almost every relevant outcome: sexual abstinence, number of sexual partners, rate of vaginal sex, condom use, teen pregnancy, and sexually transmitted disease.[viii] The only study that did seem to show abstinence-only intervention to be effective used a curriculum inconsistent with that demanded by federal criteria and which included only medically accurate information without moralism or disparagement of contraception.[ix]
In the vignette provided as part of the original essay prompt, the decision in question is not whether to advocate against the teaching of abstinence as a part of sex education, per se, but instead against the way it is taught—the federal program in the vignette teaches abstinence exclusively, includes medical inaccuracy, and is infused with morality. Such programs have been repeatedly demonstrated to be ineffective. When an effective alternative exists, it is necessary to advocate for it.
In advocacy, careful clarification of positions involves distinguishing clearly what portion of social policy affects public health. For example, in physician gun control advocacy an important distinction has been made between the fight against gun ownership and against gun violence.[x] Advocacy in sex education could similarly divide abstinence as a moral virtue and as a birth control method. The latter would allow for the teaching of abstinence alongside education about other forms of birth control. An abstinence only approach is certainly more effective then none at all but it must be carefully delivered with the exclusion of scientific falsehoods and social judgment.
Starting with an overview of the relationship of physicians to American society, we have examined the professional ethical imperative to engage in matters of public health and the shameful consequences of not doing so. A discussion of abstinence-only sexual education should be one about the evidence and merits of the educational intervention. The merits of advocacy on behalf of that intervention should be clearly recognized. To fulfill their part in the dynamic relationship we have with patients, the medical profession must continue to advocate aggressively for them on all fronts.
Engagement with norms that run counter to personal conviction is a common struggle. When a physician feels that a change in a “social” matter would benefit public health, there is a professional imperative to act, with assurance that they are within their professional rights to speak up about the matter on a public policy level.
[i] Dent v. West Virginia. 129 US 114. cited by: Starr P. The Social Transformation of American Medicine. USA: Basic Books; 1982
[ii] Starr P. The Social Transformation of American Medicine. USA: Basic Books; 1982
[iii] AMA Code of Medical Ethics. American Medical Association. http://www.ama-assn.org/resources/doc/ethics/decofprofessional.pdf. Accessed September 30, 2013.
[v] Binswanger IA, Stern MF, Deyo RA, et al. Release from prison–a high risk of death for former inmates. N Engl J Med. 2007;356(2):157-65.
[vi] Sharav V, German Medical Society Apologizes for Nazi-era Atrocities by Doctors. Alliance for Human Research Protection. May 28, 2012 Available at: http://www.ahrp.org/cms/content/view/852/9/. Accessed September 30, 2013.
[vii] Washington HA. Apology Shines Light on Racial Schism in Medicine. The New York Times. July 29, 2008. Available at: http://www.nytimes.com/2008/07/29/health/views/29essa.html?_r=0. Accessed September 30, 2013.
[viii] Sexuality Information and Education Council of the United States (SIECUS). What the Research Says on Abstinence-Only-Until-Marriage Education. http://www.siecus.org/_data/global/images/research_says.pdf. Updated October 2009. Accessed September 30, 2013.
[ix] Dreweke J. Review of New Study on a Theory-Based Abstinence Program. Guttmacher Institute. February 2010. Available at: http://www.guttmacher.org/media/evidencecheck/2010/02/03/EvidenceCheck-Jemmott-Study. Accessed September 30, 2013.
[x] Mozaffarian D, Hemenway D, Ludwig DS. Curbing gun violence: lessons from public health successes. JAMA. 2013;309(6):551-2.