The “Exceptional” Social Contract of being a Physician

I’ve been thinking a lot lately about a class I attended a couple weeks ago in which our instructor was trying to drive home for us the idea that as physicians we had signed onto an implicit “social contract” with society.

Society has invested in us our education, our prestige as a profession, granted us with respect, autonomy and trust. In return, we owe society to provide our service as healers with kindness and compassion, competence and the highest standard of socially-minded ethics. (The language above is partially stolen from a recent blog post and less recent article on the subject, but my classmates’ arguments fell along much the same lines.)

At least in part, we bought our professor’s argument. We each believed that we had some sort of duty to society as physicians and that in coming to medical school, we were accepting that duty to society. Nevertheless, we did have one objection – how was this any different from any other profession?

Lawyers and plumbers and policemen go through a course of training and licensure before they are allowed to be considered part of their profession. They are also expected to behave with kindness, competence and ethics in what they do. The fact that there are bad plumbers or corrupt policemen does not change the nature of that social contract; rather, the social contract gives us the right to prosecute these professionals for incompetence or unethical behavior, that is, a breach of their social contract. Physicians’ social contract with society is no different in this respect either, as we can be sued for malpractice or heavily criticized for lack of humanity or competence if we behave against the terms outlined above.

Nevertheless, there was a sense – and our professor was pushing for us to acknowledge this – that there was something somehow different about physicians’ relation to society. If a little boy is hit by a car outside your house, our professor argued, as a physician, you alone out of all of your neighbors have a duty to go and try and help him before the EMS team gets there. No one was disputing that we should go try and save the boy if we could, but we objected to the argument that we somehow were obligated to do so by a social contract. To our class, it felt like an incredible oversimplification trying to reduce the humanitarian act of saving a boy’s life into social calculus.

And this puzzled me. I think that social contract theory, in general, can be an incredibly powerful way of describing how society works and formulating some framework for socially-minded ethics. However, in this case, I felt myself agreeing with my classmates. Why?

A couple reasons have come to mind since that class:

1)      There is nothing all that exceptional about physicians’ social contract to society as compared to other professions. As professionals, we all have a duty to use our professional skills to serve society. Though an accountant may not be able to have helped the boy who got hit by a car beyond dialing 9-1-1, he or she still can use his or her skills to make a difference in their community – by teaching people how to better sort out their finances or helping a charity with their accounting. It’s frankly a flight of ego for physicians to believe that they alone have some sort of “special” duty to serve because of the training that they were given. Though how we serve society may be in part defined by our professional skills and abilities, we all have the duty and privilege of serving our society, no matter what our professional status or position.

2)      The most exceptional aspects of a physician’s relationship with society cannot be easily described in terms of a transactional contract. In other words, I feel that physicians are held to a higher standard of moral ethics and societal duty (at least in part) because, as part of our profession, we delve into people’s personal lives and even into their very person to an extent that few other professions do. In the AMA Journal of Ethics article, they lay out the list of things that physicians give and receive from society under the social contract. One of those things is trust – our patients trust us to do the right thing with their bodies so that we are able to do what we need to do in order to make them healthier. However, unlike other societal benefits, trust isn’t something that physicians necessarily ask for or gain anything from. Instead, it is simply the baseline condition necessary to make the patient-physician relationship work, or even exist at all.

In other professions, of course, the client trusts the professional to do right by them. We trust our lawyers to advocate for us, our policemen to protect us, and our plumbers to fix our sinks and toilets to the best of their abilities – and sometimes the consequences can be dire when they do not. However, there is a sense that the trust runs deeper between a patient and his or her physician – that when we entrust someone with our very bodies, we are entrusting them with our lives. Therefore, as physicians, we need to go beyond any personal benefit provided to us by our profession or its relation to society and deeply respect the fact that every patient, when they come to us, has entrusted us with their bodies and their lives.

  • a classmate

    Thank you for sharing your thoughts I really enjoyed this. – a classmate

    • Anonymous

      Thank YOU! Always glad to see classmates make their way here!

  • @RichmondDoc

    I largely agree with your thoughts here. It is true that *all* professionals should have an obligation to work to benefit the community, and that all of us have a duty to give back in whatever capacity we can. However, I do feel that physicians DO have a deeper obligation: unlike other professionals, the very nature and the very core of our profession is to provide care and to help others. Unlike an accountant who can serve others in a more general way (donating their services to a non-profit organization, for example) the health care professions are the only ones where we are morally obligated to provide direct, personal assistance to those who need our aid. I think your final paragraph points in the same direction: “the trust runs deeper between a patient and his or her physician…”.

    I don’t think it’s pompous or self-aggrandizing to assert that physicians have a deeper obligation to our patients and our community than other professions. I think the oath we take as physicians commits us to this deeper obligation; frankly, whether we like it or not. I think the intimate nature of the work we do, and our obligation to personally care for others puts health professionals in a different position relative a social contract.

    The fact that oversight of our profession is retained by our peers and the public (boards of medicine, nursing, etc) suggests that society feels the same way. Although there are professional organizations that provide guidance to accountants and plumbers, there are not independent boards that provide oversight and are responsible for discipline when needed. To me, this speaks to a recognition that the health care professions have a different relationship w/ society than that seen in other professions.

    Great post, and a topic that needs to be addressed. As younger physicians enter the workforce, and the boomers are replaced by the millenials, will the social contract need to be renegotiated? I think it might, and I wonder if our failure to recognize this has been at least partly responsible for current physician workforce issues…

    • Anonymous

      As you noted, as I started expanding upon in the last section, I DO definitely think that physicians do have a deeper obligation, but trying to define that obligation in terms of the social contract (while a possible starting point) is deeply insufficient because it doesn’t get at this deep obligation. It leads to the danger of trying to think of what society is giving us, as physicians, in exchange for what we owe society. Do the societal privileges of self-policing and general prestige really make up for the sometimes superhuman hours we put in? or the sacrifices we make in our personal lives to do right by our patients? I don’t really think so, but that by no means implies that I or anyone else in my generation thinks that we _don’t_ have an obligation to do the best we can for our patients.

      Instead, in the words of my classmates, it cheapens the acts of charity that physicians do every day to declare that it is due to some sort of social contract, done in exchange for some societal good. From the perspective of the younger physicians entering the workforce, we chose this profession because we care. We already do what we can to make a difference in free clinic and other student organizations. We need inspiration, lessons to make sure what we do work and encouragement to keep us going — not contracts to try and convince us to care about what we already do care about.

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  • a classmate

    It is interesting that you think that the social contract may need to be “renegotiated.” How do you think the social contract used to be defined? In the days before RBRV’s, medicine for the most part provided far greater financial rewards to physicians. What was different then now than today?

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  • RichmondDoc

    Emily;

    I think we’re actually more alike in how we look at this issue than might be
    apparent at first glance. I agree with you in terms of motivation for medical
    careers: I consider medicine a service vocation; far more than just a job. I
    think the best reason (in my mind, the only reason) to enter a medical career is because you feel called to do it. Because you feel you have something to offer to provide care for, and relief to, others who are ill. My career thus far has taken me to work in urban and rural underserved sites and to develop
    international medical relief programs because I feel I am called to do that and
    that I am capable of doing it. One of our resdiency faculty used to say “If you
    not sure what to do, always do the RIGHT thing.” Not what’s easy or what you
    prefer, but what is right according to your duty to the patient. Hence my work in underserved and marginalized communities.

    I see the social contract concept as being applied at the larger level, beyond
    individual motivation. I think any profession develops a relationship with the society in which it works; that “social contract” dictates how the profession as a whole interacts with society. That social contract is what allows the profession of “physician” to sustain itself beyond the individual drive and vision of each provider.

    I agree that the concept of the social contract is insufficient to describe why each of us enters the profession, but the profession requires some sort of understanding with society as to how it can be sustained. The expectation that physicians will have a functional health care system in which to work, the understanding that our pay and lifestyle will be in some way commensurate with the years given up to training–these “agreements” are in place in order to have a physician profession vs. individual healers. And in retun, any given physician is expected to behave in certain ways in regard to society and individual patients.

    I also wonder if the model of a social contract explains why physicians in the US work differently than elsewhere. The autonomy and independence of US physicians is so high on our list of expectations that it might explain why we don’t have a true health care system, whereas in other countries physicians’ views that they are working toward the greater good might allow them to subsume personal preferences in favor of strenghthening the system overall.

    Sorry to be so long-winded; never took a philosphy or rhetoric class and so don’t do well compressing my arguments.

    I look forward to hearing your thoughts.

    thanks

    mark

    • Anonymous

      I think that we definitely do agree more than we disagree and that perhaps in my post I may have been too blunt and dismissive of social contract theory as a generally useful way for describing professional responsibility (and within that, there may be some really interesting & unique aspects regarding physicians’ particular responsibility towards society).

      However, in the class discussion that I am referencing, my classmates and I were being introduced to the social contract as a way for elucidating our individual motivations/duties towards society as doctors-to-be. I think the punchline was to inspire us to care for the underserved. In that sense, I don’t think it works well.

      In a global sense, though, I do think that there is some merit to the social contract of professionals and am interested in thinking more about how that applies to physicians. As someone just starting out though, this general professional community is one that I’m still a very recent immigrant to, so I do not feel comfortable yet stating my position on how it is defined. I will think more about it though as my training proceeds, and hope to have more conversations with you about it as well.

      All the best,

      Emily

  • RichmondDoc

    Emily;

    I would argue your lecturer got it backwards. One should not look at an implicit social contract and then decide whether a medical career would be the best option. Instead, one should determine if medicine is their vocation and *then* decide how to approach the social contract. Many physicians emphasize what they are owed by the arrangment (money/lifestyle) and lose sight of what is expected of them (the actual work of caring for others).

    I think if you go into medicine for what I believe are the “right” reasons, then one will normally find some way to work w/ underserved patients. I think the challenge is finding those med school applicants with the needed motivation/orientation from the beginning.

    I also think the social contract idea changes over time. How your generation of physicians interact with society will be different in many ways from how my generation does. Doctors expect more work/life balance, more time away from clinical obligations. This is an ongoing and dynamic process.

    Look forward to any future discussion.

    mark

  • Jgaudet5

    Actually, courts across the nation have upheld the notion that despite the public’s beliefs, police have no duty to protect individuals (Warren vs. District of Columbia). A little off-topic perhaps, but this is the major reason the individual’s right to bear arms for personal protection is important. You could never successfully file a civil suit against a police officer, department, or government for failing to protect your person or property. When push comes to shove, the individual is 100% responsible for their own well-being.