Medicine: Contract or Covenant?

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In an increasingly consumerist culture—not to mention an increasingly litigious one—physicians and patients are tempted to view their relationship as purely contractual. To do so is not only a violation of the canons of good medicine but also ultimately dangerous. Think of a legitimate contractual agreement, like that of one and one’s plumber.  A contract is:

• Egalitarian (between equals).
• Limited in duration (the extent of the agreement).
• Quid pro quo—“this for that” (services for money).
• Enforced by law—because the contract, not relationship, is the glue.
• Based on self-interest—consumerism drives it.

In a contractual plumbing agreement, the customer wants a working toilet, and the plumber uses his skills in exchange for the monetary gain. In contractual medicine, physicians have a product (treatment) and patients (consumers) have a good to exchange (money). In this consumerist culture, the customer is always right. Hence, contractual medicine encourages a kind of schizophrenia—minimalism in one way and maximalism in another. This is how William E. May puts it in The Physician’s Covenant: Images of the Healer in Medical Ethics:

The kind of minimalism that a purely contractual understanding of the professional relationship encourages produces a professional too grudging, too calculating, too lacking in spontaneity, too quickly exhausted to go the second mile with patients along the road of their distress.

Contract medicine encourages not only minimalism, it also provokes a peculiar kind of maximalism, “defensive medicine.” Under the pressure of the fear of disease and death, patients often push for the maximum in tests and procedures, and physicians often yield to (or exploit) these fears, because they fear malpractice suits. Paradoxically, contractualism temps the doctor simultaneously to do too little and too much for the patient—too little in that one extends oneself only to the limits the contract specifies, and too much in that one orders procedures that are useful in pampering the patient and protecting oneself, even though the patient’s condition does not demand them.

Covenants—like the ancient covenants between God and his people—describe a relationship between persons, not between “providers” and “clients.” One of the words the Hebrew Bible uses to describe the covenant is a relationship of “hesed” (steadfast and enduring love). This is surely different from a contract. Covenants are:

• Based on an dis-equal relationships—physicians offer clinical art and skills, including competency in science, powers of caring and healing, over against the patient’s dis-ease.
• 24/7—there is never a time when a physician is not a physician.
• Relational—grounded in an ethic of care for patients as persons, not labs to be interpreted and problems to be solved.
• Donative (gift relationship)—although physicians are remunerated, they don’t practice for the money or for or what patients can do for them, but for what they can do for patients.

Even language offers testimony of this relationship. A “patient” is a “sufferer” or “one who endures suffering.” A “customer” is “one who purchases goods or supplies.” In medieval Latin, the word referred to a toll-gatherer or tax-collector. Surely, this does not describe the relationship between patients and their physicians.

If medicine becomes just another consumer good, then the customers tell the providers what they want, and the providers either respond accordingly or are left behind in the market. The best therapy goes to those who have the most money to offer.

Resistance to the consumerist drive in medicine takes courage and sacrifice from physicians and understanding and trust from patients. Without those virtues, caring physicians will evacuate their offices, patients will turn against them, and medicine will collapse. The answer is to re-humanize the physician-patient relationship, seeing that relationship through the lens of a covenant, not a contract.

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