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To the Editor: In their Special Communication about physician-citizens, Dr Gruen and colleagues¹ proposed that public obligations of physicians should be proportional to 3 criteria: the degree to which proposed actions directly address disease causation, their feasibility to perform, and their efficaciousness. Critical among the factors is the relation of the action to disease causation. Hence, in the authors' view, actions targeting broad socioeconomic conditions that indirectly influence health care are "aspirational goals," but not obligatory. Although the authors provided examples for distinguishing direct and indirect causes of disease, they did not establish specific guidelines. For instance, the authors stated that actions addressing cigarette smoking and needle exchange are direct and obligatory. By contrast, actions to address income disparities or to remove environmental pollutants are indirect, and thus aspirational.

This argument derives from the view that physician's public roles follow directly and exclusively from a "social contract," exchanging professional benefits . . . [Full Text of this Article]

Matthew K. Wynia, MD, MPH
The Institute for Ethics at the American Medical Association
Chicago, Ill

Chalmers C. Clark, PhD
Yale University
New Haven, Conn

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