As physicians and trainees, we take an oath to do no harm. While this orientation may have practical applications within individual treatment plans, it begs some questions: Why stop at the passive “do no harm” rather than actively confronting harm? What is the physician’s duty to their patients and communities they serve? What role can we have in addressing the structural violence that causes harm to patients, such as homelessness and displacement, food insecurity, or trauma from the police and the prison system?
To adequately address these questions, we must make the ideological shift from neutrality to intentional, politicized community engagement to confront harm. Confronting harm can take many forms, including fighting back against corporations and pharmaceutical companies that prey on patients; working to end medical practices that serve as social control and exploit marginalized people; advocating for reparations and reinvestment in communities (including but not limited to health care infrastructure); resisting colonization and state-based repression, even in the face of institutional backlash; and fighting for the liberation of Indigenous communities, both in the United States and globally.
One role the physician can take on when confronting harm is that of witness. Physicians are uniquely positioned to be witnesses to the physical and psychological manifestations of structural violence. In these cases, we must move beyond reactionary practices and begin to see patients’ concerns, symptoms and trauma as not just problems to diagnose but the outcomes of a larger sociopolitical context. It is important for us to not lose sight of the whole picture when dealing with everyday issues like struggling to provide care to a patient who cannot afford medication; while this is an opportunity to advocate for an individual patient, it is also important to note this instance as a manifestation of the harms inflicted by insurance companies and pharmaceutical companies. For many patients, their diagnosed diseases may also be in large part due to structural oppression, with food insecurity, environmental racism, and lack of access to services due to segregation and disinvestment leading to physical harm.
On an interpersonal level, the physician can serve as a witness for patients and work to address these harms through treatment and care that centers the needs and lived reality of the patient. On a structural level, the physician must work to amplify the voices of the most marginalized rather than speaking on behalf of patients. This work must be community-aligned and in service of addressing the structural roots of oppression. The group Doctors 4 Camp Closure is a good example of physicians using their social capital to witness and confront inhumane detention of migrants and refugees who experience harm at the hands of the U.S. immigration prison system. Health Justice Commons is a group that centers the voices of those most impacted by the harms of the medical-industrial complex, and they call into question the lines and implicit hierarchies between providers, patients and community members. These are just some examples of the ways in which physicians can use their position as witness to drive structural change.
A second role that physicians can take on, beyond bearing witness, is that of a worker for wages. As health systems continue to grow, most physicians are workers in an industry increasingly operated by large hospitals, health systems, insurance companies, pharmaceuticals and medical technology companies. This nexus of health care capitalism allows for the exploitation not only of patients and communities, but also us as workers as well. There is a reason there is such severe physician burnout, and it comes to the lack of power we have to make the best decisions for care. These groups that hold power benefit from physicians not organizing as workers and demanding change collectively — health care workers lose power by not building together, and it takes away from the ability to advocate as effectively as we could for ourselves, our patients and communities we serve.
While our wage work may demand that most of us work within large institutions to care for patients, we must make an active choice to align ourselves with the communities we serve over the institutions we work in. Aligning ourselves as a labor force opens radical possibilities of change by giving us greater bargaining power. Take the issue of police in hospitals and emergency rooms during the uprisings of 2020. Many physicians and health care workers took issue with the fact that the police could make arrests in the ER — individually, any one physician may not have the power to escalate this issue. An organized labor force would be able to draw the attention of health care administration and demand the removal of police in the ER and in the health system at large. Organizing collectively also protects workers from institutional backlash, as seen against health care workers who speak out openly in support of the Palestinian struggle for liberation.
This kind of organizing in health care is not new — the National Nurses Union (NNU) works because nurses see themselves as workers who are organizing for themselves and the patients and communities they serve. Just most recently, the NNU published a statement against the Centers for Disease Control and Prevention guidelines for the relaxing of the mask mandate. As witnesses to the devastation of COVID-19, and as workers concerned for their own health and wellbeing, they collectively fight for change. And while less common, resident unions exist in pockets across the country; however, as physicians move up through the hierarchy, those unions tend to disappear. As physicians move through their careers, it is crucial to keep in mind who benefits from doctors not aligning with one another and with other health care workers: hospital systems and corporations. Ultimately, it is crucial for the care of patients and the movement toward health justice that physicians align as workers and witnesses; if not, we will be complicit in the structural harms we claim to stand against.