Reflecting on the physician’s social contract

“55-year-old man with history of laryngeal carcinoma, status-post radiation therapy, laryngectomy, bilateral neck dissection, with metastases to the lung, status post thoracotomy, currently undergoing chemotherapy who is being admitted for a for first-time seizure. Patient is a transfer from Riker’s Island.”

Prisoners are a common occurrence in Bellevue Hospital. This, however, was my first prisoner-patient. The hyphenation both as I write this now and as it formed as a concept in my mindset off a series of internal dialogues and periods of self-reflection regarding the rights of patients, physicians, and if these rights were ever inalienable or rather earned privileges that could be lost under certain circumstances.

First, is health care a right or a privilege? If health care is a privilege of only contributing, law-abiding members of society, then our current inadequacies in health care delivery can be justified. However, if we are to believe it to be a right, how far does it extend, can it be lost and who is the granter of such right?

If we are to assume that health care is a right which cannot be lost, at which level is this right established and who is the granter of such right? Is it a right that is the responsibility of the state or federal government to fulfill for all citizens? Perhaps this extends to all residents as well, legal and non-legal? If a government is understood to be what it is meant to be — a representation of the people rather than an entity onto itself — then we can extrapolate that health care is a right that we the people decide to grant to each other. It is a right of the people that is given to the people by the people. In a complementary understanding, rather than an alternate one, health care can be understood as a God-given right that we as humans do not have the authority to deny of others.

If it is a right, then as a tenet of practice, everyone should be deserving of the same level and quality of care. Is a disabled, physically impaired or intellectually impaired individual any less deserving of life-preserving measures?  Are those individuals without such life circumstances, because of our biased understanding of who we believe has a “good” quality of life, any more worthy of applying “life-saving measures” on? Should physicians let pre-existing conditions affect how aggressively an individual is treated in the emergency room?

Ultimately, how and when someone should receive aggressive measures for resuscitation is dependent on the individual patient and their circumstances. However, the physician carries the responsibility to appropriately educate and when necessary make decisions in the perceived best interest of the patient. This responsibility of the physician to her or his patient is one that is obviously established on the basis of trust.

However, what if the patient is not known to the physician, but is only a stranger? What obligates a physician to care, treat and heal the other? Surely, laws and guidelines are only codifications of a perceived common understanding of appropriate behavior. However, what underlies such appropriate behavior? The social contract between the physician and society is one which has been challenged in recent times, destabilizing the very bedrock upon which it lies. Up until recently, physicians enjoyed relative autonomy, self-regulation, and respect within society and in turn, society expected competency, altruism, and professionalism. However, with the erosion of such guarantees in medicine, which may have been motivators in themselves for earlier generations of healers, these promises no longer exist.

This brings me to my final root question: What is the motivator for today’s physicians to pursue medicine and more importantly remain committed to it? And that is something that I cannot answer for all physicians and physicians-in-training. I can only hope each one of us on the physician side of the social contract can provide a fulfilling answer for ourselves. Ultimately, that answer will dictate the health and well-being of the next generation of civilization.

Hadi J. Minhas is a medical student.

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