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Ethics Talk: Why Should We Think of Loneliness in Terms of Democracy?

Learning Objectives
1. Identify key ethical values or principles at stake, as described in the program
2. Distinguish among factors of ethical, clinical, legal, social, and cultural significance
3. Articulate how central themes of clinical and ethical relevance in the program can influence health care practice
4. Explain at least one way in which micro-level clinical ethics questions intersect with broader macro-level policy questions in health care
0.5 Credit CME

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The AMA Journal of Ethics exists to help medical students, physicians and all health care professionals navigate ethical decisions in service to patients and society. The journal publishes cases and expert commentary, medical education articles, policy discussions, peer-reviewed articles for journal-based, video CME, audio CME, visuals, and more. Learn more

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Audio Transcript

[00:00:05] Tim Hoff, MA: Welcome to Ethics Talk, the American Medical Association Journal of Ethics podcast on ethics in health and health care. I'm your host, Tim Hoff.

Labeling something a public health issue seems common these days: COVID, gun violence, mismanaged miscarriages, and now with the most recent US Surgeon General's Advisory, loneliness. Why do we talk this way about some health threats, but not others? One reason we might use this language of something being a public health threat is to call attention to social, cultural, historical, economic, and political determinants of health risks. Another reason we might use this language is to warn of how those threats can undermine how we participate together in democracy.

Calling something a public health threat is to formally acknowledge how deeply entrenched risk can be in long-trodden paths we've forged together toward our present-day health problems. The problems we call public health threats demand our attention as socially situated and as culturally complex, so we might more fully and accurately appreciate how mitigating such threats could take as long as we've taken to nourish and grow them in the first place. Public health threats demand that we think broadly at the macro level and not just the micro level about our need for healing far beyond what even the best clinician could possibly achieve with an individual patient during a single clinical encounter. In short, public health threats present clinically, but they can't be resolved clinically, or at least not only clinically. We also talk about some health risks as public health threats to express how such risks undermine us all. That is, public health threats undermine us not just as individuals, but as collectives, both politically and civically.

[00:02:00] Loneliness in particular erodes our capacity for civic engagement. And this podcast looks to help us orient ourselves to loneliness not just as a problem exacerbated by individual actions, but to look deliberately at how loneliness produces and is simultaneously produced by broader social, cultural, historical, economic, and political contexts. Joining me on this episode to discuss loneliness as a threat not only to public health but to our democracy, and the micro- and macro-level interventions available to help address it, is the Surgeon General of the United States, Vice Admiral Vivek Murthy. Dr Murthy, thank you so much for being on the podcast today. [music fades]

[00:02:42] Vice Admiral Vivek Murthy, MD, MBA: Well, thanks so much, Tim. I'm looking forward to our conversation.

[00:02:45] Hoff: In your most recent Advisory, Our Epidemic of Loneliness and Isolation, which will be linked in the show notes for folks to take a look at, you put the threat of loneliness to our health in terms of other commonly understood dangers like smoking. The comparison that's drawn in that document is that loneliness is the health risk equivalent to smoking something like 15 cigarettes a day, which was just a shocking number when I first heard it. So, how does framing loneliness as a known health risk enable us both as citizens and as a nation to marshal resources for the good of US communities?

[00:03:21] Murthy: Well, Tim, one of the things that was really surprising to me when I first started digging into loneliness was just how extensive the impact of loneliness and social disconnection more broadly are on our health. And that means our health in three dimensions: our mental health, our physical health, but also the health of society. And I think when we think about issues as a health risk, that helps us put it in context, raise it on the priority list, and more, it makes us more likely to also take action to address it. Here, I think I wanted people to understand that loneliness, according to what the best data tells us, is far more than a bad feeling, but that it is actually a phenomenon that has real consequences.

So, when we think about mental health, for example, we know people struggling with social disconnection are at increased risk for depression, anxiety, and suicide, but they're also at increased risk for physical illness, for heart disease, dementia, for premature death. If you look at the societal impact, though, also, Tim, here it's also quite profound. We see that communities that are more connected to one another have lower violence rates. They are more resilient in the face of adversity like hurricanes and tornadoes. They tend to be more economically prosperous. And so, however you look at it, social connection is good for us as individuals and as communities.

[00:04:47] The challenge is that as modernity has evolved, as new technology has come into our lives, as the nature of our interactions have shifted, we have allowed social connection to fall by the wayside. Not because anyone stood up and said, “We no longer believe social connection is important.” But because it was never a clear, intentional priority for society the way I believe it should be, it's fallen to the wayside as other things have sort of come into our life, as our time, for example, has been taken over by work or by the time we spend on social media or in other venues. That time has often been taken away from our interactions with people around us, from the building of healthy relationships. And that's what we've got to get back to. And in the Advisory, what I'm calling for at the broadest level is for us to build people-centered lives and a people-centered society, recognizing that is key to our happiness, to our health, and to our fulfillment.

[00:05:48] Hoff: So, when your office publishes these reports and advisories identifying and labeling an issue as a public health threat, is the use of that kind of public health language an official act in itself that opens avenues of funding and frees up resources to address them, or is it simply useful rhetoric to help illuminate the nature and scope of the problem to the public?

[00:6:10] Murthy: Yeah. So, when we call out an issue as a critical public health issue, as the Surgeon General's office has done for generations, it unlocks three buckets or three areas of activity. One is at an individual level, it can encourage and empower people to start taking action in their own lives to, in this case, strengthen social connection. The second thing it can do is it can unlock and mobilize changes on a programmatic level. So, even since the Advisory came out, we have now heard from more and more foundations and schools and community organizations like YMCAs and others, which now want to accelerate their focus, and in some cases, build new focus areas on strengthening social connections. So, unlocking resources at a local level is a second critical thing that our advisories can do. The third, though, is on a policy level. So, we know that when it comes to social connection, government does have a role to play. It's not the only player here, and this problem's going to require individuals and communities to solve. But what government can do is fund research, lay out an actual national strategy for social connection, building on the framework for a national strategy that we issued in our advisory. Government can also convene and bring together stakeholders across the country to move forward on executing a strategic plan for the country.

[00:07:38] So, these are all areas and ways in which declaring an issue to be a public health issue and doing it from a credible perch like the Surgeon General's office can make a difference. And that's what we are really pushing for. We've already been working with legislators on legislation that they are contemplating, and now in one case, in the case of Senator Chris Murphy, have already put forward on how to address loneliness from a regulatory and policy perspective. So, this is good, it's promising, and it's…we've got to keep working, though, in this direction to make sure that the changes that we're calling for, the changes that are starting to happen now, are sustained.

[00:08:16] Hoff: I'm glad you brought up the role of the democratic process in helping to address these public health threats. So, one of the articles in this month's issue, On Health and Loneliness by Dr Amy Wendling—and there'll be a link to that in the show notes—examines key dimensions of loneliness that were first identified in part by the philosopher Hannah Arendt in her book, The Origins of Totalitarianism. Wendling notes that loneliness is a precondition for ideological shifts toward authoritarian tendencies of thinking and acting. Our ability to think and act freely can be compromised by loneliness, because social isolation can leave us vulnerable to seeking out a sense of belonging that can be dysfunctional, for example, see white nationalism or political isolationism.

When one is lonely and cannot organize their own self, as Arendt writes, “For the confirmation of my identity, I depend entirely on other people.” These kinds of authoritarian belonging rely on simplistic, emotion-laden messaging rather than the nuanced critical thinking required for democratic deliberation and pluralistic participation. When we're lonely, our need to belong is desperate, and we think less critically about the stakes for others, whether those are civil rights or economic freedoms, as long as we feel like we belong. With that connection between loneliness and belonging and nationalist authoritarian impulses roughly sketched out, can you expand on what you see as the broader consequences of loneliness to the fabric of our society and to our democracy?

[00:9:48] Murthy: Well, I think it's deeply connected to the health of society and democracy, social connection that is. Like, for a community to work and for a democracy in particular to work, people have to be invested in one another, they need to be connected to one another, and they need to feel like they belong. And if you don't have that, then you have a group of people who may occupy the same geographic space but who do not recognize how their destinies are intertwined and who aren't out there advocating for the greater good.

[00:10:23] They're increasingly advocating for smaller and smaller circles of interest. You also find that it's easier to turn people against one another when they are disconnected from each other, which makes us prey and vulnerable to foreign adversaries or other forces, even internally. They may be seeking to divide us for political or economic gain. And so, all of these threats become much more acute when a community is disconnected from one another.

By contrast, when you have communities that are tightly knit—which doesn't mean they all agree on the same things, but which means that they are invested in each other's outcomes, they care about one another, and they recognize that their shared values are greater and more important than the differences they may have on issue to issue—then you've got a community that's willing to stick together, to fight for the things that they believe in together, and to defend themselves against threats.

So, in the health context, just think about COVID-19 and think about how that was not a challenge for a day or for a week, but that became a multiyear challenge for us. When we think about the next pandemic that may come—and at some point in the future, there will be a pandemic. We don't know when, but in all likelihood, there will be something—the question is, are we prepared for the next one? And I would say on many levels, we are better prepared now than we were before in terms of our ability to develop vaccines, distribute vaccines, work on advancing therapeutics on a shorter timeline than we perhaps could've originally imagined. But the one area that I think we have to worry about has to do with social connection, because if we are fragmented, if we are not connected to one another, if we are breaking into smaller and smaller groups of people who are easily turned against one another, it is very hard for us to respond with the unity, with the speed, and cohesion that's required in the face of an acute threat. And so, that is, I believe, why social connection is a health priority. It's also a national security priority. And it's really critical for us to cultivate for the health of society and democracy.

[00:12:38] Hoff: So, in order to foster that unity that is so important to many functions of our nation, as you suggest, your Advisory points to a “connections in all policies approach” to prioritizing responses to loneliness at a national, state, local, and tribal level. These policies that are outlined in that document, for example, include paid leave to encourage family members to spend time with each other, and expanding affordable public transit to make social connection by travel easier. Could you share a few more examples with us about how the policies we forge to make our democracy work better often rely on the same policies that integrate the everyday operations of our lives and make it easier for us to connect and to be together?

[00:13:20] Murthy: Well, absolutely. And this is an interesting area where it turns out public policy can often have an impact on our ability to connect with one another, even when we don't realize it. So, for example, you think about transportation policy. And when you cut up a community with highways and with other structures that seem like they create efficiency but actually make it harder for people to see one another, or they segregate communities, that can actually make it harder for people to build and sustain the kind of connections they need.

But we can actually use public policy across the board, not just in health, as a vehicle to advance social connection. You think about education policy. We now know that when kids feel more connected to one another, when they belong, it's better for kids in multiple ways. It's better for their mental health. It's better for their performance in school. And over time, when we invest in social and emotional learning curricula that give kids the skills and tools to build healthy relationships from young ages, that can help them for years and years after they're out of school. And so, education policy, if it understands the power and importance of social connection, can help support this kind of social and emotional learning and education, which is critical for kids' overall well-being.

[00:14:42] Similarly you think about technology as well. We may think about technology purely from a commerce perspective, typically, but we now know that technology has a powerful role that it plays in our social health. And we see that, for example, with social media in particular, where while there are some benefits of social media for some people, we've had many people, especially young people, who've experienced harms from social media, who have been bullied online relentlessly, or who have been subject to harmful content, or who, because of the nature of the social media platform itself, we have many adolescents who have been sucked into an environment of hyper-comparison where they're constantly comparing themselves to other people, feeling worse about themselves, and that's taking a toll on their self-esteem and ironically, on their ability then to connect deeply with other people. But if we take that into account and say we should understand what the perhaps unintended consequences of some of our technologies may be on social connection, then that helps us take into account the pros and cons and then mitigate those risks.

And so, however you look at it, it turns out policies across the board, whether it's in education, in commerce, whether it's policies related to labor, as well as, of course, health policies, they can have an impact on our ability to connect with one another. And so, part of what we call for in the Advisory is for that connection, all-policies approach so that we recognize the impact of policies on connection and work to optimize policies so they promote and enable us to strengthen our connections with one another.

[00:16:20] Hoff: Determining the success of these policy interventions is obviously going to be important, and the Advisory also suggests that part of mobilizing the US health sector to respond to loneliness requires expanding public health surveillance. So, how should measures that help us assess whether and when our loneliness interventions have succeeded be different for clinical purposes than those used to assess success for public health purposes?

[16:45] Murthy: Well… I think there's both a clinical and public health dimension to loneliness, which is why I think it's important for both clinicians and public health professionals to be involved in both the execution and evaluation of social-connection programs. I think on an individual level, what you find is that when patients actually have more social connection in their lives, it can make it easier for them to care for their own health and well-being, for their other, the other illnesses that they may be contending with, and it can also independently have a positive impact on their health and well-being. And one of the things that we have to think about, and one of things we call for in the Advisory, is for the health care sector to have a more active role in strengthening social connection.

What that does not mean is we add five or ten more things for primary care doctors to do, because in my opinion, primary care doctors are already overworked, overburdened, and we ask a lot more of them than I think is really fair or feasible. But I do think that what we can do is find ways to make it easier in the clinical setting to detect loneliness. And we can do that through intake surveys. We can do that through conversations we have when patients are encountering their clinical providers. But the key to addressing loneliness has to do with how we strengthen partnerships between health care organizations and community organizations that do play a role in bringing people together.

So, there are a growing number of community programs that provide community members an opportunity to come together and to get to know one another. These are programs that we think and are encouraging communities to accelerate and expand and advance.

[00:18:25] But in places like the UK, where they've built a social prescribing program, they built the kinds of partnerships where if a clinician identifies a patient of theirs is struggling with loneliness, they can then refer them to one of these community programs, which will then help them strengthen their sense of connection and belonging, introduce them to others in an environment that's conducive to the building of healthy relationships. Those are the kinds of partnerships clinically that we need.

But from a public health perspective, we also have to recognize that tracking the broader prevalence of loneliness, as well as at a population level, the impact of broader interventions, whether that's, again, community-based organizations putting forward programs or whether that's governmental programs that are coming forward, that kind of evaluation is really critical so that we manage our resources appropriately and deploy them strategically. And so, just like we train public health professionals in how to evaluate the impact of public education programs and other interventions, this is an area where I think it's actually very important for us to measure the level of connection in a community, to track that over time, and to look at that as a really key metric of success because it ties to so many of the individual and community health outcomes that we care about.

[00:19:41] Hoff: And to wrap up, what do you think should be the key messages for health professions students and trainees who are in the early stages of learning the nature and scope of their obligations to public health and to our democracy?

[00:19:54] Murthy: I think just for anyone who's going into public health and the clinical professions who's listening to this, I just first want to say thank you, because we need more people who are talented, who are kind and compassionate, who have a desire to serve. We need more people like that in our clinical and public health professions, more so. We need that more so than ever. So, thank you for going into the field. I also want to say that when it comes to the people you care for, whether it's an individual patient or a community at large, just know that this issue is increasingly going to become important in the work that we do. It is certainly already important to the health and well-being of individuals and communities, but it's a place where we need innovation: innovation in how to track and how to support community-based programs, but particularly innovation in how to have a dialogue with the communities and the individuals we care for about the power and importance of social connection.

There's, unfortunately, still a lot of stigma that surrounds loneliness, and so many patients experience it. In fact, we know one in two adults in America report measurable levels of loneliness. Yet people don't talk about it because they are ashamed that somehow being lonely means that they're not likable or they're not lovable. And one of the greatest powers that you have as a health professional is to start a conversation with an individual or a community about loneliness and isolation. That can be a conversation that enables and empowers them to be open about how they're feeling, that helps them see that they aren't actually alone in their struggles. But this is a common struggle that we need to come together to address.

[00:21:29] And finally, I would just say that for all of us, including especially those who are going into the health field, we are all going to experience loneliness and isolation ourselves at some point, whether it's in training or after training. And we also should recognize that there's no shame in that experience. There's no shame in admitting to your struggles with loneliness. I'm somebody who's struggled with loneliness many times during my life, certainly many times as a child who was shy and introverted, but also at times as an adult, including when I was Surgeon General the first time during the Obama administration, for various reasons.

And so, this is a common experience. And the more we can reach out and support one another on these journeys, whether that's simply reaching out to a friend or a fellow student or a trainee, just to check in on them to see how they're doing, the more we can remind each other that while our struggles may be real, while our difficulties might be many, that we don't have to be alone in navigating them. We can help one another. We can do what we've done for thousands of years, which is to lean on one another in difficult times [theme music returns] and to look for one another during celebratory times as well, recognizing that we are better together and that we certainly go farther when we work with one another.

[00:22:49] Hoff: Dr Murthy, thank you so much for your time on the podcast today, and thank you for your service to all of us as individual citizens and as a collective nation.

Murthy: Thank you so much. I really appreciate you focusing on this subject. It's so important.

Hoff: That's all for this episode of Ethics Talk. Thanks to Dr Murthy for joining us, and thanks to the staff at the Office of the Surgeon General for helping to coordinate this podcast. To read the full November 2023 issue of the Journal for free, as well as find more podcasts, articles, and continuing education opportunities, visit our site, journalofethics.org. For all of our latest news and updates, follow us on Twitter @journalofethics. And we'll be back next month with an episode on Turfing and Belonging. Talk to you then.

Audio Information

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Enduring Material activity for a maximum of 0.50  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 0.50 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 0.50 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 0.50 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 0.50 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 0.50 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.


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