One of my most prized mementos rests on a shelf in my office. It is a framed photo of me taken at the end of April 2013. I am in handcuffs, being led by policemen off the floor of the North Carolina General Assembly as I was arrested for civil disobedience while protesting my native state's refusal to expand Medicaid to nearly half a million citizens. The photo, which appeared in the state's leading newspaper the morning after my arrest, was a gift from two graduating PA students. On the back they wrote, “Thank you for setting such an inspired example.”
This photo marks the role I played in helping to kick off a citizens' crusade that came to be known as the Moral Monday Movement. Tens of thousands of citizens have participated in this movement by protesting the enactment of regressive policies by our state legislature. I participated because I wanted to push to expand access to healthcare for poor people—and also because I wanted to set an example for PA students and other healthcare professionals by speaking out publicly on ethical issues.
When I learned of the planned protest on the evening before that first Moral Monday in April 2013, I chose to be among the first willing to face arrest because I was determined to have a white coat be a visible part of the press coverage. My first experience with the white-coat movement was earlier the same year when I sat in the North Carolina Senate gallery among other white coats silently protesting the vote to deny Medicaid expansion. We continue to push for Medicaid expansion via lobbying events, press conferences, radio shows, legislative hearings, Moral Monday coalition rallies, and newspaper opinion pages. The North Carolina Medical Board told me that 10 to 12 physicians and PAs were among the nearly 1,000 other citizens arrested for civil disobedience over the politically hot summer of 2013. One of them, Charles van der Horst, MD, a physician at the University of North Carolina at Chapel Hill, published a column on a topic similar to this one in the New England Journal of Medicine in November 2014, inspiring me to write to JAAPA readers.1
Our actions raise a number of issues in addition to those surrounding Medicaid expansion, including questions about the role of healthcare professionals in speaking out on current issues affecting our patients. Many healthcare professionals hesitate to engage in public protest. I believe that we have an ethical obligation to speak out, and that the public is eager for our opinions on healthcare issues. The public trusts us more than it does politicians and lobbyists as sources of information on healthcare reform. One of the first and best questions ordinary citizens ask about healthcare issues is, “What do the professionals think?” Healthcare professionals have a special moral and professional authority regarding healthcare topics.
Why, then, do we hesitate? Many may feel that civic engagement may appear unprofessional. We are rightly taught to keep our personal judgments out of patient care settings, and perhaps we extend this concept into the public sphere. I follow the rule of keeping my political opinions away from clinical settings, but the extension of this notion to our private lives is the healthcare professional's excuse to say and do nothing. People in all walks of life may cling to these kinds of excuses, but none of them address our responsibility to our fellow citizens. Moral paralysis is an ailment we cannot afford. These are handcuffs we don't need to wear.
Remaining silent in the face of suffering is nearly as wrong as committing outright harm. The ethical principles that we teach and learn in PA training include respect for persons, an injunction against doing harm, a duty to do good, and the honor of social justice. All of these principles lead me to assert, publicly and loudly, that healthcare should be more available to all. When we vow to keep the interests of patients foremost in our lives, we have an obligation not just to hold dear their physical well-being but also to advocate for full social and psychological health. When these needs are held hostage to political interests, and when we are in a position to make a difference by telling of the harm this will cause to real people, we are obligated to act. This is not to say that everyone in a white coat needs to be taken away in handcuffs. There are many ways to make a difference.
After 2 full days in Wake County District Court—where we were riveted by our legal team's arguments regarding our constitutional right to protest, and where I again wore my white coat—my fellow arrestees and I were called to stand before the judge as she declared us guilty of two misdemeanors. My crimes: breaking building rules by carrying a sign that read, “Have a Heart—EXPAND MEDICAID” and failing to disperse when requested to do so by the capitol police. According to the testimony of the chief of the capitol police, I would have been within the law if I had carried a sign saying “Buy Nike,” but the political content of my sign was apparently out of bounds. After our appeal to Superior Court, charges were dropped against us and almost all of the 900-plus Moral Monday arrestees. Our cases were argued by an army of volunteer civil rights lawyers. Following each court appearance, we called a press conference to restate our aims, including expansion of Medicaid as provided for under the Affordable Care Act (ACA). Most of these press conferences were aired on the local news, to our delight. The North Carolina Medical Board investigation of my arrest consisted of a phone conversation with a very nice investigator, followed by a letter declaring the issue closed without penalty. So, for those of you who wonder, the professional and financial costs to me of the handcuff escapade were nil.
North Carolina has yet to expand Medicaid under the ACA, but we believe our actions and our speeches and our writing have swayed hearts and minds. We have developed networks of white-coat activists available to speak, write, or protest as needed. And our governor and the Secretary of Health and Human Services each recently mentioned the possibility of expanding Medicaid through a waiver application. We will watch every step of that process and offer to help with details.
In his commencement address at Harvard Medical School in the spring of 2014, Surgeon General Vivek Murthy urged graduates, “If you build a life on your values and your unique vision, you will change the world, and you will inspire others to do the same.” As founder of the national healthcare access advocacy group Doctors for America, Murthy backs his words with actions. My choice has been to protest and to help organize other healthcare professionals to join our white-coat movement. As my friend and literal partner in crime Dr. van der Horst writes, “In the face of great danger to our patients and our state, we believe that remaining silent is not an option.”