To the Editor:
We read with great interest Dr. Huddle's1 article on advocacy in medical education and practice. Most strikingly absent from his argument is the scientific research demonstrating the powerful roles social and environmental conditions play in shaping both health trajectories and health disparities. This emerging research throws an important wrench in the applicability of “traditional ethics.” The ethics Huddle identifies—from Hippocrates to Percival to the American Medical Association's 1847 statement—were formulated in eras when disease was more strongly considered the direct result of health care access and quality, both of which are now known to contribute significantly less to medical outcomes than previously attributed. Based on more recent research, we know that what physicians do in clinical venues affects only 10% to, at most, 50% of health outcomes.2 In light of these findings, which fundamentally change our understanding of the origins and trajectories of disease, the traditional roles of health care professionals prove inadequate. Instead, as we translate this research to practice, our roles necessarily will be directed, at least in part, outside of clinics, where powerful social and political impacts on health can be demonstrated. This new science suggests that advocacy is, in fact, a professional virtue, not a purely civic one.
Second, Dr. Huddle suggests that advocacy education involves a mandate for partisan politicking, apparently based on the assumption that there is only one avenue through which to pursue a healthier society. Yet advocacy education and promotion do not direct the advocate toward any particular political position. There are advocates on all sides of health and social reform, representing various perspectives and approaches to social change. No calls for training in physician advocacy have recommended the partisanship that Dr. Huddle decries.
Our third critical response is nearly a cliché but bears repeating: Not acting can be interpreted as yet another political position. In fact, it may be among the most powerful of advocacy tools, as Martin Niemöller reminded us so vividly in his poem, “First they came for ....”3 Medicine, inexorably linked as it is to money and power, is an inherently political vocation. Its stakes are literally life and death, power and powerlessness. So the choice to remain out of the political debate, however political may be defined, is still a choice. Educating both new and wizened health care professionals in the comprehensive armamentarium of advocacy tools available may, in fact, be a less partisan approach than Huddle's absolute anti-advocacy education stance.
Finally, even Dr. Huddle's traditional ethics include a professional responsibility to respond to society's requests for help. Some might argue that a societal plea has been made and the medical profession has been decidedly silent.
Laura M. Gottlieb, MD, MPH
Postdoctoral fellow, Robert Wood Johnson Health and Society Scholars Program, Center for Health and Community, University of California, San Francisco, San Francisco, California; firstname.lastname@example.org.
Brian M. Johnson, MD
Clinical instructor, Department of Internal Medicine, Contra Costa Regional Medical Center, Martinez, California.
2 McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff (Millwood). 2007;21:78–93.