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  • 1. Expectations and Obligations professionalism and medicine’s social contract with society Richard L. Cruess and Sylvia R. Cruess ABSTRACT As health care has become of great importance to both individual citizens and to society, it has become more important to understand medicine’s rela- tionship to the society it serves in order to have a basis for meaningful dialogue. During the past decade, individuals in the medical, legal, social sciences, and health policy fields have suggested that professionalism serves as the basis of medicine’s relationship with society, and many have termed this relationship a social contract. However, the concept of medicine’s social contract remains vague, and the implications of its existence have not been fully explored. This paper endorses the use of the term social contract, exam- ines the origin of the concept and its relationship to professionalism, traces its evolu- tion and application to medicine, describes the expectations of the various parties to the contract, and explores some of the implications of its use. social contract: A basis for legitimating legal and political power in the idea of a contract. Con- tracts are things that create obligations, hence if we can view society as organized “as if” a con- tract has been formed between the citizen and the sovereign power, this will ground the nature of the obligations, each to the other. — Oxford Dictionary of Philosophy (1996) Centre for Medical Education, McGill University, Montreal. Correspondence: Richard L. Cruess, M.D., Centre for Medical Education, McGill University, 1110 Pine Avenue West, Montreal, QU H3A 1A3, Canada. E-mail: The authors wish to express their appreciation to Sharon Johnston, who has provided significant in- put into their understanding of the issues, and to Linda Blank, Frederick Hafferty, and William Sullivan for their invaluable advice and support. Perspectives in Biology and Medicine, volume 51, number 4 (autumn 2008):579–98 © 2008 by The Johns Hopkins University Press 579
  • 2. Richard L. Cruess and Sylvia R. Cruess HE SUBJECT OF MEDICINE’S PROFESSIONALISM has assumed increasing im- T portance during the past decades because of the widespread belief that medicine’s traditional values, which are closely linked to professionalism, are under threat (Cruess and Cruess 1997; Freidson 2001; Hafferty 2006a; Krause 1995; Starr 1984; Stevens 2001; Sullivan 2005; Wynia 1999). There is a rich lit- erature that defines professionalism and outlines medicine’s obligations as pro- fessionals (ABIM 2002; Cruess, Johnston, and Cruess 2004; General Medical Council 2006; Hafferty 2006b; Royal College of Physicians of London 2005; Swick 2000;Wynia et al. 1999).Virtually all observers contributing to this liter- ature are in agreement that professionalism serves as the basis of medicine’s rela- tionship with society, and most believe that the relationship is best described by the term social contract. Based on the concept’s foundation in philosophy and political science, we also believe that social contract is the most appropriate descriptor of the relationship. In this article, we describe how the social contract relates to professionalism, define the concept in contemporary terms, and provide an outline of the nature of the current contract. Finally, we discuss some of the implications of a social contract approach to medical professionalism. Medicine and Society There has been a surprising degree of agreement on the fundamental nature of the relationship between medicine and society.Virtually all who have described it state that society has granted medicine autonomy in practice, a monopoly over the use of its knowledge base, the privilege of self-regulation, and both financial and nonfinancial rewards. In return, physicians are expected to put the patient’s interest above their own, assure competence through self-regulation, demon- strate morality and integrity, address issues of societal concern, and be devoted to the public good (Abbott 1988; Carr-Sunders and Wilson 1933; Cruess and Cruess 1997; Elliot 1972; Freidson 1970; Kultgen 1998; Parsons 1951; Stevens 2001; Sullivan 2005; Wynia et al. 1999).While there have been disagreements about the motivation and performance of the members of the profession and the state of health of the “bargain,” its existence and the presence of a mutual state of “dependency and obligation” between medicine and society seems accepted (Freidson 2001; Haug 1973; Johnson 1972; Klein 2006; Krause 1996; Larson 1977; McKinley and Arches 1985). As long as both society and the medical profession were content, there was little effort to formally categorize their relationship. However, as changes in both medicine and society have sparked widespread dissatisfaction with the current state of health care, a variety of models have been proposed to describe medi- cine’s relationship with society. Starr (1982) first suggested that the relationship is contractual, stating that the contract was being redrawn in response to dra- matic changes in health care, such that the contract was “subjecting medical care 580 Perspectives in Biology and Medicine
  • 3. Expectations and Obligations to the discipline of politics or markets or reorganizing its basic institutional structure” (p. 380). Subsequently many observers, including social scientists, law- yers, policy analysts, bioethicists, and physicians turned to the historical concept of the “social contract.” Sullivan (2005) emphasized the link between profes- sionalism and the social contract, stating that the “the social contract became the moral basis of professionalism” (p. 54). Klein (1990) used the term “implicit bargain” when describing the relation- ship between the government, the National Health Service, and the medical pro- fession in the United Kingdom. Although some observers in the United King- dom refer to the presence of a social contract, it is probable that Klein’s choice of words influenced others who noted that the “bargain” had broken down (Davies and Glasspool 2003; Ham and Alberti 2002). Three recent studies of medical professionalism in the U.K. have used the term “implicit compact” which specifically includes doctors, patients, and society, and all state that the relationship involves reciprocity (Edwards, Kornacki, and Silversin 2002; Rosen and Dewar 2004; Smith 2004a). The Royal College of Physicians of London (2005) has proposed that morality is so fundamental to the practice of medicine that the social contract should be renamed a “moral contract” (though without elaborating on the details). The term social contract also has been applied to other relationships in con- temporary society, including some that touch medicine directly: those between society and its medical schools, between society and science, and between soci- ety and universities (Gibbons 1999; Inui 1992; Kennedy 1997; H. R. Lewis 2006; Lubchenko 1998; Ludmerer 1999; McCurdy et al. 1997; Schroeder, Zones, and Showstack 1989). The Social Contract: Origins and Evolution The concept of the social contract was developed by 17th- and 18th-century philosophers, primarily Hobbes, Locke, and Rousseau, at a time when most countries were ruled by hereditary monarchs (Crocker 1968; Masters and Mas- ters 1978). It had two purposes: to provide an historical account of the origin of the state and society as citizens united their individual “wills,” and to explain the nature of the relationship between the state and its citizens. It outlined a series of reciprocal rights and duties as being fundamental to this relationship. While the concept has not been universally accepted as the philosophic basis of the state, it has had a continuous presence in philosophic discourse (Bertram 2004; Rawls 1999, 2003). Rawls’s (1999) theory of justice is a contemporary expres- sion of contractualist thinking: “those who engage in social cooperation choose together, in one joint act, the principles which are to assign basic rights and duties and to determine the division of social benefits” (p. 10).The philosophers endorsing the concept of a social contract were clear that there is no formal legal contract. However, they justified the use of the term on the grounds that “the autumn 2008 • volume 51, number 4 581
  • 4. Richard L. Cruess and Sylvia R. Cruess rights and duties of the state and its citizens . . . are reciprocal and the recogni- tion of this reciprocity constitutes a relationship which by analogy can be called a social contract” (Gough 1957, p. 245). Contemporary interpretation of contract theory leans heavily on the idea of “legitimate expectations” as being fundamental to mutual understanding (Ber- tram 2004; Rawls 2003). In addition, the failure of one party to meet the legit- imate expectations of the other has consequences in the attitudes and actions of the other. The social contract can be considered a “macro” contract including all essen- tial services required by a population, but it has also been proposed that there are “micro” contracts, applying to individual essential services required by society, which must conform to the “moral boundaries” laid down by a macro contract (Donaldson and Dunfee 1999, 2002). Health care could be included in the over- all relationship or, given its importance to the well-being of both individuals and society, it could be governed by its own micro contract. It appears that this lat- ter approach best describes the structure of society, recognizing that health care is one of a number of conflicting priorities within the macro contract. The details of the social contract between medicine and society differ be- tween countries, being influenced by cultural, economic, and political factors. While there are many documented commonalities, there are also significant dif- ferences in the funding and organization of health care , and hence in how pro- fessionalism is expressed.What seems not to differ is the role of the healer, which answers a basic human need (Dixon, Sweeney, and Gray Pereira 1998; Kearney 2000).Those elements of the social contract that refer to the healer are relatively constant across national and cultural boundaries, while those that refer to how the services of the healer are organized, funded, and delivered may vary (Cruess and Cruess 1997; Krause 1996; Laugeson and Rice 2003). As society and healthcare evolve, the social contract also evolves, expressing the relationship between society’s dominant constituencies. The literature on professionalism recognizes that professionalism changes in response to societal needs (Freidson 2001; Krause 1996; Starr 1982; Stevens 2001). Indeed, Castellani and Hafferty (2006) have warned against continued reliance on the “nostalgic professionalism” of the past. As the social contract changes, the professionalism that serves as its basis must also evolve.Therefore, in assessing the current state of professionalism, legitimate contemporary societal expectations must be empha- sized. However, equal importance must be given to those aspects of profession- alism that are valued by both society and the medical profession but may not be given the same level of importance by the commercial sector or governments (Freidson 2001; Hafferty 2006a; Melhado 2006; Stevens 2001; Sullivan 2005; Tuohy 2003). Selecting the most appropriate descriptor of the relationship between medicine and society is important, as it has the potential to give a mutually agreed-upon framework for discussion. Originally conceived to protect both individual citizens 582 Perspectives in Biology and Medicine
  • 5. Expectations and Obligations and the public from the abuses of authoritarian rule, social contract theory now emphasizes the mutual rights and obligations of citizens and those governing them. Most of those analyzing the interface between medicine and society believe that the relationship involves reciprocal rights, privileges, and obligations. Of the many terms suggested, only social contract has an historical basis in philosophy and political science, having been in wide use for three centuries. For this reason, it does not require redefinition and should more easily serve as a basis for dialogue between the parties to the contract. The Social Contract in Health Care The social contract in health care is a mixture of the implicit and the explicit, the unwritten and the written. In all countries, the explicit parts include legis- lation outlining the structure of the health-care system, laws establishing the reg- ulatory framework, including licensing, certification, and discipline, and jurispru- dence relating to health care (Hafferty and McKinley 1993; Krause 1996; Starr 1982).The Hippocratic Oath and codes of ethics also constitute an explicit part of the contract, outlining medicine’s commitment, as do the International Char- ter on Medical Professionalism (ABIM 2002), Good Medical Practice (General Medical Council 2006), and Good Medical Practice USA (2007). Many of these documents impose legal obligations on physicians and the profession (Rosen- baum 2003; Rosenblatt, Shaw, and Rosenbaum 1997). However, there are also both written and unwritten portions entailing moral commitments that are fun- damental to both the social contract and professionalism (Pellegrino 1990; Stev- ens 2001). One cannot legislate altruism, commitment, or independent profes- sional judgment; they must come from within individual physicians (Coulehan 2005; Kultgen 1998; May 1997). Until recently, most observers have been content to outline medicine’s rela- tionship to society as bilateral, while recognizing the presence of multiple stake- holders in health care.The usual statement is that “there is a social contract be- tween medicine and society.”This seems to assume that two major players exist: a relatively monolithic medical profession made up of individual physicians and their institutions and patients and wider society. Reality is different. Rosen and Dewar (2004) analyzed the relationships be- tween the multiple stakeholders involved in health care in the United Kingdom and integrated them around the concept of reciprocity. In redefining medical professionalism, they proposed a new “compact” involving three interlocking societal components. The first group consists of patients and patient groups as well as the “public”; the second of health-care managers, the state, government departments, and the European Parliament; and the third of the medical profes- sion and “professional bodies.” There are interactions within each group, and each group has reciprocal relationships with the other two. Each relationship is “mediated” by the media, the legal system, and the regulatory framework. The autumn 2008 • volume 51, number 4 583
  • 6. Richard L. Cruess and Sylvia R. Cruess Figure 1 The social contract. commercial sector was not included as a major stakeholder or “mediator.”While we agree with Rosen and Dewar’s approach, we believe that it does not correctly outline the nature of the interrelationships. Parties to the Contract A schematic representation of our concept of the contemporary social contract in health care, including its complex interrelationships, is presented in Figure 1. The Medical Profession Medicine is not monolithic. It includes individual physicians and those insti- tutions traditionally mandated to carry out medicine’s collective responsibilities (licensing and certifying bodies, and educational and training institutions) and their national and specialty associations.The interests of primary care physicians do not always coincide with those of specialists and sub-specialization often re- sults in significant differences between specialists (Abbott 1988; Starr 1982; Stev- ens 2001, 2002). Professional associations have been described as representing an elite whose priorities may differ from those of practicing physicians. There is a constant interplay between and among individual physicians and medicine’s in- stitutions that must take place if the profession is to develop a consensus on the issues pertaining to its social contract with society (Laugeson and Rice 2003; J. M. Lewis 2006; Peterson 2003; Salter 2001, 2003). 584 Perspectives in Biology and Medicine
  • 7. Expectations and Obligations Table 1 E XPECTATIONS : T HE P UBLIC AND THE M EDICAL P ROFESSION Patients’/public’s expectations of medicine Medicine’s expectations of patients/public Fulfill role of healer Trust sufficient to meet patient’s needs Assured competence of physicians Autonomy sufficient to exercise judgment Timely access to competent care Role in public policy in health Altruistic service Shared responsibility for health Morality, integrity, honesty Balanced lifestyle Trustworthiness (codes of ethics) Rewards: nonfinancial (respect, status), Accountability/transparency financial Respect for patient autonomy Source of objective advice Promotion of the public good Society Society is also complex, consisting of patients and the general public on the one hand, and government on the other. Physicians and medicine relate to each societal component.The primary relationship of the individual physician in both moral and fiduciary terms is with the individual patient (May 1975; Pellegrino 1990; Rosenbaum 2003; Rosenblatt, Shaw, and Rosenbaum 1997).This relation- ship cannot be isolated from the system within which it operates, nor from the wishes of society as a whole. Other health professionals and their organizations, disease-oriented and consumer groups, industry, individual citizens, and the un- organized general public are all partners to the contract (Brown et al. 2004; Blu- menthal 2006; Callaghan and Wistow 2006; Ham and Alberti 2002; Morone and Kilbreth 2002; Rosen and Dewar 2004; Salter 2001, 2003).As within the medical profession, there is a dynamic interplay between the various nongovernmental stakeholders as they interact with each other, which results in the elaboration of what patients and the public wish from physicians and their organizations (Le Grand 2003). In line with contract theory, physicians and those representing them and pa- tients and the general public have expectations, “each of the other.” A proposed outline of these expectations is given in Table 1. Professionalism serves as the basis of this relationship, essentially establishing the rules of the game as outlined in medicine’s declaration of applied morality, its code of ethics. Medicine also has an important relationship with government, because the profession operates using powers delegated to it by society through government action. Governments are also complex, being composed of elected politicians, civil servants, and (particularly in publicly funded institutions) managers. Again, there is a dynamic interaction between these individuals or groups of individu- als that results in public policy. There are also a series of expectations and obli- autumn 2008 • volume 51, number 4 585
  • 8. Richard L. Cruess and Sylvia R. Cruess Table 2 E XPECTATIONS : T HE M EDICAL P ROFESSION AND G OVERNMENT Medicine’s expectations of government Government’s expectations of medicine Trust sufficient to meet patient’s needs Assured competence of physicians Autonomy sufficient to exercise judgment Morality, integrity, honesty Self-regulation Compliance with health-care system—laws Health-care system: value-laden, equitable, and regulations adequately funded and staffed, reasonable Accountability: performance, productivity, freedom within system cost-effectiveness Role in developing health policy Transparency in decision-making and Monopoly through licensing laws administration Rewards: nonfinancial (respect, status), Participation in team health care financial Source of objective advice Promotion of the public good gations resulting from the relationship between medicine and government. (See Table 2.) Because of the current dominance of the state or the commercial sec- tor, to which the state may delegate a major role, the relationship between med- icine and government is now extremely important, as are the expectations and obligations of the two parties (Freidson 2001; Krause 1996; Light 2001; McKin- ley and Marceau 2002; Starr 1982; Stevens 2002). Professionalism governs med- icine’s actions in dealing with governments. Finally, as society is made up of government and those governed, patients as citizens and the general public enjoy a relationship with government that is closer to the classical vision of a social contract. Patients, their representatives, stake- holder groups, and the general public must deal with the elected officials, civil ser- vants, and health-care managers mandated to ensure that citizens and the public receive the preventive and therapeutic measures in health expected in a modern society.The expectations and obligations of these parties are illustrated in Table 3. While professionalism does not play a role in this relationship, the nature of the social contract between the public and government is expressed in the structure and funding of the health-care system and has a profound effect upon the pro- fessionalism of medicine, either supporting or subverting its healing role and tra- ditional values (Freidson 2001; Light 2001; Stevens 2001; Sullivan 2005). The External Influences Three important external influences on the social contract and on the interac- tions between the three parties are: (1) the health-care system, including the role of the private sector; (2) the regulatory framework; and (3) the media. 586 Perspectives in Biology and Medicine
  • 9. Expectations and Obligations Table 3 E XPECTATIONS : T HE P UBLIC AND G OVERNMENT Public’s/patients’ expectations of government Government’s expectations of public/patients Quality health care Appropriate use of resources Health-care system: accessible, equitable, Reasonable expectations value-laden, adequately funded and Some responsibility for own health staffed, reasonable cost Support for public policy Transparency in decision-making and Controlled input into public policy and administration management Accountability Input into health policy The Health-Care System and the Private Sector The relationship between the commercial sector and both physicians and pa- tients is usually outlined by legal contracts (including insurance policies), not a social contract. However, the role of the marketplace in health care is clearly part of the overall social contract. Its magnitude is decided by government action or inaction and accounts for many of the national differences in the nature of the social contract (Hafferty and McKinley 1993; Krause 1996; Marchildon 2006; Rosenbaum et al. 1999; Tuohy 1999;Vogel 1986). Most countries have systems that combine public and private roles, with the nature of the mix ultimately determined by legislation. When medicine or the general public wishes to change the system, it must be done through the political process. The nature of the social contract between medicine and society imposes lim- its on the legal contracts outlining the obligations of practitioners, the commer- cial sector, and government. When these limits are exceeded, the public will re- act. Recent examples include the gag laws that prohibited physicians from informing patients of therapeutic options not included in their insurance cover- age, and the attempt to impose a 24-hour limit on hospital stays following ob- stetrical delivery.The public and the medical profession, supported by the media, objected and, working through the political process, established that some deci- sions must remain between physicians and their patients (Rosenbaum et al. 1999). There are also limits on the actions of the medical profession. A physicians’ strike in Ontario over the right to bill more than the approved fee schedule received no public support. The profession did not gain its objectives, and its reputation was severely damaged (Meslin 1987).These exemplify the often unwritten constraints on all parties to the contract to remain within the moral boundaries perceived to be part of the social contract. The Regulatory Framework The regulatory framework of a country impacts the social contract. Countries such as France, where the government retains the right to regulate, have differ- autumn 2008 • volume 51, number 4 587
  • 10. Richard L. Cruess and Sylvia R. Cruess ent contracts from those with systems drawn from the Anglo-Saxon tradition, where more emphasis is placed on the independence and autonomy of the pro- fession (Hafferty and McKinley 1993; Irvine 2003; Krause 1996). The Media The impact of the media on the social contract can be profound, especially in contemporary society with rapid communication within and between countries. The “Bristol cases” in the United Kingdom provide a powerful example. Pedi- atric cardiac surgery was carried out with unacceptably high mortality rates for years. The facts were known to many with administrative responsibility both within and without the institution, but it was not until the media revealed them to the general public that action was taken (Irvine 2003). Public indignation prompted an extensive reevaluation by government of the concept of self-regu- lation and recommendations for significant changes in the process, including partial withdrawal of the profession’s regulatory powers (Salter 2003; Secretary of State for Health 2007). The failure of the medical profession to self-regulate constituted a breach of its obligations under the contract, and the media was in- strumental in highlighting this fact, leading to a change in the contract with an alteration in the expectations of the major parties. Expectations Under the Contract As is true of all contractual relationships, there are expectations on both sides. Tables 1, 2, and 3 propose a list of the current expectations of the three parties to the social contract derived from a review of the literature (see Appendix). Many of the expectations of the three parties have been present since the modern professions were established by licensing laws in the mid-19th century, but there have been dramatic increases in the nature and magnitude of the ex- pectations and changes in how they are expressed. Societal expectations have in- creased because modern science has given the healer greater capacity to cure, in- creasing medicine’s importance to the average citizen (Rawls 1999; Starr 1982). Physicians have also altered their expectations from the 19th and early 20th cen- tury when physician incomes and status were relatively low (Klein 1990; Krause 1996). New expectations have been the added to the contract, such as the desire of individual physicians for a balanced lifestyle and the expectation that physi- cians will participate in team medicine (Blendon et al. 2006; Borges et al. 2006; Chisholm, Cairncross, and Askham 2006; Coulter 2002; Henningson 2002; Holmstrom, Sanner, and Rosenqvist 2004; Johnston 2006; Levinson and Lurie 2004; Neufeld, Maudsley, and Pickering 1998; Schoen et al. 2005; Watson et al. 2006). Because the understanding of many physicians as well as patients and the public is often based upon a nostalgic understanding of the professionalism of yesteryear, the changes that have occurred to the social contract must be under- stood by all parties. 588 Perspectives in Biology and Medicine
  • 11. Expectations and Obligations In addition to the changing expectations of the various parties, the expectations of one party may conflict with those of another.An example is the realization that younger physicians of both sexes wish time for family and outside interests (Borges et al. 2006; Henningson 2002; Holmstrom, Sanner, and Rosenqvist 2004; Johnston 2006; Levinson and Lurie 2004;Watson et al. 2006).This may conflict with the al- truism fundamental to the practice of medicine (Coulehan 2005; Inui 2003; McGaghie et al. 2002). If patients believe that their doctor is pursuing his or her own interests during the relationship, they will lose trust and the physician’s abil- ity to heal may be diminished (Coulter 2002; Hall 2005; Mechanic and Schlesinger 1996; Pellegrino 1990). Faith in the morality, integrity, and honesty of physicians is fundamental to trust. For generations this trust was given blindly. Now it must be constantly earned. It is also important for physicians to trust the health-care sys- tem within which they function, and the commercial organizations with which they deal. If this trust is not present, physician motivation changes, cynicism occurs, and patient care may suffer (Gould 2001; Hall 2005). For a century and a half, the expectation of both elements of society has been that the profession will assure the competence of its members through self-reg- ulation. Until recently, licensure and certification obtained early in a career was felt to be sufficient. Because of the well-documented failure of the profession to self-regulate, society is now demanding proof of competence, including profes- sionalism, throughout practice (Irvine 2003).This has added significant new ob- ligations to contemporary professionalism. Major changes have occurred in physician autonomy and accountability. In earlier times physicians were accountable primarily to their patients and their colleagues. They are now accountable to governments and commercial organi- zations for their competence, performance, productivity, and the cost-effective- ness of their activities (Broadbent and Laughlin 1997; Emanuel and Emanuel 1996;Timmermans 2005). In addition, courts have established new levels of ac- countability as judicial interpretation of legislation and malpractice claims have increased, particularly in the United States (Moran and Wood 1993; Rosenbaum 2003; Rosenblatt, Shaw, and Rosenbloom 1997; Starr 1982; Vogel 1986). One consequence has been a decrease in the autonomy of physicians in practice (Broadbent and Laughlin 1997; Emanuel and Emanuel 1996; Freidson 2004; Krause 1996; Rosenbaum 2003; Salter, 2001; Timmermans 2005). However, both patients and physicians continue to expect sufficient autonomy to be pre- served for physicians to make independent decisions in partnership with their patients (Chisholm, Cairncross, and Askham 2006; Neufeld, Maudsley, and Pickering 1998). Another important change in the social contract relates to the development of public policy. Health and health care are essential if citizens are to live normal and productive lives, and health-care policy has a significant impact on access, cost, and quality (Freidson 2001; Krause 1996; Moran and Wood 1993; Rich- mond and Fein 2005; Starr 1982). For this reason, the public wishes to influence autumn 2008 • volume 51, number 4 589
  • 12. Richard L. Cruess and Sylvia R. Cruess health-care policy. Physicians also wish to have input, as they believe that they possess expertise essential to the proper formulation of health-care policy. For their part, governments state that they welcome participation of the public and the medical profession, but they appear to wish to control their input (Le Grand 2003; Salter 2003). As trust in the medical profession has decreased over the past few decades, it has been realized that the perception that individual physicians and the profes- sion represent a force for good in society—a force not restricted to health care— is of great importance, something which in the past was assumed.This point has been emphasized by several eminent social scientists. Sullivan (2005) has sug- gested that practicing “civic professionalism” is essential for the profession, stat- ing that in becoming a professional, one assumes a civic identity involving a duty to function “in such a way that the outcome of the work contributes to the pub- lic value for which the profession stands” (p. 23). Stevens (2001) has written that the profession must fulfill its “public roles” and be seen to be doing so in an ex- emplary fashion in order to gain public support for the concept of professional- ism. And in his last book, Freidson (2001) has outlined what he termed the “soul” of professionalism and indicated how important its preservation is to the public good. While there are differences in expectations between the parties, there are also areas of agreement. For example, government expects patients and the general public to have what they would term “reasonable expectations” of the system (Klein 1990; Le Grand 2003; Marchildon 2006; Salter 2001), although there are differences in how individual patients and health planners would define “rea- sonable.” The same holds true for the desire of both the medical profession and the public to have a health-care system that is adequately funded and staffed, with the differences focusing on the methods and levels of funding. Contract Theory and Who Rules If the term social contract is to be a valid descriptor of the relationship between medicine and society, it should be compatible with the often shifting patterns of power and influence on public policy in the health-care field, an issue well doc- umented in the literature. In his classic work, Freidson (1970) described the dominance of medicine. Almost immediately, others questioned this dominance, suggesting that medicine was being deprofessionalized, proletarianized, and being subjected to bureaucratic control (Haug 1973; McKinley and Arches 1985; Starr 1982). Eventually all, including Freidson (2001), agreed that medicine’s dominance has been greatly diminished. The theory of countervailing forces emerged, according to which there is a dynamic interplay between the medical profession, government, and the corporate sector. The balance has shifted with either government or the corporate sector now assuming dominance depending upon the structure of the health-care system (Krause 1996; Light 2001; Mechan- 590 Perspectives in Biology and Medicine
  • 13. Expectations and Obligations ic 1991). Patients and the general public were not assigned an independent role, assuming that government would represent their interests.While confirming the loss of influence of the medical profession, recent literature has suggested that the public also has been disenfranchised and has stressed the importance of medicine engaging patients and the public in both the development of policy and in deci- sion-making at the local level (Allsop, Jones, and Baggott 2004; Cohen, Cruess, and Carpenter 2007; Krause 1996; Le Grand 2003; Morone and Kilbreth 2002; Salter 2003). Government is ultimately responsible for establishing the structure of a health-care system, including the balance between public and private payment. Tuohy (2003) has traced the changes in accountability and governance in health care. She states that health care has long had “indirect” governance, beginning with a principle-agent relationship between government and medicine and pro- ceeding to one based on a contract model. Neither appears appropriate to con- temporary conditions, where governments are “simply one set of actors among others in complex networks linking different social and economic sectors as well as different orders of relationships from the local to the total” (p. 201). She and others have called these “loosely coupled networks,” where the role of the gov- ernment is to guide, negotiate, broker, and facilitate the emergence of consen- sus. She believes that the nature of the issues facing contemporary health care is driving governance in this direction. The schematic representation of the social contract appears to be compatible with the changes in power and influence among the various parties that have oc- curred in recent times. The role of the corporate sector and the regulatory framework, both of which have a profound influence on the social contract, result from choices made by society and expressed through legislation in the structure of the health-care system.We would suggest that the “loosely coupled networks” function under the umbrella of a social contract and that the sche- matic representation provided includes the major participants in the loosely cou- pled network and outlines their interrelationships.The reciprocity described will continue to necessitate an interaction between the parties, no matter which party is dominant. Implications of This Approach Applying the concept of the social contract to professionalism, and hence to the relationship between medicine and society, has been said to reframe the discus- sion of this relationship in three ways (Kurlander, Morin, and Wynia 2004). First, it identifies the parties involved in shaping the relationship.This is essential if the complexities of contemporary health care are to be fully understood. Second, it helps to focus the discussion on the issues that pose the greatest challenge to contemporary health care, emphasizing areas of disagreement as well as consen- sus. Finally, it assists in establishing the moral boundaries of professional concern. autumn 2008 • volume 51, number 4 591
  • 14. Richard L. Cruess and Sylvia R. Cruess We would suggest an important fourth advantage: interpreting professional- ism within this framework emphasizes professionalism’s relevance to the practice of medicine and makes the profession’s obligations and the reasons for their exis- tence more understandable. In addition, the failure of individual physicians or of the profession as a whole to meet legitimate societal expectations should logi- cally result in consequences, including the possibility of a significant change in the contract. There are several implications to this approach. In the first place, the reci- procity inherent in the idea of a social contract underlines the importance of correctly interpreting the expectations of both medicine and society. In addition, the idea of reciprocity legitimizes the idea that the profession has expectations of society and should encourage the profession to negotiate those aspects of the social contract that can increase the ability of individual physicians to fulfill the role of the healer (George, Gonsenhauser, and Whitehouse 2006; Wynia et al. 1999). It also highlights the current state of affairs in the United States, where it is unclear who would actually negotiate on behalf of the medical profession in a country without a national health plan, and hence a central negotiating table (Cruess and Cruess 1997; Stevens 2001). Many societal expectations of the pro- fession must be met by medicine’s institutions.These include most aspects of self- regulation—specifically, ensuring physicians’ competence through setting and maintaining educational standards and assuring quality of care.The concept of a social contract makes these expectations and the profession’s obligations under the contract explicit and indicates why they should be the concern of every practicing physician. The final point relates to the teaching of professionalism and the transmission of professional values, the primary responsibility of medical schools and their associated teaching institutions. Teaching professionalism as the basis of medi- cine’s social contract provides a rational basis for the existence of both the expec- tations and obligations of the various parties. Under the social contract, the col- lective expectations of patients, the public, and government of the medical profession constitute a functional definition of medical professionalism and a summary of medicine’s professional obligations. As Kultgen (1998) has stated: “Entry into the profession is a voluntary act, and most people who perform it are disposed to learn its ways and take its ideology seriously.They need only to be told how” (p. 366). We believe that one should add “why”—and that the social contract provides a cogent answer. References Abbott, A. 1988.The system of professions. Chicago: Univ. of Chicago Press. Allsop, J. A., K. Jones, and R. Baggott. 2004. Health consumer groups in the UK: A new social movement? Sociol Health Illn 26:737–56. American Board of Internal Medicine (ABIM). 2002. Medical professionalism in the new millennium:A physician charter. Ann Intern Med 136:243–46; Lancet 359:520–23. 592 Perspectives in Biology and Medicine
  • 15. Expectations and Obligations Armstrong, D. 2002. Clinical autonomy, individual and collective:The problem of chang- ing doctors’ behavior. Soc Sci Med 55:1771–77. Bertram, C. 2004. Rousseau and the social contract. London: Routledge. Blendon, R. J., et al. 2006. Americans’ views of health care costs, access, and quality. Mil- bank Q 84:623–57. Blumenthal, D. 2006. Employer-sponsored health insurance in the United States: Origins and implications. N Engl J Med 355:82–88. Borges, N. J., et al. 2006. Comparing Millennial and Generation X medical students at one medical school. Acad Med 81:571–76. Broadbent, J., and R. Laughlin. 1997. “Accounting logic” and controlling professionals. In The end of professions? The restructuring of professional work, ed. J. Broadbent, M. Diet- rich, and J. Roberts, 34–49. London: Routledge. Brown, P., et al. 2004. Embodied health movements: New approaches to social move- ments in health. Sociol Health Illn 26:50–80. Brownlie, J., and A. Howson. 2006. “Between the demands of truth and government”: Health practitioners, trust and immunization work. Soc Sci Med 62:433–43 Callaghan, G., and G. Wistow. 2006. Governance and public involvement in the British National Health Service: Understanding difficulties and developments. Soc Sci Med 63: 2289–2300. Canadian Medical Association. 1999. Charter for physicians. CMAJ 161:430–33. Carr-Saunders, A. M., and P. A.Wilson. 1933. The professions. Oxford: Clarendon Press. Castellani, B., and F. W. Hafferty. 2006. The complexities of medical professionalism: A preliminary investigation. In Professionalism in medicine: Critical perspectives, ed. D.Wear and J. M. Aultman, 3–25. New York: Springer. Chisholm, A., L. Cairncross, and J. Askham. 2006. Setting standards:The views of members of the public and doctors on the standards of care and practice that they expect of doctors. Oxford: Picker Institute Europe. Cohen J. J., S. R. Cruess, and C. Davidson. 2007. Alliance between society and medicine: The public’s stake in medical professionalism. JAMA 298:670–73. Coulehan, J. 2005. Today’s professionalism: Engaging the mind but not the heart. Acad Med 80:892–98. Coulter, A. 2002. Patient’s views of the good doctor. BMJ 325:668–69. Crocker, L.G. 1968. Rousseau’s social contract: An interpretive essay. Cleveland: Case Western Reserve Univ. Press. Cruess, R. L., and S. R. Cruess. 1997.Teaching medicine as a profession in the service of healing. Acad Med 72:941–52. Cruess, S. R., S. Johnston, and R. L. Cruess. 2004. Profession: A working definition for medical educators. Teach Learn Med 16:74–76. Davies, P., and J. A. Glasspool. 2003. Patients and the new contracts. BMJ 326:1099. Davis, M., and L. R. Churchill. 1991. Autonomy and the common weal. Hastings Cent Rep 21:25–31. Dixon, D. M., K. G. Sweeney, and D. J. Gray Pereira. 1998.The physician healer: Ancient magic or modern science? Br J Gen Pract 49:309–12. Donaldson,T., and T.W. Dunfee. 1999. Ties that bind in business ethics: A social contracts ap- proach to business ethics. Cambridge: Harvard Univ. Business School Press. Donaldson,T., and T.W. Dunfee. 2002.Ties that bind in business ethics: Social contracts and why they matter. J Banking Finance 26:1853–65. autumn 2008 • volume 51, number 4 593
  • 16. Richard L. Cruess and Sylvia R. Cruess Edwards, N., M. J. Kornacki, and J. Silversin. 2002. Unhappy doctors:What are the causes and what can be done? BMJ 324:835–38. Elliot, P. 1972. The sociology of the professions. London: Macmillan. Emanuel, E. J., and L. L. Emanuel. 1996.What is accountability in health care? Ann Intern Med 124:229–39. Freidson, E. 1970. Professional dominance:The social structure of medical care. Chicago:Aldine. Freidson, E. 2001. Professionalism:The third logic. Chicago: Univ. of Chicago Press. General Medical Council. 2006. Good medical practice. London: General Medical Council. George D., I. Gosenhauser, and P.Whitehouse. 2006. Medical professionalism:The nature of story and the story of nature. In Professionalism in medicine: Critical perspectives, ed. D. Wear and J. M. Aultman, 63–86. New York: Springer. Gibbons, M. 1999. Science’s new social contract with society. Nature 402:C81–C84. Gibson, R.W. 1989.The rights of professionals in health care. In Ethical issues in the pro- fessions, ed. P.Y.Windt, et al., 296–302. Englewood Cliffs: Prentice Hall. Good Medical Practice USA.Version 0.1. Aug 15. 2007. Gough, J. W. 1957. The social contract: A critical study of its development. Oxford: Clarendon Press. Gould, S. D. 2001. Trust and the ethics of health care institutions. Hastings Cent Rep 31: 26–33. Gruen, R. L, S. D. Pearson, and T. A. Brennan. 2004. Physician-citizens: Public roles and professional obligations. JAMA 291:94–8. Hafferty, F. W. 2006a. Definitions of professionalism: a search for meaning and identity. Clin Orthop Relat Res 449:193–205. Hafferty, F. W. 2006b. The elephant in medical professionalism’s kitchen. Acad Med 81: 906–14. Hafferty, F. W., and J. B. McKinley. 1993. The changing medical profession: An international perspective. Oxford: Oxford Univ. Press. Hall, M.A. 2005.The importance of trust for ethics, law, and public policy. Camb Q Healthc Ethics 14:156–67. Hall, M. A., et al. 2000.Trust in physicians and medical institutions:What is it, can it be measured and does it matter? Milbank Q 79:613–639. Ham, C., and K. J.Alberti. 2002.The medical profession, the public, and the government. BMJ 324:838–42. Haug, M. 1973. Deprofessionalization: An alternate hypothesis for the future. Sociol Rev Monogr 20:195–211. Henningson, J. A. 2002. Why the numbers are dropping in general surgery: The answer no one wants to hear—lifestyle. Arch Surg 137:255–56. Holmstrom, I., M. A. Sanner, and U. Rosenqvist. 2004. Swedish medical students views of the changing professional role of medical doctors and the organization oh health care. Adv Health Sci Educ 9:5–14. Hughes, E. C. 1958. Men and their work. New York: Free Press. Inui, T. S. 1992.The social contract and the medical school’s responsibilities. In The med- ical school’s mission and the population’s health: Medical education in Canada, the United Kingdom, the United States, and Australia, ed. K. L.White and J. E. Connelly, 23–52. New York: Springer Verlag. Inui,T. S. 2003. A flag in the wind: Educating for professionalism in medicine.Washington, DC: Association of American Medical Colleges. 594 Perspectives in Biology and Medicine
  • 17. Expectations and Obligations Irvine, D. 2003. The doctor’s tale: Professionalism and public trust. Abington, UK: Radcliffe Medical Press. Johnson,T. 1972. Professions and power. London: Macmillan. Johnston, S. 2006. See one, do one, teach one: Developing professionalism across the gen- erations. Clin Orthop Relat Res 449:186–92. Kearney, M. 2000. A place of healing:Working with suffering in living and dying. Oxford: Ox- ford Univ. Press. Kennedy, D. 1997. Academic duty. Cambridge: Harvard Univ. Press. Klein, R. 1990.The state and the profession:The politics of the double bed. BMJ 301S: 700–702. Klein, R. 2006. Shooting down the NHS reform track. BMJ 333:1280–81. Krause, E. 1996. Death of the guilds: Professions, states and the advance of capitalism, 1930 to the present. New Haven:Yale Univ. Press. Kultgen, J. H. 1998. Ethics and professionalism. Philadelphia: Univ. of Pennsylvania Press. Kurlander, J. K., K. Morin, and M. K.Wynia. 2004.The social-contract model of profes- sionalism: Baby or bathwater? Am J Bioethics 4:33–6. Larson, M. 1977. The rise of professionalism: A sociological analysis. Berkeley: Univ. of Cali- fornia Press. Laugeson, M. J., and T. Rice. 2003. Is the doctor in? The evolving role of organized med- icine in health policy. J Health Polit Policy Law 28:289–316. Le Grand, J. 2003. Motivation, agency, and public policy: Of knights and knaves, pawns and queens. Oxford: Oxford Univ. Press. Leigh, J. P., et al. 2002. Physician career satisfaction across specialties. Arch Intern Med 162: 1577–84. Levinson,W., and N. Lurie. 2004.When most doctors are women:What lies ahead? Ann Intern Med 141:471–79. Lewis, H. R. 2006. Excellence without a soul. New York: Public Affairs. Lewis, J. M. 2006. Being around and knowing the players: networks of influence in health policy. Soc Sci Med 62:2125–36. Light, D. W. 2001. The medical profession and organizational change: From professional dominance to countervailing power. In Handbook of medical sociology, 5th ed., ed. C. E. Bird, P. Conrad, and A. M. Fremont, 201–16. Upper Saddle River, NJ: Prentice Hall. Linzer, M., et al. 2000. Managed care, time pressure, and physician job satisfaction: Results from the Physician Work Life Study. J Gen Intern Med 15:441–50. Lubchenko, J. 1998. Entering the century of the environment: A new social contract for science. Science 279:491–97. Ludmerer, K. M. 1999. Time to heal. Oxford: Oxford Univ. Press. Marchildon, G. 2006. Health systems in transition: Canada, ed. S.Allin and E. Mossialos.Tor- onto: Univ. of Toronto Press. Masters, R. D., and J. R. Masters. 1978. On the social contract. New York: St. Martin’s Press. May,W. F. 1975. Code, covenant, contract, or philanthropy. Hastings Cent Rep 5:29–38. May,W. F. 1997. Money and the medical profession. Kennedy Inst Ethics J 7:1–13. McCurdy L., et al. 1997. Fulfilling the social contract between medical schools and the public. Acad Med 72:1063–70. McGaghie,W. M., et al. 2002.Altruism and compassion in the health professions: A search for clarity and precision. Med Teach 24:374–78. autumn 2008 • volume 51, number 4 595
  • 18. Richard L. Cruess and Sylvia R. Cruess McKinley, J. B., and J. Arches. 1985. Toward the proletarianization of physicians. Int J Health Serv 15:161–95. McKinley, J. B., and L. D. Marceau. 2002. The end of the golden age of doctoring. Int J Health Serv 32:379–416. Mechanic, D. 1991. Sources of countervailing power in medicine. J Health Polit Policy Law 16:585–498. Mechanic, D. 2003. Physician discontent: Challenges and opportunities. JAMA 290:941– 46. Mechanic, D., and S. Meyer. 2000. Concepts of trust among patients with serious illness. Soc Sci Med 51:657–68. Mechanic, D., and M. Schlesinger. 1996. The impact of managed care on patient’s trust in medical care and their physicians. JAMA 275:1693–97. Melhado, E. M. 2006. Health planning in the United States and the decline of public- interest policymaking. Health Aff 84:359–440. Meslin, E. M. 1987. The moral costs of the Ontario physicians strike. Hastings Cent Rep 17:11–14. Moran, M., and B. Wood. 1993. States, regulation and the medical profession. Buckingham: Open Univ. Press. Morone, J. A., and E. H. Kilbreth. 2002. Power to the people? Restoring citizen partici- pation. J Health Polit Policy Law 28:271–88. Morreim, E. H. 2002. Professionalism and clinical autonomy in the practice of medicine. Mt Sinai J Med 69:370–77. Murray,A., et al. A comparison of physicians satisfaction in different delivery systems. J Gen Intern Med 16:451–95. Neufeld,V. R., et al. 1998. Educating future physicians for Ontario. Acad Med 73:1133– 48. O’Neill, O. 2002. A question of trust. Cambridge: Cambridge Univ. Press. Parsons,T. 1951. The social system. New York: Free Press. Pellegrino, E. D. 1990.The medical profession as a moral community. Bull NY Acad Med 66:221–32. Peterson, M. A. 2003.Who shall lead? J Health Polit Policy Law 28:181–94. Piliavin, J. A., and H.V. Charng. 1990. Altruism: a review of recent theory and research. Annu Rev Sociol 16:27–65. Rawls, J. A. 1999. Theory of justice. Cambridge: Harvard Univ. Press. Rawls, J. A. 2003. Justice as fairness: A restatement. Cambridge: Harvard Univ. Press. Richmond, J. B., and R. Fein. 2005. The health care mess: How we got into it and what it will take to get out. Cambridge: Harvard Univ. Press. Rosen, R., and S. Dewar. 2004. On being a good doctor: Redefining medical professionalism for better patient care. London: King’s Fund. Rosenbaum, S. 2003.The impact of United States law on medicine as a profession. JAMA 289:1546–66. Rosenbaum S., et al. 1999.Who should determine when health care is medically neces- sary. N Engl J Med 340:229–32. Rosenblatt, R. E., S. Shaw, and S. Rosenbaum. 1997. Law and the American health care sys- tem. New York: Foundation Press. Royal College of Physicians of London. 2005. Doctors in society: Medical professionalism in a changing world. London: Royal College of Physicians of London. 596 Perspectives in Biology and Medicine
  • 19. Expectations and Obligations Salter, B. 2001.Who rules? The new politics of medical regulation. Soc Sci Med 52:871– 83. Salter, B. 2003. Patients and doctors: Reformulating the UK health policy community? Soc Sci Med 57:927–36. Schlesinger, M. A. 2002. Loss of faith:The sources of reduced political legitimacy for the American medical profession. Milbank Q 80:185–235. Schoen, C., et al. 2005. Taking the pulse of health care systems: Experiences of patients with health problems in six countries. Health Aff 25:509–25. Schroeder, S. A., J. S. Zones, and J. A. Showstack. 1989. Academic medicine as a public trust. JAMA 262:803–12. Secretary of State for Health. 2007. Trust, assurance, and safety:The regulation of health pro- fessionals in the 21st century. London: Stationery Office. Smith, R. 2001.Why are doctors so unhappy? BMJ 322:1073–74. Smith, R. 2004a.Towards a global social contract. BMJ 338:743. Smith, R. 2004b.Transparency: A modern essential. BMJ 328:1136. Stacey, M. 1997.The case for and against medical self-regulation. Federation Bull 84:17–25. Starr, P. 1982. The social transformation of American medicine. New York: Basic Books. Stevens, R. 2001. Public roles for the medical profession in the United States: Beyond theories of decline and fall. Milbank Q 79:327–53. Stevens, R. 2002. Themes in the history of medical professionalism. Mt Sinai J Med 69: 357–62. Sullivan,W. 2005. Work and integrity:The crisis and promise of professionalism in North Amer- ica, 2nd ed. San Francisco: Jossey-Bass. Swick, H.M. 2000.Towards a normative definition of professionalism. Acad Med 75:612– 16. Timmermans, S. 2005. From autonomy to accountability: the role of clinical practice guidelines in professional power. Perspec Biol Med 48:490–501. Tuohy, C. H. 1999. Dynamics of a changing health sphere. Health Aff 18:114–34. Tuohy, C. H. 2003.Agency, contract, and governance: Shifting shapes of accountability in the health care arena. J Health Polit Policy Law 29:195–215. Vogel, D. 1986. National styles of self-regulation. Ithaca: Cornell Univ. Press. Watson, D. E., et al. 2006. Intergenerational differences in workloads: A ten year popula- tion-based study. Health Aff 25:1620–28. World Medical Association. 2005. Medical ethics manual. Ferney-Voltaire Cedex, France: World Medical Association. Wynia, M. K., et al. 1999. Medical professionalism in society. N Engl J Med 341:1612–16. Zuger, A. 2004. Dissatisfaction with medical practice. N Engl J Med 350:69–75. Appendix: Review of Literature The expectations of the various parties to the social contract cannot be derived from a single source. Tables 1 through 3 are based on a review of the literature in the following fields. Accountability and transparency: Emanuel and Emanuel 1996; Broadbent and Laughlin 1997; Rosenbaum 2003; Salter 2003;Tuohy 2003; Gruen, Pearson, and Brennan 2004; Smith 2004b;Timmermans 2005. autumn 2008 • volume 51, number 4 597
  • 20. Richard L. Cruess and Sylvia R. Cruess Altruism: May 1975; Pellegrino 1990; Piliavin and Charng 1990; McGaghie et al. 2002. Autonomy: Davis and Churchill 1991; Armstrong 2002; Morreim 2002. Generational and gender issues: Henningson 2002; Holmstrom, Sanner, and Rosenqvist 2004; Levinson and Lurie 2004; Borges et al. 2006; Johnston 2006;Watson, et al. 2006. Healing: May 1975; Pelligrino 1990; Cruess and Cruess 1997; Dixon, Sweeney and Gray Pereira 1998; Kearney 2000. Patients’ desires and satisfaction with their care: Neufeld, Maudsley, and Pickering 1998; Coulter 2002; Schoen et al. 2005; Blendon et al. 2006; Chisholm, Cairncross, and Ask- ham 2006. Physicians’ desires and job satisfaction: Gibson 1989; Canadian Medical Association 1999; Linzer et al. 2000; Murray et al. 2001; Smith 2001; Edwards, Kornacki, and Silversin 2002; Leigh et al. 2003; Mechanic 2003; Zuger 2004; Chisholm, Cairncross, and Askham 2006. Professionalism: Carr-Saunders and Wilson 1933; Parsons 1951; Hughes 1958; Freidson 1970, 2001; Elliot 1972; Johnson 1972; Haug 1973; Larson 1977; Starr 1982; Mc- Kinley and Arches 1985; Abbott 1988; Hafferty and McKinley 1993; Krause 1996; Wynia et al. 1999; Stevens 2001, 2002;ABIM 2002; Inui 2003; Le Grand 2003; Gruen, Pearson, and Brennan 2004; Royal College of Physicians of London 2005; Sullivan 2005; World Medical Association 2005; General Medical Council 2006; Hafferty 2006a; Good Medical Practice USA 2007. Public policy, including governance: Vogel 1986; Salter 2001, 2003; Laugeson and Rice 2003; Le Grand 2003; Peterson 2003;Tuohy 2003; Richmond and Fein 2005; Callaghan and Wistow 2006; J. M. Lewis 2006. Regulation of the professions: Moran and Wood 1993; Stacey 1997; Salter 2001; Peterson 2003; Rosenbaum 2003;Tuohy 2003. Trust: Mechanic and Schlesinger 1996; Hall et al. 2000; Mechanic and Meyer 2000; Gould 2001; O’Neill 2002; Schlesinger 2002; Hall 2005; Brownlie and Howson 2006. 598 Perspectives in Biology and Medicine