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2013 Amma Antwi University of the Witwatersrand School of Medicine Faculty of Health Sciences Tafadzwa Chigumba Abnel Mutambasere Ngunja Seyuba 25th February 2013 HEALTHCARE PROFESSIONALS AND SOCIAL CONSCIENCE Where does one draw the line? Introduction At the turn of the 21st Century, social dimensions of health and the impact thereof on the practice of medicine have become heated sources of debate and are of extreme importance, particularly in the context of developing countries. Pellegrino (1) reaffirms that healthcare professionals (HCPs), like all professionals, are in possession of a special body of knowledge, practice within some ethical framework and commit to the fulfillment of some broad societal need. Simply put, professionalism is a contract between the professional and society and as such serious ethical obligations are linked to the ideal of a profession (1, 2). Faculties of Health Sciences across South Africa have made a collective effort to commit to professionalism. In so doing, they commit to instilling the qualities, attitudes and values of what has come to be known as a Five Star Doctor (3), in those with whom they have contact. To date, there have been few academic writings on the subject of social conscience related to HCPs. However, it remains important for future HCPs to engage and debate on issues surrounding social conscience as well as build a sense of social conscience and what it means to a healthcare professional. By exploring the dimensions of this topic we hope to define social conscience as well as compare and contrast it to social responsibility. While we appreciate that social conscience could be a subject of discussion on its own, we will briefly discuss factors that contribute to one’s social conscience. We will end of our discussion by posing a modern version of an ancient question for HCPs. That is, to what extent must one adhere to their professional obligation to meet a patient’s needs and the needs of the community at large? More specifically, are HCPs required to have a social conscience and if so are they required to do something about the failures of the Health care system and social impact thereof? Ethical issues seldom have a definitive answer. However, by exploring different opinions we will begin to understand our own social conscience as well as that of others, helping to identify common values, visions and goals and subsequently bringing us one step closer to collectively bringing about societal change in South Africa. 1. What is social conscience? Goldberg (4) describes social conscience as the ability to reflect on deeply held opinions about social justice and sustainability. He goes on to say that in the same way that an individual can have a sense of right and wrong for personal action, they too can possess a sense of right and wrong for collective action – a social conscience. Donald and Kovac (5) highlight that not only does the individual display an interest in public affairs but also a willingness to become involved. As HCPs we are committed to serving the needs of others and according to Nelson (6) our duty to society lies beyond just the medical practice. Following this, we need to demonstrate a well-developed sense of social conscience and concern. In contrast, social responsibility can be viewed as an awareness of social problems and a commitment to try to help solve them (5). So while it is social conscience that compels us to insist on moral action and seek social transformation, (4) taking social responsibility bestows a higher level of commitment to that individual. 2. The importance of social determinants of health In defining social conscience, an awareness of the social issues contributing to ill-health is critical. In exploring when a defined social problem becomes a health problem, some of the social determinants that one needs to be aware of and how they result in health problems will be highlighted. Social determinants of health are the conditions in which people are born, raised and subsequently live, work and age (7). In addition to this, the social circumstances people find themselves in are shaped by the distribution of money, power and resources at local, national and global levels (7). The way in which a child is brought up for example, has a profound impact on their health; this includes factors such as nutrition, physical activities, social interactions as well as cultural and religious background (8). According to Statistics SA, the leading causes of death for children under-five years between the years 2006 and 2010 were intestinal infectious diseases, influenza, pneumonia and malnutrition (9), reaffirming the need to prevent ill-health by addressing basic human needs such as adequate water supply and sanitation. Health education and promotion empowers people to tackle social problems in order to prevent them from developing into health issues. The lack of education makes it difficult for people to understand some of these concepts and predisposes one to unemployment. At the end of the fourth quarter of 2012 there was an estimated 4.5 million people unemployed in South Africa (10). Continuing anxiety, food insecurity and other such consequences of unemployment, increase the chance of poor mental health and premature death (8), 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 health related. Disparities in social determinants of health are largely responsible for health inequities and the unfair and avoidable differences in health status seen within countries. South Africa, like the rest of the world, is not immune to the consequences of these inequities. Consequently, health practitioners should not treat patients in isolation but acknowledge that a health problem is not limited to a patient’s illness but influenced by their background and various challenges that make it impossible for them to lead a healthy life. 3. Are Healthcare professionals required to care or do something about the failures of the health care system and social impact thereof? The curriculum for medical students at the University of the Witwatersrand places emphasis substantially on the teaching of ethics; and an awareness of the society that a doctor working in South Africa would most likely encounter. It is arguable whether this is sufficient to make one fully aware of the issues that drive our societies. In an attempt to answer this question we will consider the pros and cons of a social conscience in HCPs. 3.1. The positive impact on society: for the greater good of humanity. Donald and Kovac (5) quoted Du Bois: “We are training not isolated men but a living group of men … And the final product of our training must be neither a psychologist nor a brick mason, but a man. And to make men, we must have ideals, broad, pure, and inspiring ends of living …’’. This statement highlights that a trained scientist is not just well versed in scientific facts and sapience thereof but rather someone who is aware that science is an entity present within a societal framework. So, science in whatever way manipulated or interpreted, will affect society in one way or another. Linus Pauling, an American chemist turned peace activist, joined a committee chaired by Albert Einstein, whose mission was to warn the public of the dangers associated with the development of nuclear weapons (5). The two rose above their careers as scientists, acting upon a social conscience. Their work against nuclear weapons was for the greater good of society, safeguarding humanity from imminent harm (5). This can easily be mirrored in HCPs, who hold a special position in society, granting them the opportunity to influence change within a community. For that reason, the lack of socially conscious HCPs may hold dire repercussions for the society. 3.2. Social conscience as an agent for circumventing spread of diseases Dwyer (11) wrote, “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”. It is perceptibly illogical for HCPs to offer employment to patients or to offer to pay for their consultation or medication, but it is also an obligation for HCPs to intervene where there is a health hazard to the public (The Harm Principle). Dwyer (11) highlighted that measures taken by the American government to deny illegal immigrants health care can lead to an increase in the spread of tuberculosis since they do not seek help in fear of being deported; thus putting the public in harm’s way. Likewise, if we consider a situation in which 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. 3.3. Health care workers as proxies for an improved system The bulk of moral responsibility in members of society is one in which they are expected to refrain from doing wrong. HCPs have an added dimension of responsibility in which they are expected not only to refrain from doing wrong or causing harm but actively strive to do what is right. Health care workers are encouraged to advocate for improvements and advancements in the healthcare system, seeing as they better understand the implications and consequences of inaccessible healthcare. In the absence of such advocates, the gap between social problems and public health issues will become narrow and the management and prevention of certain diseases more difficult. Societal growth and development is dependent on the presence of people who are willing and able to advocate for the group. This goes to show that HCPs are not meant to be subservient to a system but are rather meant to serve people. 3.4. Impact of social conscience on health professionals In supporting social conscience one must consider the impact this has on the HCP. As previously stated, social conscience encompasses those views that are considered either right or wrong for a collective (4). The problem with this is that certain views may be in direct 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 compass (4). The origins of one’s values and consequently their social conscience are dependent on a number of factors, such as family upbringing, social conditioning and life experiences, altogether shaping a person’s moral compass. Intra-personal 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 the HCP who is willing to address societal health issues. As well as question what is expected of them as providers of a fundamental service to human life. Although social conscience is not specifically mentioned in the Health Professions Council of South Africa handbooks, all of the guidelines, especially the first, rest on the assumption that HCPs should have some form of social conscience (12). On the other hand, the Bill of Rights explicitly states that one has the right to exercise their right to freedom of conscience, religion, thought and belief (13). Together with moral values these factors inevitably influence one’s readiness to promote change within society where health issues are concerned. For example, a socially aware HCP would advocate for the promotion of safer sex practice through the use of contraception in a society where teenage pregnancy is a major problem. Should HCPs who do not believe in contraception be expected then to set aside their own religious values for the good of society? Abortion Law in South Africa states that doctors may not use the freedom of conscience act to refuse giving advice or information on abortion (14). If this notion was to be held true beyond the scope of abortion, then the doctor would be obligated to inform the public about safe sex practices. Gold (15) points out that although not legally compelled, HCPs in an effort to avoid inter-personal conflict with their superiors and patients find themselves in situations where they are expected to act against their own personal values. One has to wonder if this clash between social conscience and personal values deters some HCPs from pursuing certain causes that may help the society in the long run. 3.5. Social conscience is a relative term The diversity of values in society warrants a level of caution when discussing social conscience. The approach to an ethical issue much like this one must be exhaustive, making sure to consider the individual, professional, organizational and societal factors of input. The question at hand is limited to the professional input, failing to address the fact that a professional is an individual existing within an organization, which in turn is part of a greater society. It is crucial to keep in mind that each one of these factors is a separate entity with its own challenges and considerations. Furthermore, it is often difficult to separate a discussion on social and ethical issues from economic, political and judicial issues, as these factors are interconnected. Thus, there are a number of issues to consider including the context in which this HCP exists, to adequately answer this question. 3.6. A requirement or an admired trait? If in fact HCPs were required to have a social conscience and actively exercise social responsibility, another ethical dilemma would intensify our discussion. If one’s social conscience inextricably depends on an individual’s up-bringing and moral framework thereof, to make a trait a requirement would leave many questions unanswered. Is there a set standard of social conscience and if so, what level is appropriate? Furthermore, would it be fair to impinge on an individual’s established standards? Adams (16) notes a trend in modern medicine in which patients are entitled to engage in optional behaviour, while HCPs are expected to engage in behaviour that is often mandatory rather than optional. With patient’s rights increasing by the day, then in the same breath, HCPs should have the right to choose rather than be required to fulfil more obligations such as social conscience. Adams (16) remarks, “In principal the duty not to harm is often more important than the duty to assist”. Primum non nocere – first do no harm. It is no coincidence that a duty to do no harm as opposed to a duty to assist forms one of the four pillars of medical ethics. So, should HCPs be coerced into having a social conscience? Perhaps for the greater good of society but this too on its own could be a subject for debate. While social conscience is a highly valued trait, Adams (16) argues that to coerce HCPs is morally corrupting for the profession and its practitioners. 3.7. Social conscience does not guarantee change The range of social issues that HCPs must address is large, more so in the case of a developing country such as South Africa. The role of HCPs as agents of change is to challenge the way in which the population views health and social issues. It would be impractical to deeply care and act on every social and ecological problem. While ecological problems such as global warming, loss of biodiversity and pollution ultimately lead to health problems, one must also exercise restraint and admit that it is beyond their capabilities. Noddings (17) tackles the complexity in caring and advises that we separate individual responsibility to care from collective responsibility to care. In doing so, cautioning us to be realistic and prepared to admit when we cannot do anything thus avoiding empathetic exhaustion. If social conscience entails a duty to assist, Dwyer (18) believes that the real issue is the nature, extent and fulfillment of this duty as well as its effectiveness. By discussing social conscience in relation to HCPs we are neglecting to consider firstly, the extent to which the HCP must go to fulfill this duty. Secondly, whether appropriate avenues exist to fulfill this duty and ultimately, whether it will result in true societal change. 4. Where are we now? South Africa’s current practices, avenues and shortcomings. During the apartheid era in South Africa, racial segregation was not limited to society; sadly it existed in the health sector as well. Over the years, bioethics in South Africa has advanced through several stages. The peaceful transition from apartheid to democracy fuelled an increased focus on human rights and has given bioethics in South Africa its own dimension (19). A strong body of support is necessary in order to bring about societal change in an effective and efficient manner. Under the National Health Act (2003) these are the relevant channels available (20). Provincial Health Council Premier Member of Executive Council (MEC) District Health Council (DHC) City Structures regional multi member constituencies (MMC) Hospital boards (HB) Portfolio Committe es Clinical committee (CC) Ward committee Figure 1: Diagram displaying current protocol in addressing a problem identified in a community. In a conversation with Professor Shan Naidoo, Chief Specialist Public Health Medicine, Wits (Feb 2013), the current protocol upon the identification of problem, HCP’s can approach any one of the following directly: The DHC, CC, HB, ward committees, MEC of the province, portfolio committees, the 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, there are certain civil society organizations which they can approach such as Section 27, Treatment Action Campaign (TAC), Centre for Applied Legal Studies (CALS) and Public Health Association of South Africa (PHASA). Section 27 is a private organisation named after Section 27 of the constitution of the Republic of South Africa (21). This section of the constitution deals with an individual’s right to health care, food, water and social security depending on the government’s available resources (13). Section 27 is a public interest centre which advocates for the change of social conditions that undermine human dignity and development (21). PHASA is another private organisation which aims to promote equity in health by advocating for national and international issues that impact the social conditions (22). It has been highlighted that there are many channels both public and private, available to assist HCP’s in advocating for change in communities. Thus, the decision ultimately lies with the HCP to take the first step and initiate change. Social Conscience: Once Taught Sadly Forgotten In answering this question we were stirred to reflect upon the meaning of social conscience to medical students. Upon graduation medical students all over the world recite the Hippocratic Oath. The modern oath has been revised to highlight certain issues deemed more fitting (23). The oath sworn by Wits Medical School students states that one 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 (24). Such declarations and codes of ethics as well as the bodies that govern them foster professionalism by conveying a sense of gravity and belonging to something greater than oneself (23). The idea of social conscience is at the heart of this declaration however, foregoing this does not warrant legal action. As such these oaths are not binding obligations that one should adhere to upon graduating. A study on USA doctors showed that the ideals and moral identity the Hippocratic Oath is meant to inspire, no longer serves that function once the doctors start practicing (23). To relate it to a South African context, during the course of one’s medical training Witwatersrand Medical School has community orientated projects which reinforce ideals of the Hippocratic Oath however; these ideals of service to community are often neglected once they graduate as most students are academically driven as opposed to socially driven. 5. Conclusion In reviewing different opinions on this subject it is evident that much more needs to be considered before a definitive answer is made. The question here perhaps, need not be whether HCPs are required to have a social conscience but rather whether one understand what having a social conscience entails. There is still much left to debate and a great need to discuss the role of academic institutions in developing the social conscience of students. Should educators be responsible for shaping students’ social conscience and subsequently their use of this knowledge as they advance professionally? Fundamentally, this sheds light on the fact that this is perhaps the right question for the wrong time. Finally, societal change is a shared responsibility. It is the responsibility of the state and of the people within the societal framework. We are human beings, part of a global society, should societal change be considered a professional obligation or rather an ethical one shared by all members of society? With that said, there is a need for an increase in awareness for social conscience not only in the health profession but in all other professions and in society in general. The real question remains where do HCPs draw the line in bearing this responsibility? 6. References 1. Pellegrino ED. Professionalism, Profession and the Virtues of the Good Physician. The Mount Sinai Journal of Medicine. 2002 November; 69: No.6. 2. Passi V, Doug M, Peile E, Thistlethwaite J, Johnson N. Developing Medical Professionalism in Future Doctors: A Systematic Review. Int. J. Medical Education. 2010; pp. 1:19-29. 3. Boelen C. The Five-Star Doctor: An asset to health care reform? [http://www.who.int] [Cited 2013 Feb 20] Available from: http://www.who.int/hrh/en/HRDJ_1_1_02.pdf 4. Goldberg M. 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Available from: http://books.google.co.za/books?hl=en&lr=&id=QDFzqNZZHLMC&oi=fnd&pg=PA 5&dq=social+determinants+of+health&ots=xTtFgBPOmv&sig=PGs77YK5BhZl72J T7AqPvBroIhs 9. Blaauw D. Health Inequities [unpublished lecture notes]. SCMD3000: GEMP1, University of the Witwatersrand; lecture given 10 October 2012. 10. Quarterly Labour Force Survey. Quarter 4. 2012; Pretoria: Statistics South Africa. Available from: http://www.statssa.gov.za/publications/P0211/P02114thQuarter2012.pdf 11. Dwyer J. Illegal Immigrants, Health Care and Social Responsibility. Hastings Center Report 34. 2004; No. 5, pp. 34-41 12. Guidelines for Good Practice in the Health Care Professions. Ethical and Professional Rules of the Health Professions Council of South Africa as Promulgated in Government Gazette R717/2006. Available from: http://www.hpcsa.co.za/conduct_generic_ethical_rules.php 13. Constitution of the Republic of South Africa, Chapter 2: Bill of Rights. South Africa, 1996. Available from: http://www.info.gov.za/documents/constitution/1996/96cons2.htm 14. McQuoid-Mason D. State Doctors, Freedom of Conscience and Termination of Pregnancy Revisited. SAJBL. December 2010; Vol. 3, No. 2, pp. 75-78. 15. Gold A. Physicians’ “Right of Conscience” – Beyond Politics. Journal of Law, medicine and Ethics. 2010; pp. 134-142. 16. Adams P. Coercing Conscience: Professional Duty or Moral Integrity. Journal of Social Work Values and Ethics. 2011; Vol. 8, No. 1. 17. Noddings N. Complexity in Caring and Empathy. Abstracta, Special Issue V. 2010; pp.6 – 12. 18. Dwyer J. Teaching Global Bioethics. Bioethics. 2003; 17 (5-6):pp. 432-446. 19. Benatar SR, Landman WA. Bioethics in South Africa. Cambridge Quarterly of Healthcare Ethics. 2006; 15, pp. 239–247. 20. National Health Act, 2003. Government Gazette, Vol. 469 Cape Town 23 July 2004 No. 26595 [Document on the internet]. [Cited 2013 Feb 28]. Available from: http://www.info.gov.za/view/DownloadFileAction?id=68039 21. Section 27, Catalysts for Social Justice: Incorporating the AIDS Law Project. [http://www.section27.org.za/] c2013 [Updated 2011; Cited 2013 February 22]. Available from: http://www.section27.org.za/about-us/ 22. Professional Health Association of South Africa. [http://www.phasa.org.za/] [Cited 2013 February 22]. Available from: http://www.phasa.org.za/about 23. Antiel RM, Curlin FA, Hook CC. and Tilburt JC. The Impact of Medical School Oaths and other Professional Codes of Ethics: Results of National Physician Survey. Arch Intern Med. 2011; Vol.171, No. 5, pp. 469 471. 24. University of the Witwatersrand Hippocratic Oath [http://www.wits.ac.za/]. Johannesburg: University of the Witwatersrand. c2000 [Cited 2013 February 21]. Available from: http://www.wits.ac.za/academic/health/centres/bioethics/10064/hippocratic_oath.html 7. Bibliography 1. Dhai A, McQuoid-Mason D. Bioethics, Human Rights and Health Law: Principals and Practice. Cape Town, SA: Juta and Company Ltd; 2011.