Journal Information
Vol. 221. Issue 8.
Pages 494-495 (October 2021)
Vol. 221. Issue 8.
Pages 494-495 (October 2021)
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COVID-19 pandemic, professionalism, and the social contract
Pandemia COVID-19, profesionalismo y contrato social
M. Esquerdaa,b,c,
Corresponding author

Corresponding author.
, J. Teresd
a Comissió de Deontologia Consell de Col.legis de Metges de Catalunya, Barcelona, Spain
b Institut Borja de Bioètica, Universitat Ramon Llull, Barcelona, Spain
c Hospital Sant Joan de Déu Terres de Lleida, Lleida, Spain
d Comissió de Deontologia Col.legi de Metges de Barcelona, Barcelona, Spain
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Dear Director,

The COVID-19 pandemic has posed a massive challenge for not only the healthcare system but also for the medical profession, bringing to light the need for a long-awaited and unavoidable reform to adapt it to the 21st century.

Also imperative, however, is a more profound change in the implicit social contract between health professionals and society. That is, what patients and society expect from the medical profession, and what the latter can expect to find in society.

We come from a thousand-year-old tradition in which the implicit contract, in the words of Jovell1, “meant that society granted the medical profession a special status and recognition that distinguished it from other professions, and which should imply a higher salary and the power to self-regulate”.

However, in these terms, it is necessary to question whether this implicit contract is still valid for our current society and, above all, whether it is useful for tackling future challenges. The professional values required, which arise from social change and the bioethical gaze, have been redefined by the social commitment, affectivity and empathy, respect for patient autonomy, commitment to public health, commitment to the environment, advances in medical science, the transfer of knowledge, skills, and attitudes, and the self-regulating nature of the profession2.

The previous contract no longer matches the current context of the highly corporatized professional practice, within bureaucratized health organisations, with the centralised management, limitations to professional autonomy, demanding care pressure, disgraceful job insecurity among young people, and low salaries. All of which is associated with disproportionate expectations from society in relation to the possibilities, availability, and access to health care.

Smith3 spoke about the “bogus contract” according to which patients and society expect doctors to provide solutions (bordering on miracles) to all kinds of problems, with low acceptance of finiteness and death, while assuming that doctors have higher status and incomes. This same author called for a new contract that addresses illness, death, and pain as part of life, in which medicine has some, yet limited powers of intervention, which accepts that doctors are not infallible and also need support, and which refrains from extravagant political promises and the demagogy of unlimited power without obligations.

The “mismatch” between the implicit contract (what society and people expect from doctors), and the explicit contract (contractual and labour conditions of professional practice) could be the reason behind the growing unhappiness, or burnout, in the medical profession which includes a large percentage of burnt out, exhausted, and unmotivated professionals4.

The consequences of major burnout are significant both professionally, with poorer quality of care, more medical errors, or worse care as perceived by the patient, and personally, with lower levels of empathy, poorer quality of life, job dissatisfaction, or increased risk to mental health in general4–7.

Ofri8 mentioned that this unhappiness is more profound than the standard definition of burnout: “The despair I see amongst our colleagues today, however, is more than just burnout. It is a betrayal of trust, the trust we gave to our own profession”. The burnout epidemic is more related to doctors’ disappointment with the current, industrialised professional practice and the heightened demands of the system that go beyond the provision of care on its own.

In the midst of this, the COVID-19 pandemic arrived. Health professionals have responded to the increased demand in an exemplary manner, according to the outdated contract, with noble displays of altruism and generally going beyond the call of duty, including taking on the risk of infection with insufficient protection, accepting flexible scheduling, working outside their specialisations, and fulfilling uncustomary organisational and care roles.

The pandemic has clearly and obviously exposed the imbalances and asymmetry between the fulfilment of the two parts of the social contract. It has also brought to light how this discrepancy has entailed a high cost to health professionals, from the physical, psychological, or ethical perspective, which is added to the previous hardships.

However, the pandemic can also represent a turning point and redefining moment for the healthcare field. Among the necessary changes to the post-pandemic practice of medicine, clear coherence between the implicit and explicit contract is essential. A new contract that is, as Jovell mentioned, “a starting point for redefining the relationship between medicine and society in the current context of social change to thereby be able to face the tension that exists between equity, good quality of care, excess care possibilities, and finite available resources”1.

In creating this coherence, certain factors must address adapting contracts and salaries according to the level of responsibility, as well as aspects related to the actual practice of medicine, such as the need to recover professional autonomy, competence, and the feeling of belonging to the profession and institutions9, with participation in decision-making at all levels.

Lemaire and Wallace4 identifies other key aspects such as: detecting toxic aspects in the medical profession that cause and maintain burnout, the need to promote clinical leadership and an organisational culture of support, and considering the well-being of doctors as a core part of patient care and a quality indicator for the entire health system.

Therefore, more than a patient-centred care model, perhaps we should be discussing an “aligned” model between treated individuals, health professionals, institutions, and health policies. Cohesively aligning the values, beliefs, roles, and responsibilities of the agents involved in the social contract is therefore a fundamental objective.

The medical profession in the 21st century obviously requires strengthening professional values but can only be carried out when paired with a health system that offers appropriate conditions for professional practice and a society that recognises and agrees that returning professional dignity is not the same as granting privileges.

Conflicts of interest

The authors declare they do not have any conflicts of interest.

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Please cite this article as: Esquerda M, Teres J. Pandemia COVID-19, profesionalismo y contrato social. Rev Clin Esp. 2021;221:494–495.

Copyright © 2021. Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)
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