AMA Journal of Ethics^®

Cruess RL, Cruess SR. Expectation and obligations: professionalism and medicine's social contract with society. Perspect Biol Med.2008;51(4):579-598.

“Temperance and labor are the two best physicians of man; labor sharpens the appetite, and temperance prevents from indulging to excess.”
Jean-Jacques Rousseau, Emile, or Treatise on Education

In “Expectations and Obligations: Professionalism and Medicine’s Social Contract with Society,” Richard L. and Sylvia R. Cruess consider medicine’s implicit duties to society [1]. The authors note that, although well-accepted as an appropriate model, the “social contract” in health care is a “mixture of implicit and explicit, written and unwritten” [2]. To clarify, the authors subdivide “medicine” into individual physicians and the institutions of medicine. “Society” is divided into individual patients, the general public, and the government. In the triangulation among medicine, government, and society, the balance of power and influence shifts from time to time, and, as society evolves, so must the social contract.

The authors use a schematic diagram to show the relationships between medicine and society [3]. In this diagram, the individual physician has obligations to (1) the individual patient, (2) the profession of medicine, (3) the general public, and (4) the government. Under contract theory, each party has expectations of the other and relies upon the fulfillment of those expectations, to benefit or detriment [4]. The specifics of that contract have evolved over time to fit emerging societal trends. The authors assert that the “social contract,” at its root, forms the foundation for medical professionalism and clarifies both the roles and expectations of medicine from government and society at large.

Though the authors do not rank these four obligations, I have ordered them purposefully. Much has been said about the first two obligations, those of a physician to the individual patient and to the profession of medicine. For this reason, medicine is often regarded as a calling; the interests of the patient and the profession are supposed to outweigh personal interests. The principles of beneficence, nonmaleficence, autonomy, and justice govern a physician’s duty to the individual patient [5]. The Hippocratic Oath symbolizes the physician’s obligation to both patients and the profession of medicine [6].

What the second two obligations—to the general public and the government—have in common is, as Cruess and Cruess put it, a duty to engage in “promotion of the public good” [7]. In general terms, this means that a physician accepts, and is held to, higher expectations and a more prominent social role than the average citizen. As such, a physician who ignores his or her implied responsibilities as a public servant is breaching the social contract. Many physicians fill the role of public servant nobly and admirably, but many fall short.

How should the medical profession fulfill these obligations? Consider philosopher Jean-Jacques Rousseau’s thoughts in The Social Contract, published in 1762. He boils the concept down to the following: “Each one of us puts into the community his person and all his powers under the supreme direction of the general will; and as a body, we incorporate every member as an indivisible part of the whole” [8]. As a member of a learned profession, a physician has more “powers” to put toward the general will, and ought to do so. Part of the reason our society rewards physicians with more pay is because it, justifiably, expects a greater return on investment.

One important component of the physician’s obligation to the general public is in the realm of public health. As physicians, we have a wealth of knowledge to share. For instance, the importance of smoking cessation, proper diet and exercise, and vaccination should be shared with the public as a whole. Why should we settle for counseling the individual patient when so many in the community need this advice? Physician outreach beyond the walls of a clinic or operating room should be a fundamental means of fulfilling that civic duty.

We have an integral role in public health and prevention to promote change that benefits society and improves health outcomes, even when those changes do not directly benefit us as physicians. Improving access to clean water, for instance, prevents millions of cases of water-borne illness in developed countries. An infectious diseases specialist in a country with insufficient access to clean water may have a satisfyingly large patient load, but the greater societal good demands the eradication of preventable illness wherever possible. Physicians should strive to reduce their patient load as much as possible by focusing on prevention, even though a healthier population makes fewer office visits.

Prevention also makes sense economically; a healthier population requires less health care spending per capita. Health care financing is another essential element of the public good that doctors must work toward. As in the exam room, this entails putting the general good above one’s own interests—something doctors do not always do. This has played out recently in the passage of the Affordable Care Act. Recognizing that the health care system in the United States is broken and unsustainable, physicians had to choose whether to resist change or to advocate for improving the delivery of medical care, for physicians and patients alike, in future generations. Some physicians, so adamant about maintaining the status quo and the quality of life it provides them, have favored those individual interests at the expense of the social contract.

It should be noted, however, that health care costs are not rising exponentially because physicians are too well-paid. They rise due to the lack of emphasis on primary care, the increasing burden of preventable disease, and the misallocation of health care resources. These are all areas in which physicians have expertise. The need for a gastric bypass reflects a failure of primary care and prevention in communicating the importance of diet and exercise. Dialysis for end-stage renal disease may reflect a failure in the management of diabetes, hypertension, or both. Specialists may stay in business treating these patients, but also have an excellent understanding of the course of disease and means of prevention. Physicians can and should get involved in their communities, helping to develop programs that promote healthier lifestyles and disease prevention. This is just one example; there are numerous opportunities for physicians to engage in community-building.

What about at the state and federal level? If physicians are unhappy about Medicaid payments, the Medicare Sustainable Growth Rate, or individual state issues such as medical malpractice reform, they can make their voices heard, either by communicating with their elected officials or by running for public office. The same is true of federal laws such as the Affordable Care Act. Rather than decrying the law and demanding its repeal, physicians should look at benefits the law provides and lobby for improvements that further the public good. Altering a system, such as health care, that badly needs reforming is a lengthy process and does not end with the passage of a single law, no matter how “comprehensive” it purports to be. We, as physicians, have an ongoing responsibility to shape the future of our profession for the benefit of our patients and for society as a whole. No single political party represents the spectrum of needs of the medical profession, and, therefore, physicians must continue the health care reform movement, even if it requires a partisan tug-of-war to succeed.

Physicians must remember that their social contract with society extends beyond that of the individual patient and the medical profession and into the realms of the general public and the government. As public servants, physicians should heed Rousseau’s warning:

Every individual as a man may have a private will contrary to, or different from, the general will that he has as a citizen. His private interest may speak with a very different voice from that of the public interest; his absolute and naturally independent interest may make him regard what he owes to the common cause as a gratuitous contribution, the loss of which would be less painful for others than the payment is onerous for him [9].

In the calling of medicine, at least, the opposite is true—the loss of a physician’s contributions to the public good is far more onerous than the benefit to a physician’s quality of life. To the contrary, contributing to the public good is likely to improve the physician’s quality of life by instilling a sense of accomplishment and personal satisfaction. The task is its own reward.