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The Review

An A–Z of medical philosophy

David Misselbrook
British Journal of General Practice 2013; 63 (608): 146. DOI: https://doi.org/10.3399/bjgp13X664306
David Misselbrook
Dean Emeritus of the Royal Society of Medicine, Course Director of the Diploma of the Philosophy of Medicine of the Society of Apothecaries and BJGP Senior Ethics Advisor
Roles: GP
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Contractarianism

Imagine that you were living through a horrific civil war. Your previously stable society is being torn apart. Your traditional thoughts about morality, about obeying the authorities (which ones?), about working peacefully for the good of all, these are suddenly pulled from under your feet. In horror you stand back and think: how can I tell what is right? Is there any reality to morals or are they just a veneer of social convention?

This was the challenge facing Thomas Hobbes (1588–1679) as he observed the nation’s slide into the disastrous English civil war of 1642–1651. Hobbes’ great work Leviathan (1651) imagines the state of our life if there were never to be any stable society, any ruling authority. He states: ‘In such condition, there is no place for industry; because the fruit thereof is uncertain: and consequently no culture of the earth; … no arts; no letters; no society; and which is worst of all, continual fear, and danger of violent death; and the life of man, solitary, poor, nasty, brutish, and short.’

Hobbes concludes that morality is a human invention in order to avoid this condition, and that rather than tracking any ultimate ‘rights’ or ‘wrongs’ morality simply describes an implicit social contract that includes us all. The contract is implicit: we do not have to sign up to it. Its existence may never have occurred to us. Nonetheless by living in a particular society we are part of it. This forms the basis for our social mores and indeed our whole way of life.

To Hobbes all authority systems such as kings and parliaments and laws are simply embodiments of this social contract. Their authority derives from their universal benefit. Contractarianism sees right and wrong simply an issue of mutual convenience. Thus, it is well suited to a physicalist view of the universe. It invites easy synthesis with evolutionary theory and studies of primate behaviour.

It leaves us with the problem of ‘the knave’ in society: why should a rascal not freeload on the good behaviour of others (so long as he can get away with it), if there is ultimately no right and wrong? How can we condemn Bernard Madoff (or come to that Pol Pot) if it is a matter of opinion as to how the contract should actually work?

It also becomes less convincing when we are the victims of what we perceive to be a serious injustice. Is the parent of a murdered child really to believe that they are the victims of an error of social manners rather than of a moral wrong? Clearly an implicit social contract exists in the human world. However, this does not have to mean that it lacks an underlying moral imperative. A civil war does indeed show us the horror of a failed society, but this does not mean that our belief in right and wrong as real categories in the human world must fail also.

CPD further study and reflective notes

The notes in Boxes 1 and 2 will help you to read and reflect further on any of the brief articles in this series. If this learning relates to your professional development then you should put it in your annual PDP and claim self-certified CPD points within the RCGP guidelines set out at http://bit.ly/UT5Z3V.

Box 1. Reflective notes

  • To what extent is your work as a GP governed by your contract with the PCT/CCG, and to what extent is it determined by broader societal expectations? (In other words, is there an implicit social contract in general practice that goes beyond our written contract?)

  • To what extent are we motivated by external societal expectations and to what extent by our own personal internal motivations?

  • General practice has plenty of opportunities for ‘gaming’; technically staying within the rules but failing to act for the benefit of the patient. What arguments would you use to oppose or to justify this to a visitor from Mars?

Box 2. Further reading

Primary source

Hobbes T. Leviathan. 1651. Many current reprints available.

Suggested reading, Part 1, chapters 13, 14, and 15. (About 20 pages).

Further study

Stanford Encyclopedia of Philosophy.

Contractarianism. http://plato.stanford.edu/entries/consequentialism/ (accessed 24 Jan 2013).

If your reading and reflection is occasional and opportunistic, claims in this one area should not exceed 10 CPD credits per year. However if you decide to use this material to develop your understanding of medical philosophy and ethics as a significant part of a PDP, say over 2 years, then a larger number of credits can be claimed so long as there is evidence of balance over a 5-year cycle. These credits should demonstrate the impact of your reflection on your practice (for example, by way of case studies or other evidence), and must be validated by your appraiser.

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British Journal of General Practice: 63 (608)
British Journal of General Practice
Vol. 63, Issue 608
March 2013
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An A–Z of medical philosophy
David Misselbrook
British Journal of General Practice 2013; 63 (608): 146. DOI: 10.3399/bjgp13X664306

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An A–Z of medical philosophy
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British Journal of General Practice 2013; 63 (608): 146. DOI: 10.3399/bjgp13X664306
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