In her memoir “The Cancer Journals,” radical feminist and civil rights activist Audre Lorde documented her experiences as a woman with breast cancer recovering from a mastectomy. Lorde was a black lesbian and patient who is “defined as other in every group I am a part of. I’m the outsider, both strength and weakness.”
An individual who identified as a minority on multiple levels, Lorde used her memoir as a platform to voice her experiences as a marginalized woman of color and patient in a patriarchal, white supremacist medical system and society. She was a “post-mastectomy woman who believes our feelings need voice in order to be recognized, respected, and of use.” In the memoir and throughout her life, Lorde articulated the relationship between voice and power, how the command of a language and the ability to vocalize those commands are assertions of power.
The ability to speak manifests as the ability to communicate our wishes and desires effectively. This theme is much easier to identify in books, with obvious buzzwords like “interrupt” or “drowned out,” but it is not a nebulous concept that only exists in fiction. Instead, this relationship reflects the social dynamics of reality. Studies have shown that the right to speak is “intimately tied with rights to power,” with a quantitative measure of asserting power through speech being the number of unilateral changes in conversation. The literal interruptions that occur in daily conversations are therefore common real manifestations of power dynamics embodied by voice.
Thus, this power is not necessarily singular–one can speak but not be heard or be overridden, thus effectively being silenced. This ability to silence, therefore, is one that belongs to the individual or collective group in power. Those that remain in power in society are the ones with the ability to speak and be heard, who also hold the ability to dismiss the voices of others.
The relationship between voice and power can easily be seen in our medical education as we learn the vital skill of building rapport with patients. We are cautioned to avoid over-speaking: let silence linger, giving patients the opportunity to speak. Before the migration to patient-centered care, doctors’ conversations with patients were (and may still be) largely one-sided: the doctor is the speaker, while the patient is the recipient. By teaching us to “let silence linger” and encouraging us to listen to patients’ stories, medical education is shifting the power dynamic from one of explicit hierarchy to one of collaboration–hence, patient-centered care.
Silence is an important tool that physicians need to learn how to use. The patient-physician relationship is a strange, special one because the physician is privy to so much of the patients’ personal lives. Given the physician’s historical power, physicians are in a much greater position to do harm to the patient than vice versa. As such, it is important to remain silent when the patient is speaking; after all, it is not the provider’s place to judge the patient’s actions because judgment contributes nothing positive to the relationship.
But while medical school teaches us how to use silence as a method of building better patient relationships for our future practices, it also grooms us to use silence as a protective mechanism. Instead of silence for the patients, the emphasis of silence is often placed in the context of professionalism and therefore silence on behalf of the medical sphere. As medical students, we reflect both our respective institutions as well as the larger community of medical professionals. Regardless of collaboration, our white coats are still a huge status symbol and as the wearers, we need to be particularly careful with what we say.
The ultimate rule for a physician is the Hippocratic Oath: “Do no harm.” This oath is mostly interpreted in the explicit manner of doing no physical harm, but also encompasses other forms of harm as well: mental, social and so forth. To avoid doing these less tangible forms of harm, we believe that the trick is often to simply be silent and consequently neutral. In this narrow reading of the Hippocratic Oath, by expressing no opinion, especially one that would clash with the patient’s own, we believe we do no harm and abide by the physicians’ role of ultimately treating the patient and nothing else.
As such, we are taught that medicine is supposed to be an “apolitical” sphere–the relevant facts are overwhelmingly medical, and any mention of social factors like race are instead framed as genetic. To mention race and its non-medical implications–namely, racism–is seen as irrelevant to the medicine. Multiple times, I have heard from medical students that racism and sexism are not related to medicine and public health. Additionally, these topics are sticky and dangerous–after all, to many, racism is “over” because we live in a “post-racial” society of supposed equal opportunity.
Between the doctor and patient, silence should be extended to allow room for the patient’s voice. But what about silence in response to factors affecting patients that aren’t necessarily medically related–topics that are awkward, uncomfortable, and require acknowledgment of privilege both in and outside of medicine? Silence is therefore multifaceted: it can be enforced in a top-down, oppressive manner, and it can be allowed, a willing collaboration. The two, however, can be misconstrued as being identical.
Last month, I went to a talk given by acclaimed author Salman Rushdie. The topic was on the pursuit of liberty and how freedom of speech needs to be protected, as our fundamental rights to liberty are being slowly stripped away by the current age of “political corrected-ness.” To be funny takes courage now, Rushdie said, citing the Charlie Hebdo attacks and the response to Seth Rogen and James Franco’s “The Interview.” By Rushdie’s argument, we are so bound by political “corrected-ness” and its repercussions that we are silenced from truly speaking what we think.
To be frank, I disagree. We–in medicine and in society as a whole–are not silenced by “political corrected-ness.” There is a significant difference between being unable to make jokes at the expense of marginalized individuals due to “political corrected-ness” and being unable to speak out against the systems marginalizing these individuals in the first place by being silenced or dismissed. The attacks on Charlie Hebdo were condemned internationally as acts of terrorism and violence, and rightfully so. However, there was not quite the same kind of unanimous condemnation for the acts of terrorism and violence against Muslims displayed in the movie “American Sniper,” acts that continue in reality to this day. There was not condemnation for two white men deciding that they could belittle the sufferings of North Koreans by making “The Interview” into a comedy. Instead, these movies are heralded as patriotic: staunch defendants of freedom of speech and the embodiment of true Americans. In fact, many have used freedom of speech to defend the recent SAE fraternity members’ absolutely blatant racism and condemn their expulsion — after all, how can we punish freedom of speech when it so embodies all America represents, when we all have a right to be intolerant?
Thus, silence and voice work in different ways for different people. There are existing systems in place that favor certain groups over others — in other words, being able to speak and be heard, as well as the ability to silence, belongs to individuals who are privileged. Being white grants privilege. Being male grants privilege. And ultimately, being a physician grants privilege.
We have the power to speak over patients, plain and simple, but we shouldn’t. If we are truly patient advocates, we need to know when to be silent and when to be vocal. When with the patient, either in the clinic office or at the bedside, silence can be a powerful tool that we employ on our own behalf so that we can learn what the patient needs. But when outside of the direct patient interaction, we as physicians shouldn’t be silent. Rather, we need to be conscious of the privilege afforded to us as physicians and recognize that our voices have power to change the existing racist and classist systems that continue to devalue the lives of minorities, inside and outside of our practice.
Advocacy, therefore, is not confined to the clinic. As physicians, we should not simply be “apolitical” when it comes to matters outside of medicine, because factors outside medicine affect not just our patients but our practice and our society as a whole. Essentially, we cannot afford to be apolitical and focus “just on the science” because that is a luxury that others do not have.
To be silent in the face of systematic injustices–legislative, medical, social and otherwise–is to be complicit in them. To believe that medicine is an insular, neutral field is naïve. Access to care is tied to socioeconomic class. Socioeconomic class is tied to race. And race has always been and still is tied to vastly varying levels of privilege and opportunities. To assume that a patient can simply abide by medical suggestions without any context for their social situation is to ignore a historical system of oppression that extends to multiple spheres, of which medicine is only one. How and why do geographical food deserts predominately affect lower socioeconomic communities? How do legislative barriers to reproductive health disproportionately target women in poverty and why are those women overwhelmingly black or brown? How does being constantly exposed to racism contribute to the prevalence of hypertension among the black American community? If we ignore these questions and deem them to be unrelated to medicine, then we are ignoring huge factors that perpetuate the injustices that continue to oppress entire communities.
Ultimately, what I want to point out is that silence is not always neutral. On the contrary, silence is often a sign of complicity, and the protective silence that the medical community often employs can and does do harm. Contrary to what we may believe, in most cases, silence is not apolitical; silence in the face of great injustices done to others is either willful ignorance of the injustice or full acknowledgment of the injustice’s existence without acknowledging its nature.
The natural course of this conversation turns to that of race and the ongoing events of systematic violence against minorities in the United States, particularly against black and Muslim lives. In the wake of the non-indictments of Michael Brown and Eric Garner’s killers, there was national movement from the medical student community to protest the threat to black lives. This movement stemmed from students who felt that a great injustice had been committed not just against the individuals involved, but against the entire black community in the United States. This movement stemmed from students who felt that they still face systematic injustices to this day, and that silence could no longer be tolerated, as continued silence was the same as effectively ignoring the problem.
Here, silent professionalism reaches its limits. Being a professional does not mean not having opinions. It means not having opinions that continue to marginalize individuals who are already disadvantaged. Being a professional does not mean not rocking the boat or not tackling the status quo when the status quo perpetually favors one group of individuals over another. Though it is understandably easier to focus on the medicine because that’s what we’re taught and hired to do, ignoring the injustices both within and outside of medicine does violate the Hippocratic Oath, because silence–a real, nearly tangible, oppressive weight–can and does do harm.