Medicine’s contract with society

This article is the first in a three-part series entitled ‘Sense and Sensibility: Society, Medicine and its Practitioners’.

Introduction

In all societies, healthcare is shared by the individual and by the society at large, represented by its government. Cultures and societies decide how much resources are devoted to healthcare. It is their responsibility through the policy makers to decide how resources are allocated and which conditions get priority. The context of such allocation inevitably depends upon a number of factors. Demographics of society, social and political ideologies, and economic context will all play a role in determining what funding is made available and what other resources are allocated. The relationship between doctors and society remains a complex one. Depending upon the healthcare system, doctors and society have an implicit rather than explicit contract, although this is beginning to change with ever increasing regulation in the UK at least. This relationship between doctors and potential patients (all members of the society have the likelihood of becoming ill and becoming patients seeking treatment) influences the context and the setting within which the therapeutic interaction takes place.

Professionalism in medicine has existed for centuries. The code of conduct embedded within professionalism has evolved over time in response to societal demands and pressures, and indeed will continue to do so in the future. Professional values and the professions themselves are not static but dynamic and must continue evolving. These codes emerged both from within and from outside the profession. The pressures on any healthcare system – but in the UK context on the National Health Service (NHS) with potential changes related to new providers – will alter the way medical professionals behave and their inherent code of conduct.

Social contract

Gough ¹ highlights that the social contract was based on the divine right of the kings, which also contained some elements of truth. ² Current in the 17th century, the social contract was between the kings and their subjects. Some of the natural rights belonging to the individual were surrendered in return for a guarantee of the remainder. ¹ This reflected the theory of the origin of state, i.e. of the society with an established government. Gough goes on to note that the social contract covers two different types of contract. The first one of these is the social contract proper, which presupposes that a number of individuals living together in a ‘state of nature’ agree together to form an organised society, which gives them the doctrine of ‘natural rights’. However, they agree to surrender some of these in return for a guarantee of the remainder. This is comparable with the ‘rights’ of medical profession and their surrender of some of their professional rights. The second form of contract was that of government. This contract of submission between the king and his subjects presupposes that a society already formed defines the terms on which it is to be governed. Thus, people have entered a contract with their ruler which will determine not only how they relate to each other but also resources and support, etc. The social contract on the people’s side meant obedience and deference to the king, with protection and good government in return. Both sides were expected to keep their side of the contract. The social contract had existed for millennia in different forms. Gough ¹ emphasises that by the end of the middle ages it was an accepted belief that the state originated in a contract of society and this stage of nature precedes society. At the same time, professions were building their structures, embodied in guilds. Thus, it is entirely possible that the social contract between the guilds and the society followed similar principles and this model carried on as the medical profession developed.

Contract with society

As mentioned earlier, 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. The contract between the society and the health profession is thus implicit. ³ The profession is seen as a socially based activity ⁴ with certain characteristics and regulations.

Medicine’s contract with society is implicit and this gets rewritten, often without any open negotiations. Professionals are both providers and consumers of healthcare in the context of the relationship with the society, raising some ethical issues. For some specialties, such as psychiatry, the contract inevitably focuses on risk assessment and risk management. However, of late this contract is becoming more explicit.

What does it mean?

Medicine’s contract with society emerged around 300 years ago with the professional guilds (precursors of modern bodies such as the Royal Colleges), which were responsible for offering apprenticeships (read training) and controlled the numbers of trainees. ⁵ The clinical practice of medicine has always been in the social context. The society determines resources and allocates these and the profession must deliver the expected outcomes and deliver care to certain professionally agreed standards of cares and safety. The profession controls standards and the ability to meet societal expectations. For many medical specialties such as general practice, psychiatry or pathology, there are variations in expectations and delivery of care. Professionalism consists of certain essential characteristics such as technical scientific knowledge, altruism, professional competency, integrity, honesty, probity, using finite resources for balanced delivery and self-regulation. ⁶ Of these, self-regulation is being challenged increasingly around the globe with some of the regulatory bodies having a majority of lay members on their councils.

What is explicit in the context of the NHS?

In a state sector healthcare delivery, the key stakeholders who play a major role on behalf of the society in the negotiation are politicians and civil servants. Politicians technically represent the society and the patients but not in reality. This complex relationship raises significant distress on both sides of the contractual obligations and needs to be explored further.

What should it involve?

The contract must include codes of professional conduct which have evolved over several centuries. As societies evolve and change, the ethical aspects of professional practice also develop accordingly. Sox ⁷ emphasises that these codes of professional conduct are tangible expressions of professionalism. As a result of medical scandals and political changes, the expectations within the professions have led to increased pressures on clinicians in general and on doctors in particular. The increasing spread of private and any qualified provider in the NHS in the recent times has increased the pressure further. With self-regulation of the profession under challenge, it is inevitable that these codes of ethics will change again. Both the contract and the ethics are a two-way process. When society’s dissatisfaction with healthcare delivery increases, the medical profession may feel threatened and controlled, leading to a stalemate. Ever increasing tick-box managerialism, rampant bureaucracy in form-filling and an appreciably tightening control over resources, leading to restricted healthcare delivery resulting in post code lottery, further contribute to alienation of the profession. Changing demographics, increasing demands and new technologies have further contributed to tensions within the medical profession, who are also getting mixed messages from their employers.

What does society expect?

Society expects the health practitioner to provide services of a healer who is competent, moral, transparent and accountable. ³ Furthermore, these individuals also provide objective advice and altruism. The changes related to conflict of interest have become more pronounced in the past three decades. As Gough ¹ had noted, the rights and duties of the state and its citizens are reciprocal. This reciprocity and understanding of respective roles, duties and responsibilities forms the basis of the modern social contract with the society. This mutual understanding depends upon joint obligations and expectations. The contract is implicit and unwritten. Cruess and Cruess ⁸ observe that, as long as both society and the medical profession were reasonably satisfied, there was little effort to categorise the relationship formally. They argue that there are many ways of describing this relationship, including moral imperatives ⁹ and a covenant. ¹⁰ The ethical codes are applicable to the profession as a whole. Shared misunderstanding of the purpose of action may put extra external pressure on each side.

Social expectations, availability as well as 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, and resulting tensions will influence the contractual obligations. Society in its members and those who become ill (i.e. the patients) have a responsibility for health. Clinicians have a dual role – as members of the society and as care providers. Expectations of doctors from the society and vice versa remain fairly similar and constant irrespective of healthcare systems. ³ The role of the doctor as a healer and a competent healthcare provider will also be very strongly influenced by the training opportunities.

Society expects that doctors will fulfil their roles as healers who provide timely and competent care and demonstrate trustworthiness with high levels of integrity and honesty and a focus on the greater public good. Cruess and Cruess ⁸ identify that governmental expectations of doctors are somewhat different from those of the public in that they are compliant with the healthcare system and the legal framework and are a source of objective advice. The expectations the doctors hold of the society at large and the government also vary slightly.

What do doctors expect?

Doctors in return expect to be trusted, and survey after survey suggest that as a profession doctors obtain and retain the highest levels of trust from the public. Doctors also expect society to provide by and large an adequately funded healthcare system to work in. In addition, doctors would like to have the necessary autonomy and self-regulation to work effectively in an environment. Both as specialists and as members of the society, doctors carry moral values, probity and honesty in their practice. The practice of medicine will also carry with it certain social status and adequate financial recompense. ¹¹ Other external factors, such as media, regulatory framework and other providers within any healthcare sector, play their part in this contract.

The tension embedded within this implicit contract is two-fold. 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 and these may not be met, making doctors feel vulnerable to criticism. Consequently, this contract keeps evolving in response to various factors, some of which may not be entirely clear. A series of medical scandals has led to increased regulation and, in return, doctors have felt further alienated, disenchanted and undervalued.

What should doctors expect?

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 want to do the right thing and do things right. The challenge is how much freedom they are allowed to do so by the contract holder. Disenchantment will result if the society is either too interfering or 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.

One of the biggest challenges in the past two decades has been an increase in the number of regulatory bodies, and the longstanding notion of self-regulation is beginning to change. Perhaps this reflects a change from collective self-regulation to individual self-regulation with the development of peer groups and individual appraisals with individual doctors. This is not likely to change in the immediate future. This individualistic regulation brings problems with it. Further complication is related to the introduction of revalidation on a five-yearly cycle.

Autonomy and its role and definitions in the context of changing societal expectations need to be revisited. In multidisciplinary teams, roles and responsibilities of individual professionals are clear, but autonomous clinical practice still remains the core of professionalism. What shape this autonomy takes in the context of team work needs to be clarified further.

What to do next?

It is far too early to fully assess the total impact of recent changes and upheaval in the NHS. Patient care is at the core of healthcare delivery and at the heart of the contract. Facing a major economic downturn with changes in demographics and differing patient and carer expectations, it is critical that this contract is renewed and renegotiated. Increasing consumerism and changes in the roles of other professionals will further contribute to pressures on the medical profession to be clear 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. Working with key stakeholders and educating them to realistic expectations and maintaining a dialogue to understand the concerns of patients and those of the society will provide a way forward. Instilling professional values at an early stage with a clear understanding of ethical codes will enable the society to reflect on what it expects from its doctors. This will also ensure that doctors are aware of what they can expect in return.