Previously, I wrote about politicians regulating medical practice. I support regulations that protect individual or public health. However, when these laws are not evidence-based, misguided or frivolous, and potentially harmful, as occurred when 16 state legislatures permitted over-the-counter sale of ivermectin, they are unacceptable.
There have been instances when pregnant women, who, because of circumstances, were unable to adhere to physician advice for increased bed rest to avoid premature labor, were charged with child abuse and court-ordered to be handcuffed to hospital beds until delivery under a state law on fetal welfare. This targeted primarily women in poverty, mostly of color, but did nothing to alleviate the circumstances that necessitated their inability to follow doctors’ advice. This was not ideal for the fetuses, as a lack of maternal mobility hindered their development.
For centuries, physicians pledged themselves to the Hippocratic Oath as the ethical standard by which they practiced. Beginning in the mid-19th century, as science advanced and available treatments increased, its relevance began to decline. Although fragments of the oath are still quoted, mostly on TV medical dramas, its applicability to modern medicine is limited, as it would eliminate substantial portions of contemporary practice.
Presently, there is no universal oath, and a physician’s ethical responsibilities vary by culture and government. In Communist countries, their duty is to the state, not the patient. In nations with socialized medicine, physician ethics emphasize care for the individual patient while minimizing the use of resources. In the U.S., many medical schools have their own ethical pledges. Some emphasize social justice and barely mention the individual, while others acknowledge that treating the patient requires addressing harmful environmental and social factors. Nonetheless, there are commonly accepted elements.
Physicians are placed in a difficult position when laws conflict with ethics, potentially placing an individual’s health or life, and/or a community’s well-being at risk. Does the clinician follow the law, regardless of any threat to health it may impose, or medical ethics? Dr. Steven Woolf and others have written that physicians and medical scientists cannot remain silent when laws or edicts could result in harm or are not grounded in science.
Under many laws, physicians face severe consequences for defiance, including losing their employment, medical licenses, incurring hefty fines, and facing lengthy imprisonment. These provide a strong inducement to comply. However, doing so implies acceptance and will encourage the passage of further restrictive and/or harmful legislation.
For example, suppose Secretary Kennedy’s repeated statements on the ineffectiveness and dangers of vaccines are not forcefully countered, and an increasing number of state legislatures grant additional exemptions from them, while disallowing health departments to promote inoculations; resulting in increased infections, disfigurement, disability, and death. School absenteeism would increase, business productivity would decline, and health care costs would skyrocket. Given decreased demand, vaccine production would lessen. When parents subsequently decide to vaccinate their children, the current limited vaccine supplies would be rapidly depleted. With reduced production, the shortages could not be quickly resolved, resulting in additional cases, etc.
Dennis Prager noted that courage is a rare quality possessed by few people as they lack the daring to assert themselves against the commission of wrongs. Former Justice Ruth Ginsburg similarly pointed out that “When injustice becomes law, resistance becomes duty,” and Dr. Woolf asserted that the present is not a time for silence, as this will hinder health care and scientific progress.
However, no writer indicated how best to express resistance or opposition. Several high-ranking physician-scientists resigned from federal health agencies to protest Secretary Kennedy’s actions. This has had no positive effect. Some physicians and medical students have left states with onerous laws, while several doctors and researchers have relocated to Canada or European nations. The number to date is too small to have an impact. With other nations actively recruiting U.S. physicians and scientists, a recent poll found that 75 percent of responding scientists expressed interest in leaving the U.S. Given the continuing roadblocks to practice and research imposed by the administration, this exodus may not be far off, according to experts.
Consider the effect if physicians, allied researchers, and health care workers, excluding hospitalists, emergency/trauma specialists, and minimal support staff, were to spontaneously walk out in protest of harmful legislative actions, cautioning that the strike may continue or be repeated if remedial action is not taken. “Flash” doctor strikes have proven effective in other countries, without penalties, as disciplining the protestors reinforces the care limitations of the walkout.
Alternatively, and safer, professional associations could file lawsuits. They could create a test case in a single state by contesting a law or section of one that has harmful potential. The Florida law preventing surgery on cancerous breasts, for example, would require only exclusionary wording allowing removal for neoplasms and other illnesses of reproductive organs. If victory were achieved, other states might be encouraged to rectify inappropriate laws without further litigation. Even without legal action, but only political pressure, some states have acknowledged and are correcting faulty language in hastily passed abortion laws. Alternatively, professional organizations could provide legal defense for criminally charged physicians who adhere to an ethical standard rather than a state law.
To quote John Stuart Mill: “Bad men need nothing more to compass their ends, than that good men should look on and do nothing.”
M. Bennet Broner is a medical ethicist.
