The social, economic, and political fabric of the United States is undergoing profound stress, heightened by the covid-19 pandemic. This upheaval is causing many healthcare professionals and trainees to reassess assumptions about their role in society. Among physicians and medical students, conversations are ongoing regarding the boundary of their professional responsibility and whether it includes empowering voting rights of their patients. Voting is one of many avenues to systemic change but one that has come to the fore of professional responsibility discussions, driven by a growing appreciation for the social factors which impact health and our nation’s poor handling of the pandemic. Given the critical impact of public policy on the health of patients and their communities, today young physicians are asking if they have a professional responsibility to assist the enfranchisement and safe voting of their patients.
This discussion is urgent. With 58% of poll workers over the age of 61, many are having to make the difficult choice of whether or not to volunteer on election day during the pandemic. Shortages of volunteers and the closing of polling locations have resulted in long waiting lines and inadequate social distancing. In addition, misleading statements about the legitimacy of mail-in voting forces many vulnerable citizens to feel compelled to either vote in person in November, increasing their health risk, or forego voting entirely.
The intersection of health and voter enfranchisement places physicians in a critical and unfamiliar position. Some contend that voter registration is not a proper use of physicians’ time or attention. In contrast to common mischaracterizations, voter enfranchisement efforts do not require physicians to become voter registration experts. Instead, their role is to make high-quality, non-partisan, voter registration resources available to patients. Many free, high-quality resources are immediately available. Once patients are directed to these resources, clinicians are free to move on to the next patient. Some physicians are hesitant to engage in any resource sharing due to concerns about the partisan appearance of physician voter enfranchisement activity.
In medicine, as with any profession, it is instructive to establish the difference between “citizenship” and “partisanship.” Citizenship in a democracy involves participating in social and political life, contributing to the functioning of one’s community and its public institutions while holding its elected leaders accountable. Partisanship assumes promoting a specific ideology or political interest. One can exist publicly as a citizen without expressing any partisan leanings; promoting the participation of all voting eligible citizens in our democracy is a nonpartisan civic act. Equating citizenship with partisanship, can obfuscate discussion and discourage action. In healthcare, improper distinction between nonpartisan civic engagement and partisan involvement has resulted in confusion about what may be appropriate for discussion with patients. To be sure, partisan statements have no place in the context of a medical encounter. Alternatively, so long as one avoids requiring disclosure of voting preference or citizenship status and remains consistent in supporting the voting rights of all eligible citizens, offering voter registration resources is a non-partisan and healthcare-relevant act.
Some clinicians are hesitant to engage in voter enfranchisement discussions due to concerns over legal or ethical backlash. Although individual healthcare institutions may impose specific limitations on employee speech, two things are clear; non-partisan voter enfranchisement is entirely legal in healthcare spaces and is supported by accepted codes of medical ethics. Each year the American Hospital Association hires a law firm to audit the tax code and provide legal guidelines for election-related activities in hospitals and healthcare facilities. In January, their 2020 report re-demonstrated that “section 501(c)(3) hospitals are permitted to conduct nonpartisan voter education and registration activities, which provide valuable contributions to public understanding of and debate about key issues, as long as they are not coordinated with a candidate or political party.” Similarly the American Medical Association’s (AMA) principles of medical ethics state “A physician shall, recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health” and “a physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.”
Ethical and legal support are necessary, but not sufficient in determining professional responsibility. In this instance, a growing sense of professional responsibility stems from an increasing appreciation for the broad impacts of social determinants of health (SDoH). Defined by the World Health Organization as the “conditions in which people are born, grown, work, live, and age,” SDoH are shaped by forces and systems that include “economic policies and systems, development agendas, social norms, social policies and political systems.” Whether we focus on race and ethnic disparities in pregnancy-related complications and mortality, the disproportionate low-acuity emergency room use among the young, people from ethnic minorities, and those with low incomes, or the tragic and unequal impacts of the covid-19 pandemic on ethnic minority communities, it is clear that our healthcare system is not adequately designed to serve the healthcare needs of these populations, which remain the primary targets of voter suppression.
With communities cared for by a healthcare system which is not designed for them while also excluded from discussion of reform, how can we expect changes to this vicious cycle without outside intervention? Breaking this cycle becomes an urgent professional responsibility for physicians. By encouraging our patients and their families to vote, we can serve an important citizenship and professional function in society. Including the voices of those who have been previously silenced in choosing representatives and policies that affect their health is a great step forward in patient-centered healthcare. Through voter enfranchisement, physicians have the opportunity to include patient voices in structuring the systems that impact their health. Encouraging and enabling voting becomes a standard of care and a professional responsibility.
Jon Kusner is a fourth year medical student at Harvard Medical School. He serves a co-chair of the AMSA National MedOutTheVote campaign that seeks to engage healthcare professionals and trainees in improving the health of our democracy.
Allan Goroll is a primary care physician at Massachusetts General Hospital in Boston, MA and has over 47 years of experience in the medical field. He is the past president of the Massachusetts Medical Society and has been involved in national reform efforts in medical education and healthcare delivery.
Competing interests: None declared