1st December 2017, Volume 130 Number 1466

Philip Bagshaw, Pauline Barnett

What is physician advocacy? Physician advocacy (PA) occurs when doctors speak up for the health and healthcare of patients and communities.1 There is an extensive scientific literature on PA, originating…

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Some doctors believe it is a professional responsibility to speak out publicly in defence of the health of patients and communities. Others think they should only give their views privately when asked by health authorities. With many healthcare systems in Western countries under increasing stress, with underfunding and growing unmet need for care, it is important that these divergent views on such professional responsibilities are quickly resolved. In the UK, where the National Health Service is in serious trouble, medical representative organisations are increasingly speaking openly about the problems. Will such organisations in other Western countries do the same, as-and-when their healthcare systems are similarly threatened?


Physician advocacy occurs when doctors speak up for the health and healthcare of patients and communities. Historically, this was strong in some Western countries with doctors finding that it enhanced their authority, prestige and power. But it weakened in the 20th century when the biomedical model of heath triumphed and medicine became a dominant profession. In the second part of the 20th century, this dominance was threatened by political, technological and socioeconomic forces. These weakened medicine's state support, brought it under managerial control and undermined the social contract on which trust between doctors and the community was based. Defence of the profession was assumed by medical colleges, societies and associations. They had some success in retaining professional autonomy but did not undertake open advocacy, particularly on social justice issues, and did not therefore enhance their standing in the community. Opinion is divided on the level of advocacy that it is ethically proper for the medical profession to employ. Some contend doctors should only advise authorities when expert opinion is requested. Others contend doctors should speak out proactively on all health issues, and that collective action of this type is a hallmark of professionalism. This lack of consensus needs to be debated. Recent developments such as clinical leadership have not revitalised physician advocacy. However, continued deterioration of the UK National Health Service has led some English medical colleges to take up open advocacy in its defence. It is to be seen whether medical colleges elsewhere follow suit, as and when their healthcare systems are similarly threatened.

Author Information

Philip Bagshaw, Clinical Associate Professor, University of Otago, Christchurch;
Pauline Barnett, Health Sciences Centre, University of Canterbury, Christchurch.


Philip Bagshaw, Canterbury Charity Hospital Trust, PO Box 20409, 349–353 Harewood Road, Bishopdale, Christchurch 8054.

Correspondence Email


Competing Interests



  1. Earnest MA, Wong SL, Federico SG. Physician advocacy: what is it and how do we do it? Acad Med. 2010; 85:63–7.
  2. Watson J. Should doctors enter the political fray? Medscape. 11 April 2017. Accessed at www.medscape.com/viewarticle/878374 on 26 August 2017.
  3. Pellegrino ED. Medical ethics in an era of bioethics: Resetting the medical profession’s compass. Theor Med Bioeth. 2012; 33:21–4. 
  4. Huddle TS. Political activism is not mandated by the medical profession. Am J Bioeth. 2014; 14:51–2. 
  5. Tilburt JC. Addressing dual agency: Getting specific about the expectations of professionalism. Am J Bioeth. 2014; 14:29–36.
  6. Gruen RL. Evidence-based advocacy: The public roles of health care professionals. MJA. 2008; 188:684–5.
  7. Pellegrino ED. Altruism, self-interest and medical ethics. JAMA. 1987; 258:1939–40.
  8. Komrad MS. A defence of medical paternalism; maximizing patients’ autonomy. J Med Ethics. 1983; 9:38–44.
  9. Pearson SD. Caring and cost: The challenge for physician advocacy. Ann Intern Med. 2000; 133:148–53.
  10. Sethi MK, Sathiyakumar V, Mather RC. The evolution of advocacy and orthopaedic surgery. Clin Orthop Relat Res. 2013; 471:1873–8.
  11. Geraghty KE, Wynia MK. Advocacy and community: The social roles of physicians in the last 1000 years. Parts I, II & III. Medscape General Medicine. 2000; 2(4).
  12. Brandt AM, Gardner M. Antagonism and accommodation: Interpreting the relationship between public health and medicine in the United States during the 20th century. Am J Public Health. 2000; 90:707–15.
  13. Ackerknecht EA. Rudolph Virchow: doctor, statesman, anthropologist. Madison: University of Wisconsin Press, 1953.
  14. Mackenbach JP. Politics is nothing but medicine at a larger scale: Reflections on public health’s biggest idea. J Epidemiol Community Health. 2009; 63:181–4.
  15. McKinlay JB, Marceau LD. The end of the golden age of doctoring. Int J Health Serv. 2002; 32:379–416.
  16. Starr P. The social transformation of American medicine. New York: Basic Books, 1984.
  17. Freidson E. The Changing Nature of Professional Control. Ann Rev Sociol. 1984; 10:1–20.
  18. Cruess RL, Cruess SR. Expectations and obligations: Professionalism and medicine’s social contract with society. Perspect Biol Med. 2008; 51:579–98.
  19. Hiepler M, Dunn B. Irreconcilable differences: Why the doctor-patient relationship is disintegrating in the hands of health maintenance organizations and Wall Street. Pepperdine Law Review. 1998; 25:597–616.
  20. Burau V. Health professions and the state. In: Cockerham W, Dingwall R and Quah S. eds. Wiley Blackwell Encyclopedia of health, Illness, behavior and society. 2014:1054–9.
  21. Forrow L, Sidel VW. Medicine and nuclear war: From Hiroshima to mutually assured destruction to abolition 2000. JAMA. 1998; 280:456–61.
  22. Key dates in the history of anti-tobacco campaigning. ASH (Action on Smoking and Health). 21 February 2017. Access at http://www.ash.org.uk/files/documents/ASH_741.pdf on 26 August 2017.
  23. Block JP. A substantial tax on sugar sweetened drinks could help reduce obesity. BMJ. 2013; 347:f5947.
  24. Watts N, Adojer WN, Agnolucci P, et al. Health and climate change: Policy responses to protect public health. Lancet. 2015; 386:1861–947.
  25. Barnett JR, Barnett P, Kearns RA. Declining professional dominance? Trends in the proletarianisation of primary care in New Zealand. Soc Sci Med. 1998; 46:193–207.
  26. Haug MR. Deprofessionalization: An alternative hypothesis for the future. Sociol Rev Monogr. 1973; 20(S1):195–211.
  27. Rodwin MA. Patient accountability and quality of care: Lessons from medical consumerism and the Patient Rights, Women’s Health and Disability Rights movements. Am J Law Med. 1994; 20:147–61.
  28. Light D, Levine S. The changing character of the medical profession: A theoretical overview. Milbank Q. 1988; 66(Suppl. 2):10–32.
  29. Freidson E. Professionalism Reborn: Theory, Prophecy and Policy. Chicago: University of Chicago Press. 1994.
  30. Annandale E. Proletarianization or restratification of the medical profession? The case of obstetrics. Int J Health Serv. 1989; 19:611–34.
  31. Coburn D, Rappolt S, Bourgeault I. Decline vs. retention of medical power through restratification: An examination of the Ontario case. Sociol Health Illness. 1997; 19:1–22.
  32. Peek ME, Wilson SC, Bussey-Jones J, et al. A study of national physician organizations’ efforts to reduce racial and ethnic health disparities in the United States. Acad Med. 2012; 87:694–700.
  33. Waring J. Restratification, hybridity and professional elites: Questions for power, identity and relational contingency at the points of professional-organisational intersection. Sociol Compass. 2014; 8/5:688–704.
  34. Evetts J. A new professionalism? Challenges and opportunities. Curr Sociol. 2011; 59:406–22.
  35. Obama BH. Repealing the ACA without a replacement: The risks to American healthcare. 2017. N Engl J Med. 2017; 376:297–9.
  36. McIntosh B, West S. Brexit: The consequences and impact of the NHS. Br J Healthcare Man. 2017; 23:154–7.
  37. Warmington R, Hum B, Lin D. Healthcare is political: Case example of physician advocacy in response to cuts in refugees’ and claimants’ healthcare coverage under the Interim Federal Program. U Ottawa J Med. 2014; 14:45–47.
  38. American Medical Association. How Physician Advocacy Shaped Health Care. 14 December 2016. Accessed at http://wire.ama-assn.org/ama-news/how-physician-advocacy-shaped-health-care-2016 on 26 August 2017.
  39. Coney S. Report blames business plan for unnecessary deaths in New Zealand. Lancet. 1997; 351:1188.
  40. NZ Herald. Letter from surgeons lambasts hospital managers over patient care. 24 November 2016. Accessed at http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11753565 on 26 August 2017.
  41. September 11, 2001 [editorial]. N Engl J Med. 2001; 345:1126.
  42. Horton R. Violence and medicine: the necessary politics of public health. Lancet. 2001; 358:1472–3.
  43. Huddle TS. Perspective: Medical professionalism and medical education should not involve commitments to political advocacy. Acad Med. 2011; 86:378–83.
  44. Campbell EG, Regan S, Gruen RL, et al. Professionalism in medicine: Results of a national survey of physicians. Ann Intern Med. 2007; 147:795–802.
  45. Furler J, Harris E, Harris M, et al. Health inequalities, physician citizens and professional medical associations: An Australian case study. BMC Med. 2007; 5:23.
  46. Gruen RL, Pearson SD, Brennan TA. Physician-citizens – public roles and professional obligations. JAMA. 2004; 291:94–8.
  47. Dharamsi S, Ho A, Spadafora SM, Woollard R. The physician as health advocate: Translating the quest for social responsibility into medical education and practice. Acad Med. 2011; 86:1108–13.
  48. McKee M, Mackenbach JP, Allebeck P. Should a medical journal ever publish a political paper? Eur J Pub Health 2015; 25:1–2.
  49. Dixon-Woods M, Yeung K, Bosk CL. Why is UK medicine no longer a self-regulated profession? The role of scandals involving “bad apple” doctors. Soc Sci Med. 2011; 73:1452–9.
  50. Bolsin S, Pal R, Wilmshurst P, Pena M. Whistleblowing and patient safety: the patient’s or the profession’s interests at stake? J R Soc Med. 2011; 104:278–82.
  51. Sidhom E. Medical blogging, a new horizon or a dangerous cliff. 17 Sept 2014. Accessed at http://www.frontiersin.org/blog/Medical_blogging_a_new_horizon_or_a_dangerous_cliff/16622 on 26 August 2017.
  52. Royal College of Surgeons of England. Political Update. 12 August 2017. Accessed at http://updates-rcseng.co.uk/4D4N-2MW7-B8117TP971/cr.aspx on 26 August 2017. 
  53. Clem B, Jeff M. Why welfare states persist: The importance of public opinion in democracies. The University of Chicago Press, Chicago 60637. 2007.
  54. Royal College of Physicians. Underfunded, underdoctored, overstretched. Royal College of Physicians, London. 2016. Accessed at www.rcplondon.ac.uk/guidelines-policy/underfunded-underdoctored-overstretched-nhs-2016 on 26 August 2017.


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