Social conscience and healthcare professionals: Where does one draw the line?

A Antwi, T Chigumba, A Mutambasere, N Seyuba

Reading the submissions for the University of the Witwatersrand/Medical Protection Society Undergraduate Bioethics Essay Competition made me reflect back on my own medical training – how things have changed! Granted, one would expect things to change in three decades. Our knowledge has increased exponentially, as has our realisation of what we do not know. As the island of knowledge has grown, so has the coastline of ignorance.

However, the essays did not make me reflect on the knowledge and technical improvements that medicine has to offer and which students are expected to grasp. What impressed me was the intellectual ideas that the students are now expected to grapple with.

Social conscience and social responsibility are terms that were not even in the vocabulary of most of my peers. Having students reflect on these concepts must correspond to the HPCSA’s goal of raising the moral awareness of the profession and hats off to the medical schools for their efforts.

I impressed not only by the subjects tackled but by the content of the papers submitted. In this competition there are no losers but one has to adjudicate a winner, and it gives me pleasure to introduce the paper, Healthcare Professionals and Social Conscience: Where does one draw the line? by Amma Antwi, Tafadzwa Chigumba, Abnel Mutambasere and Ngunja Seyuba. The authors are all fourth-year MB ChB students. Enjoy the read.

– G Howarth, Medical Protection Society: Head of Medical Services – Africa.

Corresponding author: A Antwi (amma_antwi2000@yahoo.com)

In this paper we hope to define social conscience and how it might apply in a healthcare context. We discuss how social problems affect one’s health. Where does one draw the line in bearing the responsibility of acting on their social conscience and what level of engagement is appropriate or enough? Are healthcare professionals required to have a social conscience, and if so must they take action regarding the failures of the healthcare system and its social impact? Ethical issues seldom have a definitive answer. However, by exploring different opinions we begin to understand our own social conscience and those of others, which helps us identify common values, visions and goals, bringing us closer to initiating societal change.

S Afr J BL 2013;6(1):6-9. DOI:10.7196/SAJBL.266

The impacts of the social dimensions of health on the practice of medicine are heated sources of debate and are extremely important, particularly in developing countries. Pellegrino1 affirms that health­care professionals (HCPs), like all professionals, possess a special body of knowledge, practise within an ethical framework and commit to the fulfilment of a broad societal need. Since professionalism is a contract between the professional and society, serious ethical obligations are linked to the ideal of a profession.1 , 2

Faculties of health sciences at South African (SA) universities have made a collective effort to commit to professionalism, by instilling the qualities, attitudes and values of a ‘five-star doctor’3 in students. It is important for future HCPs to engage with and debate the issues surrounding social conscience.

What is social conscience?

Goldberg4 describes social conscience as the ability to reflect on deeply held opinions about social justice and sustainability: in the same way that an individual can have a sense of right and wrong regarding personal action, they can possess a sense of right and wrong for collective action. Donald and Kovac5 emphasise that the individual with a social conscience displays an interest in public affairs and a willingness to become involved. This entails two dimensions of social conscience:

• awareness, which allows the individual to notice an injustice, as well as seek social transformation

• action, which enables them to bring about societal change.

On entering the profession, HCPs commit to serving the needs of others. According to Nelson,6 our duty to society lies beyond just the practice of medicine. It includes advocating on societal issues which directly or indirectly affect the health of a society, supporting transformation, promoting equity in healthcare and exhibiting an environmental consciousness.7 To adequately fulfil these duties, we need to demonstrate a well-developed sense of social conscience.

The importance of social determinants of health

The World Health Organization (WHO) defines health as a state of complete physical, mental and social well-being, and not merely as the absence of disease or infirmity.8 In exploring when a social problem becomes a health problem, we highlight some of the social determinants to be aware of and how they result in health problems. Social determinants of health are the conditions in which people are born, raised and subsequently live, work and age.9 Their social circumstances are also shaped by the distribution of money, power and resources at local, national and global levels.9

For example, how children are raised has a profound impact on their health; factors include nutrition, physical activities, social interactions and cultural and religious background. 10 According to Statistics SA, the leading causes of death for children under 5 years between 2006 and 2010 were infectious diseases and malnutrition. 11 This reaffirms the need to prevent ill-health by addressing basic needs, such as adequate water supply and sanitation. Health education and promotion empower people to prevent social problems from developing into health issues. However, a lack of general education makes it difficult for people to understand some of these concepts and predisposes them to unemployment. At the end of 2012 SA had an estimated 4.5 million people unemployed.12 The consequences of unemployment, including continuing anxiety, food insecurity and others, increase the chance of poor mental health and premature death,10 contributing to the vicious cycle of poverty and ill health.

Health problems do not exist in isolation and the root causes of ill health are as much social as they are biological. Disparities in social determinants of health are largely responsible for health inequities and the unfair and avoidable differences in health status seen within countries. SA’s experience with segregation make it especially vulnerable to these kinds of inequities. Consequently, HCPs should develop an awareness of and sensitivity to these issues. Acknowledging that a health problem is not limited to a patient’s illness, but is influenced by various challenges which make it impossible for them to lead a healthy life, ensures that patients are treated holistically.

Must HCPs act on the failures of the healthcare system and its social impact?

We consider reasons for and against HCPs acting on their social conscience.

Reasons for HCPs to act on their social conscience

Donald and Kovac5 emphasise that a trained scientist is not just well-versed in scientific facts, but is aware that science exists within a societal framework. This is particularly true of the science of medicine, which fundamentally aims to promote and maintain human well-being. Scientists have a responsibility to be aware of the role of science in the context of the societal framework. Arguably, healthcare practitioners have an even greater responsibility, given the societally directed nature of their disciplines. Thus a social conscience is central to the healthcare professions.

Dwyer13 writes that ‘Prevention is, of course, always preferable to treatment. But epidemics of treatable infectious diseases should remind us that although science has revolutionised medicine, we still need a plan for ensuring equal access to care.’ This is particularly important when there is a health hazard to the public. Measures taken by the American government to deny healthcare to illegal immigrants can increase the spread of tuberculosis, since immigrants do not seek help for fear of being deported. This puts the public in harm’s way. 13 Likewise, where there is a high incidence of vaccine-preventable diseases in children, a socially conscious doctor would advocate for the education of people on the benefits on immunisation or contact the relevant public health authorities.

For members of a society, moral responsibilty mostly consists of refraining from doing wrong. HCPs have additional responsibilities, in that they must also not cause harm and actively strive to do what is right. There is a supererogatory call on those who enter the healthcare profession, where they are encouraged to advocate for improvements and advancements in the healthcare system. This seems appropriate as HCPs better understand the implications and consequences of inaccessible healthcare, and of improvements which must be made. In the absence of such advocates, the line between social problems and public health issues becomes blurred, making the management and prevention of certain diseases more difficult. Societal growth and development depend on the presence of people who are willing and able to advocate for the social group. Therefore HCPs should not be subservient to a system but are rather meant to use the system to ensure that the health and related needs of the people are met.

Difficulties with the concept of social conscience

In advocating a social conscience, one must consider the impact this has on HCPs, particularly when certain views may conflict with one’s personal values. Change is often brought about by individuals making choices that help mould their society according to their own values and moral compasses.4 The origins of one’s values, and consequently one’s social conscience, depend on many factors, such as family upbringing, social conditioning and life experiences that shape a person’s moral compass. Intrapersonal conflict may arise when HCPs are uncomfortable advocating on society’s behalf on matters that require them to compromise their own moral values. Therefore, we must consider some of the personal costs to HCPs who are willing to address societal health issues.

Although social conscience is not specifically mentioned in the Health Professions Council of South Africa (HPCSA) handbooks, all their guidelines rest on the assumption that HCPs should have some form of social conscience.14 On the other hand, the South African Bill of Rights states that individuals have the right to freedom of conscience, religion, thought and belief.15 Together with moral values, these factors inevitably influence one’s readiness to promote health-issue changes within society. For example, in a society where teenage pregnancy is a major problem, a socially aware HCP would promote safer sex through the use of contraception. Should HCPs who do not believe in contraception be expected to set aside their own religious values for the good of society? South African abortion law states that doctors may not use the Freedom of Conscience Act to refuse to give advice or information on abortion.16 If this is held true beyond the scope of abortion, then the doctor would be obligated to inform the public about safe sex practices.

Gold17 points out that even if they are not legally compelled, HCPs attempting to avoid interpersonal conflict with their superiors and patients may find themselves in situations where they are expected to act against their own personal values. Does this clash between social conscience and personal values deter some HCPs from pursuing certain causes that may help the society in the long run?

Because our society has diverse values, caution is warranted when discussing social conscience. The approach to such ethical issues must be exhaustive, ensuring individual, professional, organisational and societal input. Limiting the question to professional input fails to address the fact that a professional exists within an organisation, which in turn is part of a greater society. Each of these factors is a separate entity with its own challenges and considerations. Furthermore, it is often difficult to separate the discussion of social and ethical issues from economic, political and judicial issues, as these are interconnected. Thus, many factors must be considered, including the context in which the HCP exists, to adequately address the matter of social conscience.

However, if one’s social conscience inextricably depends on an individual’s upbringing and moral framework, to make social conscience a professional requirement for HCPs would raise another ethical dilemma. Is there a set standard of social conscience and, if so, what level is appropriate? Would it be fair to impinge on an individual’s established standards? Adams18 notes a trend in medicine in which patients are entitled to engage in optional behaviour, while HCPs are expected to engage in mandatory behaviour. As patients’ rights increase, HCPs should also have the right to choose rather than be required to fulfil more obligations, such as having a social conscience. Adams remarks, ‘In principal the duty not to harm is often more important than the duty to assist.’ If HCPs are coerced into having a social conscience, do they have a duty to develop a social conscience as well as the duty to assist? This is a subject for debate. While social conscience is a highly valued trait, Adams argues that to coerce HCPs is morally corrupting for the profession and its practitioners.

Social conscience does not always guarantee change, and the range of social issues that HCPs must address is large. As agents of change, the role of HCPs is to challenge the way in which the population views health and social issues. It would be impractical to deeply care about and act on every social and ecological problem. While ecological problems can ultimately lead to health problems, they must exercise restraint and admit when it is beyond their capabilities. Noddings19 tackles the complexity of caring, and advises that we separate individual responsibility to care from collective responsibility to care, cautioning us to be realistic and thus avoid empathy fatigue.

Exercising social conscience

If social conscience entails a duty to assist, Dwyer20 believes that the real issue is the nature, extent, fulfilment and effectiveness of this duty. To what extent must HCPs go to fulfil this duty, do appropriate avenues to do so exist and, ultimately, will doing so result in true societal change?

Where are we now?

During apartheid, South Africa’s society and health sector were subject to racial segregation. Following a democratic transition, bioethics in South Africa has advanced through several stages, with an increased focus on human rights.21

A strong body of support is necessary to effectively and efficiently bring about societal change. In a conversation with Professor Shan Naidoo, Chief Specialist: Public Health Medicine at the University of the Witwatersrand (Wits), in February 2013, we established the current protocol upon identifying a problem that has social aspects. This would be to approach any of the following channels under the National Health Act (2003):22 the district health council, clinical committees, hospital boards, ward committees, provincial members of the Executive Council, portfolio and provincial committees or the provincial premier. Subsequently, the problem should be forwarded to the necessary governmental authorities. If the HCP’s concerns are not addressed then certain civil society organisations can be approached, such as Section 27, the Treatment Action Campaign, or the Centre for Applied Legal Studies and Public Health Association of South Africa (PHASA). Section 27 is a private organisation and public interest centre which advocates for change in social conditions that undermine human dignity and development.23 It is named after Section 27 of the Constitution of South Africa, which deals with an individual’s right to healthcare, food, water and social security, depending on the government’s available resources.15 PHASA, another private organisation, aims to promote equity in health by advocating for national and international issues that affect social conditions.24

There are many channels, both public and private, available to assist HCPs in advocating for change in communities, but the decision to initiate change ultimately lies with the HCP.

Taught, but forgotten

What meaning does ‘social conscience’ have for medical students? Upon graduation, medical students all over the world recite a modern Hippocratic Oath revised to highlight contemporary issues.25 The Wits medical students’ oath states that they will exercise their profession to the best of their knowledge and ability, for the safety and welfare of all persons entrusted to their care and for the health and well-being of the community.26 Declarations such as these, codes of ethics and bodies such as the HPCSA foster professionalism by conveying a sense of gravity, and of being part of something greater than oneself. 25 The idea of social conscience is at the heart of this declaration and underwrites many of the ethical guidelines set out for HCPs. Should HCPs forego socially conscious action, this does not warrant legal action, but the spirit of the oath is contained in the HPCSA ethical guidelines which do have quasi-legal status.

A USA study showed that the ideals and moral identity that the Hippocratic Oath is meant to inspire fall away once the doctors start practising.25 During medical training at Wits University Faculty of Health Sciences, community-orientated projects reinforce the ideals of the Hippocratic Oath. However, these ideals of service to the community often seem to be neglected once students graduate, as most graduates become financially driven as opposed to socially driven.

Conclusion

The range of opinions on this subject demonstrate how much more there is to be considered before a definitive answer is made. Perhaps HCPs need not be required to have a social conscience, but could instead be evaluated on whether they understand what having a social conscience entails? The role of academic institutions in developing students’ social conscience needs discussion. Should educators be responsible for shaping students’ social conscience and their subsequent application of it as they advance professionally? This may be the right question for the wrong time, with numerous factors to consider before it can be adequately addressed. As medical students, we recommend that informal or formal mentoring programmes between faculty members and medical students be incorporated into our curriculum. There should also be continuous and adequate interaction with suitable role models to instil moral values, ethical practice and virtue in medical students, thus promoting and developing social conscience.

Societal change is a shared responsibility between the state and the people within the societal framework. As human beings, part of a global society, should we consider societal change a professional obligation, or an ethical one shared by all members of society? Should individual or personal obligations be separate from professional obligations? An increased awareness is needed of social conscience in the health professions, in all other professions and in society in general.

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