A recent editorial published in the Journal of the American Medical Association reports on the proceedings of The Institute of Medicine’s Global Forum on Innovation in Health Professional Education Workshop. The insights developed from this group of 59 members highlighted the need for a social contract between health care professionals and society. A social contract is defined in Webster’s as “an actual or hypothetical agreement among the members of an organized society or between a community and its ruler that defines and limits the rights and duties of each.” The concept of a social contract was striking to me, because like most physicians, I had taken the Hippocratic Oath as a young physician. In fact, the Hippocratic Oath is recited by 98% of US medical students. (Dorman J. The Hippocratic Oath. J of Am Coll Health, 1995)
Is this no longer an adequate social contract?
The Hippocratic Oath has gone through several modifications to reflect major changes in modern society (Cruess R, Cruess S. Updating the Hippocratic Oath to include medicine’s social contract. Medical Education. 2014). These include a reaffirmation of the Oath by the World Medical Association known as the Declaration of Geneva in 1948 in the wake of the atrocities of World War II as well as an additional modification in the 1960s to make the Oath more secular. Nonetheless, the field of medicine, specifically healthcare delivery is rapidly changing and the Hippocratic Oath may not be an adequate social contract.
The Hippocratic Oath encompasses many covenants that we as academic physicians hold dear: commitments to not only patients but teachers and students as well. Moreover, the Oath defines commitments to justice, chastity, confidentiality, and accountability (Hulkower R. The history of the Hippocratic Oath: Outdated, inauthentic, and yet still relevant. The Einstein J of Biol and Med. 2010). However, the Oath is primarily a covenant between the physician and the patient and that focus on the individual ignores the responsibility that physicians have to the greater good of society through preventive medicine, the promotion of healthy living, and the delivery of quality medical care to all members of society.
Many of the strains in today’s healthcare environment have put patients at odds with the healthcare system. A renewal of the social contract directly between health care professionals and society could be a pathway to reinvigorating this relationship—which more recently has been dictated by external parties. Moreover, the Hippocratic Oath has applied primarily to physicians. In the IOM workshop they highlighted the need for a transdisciplinary code of ethics; in other words expanding the code of ethics across all disciplines and subsets of healthcare professionals. This underscores the importance of establishing a culture of teamwork, where all healthcare professionals acknowledge and work towards a common goal.
The Hippocratic Oath outlines what the healthcare professional should expect of each other and what individuals should expect from the healthcare professional. Yet, in order to have a social contract, the expectations should be applied more broadly to include not only what society as a whole should expect from healthcare professionals but what we as healthcare professionals should expect from society. This element of reciprocity is critical to any contract and requires dialogue from both sides. We should seek public engagement and reunite healthcare professionals with the public to drive the evolution of our healthcare system to identify and meet everyone’s needs.
The Hippocratic Oath still represents a sacred covenant between the physician, the patient, the teacher, and the student. It is symbolic of the perseverance physicians have demonstrated over the centuries for the betterment of the patient and ultimately mankind. However, in an environment that is changing so rapidly, it is clear that the expectations among healthcare professionals and society are also changing in ways that are undefined by the current paradigm. We can allow others to dictate the evolution of such a contract or we can be the driving force to protect the interests of our patients, society, and our profession.