Physician advocacy is an action by a physician to promote those social, economic, educational, and political changes that ameliorate the suffering and threats to human health and well-being that he or she identifies through his or her professional work and expertise. According to the American Medical Association, physician advocacy is essential for addressing the social determinants of health. The intersection of medical ethics, legal constraints, and advocacy poses unique challenges for health care professionals. In this article, we will explore physician advocacy from a lens of the principles of medical ethics: beneficence, nonmaleficence, autonomy, and justice.
Key points
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Physician advocacy promotes changes to improve health outcomes and address social determinants of health.
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Advocacy is guided by beneficence, nonmaleficence, autonomy, and justice.
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The ruling affects reproductive health care access, challenging patient, and physician autonomy.
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Physicians can engage in advocacy at individual, local, state, national, and social media levels.
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Balancing advocacy with clinical duties while addressing systemic issues like racism and health care disparities.
| ACA | Affordable Care Act |
| ACOG | American Congress on Obstetrics and Gynecology |
| AI | artificial intelligence |
| AIM | Alliance for Innovation on Maternal Health |
| AMA | American Medical Association |
| MMRCs | Maternal Mortality Review Committees |
| PRH | Physicians for Reproductive Health |
| SFP | Society for Family Planning |
| SMFM | Society for Maternal-Fetal Medicine |
| WHPA | Women’s Health Protection Act |
Introduction
Physician advocacy is an action by a physician to promote those social, economic, educational, and political changes that ameliorate the suffering and threats to human health and well-being that he or she identifies through his or her professional work and expertise. According to the American Medical Association (AMA), physician advocacy is essential for addressing the social determinants of health and improving health care outcomes for diverse populations. In a 2022 statement, they updated their principles for physician employment in hospitals to include advocacy. They state “patient advocacy is a fundamental element of the patient-physician relationship that should not be altered by the health care system or setting in which physicians practice, or the methods by which they are compensated.” The intersection of medical ethics, legal constraints, and advocacy poses unique challenges for health care professionals. In this article, we will explore physician advocacy from a lens of the principles of medical ethics: beneficence, nonmaleficence, autonomy, and justice. (Refer to Table 1 for notable advocacy efforts, this will be referenced throughout the article.) However, advocacy itself is not without ethical considerations. Physicians must balance their professional responsibilities with their personal beliefs and the potential risks associated with advocacy work, such as professional repercussions or legal challenges. Examples of different forms of physician advocacy efforts are found in Fig. 1 . The Supreme Court’s decision in Dobbs v Jackson Women’s Health Organization has significantly impacted clinical care along these ethical principles for both patients and their physicians.
| Autonomy State Abortion Ballot Initiatives | In response to the Dobbs decision, states with significant abortion care restrictions and those with expanded access proposed state constitutional ballot initiatives that would make abortion care a constitutional right in the states proposed. The majority of these efforts have passed with >50% support by the citizens of the state |
| Beneficence ACA | The ACA requires insurance providers to cover all Food and Drug Administration-approved contraceptive methods without cost-sharing. The ACA’s provision for contraceptive coverage without cost-sharing has been a significant advancement in supporting beneficence in contraceptive care. This policy ensures that patients can access a range of contraceptive methods without financial barriers, promoting equitable access and enhancing patient well-being |
| Nonmaleficence Maternal Mortality Review Committees The Alliance for Innovation on Maternal Health (AIM) | The establishment of Maternal Mortality Review Committees (MMRCs) has been a key advocacy initiative aimed at reducing maternal mortality. These committees analyze maternal death cases to identify contributing factors and recommend improvements in care. Research indicates that MMRCs have been effective in providing valuable insights into the causes of maternal deaths and guiding policy and practice changes. The AIM program, a national initiative aimed at reducing maternal mortality, focuses on implementing evidence-based practices and improving care quality through collaborative efforts. The program has made significant strides in promoting best practices and improving outcomes by addressing common causes of maternal mortality |
| Justice Black Maternal Health Momnibus Act 2023 | Collection of 13 bills that would work to reduce health care disparities and the maternal mortality crisis in Black pregnant people across the country. It has been introduced in various forms since 2021 and never voted on |
Autonomy: abortion restriction and reproductive autonomy
Autonomy reflects the right of individuals to make informed decisions about their own lives and bodies. For patients, autonomy encompasses the ability to make choices about their health care based on their personal values, preferences, and circumstances. This principle is critical in reproductive health, where patients’ rights to make decisions about contraception, pregnancy, and abortion are deeply personal and impactful. For physicians, autonomy involves the freedom to make clinical decisions based on their professional judgment, medical evidence, and ethical standards. This professional autonomy allows physicians to advocate for and provide care that aligns with their ethical convictions and medical expertise. However, this autonomy can be constrained by legal and institutional policies, particularly in contexts where the law intersects with medical practice. Advocacy by physicians is a crucial component of navigating the ethical landscape shaped by the Dobbs decision , (see Table 1 for a description of efforts). Physicians may advocate for policy changes that support reproductive rights and strive to create a more equitable health care environment.
The Dobbs decision has led to a patchwork of state laws regulating or prohibiting abortion, resulting in significant variability in access to reproductive health care across the United States. This variability challenges patient autonomy by creating unequal access to abortion services, thereby limiting individuals’ ability to make autonomous decisions about their reproductive health. In states with restrictive abortion laws, patients may face significant barriers to accessing care, including longer travel distances, financial burdens, and the need for complex legal navigations. These barriers undermine the principle of autonomy by restricting individuals’ ability to exercise their right to make informed choices about their own bodies.
Physicians, particularly those in states with restrictive abortion laws, may find their professional autonomy constrained by legal requirements that limit their ability to provide care. This situation creates a conflict between their ethical obligations to provide comprehensive care and the legal constraints imposed upon them. Physicians may face moral distress when they are unable to offer services that they believe are in their patients’ best interests due to legal restrictions. This conflict raises important ethical questions about the extent to which physicians should be compelled to comply with laws that they believe undermine their professional integrity and the welfare of their patients.
Beneficence: patient-centered contraception
Beneficence mandates that health care providers act in the best interests of their patient. Beneficence involves acting in ways that promote the health and well-being of patients. It encompasses actions aimed at preventing harm, providing effective treatments, and enhancing patients’ quality of life. In medical ethics, beneficence is closely related to the principles of nonmaleficence (avoiding harm) and autonomy (respecting patients’ right to make informed decisions). In the context of physician advocacy and contraception, beneficence requires physicians to ensure that patients have access to a full range of contraceptive options, provide accurate information about these options, and support patients in making informed decisions that align with their health needs and personal preferences. See Table 1 for notable advocacy efforts. Physician advocacy efforts can influence public policy, improve access to contraceptive services, and promote comprehensive patient education. See Fig. 2 for examples of contraceptive advocacy.
On the other hand, political and social barriers can hinder these efforts thereby violating the principle of beneficence. For example, policy restrictions on contraceptive access such as reducing health care coverage for contraception can limit patients’ options and impact their ability to obtain the most appropriate contraceptive method for their needs. , Socioeconomic factors, geographic location, and lack of insurance coverage can create barriers to accessing contraceptives, which can disproportionately affect marginalized groups. A significant advocacy effort that improved contraceptive access was the Affordable Care Act’s contraceptive mandate. The provision for contraceptive coverage without cost-sharing has been a significant advancement in supporting beneficence in contraceptive care. This policy ensures that patients can access a range of contraceptive methods without financial barriers, promoting equitable access and enhancing patient well-being.
Balancing beneficence with respect for patient autonomy can be challenging, particularly when patients make choices that differ from the physician’s recommendations. Physicians must navigate this balance while ensuring that their advocacy efforts support patients’ rights to make their own decisions about reproductive health. Ethical dilemmas may arise when patients choose methods that the physician believes are less effective or appropriate, requiring careful consideration of both beneficence and autonomy.
Nonmaleficence: maternal mortality
Nonmaleficence, the ethical principle of “do no harm,” underscores the commitment of health care providers to avoid causing harm to patients. It is closely related to beneficence (the duty to do good) and is essential for ensuring that medical interventions and practices are safe and effective. In the context of maternal health, nonmaleficence involves both the avoidance of harm and the proactive measures needed to reduce risks and prevent adverse outcomes during pregnancy, which requires access to family planning care. Physician advocacy plays a crucial role in addressing maternal mortality by ensuring that effective interventions and policies are in place to protect the health and well-being of pregnant individuals by working to prevent deaths and complications associated with pregnancy. See Table 2 for examples of physician advocacy related to nonmaleficence in maternal health.
| Advocating for improved maternal health care access |
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| Promoting evidence-based guidelines and best practices |
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| Addressing health disparities and inequities |
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Justice: systematic racism in medicine
Justice in this context describes fairness in the allocation of health care resources, equitable treatment of patients, and the promotion of social and health equity. It requires that health care providers and systems address disparities and ensure that all individuals have equal access to care and opportunities for health. Systemic racism, the entrenched and institutionalized practices and policies that result in racial disparities and inequities, manifests in unequal access to health care, disparities in treatment outcomes, and biases in clinical decision-making. For example, studies have shown that racial and ethnic minority patients often receive lower quality care compared to their White counterparts, even when controlling for factors such as income and insurance status. In the context of systemic racism, justice demands a proactive approach to identifying and dismantling barriers that perpetuate racial inequities in health care. Examples of physician advocacy toward justice can be seen in Table 3 .
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