Richard Smith: Doctors—the case for professional citizenship

Do doctors have extra duties as professional citizens? What are they and do they ever conflict with self-interest? Richard Smith explores

richard_smith_2014The Royal College of Physicians has a project exploring modern professionalism, and one component is citizenship. But what does citizenship mean for doctors and why does it matter? I personally believe it’s the main missing component of professionalism.

I was about to write “we are all citizens of somewhere” when I thought of Theresa May’s sneering insult “citizens of nowhere” and how Janan Ganesh, the brilliant Financial Times journalist, proudly describes himself as a “citizen of nowhere.” I’d rather be a “citizen of nowhere,” with its implication of being a citizen of everywhere, than a citizen of a prejudiced, small minded, xenophobic England.

But that’s a sideline. British doctors are citizens of somewhere, most commonly Britain. That citizenship brings privileges (freedom to move anywhere within the country, work, receive social security, and many more) but also duties (to pay taxes, vote, even fight for the country, and others). But citizenship as part of professionalism implies more for doctors. It means accepting duties (and privileges) beyond those that apply to any citizen. Other groups—for example, lawyers or politicians—will also have extra duties and privileges unique to them.

Importantly, it means accepting duties beyond the important daily work, which for most doctors is caring for patients individual by individual. These broader duties immediately invoke tensions. They may mean accepting that you cannot do everything possible for your individual patient because the resources you might devote to him or her will mean denying others. Doctors dealing with individual patients have often opted to fool themselves and ignore the tension, but as the gap between what could be done and can be afforded grows, most accept the inevitability of the tension. Ignoring the tension is the same as being “apolitical,” which simply means you support the status quo.

But the tension is not only about money, it’s also about time and attention—commodities that are in shorter supply in the modern world than money. Accepting that doctors have a professional commitment to citizenship inevitably means thinking and acting beyond their day jobs, something that is hard when achieving the status of a good doctor demands constant and continuing concentration and attention.

The question of where doctors are citizens of arises again with the extra citizenship that comes with being a doctor. It certainly means being a citizen within your immediate community, which might be a village, housing estate, town, or part of a city, and it’s perhaps here that the activities of the extra citizenship might best be enacted. But I suggest that being a doctor means being a global citizen—accepting global not just local duties.

Perhaps the best example of doctors being global citizens was International Physicians for the Prevention of Nuclear War playing an important part in ending the Cold War, reducing the risk of nuclear war, and winning the Nobel Peace Prize. But doctors have been much less active in combating the current major global threat to health: climate change. A friend who tries to involve doctors in combating climate change finds more reluctance among doctors than others. He thinks that this may be caused by “moral offsetting”: “I spend all day saving lives, I can’t spend my evening saving the planet.” But there is a sense that squabbling over the NHS may be pointless when climate change may potentially end the species.

Or what about the fact that North America has 2% of the global health burden but 25% of the health workforce, whereas Africa has 25% of the health burden but 2% of the workforce? Europe and Britain are similarly blessed with a high proportion of the health workforce but a low proportion of the health burden. Doesn’t this stark divide have implications for professional citizenship?

Then if doctors do have extra duties as professional citizens, it’s surely something to do with health. But the painful truth is that doctors are interested in disease not health and that, as I’ve argued before, healthcare swallows up resources that could be much better spent if improving health was the ultimate aim. This is where professional citizenship could conflict painfully with self-interest in that diversion of resources from healthcare to other areas with more influence on health could mean doctors losing jobs, income, and status. Similarly, there should undoubtedly be a shift of resources from hospital to primary care, but would hospital doctors go along with that, especially if it means them losing their jobs or having to retrain?

The question arises whether all doctors need to exercise professional citizenship or whether the duty can be discharged through their professional bodies. Not every doctor can be active every day on, for example, climate change, but they should have a mindset that recognises their extra citizenship and support their professional organisations in actions that may even be against their narrow self-interest. And doctors surely must act individually to exercise professional citizenship within their local communities. This might play out in England through the Sustainability and Transformation Plans that, if they are to succeed, will surely require shifting of resources that will work against the self-interest of individual doctors.

It becomes obvious that professional citizenship will not be popular with all doctors—and so promoting it may be highly risky for membership organisations like the royal colleges or the BMA. So why should they bother?

One reason is that it’s morally right, but that won’t fly with doubters. A more concrete reason is that doctors are perceived by many as reneging on their contract with the public to provide safe, accessible, high quality, cost effective care—because of things like what happened in Mid Staffs, the junior doctors’ strike, and the difficulty of getting appointments with GPs. One result of the reneging is ever increasing regulation, which is not effective and makes doctors’ lives miserable. Revitalising professionalism, which I believe must include professional citizenship, might be a way of restoring balance in the contract with the public.

Another reason for professional organisations to be bold is that doctors increasingly seem to be victims—despite being one of the most trusted, best educated, highest status, and best paid groups in society. This stems in part from doctors generally being poor leaders and weak strategic thinkers: they tend to be against the ideas of others rather than good at taking the lead on health system reform. But they are the most powerful group within any system—and can use that power to decline to go along with reform. It would be much better to lead, but that will inevitably mean adopting professional citizenship and accepting changes that work against self-interest but bring overall benefit. You could think of it as being willing to go to war to protect your country.

Richard Smith was the editor of The BMJ until 2004.

Competing interests: None declared.

RS attended a workshop jointly run by the Royal College of Physicians and the University of Oxford Arts and Humanities Research Council project Compassion in Healthcare: Practical Policy for Civic Life, where citizenship was discussed along with compassion and calling.