“Social Contract” Remains a Useful Metaphor

To the Editor: While we disagree with the principal recommendation contained in Dr. Harris’s1 recent Perspective, “It Is Time to Cancel Medicine’s Social Contract Metaphor,” we believe that his contribution offers an opportunity to enter into a dialogue on medicine’s relationship with the society it serves, an issue of importance to both parties. First, it is our firm belief that understanding medicine’s relationship to society in a time of change and uncertainty is essential if meaningful negotiations over the nature of this relationship are to take place. Many terms have been invoked to describe the relationship, including “bargain,” “covenant,” “implicit bargain,” “implicit compact,” and “moral compact.”2 However, the majority of observers, including social scientists, philosophers, lawyers, policy analysts, bioethicists, and physicians, have gravitated to the term “social contract.” In addition, “social contract” has also been used to describe the relationship between society and both universities and science, institutions closely related to medicine.2 Dr. Harris states that a contract should be the result of “un-coerced” negotiations, implying that the social contract in health care was the result of coercion on medicine’s part. This is not true. The literature on professions, mainly produced by social scientists with no vested interest in the medical profession, documents high levels of satisfaction with and trust in medicine until after World War II. In fact, the privileges and power of the profession were granted willingly by society through legislation. We do not deny that representatives of the profession actively lobbied for changes, with the aim of promoting medicine’s interests. Society participated in these negotiations to ensure high-quality care. We agree with Dr. Harris that the presence of negotiations is fundamental to the concept of a contract. Daniels3 proposed that social negotiation between the medical profession and society have been ongoing, consisting of “various forms of interaction between professional organizations and broader political institutions. It may lead to … specific legal arrangements or there may be broader understandings that emerge from public debate about specific issues.”3 We interpret much of Dr. Harris’s text as describing the negotiations that have been taking place for generations. Finally, Dr. Harris closes by stating that eliminating the term social contract will “open the door to a more complex and fruitful consideration of medical professionalism and medicine’s relationship with society.”1 We believe that dialogue between medicine and society on the nature of their relationship always has and will continue to take place and that some words describing this relationship are essential to framing the negotiations. We would ask Dr. Harris what term he would suggest and how he would establish its legitimacy. Richard L. Cruess, MDProfessor of surgery, Centre for Medical Education, McGill University, Montreal, Quebec, Canada; [email protected] Sylvia R. Cruess, MDProfessor of medicine, Centre for Medical Education, McGill University, Montreal, Quebec, Canada. Frederic W. Hafferty, PhDProfessor of medical education, Program in Professionalism and Values, Division of General Internal Medicine, College of Medicine, Mayo Clinic, Rochester, Minnesota.

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