Physicians as Activists

ON JUNE 29, Catherine Thomasson, MD, national president of Physicians for Social Responsibility (PSR), was interviewed by Jeffrey Callison on the Capital Public Radio Insight program.¹ She was in Sacramento to talk about her recent trip to Iran as part of a peace delegation. During the interview, she stressed using diplomatic (as opposed to military) means to resolve the growing conflict between the United States and Iran.

On July 10, Jeffrey Callison read the following comment from a listener responding to Dr. Thomasson's interview: "Where is it written that physicians have more expertise than others in political and moral matters? What gives a profession such as physicians a more privileged moral status than, say, plumbers or truck drivers?"²

Should we, as physicians, involve ourselves in social-political issues? Is the public interested in our viewpoints? Do we bring a unique perspective that may be valuable? Do we in fact have a responsibility to be proactive?

Models for Physician Involvement
Several models encourage the social and political activism of physicians.³In the "preventive medicine" model, physicians seek to alter or stop the course of disease and not focus on treatment alone. Achieving or improving health is recognized as more efficient and preferable than treating disease alone. According to this model, supporting laws that ban or limit toxins such as lead and/or mercury in the environment is part of the responsibility of a physician. Trying to prevent war or firearm violence is considered more effective than treating the casualties of war and guns.

The "social medicine" model recognizes the interrelation of health, disease, and social condition. Any improvement in the welfare of society will improve the health of all. In this model, physicians take an advocacy role to address these factors. For example, economic and social factors need to be addressed to successfully implement an effective worldwide approach to treating HIV illness.

The "activist medicine" model calls for social and political action to reach a desired level of health. This model states that physicians cannot adequately treat illness if there are obstacles to obtaining health. Following this model, activist physicians advocate for a shift in government priorities from the current funding of the military-industrial-corporate complex ($626 billion requested for FY2008 for the U.S. military and current wars) to addressing more of the health needs of our citizens.

These models provide physicians with a framework and rationale for speaking out on social issues. In some instances, it may even be unethical for physicians to ignore societal conditions that affect health.

Genocide, Torture, Capital Punishment
Tragically, there have been instances when physicians have not spoken out and have actually collaborated with governments in killing, torturing, and other unethical actions.

The most horrifying example is the involvement of physicians in Nazi Germany, where almost half of registered physicians were members of the Nazi party. Physicians were involved in developing and implementing radical racist eugenics, medical killings, medical experimentation, and mass genocidal murder.

Following the Nuremberg trials, international laws were created to outlaw torture and genocide. In 1975, the World Medical Association passed the Declaration of Tokyo, which prohibits any physician involvement in torture. In 1999, the American Medical Association stated: "Physicians must oppose and must not participate in torture for any reason."⁴

Despite these prohibitions, torture has continued to occur, and physicians have at times been participants. It has now been documented that a number of medical and psychological personnel in Iraq, Afghanistan, and at Guantánamo Bay, Cuba, monitored and devised coercive interrogations, falsified medical and death records, failed to provide basic health care, and failed to report abuse and signs of torture.⁵

How about physician involvement in assisting with prison executions? Many people accept this as an ethical practice. After all, are they not helping to carry out the "will of the people" and providing a more "humane" death? In the U.S., physicians have helped to design the means of death, evaluate fitness, monitor the execution process, inject the legal substances, and otherwise act as agents of the state. This has occurred even though there is a clear prohibition against physician participation by the American Medical Association, the California Medical Association, and other medical organizations. Despite this, 35 of the 38 capital punishment states explicitly allow physician participation in executions, and in 17 states their involvement is required.⁶

Physicians and the Nuclear Bomb
Physician involvement in opposing nuclear proliferation is a prime example of addressing a public health issue (the thermonuclear annihilation of the world) through political means. Following the devastation of atomic bombs on Hiroshima and Nagasaki, physicians were quickly overwhelmed by 200,000 civilian deaths. Effective care was impossible given the destruction of medical facilities and the health effects of the nuclear bombs.

In 1952, the U.S. exploded a hydrogen bomb with a yield 1,000 times greater than the Hiroshima bomb. During the 1950s, the AMA was an active participant in governmental civil defense planning for a nuclear attack. This cooperation by physicians began to change in 1962, after PSR physicians published articles in The New England Journal of Medicine that described the medical consequences of nuclear war in clinical detail. These articles concluded that a medical response to a nuclear attack would be futile and that civil defense efforts provide very little safety. The authors argued that physicians have a special responsibility to help prevent the use of nuclear weapons because of their expertise regarding the medical effects of nuclear war and their responsibility to protect the health of their patients.⁷

In 1981, the AMA Board of Trustees passed a groundbreaking resolution that "there is no adequate medical response to a nuclear holocaust" and that the President and the Congress should be informed of the "medical consequences of nuclear war so that policy decisions can be made with adequate factual information."⁸ The AMA has subsequently taken a position supporting the elimination of all nuclear weapons and other weapons of mass destruction. In 1985, the International Physicians for the Prevention of Nuclear War, of which PSR is the U.S. affiliate, was awarded the Nobel Peace Price for helping to open arms-control discussions between the U.S. and the Soviet Union and for fostering an international physicians' anti-nuclear movement.

Why Physicians Need to Act
In response to the radio show listener who questioned where physicians gain their credibility to speak out on political and moral matters, we all know physicians do not necessarily have more expertise to speak out nor do they enjoy a more privileged moral status. We do, however, have the same right as any other individual to fight for peace and justice in the world. We also have the ability - and perhaps even the moral obligation - to safeguard and enhance the health of humankind, especially if we raise our voices together through groups like PSR, Physicians for Human Rights, and Doctors Without Borders.

Following the lead of Dr. Catherine Thomasson, we can speak out on social and political conditions that affect the health and safety of our patients, our communities, nations, and the world. We can also strive to create a culture that emphasizes health with a genuine respect for all peoples and lives.

harrycwang@comcast.net

1. www.capradio.org/programs/insight/default.aspx?showid=3402&programid=10 (accessed 8/1/07)
2. www.capradio.org/programs/insight/default.aspx?showid=3456&programid=10 (accessed 8/1/07)
3. Dagi T (1998): Physicians and Obligatory Social Activism. The Journal of Medical Humanities and Bioethics 9(1):50-59.
4. American Medical Association Code of Ethics (1999): Policy E-2.067.
5. Miles S (2006): Oath Betrayed. New York, Random House.
6. Gawande A (2006): "When Law and Ethics Collide-Why Physicians Participate in Executions" New England Journal of Medicine 354:1221-1229.
7. Forrow L, Sidel V (1998): "Medicine and Nuclear War." JAMA 280(5):456-461.
8. American Medical Association (1991): Policies 520.999 and 520.997.