The world turned upside down: What does the response to a pandemic and a Supreme Court decision say about a medical specialty?
“If you stand for nothing Burr, what’ll you fall for?’
Thus, in the musical Hamilton, does the fictionalized Alexander Hamilton mock his future nemesis and murderer Aaron Burr. Hamilton takes a stand in favor of some of our most deeply held values: liberty, freedom, and independence. By contrast, Burr urges Hamilton to keep his opinions to himself. Burr’s morally unmoored self-serving strategy sets up the central antagonism of the story, and might be best summed up as: “talk less, smile more… don’t let them know what you’re against or what you’re for”.
While potentially unseemly for us, as academic anesthesiologists, to discuss politics, the current climate has made it difficult for us to remain silent. The American Board of Anesthesiology (ABA) and the American Society of Anesthesiologists (ASA) have, each in their own way, failed to rise to major challenges of the day with clarity and boldness. Specifically, we take issue with the response of these organizations to COVID-19 misinformation and to the decision of the United State Supreme Court in Dobbs v Jackson Women’s Health Organization (Dobbs).1 The responses of our professional organizations to these challenges may be characterized, unfortunately, as more Burr than Hamilton.
COVID-19 Misinformation
Over the course of the COVID-19 pandemic, it became clear that two public health battles were being fought. The first and more obvious was the battle against the virus itself. Our specialty met this challenge with expertise, aplomb, and grit. From the first days of the pandemic, we were on front lines, risking our lives performing procedures and providing bedside care to patients with a pathogen we knew very little about.
The second and more insidious battle was the battle against misinformation. Our ability to contain and control this virus depended on more than good healthcare and medical discovery. We were in need of spreading medically accurate information about infection control and therapies that could be trusted and implemented by the public at large. In this, our specialty failed.
There can be no better example of this than the actions of board certified anesthesiologist and United States Congress Representative Andrew Harris. Serving Maryland District 1, Dr. Harris voiced anti-mask sentiments after the value of this public health intervention was demonstrated,2 endorsed ivermectin after the FDA warned against it,3 and discouraged parents from vaccinating their children against COVID-19.4
How has our specialty reacted? The ABA has done nothing, despite statements by the Federation of State Medical Boards (FSMB) and the American Board of Medical Specialties (ABMS) “regarding the ethical and professional responsibility of physicians sharing information publicly to represent current scientific evidence accurately and faithfully”, stating that “misrepresentation or misapplication of science is unethical and unprofessional and harmful to patients and the public.” The ASA has likewise remained silent, making no public statements with respect to these actions. The ASA Political Action Committee (ASAPAC) continued to provide financial support to Dr. Harris, having contributed $10,000 in 2021–2022.5
We know these organizations were aware of the actions of Dr. Harris: they were pointedly brought to the attention of the ABA, the ASA, and the ASAPAC by multiple members of these organizations. Sadly, Dr. Harris is not the only anesthesiologist involved in dissemination of COVID-19 misinformation.6 The representative organizations of our specialty have failed to defend established ethical standards of medical practice. Whether these silences reflected intentionality, complacency, or political paralysis, this lack of reaction was and continues to be wrong. We can do better.
Dobbs v Jackson Women’s Health Organization
With Dobbs, the Supreme Court overturned 50 years of judicial precedent. Immediately after the ruling, a resounding number of medical societies and board specialty organizations published strongly worded warnings regarding the healthcare related consequences of this decision.7–10 The ABA was signatory to a statement that acknowledged the consequences of this decision on both providers and patients.11 However, the response of the ASA was more tepid. After a week of silence and much pressure from members with leadership roles in the society, the ASA issued a statement that would generously be described as anemic.12,13
The ASA has yet to acknowledge that Dobbs will have substantial consequences for broad swaths of its membership and their patients. Now, any anesthesiologist providing care to a patient for a dilation and curettage for miscarriage in a state with restrictive abortion laws could be indicted for conspiracy to commit first degree murder. Now, any anesthesiologist training in a state with those same restrictive laws may not be exposed to specific classes of medically indicated procedures. Now, any anesthesiologist in these states could face serious legal jeopardy for discussing or even participating in a discussion of pregnancy termination, even when medically indicated (such as in the case of an ectopic pregnancy). These legal restrictions place anesthesiologists between the rock of malpractice and the hard place of illegal behavior. Anesthesiologists caring for these patients, either through the course of routine care or as an act of professional civil disobedience, will require legal, financial, and social support — support that (at this point) we cannot expect from the ASA.
All of this leaves aside the most important impact — that on our patients. Health disparities will worsen as the privileged continue to access high-quality reproductive care while those without means cannot or are forced to pursue unsafe care. Patients may be exposed to untrained or undertrained proceduralists, surgeons, and anesthesiologists and have already started to encounter delays in care related to fearful providers.
Conclusions
The failure of the ASA to proactively address serious threats to its membership and their patients represents a breach of duty. Without question, there must be room for non-violent good faith political disagreement in any healthy democracy. Sometimes, the side you disagree with will win the day. However, failure to acknowledge the downstream healthcare consequences of political outcomes puts into peril our credibility as healthcare providers. We must never be gagged when it comes to assuring the spread of true, high-quality, just-in-time information that our patients deserve and need.
Just as politics should stop at the water’s edge, it must stop at the clinic door. No one wins, if, due to partisan differences in our community, we as physicians do not vigorously advocate to preserve our ability to have frank and difficult conversations with our patients. It is our obligation to care for our patients, and more than ever before, this obligation comes with a need for advocacy from the key organizations of our specialty. They can and must do better. We call specifically on those who currently lead these organizations to act with firmness and alacrity. Physicians value the freedom to practice high-quality medicine and independence in the patient-physician relationship. The imprimatur of board certification must continue to have meaning. Politically expeditious caution serves none of these goals. Just as the fictionalized George Washington told Alexander Hamilton, these leaders should certainly know by now that “history has its eyes on you”. And if you don’t know, now you know.
Postscript
Though all received feedback on the foregoing piece was generally positive, the following outlets declined to publish it: British Journal of Anesthesia, Anesthesia and Analgesia, and Academic Medicine. KevinMD declined entirely due to length and author constraints. We have therefore opted to publish this version on the open web. It is our hope that you will find it informative and, more importantly, that you will participate in this call to action within the anesthesiology community. Every voice counts.
Authors: (The opinions presented in this work are the opinions of the authors alone.)
Vikas N. O’Reilly-Shah, MD, PhD 1
Sara Nikravan, MD 1
Nicole M. King, MD 2
Ana Crawford, MD 3
Harriet W. Hopf, MD 4
Christine A. Doyle, MD 5
1 Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine
2 Volunteer Assistant Professor, Department of Anesthesiology, University of Cincinnati
3 Stanford University, Associate Professor Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine
4 Departments of Anesthesiology and Biomedical Engineering, University of Utah, Salt Lake City, UT
5 Vituity Anesthesia, O’Connor Hospital, San Jose, California
Disclosure of funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest: All authors declare: no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work. VOS serves as Vice Chair for an ASA Committee and as an examiner for the ABA. CAD serves as a Chair and a Vice Chair for two ASA Committees.
Author contributions: All authors meet ICMJE criteria for authorship.
References
1. SCOTUS. 19–1392 Dobbs v. Jackson Women’s Health Organization (06/24/2022).; 2022:213.