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Professionalism and Medicine's Social Contract with Society

Cruess, Sylvia, R

Clinical Orthopaedics and Related Research: August 2006 - Volume 449 - Issue - p 170-176
doi: 10.1097/01.blo.0000229275.66570.97
SECTION I: SYMPOSIUM II: Professionalism
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Medicine's relationship with society has been described as a social contract: an “as if” contract with obligations and expectations on the part of both society and medicine, “each of the other”. The term is often used without elaboration by those writing on professionalism in medicine. Based on the literature, society's expectations of medicine are: the services of the healer, assured competence, altruistic service, morality and integrity, accountability, transparency, objective advice, and promotion of the public good. Medicine's expectations of society are: trust, autonomy, self-regulation, a health care system that is value-driven and adequately funded, participation in public policy, shared responsibility for health, a monopoly, and both non-financial and financial rewards. The recognition of these expectations is important as they serve as the basis of a series of obligations which are necessary for the maintenance of medicine as a profession. Mutual trust and reasonable demands are required of both parties to the contract.

From the Centre for Medical Education, McGill University, Montreal, Quebec, Canada.

The author certifies that she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

Correspondence to: Sylvia R. Cruess, MD, Centre for Medical Education, Lady Meredith House, McGill University, 1110 Pine Ave. W., Montreal, Quebec, H3A 1A3, Canada. Phone: 514-398-7331; Fax: 514-398-7246; E-mail: sylvia.cruess@mcgill.ca.

The concept of a social contract was proposed by Hobbes, Locke, and Rousseau over 300 years ago to explain the relationship between citizens and those governing them. They suggested it was based on a reciprocal set of rights and privileges.17 In its original form, philosophers do not believe it adequately describes contemporary society, but it has persisted in political science and has been used by social scientists, lawyers, medical administrators, and physicians to describe the relationship between the medical profession and the society that grants medicine its privileges.10,12,22,27,44,48,52,54

Society used the preexisting professions as a means of organizing delivery of necessary selected complex services, such as law, the ministry, and medicine.9 When the modern medical profession was established by licensing laws in the mid-19th century, society granted physicians a monopoly over the use of medicine's knowledge base, autonomy in practice, status, and the privilege of self-regulation. This was based on the understanding the profession would assure the competence of its members, who would be devoted to altruistic service, demonstrate morality and integrity in all of their activities, and address issues of societal concern in their domain. This was and remains the essence of the social contract, which is based on professionalism. Fundamental to this relationship is trust. Society must trust individual physicians34 and physicians must believe society will meet its reasonable expectations.16

Starr51 first used the word contract in relation to health-care, stating the contract was in the process of being revised to better cope with the tensions between the medical profession and society in an increasingly complex and expensive healthcare system. Thus the social contract, which has existed since the modern professions were developed in the mid-19th century, was only articulated when the need for change became apparent. Until the past decade, professionalism was rarely taught in medical schools or during postgraduate training, although it was frequently invoked as an ideal to be pursued without defining or describing it. Medicine in most countries was a fairly homogenous profession serving societies that were not very diverse. Professionalism and professional values were shared and passed on by respected role models during the process of socialization. Trust in individual physicians and in the medical profession was high in the latter part of the 19th and first half of the 20th century.25,46,56 Clearly, the general public believed the medical profession was not abusing its monopoly, was self-regulating well enough so standards were acceptable, and the concept of the profession was worth supporting as a means of organizing the delivery of healthcare. Difficulties arose throughout the world during the 1960s and 1970s. Medicine was transformed from a cottage industry to an activity that consumes a substantial portion of each nation's wealth. An increasingly diverse and questioning society greeted traditional values and all sources of authority with skepticism. Because of the status of the professions and the power they were able to exert, their performance was scrutinized carefully. Medicine's failures-and they were and are real-were recorded extensively, largely in the social sciences literature.12,29,51 The most telling criticisms were of individual physicians, and the profession as a whole, exploiting their privileged position to pursue their own self-interest rather than serving the needs of their patients and society; medicine had failed to self-regulate, using weak standards often capriciously applied, and many of medicine's institutions were more devoted to serving their own members than serving society. Essentially, medicine was accused of failing to fulfill some of its central obligations under the social contract.

The concept of the social contract has been described by Gough as follows: “… the rights and duties of the state and its citizens … are reciprocal and the recognition of this reciprocity constitutes a relationship which by analogy can be called a social contract.”17 Its details are difficult to delineate for two reasons. First, much of it is unwritten and what is in print is found in a wide variety of places-codes of ethics, legislation granting licensure, the laws establishing the structure of the healthcare system, the rules and regulations of Medicare and Medicaid, and a host of other locations. Secondly, the modern contract is constantly evolving as the healthcare system changes, as societal needs and expectations alter, and as physician's expectations change. In spite of these difficulties and of differences in cultures and the structure of healthcare systems in different countries, there are some universal values that remain relatively constant.35 These values, which medicine and society share, give rise to a set of mutual expectations which, although not always articulated or made explicit, provide the terms of the social contract under which medicine and other professions exist in a society (Table 1).

TABLE 1

TABLE 1

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Societal Expectations of Medicine

Services of the Healer

Every physician during their practice simultaneously fills two roles: healer and professional.9 The role of the healer has been with us since before recorded history. Western medicine traces its origins to Hellenic Greece, with the Hippocratic and Aesklepian traditions forming an important part of medicine's self-image. The professions have different origins, having arisen in the guilds and universities of medieval Europe and England, but they had little impact on society, serving only a small elite.25,51,54 As the industrial revolution provided sufficient wealth so the population at large could purchase healthcare, science made healthcare worth purchasing. Society then needed some means of organizing the delivery of these increasingly complex services and turned to the preexisting concept of the profession to accomplish this. At this point, the healer acquired the rights, privileges, and the obligations of the professional. However, it cannot be stated too strongly what individual patients want and require is the traditional role of a competent and caring healer. Professionalism is a means to an end.

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Assured Competence

Society, acting through the state, has granted the professions the privilege of self-regulation by delegating some of its power to them. As a result, under the social contract, medicine is expected to assure the competence of each practicing physician.8,31,52 It does this by setting and maintaining standards for education, training, and practice. This includes identifying incompetent, unprofessional, or unethical practitioners and assisting them to correct their deficiencies or removing them from practice to where they can do no harm.25,51,54

Each physician must assume individual responsibility to be ethical and competent, but society expects more. Practitioners are also responsible for the performance of their colleagues and must support the profession's self-regulatory activities and participate in them.8,38,40

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Altruistic Service

Physicians are required in the course of the practice of medicine to ask intrusive questions, which invade a patient's privacy, and to carry out invasive procedures. This can only be permitted in an atmosphere of trust and this trust depends on the patient's belief the physician will constantly place the patient's interest before their own. This is the meaning of altruism.2,16,34,44 There has always been a conflict between altruism and self-interest. Until a few decades ago, individual physicians demonstrated their altruism by caring for the indigent at no charge. The introduction of Medicare and Medicaid in the United States and national health insurance in many countries, has largely removed this opportunity in the developed world. Physician remuneration increased, in absolute and relative terms, leading many to state the medical profession was abusing its privileged status and monopoly for its own gain at the expense of the public good.12,29

The recent generation of physicians has objected to the committment to altruism, feeling its demands have the potential to lead to an unhealthy lifestyle with stress and burnout.3,4,56 As this aspect of the social contract is renegotiated to adapt to the needs of younger members of the profession, it is essential the public continue to trust their physician will meet their needs and be there when they require care. This is an important element in the ability of the physician to heal.39 Assuring the public of medicine's altruism is possible if the public does not put unreasonable demands on physicians, and proper organization (eg, group practices) coupled with good communication, should be capable of meeting reasonable societal expectations. As altruism is such an important societal expectation, it becomes incumbent upon each physician to consistently demonstrate it in their day-to-day lives.52

Medicine's institutions and associations must also show altruism and place the welfare of society above the profession and its members. There is some evidence the loss of trust in medicine as a whole during the past few decades resulted not as much from the actions of individual physicians, but those of medicine's associations, who are believed to have given priority to representing their members, rather than promoting societal good.40,52,56

It seems axiomatic that associations are collections of individuals, and consequently individual physicians must take some responsibility for the performance of their associations.

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Morality, Integrity, and Honesty

Morality is without question the core of medical professionalism.20,21 To gain and support patient trust, the nature of medical work requires physicians be regarded as demonstrating morality and integrity and honesty.20,26 This must occur not only when they are functioning as professionals, but in their day-to-day lives as well. It is not possible to maintain trust in a physician whose behavior inside and outside of medicine does not reflect these qualities. As Brandeis pointed out, professionals are held to higher standards than are members of other occupations7 and higher standards are a major expectation of the public.

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Accountability

The professions have always been accountable, but medicine's accountability in contemporary society has been greatly expanded.11 Part of this results from the cost of modern healthcare, part from the information age, which has both informed and empowered patients, and part because of the questioning of all forms of authority that were previously the beneficiaries of blind trust.9,25,51

Medicine's traditional accountability is to patients, to colleagues, for the advice given on public policy, and for the results of self-regulatory activities.25,51,54 The well-documented failure to adequately monitor standards of practice and the abuse of the collegiality inherent in professionalism to protect incompetent, unethical, or unprofessional conduct in highly publicized cases1,23,49 has lead to an erosion of trust46,52 and diminished medicine's ability to influence the newer levels of accountability as they have been established.

In addition to the traditional areas where increased transparency and documentation are expected, physicians are now accountable in economic and political terms.11,49 The economic accountability is to the current payers for healthcare-the state and/or the market. Physicians are asked to ensure their services are cost-effective, and are, to an increasing degree, being asked to include in their decision-making the impact on the overall economics of healthcare. In political terms, they have been given responsibility for the health of populations and for some aspects of the overall functioning of the healthcare system. Without question, the newer levels of accountability are now prominent parts of a physician's daily life and regarded as an important aspect of the social contract.23,52,54

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Transparency

The professions traditionally carried out their deliberations in a relatively closed fashion.12,29,51 This was probably unintentional, as there was little public interest in their activities. However, as increasing levels of accountability were demanded, the profession came to be regarded as overly secretive in its processes and relatively insensitive to the needs of the public.29 Criticism was leveled at the methods of setting standards and over disciplinary procedures in many jurisdictions. Consequently, public membership on regulatory bodies was established or increased and public input into discipline and the setting and maintenance of standards has expanded.24,54 As a result of medicine's own initiatives, public pressure, and changes in legislation, the deliberations of most important medical organizations that have an impact on the public are now carried out in a much more open and transparent fashion.

This is clearly an important current public expectation, and it can be anticipated even more openness will be required in the future.

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Source of Objective Advice

Under the social contract, licensing laws grant physicians a monopoly over the use of medicine's knowledge base on the clear understanding this knowledge will be used to address issues promoting the health of individual patients and of society as a whole.18,52,54 Members of the medical profession are thus expected to react to concerns about the structure and cost of the healthcare system, the state of the nation's health, and new situations in medicine's domain, such as unexpected epidemics or bioterrorism.37 In recent years, medicine's advice in the area of public policy has frequently not been solicited or has been ignored, but individual citizens still expect medicine to use its expertise in an objective fashion for the betterment of society.18

In the 21st century when the cost of medical care has imposed limits on the resources available for care, physicians are often faced with a conflict between the needs of an individual patient and the need for society to limit resources.5,52,54 This dilemma will grow in the upcoming decades and the advice of all with expertise on the impact of these limitations on patients and on society will be needed to arrive at decisions that are just and effective.

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Promotion of the Public Good

Medicine has been granted status, prestige, and financial rewards many believe are only justified if individual physicians and the profession are devoted to the public good.42 Practitioners must be physician-citizens devoted to the betterment of the general welfare, and their organizations have similar responsibilities.13,40,52,54 Three eminent social scientists have emphasized the importance of this aspect of the contract: Sullivan's “civic professionalism”,54 Freidson's “reborn professionalism”,13 and Steven's “public role”.52

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Medicine's Expectations under the Social Contract

If the concept of a social contract is valid, and if it serves as the basis for societal expectations from individual physicians and the medical profession, it follows individual physicians and medicine as a profession can also have reasonable expectations from society. There are two points worthy of emphasis. In the first place, society's trust in individual physicians and in the profession is heavily influenced by how medicine is perceived to meet its obligations. It has been observed medicine's failings have resulted in a loss of trust34,46,52 and as a result, the social contract has been altered.10,25,54 However, if physicians are to be expected to put the welfare of others above their own, they themselves must trust the system in which they are working. One can interpret surveys of physician dissatisfaction as indicating the sense of disillusionment felt is because they believe society is not meeting some of its obligations.28,47 Secondly, if an implicit contract exists, then negotiating the details of this contract becomes a legitimate professional activity.55 Obviously, the medical profession would be wise to emphasize those aspects that promote the public good, but ensuring proper conditions of work and reasonable remuneration is entirely appropriate.41 However, during these negotiations, which take place in a variety of settings and situations, medicine must place the public interest first as any other approach is inconsistent with the tradition of the professional and will be unsuccessful in the long term.14,52,54

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Trust

With the onset of the questioning society, trust, which had been given blindly, now must be earned. Despite the failings of some individual physicians and the perception medicine's organizations may have favored the interests of their own members over the public good, medicine remains among the most trusted occupations and its income remains high.46,51 Most physicians demonstrate morality and integrity, work to remain competent, and carry out their activities to the best of their abilities while demonstrating concern for the welfare of their patients. They believe this should be recognized and they have earned the trust of those they serve. Contemporary physicians are more concerned about lack of trust than they are about the details of practice or financial matters28,47 and appear to believe society is not meeting its legitimate expectations. To quote an eminent sociologist: “Professionalism is based on the real character of certain services; it is not a clever invention of selfish minds.”32 Medicine must convince society by its conduct this is correct because maintaining trust is central to the process of healing.19

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Autonomy

Autonomy has been described by sociologists as a hallmark of a profession.12,25,51 Thus, under the contract, physicians expect to be granted sufficient freedom in practice so they may act in the best interests of their patients. This autonomy has never been unlimited. Customs, codes of ethics, and legal constraints have always limited it. However, the ability of a physician, in collaboration with a patient, to determine a proper course of action remains sacrosanct to the practice of medicine. If the medical profession feels it is no longer able to act in the best interest of its patients, it can legitimately resist unreasonable intrusions into its autonomy and can insist on the maintenance of conditions that will ensure it is able to serve patients. Unwarranted intrusions, such as gag laws, were deemed to be unacceptable and it is important the profession and society rejected them. Second opinions, and clinical guidelines, while perhaps resented when rigidly applied, have been deemed to be reasonable for establishing standards of care. Sufficient autonomy in practice will always remain an important expectation of the profession.

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Self-Regulation

The modern medical profession was granted the privilege of self-regulation as part of the legislation establishing licensure25,51 and this remains an expectation. The complexity of medicine's knowledge base and of the practice of medicine is the principle justification for self-regulation. Because of this complexity, it is difficult, but not impossible, for the state or the market to regulate the practice of medicine. While self-regulation has been questioned, in large part because of medicine's failures in this area, most nonmedical observers, including social scientists, have concluded it has advantages to society.50-52,54

However, when the profession fails to carry out its duties to the satisfaction of society, the contract may be altered and the state may repatriate some self-regulatory activities, as has happened recently in Britain.24,49 Thus, medicine's obligation to self-regulate, and to be seen to self-regulate well, becomes of extreme importance.

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A Value-driven and Adequately Funded Healthcare System

It is society's right to determine the structure and organization of the healthcare system they desire, and physicians have an obligation to work in the system in place. The entry of the state and the corporate sector into the health-care field has dramatically altered the social contract.30 Their efforts at cost control, relying heavily on “accounting logic,”36 have transformed healthcare delivery and resulted in a dramatic diminution of medicine's influence in healthcare. The negotiating stance of the profession has often been depicted as self-serving.

However, the healthcare system can subvert the values of the healer and the professional. The drive toward cost containment has decreased the time physicians can provide for caring and compassion.31 The pressure to make physicians into entrepreneurs carries the risk of losing their commitment to the primacy of patient needs and their sense of collegiality.33

Physicians are dissatisfied with healthcare systems in most of the developed world, feeling their influence makes it difficult to meet public expectations in a timely and effective manner.4 Implicit in the allocation of the task of caring for the health of citizens is the obligation of society, through the state, the corporate, or private sector, charitable organizations, or a combination of them all, to provide a healthcare system demonstrating inherent justice, fairness, and morality. It must also ensure sufficient resources so individual physicians can meet their responsibilities to patients and the profession collectively may meet its obligations to society.

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Role in Public Policy

Without question, medicine is frequently regarded as being yet another vested interest group when it attempts to intervene in the elaboration of public policy, and sometimes this is true.25,29,51,52 However, physicians continue to believe and expect proper use of their expertise can improve healthcare and the health of populations15,45,52 as has been shown to be true during epidemics and other national emergencies.37

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Patients and Society Share Responsibility for Health

It is increasingly apparent many influences leading to loss of health are beyond the control of physicians and the medical profession. Lifestyle, the environment, poverty, and a host of factors influence the health and well-being of individual patients. This, and the emergence of the concept of patient autonomy,35 has led to the expectation patients will accept some responsibility for their own health and will work with their doctors to promote it. It is also an expectation society will address those causes of ill health that require collective action to address.35

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Monopoly

The modern profession of medicine dates from the middle of the 19th century when licensing laws granted physicians the exclusive right to practice medicine.25,51 Before then, the healing arts were essentially unregulated and allopathic medicine competed (sometimes not very effectively) with alternative forms of healing. Although many activities previously considered exclusive to the practice of medicine have been taken over by other healthcare professionals, medicine's monopoly over its core activities remains.

As one looks into the future, one can predict the boundaries of the monopoly will change but medicine will continue to control the central activities of diagnosing and treating human disease. As it is determined other healthcare professionals are competent to carry out some aspects previously reserved for the medical profession, modern science will add others to medicine's monopoly. Medicine's attitude in approaching this issue should clearly be determined by what is best for the patient and society, rather than being overprotective of its jurisdiction. Placing the public good first is a professional obligation and a fundamental part of the social contract. However, medicine can legitimately expect the core activities of a physician will continue to be protected by licensing laws.

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Status and Rewards

Through the ages, the healer and the professional have received financial and nonfinancial rewards from society. Before the practice of medicine became as lucrative as it did during latter part of the 20th century, status in the community and the respect of colleagues and fellow citizens were important aspects of the attractiveness of medicine as a career. They remain an expectation of physicians today.25,33,51

It is also evident contemporary physicians expect to receive reasonable remuneration for their services, and they do. Medicine remains one of the best paid occupations.

Recent changes in the healthcare systems and hence in the social contract have caused physicians to question their treatment by society, and it appears changes in the nonfinancial parts of the contract, trust, status and respect as well as autonomy, are of more concern than are financial matters.28,34,47

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DISCUSSION

A tacit agreement exists between medicine and society, which has been called a social contract. Because society has chosen to use the concept of the profession as a means of organizing the services of the healer, professionalism has come to serve as the basis of medicine's social contract. Essential portions of what is expected of the physician as healer are determined by what it means to be a professional in contemporary society. It is incumbent upon the medical profession to understand professionalism and the obligations necessary to sustain it because these serve as the basis for societal expectations. It is also necessary for those representing society to understand the presence and nature of the contract and society's obligations under it.

Two points should be emphasized. First, trust is essential if the contract is to function.19,39 Healing is jeopardized when physicians are not trusted. Physicians must also have trust in the fairness of the healthcare system or they may cease to act in a professional way,6,43 with unfortunate consequences for the system. It is therefore important to both parties to the contract to maintain high levels of trust.

Second, unreasonable expectations by either side can lead to disillusionment and a loss of trust. For example, for a physician at any level to be on-call too often in the name of altruism is unreasonable, as is a medical profession demanding resources beyond society's capabilities. The contract can only function properly if each side agrees to have reasonable expectations of the other.

There are important and valid reasons for both sides to preserve professionalism as the basis of the contract. Sullivan says it well, “Neither economic incentives, nor technology, nor administrative control has proved an effective surrogate to a commitment to integrity evoked in the ideal of professionalism.”53

Acknowledgment

This material is based in part on a chapter entitled “Professionalism and the Social Contract” in “Healing as Vocation: A Primer on Professionalism” edited by K. Parsi and M. Sheehan to be published by Rowman and Littlefield in 2006.

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