Disease,illness,sickness and the contract with patients

Introduction

The recent launch of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) has stimulated debate about the diagnosis and classification of mental illness, reflecting the differing perspectives of professionals and other stakeholders. As we try to make sense of this debate, it is necessary to consider the social context within which we practise. Each society makes decisions about the resources it is prepared to devote to healthcare, with these resources then allocated according to priorities that are also chosen by society. Factors such as finances, and clinical pressures such as the demands and needs of patients, influence the actual allocation of resources, as do demographics, prevalent social and political ideologies and the economic context.

The relationship between psychiatrists and society is complex. The social contract between medicine, medical practitioners (in this case psychiatrists) and the wider population is implicit, rather than explicit (Cruess and Cruess, 2011). The relationship between doctors and potential patients (all members of society, as anyone may become ill) influences the context and the setting within which the therapeutic interaction takes place.

Disease, illness and sickness

In psychiatry, as in the rest of medicine, it has been argued (see Eisenberg, 1977) that there is a need to differentiate between ‘disease’ and ‘illness’. Disease is about pathology, whereas illness develops when disease starts to affect the patient as a whole and others around them. Disease literally means ‘dis-ease’: a malfunctioning of a biological or psychological process; illness refers to both psychosocial experience and perceived disease. Illness thus includes perception of the problem and its affective, social and relational aspects. As Eisenberg (1977) reminds us, patients suffer illness and are therefore, by and large, interested in illness and its implications; but doctors are trained to diagnose, deal with and treat diseases. This gives rise to a major discontinuity in states of being and perceived role performances, thereby creating dissonance and a disjunction between the patient and the doctor. Although patients are often interested in diagnosis, they want to know why something has gone wrong, which requires a move away from symptoms to functioning. Dealing with these patient expectations is a major challenge for doctors. Nonetheless, diagnosis is important for a number of reasons, including the collection of epidemiological information and the allocation of funding and resources. Although this separation and dissonance between the patient and the doctor often generates a gulf in terms of expectations and goals, a good clinician has to be able to bridge this divide.

To make matters even more complex, in the middle of this dichotomy there is also the concept of ‘sickness’ as decided by society. It is society that decides what is ‘deviant’ and what is seen as ‘sick’, attracting benefits such as sick leave. For any classification system, doctors determine what is pathological and try to classify it accordingly. DSM-5 is a response to, amongst other things, what goes on in the USA (Malhi, 2013a, 2013b), where local cultural values decide what constitutes pathology and what does not. In psychiatry, some of the variation is biological, some social, some psychological and some statistical. The time is ripe for psychiatry and society to review their social contract in an effort to understand the role diagnosis plays, and for both parties in the equation to develop an agreed system that can be used wisely (Bhugra et al., 2011a).

The social contract

Over the past few decades, society’s expectations of the medical profession have undergone a major change. The concept of the ‘social contract’ between psychiatry and society provides us with a useful framework within which to consider these on-going changes.

The concept of a social contract dates back to ancient history, with the original social contract between a king and his subjects being, as described by Gough (1957), implicit, not explicit. The subjects promised obedience to the king, who in return offered them protection and good government. Both sides had to keep their side of this implicit agreement, otherwise the contract, and the subjects’ allegiance, would end. As we think about how societies have developed, we can extend the notion of a social contract and apply it to other settings, such as healthcare. Society determines the systems and structures of the delivery of healthcare, along with the allocation of resources to such care. The relationship between healthcare systems and society is thus mutually inter-dependent. This contract is implicit and, while it is in fact negotiated, often no explicit negotiation takes place. Sometimes professionals are given the freedom to determine what is needed for a healthy society, whereas at other times stakeholders dictate to the profession what is needed and required. In addition, professionals themselves are both providers and consumers of healthcare, raising some ethical issues.

For some specialties, such as psychiatry, the contract inevitably focuses on risk assessment and risk management. The clinical practice of medicine occurs within the social context itself. The delivery of healthcare is a mutually profitable and negotiable contract. The profession controls standards and the ability to meet societal expectations. For certain medical specialties, such as general practice, psychiatry or pathology, there are variations in expectations and delivery. This is one of the factors that makes understanding DSM-5 somewhat difficult. In public sector healthcare delivery, politicians and civil servants are the key stakeholders who negotiate on behalf of the society and patients. Politicians theoretically represent society and patients, but this is often not the case in reality. This complex relationship causes significant distress on both sides of the contractual obligations. Bhugra et al. (2008, 2009, 2011b) highlight what stakeholders expect of psychiatry and also what psychiatrists expect regarding professionalism and professional values from each other and from their trainees.

The ethics and morality of medical practice

Classification of diseases is a professional activity, although it cannot be exclusive. Ethical aspects of professional clinical practice also need to be considered. In response to medical scandals and political changes, expectations within the professions have led to greater pressure on clinicians in general, and on doctors in particular. Society expects the health practitioner to provide the services of a competent healer with ethical and moral values. Doctors in return expect to be trusted to run an adequately funded healthcare system in which they can work. Social expectations, availability and access to resources, adequate funding of the healthcare system on the one side, and changing interventions, newer technologies and advances on the other, can contribute to mutual misunderstanding. The resulting tensions influence the contractual obligations. All members of society, including those who become ill (the patients), have a responsibility for health. Clinicians have a dual role: as members of the society and as care providers. Society’s expectations about classification are important, but professionals need to discuss these expectations both with stakeholders and with society more broadly. Whether they move from a classification of diseases to that of illnesses is an important factor in the negotiation of this contract. Both as specialists and as members of the society, doctors carry moral values, probity and honesty in their practice. The practice of medicine also carries with it certain social status and adequate financial recompense.

The tension embedded within this implicit contract is twofold. First, the contract is unwritten but the ethical codes are not. Second, the speed of change and technical advance leads to unrealistic expectations on the part of the society, which may not be met, making doctors feel vulnerable to criticism. When this happens, there is another potential problem: society moves to ‘control’ doctors by chipping away at self-regulation and their professional status. Any sudden change in public expectations, whether realistic or unrealistic, can produce further tensions in the contract. Consequently, this contract keeps evolving in response to various factors, some of which may not be entirely clear. Both sides in the contract require change if the contract is to continue, survive and be fulfilled. This negotiation must lead to a ‘new professionalism’. By and large, doctors are honest, trustworthy and driven by a desire to ‘do the right thing’ and ‘do things right’. The challenge is how much freedom they are allowed to do so by the other party to the contract. Disenchantment will result from a society that is too interfering, too controlling or too distant, with inadequate levels of support and resources. This tension can and must be resolved in a constructive manner so that both sides are able to manage the contract.

Economic downturn and the renegotiation of the social contract

Economic downturn in many parts of the world in recent years has proved a catalyst for the renegotiation of the social contract for healthcare. It is far too early to fully assess the total impact of recent changes and upheavals in healthcare systems such as the UK’s NHS, but this process of change seems inevitable in many healthcare systems worldwide. Patient care is at the core of healthcare delivery. Any society that faces a major economic downturn, with associated changes in demographics and differing patient and carer expectations, must ensure that the social contract is renewed and renegotiated. Increasing consumerism and changes in the roles of other professionals contribute further to pressure for the medical profession to be clear about what it stands for. Patients expect competent collaborative treatment with joint decision making from their doctors. The employers of doctors also expect collaboration and competence. How these three components within the contract are brought together can be resolved by a clearer understanding of changing circumstances and societal expectations. We can find a way forward by both working with and educating key stakeholders to have realistic expectations, whilst also engaging in a dialogue with them so that we understand the concerns of patients and those of society. Instilling professional values at an early stage with a clear understanding of ethical codes will enable society to reflect on what it expects from its doctors and also ensure that doctors are aware of what they can expect in return.

The professional identity of the psychiatrist

Though many of these issues apply to doctors as a whole, they are particularly problematic for psychiatrists, who have struggled to define their professionalism and subject matter (Malhi, 2008). Like all professionals, psychiatrists too aspire to professional standards and the formation of recognised groups, but the assignment of responsibilities and who ultimately defines the roles of psychiatrist has often created uncertainty. Standards of practice are widely promulgated and generally accepted; however, adhering to these and allowing for individual and personal interpretation demands flexibility and the ability to exercise judgement. These professional ‘constraints’ are further couched within societal expectations and the many perceptions society has of a psychiatrist’s role. At its broadest, psychiatrists are expected to define normality, exert control and even divine the future by assessing risk.

Assessing personality, understanding an individual and their circumstances, drawing links to potential factors and life, and underpinning all of this with putative neurobiological models is a sophisticated task, which, while forming the core of psychiatric formulation and management, is in practice perhaps the least recognised aspect of the profession. With the release of DSM-5, reductionist views of psychiatry have re-emerged. A simplistic checklist approach to diagnoses undermines the skills of psychiatrists and the importance of their role in defining disease, illness and sickness of the mind. But psychiatrists are to some extent to blame for allowing their language and role to be diluted and absorbed by others. A lack of precision around terminology, and the seemingly constant migration outwards of boundaries engulfing normalcy within psychiatric diagnoses, has meant that many ‘para-psychiatric professions’ have subsumed some of the key psychiatric roles and functions.

The crux of the problem is that judgement and responsibility have been divorced, such that while judgement regarding diagnosis and management can be proffered by all and sundry, responsibility remains the purview of psychiatrists. Put simply, psychiatrists are left holding the can whilst everyone is able to sit at the table to make decisions, often on the psychiatrist’s behalf. In practice, clinical judgement requires sophisticated, balanced reasoning and the careful evaluation of a multitude of factors. It is important, therefore, that psychiatrists have both medical training and, at the same time, an extended psychiatric training experience of managing patients with mental illness. Therefore, in addition to renewing our contract with society, perhaps we, as psychiatrists, also need to read that contract’s fine print, so that we can ensure that we accurately define our role and how we intend to serve society.