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Related editorial: Ethics, Education, and American Family Physician

Am Fam Physician. 2022;106(1):12-13

Author disclosure: No relevant financial relationships.

What are the ethical responsibilities for clinical journals publishing articles on controversial topics? Does controversy matter if the content is evidence based and the article is well written? Must all such articles be accompanied by an editorial that acknowledges opposing perspectives on a topic?

Family medicine is as diverse as the doctors who practice it and the communities we serve. Family physicians comprise a broad spectrum of age, gender, race and ethnicity, religious and spiritual beliefs, and political and philosophical ideologies who contribute an array of skill sets and styles to practice medicine in all locations. Clinically, we vary with respect to whether we care mostly for adults or also include children and adolescents; perform hospital work and maternity care or ambulatory care alone; provide palliative and end-of-life care; or provide reproductive health care. Geographically, our practices range from urban inner city to rural and frontier. Institutionally, we vary from single-physician to large-group offices in private, managed care, safety net, hospital, and academic settings.

Family physicians have always adapted our practices to meet the needs of our individual patients and our communities. Indeed, a key academic tenet of family medicine is the biopsychosocial model: Family physicians intervene for our patients holistically, in a myriad of ways, however we are best able to serve them.1 Practically, we espouse the principles of relationship-based, comprehensive, continuous, contextual, coordinated, community-focused, patient-centered care.2,3 These principles, in turn, help us address the four goals of medicine: treating illness, preventing disease, ameliorating pain and suffering, and prolonging a good life when possible and promoting a good death when not.4

This broad, generalist context produces a distinctly family medicine ethos—a moral orientation and habit of practice—that focuses our efforts on one unifying question: What, all things considered, should happen in this specific health situation? Family physicians are charged to answer this question in light of the previously mentioned principles—with a healthy sense of ethical humility about our knowledge, skills, and attitudes—and mindful of our own and our patients’ and communities’ values and beliefs.5

Although individual family physicians must follow their conscience regarding their own practice of family medicine, we should remain open to education about topics that might be considered controversial if the education is necessary to ensure that our patients receive the care they need. As family medicine and the general standard of health care continue to evolve, it is our professional duty to stay informed about developments that fit within our scope and competencies. These developments include medical knowledge and clinical care as well as practice-based learning, interpersonal and communication skills, systems-based practice, and professionalism.

American Family Physician (AFP), the premier evidence-based, educational, family medicine journal in the United States, is a leader in these efforts. Indeed, its mission and goals explicitly address this duty.6

Controversial Topics

Clinical topics commonly considered controversial include abortion and other aspects of reproductive health; end-of-life and palliative care matters, including physician-assisted dying; LGBTQIA (lesbian, gay, bisexual, transgender, queer [or questioning], intersex, asexual) care; elements of addiction medicine and chronic pain management; and various topics in complementary and alternative medicine.

Controversial community health topics include air, water, and food pollution; climate change; health equity, which includes addressing issues of health literacy, racism, immigration policy, and other social determinants of health; the aging physician and other issues of physician competency; vaccine mandates; youth sport policies; tobacco, alcohol, and substance use; and firearm safety and gun violence prevention.

When family physicians apply these concepts in practice, we are caring for real people with genuine needs. When we act on and advocate for community health issues, our neighbors pay attention, and our communities benefit. Not all of us want to participate in these pursuits—just as not all of us practice hospital medicine and maternity care—but all these matters fall within family medicine’s scope and competencies. For family physicians specifically, the question remains: What, all things considered, should I do in relation to these clinical activities and community health issues?

Just as with any other article in AFP, the content of articles about controversial topics must be evidence based; focus on family medicine; state why the education is important in advancing individual and community health care; be neutral and objective in tone; and be devoid of overt commercial, religious, political, or philosophical rhetoric. We appreciate that authors are individuals with their own experiences and that, strictly speaking, there is no philosophical “view from nowhere.”7 Authors should address the values and principles of family medicine and speak to practicing family physicians. When applicable, authors should discuss caveats and weaknesses of their work, acknowledging the diversity of opinion on the topic at hand.

Engagement

Some readers might wonder whether AFP is obligated to devote equal space to all sides of a controversial topic. The simple answer is no. Pieces published in AFP should address educationally important topics germane to the ongoing practice of family medicine in an evidence-based manner. Significant diversity of practice and opinion should be addressed, but not all sides of a given topic are relevant to the evolution of family medicine’s standard of care.

Active critical appraisal of the literature should occur when we read any medical journal. Readers may disagree with the educational importance, the relevance to family medicine, or the quality of evidence for a given topic. Such disagreement is the hallmark of any healthy profession, and addressing it is one of the best ways to push ourselves, together, to evolve. One way to do this is by conversing with colleagues, which can be a source of relief but also a source of new perspectives. Engaging patients and communities in discussions is another way to gain insight into alternative perspectives. Other ways include commenting on an article or writing a letter to the journal to share feedback.

As physicians dedicated to the care of our patients and communities, embracing the biopsychosocial model of care and practicing the principles of family medicine in our daily work, family physicians have much more in common than we have in difference. Whatever our disagreements are, we must try to communicate them with each other, respectfully. We do not need to be united on everything, but we should not let our differences of opinion divide us. Indeed, where we do have differences, we should welcome professional dialogue and discussion. Especially when it comes to education, our duty is to envision, encounter, and engage—controversy or not.

Editor's Note: If you would like to provide feedback about AFP's appearance or editorial content (e.g., articles, patient information handouts, other features), contact Matthew Neff, managing editor of AFP (afpedit@aafp.org). If you would like to write a letter to the editor, follow the instruction in the Letters to the Editor section of AFP's Authors' Guide on the AFP website (https://www.aafp.org/pubs/afp/authors.html).—Sumi M. Sexton, editor-in-chief

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