The surgeon general’s dismissal should alarm all doctors

When Dr. Vivek Murthy’s photo suddenly disappeared from the US surgeon general’s Twitter account, social media was abuzz with people speculating on which proverbial hill his career as surgeon general had ended. Doctors like me wondered which devoted guardian of the public’s health could next face the same fate.

The day after being fired, Murthy confirmed on Facebook that he had refused to abandon his commitment to “a healthier and more compassionate America.” Faced with a conflict between personal or career interest and the interests of his patient — the American population — he chose principle over paycheck, like a doctor should.

On Wednesday, seven US senators wrote to President Trump asking why Murthy was removed from his position before his term had expired “in light of (the) Administration’s pattern of politically motivated and ethically questionable personnel decisions.” Had it been his stance on gun control? Criminal drug policy? Affordable health care? Or was he dismissed for being the kind of fellow who joined forces with Elmo to debunk the anti-vaccination myths President Trump has given credence to?

The public needs to know why Murthy was asked to resign. Doctors do, too. We are often at the intersection of politics, ethics, and health and, when confronted by a conflict of interest, should act like Murthy.

He made the sort of sacrifice that defines our profession — the kind based on the unchanging “patients first” credo. But do doctors, without fail, put patients first?

Conflicts are everywhere in medicine, and sometimes the patients’ interest loses out. We know that the pharmaceutical industry uses seductive methods to influence what doctors prescribe. Few would argue about what’s right and wrong in that relationship. But wrong still happens.

Structural conflicts of interest in clinical medicine also introduce tension. For instance, most physicians are paid more to see patients with advanced disease than to help patients stay healthy, and invasive treatments pay better than watchful waiting. A difference between the patient’s knowledge and the doctor’s leaves room for supplier-induced-demand. On the other hand, if a physician is salaried rather than paid per service, there may be an incentive to provide less care. The point is, there are unavoidable conflicts between market variables and medical ones, so patients are left to trust their doctor’s commitment to optimizing their health, and conflicts of interest can arise.

Medical research has its share of conflict, which goes beyond industry funding of clinical trials. Civil societies depend on universities to be pillars of impartiality, but corporate sponsorship and special-interest funding play a role in what gets studied. So does the pressure on academic physicians to publish. Since novel findings are generally felt to be most publishable, repeating previous studies isn’t carried out as often as it should be. But repeating studies is essential to confirming what’s best for patients.

Then there are public health doctors like the surgeon general and his colleagues in the Centers for Disease Control and Prevention — the ones we trust to call the shots in pandemics or on matters of great public health importance. For them, conflicts of interest might be least recognized yet they can have extremely deleterious and far-reaching health effects. Their job is to ensure that the most vital health determinants — like social and physical environments, public policy, and health services — best promote and protect human health. No extraneous interest should supersede that one.

Like Murthy, most public health physicians work in organizations with few, if any, degrees of separation from their political masters, and these bosses very often have other interests, such as maintaining the support of their political base or appearing to have control over crises. Public health doctors who adopt positions different from their employers do so at their peril. In other words, while pharmaceutical companies use enticements to influence a clinician’s treatment of patients, governments influence a public health doctor’s treatment of the population with an implied threat: “Comply or goodbye.”

Some might characterize sacrificing an important job in the public service as naive idealism. You can’t positively influence public health “from the outside,” they might say. At least from the inside, with collaboration and a bit of compromise, you can make incremental change. The slow steps of the tortoise beat the long leaps of the hare, after all. It all sounds wise.

These platitudes will be common as long as Murthy’s bold example of standing on principle is rare. But if clinicians, researchers, and public health doctors alike — consistently, unapologetically, and with meticulous reasoning — put the interests of patients above all other interests, including their own, we could see real change. Industry may redirect efforts from marketing to innovation, research agendas may reflect the most important health needs, health system reform may finally address inequities, and patients with mental illness may be treated instead of incarcerated.

In the meantime, I hope that Murthy finds comfort in the possibility that his steadfastness will inspire something great in our profession. As Rosa Parks said, “Today’s mighty oak is yesterday’s nut that held its ground.”

Hakique Virani, MD, is a specialist physician in public health, preventive medicine, and addiction medicine and assistant clinical professor of medicine at the University of Alberta in Edmonton, Canada.