What Is a Social Contract in the Medical Field
It is important to emphasize that there is no formal contract in the legal sense of the term. On the contrary, as Gough noted, the rights and obligations of the parties to the contract are “mutual, and the recognition of this reciprocity constitutes a relationship that can be described by analogy as a social contract” (Gough, 1957, p. 245). The contemporary interpretation of contract theory relies heavily on the idea of “legitimate expectation” as fundamental to mutual understanding (Rawls, 2003; Bertram, 2004). Clearly, the fact that one party does not meet the legitimate expectations of the other party has consequences on the attitudes and therefore on the reactions of others. The reasons why data exchange may be limited in practice are partly related to the inertia of infrastructures and partly to moral conditions. Much of the infrastructural inertia is due to the way healthcare and biomedical research have historically been separated. These divisions run through staff, institutions and governance systems. In Canada, the Royal College of Physicians and Surgeons of Canada`s CanMEDS framework describes the promises made by physicians under the Statutes. Medical trainees and physicians are expected to adhere to these roles to improve patient care. According to this framework, the professional role (one of seven roles) reflects “the expectations of today`s society for physicians” in exchange for privileges granted.
Professionalism is therefore the basis of the social contract, as society and doctors have agreed to use the construction of the “profession” to organize the provision of health services. A common claim in the literature is that “there is a social contract between medicine and society,” implying that each part is monolithic. That`s not true. We have proposed an overview of the nature of the social contract between medicine and society (see Figure II-4), which is different from the only other published project we know of (Ham and Alberti, 2002). As you can see, the medical profession is made up of individual physicians and the many institutions they represent, including national and professional associations and regulatory bodies. In the circle chosen to represent the medical profession, there are a variety of strong opinions, interest groups and political orientations. Although much of this is not written, it is possible to roughly describe the terms of the contract by examining both the expectations of the medical profession and those of society. Professionalism has been defined as “a set of values, behaviours and relationships that underpin public trust in physicians” (Royal College of Physicians of London, 2005, p.
14). Trust is absolutely necessary for the social contract to work (Sullivan, 1995; Goold, 2002). Society`s expectations of physicians and the medical profession are based on both trust and understanding of these values and behaviours. This explains why professionalism is the basis of medicine`s social contract with society. Society expects physicians to behave professionally in exchange for their privileged position. If they don`t, the company will change the contract. If regulation is granted to the medical profession, they expect the profession to ensure the competence of its members. They demand compliance with health care laws and also expect members of the medical profession to be trustworthy. They believe that the professions should serve as a source of objective advice – even if this advice is often ignored – and they believe that because of the privileged position of the medical profession, the profession and its members must be dedicated to the common good. Finally, they demand a new level of accountability (Wynia et al., 1999) and want the profession to provide team-based health care, expectations that have become much higher recently. To give an example, genomic information is transpersonal in an important way, both connecting us and distinguishing us from others as instances of a family, a population, a species.
In addition, we are both connected to others and different from others by the environment we share, what we eat and how we live, which can affect our epigenome as well as our state of health. As a result of these relationships, our ability to help others through the exchange of data arises. And this pushes us even further to consolidate research and care: advances in care no longer need to be sought after in different and refined research projects, but can be extracted from the systems in which people are already involved. By placing health care in the context of the social contract, it can be placed in a so-called “macro” contract (Donaldson and Dunfee, 1999, 2002), which includes all the essential services required. Society and the health care system can support or undermine professional values, and in many cases the latter appears to be true (Cohen et al., 2007). Clearly, medicine has no direct control over society or the health care system. An obvious recourse is to negotiate a health care system that truly supports professional values, an orientation that can benefit both medicine and society (Wynia et al., 1999; Sullivan, 2005; Cohen et al., 2007). Shaping the discussion regarding the negotiation of the social contract of medicine has several advantages. Peter Mills, Deputy Director, Nuffield Council on Bioethics Making a social contract is not an easy task. In some systems, particularly in the United States, electronic health records – anonymized and aggregated with other patient data – are bought, sold and shared at will, with little or no notice and with questionable patient consent.
This is mainly because anonymized data is not considered personal health information, although studies show that it is quite easy to re-identify an individual from a data set. The consent process often takes place at inappropriate times when a patient has few opportunities to opt out of data sharing. This can be a line embedded in a long hospital admission form that indicates that a hospital has rights to all data generated about a patient from long-term care, tissue removal, etc. This data can and may be used for commercial purposes. Many patients are beginning to resist this pattern. An effective social contract could explicitly and responsibly address issues related to the appropriate management of data collected in health and research systems. There could also be assurances that, for example, health information from parties who are not health professionals will not be used in a manner that is discriminatory or harmful to individuals (e.g., B unjustified for increasing life insurance premiums, refusing home loans or withholding loans). Here are the expectations of medicine regarding the contract: FIGURE II-4 A schematic representation of the social contract of medicine with society. SOURCE: Floods and Floods, 2008. A contract includes obligations from both parties, so it is reasonable for medicine to expect certain services from society.
Recent observers have stated that negotiating these outcomes is one of the hallmarks of a contemporary profession [13]. Just as society`s trust in physicians is strongly influenced by how it believes the profession fulfills its obligations, an individual physician`s trust in society is influenced by social action. There is evidence that physicians` current dissatisfaction with how society maintains its share of the contract has less to do with financial problems than with their belief that they have lost both autonomy and respect [14:15]. Responsibility. For generations, physicians have recognized that they are accountable to each patient, to the public for strategic advice, and to each other for self-regulation. As drugs became more expensive, it was inevitable that doctors would be held accountable both economically and politically [11]. These new levels of accountability are a cause of great tension. A physician`s fiduciary duty to patients now conflicts with the social goals of medicine [12].
Providing resources to care for an individual patient inevitably reduces the resources available to other patients. As the contract evolves, this tension will remain, but medicine`s fiduciary duty to individual patients must take precedence. Compassion, altruism and commitment are an integral part of every medical practitioner`s professional identity and clearly represent the fundamental expectations of patients and the public. .