The “Exceptional” Social Contract of being a Physician

I’ve been thinking a lot lately about a class I attended a couple weeks ago in which our instructor was trying to drive home for us the idea that as physicians we had signed onto an implicit “social contract” with society.

Society has invested in us our education, our prestige as a profession, granted us with respect, autonomy and trust. In return, we owe society to provide our service as healers with kindness and compassion, competence and the highest standard of socially-minded ethics. (The language above is partially stolen from a recent blog post and less recent article on the subject, but my classmates’ arguments fell along much the same lines.)

At least in part, we bought our professor’s argument. We each believed that we had some sort of duty to society as physicians and that in coming to medical school, we were accepting that duty to society. Nevertheless, we did have one objection – how was this any different from any other profession?

Lawyers and plumbers and policemen go through a course of training and licensure before they are allowed to be considered part of their profession. They are also expected to behave with kindness, competence and ethics in what they do. The fact that there are bad plumbers or corrupt policemen does not change the nature of that social contract; rather, the social contract gives us the right to prosecute these professionals for incompetence or unethical behavior, that is, a breach of their social contract. Physicians’ social contract with society is no different in this respect either, as we can be sued for malpractice or heavily criticized for lack of humanity or competence if we behave against the terms outlined above.

Nevertheless, there was a sense – and our professor was pushing for us to acknowledge this – that there was something somehow different about physicians’ relation to society. If a little boy is hit by a car outside your house, our professor argued, as a physician, you alone out of all of your neighbors have a duty to go and try and help him before the EMS team gets there. No one was disputing that we should go try and save the boy if we could, but we objected to the argument that we somehow were obligated to do so by a social contract. To our class, it felt like an incredible oversimplification trying to reduce the humanitarian act of saving a boy’s life into social calculus.

And this puzzled me. I think that social contract theory, in general, can be an incredibly powerful way of describing how society works and formulating some framework for socially-minded ethics. However, in this case, I felt myself agreeing with my classmates. Why?

A couple reasons have come to mind since that class:

1)      There is nothing all that exceptional about physicians’ social contract to society as compared to other professions. As professionals, we all have a duty to use our professional skills to serve society. Though an accountant may not be able to have helped the boy who got hit by a car beyond dialing 9-1-1, he or she still can use his or her skills to make a difference in their community – by teaching people how to better sort out their finances or helping a charity with their accounting. It’s frankly a flight of ego for physicians to believe that they alone have some sort of “special” duty to serve because of the training that they were given. Though how we serve society may be in part defined by our professional skills and abilities, we all have the duty and privilege of serving our society, no matter what our professional status or position.

2)      The most exceptional aspects of a physician’s relationship with society cannot be easily described in terms of a transactional contract. In other words, I feel that physicians are held to a higher standard of moral ethics and societal duty (at least in part) because, as part of our profession, we delve into people’s personal lives and even into their very person to an extent that few other professions do. In the AMA Journal of Ethics article, they lay out the list of things that physicians give and receive from society under the social contract. One of those things is trust – our patients trust us to do the right thing with their bodies so that we are able to do what we need to do in order to make them healthier. However, unlike other societal benefits, trust isn’t something that physicians necessarily ask for or gain anything from. Instead, it is simply the baseline condition necessary to make the patient-physician relationship work, or even exist at all.

In other professions, of course, the client trusts the professional to do right by them. We trust our lawyers to advocate for us, our policemen to protect us, and our plumbers to fix our sinks and toilets to the best of their abilities – and sometimes the consequences can be dire when they do not. However, there is a sense that the trust runs deeper between a patient and his or her physician – that when we entrust someone with our very bodies, we are entrusting them with our lives. Therefore, as physicians, we need to go beyond any personal benefit provided to us by our profession or its relation to society and deeply respect the fact that every patient, when they come to us, has entrusted us with their bodies and their lives.