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Power and duty: is the social contract in medicine still relevant?

Financial interests are eroding the trust between doctors and the community. Brooks Elliott

TRANSPARENCY AND MEDICINE - Welcome to a new series in which we’ll showcase an array of articles examining issues from ethics to the evidence in evidence-based medicine, the influence of medical journals to the role of Big Pharma in our present and future health.

Here Eleanor Milligan and Sarah Winch discuss the erosion of the trust that underpins the relationship between doctors and their patients.

Training physicians is a significant public investment. It occurs predominantly in publicly-funded universities and health-care facilities and it’s expected that doctors, in turn, will place the needs of individual patients and society above self interest. But this idea is now being challenged.

In 2008, Richard Scheffler, a US health economist, estimated the cost of training one doctor to be approximately $1 million. While there are no firm figures available in Australia, it’s plausible that similar training costs are incurred here.

The expected return on this investment for the public is that doctors will serve the health needs of the community with competent, ethical and professional care. Although rarely explicitly stated, it’s expected that physicians will act with humanity, integrity and care. And, on an individual level, it seems that most do.

Those training as doctors also make a substantial personal investment of resources, time and intellect. Lengthy years of training coupled with high levels of individual responsibility and professional accountability are the norm.

In return for their efforts, doctors are given considerable professional autonomy, respect, social prestige and financial reward. As a result of their specialised knowledge – and the unique power that comes with it - they are afforded privilege and trust above that of many other professional groups.

This reciprocity is the basis of the social contract in medicine, which emerged in the 19th century. In return for status and financial rewards, physicians would meet the medical needs of society through service and altruism.

Threats to the social contract

The expectation of reciprocity inherent within this social contract still arguably influences how health care is funded and structured in this country. But the fundamental spirit of this contract appears under threat on a number of fronts.

First, there’s rising disquiet that financial interests are driving the “corporatisation” of healthcare. For some, the drift towards private-for-profit medicine sits uncomfortably beside community commitment to provide (through tax revenue distributed by government) universally-accessible and publicly-funded health care.

In his recent analysis of Medicare expenditure, former director of the Professional Services Review (PSR), Tony Webber, noted that an estimated two to three billion dollars are inappropriately spent every year. Much of this, he claims, arises from misuse of medical benefits scheme funding by individual physicians and corporate owners of medical businesses. Such observations undermine public trust in doctors and in their social contract.

Regarding medical care purely as a business transaction places the clinical encounter at the intersection of commerce and science – away from its traditional place at the nexus of humanity and science. For the public, this may be seen as a moral shift that signals doctors will place self-interest above the common good.

In Australia, calls for generalist primary carers to service population needs, particularly in rural areas, remain unmet while numbers of urban specialists continue to grow. Armstrong and his colleagues reported in 2007 that access to health care was becoming less equitable, out-of-pocket expenses were growing, and health inequality between the rich and poor was not reducing.

Under the social contract, what can society reasonably expect from doctors to meet community needs? And should community needs and expectations be made more explicit?

Eroding trust

Finally, high profile failures of the medical profession to effectively self-regulate (another benefit traditionally bestowed them under the social contract) have contributed to recent legislative change. The introduction of national registration now requires mandatory reporting of poorly performing, or impaired colleagues across Australia. Public perception that the profession as a group has failed to act in the public interest and effectively sanction unprofessional colleagues has further eroded public trust.

Sylvia Cruess notes, “The loss of trust in the medical profession (although not necessarily in individual physicians) comes from a better informed citizenry, which is demanding greater levels of accountability, more transparency, and greater assurance of quality. The greatest challenge to medicine’s professional status at the present time comes from the general public.”

In times of unprecedented demands on the health-care dollar, we question whether the current distribution of obligations and benefits under the health-care social contract is clear – or fair.

Declining trust in the medical profession as a whole, and with it, declining public trust in the mutual benefits underpinning the social contract should prompt us to re-define and clarify what community expectations of doctors really are.

It’s time to begin such conversations in Australia – and we can start by look at the structure and funding of health care. Clarifying the roles, incentives and obligations of those professionals who work in it would be a good start.

If health care is a shared social good funded primarily through public investment, the public deserves a stronger role in determining how these goods are distributed. In the United Kingdom and in the state of Oregon in the United States stronger public participation in key areas of health care has been achieved with some success through citizen’s juries. Such models could be considered in Australia.

We are starting just such a conversation with our series on Transparency and Medicine. This is the first instalment and articles on the theme will be published daily over the next three weeks.

You can read the other articles in the series by clicking the links below:

Part Two: Big debts in small packages – the dangers of pens and post-it notes

Part Three: Show and tell: conflicts of interest undeclared for clinical guidelines

Part Four: Eminence or evidence? The ethics of using untested treatments

Part Five: Don’t show me the money: the dangers of non-financial conflicts

Part Six: Ghosts in the machine: better definition of author may stem bias

Part Seven: Clearing the air: why more retractions are good for science

Part Eight: Pharma’s influence over published clinical evidence

Part Nine: Insight into how pharma manipulates research evidence: a case study

Part Ten: Why data from published trials should be made public

Part Eleven: Open disclosure: why doctors should be honest about errors

Part Twelve: Reaching full and open disclosure for universities, medical schools and doctors

Part Thirteen: Ethics of accepting suppliers’ gifts in the business v medical world

Part Fourteen: Conflicts of interest in guideline development: the NHMRC responds

Part Fifteen: Consumer input in Medicines Australia’s code of conduct review

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