Democracy dies in darkness

Ketil Slagstad About the author

A healthy society is characterised by a strong civic culture. As doctors, we are responsible also for the health of the body politic.

Photo: Sturlason

Medicine is politics. Per Fugelli wrote: ‘Health equals biology x culture x politics squared’ (1, p. 14). Policy design is not exclusively reserved for parliamentary assemblies, it also very much takes place in public life. Norwegian social democratic society, which is characterised by relatively egalitarian relationships and a high degree of trust in the authorities, emerged as a result of a willingness to enact strong governmental regulation – but also from a broad civic culture (2).

Medicine is power. The health services accompany us from cradle to grave, and the way in which we perceive our bodies and ourselves is largely defined by modern medicine (3). We doctors therefore wield a lot of power by force of our knowledge and position. Medical knowledge is used for the benefit of society. On the other hand, a democratic problem arises when the politicians abdicate in favour of expertocracy in matters related to health: policies are designed before they have been deliberated publicly and in parliamentary bodies (4). This further concentrates the power of medical expertise. Power should be opposed by a countervailing power, in this case by a broad and informed public. In light of an increasing sub-sub-specialisation and fragmentation of the doctor’s role, we doctors may easily resign from public debate as soon as topics that do not concern our own little niche are brought up. In addition, we are marked by an authoritarian and patriarchal culture that have not favoured doubt and public argumentation (5).

Could it be that we as doctors are not being sufficiently trained in public debate and are unaware of its democratising function? As a medical student a decade ago, I noticed how critical discussion, argumentation and the doctors’ responsibility for informing the public were absent from the curriculum. Preparing curricula for a discipline in which the knowledge base is of such an explosive nature as in medicine may be a rather thankless task. If something should be included, something else must be excluded. An email to the deans of Norway’s medical faculties shows that none of these seats of learning provide specific instruction in public debate or concrete writing courses. The University of Oslo provides a separate training course in health policy where the students practise presentation of various viewpoints in the current debate on health, and the University of Tromsø holds a special course in academic communication. This is all well and good, but argumentation is a skill that must be learned, and learning to write requires practice. Participation in public debate should not be the preserve of individual, committed doctors, it should rather be included as a part of the personal formation for which the medical faculties are responsible.

My proposal is to provide the students with quite specific writing assignments, for example writing a generally informative text about menstruation or why the PSA test should not be applied uncritically, or an argument regarding how private digital health services may supplement or undermine public health service provision. Public argumentation involves meeting an adversary with arguments, face to face, without constructing straw men, but by using references as evidence for your assertions. It is about cultivating polemics and apt formulations (6). Few debates are likely to arise in a consensus-seeking and conflict-averse climate.

Some years ago, the Journal of the Norwegian Medical Association placed the Letters to the editor column on the first pages of its printed edition as a signal of our wish to prioritise debate-related material (6). The name of the section has since been changed to Comments, to underscore that you as a reader should not write for us as editors, but for Norwegian doctors and the Norwegian public. We prioritise the comments and publish them continuously on our website. As editors, we have wished to be more than just a mailbox and to invite columnists who can articulate critical perspectives on power that have not traditionally been heard in medicine, for example former psychiatric patients (7) or activists (8). For many years, Norwegian medicine was the preserve of white men. This is fortunately no longer the case; in 2018, 44 per cent of all comments were written by women. We wish to be a journal for all of Norway’s doctors and medical students. Like other medical journals (9), we have set ourselves the goal of better reflecting the diversity of medicine and among writers, for example with regard to different genders, regions, ethnicities and career stages. By doing so, we recognise that medical journals are also responsible for combatting structurally racist and discriminating mechanisms in the medical community.

By ensuring free access to the Journal of the Norwegian Medical Association through their membership fee, Norwegian doctors give a gift to the Norwegian public. Science depends on free debate, as does democracy. ‘Democracy Dies in Darkness’ is the motto of The Washington Post. The job of ensuring a broad democratic public debate must be done by us all – acting in concert.

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