Social Contract Theory
This Profession Called “Nursing,” and its Rights, Privileges, and Obligations
This Profession Called “Nursing,” and its Rights, Privileges, and Obligations
Nursing’s Social Policy Statement and Nursing’s Social Contract
Nursing’s Social Policy Statement (NSPS) is a document that articulates the parameters of the relationship between the profession of nursing and society.1 It forms and frames both the basis for nursing’s involvement with caring practices and the shape of society vis-à-vis health and health policy. It is not about the nurse-patient relationship, but instead about nursing as an entity within society, and how that relationship is to be understood, developed, and lived out by the profession as a whole.
While Nursing’s Social Policy Statement is not about individual nurses, it is individual nurses who compose the profession, and thus all nurses are participants. It fundamentally roots the nursing-society relationship in social contract. Society recognizes a specific and specialized need—health—so it authorizes a group of workers to form an occupational group (called nursing) to address that need. Nursing, which has evolved from an occupational group into a profession, operates as a profession within the social contract.
Guide to Nursing’s Social Policy Statement does not move section by section through the NSPS. Instead, this guide intends to explore the foundational concepts that underlie nursing’s social contract, the central nervous system of the NSPS, so that its breadth, depth, and importance might be better understood. These concepts include social contract (Chapter 1); occupation, vocation, and profession (Chapter 2); citizenship, civic engagement, and civic professionalism (Chapter 3); and nursing’s global health involvement through cosmopolite professionalism, nursing’s social ethics, and social covenant (Chapter 4). Nursing’s Social Policy Statement is inextricably tied to both Nursing: Scope and Standards of Practice (NSSP) and Code of Ethics for Nurses with Interpretive Statements (“the Code”).2,3,4 The NSSP and the Code are two of the sixteen elements of nursing’s social contract. It is part of the task of this chapter to elucidate the ties that bind the three documents as foundational to nursing. To do so will require a brief consideration of the key findings of those philosophers who have most influenced our understanding of the social contract.
A Short History of Social Contract Theory: Understanding the Unwritten Social Arrangement It Creates
Any number of articles in medicine and nursing invoke the notion of social contract and presume an understanding of what that means. The writings then proceed with little or no substantive discussion of the origins, nature, or reciprocal obligations of a social contract. The concept of a social contract was developed in the fields of philosophy and political science, and as those discussions do not customarily make their way into nursing curricula, nursing students and nurses are left with little exposure to what a social contract is or how it functions. The general idea of a contract is that it is an enforceable agreement of mutual benefit made between two parties. Contracts may be written, as in suzerainty agreements of very ancient times between lords and vassals or vassal states, but more often today, social contracts are unwritten bilateral arrangements that contain conditions for both sides, and are subject to enforcement. Certain elements of social contracts may be written, such as the laws governing practice or the profession’s code of ethics, but the social contract itself is an unwritten understanding. These contracts are always two sided and have expectations for each party of the contract, so in that sense, a social contract is no different from a written one. More specifically, a social contract is an abstract construct that comes out of philosophy, ethics, and political theory. That is to say that a social contract is a metaphor or heuristic device that is used for analysis, reflection, and argument; there is no formal legal contract involved.
Social contract has two formal components. The first explains how it is that society comes into being, and the second explains society then produces a state (or a government) and a people (as in “we the people” of the United States Constitution) that interact for mutual benefit. The first component has profound though more theoretical or less tangible implications for nursing. It is the second component that is more relevant for the discussion of nursing’s relationship to and with society, as it delves into the discussion of what society needs from nursing and what nursing needs from society.
Theories of social contract reach back to antiquity though its strongest development occurs in the Enlightenment of the mid-1600s to mid-1700s. It threads its way through philosophy, religion, and politics. Early formulations are found in Plato’s Crito5,6 and Republic, Book II,7 and in Epicurus’s Principle Doctrines.8,9 However, modern social contract theory owes its development to Thomas Hobbes, John Locke, Jean-Jacques Rousseau, and more recently, to John Rawls, who relies in part upon Immanuel Kant, and David Gauthier, who modifies Hobbes’s theory. A very brief overview of the works of these theorists is given here, not to fully develop social contract theory, but to provide foundational information that can be used to situate nursing within the context of social contract theory. Social contract theory has also been subject to critique
both by feminist theorists and critical race theorists. We will look at these critiques because they are important as critiques, but also because they intersect with nursing’s concern for persons who are disadvantaged in society. We turn now to the theories of social contract and their successive formulations.
both by feminist theorists and critical race theorists. We will look at these critiques because they are important as critiques, but also because they intersect with nursing’s concern for persons who are disadvantaged in society. We turn now to the theories of social contract and their successive formulations.
Hobbes: Overcoming a Life That is “solitary, poore, nasty, brutish, and short”
Thomas Hobbes (1588-1679), in his work Leviathan (1651), sets forth his political theory in two parts.10 The first part argues that prior to the formation of society, individuals are in a State of Nature. In this state, persons are universally, necessarily, and exclusively self-interested, which causes them at all points to seek their own best interests. The State of Nature is a picture of rampant and exclusive self-interest wherein individuals are driven not only to satisfy their own desires and needs, but to avoid that which does not further the realization of their own desires. The State of Nature is a terrible place, as it is a state of brutality, fear, distrust, and danger, or, in Hobbes’s own words, “continuall feare, and danger of violent death; And the life of man, solitary, poore, nasty, brutish, and short.”11 It is a state of unavoidable and perpetual warfare, as one seeks one’s own best interests, even at the expense of another. But, Hobbes maintains that humans are also reasonable.
Because humans can be rational and reasonable, there is a way out by creating, with mutual agreement, a commonwealth—that is, civil society. It functions as a common-wealth because it serves the needs of all. However, for the commonwealth to function, and to keep rampant self-interest and warfare at bay, two things are necessary: enforceability of the “mutual covenants” or laws that govern a society, and a sovereign with the absolute authority to enforce the law. Hobbes argues that the only way people will fulfill their part of the covenant is through “the terror of some punishment greater than the benefit they expect by the breach of their covenant.” 12 According to Hobbes, the establishment of the commonwealth is the only way to create this motivating fear: “Where there is no coercive power erected [created], that is, where there is no Commonwealth, there is no propriety [moral conformity], all men having right to all things. …The validity of covenants begins…with the constitution of a civil power sufficient to compel men to keep them.” 13 The commonwealth
that is created is one in which “justice is the constant will of giving to every man his own.”14
that is created is one in which “justice is the constant will of giving to every man his own.”14
THINKING ABOUT THE COMMON-WEALTH…
Four states (Kentucky, Massachusetts, Pennsylvania, and Virginia) use the term commonwealth in their name, as in the Commonwealth of Virginia. The term has no actual legal meaning. Here it means both that the state was created by agreement of the people (not by the command of King George III), and that it serves the welfare and general good of all of its people. Sometimes commonwealth is written common-wealth, or even common wealth. It refers to the welfare, not the material wealth, of the people.
He argues that the sovereign (in his day, a monarch) has the absolute authority to enforce the laws generated under the social contract, and must be obeyed, even if he (rarely she) rules badly. The alternative is to return to the intolerable State of Nature, which no reasonable person would want. What one gives up by entering into the social contract is the right to do anything one desires and to seek one’s own needs or desires at the expense of others. In addition, individuals become subject to punishment if they do so. Under the social contract, lives are protected, mutual benefit is secured, social cooperation is assured, agreements are kept, and laws are enforced. So, under the social contract, the brutal freedoms of the State of Nature are lost in exchange for socially secured goods such as a life that can be lived without fear, distrust, or warfare. It is not the State of Nature that is of greatest interest to nursing, but rather the second aspect of social contract, the concepts of government, civil society, rights, and mutuality, for it is from this portion of social contract theory that the rights and responsibilities of nursing arise.
Locke: Power to the People
Most social contract theorists employ some form of a State of Nature. However, John Locke (1632-1704) develops the notion of a social contract with a substantively different view of humankind than that held by Hobbes. The core of Locke’s social contract theory is contained in his 1689 work Two Treatises on Government (the full title of which is Two Treatises on Government: In the Former, The False Principles, and Foundation of Sir Robert Filmer, and His Followers, Are Detected and Overthrown. The Latter Is an Essay Concerning The True Original, Extent, and End of Civil Government).15 Hobbes holds that in the State of Nature there is neither justice nor injustice, that the State of Nature is amoral. For Hobbes, morality and law come into being with the creation of civil society. Locke is different in that he maintains that humankind is not engaged in a moral free-for-all in the State of Nature, that there are some limits even in the State of Nature. Morality exists in the State of Nature as humankind discerns and operates under a Law of Nature. In his understanding of the State of Nature, all persons are equal and are in a state of perfect freedom, free from interference by others. The Law of Nature creates a moral limit to that perfect freedom: Individuals may not exercise their freedom to pursue their own desires and needs at the expense of that same freedom for others. As Locke says, “how should I look to have any part of my desire herein satisfied, unless my self be careful to satisfie the like desire, which is undoubtedly in other Men, being of one and the same nature?”16 So, this means that I may only satisfy my own desires insofar as I permit like desires to be satisfied by others. This
pursuit of my own desires is governed by “rules and canons,” moral rules, that I and all persons alike can know by reason.
pursuit of my own desires is governed by “rules and canons,” moral rules, that I and all persons alike can know by reason.
As the Law of Nature guides human behavior in the State of Nature, in contrast to Hobbes, this state is not amoral. For Locke, property (including one’s own body as property) and slavery are critical concepts: war ensues over issues of property or slavery, and once it begins, it is likely to continue. For Locke, “every Man has a Property in his own Person. This no Body has any Right to but himself.”17
Our bodies are our own property and no one has a right to them. For Locke, this includes slavery as the appropriation of the body or property of another; for nursing, this might potentially ground self-determination in health care as derivative of “property rights” rather than respect for autonomy.
Locke also identifies property as that which is created by the labor of one’s hands and combined with nature. The creation of private property—that is, real property (land)—and its acquisition removes it from that which is held in common. In the archaic language of Locke,
The Labour of his Body, and the Work of his Hands, we may say, are properly his. What-soever then he removes out of the State that Nature hath provided, and left it in, he hath mixed his Labour with, and joyned to it something that is his own, and thereby makes it his Property.18
In the State of Nature, there is no authority that enforces one’s property rights. The creation of civil society and government is therefore required in order to create laws that protect the life, health, liberty, and possessions of all, thereby in theory preventing war over theft of land or possessions, or enslavement.19
Locke also differs dramatically from Hobbes in how he views the relationship between society and government. For Hobbes, the sovereign is absolute ruler who must be obeyed even when he rules badly. Locke, however, sees the people as having a right, perhaps even an obligation, to overthrow the ruler or government when it becomes tyrannical or fails to serve the commonwealth. The people then have a right to put a new government in place. If Locke’s view sounds familiar—it is. It deeply influenced Thomas Jefferson and the leaders of the American Colonies in their decision to break away from the tyrannical King George III and to create a constitution that protects life, liberty, the pursuit of happiness, and property. It should also be noted that Locke viewed the land as the possession of those who worked it, that is, those who combined labor (plowing and planting) with the raw resources of nature (the soil). In his schema, one that is culturally bound to a European, agrarian understanding of
society, Native Americans never owned the land as their property because they did not till and plant it.20 It belonged, instead, to those who farmed it. This too informed the early founders of the United States and was used as a justification for taking Native American lands without recompense or permission. One can see that social disparities, which would eventually create health disparities, are present even at the very beginnings of the creation of the United States from the British Colonies.
society, Native Americans never owned the land as their property because they did not till and plant it.20 It belonged, instead, to those who farmed it. This too informed the early founders of the United States and was used as a justification for taking Native American lands without recompense or permission. One can see that social disparities, which would eventually create health disparities, are present even at the very beginnings of the creation of the United States from the British Colonies.
Rousseau: Social Contract Gone Wrong and the More Perfect Union
Jean-Jacques Rousseau (1712-1778) discusses social contract in two different ways. The first discussion lays out his description of the social contract gone wrong. This is found in his Second Discourse, also known as the Discourse on the Origin and Foundation of Inequality Among Mankind (1753).21 It was a radical and shocking critique of the ills of Western society in his day, particularly the economic disparities that created classes of the poor and the rich. He then follows this critique with a corrective, a normative or prescriptive version of the social contract, found in his treatise The Social Contract (1762).
Rousseau, too, employs the device of a State of Nature in which people are free, equal, and rational. However, Rousseau envisions them as independent, solitary persons, with simple needs, capable of meeting their own needs without relational ties. For Rousseau, it is a picture of humankind evolving into ever larger groups. As humankind evolves in this state of nature, the family develops into a “little society,”22 in which women are subordinated to patriarchy, solitariness disappears, language develops, enabling cooperation and the creation of communities, and cooperation begins, giving rise to leisure. These are all seen as good things by Rousseau.
As population increases, divisions of labor develop and people become less able to satisfy all of their own needs, becoming instead reliant upon others for the provision of specific needs. So the housewife needs the miller for flour, the farmer comes to the blacksmith for a plow, the blacksmith needs the miner
for ore, the miner needs both the beck (pick-axe maker) and the sawyer (lumber-maker); they all might need a bullard to write a letter…and so on. People grow less and less self-reliant and more interdependent upon the labor of others. The development of a concept of private property (my land, my plow, my pickaxe, etc.) follows, and with it the development of greed, competition, vanity, deceit, and a host of vices, in addition to inequality, social classes, and ultimately warfare; “…in short,” Rousseau writes, “competition and rivalry on the one hand, opposition of interests on the other, and always the hidden desire to profit at the expense of someone else. All these ills are the first effect of property and the inseparable offshoot of incipient inequality.”23 It is private property that is pivotal in making civil society and government necessary. Those who have property want government to protect their property, to advantage them, and to cement inequality. In Rousseau’s opinion, it is also private property for which “the vices that make social institutions necessary are the same ones that make their abuses inevitable.”24 This is the dysfunctional, dystopian social contract that he describes in the Second Discourse.
for ore, the miner needs both the beck (pick-axe maker) and the sawyer (lumber-maker); they all might need a bullard to write a letter…and so on. People grow less and less self-reliant and more interdependent upon the labor of others. The development of a concept of private property (my land, my plow, my pickaxe, etc.) follows, and with it the development of greed, competition, vanity, deceit, and a host of vices, in addition to inequality, social classes, and ultimately warfare; “…in short,” Rousseau writes, “competition and rivalry on the one hand, opposition of interests on the other, and always the hidden desire to profit at the expense of someone else. All these ills are the first effect of property and the inseparable offshoot of incipient inequality.”23 It is private property that is pivotal in making civil society and government necessary. Those who have property want government to protect their property, to advantage them, and to cement inequality. In Rousseau’s opinion, it is also private property for which “the vices that make social institutions necessary are the same ones that make their abuses inevitable.”24 This is the dysfunctional, dystopian social contract that he describes in the Second Discourse.
THINKING ABOUT THE STATE OF NATURE…
Is humankind intrinsically good, or intrinsically evil? This question sits underneath discussions of the State of Nature in the different social contract theories. Think back to William Golding’s famous novel Lord of the Flies, for which he was awarded the Nobel Prize in Literature. The novel contains many of the themes of State of Nature discussions in social contract theories, themes such as human nature, individual self-interest, and the common good. In Lord of the Flies, a group of preadolescent, well-educated, civilized British boys are marooned on an uninhabited, paradise-like island. The story starts out well enough as they set about establishing a form of order and governance that will help them survive and be rescued. The situation devolves disastrously into savagery before they are actually rescued. The novel is a good read, though a hard read, and useful for reflecting on social contract.
As a corrective, Rousseau envisions a different kind of social contract (sometimes called a social compact). In his normative reenvisioning of the social contract, communities come together to form a society and everyone places “his person and all his power in common under the supreme direction of the general will; and as one, we receive each member as an indivisible part of the whole.”25 One people, a people is formed to become one society, uniting individual wills to create one general will, enabling all to live together. It is the general will that decides and directs the actions of the society. For Rousseau, this act “whereby a people is a people…is the true foundation of society.”26 In becoming a (one) people, individuals give up the liberties of the State of Nature, instead, transferring their freedoms to the people as a collective body. This collective body becomes sovereign, creating a collective or general will that seeks to work for the good and benefit of all those who compose the people. So, as one people, the individual will becomes a general will that both defines and seeks the common good. The people are sovereign and through a democratic process form a government that executes the general will of the people. That general will is always to be determined through a democratic process. Ideally, in Rousseau’s democracy, each and every citizen participates in deciding the laws that will govern the people.
And yet, not everyone participates in shaping the general will. Low voter turnout in elections indicates a failure of the one people to participate in shaping the general will. In addition, it should be noted that in the 1700s, democracy in the American Colonies and early United States was somewhat less than “democratic.” While considered citizens, white women could not vote until 1920, some 144 years later. African American women still faced difficulties voting through the 1960s (particularly in the South, where state laws
essentially prohibited most from voting).27 In fact, women, those under the age of majority, white men who did not own land (real property), indentured servants, slaves, and Native Americans could not vote in colonial America. Only freemen could vote. Historically, a freeman was: (a) not a slave, (b) a member of a municipal corporation (a city or a borough) who possessed full civic rights, especially the right to vote, and (c) a freeholder (landowner).28 Until relatively recently, these were the only people allowed to decide what constituted the general will and thus the common good.
essentially prohibited most from voting).27 In fact, women, those under the age of majority, white men who did not own land (real property), indentured servants, slaves, and Native Americans could not vote in colonial America. Only freemen could vote. Historically, a freeman was: (a) not a slave, (b) a member of a municipal corporation (a city or a borough) who possessed full civic rights, especially the right to vote, and (c) a freeholder (landowner).28 Until relatively recently, these were the only people allowed to decide what constituted the general will and thus the common good.
This Lockean sense of a social contract and Rousseau’s notion of the people deeply informs the U.S. Constitution. The Preamble to the Constitution of the United States (1789) states:
We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America. 29
In only 52 words, the concepts of the one people, the common good (“general welfare”), the absence of the strife of the State of Nature (domestic tranquility), liberty and justice as part of the common good, and more, are present in the Preamble. These concepts are then expanded in the Constitution itself. While social contract is a philosophical and political concept, it finds real life expression in the way in which the United States was envisioned and conducts its life today. More importantly, as will be seen shortly in the critiques of social contract, who does or does not participate in constituting the general will, and thus determining the common good, has profound implications for the structure of the healthcare system, healthcare delivery, and health disparities.
Rawls: The Two Principle Prenuptial Agreement to the Social Contract
Social contract theory had lain fallow until John Rawls broke new soil with the publication of A Theory of Justice in 1972.30 Rawls employs Immanuel Kant’s understanding of humankind as rational beings, able to reason from a universal point of view—that is, a point of view from which all (all = universal) rational persons can argue impartially Rawls develops his own version of the State of Nature, a theoretical construct he terms the Original Position, that is characterized by a Veil of Ignorance. Under the Veil of Ignorance, I do not know who I am; I have no knowledge of my sex, age, race, socioeconomic status, education, or even what I might need or desire. Without this knowledge I am rational and disinterested (not influenced by my own self-interests) and can discover what justice requires and what is fair. Rawls maintains that everyone and anyone behind the Veil of Ignorance would choose the same rational, disinterested,
universal principles of justice, in agreement with all others arguing from the same original position. We would all choose fairly. In a sense, it is like dividing a pie. If you are slicing the pie and you don’t know which piece will be yours, you will cut the pie in even pieces. Rawls maintains that his theory is one of justice defined as fairness.31 From this original position, persons can reason to what is just and fair. Justice then helps us decide what is needed in order to live together as a society.
universal principles of justice, in agreement with all others arguing from the same original position. We would all choose fairly. In a sense, it is like dividing a pie. If you are slicing the pie and you don’t know which piece will be yours, you will cut the pie in even pieces. Rawls maintains that his theory is one of justice defined as fairness.31 From this original position, persons can reason to what is just and fair. Justice then helps us decide what is needed in order to live together as a society.
Rawls describes the two principles of justice that would arise universally from the original position behind the Veil of Ignorance:
The first requires equality in the assignment of basic rights and duties, while the second holds that social and economic inequalities, for example inequalities of wealth and authority, are just only if they result in compensating benefits for everyone, and in particular for the least advantaged members of society.32
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