If one of the privileges of performing medicine is the windows that it opens into the worlds of vulnerable people, one of the frustrations is that many of the ills therein seem irremediable.
In this post we explore medical advocacy. Do medical practitioners have a duty to advocate? What is their role in addressing systemic factors that contribute to the poor health of their patients?
The Foundations of Care
The journey through medical school prepares students in many ways. My education established a broad biochemical, ethical, and psychosocial base; in the first two years of medical school we were encouraged to conceptualise pathologies from many angles.
In clinical years, teaching on placements has resembled an avalanche of specialised knowledge that risks burying empathy and freezing broader moral duties at the threshold of the ward. Medicine starts to more exclusively mean ordering biochemical tests, writing prescriptions or making referrals.
These things are vital, but an argument may be made that, just as a person’s suffering may continue once they leave the clinic or ward, the doctor’s duty to care for a patient continues to apply under a name less commonly discussed in medical school: the duty to advocate for patients.
Professionalism and the duty to advocate
The concept of a duty to advocate exists explicitly in many professional codes for doctors.
The Declaration of Professional Responsibilities of the American Medical Association, for example, states that physicians should “advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being”.
In the UK, the NHS Constitution directs staff to help “reduce inequalities in experience, access, or outcomes between differing groups or sections of society requiring healthcare”. For medical students, the GMC requires in its Outcomes for Graduates that new doctors:
Assess, by taking a history, the environmental, social, psychological, behavioural, and cultural factors influencing a patient’s presentation, and identify options to address these, including advocacy for those who are disempowered.
These professional standards certainly carry some authority. But they also point to wider questions about the role of medicine within society. Do medical professionals have a unique duty within society? What does it mean for medicine when health problems are caused by social, cultural, or political actions?
Special duties of medical professionals
Doctors frequently see parts of their patients’ lives that are ordinarily hidden. This is a privilege of the doctor: “society gives you rights and license it gives to no one else, in return for which you promise to put the interest of those for whom you care ahead of your own”. This social contract, along with the high public trust in the profession, gives doctors a unique voice in public discourse. Finding that voice, however, is another matter; by speaking up for the voiceless, you bear their standard and expose yourself to their opponents.
Just as doctors can have a strong voice, they can also tell powerful tales: in looking through windows into darker worlds, doctors bear witness to what may otherwise be unimaginable to many people. The concept of bearing witness, or témoignage, has a powerful legacy within modern medicine. This is most famously championed by Médecins Sans Frontières (MSF), for whom the concept of bearing witness entailed going where others would not go in order to shed light on atrocities.
Although most UK medical professionals will not work in war zones, the principle nevertheless applies. Having sought a career in which people can expose themselves in ways that would be inconceivable in almost any other context, doctors have, at least indirectly, sought out abuses of individual dignity. The vital part for this discussion, however, is to recognise when these abuses are the result of society-level phenomenon (economic gradients, social stigma, discrimination), and to then seek out the causes of these phenomena in order to publicise the effects afflicting individual patients.
Therefore, doctors simultaneously see things that the rest of society may never see and possess a voice that has an unusual capacity to be heard. This, if nothing else, forms the moral basis of a duty to advocate.
Doctors, illness, and societal problems
Being able to seek out the causes of abuse, however, is a difficult task; it is not the burden of doctors alone to elucidate and remedy the social determinants of health and disease. Nevertheless, doctors have a vital role in this process.
One example is the ‘pragmatic solidarity’ described by the anthropologist-doctor Paul Farmer.
Farmer framed ill health as a product of the abuses of those with power over those without, a phenomenon he termed ‘pathologies of power’. Pragmatic solidarity provides the blueprint for a compassionate response, and entails the “rapid deployment of our tools and resources to improve the health and wellbeing of those who suffer from this violence”.
In this sense, a patient who arrives at the GP malnourished following welfare cuts may be argued to have suffered from a pathology of power. In the UK, this is currently of great relevance: the austerity measures taken by the current Conservative UK government since 2010 have led to a decline in local authority budgets, with a corresponding decline in social services. Importantly, the degree to which these cuts were necessary, and the fairness with which they were implemented, have been questioned. The UN Special Rapporteur on Extreme Poverty, Philip Alston, described them as “punitive, mean-spirited, and often callous”. The Institute of Health Equity also described the cuts of austerity as “regressive and inequitable”, noting that they have been “greatest in areas where need is highest”.
What does this mean to a doctor seeing a malnourished patient in an area impacted by these cuts?
Although malnutrition can be treated in the hospital, it cannot be cured; the patient will return to the world which gave them little option but to eat less, and poorer quality, food. The doctor must then understand what they believe to be contributing to the conditions of that patient’s ill health. If it is their poverty, then it should be the doctor’s concern. If that poverty was caused by inequitable policy, this should be the doctor’s outrage.
Making the causal connection, however, is not always simple: it requires judgement and time to research and draw conclusions; it will to some degree rest on the doctor’s pre-existing beliefs. But open discussion within the medical community has an important role here, as well as leadership from organisations like the British Medical Organisation, which in the case of the health impacts of austerity has drawn its conclusions on the matter.
Ultimately, however, the doctor has seen the results of a systemic process: the poor health of their patient. As the health of their patient is the doctor’s concern, so too is the cause of that poor health. As part of aiding that person, of offering them pragmatic solidarity, doctors can use their own status to aim upstream, to voice their opinions on the political, religious, or cultural causes of ill health, to participate on behalf of their patients.
When you make the care of your patient your first concern, you inherit a duty to advocate and participate on their behalf. What this advocacy looks like in public health and medicine will be explored in future posts, including potential pitfalls.
Conclusions
In this post, it has been argued that medical students and professionals accept a special role within society that gives them a special voice. Through bearing witness and offering solidarity, our voices have the power to empower. When we accept a duty to care for patients, it is argued that we also inherit a responsibility to care about causes of ill health; there is a space for medics to look upstream and search for answers on behalf of those who can scarcely look for much more than their next meal or roof.
Medicine and politics are interwoven like threads in a rope: they can intertwine to form nets that catch those who stumble, and ladders out of poverty and poor health. Medical advocacy has an important role to play in giving form to these threads.
(1) Farmer P (2004). Pathologies of Power: Health, Human Rights, and the New War on the Poor (Berkeley: University of California Press).