EDITOR'S PAGE
What is our contract with society?
William W. Parmley, MD, MACC
Send correspondence to: William W. Parmley, MD, MACC, Editor-in-chief, Journal of the American College of Cardiology, 415 Judah St., San Francisco, California 94122
I recently interviewed a young woman for a summer job in our division who had just graduated from college and was preparing applications for medical school. Partly to enhance her medical school applications, but mostly because of her own inner beliefs, she had worked part-time at a number of places over the past few years that dealt directly with attempts to correct some of the problems in our society. These included a free AIDS clinic, a rehabilitation clinic for drug addicts, an agency to assist the poor and homeless, and a tutoring service for disadvantaged children and adults. Her description of these efforts was both heartwarming and, at the same time, discouraging because of the magnitude of the problems. I reflected back on my own idealistic feelings prior to medical school during two years of missionary work. I remembered colleagues who had spent time in the Peace Corps, done public health service on Indian reservations, or participated in other activities to fulfill what they believed was a social contract with humanity.
Do we as physicians have a greater social contract in this regard than anyone else in the world? The simple answer is probably "no." Every individual is part of the same Family of Man and therefore has a responsibility to help others as circumstances allow. Despite the bottom-line mentality in our country these days, we nevertheless see wonderful examples of man helping man throughout our society and throughout the world. As physicians, however, we have a special opportunity to help others, because of our unique profession. We deal everyday with problems of sickness, sorrow, and disability. Surely, we are in a better position than others to provide direct help with some of these daily problems of life. More importantly, by virtue of income or knowledge, we are also in a special position to assist others. I marvel at those physicians who take time out of their practices and lives to go abroad and provide, free of charge, the medical care that is specifically needed in a given country. Others donate time and efforts locally in free clinics or other facilities because of their personal contract with society.
Some in our profession have had international roles in trying to better the world. For example, Dr. Paul Dudley White said the following at the opening session of the first World Congress of Cardiology in Paris in 1950: "We who are ‘medecins du coeur’ would also like to perform the miracle of healing the troubled world of today by a universal bond of spiritual brotherhood and medicine from the heart" (1). It doesn’t take more than a cursory look around the world to realize how many social problems there are. Inequality in health is a recognized fact (2). A summary of some of these problems was succinctly presented by Dr. Rene Favalono (1) in a special article: - "More than 1,000 million people live in absolute poverty. This is more than 3 times the population of the European Community.
- Approximately 900 million adults are illiterate.
- Approximately 2,000 million people are deprived of potable water.
- Approximately 100 million people, a figure equivalent to the combined populations of France, Spain, and Belgium are homeless.
- Approximately 800 million people go hungry every day.
- There are 150 million undernourished children below the age of five years.
- Fourteen million children under five years old die every day."
Lest we think we are spared in the U.S. from this human toll, the article goes on to point out that although we have one of the highest levels of per capita food consumption in the world, 30 million of our inhabitants, including 13 million children <12 years old are hungry because of problems with access to food (1). Among industrial countries, the U.S. has the highest per capita income but the highest level of human poverty (16.5%) as measured by a Human Poverty Index (3).
I wonder if these staggering figures have any impact on us as physicians. Certainly there is a growing dissatisfaction among doctors with the current medical environment. I’m sure that some believe that society owes them much more than they are getting. A recent poll by the California Medical Association strikingly illustrates this dissatisfaction among physicians in California. As reported in the San Francisco Chronicle (4), 75% said that they have become increasinly dissatisfied with their profession in the last five years. Low payments from HMOs and other bureaucratic hassles were the primary source of the frustration. Forty-three percent said they plan to stop practicing medicine during the next three years!!! (The title of the report was: "And Then There Were None: The Coming Physician Supply Problem.") Although dissatisfied physicians were more likely to respond to the survey than contented physicians, and thus skew the results, this nevertheless represents a strong trend in our current medical environment.
At a time, therefore, when physicians feel that they are being shortchanged by society, is it even reasonable to ask what we are giving back to society via our own personal social contract? The answer, of course, is "yes." It is more important than ever for each of us to ask the question: "How can I personally make the world a better place to live?" As my wife and I look forward to our own pending missionary service to begin about a year from now, we strongly believe in our own personal social contract with humanity. With so much to do in this world, the question should not be "should I?," but "how can I?" Each of us alone can’t fix everything, but we can each do something.
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References
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1. Favaloro R. A revival of Paul Dudley White—an overview of present medical practice and of our society. Circulation. 1999;99:1525–1537[Free Full Text]
2. Marmot M. Inequalities in health. N Engl J Med. 2001;345:134–136[Free Full Text]
3. United Nations Development Program (UNDP). Human Development Report 1998: Consumption for Human Development. New York, Oxford: Oxford, University Press, 1998.
4. Colliver V. San Francisco Chronicle, July 14, 2001: A-3, A-5.
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