Posted on December 17, 2018 at 1:59 PM
In the wake of the recent Twitter fight between the National Rifle Association and U.S. physician groups over whether doctors should speak out about firearm policy issues, we argue that professionalism actually requires that doctors take on a leadership role in gun policy debates, even if (in fact, especially if) doing so is politically fraught and financially harmful to them.
The recent publication of a position paper, Reducing Firearm Injuries and Deaths in the United States, by the American College of Physicians prompted the NRA to assert that physician groups should “stay in their lane” and not talk about gun policy issues. So far, the push-back against this admonition has been mostly to emphasize the terrible medical consequences of gun violence, which is appropriate. But medical groups have been mostly silent on the basics of medical ethics and what is required of them as professionals, and that’s an oversight.
Why professions matter today
Translated from Latin, the word “profession” literally means “to speak forth.” So a profession is a group of people who have come together to publicly declare – sometimes even out loud in the form of a creed or an oath – the standards and values that guide their work. This is why new doctors often recite the Hippocratic Oath, and it’s why every profession has a code of ethics. Oaths and codes are ways of speaking forth – professing – what members of the public can expect in terms of skills and attitudes from members of the group. They make up one side of a social contract, in which the members of the profession seek the trust of the public, and all the perks that come with that, in exchange for keeping the promises made in their codes and oaths.
For physicians, their main professional promise is to look out for their patients’ best interests, including putting the health of their patients before their own self-interest. That’s critical for patients, because without the assurance that physicians will always put them first, patients could not, and probably should not, rely on physicians for care when they are at their most vulnerable. For the sick, injured, or dying to place their lives in the hands of a physician, sometimes a stranger, they need to be completely confident that physicians are devoted to patients’ health and well-being and not just looking to enrich themselves.
But there’s more. Upholding professional values isn’t just necessary for strong patient-doctor relationships. It also can help sustain a healthy democracy. Professional values can actually serve as a morally stabilizing force in communities. Truth, trust, the willingness to put the interests of others ahead of one’s own, the impartial treatment of all people without regard to race, culture or income – these are the moral values on which the profession of medicine is grounded, and they happen to be the same moral values necessary to sustain a well-functioning democracy.
Today these values are at risk. Mistrust, xenophobia, hate, bias, partiality, and selfishness sometimes feel like they are becoming new moral norms. Since 2017, trust in government “to do what is right” dropped by 14 percentage points among the general U.S. population. Businesses, NGOs, and the media are experiencing similarly dismal levels of trust, and the Edelmen Trust Barometer is warning of an impending “trust crash.”
Physicians continue to score quite high in public trust, with 65% of U.S. adults saying physicians have “high /very high honesty and ethical standards.” Physicians rank fourth among the most trusted professions, following only nurses, military officers, and grade school teachers. Given the crisis of mistrust all around us today, it is more essential than ever that medical professionals uphold their promises and step up to safeguard the moral norms that our society needs to thrive.
Professionalism demands that doctors speak out
If a profession is a group seeking to earn the public’s trust by openly speaking forth on a set of shared promises, then professionalism is best understood as the belief system (the –ism) underlying these promises. In medicine, professionalism is the notion that society can and should trust medical groups to set and enforce standards of practice and ethical norms, based on their promise that they will always use these prerogatives to help improve the health of the community. In other words, professionalism means that with the privilege of self-regulation comes the responsibility to use medical skills and knowledge to promote public health, even when doing so is politically uncomfortable or financially harmful to doctors.
Obviously, speaking out against the NRA can be politically uncomfortable. But what’s rarely said is this: just as gun manufacturers make money from selling guns, physicians make money from treating the victims of gun violence. Bluntly speaking, that means reducing gun violence would actually be financially harmful for doctors, so the self-serving path would be for medical groups to stay silent and for doctors to just keep getting paid to patch up the people injured and killed in gun violence.
Of course, the idea that physicians would stay silent to prop up high levels of gun violence is ridiculous. After all, doctors would never urge people to keep smoking, drinking, or eating fast food, even though those are good for business too.
But why are these ideas ridiculous? They are ridiculous because we all, deep down, actually believe in physician professionalism, which demands that doctors tackle these issues. If physicians were to remain silent in the face of an epidemic – whether of gun violence or from any other source – it would rightly be interpreted as opportunistic, uncaring, and professionally incompetent. Worse, it would be a blatant breach of doctors’ collective promise to always seek to improve the health of the public, even when it’s not easy and even when it might cost doctors some revenue.
And guns are like smoking, drinking to excess, and eating junk food in more ways than one. For each of these products there are self-serving constituencies, uninterested in the health of the public, who wish doctors would just stop talking about the role of their products in hurting people.
But doctors won’t stop, because speaking out when it is difficult and costly is exactly what makes the profession of medicine worthy of the public’s trust, and thank goodness for that. The willingness of physician groups to speak out on gun policy is critical for public trust in medicine, and today it might also be reinforcing the values that are at the heart of our democracy. It proves that professional norms of truth, trust, impartiality, and placing the interests of others before self are more resilient in the medical profession than some might have realized – and maybe seeing physician groups uphold these values will help preserve these values among the general population, too.
So, while it might be inconceivable to the leadership of the NRA that the American College of Physicians and the American Medical Association—which perhaps it regards as mere trade groups — could act against the financial best interests of their constituents, for these medical groups it’s actually business as usual when it comes to public health issues. After all, speaking out on issues like gun violence is what proves medicine really is a profession and not just a trade.
Patricia Illingworth, JD, PhD, is a professor at Northeastern University and a senior fellow at the Carr Center for Human Rights Policy at the Harvard Kennedy School. Matthew Wynia, MD, MPH, is a professor of medicine and director of the Center for Bioethics and Humanities at the University of Colorado, Anschultz Medical Campus.
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