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Ethics Talk: Revitalizing Democracy During COVID-19 Pandemic and Beyond – Part 2

Learning Objective
Identify key ethical values or principles at stake, as described in the program
0.5 Credit CME

In this video edition of Ethics Talk, journal editor in chief, Dr Audiey Kao, talks with members of an American Academy of Arts and Sciences commission charged with developing recommendations aimed at restoring trust in our constitutional democracy.

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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

Video Transcript

Dr Audiey Kao: The COVID-19 pandemic has also limited traditional in-person voter registration activities. As a result, there've been reports that increasing numbers of doctors, nurses, and other health professionals have taken on the responsibility of registering patients to vote because they view that quote-unquote “civic health” or greater engagement by the electorate can be seen as an important determinant of the public's health. What are the barriers to making voter registration simpler and easier? And how does the recommendations from the commission support that?

Eric Liu: Well, it's such an important question right now. And I want to go to the premise of your question, because there are increasing numbers of health professionals and students and clinicians who are taking on this responsibility. I've recently been introduced to a great new venture that emerged out of Boston called VotER, which is activating ER providers and physicians to do exactly this work, using some assistive technology to make it super simple for folks sitting in an ER to, in fact, register. I mean, you may have a lot on your mind then, but it's also an acute moment to realize the system is going to be most responsive to you if you actually show up and vote.

And I think you also allude to a thing that Antonia described earlier, which is the social determinants of health and this idea of civic health, right? Civic health is bound up inextricably with physical health, and with mental health, for that matter, right?

Kao: Yeah.

Liu: And so, the barriers to making voter registration simpler, the barriers to access to the voting booth or to the ballot box are barriers not only to voting, they are barriers to health. And so, I think certainly, folks listening to this conversation today, I hope you see it as part of your professional responsibility to discharge ways to actually make it easier for your patients and those you care for and their families to participate. As you know, the laws that determine voter registration vary from state to state, and we know that it's a very simple equation. States that have more onerous requirements end up having lower voter turnout. And, of course, the pandemic has compounded that problem.

There are several things that we call for in the commission's report. One, in the first place, universal automatic voter registration. So, any time any citizen interacts with any agency of government, they should be able to have an opportunity to register to vote or to update their registration status. We also recommend same-day registration as a way to make it possible for people who, because they've moved or because, again, the pandemic has made it difficult for them to update things with a long lead time, to make that registration as not onerous as possible. And so, in the first place, I think it's really important for medical professionals to know what your own state's registration laws are, and if your state doesn't have automatic and same-day registration, to advocate for those. And in a great man bites dog way, having doctors advocate for reforms of the system will get the attention of legislators and get the attention of lawmakers in your state because it's not the usual suspects, right?

Kao: Right.

Liu: Doctors showing up and saying, hey, my patients need to be able to vote, is going to make people sit up and pay attention. And ensuring that your patients are able to have, to request absentee ballots if your state allows it so they can vote safely during this pandemic. I think there are ways as well where physicians and other medical professionals can literally serve as health care workers at polling centers right now. So, where there is still in-person voting, to be part of the provision of a sense of security, that doing so can be done safely, that doing so can be done in the presence, the white coat effect that can be brought to bear in a positive way in the process of voting and democracy, too.

And I would say as well, I mean, we have a pretty important recommendation at the heart of this commission, which is an expectation of universal voting by all citizens. In the same way that we have an expectation of universal jury duty, if called, you shall serve. And if you serve, you'll get some modest compensation for your time, but you will serve. That is an expectation that we believe is required in the United States. And in all these reforms that we propose here, again, it can't just be left to the quote-unquote “democracy professionals,” people, civic nerds like me who do this for a living, right? It's not enough. It's got to be people in the health professions who see and can connect the dots between civic health, mental health, physical health, and recognize all those determinants are interconnected and that voting is just one immediate pathway in to power, so that your patients have more power to actually improve the state of their bodies and their health and their minds, so that your own work as a health care professional gets easier over time.

Wallace Jefferson: I think it's important, just one comment on that, is one of the realistic barriers to expanded voting is that by suppressing the vote, a party gains a political advantage. And this can happen on both sides of the aisle, Republicans and Democrats. And I think it's important for medical professionals, but all citizens to say that is an invalid use of power, to suppress the vote. It used to be used to suppress votes of women. It used to be to suppress the votes of African Americans and other minorities. And I think we have developed over time to understanding that is improper. That's an invalid use. The whole core of our democracy is the people's access to the ballot in order to show what they believe is needed in our democracy. And I think the medical profession, lawyers, accountants, firefighters, everybody has a stake in promoting that access.

Kao: Yeah. No, I appreciate these last points that you just made, Jefferson, as well as the point that you just made, Mr. Liu, and the points that Ms. Hernández made about social determinants of health because I'm harkening back. Obviously, I never practiced at a time when it was routine for doctors to make house calls. Back in those days, doctors were immersed within the lives of their patients. They saw where they lived. They saw the whole person. And that involved just not their physical health, their physical and mental health, but those determinants, those barriers that limited their ability to exercise their rights and freedoms in this country. So, I appreciate those last points that you've all made.

So, during this pandemic, we are seeing misinformation easily and widely propagated through digital platforms and social networks to the point where public health guidance is disregarded and politicized by too many of us. Another one of the commission's recommendations calls for attacks on digital advertising that would support experimental approaches to public social media platforms as well as local and regional investigative journalism. Can you speak to the commission's thinking behind the relevance and importance of this quote-unquote “Twitter-induced” recommendation in your final report?

Antonia Hernández: Well, it, at its core, is a realization of the role of modern media and the decrease, unfortunately, of the traditional means of communications—the newspapers, public radio, public television—where one could trust the facts instead of fake news. Social media can be used for bad purposes: the influence, foreign influence, in our elections, partisan divide, but it can be used for good purposes. And we just have to acknowledge technology. But let me move you a little bit further into the issue of technology.

The pandemic is literally a transformational phase in our evolution. Virtually, we are connecting via Zoom. The majority, vast majority, of poor people, minorities, African Americans, don't have access to the digital, to technology, so that if we don't address the digital divide today, we are once again embedding the inequalities. Access to the Internet to be connected is not a privilege. Think about what's happening in medicine, telemedicine. I can communicate with my doctor through a text, through Zoom. I have private insurance. Most Latinos, African Americans, poor, farm workers don't have that access. So, when you talk about what's happening today, the digital divide, if we don't address the digital divide, think about the discussion and what you're seeing today in the front page of every newspaper and television. What is it? Virtual learning. How our kids, most of them in public school and poor, don't have access to the Internet. So, I think as we think about our form of government, where we think about our democracy, we have to think of evolving our democracy to be able to use the tools and mechanisms that technology brings in order us to have that communal place.

Liu: What Anthonia's describing here in all these different contexts—immigrant households, communities where the digital divide is painfully playing out—what we're talking about here is civic infrastructure: the spaces, the places, the tools, the technologies, the ways for us to be able to equally participate in self-government. And the reality of social media and digital platforms is that commercial digital platforms support themselves with payments from advertisers who track our movements, our searches, our conversations, right? And we believe as a commission that the proceeds of this targeted advertising that these companies engage in should be taxed at the state and federal level. And those proceeds should be used to fund experiments in civic infrastructure, whether it's closing the digital divide, whether it's about creating spaces and places, libraries, other zones and places where you can have that equality of access to the knowledge and information needed to participate in democracy and to support media itself that is in the public interest. And so, I just think that closing of that loop there is super important.

Kao: Yeah. Well, I appreciate your point about civic infrastructure, and I also appreciate Ms. Hernández's points.

Finally, as we conclude our conversation, I'd like to end kind of where we started and talk about trust. Because in medicine, trust is an essential element of a therapeutic patient-physician relationship. Without trust, patients are less likely to share personally sensitive information, they're less likely to adhere to treatment recommendations, and they're less likely to see their physicians as advocates for their best interests. And I know we've alluded to this vicious cycle already, but untrustworthiness begets more distrust. So, this vicious cycle can be quite difficult to break without effort and commitment. And the commission's recommendations are in many ways ultimately aimed at restoring public trust in government. So, what role—and you've already alluded to this at many points in our conversation—what additional points would you like to make?

Liu: Well, I think your question really lays out pretty powerfully the fragility and the miracle of a functioning democracy. We tend to take for granted, until times like the times we're living in, that democracy works only if enough of us believe democracy works. [chuckles] And once that belief begins to evaporate, not just on the margins, but at the core, you realize how evanescent that mutual faith is and that mutual agreement to bestow upon the system a sense of legitimacy, right? And so, in democracy in particular, trust both as among citizens and residents and participants in civic life and as between the people and those who we elect or those who we endow with authority, right? And this is where physicians, nurses, people in the medical profession really have a pivotal role to play. It's not only about feeding a sense of trust and being the voice that says, “Hey! Get empowered, learn more, understand, let me help you get registered, let me expose you to the broader system that you're part of.” But it's also, “Hey! Let me tell you about facts. Let me tell you about science. Let me actually ground you in what's happening here.”

In a sense, what I'm saying is people who are watching this conversation right now, you have an incredible writ and grant of authority and power, and you face a very simple choice when you recognize the scale and scope of that power. Are you going to hoard it, or are you going to circulate it? That's it. And your job, especially as physicians, but anybody in the health professions right now, your job has to be to be circulating it, and to circulate your authority and trust to help bring more people into the fold of participation, to share your knowledge with more people. Yes, you do that about health care matters and medical matters. But again, you have the authority to say, you know what? I work in a profession where you have to think in terms of systems, where you have to think epidemiologically, where you have to understand that things have multiple causes. I'm going to show others how to think that way, too, in my community, right?

And our work as a democracy, this is not just about the Commission on Democratic Practice of the American academy of Arts and Sciences, and it's not just about the AMA. Physicians have to be catalysts right now. I mentioned at Citizen University, we do work that is all about cultivating civic faith. And we have a program called Civic Saturdays, which are these gatherings that are essentially a civic analog to a faith gathering, right? And we've got another program called the Civic Seminary where we train people from all different walks of life to lead these gatherings, right? And these gatherings are not about indoctrination or blind faith. They're about coming together across lines of difference in a community to ask, how do we make this democracy worth believing in?

Well, I tell you about this because just last week, we finished our latest cohort of the Civic Seminary, and one of our fellows in this program is a physician. He's a physician educator at NYU. And so, he was talking about the responsibility he has in a radiating set of concentric circles: his own patients, the students he works with, the residents and fellows he works with, his colleagues who are nurses, nurse practitioners, med techs, the whole ecosystem, right?

Kao: Yeah.

Liu: And he was beginning to understand that he couldn't just do what, frankly, many professionals—doctors included, but I'm trained as a lawyer—any professional gets trained to do, which is to hone in on narrow and limit your kind of septic focus just to this particular thing, right? And he realized he had to take off those blinders and begin to model for everyone else what it looks like to think about how we're interconnected and how our fates are entwined and how trust based on knowledge, based on a sharing and circulation of expertise, is crucial both to medicine and to democracy. And that particular physician, I think, is a model for what everyone watching right now can be as a physician citizen and a citizen physician.

Kao: Yeah.

Hernández: Well, I just want to add that it's a perfect way to sort of close this discussion. The pandemic has shown the world the important role of medicine. Who are the people out there in the front line saving lives, out there, sacrificing their own well-being? But they're also seeing, going back to what is causing this pandemic to increase: the failure of trust, the failure of believing that a simple thing is a mask is going to save your life and the life of others. That a simple thing as distancing is going to save people's lives. So, I would say that today, the medical profession has rebuilt its trust and its value in the world, not just American society, but the world. And as such, it has earned that trust that it must, it must use that trust to talk about the larger societal issues.

Kao: Yeah.

Hernández: You, the medical profession, have earned the right to be trusted because you're in the front line. Use that trust to imbue people with a sense of civic power to change the conditions we're in. So, to me, that's what it is. It's all about trust.

Kao: Yeah.

Jefferson: And I'll just add on top of what Eric and Antonia said. And I'm just, I'm thankful that they have had an opportunity to talk to the medical profession the way that they have. Let me just provide a practical way. As we heard earlier, many times, that there are encounters between the medical profession and patients, there is at bottom some legal need. Somebody was evicted, and they're homeless. And they acquire diseases based on that homelessness when maybe they should never have been evicted at all. Or a veteran comes in, somebody who's served our country, and comes in and doesn't have the benefits to have his or her medical needs taken care of. The doctors and medical professionals, they witness these incidents. And here's what I would recommend. And this is because it was based on my background in the law and as Chief Justice of the Supreme Court of Texas: go to the Bar Association and let them know what you're seeing.

Go, in fact, to the Chief Justice in your state and say, “Here is what we are encountering in our communities. Chief, will you convene a public hearing where we can talk about these issues and bring in medical professionals, bring in housing authorities, schools, and school districts and talk about them?” And the one thing that I know that a Chief Justice can do, that Chief has the power to convene people and to—You know, if you pick up the phone and you're the Chief Justice and say, “Can you come down on Friday and speak about a crisis in the medical area that we can, as a community, fix,” they will come. That is a practical way to start putting these matters on a larger agenda and get outside of the bubble, as Eric said, and use the power, as Antonia said, to improve our democracy.

Liu: Dr Kao, if I could just say at the very end here, to invite your members to read more about our report, but also to participate in the implementation. We are committed as a commission to spend the next six years leading up to the 258th birthday of the United States implementing these recommendations and making substantial progress on them. And we would so benefit from having the participation of your members and of the AMA as a whole in joining us on whatever one of these recommendations you all feel, see fit to be moved to engage on. We would love to have you as champions and allies in this effort.

Kao: Yeah. Well, I appreciate all of your deep thoughts and perspectives and your civic call to action. I want to thank Antonia Hernández, Wallace Jefferson, and Eric Liu for, again, providing their expertise and insights about the Commission's work with our audience today. Thank you all for being guests on Ethics Talk today.

Hernández: Thank you.

Liu: Thank you so much for having us.

Jefferson: Stay safe.

Hernández: Thank you. Be safe.

Kao: For more COVID ethics resources, please visit the AMA Journal of Ethics at JournalOfEthics.org. And finally, to we, the people, out there, I want to encourage everyone to get registered and vote in the upcoming November elections. Our civic and public health depend on it. Be safe and be well. We'll see you next time on Ethics Talk. [bright theme music plays]

Video Information

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

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

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 CME points in the American Board of Surgery’s (ABS) Continuing 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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