The power of professionalism: should it be used as a political weapon?

How many doctors does it take to change a light bulb?

Only one.

The doctor stands on a ladder and holds the bulb while the whole world revolves around him.

One reason doctors think we are gods is that some people treat us like gods. Like ministers, priests, rabbis, and professors, we have the power of professionalism. Parents of babies I cared for in my neonatologist years would jump in the nearest river if I asked them to.

Well, not literally, but you get the point. When a physician uses the power of professionalism as a political lobbying tool, is it ethical behavior or exploitation?

Emily Brooker graduated from Missouri State University in May, 2006. Now she is suing MSU, claiming that her First Amendment rights were violated in a university class.

Allegedly, one of Brooker's professors required each student to participate in a class project by signing a letter, written on MSU letterhead and to be sent to the Missouri state legislature. The letter endorsed adoption of children by gay couples.

Booker refused to sign the letter. According to the lawsuit, her professor claimed that refusal to participate in this prescribed manner violated the School of Social Works' "Standards of Essential Functioning in Social Work Education."

University president Michael Knietzel promised the press that MSU would promptly investigate the matter. (1) A few days later MSU settled the suit.

Brooker received $9,000 cash plus tuition and fees toward a Master's degree at any Missouri university, and expungement from her record of a university ethics committee's review of the matter. The professor will be allowed to keep his position on the university faculty.

What is politics?

Like ethics, politics is a clumsy word because it is singular but ends in "s." Also like ethics, politics means different things to different people. Some think of politics as synonymous with electioneering. It is not.

The political process is the art and science of guiding, influencing, and implementing government policies at the federal, state and local level.

The electioneering process is a periodic opportunity for citizens to elect government leaders whose policy beliefs best reflect the will of the voting majority.

Ask an executive, "Are you active in politics?" The response will likely be that look; the one that says, "Well, duh, did you just fall off a turnip truck?"

Activity in the political process, such as influencing state regulations governing hospitals, is part of an executive's job description.

Now ask a doctor, "Are you active in politics?" The reaction may be a quick and absolute denial. "No way, and I never will be."

Yet you happen to know that the doctor contributes to candidates' election campaigns and that he often attempts to persuade people to think his way about a political issue.

Is the doctor lying? Chances are that he is not. The physician may equate "active in politics" with "run for public office." Articles on doctors in politics sometimes inadvertently contribute to that extremely narrow view. (2)

Lobbying and lobbyists

Like every other citizen, a physician is often an amateur lobbyist.

Any effort to persuade elected representatives to pass or defeat a legislative proposal is participating in the political process. Such an effort is called lobbying.

With persuasive arguments, lobbyists would pitch representatives to vote for the interests of the business or activist group paying the lobbyist. Today, lobbying has a bad name. Not infrequently, lobbyists eschew persuasive argumentation in favor of simply "hiring" a few legislators. If not the norm, this practice is too widespread to be acceptable in a country that claims to be on the moral high ground.

Make no mistake about it; unethical practices by some lobbyists do not negate the importance of lobbying. And amateur, grassroots lobbying efforts and letters to the editor are as important as more sophisticated efforts of professional lobbyists.

Should physicians participate in this process? Of course. It's a free country.

However, because of the power of professionalism, there is arguably a legitimate double standard. To avoid betraying the trust of patients and fellow citizens, and also to avoid sullying the medical profession's reputation for ethical and moral behavior, a physician must be especially careful not to exploit the power of professionalism.

A physician's participation in the political process and/or in electioneering is arguably ethical rather than exploitative if six criteria are met:

1. The doctor's interest in the issue is part of his or her professional ethic.

The doctor asks patients to write Congress urging tight emission standards for auto manufacturers, in the interest of clean air which is a public health concern.

2. The doctor has no conflict of interest.

The doctor will not benefit economically if his candidate or his political position prevails.

3. The doctor does not play the quality card, or use any other technique to play on people's fears.

"If this measure is passed it will almost certainly impair doctors' ability to practice the best medicine possible for each and every patient."

By the way, hospitals love to play this quality card. "We want the public to be aware that if this measure is passed, the only option open to us will be to close the emergency department of the hospital and simultaneously reduce the number of nurses per patient on each inpatient floor."

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4. The doctor does not lobby against the interests of another professional group.

"Chiropractors should never get hospital privileges of any kind under any circumstances." Arguably these are the facts in this matter:

On one hand, a chiropractor who uses the hospital's credentialing mechanism to request privileges including surgery and prescribing drugs is either unaware of the limits of his or her license or is playing games with the credentialing process.

On the other hand, health care centers can no longer claim to offer comprehensive health care services if a chiropractic staff is not available to deal with the aches and pains of an aging population.

Indeed, political positions on matters of professional credentialing are way out of place. Those responsible for credentialing patient care professionals must carefully and ethically walk a fine line between protecting patients from marginally qualified or careless practitioners on one hand and fairness to applicants on the other. Neither politics nor any other subjective element has a place in credentialing professionals.

Is the applicant qualified? Does the health care center need the services of the applicant in order to best serve its community of patients and potential patients? Those are the only questions in credentialing. To be ethical and just, both those questions must be answered by fairly and honestly interpreting available relevant, reliable and objective data.

5. The doctor never suggests tit for tat.

"Voting for my candidate would almost certainly mean that I could hand out more free drug samples." What a far-fetched idea. Surely such a thing would not make sense to any physician, ever. On second thought, one never knows where common sense might mislead us.

Read again the story at the beginning of this piece. Even if this was not an obvious misuse of the power of professionalism by a young instructor, the university quickly saw that attorneys could easily make it seem so.

Interestingly enough, the professor's sexual orientation and political beliefs have not been publicized. It is possible that this was an honest mistake by a young man doing what he is supposed to be doing ... thinking like a professor.

In that mode, common sense might suggest that the full benefit of the class project is not achieved by writing the letter, or even by sending the letter. To the professor, perhaps it made sense that the class project was not complete until students had the satisfaction of receiving a reply to the letter.

Physicians who think like physicians sometimes make unbelievable mistakes. For example, in the 1988 presidential campaign a physician group became a laughing stock when its spokesman was asked, "Why do you not want Governor Dukakis to become president?"

The answer was, "Because he is too pro-patient."

Does that mean doctors are anti-patient? Oh, good, just what we need the public to hear.

Executives thinking like executives make mistakes, too. "I know how we'll save money. Gag the doctors; hide from patients the fact that they truly need medical tests and treatments that we don't want to provide because they cut too deep into our profit margin."

There goes the public trust on which sustainable market share must be built.

6. If a doctor is a physician leader in the hospital's medical staff organization, he or she does not make use of this position to sound like he is speaking for the hospital.

"As chief of staff at Central Community Hospital, I urge you to vote for this measure." Same to you, Dr. VPMA, unless of course the board and CEO have authorized you to speak on behalf of the hospital.

So, is it ethical or exploitative for physicians to use the power of professionalism in the political process? As with many such questions, the answer is, "It depends." The devil is either in the details, or he is not.

Richard E. Thompson, MD, is former vice president of the Illinois Hospital Association, taught ethics at St. Petersburg College and Missouri State University, and is author of Think Before You Believe, Xlibris, 2005. He can be reached at [e-mail].

References

1. Koehler, S. "Nietzel: MSU takes allegations seriously." Springfield (MO) News-Leader. November 3, 2006.

2. Ryan, P. "Physicians often shocked by political reality." The Physician Executive, 30(1):4-7, January/February 2004.

By Richard E. Thompson, MD

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