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For many physicians, discussing political beliefs or controversial advocacy work with patients seems inappropriate or even unethical, though many patients may have no problem with it.
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October 2020Discussing Delicate Subjects
According to the 2018 Medscape Ethics Report, more than 5,200 physicians across more than 29 specialties were divided in their opinion: Forty-three percent advised against discussing political beliefs with patients, 23% said it was fine to have the discussions, and 33% said it depended on a number of factors, such as the state of the physician–patient relationship or whether the patient asked a question.
The American Medical Association has its own code of ethics relating to discussing politics with patients. While acknowledging that physicians enjoy the same privileges of free speech shared by all Americans and noting that it’s commendable for physicians to exercise their political rights as citizens by running for political office or lobbying for political positions, parties, or candidates, the code also states that physicians must be sensitive to the inherent imbalance of power in the patient–physician relationship. Patients may also simply have the desire to maintain their privacy when it comes to sharing their views. Among other things, the AMA recommends that physicians do not initiate political conversations during clinical appointments and don’t allow any political differences they may have with a patient to interfere with delivering professional care.
With the national election season upon us, ENTtoday asked two physicians who write about medical ethics whether or not it would be appropriate to discuss politics or controversial advocacy work with patients. Their answer: It depends on the topic and the tone of the conversation.
About Politics
When a patient asks their physician a question related to politics, it’s important to take a moment to think before responding right away, according to ENTtoday’s medical ethics columnist G. Richard Holt, MD, D Bioethics, clinical professor of otolaryngology at the Center for Medical Humanities and Ethics at the University of Texas Health Science Center in San Antonio.
“Political discussions can be loaded with significant emotional and personal differences, and the physician should be very circumspect regarding participating in such a discussion with patients,” he said.
While a longstanding relationship with a patient known to be like-minded and with whom the physician shares common viewpoints of an ethical nature may make conversation in these areas possible, Dr. Holt believes it’s usually best to demur and steer the conversation clear of the topic. “In nearly all situations regarding politics, I believe both the patient and the physician are best served in their professional relationship if these topics aren’t discussed, and the physician assumes a neutral pose,” he said.
When a patient asks about their physician’s political views, everything depends on the existing relationship.
According to Jerry Avorn, MD, professor of medicine at Harvard Medical School in Boston and author of the JAMA opinion article, “Engaging with Patients on Health Policy Changes,” (https://jamanetwork.com/journals/jama/article-abstract/2666172) when a patient asks about their physician’s political views, everything depends on the existing relationship.
“Some doctors, especially in small communities, may have a friendship or social relationship with the patient,” he said. “That would be different from one in which it’s all about the medical care only. In the latter case, I’d stay away from political chat unless the patient gives permission by asking for one’s views.”
About Healthcare Policy
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From time to time, patients may ask a physician’s opinion on healthcare policy. “This may be because they lack experience in these areas and are truly seeking guidance,” Dr. Avorn said. “In that case, it’s fine to respond to such questions.”
Some health policy issues aren’t as emotionally charged as others, and an appropriate discussion between physician and patient may be possible, said Dr. Holt. For instance, if the patient is interested in learning more about health policies on preventing head and neck cancers, that topic could be pursued. Or, in the current clinical environment, the patient may request an educated opinion on the available evidence for the use of alternative therapies in treating COVID-19 infections. “Evidence should be provided for most questions on health policies, with expert avoidance of trigger comments or personal viewpoints,” Dr. Holt said.
The best way to address healthcare policy concerns with patients without politicizing them is to keep the focus where it belongs. “Explain to the patient that this is about their healthcare coverage,” said Dr. Avorn, “and not a Republican-Democratic political issue, per se.” In the event that it becomes clear the patient still feels uncomfortable with the discussion, it’s best to back off. “You just need to lay the basic idea before them and educate them, as we would do with other risks like social distancing and hand washing,” Dr. Avorn said.
Dr. Avorn said he would only discuss the topic of COVID-19 in terms of safety or with a patient who brings it up with regard to their personal healthcare. If, on the other hand, the patient asks directly about the federal or state response to the pandemic, Dr. Avorn said that would open the door to answering with one’s opinions. “It would be silly to say, ‘I can’t talk to you about that,’” he said.
About Controversial Advocacy Work
Discussions regarding involvement in advocacy work that may be viewed as controversial, such as immigration, abortion, or dealing with healthcare access, can be difficult to navigate and should be avoided, as the physician in this case clearly has a viewpoint. Other causes that are considered less controversial, such as preventing childhood injuries and cancers or protecting the elderly from abuse, may weather political divides more easily.
Dr. Avorn said unless there’s an existing friend-like relationship with the patient, he wouldn’t bring up advocacy work that might be considered controversial, but if there is, or if the patient asks, then he feels it’s fine to be open and candid.
Obviously, there’s a wide range of opinions among physicians on these topics. Discussions of a political nature could potentially distance the patient from the physician, which in turn could affect the patient–physician relationship. And, if the patient becomes uncomfortable, they could even decide to leave the practice. “I personally don’t believe the risk is worth the benefit,” said Dr. Holt.
Renée Bacher is a freelance medical writer based in Louisiana.