Professional Behaviors of Physicians and Pursuing Social Justice

To the Editor: In their Commentary, Dr Kirch and Mr Vernon¹ noted that among the 4 pillars of medical ethics, justice stands apart. Considerations of justice are indeed underemphasized in the professional behaviors of physicians relative to the 3 other virtues of beneficence, nonmaleficence, and respect for autonomy. What the authors failed to note is the striking difference in focus, skills, and behaviors necessary to effectively practice justice as a clinician.

Beneficence, nonmaleficence, and a respect for autonomy are bedside virtues. They can be reliably and adequately addressed in the interaction between 2 people: a physician and patient. They are easily incorporated in the practice life of any physician in the course of patient care. Attending to justice requires a much broader focus. To even consider justice requires accounting not just for an individual, but for the relationship of that person to the community and to society as a whole. To seek justice a physician must act not in a clinical capacity, but as a citizen, an advocate, and an activist. Physicians are not prepared for these roles. It is therefore not surprising that some physicians do not consider it “their personal responsibility to work to rebalance the principles of medical ethics.”¹

The authors are correct that the medical profession can no longer ignore its obligation to social justice. The profession must provide leadership in the creation of a sustainable health care system that will not tolerate disparities in care or outcomes and that will ceaselessly demand equal opportunities for health for every individual.

As part of its charter on professionalism, the American Board of Internal Medicine (ABIM) called for “public advocacy on the part of each physician.”² The American Medical Association holds that physicians must “advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.”³ However, attending to justice requires moving beyond aspirational statements to action and leadership. This necessitates training future physicians for these roles, incorporating competencies of leadership and advocacy into undergraduate and graduate medical education requirements. Professional societies must provide support and training for practicing physicians in these same skills. Academic medical centers, clinical organizations, and individual practices must find ways to encourage, facilitate, and reward the activities that promote justice.