Saturday, September 11, 2010

The Social Contract

Reading through old, saved links I found one that I had overlooked the first time around.  The American Medical Association Journal of Ethics posted on online article discussing the nature of the social contract between physicians and the general society. 

In the article, the authors lay out the fundamental tenets of what this social contract requires in order to be successful.  As with all contracts, there are obligations on each side:

Societal expectations of physicians:
  • The services of the healer
  • Guaranteed competence
  • Altruistic service
  • Morality and integrity
  • Promotion of the public good
  • Transparency
  • Accountability
In return, physicians expect the following out of society:
  • Autonomy
  • Trust
  • Monopoly
  • Status and rewards
  • Self-regulation
  • Functioning health care system
I think that in an ideal situation, these agreements and stipulations make sense.  In essence, society expects to have competent and trusted healers who put patients' well being at the forefront, who will be open and accountable for their actions, and who work toward the greater good.  Meanwhile, physicians expect to be given trust and freedom to work individually within a viable health care system, to regulate themselves, and to be given both tangible and intangible rewards for being the sole providers of designated health care services.  If both sides of the agreement were being lived up to, then this construct would make sense.  But I fear that part of our current health care issues (costs, access, etc) result from each side's reneging on this contract.

As a physician, it is easy (and far more comfortable) to point the finger at society's failings.  Physicians can claim that society has failed to give the promised monopoly, as mid-level providers and physician extenders take larger roles in health care.  We can note that the status and rewards physicians have today are not equal to those given years ago.  And we can point at the dysfunctional health care "system" as a fundamental flaw that harms our ability to provide care.  Physicians can easily claim to be the aggrieved party in this arrangement.

But we must look honestly at our role in the arrangement, and acknowledge that our actions have helped lead to our current situation, and the weakening social contract.  Because we claim autonomy, we often act in our own best interests (and not necessarily from the perspective of enlightened self interest) and make decisions that do not reliably benefit the common good.  In a health care system where volume is rewarded, we do more tests and see more patients--which leads to increased costs for all, and weakens our health care system.  We get upset when we are asked to be transparent about our actions, or when we are held accountable for what we have done.  We are supposed to be altruistic at all times, but our actions are often tinged with at least a hint of self-interest (income, scheduling, etc).

The social contract is a fundamental construct that establishes the rules and roles between professions and society at large.  In the medical realm, though, I fear that both sides have violated its terms.  And I believe that both sides need to take responsibility and work to address this.

Physicians need to recognize the trusted role we have and the sensitive and intimate nature of our work.  We need to be truly altruistic, and work to meet patients' needs (and act in their best interest) at all times.  We need to be open and transparent about what we do, and we need to honestly deal with colleagues who are not competent or who do not meed professional obligations.  And we need to be constantly aware of how our decisions will affect society at large--not just our patients.

Similarly, society needs to ensure that physicians are reimbursed in ways that make it possible to pay off student loans and to make up for the fact that we lose 7 to 10 of our most productive years to complete medical school and post-graduate training.  We need to be given (and we need to earn) the trust to practice without excessive intrusions from insurance companies or from regulators.  And, as a society, we need to ensure that the health care system in place truly allows physicians to provide the care we are expected to.

In medical school, if one is asked a question about the cause of any illness, a safe cop-out answer is "multifactorial".  Almost no disease can be traced to a single cause.  The current failures of our health care system are similarly multifactorial and there is plenty of finger-pointing to go around.  But by refocusing on the social contract, and the agreements (implicit or explicit) necessary for the medical profession to fulfill its role, we might be able to come up with a plan to start making things right.


Carolyn Hastie said...

Mark, you have presented a very careful, thoughtful synopsis of the situation facing public health and medicine. Thank you for your insights.

Carolyn Hastie said...

I've been thinking and would love to know your take on the tensions between nursing and medicine and midwifery and medicine.

mark said...

Thanks for the comments, Carolyn.

The reply got long, so I made it its own post:

Let me know what you think.

DrSnit said...

I just blogged my comment b/c it was too long: