In Reply to Cruess et al

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The article to which Drs. Cruess, Cruess, and Hafferty respond was prepared by Dr. Harris; however, both of us contributed to its message. We welcome their invitation to develop a larger dialogue on medicine’s relationship with society.
Drs. Cruess, Cruess, and Hafferty want to ensure “meaningful negotiations” over the nature of the relationship between medicine and society. In stating this goal they reassert a model in which (1) medicine is separate and distinct from the rest of society, and (2) any relationship between the parties is best described as a bilateral contract. The point of Dr. Harris’s article is that we reject both of these assertions on theoretical and historical grounds. Their statements that “the majority of observers” use the term “social contract” and that the medical profession was well respected until after World War II do not address the substance of these arguments.
Moreover, there is ample evidence that the medical profession in the United States had a very fractious relationship with society before 1900 and after 1930. Nor are we alone in questioning whether the traditional contract model is inevitable or desirable for what they grant are multiple relationships with different parties at different levels. For example, the medical profession in the United Kingdom has explicitly rejected the concept of “contract” in favor of “partnership.”1
As Dr. Harris argued, our concern is that the “social contract” metaphor limits the understanding and teaching of professionalism by misrepresenting the moral underpinnings of the physician’s responsibilities as a bilateral bargain. Many physicians practice ethically in specialties where rewards and privileges are comparatively low. Few if any physicians find the privilege of self-regulation more morally grounding than the humanity and vulnerability of their patients. Fostering a sense of these complex responsibilities is our mutual goal.
We do agree with the correspondents that medical professionalism goes beyond the individual physician–patient relationship. Part of the challenge of teaching and learning professionalism is to broaden students’ (and the profession’s) understanding of social processes and the nature of society. We believe that it is possible to do this without reasserting the traditional (U.S./Canadian) claim of professional exceptionalism. We are pleased that Academic Medicine encourages this kind of discussion and welcome the chance to continue it here and in other settings.
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