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Keep Politics Out of Examining Room

MANAGED CARE May 2003. © MediMedia USA
Ethics

Keep Politics Out of Examining Room

Physicians, teachers, and clergy are among those professions that enjoy particular respect. They must preserve equanimity in the face of ephemeral social movements.
Michael S. Victoroff, MD
MANAGED CARE May 2003. ©MediMedia USA

Physicians, teachers, and clergy are among those professions that enjoy particular respect. They must preserve equanimity in the face of ephemeral social movements.

Michael S. Victoroff, MD

War protests and freedom of speech. Remembrance of times past. The U.S. has embarked on another foreign military adventure. It's worth reviewing some of the polarizing effects of war on civilian professionals.

A microcontroversy appeared in the news a few weeks ago in connection with a school incident in which a student notified her parents that her teacher had worn a political button to class. In the normal pattern of such events, the parents complained to school authorities, the press was duly alerted, and readers starved for legitimate journalism were offered some lightweight debate about limits on the right of political expression in public schools. We are likely to get more practice at this.

The question was whether teachers should make public displays of affiliation, on the job. The answer is transferable to physicians and other health professionals, and others in similar roles.

Exemplary profession

The provocative political "button" that pushed the indignation buttons of the offended parents declared, "He's not my president!" As with all topical satire, the message only makes sense if you're up on current events. Presumably, this slogan aimed criticism at George W. Bush and his ambitions in Iraq. As a political one-liner, it's fairly restrained compared to "Impeach Nixon!" and "Sic Semper Tyrannis!" But, at times when propaganda floods the septic tanks of the daily media, folks get touchy about their neighbors' political views.

The First Amendment isn't at issue here. What's at stake is when it might be proper for individuals to curb their right of expression in certain environments. In the case at hand, nobody argued that students should be forbidden to wear political buttons (even pinned through their eyebrows); just teachers, presumably pinned to teacherly apparel. Why might this be reasonable?

Certain professions are granted special moral status because they are involved closely with the core problems of ethics. I call these the "Exemplary Professions." Among them are law (including law enforcement), medicine, teaching, and the clergy. This is not to say that every member of these professions always acts in an exemplary way. Nor should other occupations be disregarded as moral guides. But, in our culture — despite due cynicism and the lash of satire — lawyers, doctors, teachers and clergy, in general, enjoy particular respect, because society looks to them as examples.

Contrast these with the honor we withhold today from other important professions, including politics, military, industry (including business and finance), and science.

My definition of "professional" is, "One who can manage significant conflicts of interest, to the advantage of the person served." This responsibility creates a bond of trust between the professional and the client, patient, student, or congregant. No matter what we may think of lawyers or priests in general, we strongly tend to support our own, despite any misgivings about the discipline as a whole. And, this faith (and doubt) extends beyond the ones we choose freely, to those we're thrown up against by circumstances, for example in an emergency room.

We hope that the paramedic, the nurse and the neurosurgeon we meet by accident will live up to the humanistic and technical standards we pray belong to their entire profession.

This relationship is like that of many teachers and students, because often students don't have much choice of who serves them. This isn't so different from some specialist physicians or lawyers, or when there's only one rabbi in the neighborhood. The less choice people have, the more it behooves professionals to be circumspect about their own political, moral and religious leanings, just as they ought to be reserved in expressing other personal biases. It's simply better if we don't know how our urologist feels about Eskimos, or people who drive SUVs.

Where buttons are concerned, I think we can make a case for saying, "Professionals should not use their status as a pulpit from which to broadcast mundane political messages." The key concept is "mundane," meaning "worldly," in the sense of commonplace and ordinary.

When a professional advertises a political position with an emblem such as a button, it changes the terms of the professional relationship (teacher-student, doctor-patient, etc.). Such relationships are inherently unequal, because the "learned" party is held — rightfully — in a position of superior regard, at least in the subject matter concerned. So, the effect of a political button can vary.

If you don't have a position on the issue the button addresses, your respect for the wearer might persuade you that its message is credible. This is the intent of slogans. They are not arguments, but telegraphic symbols of arguments that save recipients from having to think things out for themselves. On the other hand, if you oppose the button-on position, you might lose some respect for the wearer. Psychologists (and lawyers who get called in these cases) call this a "boundary violation."

This occurs when a professional relationship becomes contaminated by material that is irrelevant or inappropriate. Examples are when your gym teacher invites you to the prom, or your psychiatrist asks you for a stock tip. These intrusions threaten the bubble of trust that makes professional relationships work.

Not every teacher, minister or doctor wearing an "Alfred E. Newman for President" T-shirt is going to lose the faith of the flock, but it might bother you if your oncologist kept Kevorkian's autographed photo in her waiting room. Political slogans span a wide range. Some can be as emotionally placid as "Sam for Dogcatcher!" Others, like "Death to the Jews!" or "Nuke Hanoi!" are designed for ferocious impact. So, it's not just "everyone's right to free expression" that has to be considered when a professional puts on a badge. The ethical distinctions — as they do so often — depend on proportionality.

Etymologist and poet John Ciardi, on an old NPR program from 1984, observed that the word "slogan" originally meant, "A call to the armed host." "An emotionally charged noise." A battle cry, not an assertion of provable truth.

Zone of trust

Mundane political buttons arguably don't sway many opinions. They're little more than bad jewelry. When they're concordant, it's not on a meaningful level. When discordant, they're counterproductive. Even satirical ones aren't usually very funny (with some charming exceptions). The chief reason professionals should avoid political banners is because they suggest that the wearer is intellectually trite.

Serious emblems require a different analysis. These include political and religious symbols that express deep beliefs.

If your teacher is a nun, you can assume some things about her religious attitudes. Being her student means you are OK with what you assume. Some patients are comfortable with overtly religious doctors, and a minority even seek them out. But, doctors who make religion part of their medical practice automatically exclude some patients from their zone of trust. "So, what?" you might say.

This may not be a problem for patients who have the chance of free and informed consent. It's like choosing a gynecologist who doesn't give birth control to unmarried women. But, you can see that, in an emergency department, for example, where anxiety is high and relationships are not voluntary, displays of religious, political or social biases can be directly harmful, even if they are sincere and well intended.

By this reasoning, police in most jurisdictions are forbidden to wear political banners. A speeder, pulled over by an officer wearing a political pin, might have different expectations about how justice will be served, depending on whether they're wearing the same or opposite buttons. Professionalism is constantly at war with the suspicious side of human nature, partly because distrust often proves founded.

The problem is tougher with emblems of beliefs too strong to suppress. I'm not talking about race and gender, although these also obviously elicit biases, but symbols we control. What does a Muslim patient feel, when the face seen over the surgical drape is wearing a yarmulke? What does Jed Clampett make of the dreadlocks on his Jamaican proctologist? Some of us may consciously choose to limit the number of people who feel comforted by our presence but, I would argue, one goal of an exemplary professional is to broaden this group, not narrow it.

Clergy are in a special situation, and we permit them more latitude than other professionals in displaying their affiliations. Sectarianism is an integral part of religion. We expect clergy to wear tokens, distinctive costumes and usually special hats, so we can readily classify them. Even so, hospital and battlefield chaplains must often suspend their terrestrial orthodoxies, and represent faith in its higher form.

To perform their work, one of the essential norms that exemplary professionals — even clergy — must preserve is equanimity in the face of ephemeral social movements. It's hard to predict what political sentiment might injure a professional relationship. Even an innocuous "anti-smoking" badge could intimidate a patient in some settings. I remember during the Cold War, after a fun and dynamic seminar with visiting professors from the Soviet Union, I decided not to wear at work their gift, a tiny red lapel pin in the form of a hammer and sickle. I would have been happy to explain it, but, I also would have felt obliged to.

So, my advice to teachers, doctors, and the rest takes this form: To every thing there is a season. Unless it's worth alienating someone you serve, keep your views buttoned up, on duty. On your own time, the rules are more flexible.

Your fellow advocates should understand that you can compartmentalize your advocacy without compromising it. Those you serve will thank you for putting their interests above politics.

Michael S. Victoroff, MD, is a family practitioner in Denver who has also been an HMO medical director.

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