Macauley wrote:
The threat itself may be enough to force the government to realize that while special interests (like the health insurance industry) have the money, physicians themselves have the power to document and bill and therefore to change the system. For the sake of the tens of millions of patients currently without health insurance, physicians must be willing to risk much of what they hold dear: their reputations, their incomes, their status in society. Only through self-sacrifice will sea change be effected, but with sufficient devotion and commitment, the goal is attainable.
Two decades later—when
more than 31 million Americans remain uninsured, thousands continue to die each month due to for-profit healthcare exclusion, and U.S. doctors are rewarded with the world’s highest
physician incomes—the medical profession has yet to take such risks. Now, in the wake of the Supreme Court’s decision on abortion care, the majority of
doctors,
hospitals, and organizations like
Planned Parenthood are not only
declining to resist legal restrictions that further deny care to our patients; many are preemptively canceling appointments and denying people abortion care in anticipation of possible future liability.
This behavior is in line with the observations of historian Timothy Snyder, who has
written, “Most of the power of authoritarianism is freely given. In times like these, individuals think about what a more repressive government will want, and then offer themselves without being asked. A citizen who adapts in this way is teaching power what it can do.” For doctors in America’s famously hierarchical and risk-averse
medical culture, we have long been trained to obey the rules without questioning them; when the rules contravene our mandate to provide care, however, we must check our ingrained impulses.
Doctors in America now face a choice: we can submit to legal decisions—imposed by an
anti-democratic institution—that harm our patients while we enjoy the benefits of complicity with state-sanctioned violence, or we can organize to provide care to our patients while accepting
the personal hazards that come with fulfilling our ethical obligations as privileged caregivers.
As moral philosopher John Rawls wrote, in the practice of civil disobedience, “We must pay a certain price to convince others that our actions have, in our carefully considered view, a sufficient moral basis in the political convictions of the community.” By defying the law and aligning ourselves with our patients rather than repressive legal systems, some doctors may incur professional penalties or even criminal prosecution. This may be unavoidable in some cases, but a politics predicated primarily on heroic individual self-sacrifice is not a viable path forward.
What we need is strategic, organized refusals to cooperate with unjust laws such that we take on risk not as isolated doctors but as coordinated collectives. Work stoppages, which would in many instances not just inconvenience administrators and officials but also harm our patients, are not our only option. In America’s
fee-for-service healthcare system that’s been so thoroughly constructed around
billing codes, documentary disobedience may be our most effective tactic.
Rather than recording abortion care under an individual doctor’s name, for example, the entire staff of a hospital or clinic could co-sign in open violation of repressive laws. Alternatively, we could together refuse to document or bill for abortion and prenatal care prior to fetal viability at twenty-four weeks’ gestation, instead filing this care under other medical billing codes and shifting its cost to the rest of our healthcare systems. Going further, to demand changes to unjust laws, we could strategically send public and private insurance systems into chaos within days via organized false billing without ever interrupting delivery of services to our patients. In all of this, we would need to compel our healthcare institutions, which depend on their physician employees and cannot operate without us, to join in refusing to comply with legal obstructions to care.
Healthcare’s powerful professional organizations, such as the American Medical Association, American Nurses Association, and the American College of Obstetricians and Gynecologists, for example, could use their resources to help organize healthcare workers and issue guidance on how to document care to circumvent individual legal liability insofar as possible. They could also petition private healthcare companies to donate to this cause, put pressure on state medical boards to refuse to pursue punitive measures against doctors and nurses who break abortion laws in service of patient care, and guarantee legal and economic support for healthcare workers if they are legally threatened for providing medically appropriate care.