Professional Documents
Culture Documents
Expectations and
Obligations
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)
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.
579
10_51.4cruess:03_51.3thagard 335– 9/30/08 1:53 PM Page 580
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
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.
Figure 1
The social contract.
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-
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).
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.
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.
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.
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