A Doctor’s Plea for Civil Discourse

Right and wrong. Good and bad. With us or against us. This is the discourse of today’s polarized world. People use every available platform to boost their opinions and rally the like-minded. Those who disagree with them are evil, on the wrong side of history, animals, less than human. I’m an internal medicine physician at Sunnybrook Health Sciences Centre in Toronto. Doctors like me aren’t immune to this climate. In fact, we struggle with it regularly, navigating charged conversations on sensitive issues—including ones that cut to the core of our work, like abortion, medical assistance in dying, vaccinations, pain medication during pregnancy and gender-affirming care for youths.

These days, logical debates quickly devolve into personal attacks. James Downar, a critical care and palliative care physician in Ottawa, told me fellow doctors have publicly called him a murderer for providing MAID. An abortion provider I know—I’ll call her Mary—has worked for over 30 years in nearly every province and territory. She told me about a colleague who harassed her daily, saying, “How do you kill 15 babies in one day? Doesn’t it make you sick?” In an online forum for physicians, a surgeon I know saw colleagues being called “fat-phobic” and “bigoted” for asking questions about Ozempic and discussing exercise regimens. And one emergency doctor, who organized petitions and lobbied for community support to keep the women’s health program open at her hospital, was publicly attacked by hospital leadership. They called her crazy, and one of the senior physician leaders said, “Is something wrong with her mental health?”

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This kind of incivility is frighteningly widespread in medicine. A 2024 article in the Canadian Medical Association Journal highlighted that more than 75 per cent of health-care workers have seen physicians engaging in uncivil conduct. Nearly one in three doctors are subjected to rude, dismissive and aggressive behaviour by other physicians on a weekly or even daily basis.

Many physicians who lash out at colleagues aren’t driven by malice. They believe they’re fighting for what’s right. But emotions and tribal loyalty get in the way. For instance, I asked one family physician who advocates for autistic patients how she perceives people she disagrees with. “I believe that if you disagree with me, you are a bad person,” she admitted. The doctor who advocated for her hospital’s women’s health program once yelled at a colleague who supported a policy she opposed: “If a woman dies at the hospital, it will be because of you.” She wasn’t proud of her behaviour.

When doctors vilify one another, it’s patients who pay the price. When people call Downar a murderer for supporting MAID, he says, they fuel a dangerous myth that palliative care doctors are malicious hasteners of death. “This misinformation and name-calling undermines people’s confidence in health-care practitioners,” he told me. It also undermines our ability to present ourselves as safe and reliable providers of care for all. When a patient who believes in something—let’s call it X—sees a physician post something like, “We have to come together and campaign against X; all people who believe X are monsters,” they are likely to feel unsafe with that doctor. How could they trust that such a provider would help someone they see as evil?

Ultimately, when doctors disparage each other, they stifle meaningful debate, the kind that could make patient care better. One OBGYN I work with wants to discuss ethical questions about gender-affirming hysterectomies for youth but doesn’t feel comfortable to do so. He’s afraid that he’d be labelled a transphobe. It’s a frustrating position for someone like him, who cares for many trans patients and actively advocates for their rights. What he wants, he says, is not to challenge their access to care but to improve it. “There’s this sense that if you say something that goes against the prevailing view you’ll be accused of being a bigot or providing bad care,” he told me.

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Casting people as heroes or villains may work in Disney movies, but it’s a lousy way to understand real life or to have difficult conversations. Once we turn the people we disagree with into evil caricatures, meaningful dialogue becomes impossible. A colleague we’ve framed as a malevolent moustache-twirler will always feel misunderstood, and we’ll probably feel the same way if they’ve simplified us in turn.

Can we change the tone of these fiery conflicts? Absolutely. In a recent article in the Canadian Medical Education Journal, I proposed, along with my colleagues Jerry Maniate and Ayelet Kuper, a set of principles for what we call “civil discourse,” the idea that we can challenge ideas passionately without attacking the people who hold them.

Civil discourse is different from civility, which refers to mere politeness and doesn’t guarantee respect and real engagement. Civil discourse goes deeper: it involves respecting both parties’ right to disagree and being willing to listen and reflect on the other’s point of view. Each person must feel physically and psychologically safe to share their opinions without fear of punishment, hate or violence.

Above all, civil discourse demands that we treat each other as well-meaning: that our default position assumes that both parties want to do good, even when we diverge on how to get there. This allows us to have tough conversations while maintaining our mutual respect. For example, if I were arguing with a colleague and unintentionally used language that denied the other person the right to disagree (“If you don’t change your mind then you’re a murderer”), I hope they’d gently correct me, and that I would take the feedback with grace. This approach helps defuse tension and makes room for nuance and empathy.

We shouldn’t just encourage civil discourse at hospitals and medical schools—we should make it official policy. In this way, health-care providers would have a shared standard for debate: leaders could use these principles to determine whether a statement or social media post adheres to a code of professionalism, and medical schools could teach future doctors how to engage fiercely in advocacy without abandoning collegiality or respect.

Here’s an example of how it could work. When James Downar and his colleagues in the ICU clashed over the ethics of MAID, their debate resulted in a long email exchange. On charged questions such as, “Is it ever morally permissible for a doctor to cause death?” they presented opposing views without name-calling or moral grandstanding. They disagreed on religious, moral and professional grounds, but they also found they agreed on certain points; for instance, that MAID shouldn’t be offered to people experiencing only transient suffering and, conversely, that patients should be allowed to prioritize comfort over elongation of life if they wish. What began as an effort to persuade one another gradually evolved into a search for mutual understanding. “As they’re challenging my arguments, we are all drilling down on our ethical bedrock,” Downar told me. This dialogue was so successful that they published a scholarly article documenting their debate.

Practising civil discourse fosters open-mindedness. For example, Mary, the veteran abortion provider I mentioned earlier, told me about a family doctor who opposed abortion and refused to refer patients seeking one. Even so, some of her patients found their way to Mary on their own. One woman, instead of keeping it from the family doctor, returned to explain her reasoning, her circumstances and the emotional weight behind her decision. This exchange helped the family doctor better understand the plight of her patients. After that, she began referring patients seeking abortion for serious fetal anomalies to Mary for care. In turn, Mary was inspired to acknowledge the religious and moral convictions of colleagues who oppose her practice. “I’ve learned that I need to slow down and recognize where people come from and learn more about them. That has been helpful,” she told me.

I’m watching our health-care communities be pulled apart by conflicts that we’re too nervous to confront head-on and too angry to navigate effectively. I worry about the ability of doctors to keep providing excellent care if we stop trusting each other and lose the trust of our patients. But I know that this rupture isn’t inevitable. We can recognize that everyone is trying to do good and insist that others use language that reflects this.

If we commit to practising civil discourse and calling out its absence when we see it, we simultaneously identify the problem and the solution. It will allow physicians to advocate fiercely for systemic change without disparaging colleagues or patients. This is how we preserve excellence in health care, even when we disagree. And if this practice catches on in the broader cultural zeitgeist, then maybe we can shed our animosity and open the echo chamber doors, enough to let the light in.

Ariel Lefkowitz is a physician and educator based in Toronto.