e40(1) C OPYRIGHT Ó 2014
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Ethics in Practice Talking Politics with Patients Ryan M. Eggers, MA Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
The political debate about health systems is still raging around the United States, and patients are constantly bombarded with information about politics and medicine from friends, coworkers, and the media. Some of that information is true, and some is not. One important source patients may turn to is one they implicitly trust: their physician. Physicians are valuable sources of information regarding the current state of medical practice and the necessary changes to it. While few physicians will get the chance to testify before Congress or interview on television, all physicians have the opportunity to engage in the politics of medicine with their patients. However, engaging patients in this area can be a tricky venture. The first difficulty lies in an accurate definition of the term politics. The original usage of the term originated from Aristotle’s book Politics, which translates as ‘‘the things concerning the polis [Greek city-state],’’ or ‘‘affairs of state.’’1 Thus, a common connotation of politics is ‘‘that which concerns the operation of government.’’ Other definitions can range from ‘‘specific legislative actions’’ to ‘‘anything that influences the thought of another person or organization, especially in an attempt to resolve conflict or come to a collective decision.’’ For the purpose and scope of this article, politics refers to ideas or actions that relate to the operation of a governmental or regulatory organization. Our political feelings and opinions are practical extensions of our worldview, and our worldview is deeply connected to our individual sense of what it means to be human. That is, politics is linked to our deepest sense of ourselves. By nature of the role of government and our sense of duty to follow laws, politics also carries with it profound potential consequences for our lives. These two things contribute to making political discussions
highly contested and emotional events of which physicians should be wary. Political discussions also carry the potential for improving the physician-patient relationship and for increasing the knowledge of both physicians and patients. There exists essentially nothing in the current literature or professional guidelines that directly addresses these interactions. This paper will attempt to highlight the relevant principles and offer some potential guidelines on appropriate behavior through discussion and case analysis. Balancing the Principles The American Academy of Orthopaedic Surgeons (AAOS) does not yet offer specific guidelines on how to approach the issue of political discussions with patients, but their other guidelines provide the basis for inferences. The following four excerpts are taken from the 2013 AAOS Guide to Professionalism and Ethics in the Practice of Orthopaedic Surgery 2. ‘‘The orthopaedic profession exists for the primary purpose of caring for the patient. The physician-patient relationship is the central focus of all ethical concerns.’’ (page 15). ‘‘The orthopaedic surgeon also has a responsibility to seek changes in legal requirements that are contrary to the best interest of the patient.’’ (page 15). ‘‘The orthopaedic surgeon has a responsibility not only to the individual patient, to colleagues and orthopaedic surgeons-intraining, but also to society as a whole.’’ (page 16). ‘‘The medical profession requires physicians to subordinate their own interests in favor of the patient’s best interests and
Disclosure: The author did not receive payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. He, or his institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. The author has not had any other relationships, or engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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TABLE I AAOS Ethical Principles The Physician Has an Ethical Duty to Primarily the patient Society as a whole The profession Subjugate personal interests
hold themselves to high ethical and moral standards.’’ (page 149).
At the heart of the ethical dilemma in political conversations is the conflict of four principles, also summarized in Table I. They are (1) the primary duty to the patient, (2) the duty to society as a whole, (3) the duty to the profession, and (4) the subjugation of the physician’s personal interests. This order does not represent an absolute hierarchy, but like the four bioethical principles of Beauchamp and Childress (autonomy, beneficence, nonmaleficence, and justice), they should be balanced through a process called ‘‘reflective equilibrium,’’ wherein the merits of each principle are weighed against those of the others for each ethical dilemma3. These four principles should not be misconstrued as rigid rules, but should serve to inform case-by-case decisions for individual physicians. Politics and Patients Inherent in the physician-patient relationship is an acknowledged power differential. Patients are compelled to take a relatively compliant role, but the physician’s role is one of power because he or she possesses necessary information for effective treatment. This powerful position can be abused, whether intentionally or not, when the physician discusses his or her political opinions with a patient. Physicians should be mindful of this power dynamic, specifically when the issue is only indirectly related and input is unsolicited. In his chapter on ‘‘Moral Influence of Physicians,’’ nineteenth century medical ethicist Dr. Worthington Hooker said, ‘‘What responsibility then rests upon the physician! How careful should he be in the expression of his opinions!’’4 A physician could be more informed about a political topic than the patient, but this alone does not justify a top-down approach in the same way a diagnosis or treatment plan is communicated. After all, patients rarely make appointments to speak to their physicians about political issues. A potential pitfall in talking politics with patients comes when a physician’s agenda seems self-serving on the surface. An example of this situation is Medicare or Medicaid reimbursement rates. The real issue may be the financial solvency of the practice and the access of patients to services, but physicians who do not clarify such issues run the risk of seeming self-serving. Effectively communicating this distinction may be critical to maintaining the best understanding of the physician’s intent. Another effective approach to talking politics with patients comes from a page in the physician-lobbyist playbook: tell your story. Many physicians who advocate to the legislature make
their case more relatable and poignant with a personal story. The same principle can apply to dealing with patients. For example, instead of talking about how regulations are bad in general, tell a story of how complying with a certain regulation took time and energy away from your practice without offering any protections for the patient, thus decreasing both access to and quality of care. If the patient already has a formed opinion that is in opposition to yours, a story is an effective way to communicate your position without closing that patient off. It is also an effective way to influence the patient without directly challenging his or her belief, which could have a negative impact on the relationship. It may be helpful to consider situations by using the categories summarized in Table II. The most ideal discussions are those that are directly related, solicited, and specific. The least ideal discussions are unrelated, unsolicited, and nonspecific. These categories may help the physician decide how to pursue political conversations and how not to pursue them. Physician Advocacy An orthopaedic surgeon’s primary duty is to the patient5. This has been a foundation of Western medicine since the time of Hippocrates. However, there may be situations in which there is a perceived threat to the physician’s ability to serve the needs of society or a perceived threat to the practice of medicine. In those situations, the primary duty to the patient may not hold supreme. In such situations, a physician should broach the subject of politics with his or her patients to maintain his or her duty to society and to the profession regardless of the impact that may have on an individual patient. Information need not always flow from physician to patient, however. The history and physical examination are a collection of patient information. Thus the patient possesses information that is valuable to the physician. This principle can be useful when the patient initiates political discussions, and the physician can facilitate that discussion in the same way the physician facilitates a patient’s narrative history. The effect of this is to help the patient feel like his or her opinion is being heard, which will build trust between patient and physician. This approach can also be useful for physicians who want to understand patient experiences to better inform their own opinions. There are many issues about which an orthopaedic surgeon may be knowledgeable and passionate but that may not be appropriate to discuss with patients. It is up to the physician to decide which is which. If a physician feels strongly about a particular political issue but does not want to come across too strongly to a patient, the AAOS provides position statements that can be an effective communication tool6. Information communicated in this way may come across more favorably to patients, since it will seem less like the individual physician’s opinion and more like a consensus opinion among orthopaedic surgeons. Physician advocacy exists outside of the physicianpatient dyad. The responsibility of physicians to seek changes to the health-care system—a system that is increasingly directed by third-party interests—has never been so pressing. There are
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TABLE II Categories Applying to Physician-Patient Communication Category
Comment or Example
Relatedness to patient Directly related
Regulation that will limit ability to practice, such as Medicare reimbursement
Indirectly related
Marijuana laws, nutritional regulations, etc.
Unrelated
General social issues, such as immigration, education, foreign policy, etc.
Directionality Outgoing
Physician is making the commentary
Incoming
Patient is making the commentary
Bidirectional
Mutual discussion
Solicited
Patient asks the physician’s opinion (or vice versa)
Unsolicited
Physician makes commentary uninitiated by patient (or vice versa)
Solicitation
Specificity Specific
‘‘U.S. House of Representatives Bill 1911 will increase the physician workforce’’
Nonspecific
‘‘Socialized medicine is a bad idea’’
many state and national physician advocacy organizations, including the AAOS Government Relations Office7, through which physicians can and should have an impact on the practice of orthopaedic surgery beyond patient interactions. Proposed Behavior and Guidelines Extrapolating from the basic AAOS practice principles listed above, several suggestions for political discussions with patients, summarized in Table III, are proposed. These guidelines are not intended to regulate or proscribe behavior, only to inform the physician’s decisions about how and when to talk politics with patients. Case Illustrations The following cases will attempt to illustrate the guidelines mentioned above. CASE 1. During a casual chat with an orthopaedic surgeon while waiting for the electronic health record to boot up, a patient
makes an offhand comment about how fortunate it is that the most recent national immigration bill did not pass. This topic is irrelevant to the physician-patient encounter, and immigration reform is not likely to have a direct impact on the physician’s ability to care for that patient, although it may impact the practice of medicine depending on the specifics of the bill. Since the patient initiated the conversation, there has certainly been no inappropriate conduct on the part of the physician. The physician can either pursue the conversation or deflect it. Simply agreeing with the patient is not likely to cause any harm to the patient or the relationship, so long as the physician maintains personal integrity in doing so. It is not advisable to directly engage the patient if the physician disagrees. However, an effective deflecting approach may be to ask questions of the patient to elicit their feelings and ideas. While this does not contribute to the clinical situation, it may help build the trust necessary for an effective physician-patient relationship.
TABLE III Proposed Guidelines for Talking Politics with Patients 1. Ask yourself whether the patient will benefit from what you are intending to communicate 2. Restrict topics to those that directly impact patient welfare, patients’ ability to access your services, or your ability to provide services that benefit patients 3. Be proactive in speaking about issues that directly affect your patients and your practice 4. Be extremely judicious when engaging patients who initiate political discussions outside of your realm of expertise, outside of the duties of the physician-patient relationship, and outside the duties to society and the profession 5. Be specific, and use personal experience whenever possible 6. Clarify issues that are likely to seem self-serving on the surface 7. Solicit or facilitate patients’ opinions 8. Do not be condescending toward patients’ opinions or beliefs
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CASE 2. During a follow-up visit, a patient asks her orthopaedic surgeon how a proposed tort reform legislative package may impact the surgeon’s ability to continue to practice in that state. This is an appropriate opportunity to have a discussion, as the patient is requesting expert information on an issue that that patient knows will affect her care. Malpractice reform is an important issue in orthopaedic surgery, and it is important that patients are aware of how malpractice laws impact their surgeon’s practice and thus the ability of patients to access care. The patient solicited the information, and that information is directly relevant to the patient and the practice of medicine. The physician could end the conversation with a request that the patient contact her representative about the legislation. Malpractice reform is often an emotional topic for physicians, so it is important to keep a close eye on one’s state of mind when having such discussions. CASE 3. A patient asks his orthopaedic surgeon if she is for or against gun control. This represents a difficult situation because the patient is initiating the conversation, similar to the situation in Case 1. It is also a difficult situation because this particular topic can be a highly personal and divisive one for both physicians and patients. However, analyzing this case can still elicit principles that can inform political discussions. An important difference between this case and Case 1 is that the topic of gun control is more relevant to a physician-patient interaction than is immigration. In the case of a component of proposed gun control legislation requiring physicians to inquire about gun ownership and to report that to a state agency, the physician would face a conflict of interest between obeying the laws governing practice and protecting the interest and privacy of patients. Additionally, orthopaedic surgeons play a role in discussing gun safety and education with their patients as a preventive measure. These examples illustrate a favorable way in which to reorient an otherwise precarious discussion to fulfill the primary duty of serving the patient’s best interest. CASE 4. An orthopaedic surgeon has been following the development of a state bill that will divert funds into the state’s postsecondary education fund, which he believes is good for the state. He brings up the issue during patient visits, urging his patients to call their legislator to support the bill. This is an inappropriate use of the physician’s position. While the issue may have great personal significance to the physician, and the physician still has a right to free speech under the U.S. Constitution, there are limitations to personal interest that are imposed by the obligations of the physician-patient relationship. That relationship does not exist to serve the needs of the physician; it exists to serve the needs of the patients. The actions of the orthopaedic surgeon in this case are self-serving, with no direct, relevant benefit to the patient. However, part of the societal responsibility of the orthopaedic surgeon includes supporting activities that increase the well-being of the patient and community8. Thus, it is appropriate for the physician to advocate for this bill, just not in the patient interaction when unsolicited.
CASE 5. A bill is moving through the state legislature that will expand the scope of practice for nonphysicians, potentially endangering the orthopaedic patient population. An orthopaedic surgeon adds a few minutes to the end of each visit to talk about the dangers of the bill and how it might affect his patients. This conversation is not only appropriate, but is recommended. Orthopaedic surgeons are expected to seek changes to laws that negatively impact patients. Nonphysician practitioners occasionally attempt to expand their scope of practice, or legislators will make the attempt for them. In some cases this can help patients access care, and in some cases it can harm patients. In discussing scope of practice expansion with patients, it is important to be clear about the factual reasons for opposition, avoiding the misunderstanding that opposition is for business or personal reasons. Being proactive about educating patients in this manner fulfills all four ethical obligations with no conflict among them. CASE 6. An orthopaedic surgeon who is upset about a recent scandal befalling the state governor’s office vents to her patients about how awful the current governor is. This discussion is inappropriate because the physician is using the opportunity to vent her frustrations about an issue that does not involve any aspect of patient care or the practice of orthopaedic surgery. That physician has neglected the primary responsibility to patients and the obligation to subjugate personal interests to those of patients. Additionally, this physician does a disservice to the profession by acting in an unprofessional manner. A Real Case Example—Lessons Learned The following is a real case that received national media coverage in April of 20109,10. Dr. Jack Cassell, a Florida urologist, posted a sign on his office door that said ‘‘If you voted for Obama, seek urologic care elsewhere. Changes to your health care begin right now, not in four years.’’ When negative reactions began to spread, Dr. Cassell stood by his sign. He clarified that he was not actually turning away patients, because that would be unethical. Additionally, he did not attempt to assess whether someone did in fact vote for President Obama. According to Dr. Cassell, his sign was designed to make a point about his feelings on the health-care reform law (the Patient Protection and Affordable Care Act, or PPACA), feelings that were prompted by a concern for his patients’ well-being. Both the American Medical Association (AMA) and the AAOS maintain that physicians may choose the patients whom they serve11,12. The limitations provided on the choice of patient acceptance do not include anything suggestive of political affiliation or ideology13. Thus, in addition to there being no legal restrictions, there is no explicit ethical guidance from professional organizations as to whether or not that type of action should be pursued. Although there may be no law or code preventing Dr. Cassell’s actions, those actions certainly are cause for ethical consideration. In Dr. Cassell’s opinion, PPACA would have a profoundly negative impact on his practice and his ability to care for his patients. Beyond that, he believed that PPACA would have a negative impact on the ability of society to obtain quality care
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whether or not they received it from him. A case can be made that patients’ access to his care was not hampered if Dr. Cassell did not actually screen people on the basis of their voting history. As he stated, only a few people complained and most were very agreeable and supportive10. However, it can also be argued that the duty to provide for the needs of patients was violated when the patients felt that he was discriminating against them. The AAOS states that ‘‘patients who entrust their medical care to orthopaedic surgeons have an expectation that they will be treated with compassion, empathy, honesty, and integrity.’’14 It is reasonable for patients to suspect that, given the contents of the sign, they would not be treated with empathy or integrity and would not receive the best care depending on their political preferences. Stating that they should seek care elsewhere is easily interpreted as lacking compassion. Dr. Cassell appeared to have decided that this was a situation in which his obligation to society and to his profession and his obligation to make necessary legal changes to protect his patients imposed justifiably on the duty to promote each individual patient’s best interest. Both the AMA and the AAOS state that the physician has an obligation to change laws that will negatively impact his or her patients3,9. Since there is not an objective way to determine whether or not patients will be negatively impacted, the discretion is left to the physician. Physicians alone are responsible for balancing the competing ethical
duties and for accepting the consequences of their actions made on the basis of those considerations. Conclusions Politics can be a difficult topic to discuss in the physician-patient relationship, yet the impact of legislation and policy on the practice of orthopaedic surgery is substantial. Physicians occupy a unique position to advocate for changes in the rules and laws governing their practice. They are bound by duty to serve in the best interests of the patient, to society as a whole, to their profession, and to the subjugation of their own interests, and they should carefully balance those principles in the dilemmas they face. They are also expected to take an active role in changing the legal environment when it is harmful to patients. Little guidance on this matter exists in the literature or professional codes of behavior. This article has articulated a starting point for a code of behavior and a foundation for guiding the ethical approach to talking politics with patients. n
Ryan M. Eggers, MA Center for Christian Bioethics, Loma Linda University, 10710 Lindesmith Avenue, Whittier, CA 90603
References 1. Online Etymology Dictionary. Politics. 2013. http://www.etymonline.com/index. php?term=politics&allowed_in_frame=0. Accessed 2013 Nov 30. 2. American Academy of Orthopaedic Surgeons. Guide to professionalism and ethics in the practice of orthopaedic surgery. Rosemont: American Academy of Orthopaedic Surgeons; 2013. p 15, 16, and 149. http://www.aaos.org/about/ papers/ethics/ethicalpractguide.pdf. Accessed 2013 Nov 30. 3. Beauchamp TL, Childress JF. Principles of biomedical ethics. 6th ed. New York: Oxford University Press; 2009. 4. Hooker W. Physician and patient. New York: Baker and Scribner; 1849. p 391. 5. American Academy of Orthopaedic Surgeons. Guide to professionalism and ethics in the practice of orthopaedic surgery. Rosemont: American Academy of Orthopaedic Surgeons; 2013. Principles of medical ethics and professionalism in orthopaedic surgery. p 15. http://www.aaos.org/about/papers/ethics/ ethicalpractguide.pdf. Accessed 2013 Nov 30. 6. American Academy of Orthopaedic Surgeons. Guide to professionalism and ethics in the practice of orthopaedic surgery. Rosemont: American Academy of Orthopaedic Surgeons; 2013. http://www.aaos.org/about/papers/ethics/ ethicalpractguide.pdf. p 39-64. Accessed 2013 Nov 30. 7. American Academy of Orthopaedic Surgeons. Government relations. http://www. aaos.org/Govern/Govern.asp. Accessed 2013 Nov 30. 8. American Academy of Orthopaedic Surgeons. Guide to professionalism and ethics in the practice of orthopaedic surgery. Rosemont: American Academy of Orthopaedic Surgeons; 2013. Principles of medical ethics and professionalism in orthopaedic surgery. p 16. http://www.aaos.org/about/papers/ethics/ ethicalpractguide.pdf. Accessed 2013 Nov 30.
9. Fox News. Florida doctor stands by anti-’Obamacare’ sign despite threat of complaint. 2010 Apr 5. http://www.foxnews.com/politics/2010/04/05/ florida-doctor-stands-anti-obamacare-sign-despite-threat-complaint/. Accessed 30 May 2013. 10. Los Angeles Times. Doctor advises Obama voters to ‘seek care elsewhere’. http://articles.latimes.com/2010/apr/04/nation/la-na-gop-doctor4-2010apr04. 2010 Apr 4. Accessed 30 May 2013. 11. American Academy of Orthopaedic Surgeons. Guide to professionalism and ethics in the practice of orthopaedic surgery. Rosemont: American Academy of Orthopaedic Surgeons; 2013. Code of medical ethics and professionalism for orthopaedic surgeons. p 18. http://www.aaos.org/about/papers/ethics/ ethicalpractguide.pdf. Accessed 2013 Nov 30. 12. American Medical Association. Code of medical ethics. http://www.ama-assn. org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/ principles-medical-ethics.page? Accessed 2013 Nov 30. 13. American Academy of Orthopaedic Surgeons. Guide to professionalism and ethics in the practice of orthopaedic surgery. Rosemont: American Academy of Orthopaedic Surgeons; 2013. Code of medical ethics and professionalism for orthopaedic surgeons. p 17. http://www.aaos.org/about/papers/ethics/ ethicalpractguide.pdf. Accessed 2013 Nov 30. 14. American Academy of Orthopaedic Surgeons. Guide to professionalism and ethics in the practice of orthopaedic surgery. Rosemont: American Academy of Orthopaedic Surgeons; 2013. Standards of professionalism: professional relationships. p 149. http://www.aaos.org/about/papers/ethics/ethicalpractguide. pdf. Accessed 2013 Nov 30.
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Ethics in Practice Talking Politics with Patients Ryan M. Eggers, MA Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
The political debate about health systems is still raging around the United States, and patients are constantly bombarded with information about politics and medicine from friends, coworkers, and the media. Some of that information is true, and some is not. One important source patients may turn to is one they implicitly trust: their physician. Physicians are valuable sources of information regarding the current state of medical practice and the necessary changes to it. While few physicians will get the chance to testify before Congress or interview on television, all physicians have the opportunity to engage in the politics of medicine with their patients. However, engaging patients in this area can be a tricky venture. The first difficulty lies in an accurate definition of the term politics. The original usage of the term originated from Aristotle’s book Politics, which translates as ‘‘the things concerning the polis [Greek city-state],’’ or ‘‘affairs of state.’’1 Thus, a common connotation of politics is ‘‘that which concerns the operation of government.’’ Other definitions can range from ‘‘specific legislative actions’’ to ‘‘anything that influences the thought of another person or organization, especially in an attempt to resolve conflict or come to a collective decision.’’ For the purpose and scope of this article, politics refers to ideas or actions that relate to the operation of a governmental or regulatory organization. Our political feelings and opinions are practical extensions of our worldview, and our worldview is deeply connected to our individual sense of what it means to be human. That is, politics is linked to our deepest sense of ourselves. By nature of the role of government and our sense of duty to follow laws, politics also carries with it profound potential consequences for our lives. These two things contribute to making political discussions
highly contested and emotional events of which physicians should be wary. Political discussions also carry the potential for improving the physician-patient relationship and for increasing the knowledge of both physicians and patients. There exists essentially nothing in the current literature or professional guidelines that directly addresses these interactions. This paper will attempt to highlight the relevant principles and offer some potential guidelines on appropriate behavior through discussion and case analysis. Balancing the Principles The American Academy of Orthopaedic Surgeons (AAOS) does not yet offer specific guidelines on how to approach the issue of political discussions with patients, but their other guidelines provide the basis for inferences. The following four excerpts are taken from the 2013 AAOS Guide to Professionalism and Ethics in the Practice of Orthopaedic Surgery 2. ‘‘The orthopaedic profession exists for the primary purpose of caring for the patient. The physician-patient relationship is the central focus of all ethical concerns.’’ (page 15). ‘‘The orthopaedic surgeon also has a responsibility to seek changes in legal requirements that are contrary to the best interest of the patient.’’ (page 15). ‘‘The orthopaedic surgeon has a responsibility not only to the individual patient, to colleagues and orthopaedic surgeons-intraining, but also to society as a whole.’’ (page 16). ‘‘The medical profession requires physicians to subordinate their own interests in favor of the patient’s best interests and
Disclosure: The author did not receive payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. He, or his institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. The author has not had any other relationships, or engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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hold themselves to high ethical and moral standards.’’ (page 149).
At the heart of the ethical dilemma in political conversations is the conflict of four principles, also summarized in Table I. They are (1) the primary duty to the patient, (2) the duty to society as a whole, (3) the duty to the profession, and (4) the subjugation of the physician’s personal interests. This order does not represent an absolute hierarchy, but like the four bioethical principles of Beauchamp and Childress (autonomy, beneficence, nonmaleficence, and justice), they should be balanced through a process called ‘‘reflective equilibrium,’’ wherein the merits of each principle are weighed against those of the others for each ethical dilemma3. These four principles should not be misconstrued as rigid rules, but should serve to inform case-by-case decisions for individual physicians. Politics and Patients Inherent in the physician-patient relationship is an acknowledged power differential. Patients are compelled to take a relatively compliant role, but the physician’s role is one of power because he or she possesses necessary information for effective treatment. This powerful position can be abused, whether intentionally or not, when the physician discusses his or her political opinions with a patient. Physicians should be mindful of this power dynamic, specifically when the issue is only indirectly related and input is unsolicited. In his chapter on ‘‘Moral Influence of Physicians,’’ nineteenth century medical ethicist Dr. Worthington Hooker said, ‘‘What responsibility then rests upon the physician! How careful should he be in the expression of his opinions!’’4 A physician could be more informed about a political topic than the patient, but this alone does not justify a top-down approach in the same way a diagnosis or treatment plan is communicated. After all, patients rarely make appointments to speak to their physicians about political issues. A potential pitfall in talking politics with patients comes when a physician’s agenda seems self-serving on the surface. An example of this situation is Medicare or Medicaid reimbursement rates. The real issue may be the financial solvency of the practice and the access of patients to services, but physicians who do not clarify such issues run the risk of seeming self-serving. Effectively communicating this distinction may be critical to maintaining the best understanding of the physician’s intent. Another effective approach to talking politics with patients comes from a page in the physician-lobbyist playbook: tell your story. Many physicians who advocate to the legislature make
their case more relatable and poignant with a personal story. The same principle can apply to dealing with patients. For example, instead of talking about how regulations are bad in general, tell a story of how complying with a certain regulation took time and energy away from your practice without offering any protections for the patient, thus decreasing both access to and quality of care. If the patient already has a formed opinion that is in opposition to yours, a story is an effective way to communicate your position without closing that patient off. It is also an effective way to influence the patient without directly challenging his or her belief, which could have a negative impact on the relationship. It may be helpful to consider situations by using the categories summarized in Table II. The most ideal discussions are those that are directly related, solicited, and specific. The least ideal discussions are unrelated, unsolicited, and nonspecific. These categories may help the physician decide how to pursue political conversations and how not to pursue them. Physician Advocacy An orthopaedic surgeon’s primary duty is to the patient5. This has been a foundation of Western medicine since the time of Hippocrates. However, there may be situations in which there is a perceived threat to the physician’s ability to serve the needs of society or a perceived threat to the practice of medicine. In those situations, the primary duty to the patient may not hold supreme. In such situations, a physician should broach the subject of politics with his or her patients to maintain his or her duty to society and to the profession regardless of the impact that may have on an individual patient. Information need not always flow from physician to patient, however. The history and physical examination are a collection of patient information. Thus the patient possesses information that is valuable to the physician. This principle can be useful when the patient initiates political discussions, and the physician can facilitate that discussion in the same way the physician facilitates a patient’s narrative history. The effect of this is to help the patient feel like his or her opinion is being heard, which will build trust between patient and physician. This approach can also be useful for physicians who want to understand patient experiences to better inform their own opinions. There are many issues about which an orthopaedic surgeon may be knowledgeable and passionate but that may not be appropriate to discuss with patients. It is up to the physician to decide which is which. If a physician feels strongly about a particular political issue but does not want to come across too strongly to a patient, the AAOS provides position statements that can be an effective communication tool6. Information communicated in this way may come across more favorably to patients, since it will seem less like the individual physician’s opinion and more like a consensus opinion among orthopaedic surgeons. Physician advocacy exists outside of the physicianpatient dyad. The responsibility of physicians to seek changes to the health-care system—a system that is increasingly directed by third-party interests—has never been so pressing. There are
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TABLE II Categories Applying to Physician-Patient Communication Category
Comment or Example
Relatedness to patient Directly related
Regulation that will limit ability to practice, such as Medicare reimbursement
Indirectly related
Marijuana laws, nutritional regulations, etc.
Unrelated
General social issues, such as immigration, education, foreign policy, etc.
Directionality Outgoing
Physician is making the commentary
Incoming
Patient is making the commentary
Bidirectional
Mutual discussion
Solicited
Patient asks the physician’s opinion (or vice versa)
Unsolicited
Physician makes commentary uninitiated by patient (or vice versa)
Solicitation
Specificity Specific
‘‘U.S. House of Representatives Bill 1911 will increase the physician workforce’’
Nonspecific
‘‘Socialized medicine is a bad idea’’
many state and national physician advocacy organizations, including the AAOS Government Relations Office7, through which physicians can and should have an impact on the practice of orthopaedic surgery beyond patient interactions. Proposed Behavior and Guidelines Extrapolating from the basic AAOS practice principles listed above, several suggestions for political discussions with patients, summarized in Table III, are proposed. These guidelines are not intended to regulate or proscribe behavior, only to inform the physician’s decisions about how and when to talk politics with patients. Case Illustrations The following cases will attempt to illustrate the guidelines mentioned above. CASE 1. During a casual chat with an orthopaedic surgeon while waiting for the electronic health record to boot up, a patient
makes an offhand comment about how fortunate it is that the most recent national immigration bill did not pass. This topic is irrelevant to the physician-patient encounter, and immigration reform is not likely to have a direct impact on the physician’s ability to care for that patient, although it may impact the practice of medicine depending on the specifics of the bill. Since the patient initiated the conversation, there has certainly been no inappropriate conduct on the part of the physician. The physician can either pursue the conversation or deflect it. Simply agreeing with the patient is not likely to cause any harm to the patient or the relationship, so long as the physician maintains personal integrity in doing so. It is not advisable to directly engage the patient if the physician disagrees. However, an effective deflecting approach may be to ask questions of the patient to elicit their feelings and ideas. While this does not contribute to the clinical situation, it may help build the trust necessary for an effective physician-patient relationship.
TABLE III Proposed Guidelines for Talking Politics with Patients 1. Ask yourself whether the patient will benefit from what you are intending to communicate 2. Restrict topics to those that directly impact patient welfare, patients’ ability to access your services, or your ability to provide services that benefit patients 3. Be proactive in speaking about issues that directly affect your patients and your practice 4. Be extremely judicious when engaging patients who initiate political discussions outside of your realm of expertise, outside of the duties of the physician-patient relationship, and outside the duties to society and the profession 5. Be specific, and use personal experience whenever possible 6. Clarify issues that are likely to seem self-serving on the surface 7. Solicit or facilitate patients’ opinions 8. Do not be condescending toward patients’ opinions or beliefs
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CASE 2. During a follow-up visit, a patient asks her orthopaedic surgeon how a proposed tort reform legislative package may impact the surgeon’s ability to continue to practice in that state. This is an appropriate opportunity to have a discussion, as the patient is requesting expert information on an issue that that patient knows will affect her care. Malpractice reform is an important issue in orthopaedic surgery, and it is important that patients are aware of how malpractice laws impact their surgeon’s practice and thus the ability of patients to access care. The patient solicited the information, and that information is directly relevant to the patient and the practice of medicine. The physician could end the conversation with a request that the patient contact her representative about the legislation. Malpractice reform is often an emotional topic for physicians, so it is important to keep a close eye on one’s state of mind when having such discussions. CASE 3. A patient asks his orthopaedic surgeon if she is for or against gun control. This represents a difficult situation because the patient is initiating the conversation, similar to the situation in Case 1. It is also a difficult situation because this particular topic can be a highly personal and divisive one for both physicians and patients. However, analyzing this case can still elicit principles that can inform political discussions. An important difference between this case and Case 1 is that the topic of gun control is more relevant to a physician-patient interaction than is immigration. In the case of a component of proposed gun control legislation requiring physicians to inquire about gun ownership and to report that to a state agency, the physician would face a conflict of interest between obeying the laws governing practice and protecting the interest and privacy of patients. Additionally, orthopaedic surgeons play a role in discussing gun safety and education with their patients as a preventive measure. These examples illustrate a favorable way in which to reorient an otherwise precarious discussion to fulfill the primary duty of serving the patient’s best interest. CASE 4. An orthopaedic surgeon has been following the development of a state bill that will divert funds into the state’s postsecondary education fund, which he believes is good for the state. He brings up the issue during patient visits, urging his patients to call their legislator to support the bill. This is an inappropriate use of the physician’s position. While the issue may have great personal significance to the physician, and the physician still has a right to free speech under the U.S. Constitution, there are limitations to personal interest that are imposed by the obligations of the physician-patient relationship. That relationship does not exist to serve the needs of the physician; it exists to serve the needs of the patients. The actions of the orthopaedic surgeon in this case are self-serving, with no direct, relevant benefit to the patient. However, part of the societal responsibility of the orthopaedic surgeon includes supporting activities that increase the well-being of the patient and community8. Thus, it is appropriate for the physician to advocate for this bill, just not in the patient interaction when unsolicited.
CASE 5. A bill is moving through the state legislature that will expand the scope of practice for nonphysicians, potentially endangering the orthopaedic patient population. An orthopaedic surgeon adds a few minutes to the end of each visit to talk about the dangers of the bill and how it might affect his patients. This conversation is not only appropriate, but is recommended. Orthopaedic surgeons are expected to seek changes to laws that negatively impact patients. Nonphysician practitioners occasionally attempt to expand their scope of practice, or legislators will make the attempt for them. In some cases this can help patients access care, and in some cases it can harm patients. In discussing scope of practice expansion with patients, it is important to be clear about the factual reasons for opposition, avoiding the misunderstanding that opposition is for business or personal reasons. Being proactive about educating patients in this manner fulfills all four ethical obligations with no conflict among them. CASE 6. An orthopaedic surgeon who is upset about a recent scandal befalling the state governor’s office vents to her patients about how awful the current governor is. This discussion is inappropriate because the physician is using the opportunity to vent her frustrations about an issue that does not involve any aspect of patient care or the practice of orthopaedic surgery. That physician has neglected the primary responsibility to patients and the obligation to subjugate personal interests to those of patients. Additionally, this physician does a disservice to the profession by acting in an unprofessional manner. A Real Case Example—Lessons Learned The following is a real case that received national media coverage in April of 20109,10. Dr. Jack Cassell, a Florida urologist, posted a sign on his office door that said ‘‘If you voted for Obama, seek urologic care elsewhere. Changes to your health care begin right now, not in four years.’’ When negative reactions began to spread, Dr. Cassell stood by his sign. He clarified that he was not actually turning away patients, because that would be unethical. Additionally, he did not attempt to assess whether someone did in fact vote for President Obama. According to Dr. Cassell, his sign was designed to make a point about his feelings on the health-care reform law (the Patient Protection and Affordable Care Act, or PPACA), feelings that were prompted by a concern for his patients’ well-being. Both the American Medical Association (AMA) and the AAOS maintain that physicians may choose the patients whom they serve11,12. The limitations provided on the choice of patient acceptance do not include anything suggestive of political affiliation or ideology13. Thus, in addition to there being no legal restrictions, there is no explicit ethical guidance from professional organizations as to whether or not that type of action should be pursued. Although there may be no law or code preventing Dr. Cassell’s actions, those actions certainly are cause for ethical consideration. In Dr. Cassell’s opinion, PPACA would have a profoundly negative impact on his practice and his ability to care for his patients. Beyond that, he believed that PPACA would have a negative impact on the ability of society to obtain quality care
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whether or not they received it from him. A case can be made that patients’ access to his care was not hampered if Dr. Cassell did not actually screen people on the basis of their voting history. As he stated, only a few people complained and most were very agreeable and supportive10. However, it can also be argued that the duty to provide for the needs of patients was violated when the patients felt that he was discriminating against them. The AAOS states that ‘‘patients who entrust their medical care to orthopaedic surgeons have an expectation that they will be treated with compassion, empathy, honesty, and integrity.’’14 It is reasonable for patients to suspect that, given the contents of the sign, they would not be treated with empathy or integrity and would not receive the best care depending on their political preferences. Stating that they should seek care elsewhere is easily interpreted as lacking compassion. Dr. Cassell appeared to have decided that this was a situation in which his obligation to society and to his profession and his obligation to make necessary legal changes to protect his patients imposed justifiably on the duty to promote each individual patient’s best interest. Both the AMA and the AAOS state that the physician has an obligation to change laws that will negatively impact his or her patients3,9. Since there is not an objective way to determine whether or not patients will be negatively impacted, the discretion is left to the physician. Physicians alone are responsible for balancing the competing ethical
duties and for accepting the consequences of their actions made on the basis of those considerations. Conclusions Politics can be a difficult topic to discuss in the physician-patient relationship, yet the impact of legislation and policy on the practice of orthopaedic surgery is substantial. Physicians occupy a unique position to advocate for changes in the rules and laws governing their practice. They are bound by duty to serve in the best interests of the patient, to society as a whole, to their profession, and to the subjugation of their own interests, and they should carefully balance those principles in the dilemmas they face. They are also expected to take an active role in changing the legal environment when it is harmful to patients. Little guidance on this matter exists in the literature or professional codes of behavior. This article has articulated a starting point for a code of behavior and a foundation for guiding the ethical approach to talking politics with patients. n
Ryan M. Eggers, MA Center for Christian Bioethics, Loma Linda University, 10710 Lindesmith Avenue, Whittier, CA 90603
References 1. Online Etymology Dictionary. Politics. 2013. http://www.etymonline.com/index. php?term=politics&allowed_in_frame=0. Accessed 2013 Nov 30. 2. American Academy of Orthopaedic Surgeons. Guide to professionalism and ethics in the practice of orthopaedic surgery. Rosemont: American Academy of Orthopaedic Surgeons; 2013. p 15, 16, and 149. http://www.aaos.org/about/ papers/ethics/ethicalpractguide.pdf. Accessed 2013 Nov 30. 3. Beauchamp TL, Childress JF. Principles of biomedical ethics. 6th ed. New York: Oxford University Press; 2009. 4. Hooker W. Physician and patient. New York: Baker and Scribner; 1849. p 391. 5. American Academy of Orthopaedic Surgeons. Guide to professionalism and ethics in the practice of orthopaedic surgery. Rosemont: American Academy of Orthopaedic Surgeons; 2013. Principles of medical ethics and professionalism in orthopaedic surgery. p 15. http://www.aaos.org/about/papers/ethics/ ethicalpractguide.pdf. Accessed 2013 Nov 30. 6. American Academy of Orthopaedic Surgeons. Guide to professionalism and ethics in the practice of orthopaedic surgery. Rosemont: American Academy of Orthopaedic Surgeons; 2013. http://www.aaos.org/about/papers/ethics/ ethicalpractguide.pdf. p 39-64. Accessed 2013 Nov 30. 7. American Academy of Orthopaedic Surgeons. Government relations. http://www. aaos.org/Govern/Govern.asp. Accessed 2013 Nov 30. 8. American Academy of Orthopaedic Surgeons. Guide to professionalism and ethics in the practice of orthopaedic surgery. Rosemont: American Academy of Orthopaedic Surgeons; 2013. Principles of medical ethics and professionalism in orthopaedic surgery. p 16. http://www.aaos.org/about/papers/ethics/ ethicalpractguide.pdf. Accessed 2013 Nov 30.
9. Fox News. Florida doctor stands by anti-’Obamacare’ sign despite threat of complaint. 2010 Apr 5. http://www.foxnews.com/politics/2010/04/05/ florida-doctor-stands-anti-obamacare-sign-despite-threat-complaint/. Accessed 30 May 2013. 10. Los Angeles Times. Doctor advises Obama voters to ‘seek care elsewhere’. http://articles.latimes.com/2010/apr/04/nation/la-na-gop-doctor4-2010apr04. 2010 Apr 4. Accessed 30 May 2013. 11. American Academy of Orthopaedic Surgeons. Guide to professionalism and ethics in the practice of orthopaedic surgery. Rosemont: American Academy of Orthopaedic Surgeons; 2013. Code of medical ethics and professionalism for orthopaedic surgeons. p 18. http://www.aaos.org/about/papers/ethics/ ethicalpractguide.pdf. Accessed 2013 Nov 30. 12. American Medical Association. Code of medical ethics. http://www.ama-assn. org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/ principles-medical-ethics.page? Accessed 2013 Nov 30. 13. American Academy of Orthopaedic Surgeons. Guide to professionalism and ethics in the practice of orthopaedic surgery. Rosemont: American Academy of Orthopaedic Surgeons; 2013. Code of medical ethics and professionalism for orthopaedic surgeons. p 17. http://www.aaos.org/about/papers/ethics/ ethicalpractguide.pdf. Accessed 2013 Nov 30. 14. American Academy of Orthopaedic Surgeons. Guide to professionalism and ethics in the practice of orthopaedic surgery. Rosemont: American Academy of Orthopaedic Surgeons; 2013. Standards of professionalism: professional relationships. p 149. http://www.aaos.org/about/papers/ethics/ethicalpractguide. pdf. Accessed 2013 Nov 30.
