Physicians as CitizensPhysicians as Citizens

To the Editor: In their Special Communication about physician-citizens, Dr Gruen and colleagues¹ proposed that public obligations of physicians should be proportional to 3 criteria: the degree to which proposed actions directly address disease causation, their feasibility to perform, and their efficaciousness. Critical among the factors is the relation of the action to disease causation. Hence, in the authors' view, actions targeting broad socioeconomic conditions that indirectly influence health care are "aspirational goals," but not obligatory. Although the authors provided examples for distinguishing direct and indirect causes of disease, they did not establish specific guidelines. For instance, the authors stated that actions addressing cigarette smoking and needle exchange are direct and obligatory. By contrast, actions to address income disparities or to remove environmental pollutants are indirect, and thus aspirational.

This argument derives from the view that physician's public roles follow directly and exclusively from a "social contract," exchanging professional benefits for a commitment to "promote society's health." But this implicit contract is only part of the story. A fuller understanding comes from recognizing that the medical profession operates in society as a collective public trust.²

Collective public trusts play a crucial role in the moral, economic, and political structures of a free and just society—and holding such a medical trust confers special obligations, some of which are uniquely collective, not individual, and not all of which directly relate to disease causation. For example, as stewards of a public trust, medical professionals have special obligations to set shared ethical standards and even to act collectively against unjust laws that affect health.³ Hence, laws that would have used the health care system to discover and deport illegal immigrant patients deserved to be disobeyed by physicians collectively, as did managed care "gag clauses."^{4 - 5} Such actions of collective professional civil disobedience are primarily directed against laws and policies that enable harm, not against the harm itself, as would be the case with an antismoking campaign. Other professional obligations are even less clearly related to disease causation yet are necessary to uphold a collective public trust. For instance, rules against conflicts of interest generally have no direct bearing on disease outcomes in the short run, yet they are decisive in maintaining public trust.

Although Gruen and colleagues did seek some principled limits on physicians' public obligations, we are concerned that, without further qualification, the model they offer might put at risk some professional obligations that are indispensable for sustaining the profession's standing as a public trust.