Medical Professionalism Expectations Obligations

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Richard L. Cruess and Sylvia R. Cruess

Expectations andObligations

professionalism and medicine’ssocial contract with society

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: [email protected].

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, andWilliam Sullivanfor 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

ABSTRACT As health care has become of great importance to both individualcitizens 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. Duringthe past decade, individuals in the medical, legal, social sciences, and health policy fieldshave suggested that professionalism serves as the basis of medicine’s relationship withsociety, and many have termed this relationship a social contract. However, the conceptof medicine’s social contract remains vague, and the implications of its existence havenot 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 tothe 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 natureof the obligations, each to the other.

— Oxford Dictionary of Philosophy (1996)

10_51.4cruess:03_51.3thagard 335– 9/30/08 1:53 PM Page 579

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Perspectives in Biology and Medicine

THE SUBJECT OF MEDICINE’S PROFESSIONALISM has assumed increasing im-portance during the past decades because of the widespread belief that

medicine’s traditional values, which are closely linked to professionalism, areunder threat (Cruess and Cruess 1997; Freidson 2001; Hafferty 2006a; Krause1995; 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 MedicalCouncil 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 bythe term social contract.

Based on the concept’s foundation in philosophy and political science, we alsobelieve that social contract is the most appropriate descriptor of the relationship. Inthis article, we describe how the social contract relates to professionalism, definethe concept in contemporary terms, and provide an outline of the nature of thecurrent contract. Finally, we discuss some of the implications of a social contractapproach to medical professionalism.

Medicine and Society

There has been a surprising degree of agreement on the fundamental nature ofthe relationship between medicine and society.Virtually all who have describedit state that society has granted medicine autonomy in practice, a monopoly overthe use of its knowledge base, the privilege of self-regulation, and both financialand nonfinancial rewards. In return, physicians are expected to put the patient’sinterest above their own, assure competence through self-regulation, demon-strate morality and integrity, address issues of societal concern, and be devotedto the public good (Abbott 1988; Carr-Sunders and Wilson 1933; Cruess andCruess 1997; Elliot 1972; Freidson 1970; Kultgen 1998; Parsons 1951; Stevens2001; Sullivan 2005; Wynia et al. 1999).While there have been disagreementsabout the motivation and performance of the members of the profession and thestate of health of the “bargain,” its existence and the presence of a mutual stateof “dependency and obligation” between medicine and society seems accepted(Freidson 2001; Haug 1973; Johnson 1972; Klein 2006; Krause 1996; Larson1977; McKinley and Arches 1985).

As long as both society and the medical profession were content, there waslittle effort to formally categorize their relationship. However, as changes in bothmedicine and society have sparked widespread dissatisfaction with the currentstate of health care, a variety of models have been proposed to describe medi-cine’s relationship with society. Starr (1982) first suggested that the relationshipis 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


to the discipline of politics or markets or reorganizing its basic institutionalstructure” (p. 380). Subsequently many observers, including social scientists, law-yers, policy analysts, bioethicists, and physicians turned to the historical conceptof the “social contract.” Sullivan (2005) emphasized the link between profes-sionalism and the social contract, stating that the “the social contract became themoral 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 choiceof words influenced others who noted that the “bargain” had broken down(Davies and Glasspool 2003; Ham and Alberti 2002). Three recent studies ofmedical professionalism in the U.K. have used the term “implicit compact”which specifically includes doctors, patients, and society, and all state that therelationship involves reciprocity (Edwards, Kornacki, and Silversin 2002; Rosenand Dewar 2004; Smith 2004a). The Royal College of Physicians of London(2005) has proposed that morality is so fundamental to the practice of medicinethat the social contract should be renamed a “moral contract” (though withoutelaborating 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 betweensociety 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, andShowstack 1989).

The Social Contract: Origins and Evolution

The concept of the social contract was developed by 17th- and 18th-centuryphilosophers, primarily Hobbes, Locke, and Rousseau, at a time when mostcountries were ruled by hereditary monarchs (Crocker 1968; Masters and Mas-ters 1978). It had two purposes: to provide an historical account of the origin ofthe state and society as citizens united their individual “wills,” and to explain thenature of the relationship between the state and its citizens. It outlined a seriesof reciprocal rights and duties as being fundamental to this relationship.Whilethe concept has not been universally accepted as the philosophic basis of thestate, 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 choosetogether, in one joint act, the principles which are to assign basic rights andduties and to determine the division of social benefits” (p. 10).The philosophersendorsing the concept of a social contract were clear that there is no formal legalcontract. However, they justified the use of the term on the grounds that “the

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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 calleda 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 ofthe 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 andsociety, 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 careis 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, whichanswers a basic human need (Dixon, Sweeney, and Gray Pereira 1998; Kearney2000).Those elements of the social contract that refer to the healer are relativelyconstant across national and cultural boundaries, while those that refer to howthe services of the healer are organized, funded, and delivered may vary (Cruessand Cruess 1997; Krause 1996; Laugeson and Rice 2003).

As society and healthcare evolve, the social contract also evolves, expressingthe relationship between society’s dominant constituencies. The literature onprofessionalism recognizes that professionalism changes in response to societalneeds (Freidson 2001; Krause 1996; Starr 1982; Stevens 2001). Indeed, Castellaniand Hafferty (2006) have warned against continued reliance on the “nostalgicprofessionalism” of the past. As the social contract changes, the professionalismthat serves as its basis must also evolve.Therefore, in assessing the current state ofprofessionalism, 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 begiven 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 medicineand society is important, as it has the potential to give a mutually agreed-uponframework for discussion. Originally conceived to protect both individual citizens


and the public from the abuses of authoritarian rule, social contract theory nowemphasizes the mutual rights and obligations of citizens and those governingthem. Most of those analyzing the interface between medicine and society believethat the relationship involves reciprocal rights, privileges, and obligations. Of themany terms suggested, only social contract has an historical basis in philosophy andpolitical science, having been in wide use for three centuries. For this reason, itdoes not require redefinition and should more easily serve as a basis for dialoguebetween 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; Starr1982).The Hippocratic Oath and codes of ethics also constitute an explicit partof the contract, outlining medicine’s commitment, as do the International Char-ter on Medical Professionalism (ABIM 2002), Good Medical Practice (GeneralMedical Council 2006), and Good Medical Practice USA (2007). Many of thesedocuments impose legal obligations on physicians and the profession (Rosen-baum 2003; Rosenblatt, Shaw, and Rosenbaum 1997). However, there are alsoboth 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 (Coulehan2005; 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 andtheir 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 Kingdomand integrated them around the concept of reciprocity. In redefining medicalprofessionalism, they proposed a new “compact” involving three interlockingsocietal components. The first group consists of patients and patient groups aswell as the “public”; the second of health-care managers, the state, governmentdepartments, and the European Parliament; and the third of the medical profes-sion and “professional bodies.” There are interactions within each group, andeach group has reciprocal relationships with the other two. Each relationship is“mediated” by the media, the legal system, and the regulatory framework.The




commercial sector was not included as a major stakeholder or “mediator.”Whilewe agree with Rosen and Dewar’s approach, we believe that it does not correctlyoutline the nature of the interrelationships.

Parties to the Contract

A schematic representation of our concept of the contemporary social contractin 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) andtheir national and specialty associations.The interests of primary care physiciansdo 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 anelite whose priorities may differ from those of practicing physicians.There is aconstant interplay between and among individual physicians and medicine’s in-stitutions that must take place if the profession is to develop a consensus on theissues pertaining to its social contract with society (Laugeson and Rice 2003;J. M. Lewis 2006; Peterson 2003; Salter 2001, 2003).

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Figure 1

The social contract.


Society

Society is also complex, consisting of patients and the general public on theone hand, and government on the other. Physicians and medicine relate to eachsocietal component.The primary relationship of the individual physician in bothmoral and fiduciary terms is with the individual patient (May 1975; Pellegrino1990; Rosenbaum 2003; Rosenblatt, Shaw, and Rosenbaum 1997).This relation-ship cannot be isolated from the system within which it operates, nor from thewishes 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 andKilbreth 2002; Rosen and Dewar 2004; Salter 2001, 2003).As within the medicalprofession, there is a dynamic interplay between the various nongovernmentalstakeholders as they interact with each other, which results in the elaboration ofwhat patients and the public wish from physicians and their organizations (LeGrand 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 proposedoutline of these expectations is given in Table 1. Professionalism serves as thebasis of this relationship, essentially establishing the rules of the game as outlinedin medicine’s declaration of applied morality, its code of ethics.

Medicine also has an important relationship with government, because theprofession operates using powers delegated to it by society through governmentaction. 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-



Table 1 EXPECTATIONS: THE PUBLIC AND THE MEDICAL PROFESSION

Patients’/public’s expectations of medicine Medicine’s expectations of patients/public

Fulfill role of healer

Assured competence of physicians

Timely access to competent care

Altruistic service

Morality, integrity, honesty

Trustworthiness (codes of ethics)

Accountability/transparency

Respect for patient autonomy

Source of objective advice

Promotion of the public good

Trust sufficient to meet patient’s needs

Autonomy sufficient to exercise judgment

Role in public policy in health

Shared responsibility for health

Balanced lifestyle

Rewards: nonfinancial (respect, status),financial


gations resulting from the relationship between medicine and government. (SeeTable 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 andobligations 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 ascitizens and the general public enjoy a relationship with government that is closerto 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 publicreceive the preventive and therapeutic measures in health expected in a modernsociety.The expectations and obligations of these parties are illustrated inTable 3.While professionalism does not play a role in this relationship, the nature of thesocial contract between the public and government is expressed in the structureand 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 roleof the private sector; (2) the regulatory framework; and (3) the media.

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Table 2 EXPECTATIONS: THE MEDICAL PROFESSION AND GOVERNMENT

Medicine’s expectations of government Government’s expectations of medicine

Trust sufficient to meet patient’s needs

Autonomy sufficient to exercise judgment

Self-regulation

Health-care system: value-laden, equitable,adequately funded and staffed, reasonablefreedom within system

Role in developing health policy

Monopoly through licensing laws

Rewards: nonfinancial (respect, status),financial

Assured competence of physicians

Morality, integrity, honesty

Compliance with health-care system—lawsand regulations

Accountability: performance, productivity,cost-effectiveness

Transparency in decision-making andadministration

Participation in team health care

Source of objective advice

Promotion of the public good


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 asocial contract. However, the role of the marketplace in health care is clearly partof the overall social contract. Its magnitude is decided by government action orinaction and accounts for many of the national differences in the nature of thesocial contract (Hafferty and McKinley 1993; Krause 1996; Marchildon 2006;Rosenbaum et al. 1999;Tuohy 1999;Vogel 1986). Most countries have systemsthat combine public and private roles, with the nature of the mix ultimatelydetermined by legislation. When medicine or the general public wishes tochange 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 frominforming 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’ strikein Ontario over the right to bill more than the approved fee schedule received nopublic support.The profession did not gain its objectives, and its reputation wasseverely damaged (Meslin 1987).These exemplify the often unwritten constraintson all parties to the contract to remain within the moral boundaries perceived tobe part of the social contract.

The Regulatory Framework

The regulatory framework of a country impacts the social contract. Countriessuch as France, where the government retains the right to regulate, have differ-



Table 3 EXPECTATIONS: THE PUBLIC AND GOVERNMENT

Public’s/patients’ expectations of government Government’s expectations of public/patients

Quality health care

Health-care system: accessible, equitable,value-laden, adequately funded andstaffed, reasonable cost

Transparency in decision-making andadministration

Accountability

Input into health policy

Appropriate use of resources

Reasonable expectations

Some responsibility for own health

Support for public policy

Controlled input into public policy andmanagement


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 incontemporary 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 foryears. The facts were known to many with administrative responsibility bothwithin and without the institution, but it was not until the media revealed themto the general public that action was taken (Irvine 2003). Public indignationprompted an extensive reevaluation by government of the concept of self-regu-lation and recommendations for significant changes in the process, includingpartial withdrawal of the profession’s regulatory powers (Salter 2003; Secretaryof State for Health 2007).The failure of the medical profession to self-regulateconstituted 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 analteration 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 partiesto the social contract derived from a review of the literature (see Appendix).

Many of the expectations of the three parties have been present since themodern 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; Krause1996). New expectations have been the added to the contract, such as the desireof 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 Lurie2004; Neufeld, Maudsley, and Pickering 1998; Schoen et al. 2005;Watson et al.2006). Because the understanding of many physicians as well as patients and thepublic is often based upon a nostalgic understanding of the professionalism ofyesteryear, the changes that have occurred to the social contract must be under-stood by all parties.

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In addition to the changing expectations of the various parties, the expectationsof one party may conflict with those of another.An example is the realization thatyounger physicians of both sexes wish time for family and outside interests (Borgeset al. 2006; Henningson 2002; Holmstrom, Sanner, and Rosenqvist 2004; Johnston2006; 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 herown 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 Schlesinger1996; Pellegrino 1990). Faith in the morality, integrity, and honesty of physiciansis fundamental to trust. For generations this trust was given blindly. Now it mustbe constantly earned. It is also important for physicians to trust the health-care sys-tem within which they function, and the commercial organizations with whichthey 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 beenthat the profession will assure the competence of its members through self-reg-ulation. Until recently, licensure and certification obtained early in a career wasfelt to be sufficient. Because of the well-documented failure of the profession toself-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. Inearlier times physicians were accountable primarily to their patients and theircolleagues.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 Emanuel1996;Timmermans 2005). In addition, courts have established new levels of ac-countability as judicial interpretation of legislation and malpractice claims haveincreased, particularly in the United States (Moran and Wood 1993; Rosenbaum2003; Rosenblatt, Shaw, and Rosenbloom 1997; Starr 1982;Vogel 1986). Oneconsequence 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 theirpatients (Chisholm, Cairncross, and Askham 2006; Neufeld, Maudsley, andPickering 1998).

Another important change in the social contract relates to the developmentof public policy. Health and health care are essential if citizens are to live normaland 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




health-care policy. Physicians also wish to have input, as they believe that theypossess expertise essential to the proper formulation of health-care policy. Fortheir part, governments state that they welcome participation of the public andthe medical profession, but they appear to wish to control their input (Le Grand2003; Salter 2003).

As trust in the medical profession has decreased over the past few decades, ithas 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 hasbeen 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 dutyto 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 thatthe 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 thepublic good.

While there are differences in expectations between the parties, there are alsoareas of agreement. For example, government expects patients and the generalpublic to have what they would term “reasonable expectations” of the system(Klein 1990; Le Grand 2003; Marchildon 2006; Salter 2001), although there aredifferences in how individual patients and health planners would define “rea-sonable.” The same holds true for the desire of both the medical profession andthe 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 betweenmedicine and society, it should be compatible with the often shifting patterns ofpower 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 thedominance of medicine.Almost immediately, others questioned this dominance,suggesting that medicine was being deprofessionalized, proletarianized, andbeing subjected to bureaucratic control (Haug 1973; McKinley and Arches 1985;Starr 1982). Eventually all, including Freidson (2001), agreed that medicine’sdominance has been greatly diminished. The theory of countervailing forcesemerged, according to which there is a dynamic interplay between the medicalprofession, government, and the corporate sector.The balance has shifted witheither government or the corporate sector now assuming dominance dependingupon the structure of the health-care system (Krause 1996; Light 2001; Mechan-

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ic 1991). Patients and the general public were not assigned an independent role,assuming that government would represent their interests.While confirming theloss of influence of the medical profession, recent literature has suggested that thepublic also has been disenfranchised and has stressed the importance of medicineengaging 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 ahealth-care system, including the balance between public and private payment.Tuohy (2003) has traced the changes in accountability and governance in healthcare. She states that health care has long had “indirect” governance, beginningwith 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 amongothers in complex networks linking different social and economic sectors as wellas different orders of relationships from the local to the total” (p. 201). She andothers 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 isdriving governance in this direction.

The schematic representation of the social contract appears to be compatiblewith 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 regulatoryframework, both of which have a profound influence on the social contract,result from choices made by society and expressed through legislation in thestructure of the health-care system.We would suggest that the “loosely couplednetworks” 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 willcontinue to necessitate an interaction between the parties, no matter whichparty is dominant.

Implications of This Approach

Applying the concept of the social contract to professionalism, and hence to therelationship between medicine and society, has been said to reframe the discus-sion of this relationship in three ways (Kurlander, Morin, andWynia 2004). First,it identifies the parties involved in shaping the relationship.This is essential if thecomplexities of contemporary health care are to be fully understood. Second, ithelps to focus the discussion on the issues that pose the greatest challenge tocontemporary health care, emphasizing areas of disagreement as well as consen-sus. Finally, it assists in establishing the moral boundaries of professional concern.




We would suggest an important fourth advantage: interpreting professional-ism within this framework emphasizes professionalism’s relevance to the practiceof medicine and makes the profession’s obligations and the reasons for their exis-tence more understandable. In addition, the failure of individual physicians or ofthe profession as a whole to meet legitimate societal expectations should logi-cally result in consequences, including the possibility of a significant change inthe 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 ofcorrectly interpreting the expectations of both medicine and society. In addition,the idea of reciprocity legitimizes the idea that the profession has expectationsof society and should encourage the profession to negotiate those aspects of thesocial contract that can increase the ability of individual physicians to fulfill therole 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 itis unclear who would actually negotiate on behalf of the medical profession ina 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 andmaintaining educational standards and assuring quality of care.The concept of asocial contract makes these expectations and the profession’s obligations underthe contract explicit and indicates why they should be the concern of everypracticing physician.

The final point relates to the teaching of professionalism and the transmissionof professional values, the primary responsibility of medical schools and theirassociated 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 medicalprofession constitute a functional definition of medical professionalism and asummary of medicine’s professional obligations. As Kultgen (1998) has stated:“Entry into the profession is a voluntary act, and most people who perform itare disposed to learn its ways and take its ideology seriously.They need only tobe told how” (p. 366). We believe that one should add “why”—and that thesocial contract provides a cogent answer.

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Appendix: Review of Literature

The expectations of the various parties to the social contract cannot be derivedfrom a single source.Tables 1 through 3 are based on a review of the literaturein the following fields.

Accountability and transparency: Emanuel and Emanuel 1996; Broadbent and Laughlin1997; Rosenbaum 2003; Salter 2003;Tuohy 2003; Gruen, Pearson, and Brennan 2004;Smith 2004b;Timmermans 2005.




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 Silversin2002; Leigh et al. 2003; Mechanic 2003; Zuger 2004; Chisholm, Cairncross, andAskham 2006.

Professionalism: Carr-Saunders and Wilson 1933; Parsons 1951; Hughes 1958; Freidson1970, 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; Sullivan2005; World Medical Association 2005; General Medical Council 2006; Hafferty2006a; 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 andWistow 2006; J. M. Lewis 2006.

Regulation of the professions: Moran and Wood 1993; Stacey 1997; Salter 2001; Peterson2003; 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.

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Medical Professionalism Expectations Obligations

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