Responsibilities of Medical Professionals Amidst Geopolitical Conflict

Abstract

The ethical responsibilities of healthcare professionals amidst geopolitical conflict, particularly regarding their impact on patient care and healthcare delivery, present a significant challenge, especially during current strife. With the rise of national and international discord and debate, and the close relationship between war and healthcare, healthcare organizations are increasingly pressured to comment, which can reflect societal engagement, but also pose demands for maintaining professionalism. This article discusses the need for healthcare practitioners to navigate their roles in advocacy without compromising patient care, emphasizing the importance of self-reflection, adherence to ethical standards, and effective communication. We also address the implications of politicization within healthcare settings, offering strategies to uphold professional integrity and prioritize patient-centered care amidst the complexities of geopolitical tensions. While the premise of this paper was prompted by geopolitical conflict, the principles emphasized are broadly applicable to an array of controversial issues. By fostering a culture of inclusivity and respect, healthcare professionals can mitigate the risks associated with politicization and ensure a commitment to the fundamental principle of “do no harm.”

MEDICINE AND GEOPOLITICAL CONFLICT

Medical institutions and organizations face increasing pressure to release statements regarding significant national events¹ and geopolitical conflicts,² particularly those with public health concerns.^3–5 Similarly, some physicians feel compelled to use their platforms for advocacy/activism when they identify with specific health-related causes. This is potentially beneficial because the public respects healthcare organizations and physicians.^6–8 Regarding advocacy/activism concerning international conflicts, there is often controversy, and statements by organizations can easily be perceived as one-sided or underdeveloped. Silence or lack of statements might be interpreted as lack of concern⁹ and there are potential adverse spillover effects of conflicts into the workplace.^10,11

A prime example is the war following October 7th, where polarized positions have appeared in prominent medical journals unlike other recent conflicts.^12,13 Controversy has flared concerning statements made by universities, medical centers, and medical schools.¹⁴ Hate speech has emerged in academic medical centers; protests and public demonstrations have occurred outside facilities, and some physicians’ social media posts have resulted in termination or censure for expressing opinions on both sides of the conflict.^15–17 Tensions are running high.

Even prior to this eruption and the resulting stress, physician burnout in the U.S. was estimated to be over 40% and may be exacerbated during times of unrest.¹⁸ The impact of stress related to geopolitical conflict has not been quantified, although it seems likely that consistent emotional strain of current events adds to allostatic load.¹⁹ War-related news consumption can increase anxiety by at least 1.5-fold.²⁰ International political conflicts ignite strong emotions, deeply held convictions, and social fragmentation, causing some individuals to become embroiled in passionate debate.²¹

SPILLOVER OF CONFLICT INTO THE HEALTHCARE SPACE

Social media amplifies already strong stances on public issues and contributes to shaping opinions during conflicts.²² Considerable effects from geopolitical conflicts range from anger, feelings of isolation, fear, concern for those in the war zone, among others, and these have been experienced by physicians and medical students alike.¹⁴ During the current Middle East war, significantly increased incivility (demarcated by verbal hostility, dismissiveness, and condescension) has manifested as hostile or tense messages on medical listservs, which are ordinarily utilized for collegial discussions.²³ With the increase in incivility since October 2023, more than 140 Title VI Office of Civil Rights complaints related to the presence of hostile learning environments for students, some of which include medical campuses, exist.²⁴

The degree of politicization and polarization in healthcare from the current geopolitical conflict is a phenomenon that has been understudied. During the COVID-19 pandemic, a similar socio-political rift emerged.²⁵ Differing opinions about the cause, treatment, and prevention of infections and role of lockdowns, masking, and vaccination occupied media platforms.²⁶ Related manifestations for physicians were compassion fatigue, diminished empathy, greater frustration, increased resentment, and isolation.²⁷

POTENTIAL COMPROMISES TO CARE RELATED TO DISCORD/INCIVILITY

The Joint Commission recommendations outline the need for preventing workplace violence, defined as “an act or threat occurring at the workplace that can include: verbal, nonverbal, written, or physical aggression; threatening, intimidating, harassing, or humiliating words or actions; bullying; sabotage; sexual harassment; physical assaults; or other behaviors of concern involving staff, licensed practitioners, patients, or visitors.”²⁸ Significant levels of incivility are already problematic in healthcare and are well-documented in the nursing literature.^29,30 Few studies, however, have examined physician incivility,³¹ despite incivility occurring at higher rates in academic medicine.³² In a multicenter, prospective randomized trial, anesthesiology residents were assigned to a normal or “rude” environment. Following a simulated operating room crisis, those exposed to incivility had significantly lower performance on all metrics, including vigilance, diagnosis, communication, and patient management.³³ Discussing geopolitical conflicts, and the potential resultant incivility, may similarly serve as a risk to patient care (Fig. 1).

Figure 1.

Conflicts may impair clinician-patient and clinician-team interactions and may reduce quality of patient care. Cohesive healthcare teams promote positive outcomes for patient care. If a scenario emerges in which tension connected to conflicts seeps into healthcare workspaces, it may pose risks to patient care. Without thoughtful awareness, biases (implicit or overt), discord, and incivility among practitioners potentially impacting the patient-clinician dynamic may erode patient trust and promote untoward outcomes. Increased division, compassion fatigue, decreased empathy, and greater frustration can also contribute to reduced quality care. Polarized views and teams can potentially contribute to impaired decision-making, disrupt collegiality, and cause hostile environments that can erode clinician and patient success. The dashed lines represent the nuance of the correlation as a possibility, given that discussing difficult topics does not always breed incivility. Overall, thoughtful reflective discourse is encouraged, and clinicians should always be thinking about how their actions and interactions may be impacting patient care and collegiality.

It is aspirational for professionals to be able to discuss controversial contemporary issues in a dedicated forum utilizing respectful dialogue. At Dartmouth, appropriate discourse in the face of divergence has been effectively modeled.³⁴ This should be emulated to ensure that discussion alleviates rather than exacerbates tension and facilitates rather than harms collegiality in patient care. The Dreyfus model of development, promoted by the Accreditation Council for Graduate Medical Education (ACGME), offers a framework for this type of discourse. The model describes professional competencies and “expertise,” relevant to clinicians’ professional behavior.^35,36 “Expertise” encapsulates responsibility, dual-processing, reasoning, analytic thinking, understanding how to incorporate information from evolving situations, extrapolation, situational discrimination, and capacity to tolerate ambiguity, and recognizing nuance.^37,38 This model aids in developing the virtues necessary for discourse and has elements applicable to many areas of critical thinking as it requires self-awareness, self-reflection, and an understanding of limitations and competencies when evaluating and discussing complex information.

ETHICAL ADVOCACY

Public health advocacy constitutes actions designed to gain political commitment, policy support, social acceptance, and systemic support for a particular health goal or program.³⁹ General advocacy involves strategic actions and communications to raise awareness, generate concern, and prompt policymakers to address issues or injustices.⁴⁰ Advocacy for policy changes that address health or access are commendable and critical.^41,42 There is, however, a distinction: advocacy involves working within an existing system to influence change (i.e., lobbying). Activism differs in approach, is more direct and confrontational, and aims to disrupt to enact change (i.e., protests or boycotts). Both are crucial to drive social progress but operate differently. Concerns arise when medical professionals participate or encourage engagement in agitational activism, which involves provocation or disruption.⁴³ These actions may draw attention to issues that might be overlooked but can be polarizing or extreme. The confrontational and divisive nature of agitational activism (due to garnering strong emotional responses and possible public unrest) can alienate individuals and groups who could otherwise be allies in pursuit of meaningful change.^44,45

Alleviation rather than agitation should be encouraged. Misinformed rhetoric that foments hate and xenophobia decreases the possibility of peaceful resolutions. Healthcare practitioners are uniquely positioned to help people feel safe, especially in the context of advocacy and activism. Agitational activism is likely not the most ethical or effective form of advocacy, as it may lead to unintended suffering or violence, which is in direct contradistinction to the oath: “do no harm.”⁴⁶

MODELS OF BENEVOLENCE

Physicians are looked upon as authority figures and paradigms of benevolence.⁴⁷ Solomon Asch, a social psychologist, found that most individuals shift their opinions to ones that are clearly wrong when influenced by others with strong conviction, even in the absence of a power differential.⁴⁸ In the 1960s, Stanley Milgram sought to understand how many Nazis committed Holocaust atrocities. Participants were asked to administer what they believed were increasingly painful electric shocks to another person. Those most willing to follow orders were directed by an authority figure wearing a doctor’s coat.⁴⁹

Asch and Milgram’s work underscores how easily opinions may be shaped and encourages physicians to reflect on the impact their opinions and behaviors have on others, especially patients. Just as participants in Milgram’s study obeyed the medical authority figures’ commands, individuals may be inclined to conform to other harmful directives and recommendations. Therefore, it is imperative for healthcare professionals to be thoughtful in their stances or statements, particularly on political matters in publications or on social media.⁵⁰

SELF-REFLECTION FOR THE SAKE OF PATIENT CARE

Physicians influence the physical, emotional, and spiritual well-being of patients. However, implicit biases and blind spots are consistent with human nature, ubiquitous, and can interfere with clinicians’ duties. Self-reflection is thus critically important.^51,52 Education about personal and societal implicit biases can aid in overcoming unconscious attitudes that lead to negative outcomes, and a commitment to this standard should be fundamental in medical care.⁵³ While there are different concepts that fall under the mantle of advocacy (social media posts or direct conversations), inadvertent messages are always being sent through actions we take, consciously or unconsciously.

Questions to ask when considering engaging in advocacy/activism:

• What messages are we communicating to patients by engaging in advocacy/activism?

• What biases emerge (consciously or otherwise) at bedside or during patient encounters?

• How might patients and colleagues react to practitioners heavily involved in public advocacy/activism?

• Might patients and colleagues perceive that their practitioners do not have enough space or are not emotionally available to be open to their perspective/experience?

Inadvertently, if engaged in agitational activism, practitioners may convey passion and dedication but also may not be acknowledging other patients’ experiences, which could undermine patient care. Fried and colleagues have noted, “when equipped with the right tools, physicians can be… effective at informing, shaping, and driving public debates about the systems and policies that cause patients’ health to flourish or fail.”⁵⁴ This includes responsibilities in clinician awareness and conduct during times of unrest (i.e., geopolitical or civil).

THOUGHTFUL INTERACTIONS DURING HEIGHTENED CONFLICT

Expressing political opinions or recommendations on non-medical topics may be admirable and also, at times, risks doing patients, colleagues, and students a disservice when they detract and distract from clinical work, learning, and collaboration.⁵⁵ Moreover, inserting non-health-related agendas during patient encounters is antithetical to care, compromises the therapeutic-alliance, and can undermine overall well-being, impede interest in follow-up, and thwart engagement in care. Incidents of undermining trust in the physician–patient relationship by unprompted sharing of personal viewpoints on charged topics, for example, have been anecdotally reported and highlight the importance of setting boundaries to prevent imposing personal beliefs on patients and colleagues.⁵⁶ In certain instances, state laws prohibit practitioners from discussing particular subjects with patients, such as owning a firearm.⁵⁷

In surveys, patients felt that physicians’ attire influenced their interaction with and perception of the clinician.⁸ Therefore, healthcare professionals should also carefully consider the impact of wearing symbols (i.e., flags or political slogans), especially during heightened geopolitical tensions. Physicians should behave in accordance with The Joint Commission guidelines around creating safe spaces for patients and employees. This principle extends to students, trainees, and junior colleagues, who are acutely aware of the hierarchy and power differential with superiors.⁵⁸ Physicians should be cautious that personal ideologies do not pressure junior colleagues, do not hinder their educational experience, and in general, avoid abuse of power dynamics. Supervisors are encouraged to think about how to support causes meaningful to them without hindering education.

CONSIDERATIONS WHEN “WEIGHING IN”

Medical professionals must remain vigilant that inadvertent harm can arise from making brief, underdeveloped, uninformed, or emotionally charged public statements.⁵⁹ Expressing opinions without a meticulous and factual understanding of the historical, cultural, and political nuances of any conflict contributes to misinformation and further polarization.

When expressing political views publicly, it is necessary to balance personal freedom of expression with professionalism and awareness of public perception.²² Physicians should consider what and why they are sharing, beware of amplifying misinformation, and be respectful and tolerant. Critical omissions and fallacious content in editorials on geopolitical issues jeopardize truthful publishing in medical journals and health professionals’ understanding of such issues.^50,60,61

Generally, practitioners are trained to provide compassionate and empathetic care, but most are not experienced in political science and may lack expertise in nuanced complexities of world conflicts.^62,63 While intentions may be good, issuing statements on complicated political events can lead to unintended consequences. There have been recent increases in incidences of hate crimes and reports of individuals feeling unsafe in academia and the workplace.⁶⁴ ACGME guidelines should always be top of mind.³⁵

KEY STRATEGIES AND RECOMMENDATIONS

During geopolitical conflicts and the resulting politicization within healthcare, maintaining professional integrity and safe environments is crucial (Table 1). Adhering to these strategies, physicians can uphold their ethical commitments and ensure patient-centered care and professional integrity amidst complexities of the divisions that exist within the world.

Table 1.

Key Strategies and Recommendations

Key theme	Recommendation/action
Education and training	Emphasize education in medical ethics, cultural competence, and conflict resolution to navigate the challenges posed by geopolitical events with sensitivity and compassion. Incorporate specialized training into existing curriculum
Self-reflection and awareness	Physicians should engage in self-reflection to identify and mitigate personal biases that are both conscious and unconscious, ensuring that they do not influence patient care or professional interactions with special attention given to holding positions of authority
Clear communication and fostering dialogue	Develop skills to communicate effectively and set boundaries that prevent the imposition of personal beliefs on patients and colleagues, safeguarding relationships
Promoting inclusivity and respect	Foster an environment that respects all colleagues and implements policies that enhance a positive workplace culture and promotes optimal patient care
Support and resources	Access to resources and support systems is vital for managing the emotional toll of working in a polarized setting, preventing burnout, and moral distress
Ethical guidelines and oversight	Healthcare institutions should establish ethical guidelines aimed at addressing challenges of politicization, polarization, and divisiveness informed by consultations with a broad range of stakeholders to reflect a range of experiences
Adherence to factual reporting and objective discourse	Practitioners must commit to the dissemination of information and the expression of opinions grounded in verifiable facts and evidence-based conclusions. It is imperative to eschew the propagation of misinformation and to consciously avoid the use of rhetoric that may be perceived as biased or inflammatory. This involves commitment to objectivity, especially in the documentation and communication of information that could impact public perception and decision-making. The commitment to factual accuracy and the avoidance of sensationalism are essential in upholding the ethos of trust and credibility intrinsic to the healthcare profession

CONCLUSION

Clinicians are encouraged to strive for unity and inclusivity during trying times. We propose practitioners embody a spirit of collaboration despite potentially fragmenting emotions and ideological differences. By acknowledging limitations, engaging in reflection, identifying blind spots, promoting informed dialogue, and avoiding pitfalls, practitioners can contribute to a more caring and humane healthcare ecosystem and world. Professionals have an obligation to foster healthy, respectful dialogue, devoid of hate. Doing so can provide needed and valuable modeling when faced with fraught times.

Declarations:

Conflict of Interest:

The authors declare that they do not have a conflict of interest.