A group of West Virginia surgeons went on strike in January 2003, changing the law. Within a matter of weeks, this motivated thousands of doctors in New Jersey to take action; they joined together to stop treating patients outside of emergencies, putting pressure on state lawmakers to give in to their demands. There was no legal justification for either of these concerted political actions. Nobody was ever charged with them.
It stands to reason that the striking doctors were attempting to guarantee healthcare for their patients, given that roughly 80 million Americans were uninsured and systematically excluded from medical care in a for-profit system that contributed to tens of thousands of preventable deaths each year. In that case, you’d be mistaken. In both cases, the doctors wanted lower malpractice liability caps, which is a goal with much less moral heft.
While American doctors have long insisted that healthcare shouldn’t be “politicized,” we have long recognized that healthcare is inherently political and have organized accordingly. It’s just that, historically, physicians have organized politically around causes that benefit their own pockets rather than issues of public health, patient safety, and widespread access to medical care. However, the same political strategies we’ve employed in the past could be redeployed for other, more patient-centered goals.
Specifically, doctors in more than a dozen states where Roe v. Wade was overturned by five unelected Supreme Court justices could now band together to challenge unfair laws and continue to treat pregnant people in need. We can learn from our country’s rich history of civil disobedience and our dominant position in the medical billing industry and put it to use.
As a leading bioethics journal, The Hastings Center Report published a proposal by Robert Macauley in 2005 that advocated for civil disobedience on the part of U.S. doctors to expand access to healthcare to the uninsured and underinsured. He warned that uninsured patients would be billed for medical care coordinated under the names of those with Medicare and Medicaid coverage unless the government “fulfilled its obligation of guaranteeing basic health care for all Americans, under threat of medical anarchy.”
Even if special interests (like the health insurance industry) have the money, doctors have the power to document and bill, so they can change the system, Macauley wrote. Doctors need to be willing to put their careers, incomes, and social standing on the line to help the tens of millions of people who do not have access to health insurance. Only through personal sacrifice can a sea change be achieved, but this is doable with enough focus and effort.
Twenty years later, when more than 31 million Americans still lack health insurance, thousands continue to die each month due to for-profit healthcare exclusion, and U.S. doctors are rewarded with the world’s highest physician incomes, the medical community has yet to take such risks. Now, in the wake of the Supreme Court’s decision on abortion care, most doctors, hospitals, and organizations like Planned Parenthood are not only declining to resist legal restrictions that further deny care to our patients, but many are proactively canceling appointments and denying people abortion care in anticipation of possible future liability.
Similarly, historian Timothy Snyder has noted that “most of the power of authoritarianism is freely given,” which is consistent with this behavior. When people are anticipating the needs of a more authoritarian government, they are more likely to volunteer their services without being formally requested to do so. A citizen who demonstrates such flexibility demonstrates to the powerful the limits of human adaptability. Doctors in America’s notoriously hierarchical and risk-averse medical culture have long been trained to obey the rules without questioning them; when the rules contravene our mandate to provide care, however, we must check our ingrained impulses.
The medical community in the United States is currently at a crossroads: we can either give in to the legal decisions imposed by an anti-democratic institution that harm our patients while reaping the benefits of complicity with state-sanctioned violence, or we can band together to meet our ethical obligations as privileged caregivers despite the risks involved.
“We must pay a certain price to convince others that our actions have, in our carefully considered view, a sufficient moral basis in the political convictions of the community,” wrote moral philosopher John Rawls about the act of civil disobedience. Some doctors may face disciplinary action or even criminal prosecution if they side with their patients against oppressive legal systems. While this may be inevitable in some situations, a politics based on the heroic sacrifice of individuals is not a sustainable strategy.
We need well-planned collective actions to refuse to comply with unjust laws, rather than individual doctors taking risks without consulting with their colleagues. We do not have to resort to work stoppages, which would cause problems for both our patients and our administration. Documentary disobedience may be the most effective strategy in the American fee-for-service healthcare system, which has been built almost entirely around billing codes.
The entire medical staff at a hospital or clinic could co-sign illegal abortion records instead of just one doctor, for example. We could also agree to not record or bill for abortions or prenatal care received before fetal viability at 24 weeks of gestation, instead putting the cost of these procedures on other parts of our healthcare systems. Further, we could strategically cause public and private insurance systems to collapse within days through coordinated false billing without ever interrupting service delivery to our patients, in order to demand changes to unfair laws. For all of this to work, we’d have to convince the healthcare facilities we rely on to join us in refusing to comply with legal obstructions to patient care.
We should force states that are trying to criminalize abortion care to shut down hundreds of hospitals and prosecute thousands of doctors if they want to survive. To the states: try shutting down your entire healthcare system. Hold accountable those who would seek to restrict access to abortion services for their constituents. If the medical community actively opposed the politicians, very few of them would be willing to push this through. Those politicians wouldn’t last long in office even if they tried, and doctors who stood by their ethical principles helped ensure that.
American doctors can make amends for our past inaction by patients and the public in demanding universal healthcare and a guaranteed public health safety net by adopting a politics of care rather than compliance. Henry David Thoreau urged citizens in On the Duty of Civil Disobedience to “cast your whole vote, not a strip of paper merely, but your whole influence.” We should all take his advice to heart. “A minority has no power as long as it stays in step with the majority; in fact, it ceases to exist as such; but it can do incredible damage when it clogs with all its might.” One million American doctors would be a formidable force.
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