Doctors should take part in acts of civil disobedience to advocate for patients

Physicians are expected to always act in the best interest of their patients. Increasingly, many doctors find they must speak up and be advocates before a world that seemingly cares little for the lives and rights of their patients.

In some cases, that advocacy has been in the form of civil disobedience against policies and laws seen to be unjust or inequitable. For example, a group of doctors in Québec recently took part in a one-day strike to protest Israel’s assault on Gaza.

However, civil disobedience by physicians is complicated. There’s an inherent, unresolved tension within the medical profession related to this form of advocacy. On the one hand, medicine is a profession of norms, rules, regulations, standards and tradition. On the other, there are often times of moral crisis that call on us to challenge norms, rules and expectations.

This tension is brought into sharp relief by the reaction of Canada’s medical establishment to acts of civil disobedience by physicians. Physicians risk censure by professional bodies, revocation of their licences to practice medicine and even job loss.

A notable example comes from Dr. Peter Bryce, who was forced into early retirement and died in relative obscurity after taking a principled position on the health of the Indigenous people, especially children in residential schools.

As the world continues to witness war and conflict, and as climate-related disasters impact the health and well-being of more people, the voices of doctors become increasingly vital.

What makes a good doctor?

The question of what makes a good doctor has been the focus of several educational, professional and regulatory medical bodies over the past number of decades. Descriptions of good doctors centre on values that the medical profession asserts are timeless and inherent, such as respect for patient autonomy and altruism.

A closer examination reveals that most of those values are not as inherent or timeless as the profession claims. Along with colleague, Prof. Lorelei Lingard, we’ve explored the claim that altruism is one of those values. We examined how the medical profession has demanded altruism over the years by exploring the Canadian Medical Association’s (CMA) codes of ethics over time.

The first CMA Code of Ethics was published in 1868, a year after Canadian Confederation, and revised regularly every few years. In all, we examined 19 versions of the code from 1868–2004. We read each version and identified altruistic content, and found that, while earlier codes — 1868 and 1922 for example — contained upwards of 12 altruistic statements, the 2004 code contained none.

We defined altruism as statements that urge physicians to place the interests of their patients ahead of their own.

In that sense, not only did the 2004 code contain no altruistic statements, it contained statements that asked physicians to put their own interests ahead of their patients’ interests, such as terminating the patient-doctor relationship and prioritizing one’s own health over their practice.

One discovery was particularly startling: Far from this being a recent phenomenon, the de-emphasis of altruism was gradual with major changes occurring in 1938 and in 1970.

For example, in 1928 the code stated that, in the event of epidemics, “when pestilence prevails,” physicians ought to attend to their patients, even at risk to their own lives. In the 1938 code, that statement disappears entirely. Over the course of the following 50 years, every one of the original altruistic statements was lost in one revision or another of the code.

The need for civil disobedience

The practice of medicine clearly changes over time, and yet at any given point, the medical establishment holds current practice to be not merely a constructed, socially negotiated set of practices, but as an immutable, almost divine writ. And those fundamental shifts have been the norm throughout the history of medicine. But, at every point, physicians are expected to conform to the standard of the day.

Shifts in medical values are not always for the better. We seem to conveniently ignore that physicians and the medical establishment were integral to many societally sanctioned acts of malfeasance or transgression. To be considered good, doctors must demonstrate obeisance to the prevailing norms and values of the day.

It was “good” Canadian doctors who participated in the forced sterilization of Indigenous women. “Good” American doctors in the 1950s knowingly failed to provide proper treatment to African American men with syphilis. And “good” German doctors attended in Nazi concentration camps.

This is why civil disobedience should be respected, not censured. Admittedly, it is difficult to codify “acceptable” civil disobedience, since it is, by definition a transgressive act. Acts of civil disobedience are anchored in individual morality.

In a culture where morality is increasingly individualized, agreeing on universal parameters to describe civil disobedience is likely an impossible undertaking. Additionally, codifying dissent risks draining its potency as a form of protest.

There have been attempts to set parameters for “acceptable” civil disobedience. Reasonableness is one such parameter. Others have proposed parameters like the existence of genuine injustice, exhaustion of legal channels and a reasonable prospect of success. However, all these parameters are a matter of subjectivity and are themselves areas of contention even within groups opposed to specific policies or practices.

By its very nature, civil resistance is not a risk-free endeavour. Legal institutions must continue to uphold the law. But regulatory agencies like licensing bodies and medical associations should not punish physicians for their acts of civil disobedience based on genuinely held moral beliefs.

It is perhaps unreasonable to expect establishment institutions to speak out against injustice, but when it comes to moral acts of personal sacrifice by their members, the least they can do is refrain from censuring those willing to speak out.