Monday, August 21, 2017

Medicine and the Limits of Politics

The obligations on the medical profession do not extend to the ideology or platform of any political party.

It's a big week for the Canadian Medical Association (CMA), holding its 150th General Council meeting in Quebec City. Between the uproar over the government's plan to hike taxes on small corporations (in particular MD corporations), and the somewhat less graspable opposition to the CMA's new strategic plan, there are bound to be some debates that raise the temperature in the room. That's not a bad thing, because apparently the conference room is an icebox.

These sorts of debates within the profession are nothing new. Doctors have argued about money since the time of Hippocrates, and understanding the so-called social determinants of health - that is, how socioeconomic factors like income and housing lead to poor health - is now a core part of the medical school curriculum. What is a more recent development, however, is the expectation that doctors be "health advocates" for their patients and the communities they serve.

It's hard to argue the rationale. Those of us working in health care, particularly when we work with marginalized populations, know all too well the need to speak on behalf of those who lack the means to speak for themselves. And apart from elected politicians, there aren't many people in a community that can match an MD's capacity to have his or her voice heard, in local or even national media. 

That said, when a doctor's role as advocate extends to ever-broader patient populations and ever-broader areas of public policy, and terms like "social accountability" are bandied about with ever-increasing nonchalance, the profession inches ever-closer to being not independent, valued professionals, but a collection of glorified public servants in service of a political ideology, or, worse still, a particular political party.

I've witnessed it personally, when a room full of doctors and nurses erupted in applause at a politician's plea to put "the right party in power". That same party, since that election, has forged ahead with a half-baked plan to restructure primary care without stakeholder input; has refused to hold accountable the people that made a shambles of home care; has made the College of Physicians a de facto arm of the government; has taken no significant steps to ease pressure on overcrowded hospitals; and has wasted war chests of money on one file after another.

The point is that while doctors have obligations to their patients, and to a lesser extent their communities, those obligations should not and do not extend to all aspects of public policy. There is no part of the MD job description, and no part of the definition of "professionalism" that includes devotion to a particular tax structure, environmental scheme, or article of foreign policy. Simply because a doctor is obliged to advocate for secure housing, he or she is not obliged to support taxation of "privileged" professionals to pay for it. Nothing in any code of ethics makes self-interest on its own an act of transgression. To the benefit of nobody, this conflict is playing out right now, with back-and-forth moralizing on the tax issue, and personal attacks rearing their ugly heads once more on social media.

There is a danger in ascribing a moral dimension to areas of public policy that don't directly affect patient care. First and foremost, it plays to the agenda of one political party over another, regardless of which end of the political spectrum the party professes to champion. It has the whiff of hubris, of making one doctor superior to another for reasons having nothing to do with knowledge, experience, or clinical skill. Worst of all, however, it will lead to a political "litmus test" that could affect a doctor's candidacy for professional committees, job prospects, or even entry into the profession. Unless they interfere directly in patient care - and this is where Colleges are responsible for drawing up boundaries - political leanings should not affect one's ability to thrive in medicine.

So this is my plea, to friends, colleagues I've met in person, and those I have yet to or might never meet: take a deep breath, and ask if the fight is really about patient care or not. If the answer is 'yes', keep it civil, and listen to one another. If the answer is 'not really' or 'no', remember that smart, caring, curious, and dedicated people are welcome in the profession of medicine, regardless of where they fill in the X at the ballot box.

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