I am happy that my article has provoked a spirited response among readers of Academic Medicine. Several correspondents (Banack; Stull; Sud) mistakenly suggest that I oppose society-level advocacy by physicians. I question not the legitimacy of such advocacy but whether it is a necessary aspect of professional identity. Halliday et al. seek a middle ground on the necessity of physician advocacy: the exigencies of social need make such advocacy not entirely optional; at the same time, not all physicians need engage in it. I agree with Halliday that some (not all) physicians with the requisite aptitudes and inclination would do well to take on advocacy roles. I fear, however, that a middle ground between “optional” and “required” may prove illusory. A more peremptory stance on advocacy for social change, requiring it of all physicians, emerges from several other letters.
The argument for this stance goes: Patient health is a norm that should govern physician action (Gottlieb). Social factors loom larger than medical interventions in determining population health (Gottlieb; Kuo; Palfrey). Physicians, to be true to their identity, must, therefore, be advocates for social changes that would further health (Gottlieb; Kuo). Such advocacy ought not to be regarded as political (Kuo) or partisan (Gottlieb; Stull). Or if it is political, that is OK because medicine is “inherently political” (Gottlieb) or has become politicized (Schickedanz), and, anyway, not advocating is a political stance (Gottlieb).
The difficulty with this argument is not in the premises, but in the inference from the causes of ill health to a physician's obligation to advocate. There is no necessary connection between the underlying causes of problems addressed by an occupation and the accepted scope of that occupation's work. While physicians are necessarily committed to the health of their patients, there are compelling reasons why physicians ought not to regard the achievement of societal health through the political process as a similarly necessary part of their mission. The determination of measures that will achieve given societal health benefits may be a matter of medical expertise; weighing those benefits against their costs in other goods foregone is not. Such weighing involves normative judgments that physicians make with no more authority than do other citizens. That being the case, professional morality does not (and must not) demand that physicians always favor spending more resources on health and less on, say, pensions or police.
For some physicians, professional and political identities join together. For others, politics remains separate from professional work. Citizens who happen to be physicians may or may not prefer additional increments of societal health to alternative goods when choosing among such goods in the political arena, and any such political preference is perfectly legitimate. That being so, it is a usurpation of our political prerogative as citizens to insist that we as physicians must be advocates for more resources aimed at health or health care rather than at competing goods in any given political context.
Contra Kuo, Gottlieb, and Stull, advocacy aimed at increasing health at the societal level inevitably involves contestable political stances and will, in the absence of societal consensus, inevitably be “political” and partisan. Our profession is, of course, politically situated. It does not follow that we should politicize it (or politicize it further) by instituting mandatory physician advocacy. Many physicians who engage in health-related political advocacy are doing the best they can for society and deserve nothing but praise for that work. Others do what they see as their best by conducting their clinical work according to professional norms and engaging in politics (or not) outside of medicine. That is also a legitimate choice. Let's allow those physicians who so choose to leave their politics at home when they don their white coats.
Thomas S. Huddle, MD, PhD
Professor of medicine, Division of General Internal Medicine, Department of Medicine, University of Alabama Birmingham School of Medicine and Birmingham VA Medical Center, Birmingham, Alabama; email@example.com.