By David J. Gibson, MD
ELSEWHERE IN THIS ISSUE of SSV Medicine, Dr. Harry Wang, president of Physicians for Social Responsibility in Sacramento, argues physicians should be vocal activists on public policy issues. My reaction is yes and no - mostly the latter.
Arguing the negative is akin to opposing motherhood and apple pie. For the past decade, the CMA has organized annual "Leadership Academies." Their purpose is to educate physicians about public policy issues. One goal is to encourage attendees to stand for election to public office. Furthermore, the two most sought after spokespersons by advertising and activist groups are celebrities and physicians.
To clear the table of non-issues, I stipulate that Americans have the freedom to express their opinion on any issue. No matter how tangential, you have the right to express yourself - even if no one cares to listen to your point of view.
What's more, physician organizations and groups have a vital role to play in expressing expert consensus on issues of the day. Dr. Wang references the AMA Board of Trustees resolution in 1981 that "there is no adequate medical response to a nuclear holocaust." Few would argue this is not a credible addition to the debate.
My major problem is when individual physicians seek unearned credibility by attaching their academic title to public statements. Mr. Wang does not have the same credibility as Dr. Wang. In the public square, you defend your position based on reason and facts. To short cut your progress to credibility by flashing the MD degree inevitably leads to defeat in the battle of ideas, with loss of credibility for the profession as collateral damage.
Beyond this central objection to exploiting the degree, physicians have a long and undistinguished history of performing poorly on public policy issues. As Dr. Wang points out, "almost half of registered German physicians were members of the Nazi Party." The ridiculous racial theories of the Nazis had their roots in an international eugenics movement whose principal supporters included physicians and academics.
In June of this year, Sacramento revisited the sordid past of C. M. Goethe, whose name was attached to a middle school as a result of his philanthropic activities in the 1920s. In addition to his good works, Mr. Goethe was one of America's leading eugenicists. A recent display in the SSV Museum of Medical History exploring the eugenics movement noted that many physicians in Sacramento and across the state supported Goethe and his preposterous theories.
The idealism of these physicians was unchecked by reality. They helped fuel the worldwide eugenics movement during the first half of the 20th century. English intellectual Herbert Spencer articulated the lofty goal of eugenics by announcing that "all imperfection must disappear." Margaret Sanger called for forced sterilization, concentration camps, and birth control for the "creation of a new race." The ideals of Planned Parenthood's founder were partially realized through the sterilization of nearly 70,000 people by various state governments, including California. In Germany, these same ideals - "a new race" - resulted in something far more horrible.
When physicians expand the scope and reach of science in medicine, our accomplishments are unparalleled. When we step outside our area of competence and become activists in the public arena, the results can be tragic. The following admittedly selected list provides but a few infamous examples:
Karl Brandt (1904-1948) - Nazi human experimentation.
Radovan Karad×ic (b. 1945) - ethnic cleansing in Yugoslavia.
Franšois ("Papa Doc") Duvalier (1907-1971) - President and later dictator of Haiti.
Josef Mengele (1911-1979) - the "Angel of Death," Nazi human experimentation.
Jack Kevorkian (1923- ) - convicted of second-degree murder, Michigan, April 13, 1999.
Shiro Ishii - head of Japan's Unit 731 during World War II, which conducted human experimentation for weapons and medical research.
Khalid Ahmed, Bilal Talal Abdul Samad Abdulla, Muhammad Haneef, Mohammed Jamil Abdelqader Asha - all physicians arrested for involvement in the failed car bombings in Glasgow and London this year.
Physicians who enter politics generally occupy the backbench and remain active in the politics for only a short time. Those who remain occasionally attain prominence but tend to gravitate toward extremes of their political parties. Tom Coburn, Ron Paul, Jim McDermott and Howard Dean illustrate this observation.
In Team of Rivals, Doris Goodwin discusses Lincoln's presidency and his cabinet members and political competitors: New York Senator William H. Seward, Ohio Governor Salmon P. Chase, and Missouri's distinguished elder statesman Edward Bates. Goodwin notes, "All four studied law, became distinguished orators, entered politics, and opposed the spread of slavery."
Why do physicians have a poor record of accomplishment for political leadership when other professions, particularly the law, spawn leaders in each generation? What is unique about medicine that generates political extremists in each generation? There are no simple answers. The causality is as varied as are the individuals. However, common threads run through the profession that allow us to speculate.
To begin with, physicians do not represent the norm in any society. We are highly selected for intelligence, work ethic and commitment. We live most of our youth in rigorous and cloistered academic environments and generally enjoy upper middle-income lifestyles. We are highly respected and action-oriented individuals.
All this enhances the physician's ability to serve society as a trusted healer and confidant. Unfortunately, none of it translates into moderation in the give and take of the political arena. The following five characteristics detail why physicians should approach involvement in elected political positions or activist roles with caution.
Temperament and Training are Absolutists.
Physicians live in a world of absolutes with limited shades of gray. Antibiotics are effective in treating only certain infections. Metabolic syndrome must be addressed at an early stage of the disease. Diabetics should be monitored semi annually with glycosylated hemoglobin (hemoglobin Alc) testing. Most arrhythmias should be aggressively suppressed. All of this works against the give and take of politics with the inevitable compromise required to move forward.
When confronting great social issues, physicians are ill prepared to balance competing and frequently equally correct answers: the value of individual life balanced against a woman's right to choose; the start of human life versus stem cell research; parental authority and curriculum in the public schools; alternative life styles and family structures. These grey issues require pragmatic fudging of ideals. On these and other controversial issues, physicians tend to seek the "right" answer. Our temperament and training ill prepares us to accommodate the strongly held views of those with whom we disagree (remember the example of Tom Coburn and Howard Dean?). This opens the gravitation to the extreme within single-issue advocacy groups.
Most politicians advance by serving time as elected local officials or as staff members for legislators. Physicians usually bypass this time-in-grade political apprenticeship and enter elected office at the legislative or higher level of public service. As a result, physicians generally lack the comity, relationships and camaraderie other politicians have developed over their years of service - and without which they rarely succeed as effective legislators or political leaders.
Fail to Grasp Unintended Outcomes in Public Policy.
Physicians' personal experience with debilitating and fatal illnesses clouds their ability to grasp nuances of public policy. Thus, we tend to embrace ideologies that promise to save the world but invariably fail. Instead, these ideologies breed fanaticism, justify dishonesty, and cloud reality. They keep adherents transfixed on the unreachable goal of human perfectibility. Crimes, lies, and even murders committed on the ideology's behalf are ignored, excused, and denied. Aristotle, in his Lyceum lectures on Nicomachean Ethics, observed that most evil is committed in the name of the good.╣
This physician tendency to obeisant support for Nicomachean Ethics appears in the creeping dominance of "nanny medicine" - the coercive use of tax policy to curb sinful behavior. Taxing "bad" but legal products and activities - such as foods that are high in sodium or fats (a Twinkie tax may be on the horizon) or taxing alcohol all lead to the same public policy conundrum - illustrates government's progressive dependence on regressive sales and excise taxes. Low-income households in California now pay a greater share of sales and excise taxes than the wealthy. Additional nanny taxes will only exacerbate this problem.
The cigarette tax is a classic example of unintended tax policy outcomes. Cigarettes are the world's most heavily taxed consumer product (state taxes range from 5 cents to $2.46 per pack; the federal tax is 39 cents). Smokers are about as popular in this country as terrorists and telemarketers; so there are few easier targets for legislators' voracious hunger for new tax revenues (cigarette taxes, by the way, are rarely used to treat resulting disease in that it is not in the states' interest to to reduce the use of the sinful taxed product). In 2004, the states took in $12.3 billion in cigarette taxes.
Should tobacco taxes plummet because smokers stop using tobacco or, more likely, the product's distribution go underground,▓ the evolving black market created by tobacco taxes will make the Sopranos look like choirboys. California would stand to lose $2.3 billion annually, New York $2.1 billion, Texas $1.7 billion and Michigan more than $1 billion.
All of the above is bad for medicine. We are collectively viewed as paternalistic prudes and scolds. We advocate using government's coercive power to influence fellow citizens to make choices they would make themselves - if only they had our strength of will and sharpness of mind. In the past, this behavior was indigenous to "church ladies" and led to derision. We risk for the same fate. Medicine's patron saint will soon be Carrie Nation.
Frequently Favor Their Own Pecuniary Interests.
Physician political groups frequently use the political process to advance their own pecuniary interests but inevitably, as Nicomacheans, posture that they are protecting the patient's interest. This cynicism inevitably lowers the public's respect for the profession. For example, the annual mosh pit process of lobbying and political campaign contributions in exchange for protecting scope of practice franchises sickens the public.
Another current example: state medical societies in Illinois and Massachusetts are pushing for new regulations to impede the growth of nurse practitioner-staffed convenient care clinics in retail settings. They are using expensive permit requirements, and prohibitions against advertising that compares fees of convenient care clinics with those of physician offices. These efforts that drive up the cost of primary care at the public's expense have not gone unnoticed.
The primary reason for discouraging physician engagement in the public square relates to the waste of our most critical resource. Expounding on subjects about which we have little knowledge detracts from our contribution to solving looming problems about which we know a great deal. The cost of health care in this country is destroying our economy. This problem cannot be successfully addressed without engaging motivated and articulate physicians.
I support Dr. Harry Wang's contention that physicians, as individuals, should be active in the public debate. Despite the dangers of physicians participating as activists and partisans in the political process, as an American I support engagement as individual citizens.
As an individual, you have the right to become a condescending, self-righteous prude if you wish. You can talk at length about things you know little about. Of course, no one is obligated to listen to you.
However, do not use your respected MD degree to short cut your way to credibility - it will not work. Furthermore, do not presume to speak for me - you do not. If you want to represent the profession, do it the hard way. Engage in organized medicine. Become a leader on your medical staff. Write articles for peer reviewed specialty journals. In short, do the heavy lifting of consensus building.
Otherwise, as an individual, feel free to bore everyone to death with your points of view on social responsibility and world peace.