JBJS | Professionalism and Medicine's Social Contract*

The Journal of Bone & Joint Surgery, Volume 82, Issue 8

The Orthopaedic Forum | August 01, 2000

Professionalism and Medicine's Social Contract*

Richard L. Cruess, M.D.; Sylvia R. Cruess, M.D.; Sharon E. Johnston, M.A.

The Centre for Medical Education McGill University 1110 Pine Avenue West Montreal, Quebec H3A 1A3, Canada E-mail address for R. L. Cruess: rcruess@med.mcgill.ca
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Funds were received in total or partial support of the research or clinical study presented in this article. The funding source was The McConnell Family Foundation, Montreal.

The Journal of Bone & Joint Surgery. 2000; 82:1189-1189

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Introduction

The role of the physician in modern society has undergone an extraordinary transformation in the past few decades^31,42. Those who entered practice a generation ago had almost unquestioned authority, could usually pick their geographic location and mode of practice, and generally had substantial control over the method and amount of remuneration as well as over their lifestyle. The resources allocated to health care were expanding, and science was providing new and exciting methods to relieve human suffering. Physicians were treading relatively familiar paths, perpetuating patterns and practices of medicine that they believed were part of its tradition. Finally, they genuinely felt that as professionals they were providing useful services both to their patients and to society and thus were engaged in a noble calling. As the medical profession, including orthopaedic surgery, faces a new century, much has changed and medicine's response has often been defensive and insensitive to the needs of society⁴⁰. In the nineteenth century, professionals were granted prestige, status, and financial rewards under the assumption that they would organize their lives around the concepts of service and altruism and would address the principal concerns of society. This arrangement is now understood to have constituted a social contract between medicine and society^9,43,44, and it appears to have been one of the casualties of recent years, in which all forms of authority were regarded with skepticism by a questioning society⁷. The contract has been mostly unwritten and therefore implicit, and, until recently, it evolved slowly. The value system and the obligations necessary to sustain it were transmitted by respected role models in a relatively unstructured way, a process that was facilitated by the homogeneous nature of the medical profession and the relative simplicity of both society and the health-care system¹⁰.

It is apparent to all that the expectations of society and those of the profession have diverged and that a gap has grown between medicine and the society that it serves¹². A rather extensive body of literature in the social sciences - and to a lesser extent in bioethics - has recognized the importance of professionalism as the bridge between society and the healer. Both society and the medical profession must understand the relationship that binds them. This includes comprehending the nature of professionalism, how it has evolved, and the current pressures threatening it.

The Healer and the Professional

The healer has been necessary to humankind since before recorded history and generally has been granted privileged status. In the Western world, the roots of the healer can be traced to Hellenic Greece, with the Hippocratic oath serving as the foundation of medicine's self-image in most countries². As an example, when orthopaedic surgery wanted a universal symbol, it turned to the plane tree of Hippocrates, thus linking itself with one of the most noble traditions in Western society.

When medicine was simple, healers did not require organization or structure. As medicine became more complex, society used the preexisting concept of the profession as a means of organizing the delivery of health services^{7,15,17,26,43}. This concept formed the basis of medicine's social contract with society.

The roots of the professions are in the guilds and universities of medieval Europe. The modern professions were established in the mid-nineteenth century, when laws governing licensure granted a monopoly over practice, with a clear understanding that professions would be altruistic and moral and would address society's concerns. These laws delegated many of society's own powers to the professions with the expectation that the professions would provide a social good^27,43. Society has always had the right to modify or withdraw these powers should it become dissatisfied with the performance of its professions.

Professionalism

The professions have often felt that they could define themselves. As professionalism is the basis of a social contract, this cannot be true and society must be party to the terms of the contract. Both society and the profession must agree on a definition to serve as the basis for mutual understanding and expectations. The Oxford English Dictionary defines a profession as: "The occupation which one professes to be skilled in and to follow, a) A vocation in which a professed knowledge of some department of learning or science is used in its application to the affairs of others or in the practice of an art founded upon it, b) In wider sense, any calling or occupation by which a person habitually earns his living."³⁶ This definition is appropriate for medicine as it includes the word "profess." Physicians make a public commitment to a set of values when they recite the Hippocratic oath or its modern equivalent. This definition also stresses the importance of the acquisition of knowledge and skills in order to serve others, and it recognizes both the scientific basis of medicine and its art, which is based on tacit knowledge. Because professionals serve others and their activities are expected to be altruistic, professions are thus value-laden. Finally, the definition recognizes that a profession represents a calling in which one is expected to earn a living.

Professions, because they are knowledge-based and represent expertise that is essential to society, have come to occupy a very important place. Some have suggested that a modern civic society functions along a trilateral axis that includes government, the private sector, and the professions⁴⁹. Because of this centrality, authors in the social sciences have continuously examined the concepts of the modern profession and professional behavior. They have expanded on the definition and documented the characteristics of a modern profession. Even those who are critical of the concept agree that there are core elements in every profession^15,26,43. First, as professionals have specialized knowledge that is not easily understood by the average citizen, they are given a monopoly over its use and are responsible for its teaching. Second, this knowledge is to be used in the service of individual patients and society in an altruistic fashion. Third, the inaccessible nature of the knowledge and the commitment to altruism form the rationale for granting the professions autonomy sufficient to establish and maintain standards for the practice of their vocation, using self-regulation as a means of ensuring quality. Fourth, in exchange for this autonomy, professionals are expected to assume responsibility for the integrity of their knowledge base, to expand it through research, and to ensure the highest standards for its use.

Many of the profession's responsibilities have been, and continue to be, assigned to licensing bodies and other associations, all of which are essentially controlled by the profession. Professional associations utilize collegiality as a means of establishing common goals and encouraging commitment to these goals²⁰. They have the obligation to discipline those who engage in unprofessional and incompetent behavior. They therefore serve an essential function, and professions can flourish only if their members actively participate in their activities. In addition, they must be seen to reflect the morality of professionalism³⁹.

Even those who are critical of professionalism recognize its inherent morality and virtue and agree that professionalism is an ideal to be pursued. Society uses the concept of the profession to encourage and support attitudes and patterns of behavior that will foster both competence and altruism²⁷. Its trust is dependent on the profession meeting its responsibilities^24,26,33,37. Thus, if a profession is felt to be failing in its duties, professional status may be withdrawn or seriously modified.

The Evolution of Professionalism

The evolution of societal attitudes toward professionalism is well documented in the social sciences and bioethics literature, a large and rich body of work that is not easily available to practicing physicians. Writings from the early 1900s to the 1960s, produced by individuals of great stature, were largely favorable to the concept^{4,6,14,37,46,47}. There was faith in the virtue, morality, and service commitment of the professions. Early sociologists documented and defined professionalism and identified the tension between altruism and self-interest, but they felt that the collegial nature of the professions would encourage altruistic behavior. With the development of the "questioning society" in the 1960s and 1970s, all forms of authority and expertise were challenged, and the earlier belief in altruism was deemed naive^{15,18,21,23,28,32}. The world of ideas and ideals entered a period of deconstruction, which coincided with the entry of the state and the corporate sector into the health-care field^26,34. Medicine's institutions were challenged and were believed to place greater emphasis on the economics of practice than on the welfare of society. Self-interest was felt to be dominating altruism. The literature of the period questioned the monopoly enjoyed by all professions and the self-serving use that the professions and their associations made of the power of this monopoly^15,23,28,32. It was noted that the professions were inaccessible to large segments of society²⁸, and it was suggested that collegiality had been used to protect incompetent or unprofessional behavior. Medicine was examined in economic terms and was accused of controlling its own market, and, because of the nature of health, of creating and then exploiting a demand for health services^21,28. The medical profession also was accused of ignoring issues of great concern to society, such as access, cost, and quality⁴³. Finally, because of its dominant role in health care, the medical profession was blamed for the many defects in the health-care system. This literature, which was extremely perceptive, had a profound impact on public policy. It was believed that the conflict between the profession's ability to promote its own interests and its obligation to use its privileges in the best interests of society represented a major flaw in the social contract.

The view presented in recent literature is different. Some have commented that as medicine has lost control over its marketplace to the state and the corporate sector, its impact on public policy has been greatly diminished^26,34. As the state and the corporate sector have become more dominant, the blame for defects in the system has shifted from the profession to those bodies. Previous authors have identified three ways of organizing the delivery of complex services, including health care^16,34. The professional model was used until recent times, the bureaucratic model characterized the communist system, and the market-driven system is now predominant in the United States. The great difficulty of maintaining values in the bureaucratic or market-oriented systems has led most authors to return to the professional model (with some bureaucratic overlay) as either the least unattractive or the most attractive alternative^16,22. It seems ironic that as medicine has been seen to lose power (because of its changing relationship to the state and the marketplace), it has become more trusted, and the professional, who is central to the social contract, has appeared more acceptable^26,44.

While authors in the social sciences literature have shown renewed faith in professionalism, they are in agreement about the need for a renewed professionalism, one that is clearly understood by medicine and that is sustained by a renewed commitment on the part of the profession to meet its obligations.

The Social Contract and the Future

The greatest challenge to medicine's professional status at the present time comes from the general public. 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 quality¹².

Professionalism and the values that it carries are threatened throughout the developed world^17,26. While the threats themselves are similar, their expression varies in different countries depending on the national culture and the structure of the health-care system. Thus, in the United Kingdom, the public is demanding a greater commitment to self-regulation because of well publicized examples of incompetent and unprofessional behavior^22,41. In Canada, where the state as the principal payer acts much like the corporate sector, diminution of resources devoted to health care has led to severe tension between the physician's responsibilities to the patient and to society³⁵. In the United States, the market-driven system, with its emphasis on competition, has encouraged the development of the "physician entrepreneur" and has imposed intrusive cost-containment mechanisms that have had a major impact on practice^2,3,25,26,43. Perhaps the principal challenge facing American physicians is to convince the public that they are capable of acting in the best interests of the patient and society in a system in which the commitment to the fiduciary duty to the patient and to altruism appears to be actively discouraged.

In effect, this is the context within which medicine's social contract is being renegotiated, and professionalism remains the basis of the agreement. The negotiations occur in a wide variety of settings and situations and result in changes that range from minor (a changed fee schedule) to major (a national health-care program or new regulations). All parts of society, including professionals and their associations, politicians and governments, the courts, commercial interests and unions, the media (including editorialists), patient representatives, economists, sociologists, ethicists, and community leaders from virtually any field, can influence the negotiations. As changes are made, it is important that what was implicit be made more explicit because the contract serves as the basis for the expectations and obligations of both society and the profession. The issues are complex, and changes can have unforeseen consequences. For this reason, medicine's expertise is more necessary than ever, and, as medicine is no longer blamed for the major defects in the system, there is an opportunity to reestablish its role as expert on health policy^8,9,44. The public, which has also been largely excluded from the decision-making process^26,44, is unhappy with the predominance of the state and the corporate sector in the field of health care. As a result, the medical profession, if it conducts its affairs properly, can have a major impact that should result in a better system. To accomplish this goal, medicine must recognize and address society's legitimate concerns, and medicine's institutions must first ensure that the traditional terms of the social contract are met. Public trust is largely dependent upon this. If the profession is seen to be failing to meet its obligations, the newer levels of accountability, which are now without question part of the contract, will become more intrusive and medicine will have a limited ability to influence their evolution.

Professional codes of ethics govern the conduct of both the professional and the healer. Such codes have several roles. They represent applied morality, provide members of the profession with a checklist for standards of practice, and are part of the guarantee of quality assurance to society. They are the most visible symbol of the moral base of the social contract. General codes are developed and promulgated by national medical associations, and some specialty bodies², such as the American Academy of Orthopaedic Surgeons¹, have extended them to make them more specific to their own disciplines. These codes are constantly evolving to cope with new expectations as they arise, both within the profession and at the interface between the profession and society. Because of the importance of these codes to the social contract, members must be aware of their details and must use them to govern their conduct.

Society expects that the traditional obligation of medicine to self-regulate will reflect the morality of the profession and will be met in a fair, open, and stringent fashion. Throughout the history of medicine, many aspects of self-regulation have been handled well. However, the belief that the process remains overly secretive, the well publicized failure to deal with incompetent physicians^41,43, cases of sexual impropriety¹¹, and the presence of financial misdeeds and conflicts of interest² have negatively influenced the public's perception of the profession. Recent intrusions into the autonomy both of the profession and of physicians are not random events but are the result of this perception. In addition, questions have arisen about the integrity of medicine's knowledge base following reports of wide variations in patterns of practice for similar conditions⁴⁸ and well publicized reports of incidents of scientific fraud¹⁹. The growing use of guidelines and evidence-based medicine has arisen in response to these issues, as have demands for recertification from both professional bodies and the public. Thus, society is requiring that medicine meet its traditional responsibilities in a more open and transparent fashion. While progress has been made, it is clear that more must be done and must be seen to be done.

The new responsibilities that are currently expected under the social contract are less familiar and represent substantial additions to the traditional obligations. It is now understood that physicians have three levels of accountability¹³. All acknowledge the fiduciary responsibility to both patients and colleagues, which has always been present. The two new levels have been termed economic, representing the responsibility to those who pay for the service (individuals, the state, or the corporate sector), and political, representing the responsibility to society for the health of the population and the use of resources. These responsibilities are now a reality of professional life. The application by some payers (including both the state and the corporate sector) of accounting logic⁵ to the practice of medicine has intruded into the physician's autonomy in decision-making and has often severely restricted the time allotted for the treatment of the individual patient³⁰. Guidelines and evidence-based medicine have been some of the tools utilized to control costs, often with little consideration of their impact on health care. Finally, in an era of limited resources, the welfare of society is often placed above that of the individual patient, and the physician is placed in an essentially untenable legal and moral situation^29,42, something now recognized by the public. These conflicts are not easy to resolve and will require some real changes in attitude as the contract evolves⁴².

Medicine has some reasonable expectations that must be met as the social contract is being renegotiated. There is general agreement that a demoralized and noncompliant medical profession is incompatible with an effective health-care system and that major changes cannot be carried out effectively without the collaboration of the profession³. As a partner in the contract, the first thing that medicine should expect is respect. Probably the most discouraging aspect of the present situation is that the evolution of health care, irrespective of the actual structure of the system, is undermining the beliefs and practices that lent meaning to and fostered pride in the activities of physicians. Most physicians are convinced that there is a moral basis for their activities, that they are devoted to service, and that they therefore deserve respect in spite of some real failings by some of their colleagues and the profession. Therefore, changes in the health-care system must be instituted with an understanding of their impact on the physician and the doctor-patient relationship. Second, the newer levels of accountability must be examined with care. Many of the new regulations are essential, given the cost and complexity of modern services. Others are not directly related to quality of care or cost⁵, and medicine has a perfect right to resist them in a socially responsible fashion⁴⁹. A major part of the dialogue should revolve around the impact of regulations on the doctor-patient relationship and the ability of the physician to give quality care. Third, it is well recognized that guidelines can be of great benefit but that they have limitations⁴⁵. They are universally acceptable only in areas of absolute certainty, which rarely exist in the practice of medicine. The art of medicine is based upon judgment and experience and is difficult to quantify. It is, however, the basis of much medical practice and must be protected. For this reason, guidelines must be used wisely. Fourth, as self-regulation becomes more rigorous and more open, it must be carried out with discretion, not to protect physicians but to avoid unnecessarily jeopardizing trust in the profession. Finally, the processes that are established by the state or the corporate sector for compliance with new requirements for accountability and quality control should be validated, and their impact on patient care should be known before they are fully implemented. If medicine is to be held to standards based on evidence, so must the regulations governing medicine.

Overview

The social contract between medicine and society is based upon professionalism. As this contract evolves, physicians and their institutions must have a clear understanding of professionalism as the rationale for the obligations that they are expected to meet. Medicine's traditional responsibilities must be carried out in a more rigorous fashion in order to justify the trust of society, which is required for the healer to function and for medicine to have an impact on the rules and regulations that will be developed to accommodate new levels of accountability.

The future of medicine will depend greatly on the regulatory procedures that will be established and medicine's attitude toward them. If the rules are reasonable, they should be incorporated into medicine's "internal morality"³⁸ - the values, norms, and rules that are intrinsic to the practice of medicine. If they remain a part of the "external morality" of practice, reflecting only "the ethos of their wider society,"³⁸ the average practitioner will be reluctant to comply because the rules will be seen to have been imposed.

Therefore, the ideal of professionalism, founded on altruism, morality, and virtue, must be incorporated into the procedures by which medicine will regulate itself and be held accountable. While it may appear unrealistic to expect physicians to regard the newer rules and regulations and the inevitable bureaucracies with anything but suspicion, these procedures will function properly only if the profession believes in both their appropriateness and their validity. Medicine ultimately must function within the health-care systems developed by society, but society's great need and respect for the healer will always protect the relatively privileged position of physicians if they are seen to be consistently devoted to the ideals of integrity and service.

Richard L. Cruess, M.D. Sylvia R. Cruess, M.D. Sharon E. Johnston, M.A.

The Centre for Medical Education

McGill University

1110 Pine Avenue West

Montreal, Quebec H3A 1A3, Canada

E-mail address for R. L. Cruess: rcruess@med.mcgill.ca

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