Medical Associations as Social Partners in Support of Democracy

The silence of American medical associations in the wake of the attempted coup on January 6, 2021, is deafening. In the week after the attempt, professional associations, business groups, and individual corporations of all types have not only denounced the actions of the armed white-supremacist insurrectionists who stormed the U.S. Capitol, but also demanded the removal from office of President Trump, and withdrawn campaign funding from Republican officeholders who failed to uphold the results of the legitimate November 2020 election. A failure of major organizations representing physicians to speak out at this critical moment for our nation’s democracy will be interpreted as acquiescence with white supremacy. It also suggests a deep misunderstanding on the part of their leadership of the important, positive role these organizations, as social partners, can play in political life.

It is likely that few Americans have heard the term “social partners” used to refer to business organizations, labor unions, and other professional associations—at best, we tend to think of them as advocacy organizations, and at worst, as nefarious special interest groups whose activities can undermine the collective good. But in Europe, civil-society organizations representing labor, management, and the professions have been called on since the time of the Industrial Revolution to help resolve social conflicts, and even since the Second World War, social partners in Europe have acted when needed to defend democracy. For example, the Spanish organization of business groups sided with the king in 1981 to thwart a right-wing coup attempt, and more recently, German business associations have mobilized against the rise of the populist right in that country (1).

This is especially important when democratic institutions are weak or do not enjoy a great deal of legitimacy—as has become so evidently the case in the United States in recent years. Elections are rare and provide only episodic moments when the public can express their preferences about policy. But when the social partners are big and broad enough to represent large swathes of the electorate, social partnership can provide an effective, ongoing conduit for the expression of the public’s interests.

It may come as a surprise that some of America’s most staunchly Republican-leaning associations, such as the National Association of Manufacturers, the Business Roundtable, and the U.S. Chamber of Commerce were among the first to decry Republican lawmakers’ involvement in the attempted coup (2, 3). Yet there is good reason for professional associations like these to take a stand when democracy is at stake. Business and professional organizations benefit from protecting democracy, not only because most members believe that democracy is normatively good, but also because they benefit: democracy is the system that best protects the freedoms on which associations and their members rely (4). Without the right to assemble or to express political and policy preferences without fear of retribution, associations could not function. And without democracy, there is no meaning to the most fundamental concern of many members, the right to practice their profession or run their business free of arbitrary government interference. For all of these reasons, social partners, including medical associations, have an interest in acting to protect democracy.

Individual associations may represent the particular interests of their members rather than the whole of medicine (e.g., the American College of Physicians represents only internists, the American Medical Association is dominated by specialist groups [5], and associations of physicians do not represent nurses, insurers, or hospitals). But taken together, healthcare associations represent a sector that accounts for almost 20% of the U.S. gross domestic product and 12% of U.S. employment (6, 7). A number of key players in this sector have already taken important public stands in support of democracy. For example, both the Pharmaceutical Research and Manufacturers of America, the association representing drug manufacturers, and the Blue Cross Blue Shield Association of insurers announced that they would cease donating to lawmakers who voted not to certify the results of the election (8, 9). Associations representing physicians should do the same.

Although some physicians have recently embraced their role as authoritative experts on critical health issues affecting our democracy (e.g., gun violence [10]), many physicians understandably hesitate to engage in or support activities that they fear will alienate some patients or politicize the profession. But the truth is that any physician who belongs to a professional association is already engaged, albeit one step removed, in politics. Medical associations have a long history of political engagement that has included making statements, bankrolling public-relations campaigns, lobbying, and making campaign contributions. The American Medical Association’s decades-long fight against “socialized medicine” beginning in the New Deal era is the best-known example (11), but physician lobbying and campaign contributions aimed at affecting regulation of the practice of medicine is widespread (12, 13). Most recently, medical associations have endorsed restrictions on gun sales (14) and Medicare for All (15, 16). It is time for medical associations to exercise their significant political clout on behalf of an issue that is essential both for physicians, as citizens, and membership associations, as social partners: a well-functioning democracy.

What can medical associations do to promote democracy in this critical moment? Political science research has shown that undermining the rule of law and attacks on the legitimacy of elections by the losing party, if left unanswered, can undermine the norms that uphold democracy and lead to authoritarian takeover (17). President Trump and numerous Republican elected officials have rejected the validity of a legitimate election and threatened the peaceful transfer of power, pressured state legislators and officials to overturn the results of freely conducted elections, endorsed the actions of white supremacists, and incited a violent attack on the nation’s Capitol that resulted in five deaths. Insurrectionists have issued death threats against governors and members of Congress and continue to threaten violence in state capitals even as the National Guard has made targets in the national capital less accessible. All of these actions endanger our democracy. But activated social partners can push back.

Medical associations can begin by issuing immediate statements, as many other social partners have already done, that make clear who they will hold responsible for breaches with democracy. President Trump and those elected leaders who supported or defended his actions calling into question the legitimacy of the election should be named and censured to signal clearly to potential future insurrectionist leaders—including those currently inciting violence in state capitals—the consequences of their actions.

In the American political system, campaign donations talk. Not-for-profit organizations are prohibited from making campaign contributions directly to individual lawmakers, but many have political action committees. Medical associations should make clear that their political action committees will not support the reelection campaigns of lawmakers who voted against certifying the election or who support any other actions against the Constitutional basis of the Republic in the coming days and weeks. Associations can also educate their members about the campaign contribution–related actions taken by organizations in the health sector, like the Pharmaceutical Research and Manufacturers of America and the Blue Cross Blue Shield Association, and about the importance of personally supporting lawmakers who defend democracy.

Finally, medical-association staff should act in social partnership by working behind the scenes with legislators with whom they already have relationships to support democracy. As part of their lobbying efforts, medical associations have cultivated close relationships with many lawmakers. These personal relationships are an important conduit for information, and association staff should convey how serious they are about the need to take any actions that are necessary to defend democracy.

In short, associations representing physicians should exercise their role as social partners by demanding the immediate removal of the President and any elected officials who supported the insurrection and by withdrawing financial backing from any lawmakers who do not act strongly in the interests of democracy in the coming days and weeks. In the medium term, medical associations can also support democracy by pressuring lawmakers to ensure justice and accountability even after the immediate threat of violence has passed. In this vein, scholars of “transitional justice,” the branch of political science devoted to understanding how societies move on in the aftermath of assaults on civic life, have highlighted the urgent need to end voter-suppression efforts (18) and to establish a national “truth and reconciliation” commission on racial injustice similar to the 1980s-era commission on Japanese internment (19).

In the long term, speaking up in this moment when democracy is under attack will only strengthen physician organizations. Social partners need democracy as much as democracy needs social partners.