Ethics of politcal advocacy by one's doctor.

November 7, 2009 3:52 PM

Question about the ethics of mixing physician care and politcal advocacy.

This evening my wife received an email from her psychiatrist urging her to contact our Cong. Rep. to support the recently offered Pitts-Stupak amendment to the current health care reform bill under debate in the U.S. House of Rep. My wife is quite upset and views this as a violation of trust and their professional relationahip by the doctor.

Specific policy differences aside, is it considered acceptable for physicians to advocate politically amongst their patients, particularly if the matter under consideration is not relevant to that care?

posted by anonymous to human relations (37 comments total)

I don't know how that would be a violation of "trust" - the physician didn't reveal any private information of the patient's.

Frankly, I like it when people do this sort of thing, and I certainly feel it's acceptable. It allows me to boycott service providers which support issues I find repellant and to offer greater support to service providers who are 'right on" politically. The service provider runs the risk of alienating clientele, but that's their own doing.
posted by Dee Xtrovert at 3:58 PM on November 7, 2009 [3 favorites]

As far as formal medical ethics promulgated by the APA or similar groups, I don't know. From a layman's perspective, that strikes me as a Bad Thing. Psychiatrists arguably have even more sway over their patients than physicians, etc., and so should be particularly careful to keep their advice even-keeled and neutral. The situation would be different, for instance, where there were no doctor-patient relationship and your wife knew the psychiatrist socially.
posted by Inspector.Gadget at 4:00 PM on November 7, 2009

I worked with a teacher who told her students to tell their parents to vote for some prop ensuring higher funding for the district. It made me uncomfortable, but I get the feeling this sort of thing happens often. Like Xtrovert says, I don't see your situation as a violation of trust, but it does seem tacky. I wouldn't let it affect your or her trust in the doctor's ability to provide quality care.
posted by monkeymadness at 4:10 PM on November 7, 2009

This evening my wife received an email from her psychiatrist

It may not be the wisest course to urge mentally ill patients to "take action" ... I can imagine that some people, struggling with mental or personality problems, might be offended at a doctor urging them to support a political cause, because such people already have enough to worry about. But, having said that ...

Specific policy differences aside, is it considered acceptable for physicians to advocate politically amongst their patients, particularly if the matter under consideration is not relevant to that care?

What could conceivably be the ethical problem with this? If this physician thinks pending legislation could adversely affect patient care, then that physician is absolutely free to communicate his or her beliefs, try to persuade others to share those beliefs, whether they are patients or not.

Just because you are treating someone for an illness doesn't mean you have to be an automaton who can't try to persuade others of the correctness of a political view.
posted by jayder at 4:12 PM on November 7, 2009

I'm a medical student - in our hospitals, we are not permitted to wear political buttons, and in general refrain from political discussion with our patients unless it relates to their care. The majority of the attending physicians will express their political opinion if a patient asks, but don't go out of their way to ask them to advocate for specific bills, etc.

What your wife's psychiatrist strikes me as a violation of physician-patient trust, and a potential compromise to her care, especially in mental health, where trust is the foundation of the therapeutic relationship.

I would say, though, that political awareness and patient advocacy are certainly in fact a requirement for physicians. If our modern oaths say that "prevention is preferable to cure" then it's impossible not to be involved.

But we don't make our patients footsoldiers for better salaries or reimbursement. That's just wrong.
posted by archofatlas at 4:19 PM on November 7, 2009 [2 favorites]

Actually, this one is easy. Yes - it's a breach of professional ethics; in particular it is a gross violation of the boundaries set at the initiation of the psychiatrist-patient relationship. I could go on and explain why this is so but I am late for an evening out. But, really, this is a no-brainer within the profession. Unsolicited contact with patients in any shape, form or fashion is unethical.
posted by Gerard Sorme at 4:32 PM on November 7, 2009 [6 favorites]

That seems incredibly inappropriate, and if it were me, I would find a new shrink and complain to whoever's in charge of supervising this shrink.

A doctor signing a petition, joining a march, giving expert testimony, donating their own money to a cause--SUPER AWESOME. A doctor sending me a note telling me to "take action" for a cause? SUPER CREEPY.

And those of you who think this is great--would you think it was so great if the cause was, say, Operation Rescue?
posted by Sidhedevil at 4:39 PM on November 7, 2009

What an asshole, so inappropriate, who cares if it's "acceptable".

It upset your wife, he's not paid to do that without "purpose" towards her treatment (advancing his political agenda is irrelevant).

Call him out on how this incident is basically in direct conflict with the explicitly stated goals of her therapy session, and see how he responds.
posted by zentrification at 4:42 PM on November 7, 2009

I'll take up where Gerard Sorme and Sidhedevil leave off: Dual relationships are a clear violation of professional ethics, and asking a patient for a favor constitutes a dual relationship. The fact that her psychiatrist's request for advocacy made your wife uncomfortable is an obvious clue.

What if your wife is pro-choice and doesn't support the amendment? How can her psychiatrist possibly put her in the position of having to choose between her own beliefs (which, presumably, the psychiatrist does not know) and pleasing her psychiatrist? On what planet does that benefit her?

I would think that vociferous complaints both to the psychiatrist and his/her supervisor is definitely in order.
posted by DrGail at 4:43 PM on November 7, 2009 [6 favorites]

I don't know the laws about this, but I'd like to share my thought about why this is inappropriate. Imagine a friend did this. You would probably think, "Hmm, we disagree," and maybe have some banter with the friend, but it's all ok.

But this is not a friend. So, if she thinks, "Hmm, we disagree," does she feel like she cannot say that? Cannot have some banter over the pros/cons? Does she worry that doing so might affect her care?

Her relationship with her psychiatrist is one that gives the psychiatrist quite a bit of power -- he discusses her inner-most fears with her, prescribes her medicine, and so on. With that power comes, in my mind, an obligation to only be a psychiatrist -- not a friend. I believe he's crossed that line, and if I were in that situation I'd report him to whoever helps psychiatrists stay on the other side of that line (boss, hospital administration, board).
posted by Houstonian at 4:55 PM on November 7, 2009

This is a professional your wife pays to listen to her problems, prescribe and change her medication as necessary, and that's it. She doesn't pay the doc to hear political opinions, and the doc doesn't care for her so that she'll vote the way the doc wants.

DTMFA, and let the practice manager know why in a polite letter.
posted by fairytale of los angeles at 5:06 PM on November 7, 2009

Find a new psychiatrist, inform the current one that their advocacy has violated the sense of trust necessary to work together properly. I would also consider filing an ethics complaint, this is completely over the line. If there are any other visible recipients of the email, this would also likely be a privacy violation.

This isn't just inappropriate, this kind of behavior is actively detrimental to the goals of the professional relationship.
posted by Saydur at 5:09 PM on November 7, 2009 [1 favorite]

As a physician, I personally think this is dreadful. Absolutely dreadful, and moreso as it relates to a fairly emotionally charged issue like abortion in the context of psychiatric care.
posted by drpynchon at 5:51 PM on November 7, 2009 [2 favorites]

Oh also, it wouldn't surprise me if licensing boards would take offense to a pattern of this sort of behavior, and it may even be considered punishable to use your patients' private contact information for anything other than patient care (ie to urge for unsolicited political action).
posted by drpynchon at 5:56 PM on November 7, 2009

For those that don't know, the Pitts-Stupak amendment would make it illegal for the public option and any insurance plan on the public exchange to cover abortions. That's a highly controversial position to take.
posted by delmoi at 5:58 PM on November 7, 2009 [1 favorite]

Something to consider: is there any possibility that this psychiatrist is not tech-savvy enough to successfully send an e-mail to his personal contacts only, and thus accidentally sent this e-mail to his whole address book?

But if it was intentional: no, not acceptable.
posted by Meg_Murry at 6:02 PM on November 7, 2009

I agree, this is unethical and violates doctor/patient relationships on top of if he asked for her email, he just did the all mighty spam violation. Did anything in her paperwork that she signed say that by giving her contact information, she just signed her privacy away (i.e. mailing address to be sold/used, email address, phone number ,etc). Plus this healthcare bill is his opinion/feelings. He shouldn't push his views on to her.

Time for a new psychiatrist.
posted by stormpooper at 6:32 PM on November 7, 2009

Yes, it's a gross violation. See American Psychiatric Association, American Psychiatric Association: The Principles of Medical Ethics, With Annotations Especially Applicable to Psychiatry:

Section 1, Annotation 1: "A psychiatrist shall not gratify his or her own needs by exploiting the patient. The psychiatrist shall be ever vigilant about the impact that his or her conduct has upon the boundaries of the doctor–patient relationship, and thus upon the well-being of the patient. These requirements become particularly important because of the essentially private, highly personal, and sometimes intensely emotional nature of the relationship established with the psychiatrist."

Section 2, Annotation 2: "The psychiatrist [...] should not use the unique position of power afforded him/her by the psychotherapeutic situation to influence the patient in any way not directly relevant to the treatment goals."

Section 9: "A physician shall support access to medical care for all people."
posted by WCityMike at 6:55 PM on November 7, 2009 [10 favorites]

I take back what I said earlier. I agree now that with those saying it is unethical.
posted by jayder at 7:15 PM on November 7, 2009

Ok, well WCityMike's "section 2" quote pretty much takes care of that. I would say relevance can be argued on the other two listed, but the second one clinches it. Thanks for posting those.
posted by monkeymadness at 7:40 PM on November 7, 2009

If the professional believes that supporting a some policy will lead to better care for his/her patients and others, there's nothing wrong with telling patients same.
posted by gjc at 8:47 PM on November 7, 2009

If the professional believes that supporting a some policy will lead to better care for his/her patients and others, there's nothing wrong with telling patients same.

Even if I agreed with this, and I don't think I do, I'm having a really hard time seeing how that could apply in this case. How would making it difficult for women to get abortions help anonymous's wife's treatment?
posted by craichead at 9:20 PM on November 7, 2009

If this happened to me, I would WITHOUT A DOUBT report this person to the APA ethics board, and cease contact with him. This is a serious ethical violation.
posted by so_gracefully at 9:23 PM on November 7, 2009 [3 favorites]

Yeah, no, gjc. Calling him/her "the professional" obscures the issue; "the professional" is not a plumber. The psychiatrist/patient relationship is unique even within the doctor/patient relationship paradigm and this is totally inappropriate and unethical.

I'd be annoyed with my plumber if he started emailing me about, um, controversial plumbing legislation, but my relationship with my plumber is not as intimate, delicate and asymmetrical as my relationship with my psychiatrist.
posted by chesty_a_arthur at 4:23 AM on November 8, 2009

it seems like section 2 is there to prevent psychiatrists from being invested at all in their position as social/political actors. kind of like a union-busting measure for a more bourgeois profession--that is, to get these professionals to avoid seeing what binds them (and their customers/patients too!) in common and how they mutually effect/are effected by the establishment.

imagine, if you will, a similar askmefi question: "a machinist in the local glass factory passed a link on to my wife about an upcoming bill dealing with several important labor regulations. not only is it against his job's rules to solicit people in such a way, my wife is worried/angry that it is a violation of the sanctity of our relationship as customers to their business." i think it's a bit less clear how this could be an earth-shatteringly unethical act in this case. laden with problems & iimplications, yes, but necessary for, well, what the anonymous poster said: political advocacy.

in light of this hyperbolic analogy, i say that it is ethical, despite being against regulations. although i'm sure it does muck up the supposedly "blank slate" of the doctor-patient relationship. interesting, it really does pit pressing political concerns against the weekly appointment in some way; but then again, i've known several people who've had to cease these relationships for other reasons--like meeting someone in common, or getting to know the psychiatrist's children well--and it doesn't seem to bother them then.

hm! what an interesting case study...i'd love to see how my position--on it being ethical--has also backfired in favor of a racist campaign, for example, and compare notes...
posted by parkbench at 4:47 AM on November 8, 2009

Something to consider is that asking MetaFilter whether a behavior is a violation of professional ethics, versus asking whether it's merely tacky, are two very different endeavors. The latter can easily be answered by lay folk; it's basically just a poll. But your question isn't a poll. Professional ethics codes use specific, sometimes term-of-art language, and asking a bunch of lay folk with zero background in the field to interpret and speculate on that language...well, you might take some of the responses and 'explanations' above with a grain of salt.
posted by cribcage at 6:01 AM on November 8, 2009

> it seems like section 2 is there to prevent psychiatrists from being invested at
> all in their position as social/political actors.

Psychiatrists, in their role as people who are supposed to help, both therapeutically and pharmaceutically, aid the patient in the healing of mental problems and aberrations from the norm, should not be social/political actors. A psychiatrist should not be acting on their beliefs about abortion when treating a daughter for schizophrenia, nor should they be acting on their beliefs as to the correct political party to be in charge when treating someone's depression.

The section obviously doesn't constrain them from acting socially/politically period – it constrains them from advocating their own personal social/political beliefs with the individuals whom they treat, who, by default, are usually mentally and emotionally vulnerable.

> imagine, if you will, a similar askmefi question: "a machinist in the local glass
> factory passed a link on to my wife about an upcoming bill dealing with several
> important labor regulations. not only is it against his job's rules to solicit
> people in such a way, my wife is worried/angry that it is a violation of the
> sanctity of our relationship as customers to their business." i think it's a bit
> less clear how this could be an earth-shatteringly unethical act in this case.
> in light of this hyperbolic analogy, i say that it is ethical, despite being
> against regulations.

The relationship one has with their local glass factory assembly worker is about ten thousand times less significant, less intimate, and less influencing to an individual than their relationship with their psychiatrist. Your proposed similar question isn't similar at all.

It's like telling someone that their mother telling them "I don't love you" isn't significant because you wouldn't feel bad if the hot pretzel vendor outside your work said "I don't love you".
posted by WCityMike at 7:29 AM on November 8, 2009 [2 favorites]

Professional ethics codes use specific, sometimes term-of-art language, and asking a bunch of lay folk with zero background in the field to interpret and speculate on that language...well, you might take some of the responses and 'explanations' above with a grain of salt.

While it's pretty clear this is unethical, you don't have to take the word of anyone here on it. Report it to the APA and the state licensing authority and let the professionals there sort it out.
posted by grouse at 8:18 AM on November 8, 2009 [1 favorite]

I didn't say the doctor's belief had to be rational or justifiable. Just that the doctor had to believe that it would be in the patient's best interest. A doctor can be wrong and still be ethical.

But it seems like there are different kinds of ethics going on here. The doctor could well have acted ethically in a personal way, but have broken the rules of his professional organization.

Not to mention, this bill seems to do nothing to interfere with a person's right to get an abortion. It simply stops federal dollars from being used for them.
posted by gjc at 8:40 AM on November 8, 2009

If this psychiatrist has sent this email to any of his clients who have had or are considering having abortions, they will now not be able to discuss that event and the impact on their life without fearing judgment from him. It's no longer a safe neutral space for them. This is directly detrimental to the doctor-patient relationship.
posted by heatherann at 8:41 AM on November 8, 2009 [2 favorites]

It is a) unethical, b) an ethics violation, and c) a truly DISGUSTING thing for a psychiatrist or any physician to have done. This puts any patient who has ever faced, or is facing, or may potentially face an unplanned pregnancy in an impossible position within the theraputic relationship.

And Christ knows I am projecting here, but had I recieved this email from my psychiatrist, I would feel horrendously, irrevokably judged and dammed and shamed and betrayed. I have no idea if your wife has ever had an abortion or is even pro-choice, but holy hell - for someone on his list, statisitcally speaking, this reaches way past the theoretical and into the actual in the worst possible way.

I would report as grouse suggested, without hesitation. I would also be furious, and in the market for a new psychiatrist immediately. And because I'm me, I'd fire that shrink at enormous volume.
posted by DarlingBri at 8:49 AM on November 8, 2009 [4 favorites]

Consult the medical ethics code of your jurisdiction. That will give you the basis for informed opinion. Otherwise, WCityMike has it. These questions are always answered by reference to the actual standards.

But I do believe it is unprofessional. I am in a client-based profession and I always keep my political views to myself unless prompted by the client.
posted by Ironmouth at 9:03 AM on November 8, 2009

But it seems like there are different kinds of ethics going on here. The doctor could well have acted ethically in a personal way,

I disagree profoundly, but as others have said, that's irrelevant to the questioner.

but have broken the rules of his professional organization.

Almost certainly the case.

And as others have said, report this to the supervisor, the professional organization, the state medical board, and anyone else who needs to know about this shit.
posted by Sidhedevil at 10:54 AM on November 8, 2009

Just for emphasis, I agree with Meg Murry that your wife should ask her psychiatrist if the e-mail was sent to her by mistake.
posted by brina at 12:35 PM on November 8, 2009

The doctor could well have acted ethically in a personal way, but have broken the rules of his professional organization.

This is not a personal relationship; it is a professional one. Personal ethics or morals are entirely irrelevant.
posted by drpynchon at 1:12 PM on November 8, 2009

Everything a psychiatrist says and does while interacting with a patient should be for the benefit of the patient. No exceptions. For myself, I'd be taken aback, and not comfortable at all to get such an email from any doctor. It seems to say, "I feel this way, and I want my patient to do me a favor and further my agenda."

Does this psychiatrist believe that it's beneficial to your wife that she oppose an amendment that seeks to prevent using taxpayer dollars to subsidize abortions? Seems like a stretch, unless she's already told the doctor she wants to take action in such a way.

If the doctor is asking the patient to act to promote the doctor's personal or professional agenda, then it's wrong.

If your wife is uncomfortable about the email, can she bring it up? Or can she talk with him about feeling uneasy about discussing certain things? The doctor should welcome such a discussion. If he's defensive or not supportive of her feelings, I'd be concerned.
posted by wryly at 4:23 PM on November 8, 2009

I disagree with those who suggest further engagement with the psychiatrist. The psychiatrist is has a power imbalance in the relationship with the patient and is in a position of trust. The psychiatrist appears to have violated this trust. Discussing things is only an invitation for them for them to further abuse this trust and manipulate the patient into acting in the psychiatrist's own interest by not reporting the breach of ethical practice. The state licensure authorities and the APA will be in a much better position to decide whether this breach was significant or intentional.
posted by grouse at 6:38 PM on November 8, 2009 [1 favorite]