Setting the limits on medical advocacy
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Here is an interesting and slightly alternative view to advocacy and the patient in today's medical world
When the Port Arthur massacre occurred in 1996, I was newly appointed as Dean of the Sydney Medical School.
Simon Chapman, one of our senior public health professionals well known for his anti-tobacco advocacy and campaigning, was strongly associated with the anti-gun backlash to the Tasmanian atrocity. We provided space in the School of Public Health to accommodate several members of the anti-gun advocacy group and a small grant to help them do research in relation to this matter. The treasurer of a charitable foundation associated with the faculty resigned, protesting that gun control had nothing to do with medicine or public health.
A colleague wrote to me recently saying, in the light of the asylum seeker controversy:
There seems to be a tension between the broader and narrower conceptions of the profession’s responsibilities. It waxes and wanes between those who take a fairly straightened view of what should rightly fit within the field of medical profession advocacy, and those who think the ethical obligation of doctors requires that they advocate on a broad range. From a certain viewpoint, most things can have implications for health. But is it feasible (or effective) for doctors to speak out on many, or is there reason to focus attention and effort? If so, how is such a selection to be made?
I suspect that this will always remain a matter of personal judgment, but there are three signposts that may help. I feel like the Dalai Llama who, when visiting Westmead Hospital in June 2013, was asked a tricky ethical question and answered with a thoughtful smile, “I don’t know. You’ll have to work that out!” Three signposts may make the journey a little easier.
Our duty of care
First, doctors have a duty of care to the patient in front of them that trumps everything else.
Our duty of care obliges us to do all that we can that is consistent with our patient's wishes to enable them to live a life that, as economist Amartya Sen says so elegantly, “they have reason to value”.
We do not have a duty of anywhere near the strength of the duty of care to save money, or to consider where else the resources we are using might be applied. The patient comes first. This ethic leads doctors to do amazing and wonderful things such as Catherine and Reg Hamlin for women with fistulae in Ethiopia - both caring for them and advocating for prevention and justice for them.
Advocacy for health beyond our individual patient
But second, beside our duty of care to individual patients there are other things that claim our attention and energy. We are at our strongest here when our advocacy is over matters closest to our professional competence. Services provided through committees, help to patient advocacy groups and other community agencies and consultancies are in this category.
Third, and here things become slippery, as senior members of society and of the small stratum of highly educated elite, we have several other responsibilities beside those to our individual patients.
The slippery slope
Expressing views and advocating for things beyond our professional competence - as when medical groups wrote letters endorsing Hitler’s rise to power - can be dangerous. You can hold whatever political or religious views you like and advocate for these as a citizen. But once the medical mantle is donned, the ethical coordinates are reset.
In a bright and interesting paper published recently in The Lancet, academics from Bristol and Southampton reviewed the history of medical lobbying. They stated that, in the light of the growing chronic disease burden due to behaviours that derive from unhealthy environments, lobbying is needed to combat the “large sums of [spent] marketing commodities such as sugar-laden drinks that add to that burden”. Should we be lobbying and advocating for less sugar in our diet?
Two topics bring the contemporary debate about medical advocacy and how far we as doctors should go into focus - climate change and asylum seekers.
Climate change and asylum seekers
Feelings run strongly in both directions over climate change. There are doctors who hold the view that it is the largest future threat to human health and that they should advocate for all the measures that have been proposed to prevent or at least mitigate it.
The evidential base for concern about climate change derives from climate science, but not medical science, and so we are not on strong ground as medical practitioners when we join the debate. There is, however, an accumulating corpus of research data and modelling about health effects that can be used by medical and public health advocates.
Asylum seekers, whose management challenges us and many other countries at several ethical levels, have a special appeal to the medical profession because depression, anxiety, impaired development during childhood follow from the ghastly business of seeking asylum, made many times worse by hostile responses and incarceration in the countries where asylum is sought.
The recently revoked embargo on medical and other health professionals speaking out about what they have observed when treating patients in the Australian detention centres reminds us of the limits of power to medical advocacy.
In this case, national political policies were held for a time to be superior to the duty of medical care to speak truth to power on behalf of our patients.
This unhappy event serves to remind us that medicine and health are players in a much larger game - that of national and international politics and economics.
Thank your lucky stars that we have the freedom that we do - and advocate for its preservation!
Published: 22 Nov 2016
When the Port Arthur massacre occurred in 1996, I was newly appointed as Dean of the Sydney Medical School.
Simon Chapman, one of our senior public health professionals well known for his anti-tobacco advocacy and campaigning, was strongly associated with the anti-gun backlash to the Tasmanian atrocity. We provided space in the School of Public Health to accommodate several members of the anti-gun advocacy group and a small grant to help them do research in relation to this matter. The treasurer of a charitable foundation associated with the faculty resigned, protesting that gun control had nothing to do with medicine or public health.
A colleague wrote to me recently saying, in the light of the asylum seeker controversy:
There seems to be a tension between the broader and narrower conceptions of the profession’s responsibilities. It waxes and wanes between those who take a fairly straightened view of what should rightly fit within the field of medical profession advocacy, and those who think the ethical obligation of doctors requires that they advocate on a broad range. From a certain viewpoint, most things can have implications for health. But is it feasible (or effective) for doctors to speak out on many, or is there reason to focus attention and effort? If so, how is such a selection to be made?
I suspect that this will always remain a matter of personal judgment, but there are three signposts that may help. I feel like the Dalai Llama who, when visiting Westmead Hospital in June 2013, was asked a tricky ethical question and answered with a thoughtful smile, “I don’t know. You’ll have to work that out!” Three signposts may make the journey a little easier.
Our duty of care
First, doctors have a duty of care to the patient in front of them that trumps everything else.
Our duty of care obliges us to do all that we can that is consistent with our patient's wishes to enable them to live a life that, as economist Amartya Sen says so elegantly, “they have reason to value”.
We do not have a duty of anywhere near the strength of the duty of care to save money, or to consider where else the resources we are using might be applied. The patient comes first. This ethic leads doctors to do amazing and wonderful things such as Catherine and Reg Hamlin for women with fistulae in Ethiopia - both caring for them and advocating for prevention and justice for them.
Advocacy for health beyond our individual patient
But second, beside our duty of care to individual patients there are other things that claim our attention and energy. We are at our strongest here when our advocacy is over matters closest to our professional competence. Services provided through committees, help to patient advocacy groups and other community agencies and consultancies are in this category.
Third, and here things become slippery, as senior members of society and of the small stratum of highly educated elite, we have several other responsibilities beside those to our individual patients.
The slippery slope
Expressing views and advocating for things beyond our professional competence - as when medical groups wrote letters endorsing Hitler’s rise to power - can be dangerous. You can hold whatever political or religious views you like and advocate for these as a citizen. But once the medical mantle is donned, the ethical coordinates are reset.
In a bright and interesting paper published recently in The Lancet, academics from Bristol and Southampton reviewed the history of medical lobbying. They stated that, in the light of the growing chronic disease burden due to behaviours that derive from unhealthy environments, lobbying is needed to combat the “large sums of [spent] marketing commodities such as sugar-laden drinks that add to that burden”. Should we be lobbying and advocating for less sugar in our diet?
Two topics bring the contemporary debate about medical advocacy and how far we as doctors should go into focus - climate change and asylum seekers.
Climate change and asylum seekers
Feelings run strongly in both directions over climate change. There are doctors who hold the view that it is the largest future threat to human health and that they should advocate for all the measures that have been proposed to prevent or at least mitigate it.
The evidential base for concern about climate change derives from climate science, but not medical science, and so we are not on strong ground as medical practitioners when we join the debate. There is, however, an accumulating corpus of research data and modelling about health effects that can be used by medical and public health advocates.
Asylum seekers, whose management challenges us and many other countries at several ethical levels, have a special appeal to the medical profession because depression, anxiety, impaired development during childhood follow from the ghastly business of seeking asylum, made many times worse by hostile responses and incarceration in the countries where asylum is sought.
The recently revoked embargo on medical and other health professionals speaking out about what they have observed when treating patients in the Australian detention centres reminds us of the limits of power to medical advocacy.
In this case, national political policies were held for a time to be superior to the duty of medical care to speak truth to power on behalf of our patients.
This unhappy event serves to remind us that medicine and health are players in a much larger game - that of national and international politics and economics.
Thank your lucky stars that we have the freedom that we do - and advocate for its preservation!
Published: 22 Nov 2016
