Opinion | The Demise of the Social Contract in Medicine

As we enter the third year of the COVID-19 pandemic, much attention focuses on the public’s lack of trust in healthcare. Yet, virtually no one is considering how the pandemic has affected healthcare workers’ trust in healthcare organizations and our society at large. That distrust was exposed in the swift and brutal reactions of healthcare workers to recent policy changes made by the CDC and the American Heart Association (AHA) before it that benefit patients, but without equal attention to the impact on healthcare workers.

First, to respond to the acute staffing crisis created by sick healthcare workers, the CDC in late December shortened the isolation period for COVID-19 positive healthcare workers from 10 days to 7 days, and said it could be cut even shorter in a crisis. A few days later, the isolation period was further cut to 5 days for everyone. In October, the AHA interim guidance on CPR and resuscitation for COVID-19 patients resurfaced. That guidance specifies that “chest compressions should not be delayed for retrieval and application of a mask or face covering for either the patient or provider,” citing the low risk of COVID-19 transmission in healthcare settings.

While both of these decisions were clearly made to benefit patients, they are, unfortunately, slaps in the face for a demoralized healthcare workforce — one that simply lacks any trust right now, both in the healthcare system and the public at large.

While one could potentially chalk these up as missteps in messaging or decision-making by these organizations, we believe it is a harbinger of something even larger: the demise of the social contract in American medicine.

That social contract has, for generations, formed the bedrock of healthcare in America. Defined as a foundational understanding between medical professionals and society that forms the underpinning of “professionalism,” that social contract implores physicians, nurses, and other health professionals to fulfill their role as healers — thereby ensuring competence, altruism, morality, integrity, and promotion of the public good. In exchange, society grants medicine trust and high social prestige, the ability for the profession to self-regulate, and shares in the responsibility for improving public health and ensuring that our healthcare infrastructure and systems are resourced and supported.

But not anymore.

Indeed, both the CDC and AHA decisions assume the social contract is healthy, alive, and well, thereby anticipating these policies will be received with minimal pushback. By this reasoning, the healthcare workforce should want to do everything in its power to ensure access to care for the public in light of the staffing crisis, and would welcome the shortened isolation period to get back to work. Similarly, it assumes healthcare workers would not want to delay life-saving chest compressions for a patient, as long as the risk to them was minimal.

Unfortunately, that is far from where our profession stands right now.

Unlike the early days in spring 2020, where many parts of the country honored the social contract by answering our call to “flatten the curve,” banging pots and pans, sewing masks, and providing a slew of services and support for our healthcare workforce, society has moved on — and so too has the profession. Research shows that physicians are leaving the field at a rate four times higher than before the pandemic, and since February 2020, nearly 1 in 5 healthcare workers have quit their jobs — data collected well before the omicron wave.

Our social contract is in need of major resuscitation after over 20 months of a pandemic prolonged by: society’s inadequate vaccination rates; a persistent and increasing distrust of the medical establishment; the viral proliferation of disinformation; continued attacks on healthcare workers for promoting public health and vaccinations; and a blatant disregard for the sustainability of the healthcare system and the healthcare workforce itself.

In spring 2020, our profession charged to the frontlines, even as we begged for PPE better than the garbage bags available amid national PPE shortages, because — despite the many inconsistencies of American healthcare — our workforce fundamentally believed in medicine as a social contract and never questioned our obligation to patients above ourselves.

Two years later, as the reactions to the AHA and CDC’s recent decisions demonstrate, that contract is in shambles. As our healthcare workforce and institutions are now asked to hold the line against all odds, we would all do well to anchor ourselves in this new reality — one in which the social contract and the healthcare workforce must both be healed.

Ali Khan, MD, MPH, is a general internist in Chicago and chief policy officer for the Illinois Medical Professionals Action Collaborative Team (IMPACT). Shikha Jain, MD, is an assistant professor of medicine at the University of Illinois in Chicago and CEO of IMPACT. Vineet Arora, MD, MAPP, is the Herbert T. Abelson Professor of Medicine and Dean for Medical Education at University of Chicago Medicine.

Last Updated January 06, 2022