AMA Journal of Ethics^®

Policy lies downstream of society. Mandates are not self-executing; to work, policies need to be followed, guidance needs to be believed. Public health is rooted in the soil of trust. That soil has thinned in America.
Ezra Klein¹

In 2020, the United States faced a public health threat unparalleled in recent memory. With the rapid spread of the novel coronavirus (SARS-CoV-2), the United States grappled with unprecedented strains on its public health infrastructure, accompanied by a death toll that has not been seen since the 1918 influenza pandemic.² Responsible for informing public health policy in the midst of an election cycle, medical professionals vested with government authority—hitherto referred to as clinician governors—were thrust into the limelight. As they worked to translate emerging scientific evidence into policy, they navigated innumerable ethical challenges, mounting public scrutiny, and public distrust.

In such emergency scenarios, the role of clinician governors in preparing, building, and maintaining health sector capacity becomes increasingly salient. However, even during periods of relative stability and prosperity, US clinicians serving in the federal government or in state governments have myriad responsibilities as regulators, science communicators, providers of health care services, and sponsors of applied research. By means of an implicit social contract, they are accountable to patients, the public, and their professions in ways that transcend clinicians’ typical fiduciary duties to individual patients, colleagues, and institutions.³ One reason for this extra layer of accountability is that when clinicians draw upon their professional skill sets to help administer agencies, formulate law, or enforce regulations, they are vested with legal authority beyond the scope of normal practice, such as the issuance of public health mandates.

The complex nature of clinician governors’ roles and responsibilities in the best of times and during crises is the topic of discussion in this month’s issue of the AMA Journal of Ethics. The issue is a meditation on various ethical considerations that health professionals in government face and how they must utilize their position of authority to address gaps in health care delivery, triage protocols, preserve scientific objectivity when communicating with the public, and minimize conflicts of interest due to their involvement with the private sector. Importantly, the issue addresses questions of public speech guidelines in the context of an “infodemic,” which illustrate rather concretely the degree of interpenetration of government and medical authority that renders void traditional norms of noninterference in authorities’ respective spheres of influence.

In particular, this issue focuses on one of the most glaring aspects of the pandemic response: public distrust of government authority. Two years into the COVID-19 pandemic, a NewsNation/Decision Desk HQ survey found that 31% of Americans approved of Dr Anthony Fauci’s COVID-19 advice and 45% approved of President Biden’s pandemic response.⁴ The Johns Hopkins Center for Health Security and the Nuclear Threat Initiative’s 2019 Global Health Security Index demonstrates that, despite ranking first on metrics of pandemic preparedness, the United States was at the bottom of the ladder in terms of public trust in government.¹ A 2021 Pew Research Center poll found that a major consequence of public distrust in government authority is increasing sociopolitical division, illustrated by the fact that 88% of Americans believe that Americans are more divided than before the pandemic.⁵ Social trust in medical care is a theme explored at length, with several contributors suggesting that it is dependent on factors such as the extent of federal authority over locally coordinated triage protocols, clinician advocacy for and regulation of novel interventions, professional obligations to impart legitimate information to the public, and federal regulation of clinician policy makers’ ties to industry.

Topics in this theme issue have come to the fore relatively recently, but they have lasting importance for the future of public health in the United States. The contributors and I hope that this theme issue will shed light on the gravity of the issues raised, as well as on the importance of clinician governors conducting their affairs in light of rigorous scientific standards and a commitment to objectivity.