It Is Time to Cancel Medicine’s Social Contract Metaphor

Abstract

There is agreement that the complex relationship between medicine and society is best described as a metaphorical social contract and that professionalism is the medical profession's contribution to this contract. Metaphors can help clarify abstract concepts, but they can also be abused if the counterfactual attributes of a metaphor become attributed to its subject. This seems to be happening with medical professionalism, which has sometimes been reduced to a contracted deliverable and a bargaining chip. The undesirable attributes of the social contract metaphor may be hindering efforts to understand and teach medical professionalism. Despite its theoretical weaknesses, the social contract metaphor has historical credibility because of its alleged association with the 1847 Code of Medical Ethics and the subsequent ascension of regular (allopathic) medicine in the early 20th century. However, the record does not support an argument that the intended purpose of the 1847 Code was to create a social contract or that one ever arose. The alternative account that a contract did arise, but physicians were poor partners, is neither satisfying nor explanatory. As now used, medicine's social contract metaphor has serious theoretical and historic weaknesses. Medical educators should remove this narrow and overworked metaphor from their discussions of professionalism. By doing this, educators and the profession in general would only lose the ability to threaten themselves with the cancellation of their social contract. In return they would open the door to a more complex and fruitful consideration of medical professionalism and medicine's relationship with society.