Although rarely explicitly stated, it’s expected that physicians will act with humanity, integrity and care. And, on an individual level, it seems that most do.
Those training as doctors also make a substantial personal investment of resources, time and intellect. Lengthy years of training coupled with high levels of individual responsibility and professional accountability are the norm.
In return for their efforts, doctors are given considerable professional autonomy, respect, social prestige and financial reward. As a result of their specialised knowledge – and the unique power that comes with it – they are afforded privilege and trust above that of many other professional groups.
This reciprocity is the basis of the social contract in medicine, which emerged in the 19th century. In return for status and financial rewards, physicians would meet the medical needs of society through service and altruism.
Threats to the social contract
The expectation of reciprocity inherent within this social contract still arguably influences how health care is funded and structured in this country. But the fundamental spirit of this contract appears under threat on a number of fronts.
In his recent
analysis of Medicare expenditure, former director of the
Professional Services Review (PSR), Tony Webber, noted that an estimated two to three billion dollars are inappropriately spent every year. Much of this, he claims, arises from misuse of medical benefits scheme funding by individual physicians and corporate owners of medical businesses. Such observations undermine public trust in doctors and in their social contract.
Regarding medical care purely as a business transaction places the clinical encounter at the intersection of commerce and science – away from its traditional place at the nexus of humanity and science. For the public, this may be seen as a moral shift that signals doctors will place self-interest above the common good.
Finally, high profile failures of the medical profession to effectively self-regulate (another benefit traditionally bestowed them under the social contract) have contributed to recent legislative change. The introduction of national registration now requires mandatory reporting of poorly performing, or impaired colleagues across Australia. Public perception that the profession as a group has failed to act in the public interest and effectively sanction unprofessional colleagues has further eroded public trust.
Sylvia Cruess notes, “The loss of trust in the medical profession (although not necessarily in individual physicians) comes from a better informed citizenry, which is demanding greater levels of accountability, more transparency, and greater assurance of quality. The greatest challenge to medicine’s professional status at the present time comes from the general public.”
If health care is a shared social good funded primarily through public investment, the public deserves a stronger role in determining how these goods are distributed. In the
United Kingdom and in the state of
Oregon in the United States stronger public participation in key areas of health care has been achieved with some success through citizen’s juries. Such models could be considered in Australia.
http://theconversation.edu.au/power-and-duty-is-the-social-contract-in-medicine-still-relevant-3941
