Abstract
Medicine is described as the second oldest profession, and for millennia, doctors and physicians have been told to do no harm to their patients. It is fairly obvious that the practice of medicine occurs in the context of society’s needs and demands. It is the society which determines what is seen as abnormal (and therefore sick or ill) and society that agrees to pay for the healthcare systems and also mould these according to explanatory models of healthcare. The acceptance of alternative or complementary systems in addition to or in preference to allopathic systems will allow certain funding and resources made available for all the systems which are required and preferred by the population. Depending upon the explanatory models and understanding of illness behaviours locally, societies will determine what models of care are acceptable. Resource allocation accordingly within which medicine is to be practised is a matter of social choice and should be seen as related to a number of social and epidemiological factors as well as to the implicit social contract between medicine and society represented by stakeholders such as politicians. Healthcare policies influence financial allocation, which in turn will influence the structures within which healthcare services are planned, developed and delivered.
The concept of a social contract dates from several centuries (Gough, 1936). In an erudite volume, Gough (1936) outlines that the origins of the social contract were between kings and their subjects. Such a contract was implicit. Subjects would give up some of their rights to the king and, in turn, he would protect them and look after them in a benevolent governance. This implicit contract also determined how subjects not only related to their rulers but also towards each other. Even within largely democratic structures, such a contract or compact remains in place between the rulers and the governed. Through elections and voting, the population chooses one ruler or their party over another and thus gives them the mandate to provide good governance and basic amenities, including education and healthcare facilities. Irrespective of the resources and style of government, certain basic needs are asked for by the ruled and the rulers are expected to deliver these.
Medicine as a profession has also had an implicit social contract with society (Cruess, 2006), regardless of the healthcare systems in place. However, often this compact or contract gets forgotten. Society expects from the medical practitioner services of a competent physician, certain moral values, including transparency and probity, but also someone who is a healer (Cruess, 2006). Doctors are also seen as key and important providers of objective advice to the society as a whole. One of the key characteristics of the professional is to be altruistic. However, this value of altruism will vary according to the healthcare system. If the system is entirely private, then altruism may mean giving up some free time to provide free advice or healthcare; and if the system is state run, then altruism may have a different approach. In return, doctors expect that the society will allow them to have a degree of clinical autonomy as reflected in self-regulation. They will also expect a degree of trust supported by adequate resources and financial or social recognition for their clinical commitments and what they do (Cruess and Cruess, 2010). It has been shown consistently and regularly in surveys that doctors have the highest degree of confidence and trust of their patients and the population as a whole when compared with other professions such as politicians and journalists, who always come low on scales of approval.
The tension within this social contract between the medical profession (represented by doctors) on the one hand and the society as a whole (represented by the policy makers and the government) on the other is related to several questions. First, the question arises as to the process of the contract; as it is implicit and unwritten, it may not be entirely clear what is being said or done on whose behalf on either side. The second question relates to the first one. If as is likely the rapid advances in technological aspects of medicine continue to add to the costs of healthcare delivery and consequently demand for newer and safer treatments increases, then how does the society pay for these and does the society expect the medical profession to ration research and clinical services? Third, society continues to evolve and fragment with global expectations, thus making it almost impossible to identify who the representatives of the society are with whom the contract is to be negotiated. In addition, as the society evolves and with generational changes, social expectations and social roles change and doctors may not be cognisant of that. As Cruess and Cruess (2008) point out, the practice of medicine carries with it both financial rewards and social status and prestige and, therefore, some individuals choose to go into medicine for these rewards whereas others have a more altruistic motive. There is no doubt that there are hundreds of thousands of ethically practising and committed doctors around the globe, but how do they identify and feed into the social contract?
How does the social contract between medicine and society work out in global settings? In many parts of the world, for example, India, doctors accept kickbacks for referring patients for laboratory investigations or scans leading to unnecessary procedures and potentially fatal consequences. Berger (2014) goes on to explore the role the pharmaceutical companies play by rewarding increased number of prescriptions of their drugs and adding to corruption in the medical workplace. In an extremely personal and professional relationship, the potential of status abuse is inherent. This may be more common in some cultures than others depending upon regulatory factors. But doctors should be regulating themselves and should not have to rely on regulatory bodies to dictate their behaviours.
There is no doubt that in many cultures, especially where patients are able to and want to pay for choice, rapid doctor-shopping may reflect expectations from private medicine as well as a distrust of doctors. Most of the doctors are hard-working, ethical and committed. As part of the social contract, society expects from doctors (including psychiatrists) the services of a ‘healer’ by a doctor who is competent, has probity and integrity, is able to manage risk and is accountable and transparent. Society also expects the profession to be the source of collective advice (Cruess, 2006). In return, doctors expect that the society will give them autonomy, trust them and provide them with a healthcare system which is value driven and adequately funded. In addition, doctors expect that they are allowed to manage risk and compensated with financial and social rewards. As part of society, patients expect quality care from their doctors. They want excellent communication skills in their clinicians with services which are accessible. They expect their doctors to advocate for them and also to be educators (Bhugra, Sivakumar, Holsgrove, Butler, & Leese, 2009).
The way forward
Self-regulation is a major component of being a professional (Cruess, 2006), and this has been the case for centuries. A major responsibility of any regulator is to set, assess, maintain and monitor standards of training, continuing professional development and delivery of clinical care. The standard of healthcare delivery that is adequately funded is another major responsibility for the regulator to oversee. Ethics teaching through role modelling using clinical teachers who lead by example has been recommended as a potential way forward (Royal College of Physicians, 2005; Passi, Doug, Peile, Thistlethwaite, & Johnson, 2010). It is imperative that professional values and ethics are taught at an undergraduate level and continue throughout one’s career (Hilton & Slotnick, 2005; Jones, Hanson, & Longacre, 2004). Furthermore, the continuing medical education programmes or continuing professional development must provide ongoing teaching in ethical and professional frameworks for dealing with patients and their families and carers. In many countries around the globe, the apprenticeship model in medical education is the only model, so the teachers must set the examples of probity and moral values. If professionalism is not set at the heart of clinical practice, this would create problems for the patients who are at their most vulnerable.
Conclusion
Medicine as one of the original professions carries with it a moral and ethical imperative. The social contract between the profession and the society at large needs to be renegotiated accordingly to cultural values and values of social justice as a matter of urgency. As part of the social contract negotiation, such a negotiation must include those who are most in need of healthcare – patients, their families and carers. They may be represented by the stakeholders such as politicians and policy makers, but their voices and needs must be recognised. On the other hand, the medical profession must look into its own heart and explore what is needed and what is being done in their name. The profession needs patients as their advocates in the same way that patients can and do advocate for their doctors. Teaching of ethics at all levels of training must be given due importance without further delay. There are universal ethical values and culturally relativist values which ought to be pulled together. If the profession does not take such a lead urgently, future generations of doctors will marvel at the failures of their forefathers.