This essay is adapted from “Random Acts of Medicine: The Hidden Forces That Sway Doctors, Impact Patients, and Shape Our Health,” out now from Doubleday.
“Honey, I forgot to duck,” Ronald Reagan said to his wife as he was wheeled to the operating room of George Washington University Hospital on March 30, 1981. He had just been shot and was bleeding into his left chest. He would require emergent surgery, and a team of surgeons was headed with him to the OR.
Treating gunshot wounds is, sadly, a routine part of trauma care. But operating on the president — with a handful of Secret Service agents observing in the operating room — was atypical, to say the least. Shortly before being placed under anesthesia, President Reagan sensed some tension in the room.
“Please tell me you’re all Republicans,” he said to the OR team. They laughed.
“Today, we’re all Republicans, Mr. President,” one (Democratic) surgeon replied, reassuring his patient that political disagreements would not be playing a role in their surgical care, which would ultimately prove successful.
Ronald Reagan was known to make such quips, and given the gravity of the situation, we’re sure the doctors were grateful for his willingness to break the ice. But there is a kernel of truth to every joke. It’s enough to make you wonder: Does your doctor’s politics affect the care they give?
To answer the question of whether a doctor’s politics are relevant to the care they provide, we have to first assess two factors: how political doctors are, as a class, and whether those politics bleed into the way they treat patients.
The first we can easily dispense with: Doctors can and do often get involved in politics. Polling suggests most physicians identify with a political party. Historically, they have leaned toward the Republican Party, but in recent elections they have leaned Democratic for a number of possible reasons. Physician groups and societies also advocate for policies at the national, state, and local levels. Individual physicians donate millions of dollars to political campaigns, with one study showing an almost tenfold increase in physicians’ campaign contributions from 1991 to 2012 (a trend we can only imagine has continued into recent elections).
The second question of whether a doctor’s political leanings bleed into the care they give isn’t so straightforward.
A 2016 survey study, conducted by the Tufts University political scientist Eitan Hersh and the Yale psychiatrist Matthew Goldenberg, asked about 230 Democratic and Republican primary care physicians to read a short vignette about a hypothetical patient and rate the “seriousness” of various medical issues the patient presented. The researchers purposely included both politically charged and nonpolitically charged issues. For example, one vignette focused on tobacco use, a non-charged issue. It described a patient who “acknowledges engaging in social smoking, consuming ~15–20 cigarettes per week (2-3 per day), a habit that began at age 18.” A charged vignette said that the patient “acknowledges having had two elective abortions in the last 5 years. She denies any physical complaints or complications associated with these procedures. She is not currently pregnant.” If politics were influencing doctors, we ought to see a difference in their views of the “seriousness” of charged issues and no difference when it came to non-charged issues.
That’s precisely what the researchers found. Republican doctors perceived patients who had had prior abortions — and in other charged vignette, those who had used recreational marijuana — to have more “serious” medical issues than Democratic doctors. Democratic doctors perceived the presence of firearms in the home to be a more concerning issue than Republican doctors. Meanwhile, non-wedge issues — like tobacco and alcohol use, obesity, and depression — were viewed as similarly serious.
The differences extended beyond their assessments to their recommendations. Republican doctors more often said they would encourage the patient in the above vignette not to have more abortions and would discuss abortion’s effects on mental health. Republican doctors were also more likely to recommend that patients using marijuana quit and to discuss the health and legal risks associated with its use.
Survey responses are one thing, but how might those differences in beliefs translate to actual differences in care? In a natural experiment that took advantage of the Roman Catholic Church’s well-established views on contraception, the economists Elaine Hill of the University of Rochester and David Slusky and Donna Ginther of the University of Kansas looked at what happened when hospitals changed ownership between Catholic and non-Catholic entities from 1998 to 2013. They found that after hospitals switched to Catholic ownership, rates of tubal ligations (the procedure commonly referred to as “getting your tubes tied”) fell. Meanwhile, when hospitals were sold from Catholic owners to non-Catholic owners, the rate of tubal ligations went up. Taking the data together, they estimated that Catholic ownership was associated with a 31% decrease in tubal ligation procedures.
This was a study of institutional beliefs, rather than those of individual physicians. It’s altogether possible that many women ended up seeking tubal ligation elsewhere, at non-Catholic facilities. But it offers persuasive evidence that the beliefs and values of someone other than the patient could very well affect their options for care.
There are few subjects in health care in the past few decades that have risen to such national prominence as the end-of-life care of one person: Terri Schiavo. Schiavo had suffered a cardiac arrest in 1990 and remained in a persistent vegetative state until 2005, when her case became a national topic of debate when her family members disagreed as to whether to remove her feeding tube to let her pass away. President George W. Bush, speaking in terms consistent with his party’s long-held stance on abortion and supported by Republicans in Congress, felt they should “err on the side of life” and thus keep Schiavo alive. Ultimately, the courts had final say, and Schiavo’s feeding tube was removed; she died two weeks later.
If the Terri Schiavo case was representative, would Republican doctors caring for patients at the end of their lives “err on the side of life,” as President Bush had put it, and provide more aggressive care for terminally ill patients than Democratic doctors?
Working with some fellow researchers, one of us turned to the data, with the goal of determining differences between Democratic and Republican doctors’ practices for patients at the end of life. The study examined patients hospitalized in intensive care units from 2008-2012, a few years after Schiavo died, focusing on measures like time spent in the ICU and use of intensive treatments for organ failure like CPR, placement of a breathing tube, dialysis, and artificial nutrition. It also looked at total spending on end-of-life care and how frequently patients were transitioned to hospice care, where treatment is focused on comfort rather than resolving the underlying illness. Using publicly available political campaign contributions, the study ultimately identified about 1,500 Democratic physicians and about 770 Republican physicians, as well as more than 23,000 who had not made any donations.
In a statistical model that accounted for differences in patient and doctor characteristics and compared outcomes between Democratic and Republican doctors working within the same hospital, there were no differences in the intensity of end-of-life care provided to patients between Democratic, Republican, and non-donating doctors: no differences in costs, ICU use, mechanical ventilation, artificial nutrition, or hospice.
So at least when it came to this one question at the intersection of medicine and politics, a doctor’s political affiliation, it seemed, wasn’t influencing the care provided to hospitalized patients at the end of their life.
In other words, as Ronald Reagan’s surgeon suggested, a doctor’s politics can take a backseat.
Anupam B. Jena is an economist, physician and professor at Harvard Medical School. Christopher M. Worsham is a critical care physician and public health researcher at Harvard Medical School. They are the authors of “Random Acts of Medicine: The Hidden Forces That Sway Doctors, Impact Patients, and Shape Our Health” and the Random Acts of Medicine Substack.