Obligations to share knowledge

Strous and Karni1 recently argued that physicians have duties to share medical knowledge not only with their patients, but also in the service of population and community health outreach. While Strous and Karni defend a version of medical paternalism warranted by this obligation, they also call for creativity on the part of healthcare providers to reach insular communities in order to share medical knowledge in culturally sensitive ways. They ground their view in the revised language of the Physician’s Pledge from the World Medical Association Declaration of Geneva that states ‘I WILL SHARE my medical knowledge for the benefit of the patient and the advancement of healthcare.’2 As an interpretive matter, it is not clear that the physician’s pledge implies what Strous and Karni attribute to it. As a normative matter, it is even less clear that the lessons of COVID-19 suggest it ought to.

Strous and Karni understand the commitment to share medical knowledge for the advancement of healthcare as obligating physicians to ‘leave the confines of the clinical treatment room and share medical knowledge with the public.’ However, the advancement of healthcare through knowledge sharing takes many forms. Physicians advance healthcare by sharing knowledge through research, clinical innovation or advocacy efforts to improve healthcare funding, policy, and practice. None of these modes of advancing healthcare through knowledge sharing involves community outreach, which is one possible, but not obligatory, way to advance healthcare.

Rejecting the interpretation of the Geneva Declaration by Strous and Karni does not defeat the possibility of a duty to share medical knowledge publicly, but leaves open the question: should individual physicians be required to share medical knowledge with a general public, or specific communities, beyond their patients? Doing so might appear to be an incontrovertible good, by democratising knowledge and supporting more equitable access to medical information. But the example of the COVID-19 pandemic motivating the analysis from Strous and Karni raises complex questions regarding what knowledge, whose expertise and which experiences ought to be amplified through public-facing outreach.

Shared and collective responsibility

The philosophical literature distinguishes between collective and shared responsibility. Collective responsibility is the responsibility to act as or by a group and does not require that all or any individual members of the group are individually responsible. A shared responsibility framework, on the other hand, attributes responsibility to individuals by virtue of their participation in a group. Shared responsibility demands that each individual member of the group is in some way accountable for the group’s actions, though accountability need not be distributed equally.3 Strous and Karni vacillate between attributing collective and shared responsibility for sharing medical information.

On the one hand, this shows how the relationship between individual, shared and collective responsibility cannot be neatly untangled. On the other hand, distinguishing between collective and shared responsibility, though rife with thorny questions about the metaphysics of groups, and the relationship between individual and collective action,4–6 helps delineate sources of authority and accountability. Whether individual physicians have either shared or collective responsibility for information dissemination changes whether physicians speak as, for, or with their profession when conducting public outreach.

Given the stakes of a pandemic, Strous and Karni suggest that ‘the ethical argument would dictate that even though the responsibility of the physician in clinical medicine is limited to… the patient lying in the treatment bed, from a public health perspective the physician needs to reach out beyond the patient bed’ as part of ‘the ethical obligation of the physician to promote good healthcare.’ Moreover ‘[a]ttention to the population also reflects the ethics of social justice’ that ‘demand[s]… healthcare providers share health information’ to address health disparities. They defend shared responsibility on the part of individual physicians in their role as members of the group ‘physicians’.

Yet they also assert the collective responsibility that ‘the entire healthcare profession is responsible for sharing knowledge of the public health threat and subsequent safety requirements including social distancing, hand cleansing, mask wearing and more.’ An obligation on the part of the healthcare profession does not entail each individual physician being responsible for sharing such knowledge. The medical profession’s collective responsibility would be to acquire, then disseminate, accurate information regarding COVID-19 transmission and prevention.

The nature of information

For both practical and social justice reasons, public health information should be widely available, in ways readily understandable by non-experts, and through formats that ensure the broadest outreach possible to diverse populations. Strous and Karni suggest not only eroding the distinction between patient-specific and public health roles for individual physicians regarding public health outreach, they argue that ‘measured medical paternalism’ is necessary for both public health and social justice because ‘if individuals fully understood the hazardous consequences of disregarding pandemic measures, they would behave differently.’

The premise that but for access to the right information people would take appropriate precautions oversimplifies both the nature of information shared, and how people integrate information into their behaviours. Presumably physicians have access to information about pandemic precautions and their scientific justifications. Yet physicians and non-physicians alike form their personal and professional views based on particular facts that they interpret through their experiences, personal or political convictions, and cultural or religious priorities.

For example, a family physician invited his extended family for a holiday meal despite Centers for Disease Control and Prevention guidance against gatherings among multiple households7 because ‘he thinks he and his family already had [COVID] and it wasn’t a big deal.’8 Presumably Strous and Karni do not imagine this physician, whose views are biased by his personal experience of COVID, when imagining individual physician obligations to share information with their patients, and with the public. But how does he fit with their claims?

Two physicians running urgent care facilities in California publicly shared information about COVID-19 testing at their own facilities, suggesting that policies regarding social distancing, shelter at home orders and some business restrictions were unwarranted. Their conclusions were quickly rejected by epidemiologists and public health professionals yet amplified by news and social media.9 In this case, these physicians spoke out based on their own medical experiences with COVID-19, but their knowledge was incomplete, and possibly shaped by other values or perspectives. These examples complicate the argument that individual physicians are required to speak out about public health, especially if the topic falls outside their areas of expertise. Such outreach potentially runs counter to public health or social justice aims.

Speaking as, for, or with the medical community

The risk when individual physicians speak for themselves as physicians but not with the medical community, is that they could be seen as speaking both with and for a medical community: their individual contribution is incorrectly viewed as collective action. Individual physicians moving beyond their exam room to advocate publicly for widely accepted scientific fact adopted by their professional organisations, and individual physicians using their standing as a medical authority to advocate for their own view (which may be influenced by limited data or political, religious or social commitments) are not equivalent.

Ethical medical care benefits from deliberation, and at times revision, of norms and practices,10 as well as from recognition that both patients and physicians have multiple intersecting values and commitments. Just as patients in a plural society have diverse values and preferences motivating their medical choices, diverse values and preferences of physicians inform their medical practice. Such complexities, however, go unaddressed by Strous and Karni, who seem to imagine physicians as a homogeneous group that uniformly accept and endorse all medical guidance, at least as it pertains to COVID-19. The examples provided here suggest otherwise. Where does this leave any individual requirement on the part of physicians to public outreach during a pandemic?

Collective conclusion

There is a collective responsibility on the part of the healthcare profession to promote and share medical knowledge, for reasons of both health and equity as Strous and Karni suggest. But collective responsibility, for both better and worse, does not entail individual responsibility on the part of each agent comprising the collective. A productive shared responsibility for individual physicians related to this collective responsibility might be better captured by cultivation of medical humility rather than medical paternalism: recognising when one is not expert, deferring to the guidance and standards of professional organisations, and not exploiting medical authority as license (let alone obligation) to share biased or limited information.

Doing so brings the physician into a shared practice, alongside diverse communities, some of which may resist medical knowledge and outreach, that recognises how different experiences and perspectives influence not only knowledge, but also the values and processes for evaluating knowledge. To share something—whether responsibility, knowledge, decisions or blame—is to work against domination and paternalism, in the spirit of collaboration, mutual exchange, and, ideally, collective health.