Physicians, even when acting as private citizens, should be held to a high standard of conduct on social media and elsewhere -- higher than the average citizen -- because our patients deserve to receive care that is free of political undertones and biases. If physicians spew hatred in any direction -- even as private citizens -- it may be protected by the law, but it will simply serve to alienate us from our patients.
Let's take a closer look at a current controversy. Since October 7, academic institutions have witnessed fallout over public comments by institution officials about the war between Israel and the Hamas militia in Gaza. Physicians, who are governed by the Hippocratic Oath to "first do no harm," have also been weighing in on the controversy. Public institutions must abide by the free speech protections of the First Amendment, making it difficult to discipline physicians whose speech and public actions may seem to violate the Hippocratic Oath.
While acts of violence and harassment are not permitted in public institutions, hate speech is by the First Amendment. Private institutions can make their own decisions about when to dismiss or discipline physicians based on often state laws or organizational codes of conduct that govern what employees can and cannot do inside and outside of work. NYU, Lenox Hill, and Johns Hopkins have on both sides of the debate based on social media postings.
The concept of "first do no harm" pertains to clinical decision-making, but many would argue it should govern all of our interactions with our patients. What rules, then, should govern physicians' speech outside of the realm of clinical medicine, as private citizens?
The internet now serves as a de facto database where individuals can access a physician's published political views (if the physician has shared them) before they have to rely on that physician for treatment. For example, a patient can google their ob/gyn and often determine his or her on abortion. The patient can then decide whether to choose that physician's practice.
Yet, under many circumstances patients have no choice in their doctor. I work in the emergency department, where patients and their families arrive anxious and often acutely ill, and have no control over which physician will be providing their care. For patients who require admission to the hospital, the same rules apply. The physician or surgeon is simply assigned to the patient based on their medical needs with no regard for patient choice.
What happens, then, when patients find themselves under the care of a physician they did not choose who has now gone rogue as a private citizen on social media? Imagine the physician you were assigned had views different from your own: say, they praised Hamas or suggested we shut our own hospital down as a symbol of solidarity with Gaza. What if your physician had posted offensive cartoons about Arab people like those of the NYU oncology director?
To be sure, free speech protections are crucial for physicians in all work environments, public or private. In California, the proposed aimed to revoke a physician's medical license if they disseminated "disinformation or misinformation" related to COVID-19. If it had passed, a doctor conveying information about COVID-19 that ran counter to state beliefs (which during the pandemic did not keep pace with emerging scientific data) would have resulted in revocation of one's medical license.
Other nefarious politically motivated efforts to control physicians' speech have included on providing abortion counseling and resources led by anti-abortion activists, and restrictions regarding what we can ask our patients about -- even when it's critical to clinical decision-making, such as in the case of a suicidal patient. Doctors must be afforded the right of free speech regarding their practice of clinical medicine. As trained professionals, we must be able to guide our patients' medical decision-making in the privacy of an exam room, free of politics. Even outside of the exam room, physicians increasingly use social media as a platform for education, dissemination of academic work, or even medical advice.
Doctors are human beings with the right to political views, which may conflict with the opinions of their patients. Even if a patient expresses views that are morally repugnant, we, as physicians, must still provide that patient with the same standard of care as we do for all other patients.
So, while I'm not advocating against free speech for physicians, the way in which a doctor's private views are shared with the public must be thoughtful, taking care not to create an environment that could cause the people we care for moral or emotional harm. To help guide physicians, many employers -- including my own -- offer social media specific to doctors' personal accounts. These guidelines include avoiding posting comments that could be perceived as offensive, inappropriate, or demeaning, and appropriately identifying yourself as a university employee if your post includes information or opinions about the university.
The problem is, these guidelines are ambiguous, and maybe necessarily so, in order to avoid any perception of infringing on First Amendment rights. However, one piece of the guidance is particularly salient: to "expect that your posts and comments on others' posts can and may be seen by...prospective patients."
Indeed, the privileges of a physician, with access to the private details of patients' physical and psychological conditions, are accompanied by responsibilities that hold physicians to a higher standard than private citizens. Patients seeking emergency medical care should not be burdened by concerns that their care may be compromised because they are Jewish or Palestinian or belong to any community that their physician has railed against in a public space. While hate speech from a physician's private social media account may be protected by the First Amendment, it stands in stark contrast to the ethical embodiment of "first do no harm."
is a professor of clinical emergency medicine and Chief of Emergency Medicine at UCSF Medical Center. She is a public voices fellow of the OpEd Project.