Medicine's social contract across borders.

Abstract

Medicine is described as the second oldest profession, and for millennia, doctors and physicians have been told to do no harm to their patients. It is fairly obvious that the practice of medicine occurs in the context of society’s needs and demands. It is the society which determines what is seen as abnormal (and therefore sick or ill) and society that agrees to pay for the healthcare systems and also mould these according to explanatory models of healthcare. The acceptance of alternative or complementary systems in addition to or in preference to allopathic systems will allow certain funding and resources made available for all the systems which are required and preferred by the population. Depending upon the explanatory models and understanding of illness behaviours locally, societies will determine what models of care are acceptable. Resource allocation accordingly within which medicine is to be practised is a matter of social choice and should be seen as related to a number of social and epidemiological factors as well as to the implicit social contract between medicine and society represented by stakeholders such as politicians. Healthcare policies influence financial allocation, which in turn will influence the structures within which healthcare services are planned, developed and delivered. The concept of a social contract dates from several centuries (Gough, 1936). In an erudite volume, Gough (1936) outlines that the origins of the social contract were between kings and their subjects. Such a contract was implicit. Subjects would give up some of their rights to the king and, in turn, he would protect them and look after them in a benevolent governance. This implicit contract also determined how subjects not only related to their rulers but also towards each other. Even within largely democratic structures, such a contract or compact remains in place between the rulers and the governed. Through elections and voting, the population chooses one ruler or their party over another and thus gives them the mandate to provide good governance and basic amenities, including education and healthcare facilities. Irrespective of the resources and style of government, certain basic needs are asked for by the ruled and the rulers are expected to deliver these. Medicine as a profession has also had an implicit social contract with society (Cruess, 2006), regardless of the healthcare systems in place. However, often this compact or contract gets forgotten. Society expects from the medical practitioner services of a competent physician, certain moral values, including transparency and probity, but also someone who is a healer (Cruess, 2006). Doctors are also seen as key and important providers of objective advice to the society as a whole. One of the key characteristics of the professional is to be altruistic. However, this value of altruism will vary according to the healthcare system. If the system is entirely private, then altruism may mean giving up some free time to provide free advice or healthcare; and if the system is state run, then altruism may have a different approach. In return, doctors expect that the society will allow them to have a degree of clinical autonomy as reflected in self-regulation. They will also expect a degree of trust supported by adequate resources and financial or social recognition for their clinical commitments and what they do (Cruess and Cruess, 2010). It has been shown consistently and regularly in surveys that doctors have the highest degree of confidence and trust of their patients and the population as a whole when compared with other professions such as politicians and journalists, who always come low on scales of approval. The tension within this social contract between the medical profession (represented by doctors) on the one hand and the society as a whole (represented by the policy makers and the government) on the other is related to several questions. First, the question arises as to the process of the contract; as it is implicit and unwritten, it may not be entirely clear what is being said or done on whose behalf on either side. The second question relates to the first one. If as is likely the rapid advances in technological aspects of medicine continue to add to the costs of healthcare delivery and consequently demand for newer and safer treatments increases, then how does the society pay for these and does the society expect the medical profession to ration research and clinical services? Third, society continues to evolve and fragment with global expectations, thus making it almost impossible to identify who the representatives of the society are with whom the contract is to be Medicine’s social contract across borders