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Amma Antwi
University of the
School of Medicine
Faculty of Health Sciences
Tafadzwa Chigumba
Abnel Mutambasere
Ngunja Seyuba
25th February 2013
Where does one draw the line?
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
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
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
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
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
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
Member of
Council (MEC)
District Health
Council (DHC)
City Structures
regional multi member
constituencies (MMC)
Hospital boards
Clinical committee (CC)
Ward committee
Figure 1: Diagram displaying current protocol in addressing a problem identified in a
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
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
6. References
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The Mount Sinai Journal of Medicine. 2002 November; 69: No.6.
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Professionalism in Future Doctors: A Systematic Review. Int. J. Medical Education.
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about Social Justice and Sustainability, University of Strathclyde and the Centre for
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October 2012
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7. Bibliography
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and Practice. Cape Town, SA: Juta and Company Ltd; 2011.