Nothing is perhaps more emblematic of the medical profession than a doctor's white coat. As medicine evolved from quackery to an applied science at the turn of the 20th century, physicians adopted the attire of the laboratory — knee-length coats — to shore up their credibility as true scientists. The pure, neutral white color conveyed a doctor's status as a dispassionate healer who was inspired solely by human suffering and unmoved by the surrounding political and social milieu.
The importance of the white coat is still an important part of the profession, as fledgling medical students are "coated" in official ceremonies prior to the start of their first class in school. Bestowing this article of clothing on aspiring healers symbolizes their membership in a new fraternity: The doctors, past and present, who have pledged fealty to medical science and its compassionate and unbiased practice.
Underneath the white coat, doctors are complex, multifaceted humans and citizens who harbor cultural beliefs, religious convictions and political ideologies.
But this lofty commitment to the Hippocratic Oath can be porous. Underneath the white coat, doctors are complex, multifaceted humans and citizens who harbor cultural beliefs, religious convictions and political ideologies. And increasingly, these ideas are squeezing past the solemn promises made to patients, especially when it comes to conflicts between medical care and religious freedom.
This all holds particular relevance after the recent midterm elections further laid bare the yawning chasm between America’s partisan camps. As George Packer of the New Yorker recently noted, “Our tribes are competing for power over the state, the media, public opinion, the verbal battleground. When politics becomes a perpetual tribal war, ends justify almost any means and individuals are absolved from the constraints of normal decency.”
Illness has no party affiliation. Medical care is something sought by individuals irrespective of the partisan trenches that they regularly occupy. And as such, hospitals remain one of the few places where the entire spectrum of society is regularly encountered and intimately engaged.
Yet increasingly, a government-sanctioned movement to ensure "religious liberty" is encouraging doctors to not only choose the kinds of treatments they want to provide but also to select which kinds of patients they want to treat. According to surgeon, writer and public health researcher Atul Gawande, this callous denial of a patient’s “common core of humanity” is a deeply troubling trend for the medical profession, which has always aspired to “sustain bedrock values that matter across all of society.”
An important study in PNAS, or Proceedings of the National Academy of Science, found that Democratic and Republican physicians “differed substantially” in their levels of expressed concern and recommended treatment strategies for politicized health issues, like abortion and gun safety. In other words, the partisan leanings of doctors are leading to “unwarranted variation in patient care,” the study authors said.
The political leanings of physicians tend to mirror broader American demographic divides: Republican doctors tend to be men, older and higher-paid specialists (surgery, anesthesiology and urology) while their Democratic counterparts are more likely to be women, younger and lower-paid specialists (infectious diseases, psychiatry and pediatrics). As citizens and people of conscience, they also donate to campaigns, run for political office and advocate on behalf of their patients.
To be clear, it's perfectly normal and expected that doctors would share differing political and cultural perspectives. But it becomes a problem if those differing perspectives start to negatively impact patients.
The PNAS study surveyed Democratic and Republican primary care physicians on a variety of clinical scenarios including apolitical topics (alcohol use, tobacco use, helmets, obesity and depression) and more politically salient issues (marijuana use, elective abortion, firearm storage and engagement with sex workers). It found, for example, that Republican doctors are more likely to encourage the cessation of marijuana use and emphasize its legal risks. They are also more likely to discuss the mental health aspects of abortion and discourage the procedures. Democratic providers are more likely to urge patients not to store firearms at home.
Study author and political scientist Eitan Hersh concluded that the “findings suggest you are going to get different care.” This raises the inescapable concern that some critical medical advice on issues like reproductive health or H.I.V. prevention will be dictated by a doctor’s political stripes and not by evidence-based medicine.
President Donald Trump's administration is arguably exacerbating the problem. This summer, the Department of Justice announced the creation of a new "Religious Liberty Task Force." The task force instructs federal agencies to allow individuals and organizations latitude when deciding whether or not to act if they believe their freedom of religious expression is encumbered. The task force has already augmented the Health and Human Services’ Conscience and Religious Freedom Division, further easing the path for doctors and nurses to refuse treatment for patients based on religious and cultural grounds.
These refusals, as cardiologist and writer Haider Warraich observed, “can span the entire spectrum of life, from issues related to contraception, abortion, and childbirth to care at the end of life.” They could also potentially worsen an already difficult situation for LGBT patients, who are already discriminated against at the bedside. Additionally, given Supreme Court Justice Brett Kavanaugh’s previous stances on cases related to religious liberty and health care, doctors may be further emboldened by Supreme Court rulings in the future.
Doctoring is often about making oneself comfortable with being uncomfortable. This means prioritizing the patient’s values and goals over our own.
As Larry T. Decker, the executive director of the Secular Coalition, an advocacy group for nontheists, told The Washington Post in January: “This move by the Trump administration does not protect conscience but instead weaponizes it, turning religious belief into yet another barrier between vulnerable patients and the health care they need.”
We cannot allow medicine to become another battleground for our rising partisan conflicts. Doctors did not graduate from medical school to become armed combatants in the country’s culture wars. But already, organizations like the Human Rights Campaign and the American Association of Pro-Life Obstetricians and Gynecologists are putting together lists of LGBT-friendly and pro-life providers, respectively, in order to try to safeguard against just such a scenario.
Doctoring is often about making oneself comfortable with being uncomfortable. This means prioritizing the patient’s values and goals over our own and maintaining mutual respect and tolerance despite not always agreeing with their choices. It is treating based on the latest evidence and expert consensus and not on personal conscience.
This was the spirit embodied by Jewish and non-Jewish doctors at Allegheny General Hospital, who treated the anti-Semite responsible for the unconscionable carnage that occurred at the Tree of Life synagogue in Pittsburgh. This was also the spirit embodied by the doctors and other healthcare professionals who signed an open letter to the NRA after being rebuked to “stay in their lane” and on the sidelines of the national gun conversation. “To be clear: We are not anti-gun. We are anti-bullet hole,” the letter stated.
In medicine, Atul Gawande reminds us, “you are asked to open yourselves to others’ lives and perspectives-to people as well as to circumstances you do not and perhaps will not understand.” This is why the hospital remains one of the last spaces in our society where biases are readily shed and curiosity and empathy can still unlock the common humanity of others. Renewing our commitment to patients amidst the national rancor could help restore hope in the fundamental principle upon which this country was founded: all men are created equal.