Wednesday, March 16, 2011

Doctor's Notes, Political Beliefs, and Medical Ethics

On February 19, during the protests against Governor Scott Walker's union-busting proposal, a video appeared showing physicians offering to provide "doctor's notes" for protesters at the rally, presumably to be used with employers to excuse absences. I infer from the video that physicians who supported the protests provided notes to protesters as an act of solidarity with an advocacy cause.

Yesterday it was reported that eleven physicians who are believed to have been providing doctor's notes at the protests have received complaints from the Wisconsin Department of Regulation and Licensing. Responses are due on March 21.

I supported the protests, and if I'd been a physician in Wisconsin I would have joined protesters at the capital, but I would not have given out doctor's notes. During the Vietnam era psychiatrists were not infrequently asked by draft age men to provide medical testimony that they suffered from a psychiatric illness that would make them undraftable. Colloquially this was called "copping out on a nut."

I opposed the war and frequently participated in marches and rallies against it, but I didn't write cop-out-on-a-nut letters. Physicians are given a special status in society through licensure, laws that create a framework for practice, and social respect that abets healing potential. I regarded truthfulness in medical testimony as one of the underpinnings for the profession's ability to function. Truthfulness was part of our implicit contract with society. As a citizen it was my duty to advocate in accord with my political beliefs and values. As a physician it was my duty not to use the privileges society gives the profession deceitfully.

(This doesn't mean that truthfulness trumps all other values. If a physician in Nazi Germany knew that his patient was a Jew and was asked by the SS, the ethical answer would have been "no." But Scott Walker is not Adolph Hitler.)

It's not uncommon for patients to ask psychiatrists and primary care physicians for letters to excuse absences from work caused by alcoholism. These requests sometimes created opportunity for a valuable conversation that went something like this:
Patient: "Doc, I missed work on Monday. I had a terrible headache and couldn't drag myself out of bed. Could you write a letter for me so I can get paid?"

Physician: "We've talked a lot about the problem you're having with alcohol. Was that involved here?"

Patient: "I guess so. I really tied one on this weekend."

Physician: "I'd like to see you get paid, and you did miss work for legitimate medical reasons, but I'm not sure you'll want me to write a note."

Patient: "Why's that? That's what I'm here for!"

Physician: "I would want to write a true medical letter. You really were out because of illness. The illness is alcoholism. It's a serious illness and for some people it's fatal, but it's definitely treatable. Some employers understand this and want to help their employees get a grip on the condition. Does that apply to your employer?"
Occasionally the employer understood alcoholism as a treatable condition, and we enlisted the employer along with the family in developing a treatment plan. More often the patient said "let's forget about the note." But the discussions gave a chance to reinforce the view that alcoholism is a chronic condition, difficult to treat but definitely helpable.

In the overheated political atmosphere in Wisconsin the note-writing physicians could be at risk for severe penalties, such as suspension or even loss of license. That outcome would be too severe. These physicians were presumably acting on principle with the aim of supporting a healthy body politic. I don't favor using ethics education as a disciplinary response to situations like sexual boundary violations where the rights and wrongs are obvious. The problem with doctor-patient sex is behavior, not understanding. But in the Wisconsin situation there are real questions and controversies. An appropriate penalty might be some form of community service combined with a group assignment to write an ethical analysis critiquing their decision to write the notes and discussing the ethics of advocacy.

(When I put "doctor's notes" into Google I discovered that there's a thriving industry in fake letters (see here for an example).

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