Psychiatry's Contract with Society: Concepts, Controversies, and Consequences

This book provides a predominately British perspective on the social contract between psychiatry and society (21 of the 26 authors are from the United Kingdom, two from Canada, two from Australia, and one from Denmark). The 18 chapters trace the changing nature of the role of British psychiatry while documenting British society's discontent with doctors' behaviors and delineating some of the reasons behind the regulatory changes that have taken place over the past decade.

As might be expected from a compendium of articles, there is some unevenness in the writing from author to author and also some duplication of concepts and explanations. The chapter by Cruess and Cruess, titled “Medicine's Social Contract With Society: Its Nature, Evolution and Present State,” is arguably the defining chapter of the book. The authors report on the historical context of the social contract, describe some examples (both in the United Kingdom and the United States) where practitioners have fallen short and of the ebb and flow of responses and counter responses between medicine and society, and argue for the role of doctors to enter the political process to negotiate more of the terms of the contract. They present several examples of how physicians and patients used legislative initiatives to overturn restrictions imposed by commercial interests on doctors' responsibilities for their patients. One example was when doctors were proscribed from explaining to patients the range of therapeutic options covered in their insurance plans and another was the attempt to limit obstetrical delivery hospital stays to 24 hours.

Cruess and Cruess place the concept of the social contract in its historical context, dating back to philosophers such as Rousseau, Locke, and Hobbes. While not a legal contract in any formal sense, the social contract does attempt to define the relationship between citizens and the state. In the instance of medicine in general and psychiatry in particular, a social contract provides a conceptual framework to examine the complex relationship our field has with both our patients and the larger society and helps to define our professionalism.

Society trusts that psychiatrists will use their expertise to look after the mental health of its citizens. We are expected to be objective, to maintain high standards of conduct, to be altruistic, to not seek monetary gain, and to avoid conflicts of interest. In exchange, we will be able to regulate ourselves, establish our own work standards, and regulate recruitment, training, and credentialing as well as earn a comfortable living. Failure to act in this fiduciary role results in society taking action to reduce our autonomy.

U.S. psychiatric history is replete with examples of how society has responded to the field of psychiatry not fulfilling its obligations in the social contract. The profession's failure to vigorously respond to the occurrence of patient-therapist sex resulted in state legislatures criminalizing the act. Failing to choose the lowest-cost effective medication resulted in the restriction of prescribing independence by requiring psychiatrists to obtain prior authorization and limiting therapeutic choices to preselected formularies. Accepting gifts, dinners, consultantships, etc., from pharmaceutical companies has resulted in congressional investigations, with demands for greater transparency, the Physician Payment Sunshine Act, and even criminal prosecutions.

This book uses the social contract to discuss in greater detail the role and demands of professionalism in clinical practice. Its focus on circumstances in the United Kingdom and the changes in its national health system does limit some of the applicability to issues in the United States. Yet the difference in perspective also permits a more distanced reflection on concerns that do overlap between the two regions.