Dedication • Guide to Nursing's Social Policy Statement • iii
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Chapter 1. Social Contract Theory • Guide to Nursing's Social Policy Statement • 1
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 prac-
tices 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 partici-
pants. 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 con-
cepts 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 pro-
fessionalism, 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.
Chapter 1.
Social Contract Theory
This Profession Called “Nursing,”
anditsRights, Privileges, and Obligations
2 • Guide to Nursing's Social Policy Statement • Chapter 1. Social Contract Theory
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 Crito
5
,
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 foun-
dational information that can be used to situate nursing within the context of
social contract theory. Social contract theory has also been subject to critique
Chapter 1. Social Contract Theory • Guide to Nursing's Social Policy Statement • 3
both by feminist theorists and critical race theorists. We will look at these cri-
tiques 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 univer-
sally, 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 ram-
pant and exclusive self-interest wherein individuals are driven not only to sat-
isfy 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, “con-
tinuall 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 func-
tions 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
T -…
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.
4 • Guide to Nursing's Social Policy Statement • Chapter 1. Social Contract Theory
that is created is one in which “justice is the constant will of giving to every
man his own.”
14
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 sub-
stantively 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 per-
fect 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
Chapter 1. Social Contract Theory • Guide to Nursing's Social Policy Statement • 5
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 con-
trast 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 relation-
ship 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 pur-
suit 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
6 • Guide to Nursing's Social Policy Statement • Chapter 1. Social Contract Theory
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 fol-
lows 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 with-
out 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, solitari-
ness 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
T S N…
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 disas-
trously into savagery before they are actually rescued. The novel is a good read, though a hard
read, and useful for reflecting on social contract.
Chapter 1. Social Contract Theory • Guide to Nursing's Social Policy Statement • 7
for ore, the miner needs both the beck (pick-axe maker) and the sawyer (lum-
ber-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 nec-
essary. 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.
As a corrective, Rousseau envisions a different kind of social contract (some-
times 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 col-
lective 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 shap-
ing the general will. In addition, it should be noted that in the 1700s, democ-
racy 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 diffi-
culties voting through the 1960s (particularly in the South, where state laws
8 • Guide to Nursing's Social Policy Statement • Chapter 1. Social Contract Theory
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 ser-
vants, 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 (“gen-
eral welfare”), the absence of the strife of the State of Nature (domestic tran-
quility), 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 character-
ized 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,
Chapter 1. Social Contract Theory • Guide to Nursing's Social Policy Statement • 9
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
The first principle accords individuals maximum liberty compatible with like
liberty for all.
33
We saw this similarly in Locke: maximum freedom compatible
with like freedom for all. The second principle permits social and economic
inequalities only if such inequalities also serve to better the situation of the
least well off in society.
34
This is Rawls’s difference principle.
35
Choosing in this
way would mean that if, when the Veil of Ignorance lifts, I find myself among
the least advantaged in society, even despite difference (inequality), my lot is
still improved. His argument is not specifically about wealth, and not about
a redistribution of wealth, though it is, in part, about sharing in wealth. For
Rawls, there are primary social goods to which all are entitled, such as liberty,
opportunity, justice, and so forth. The maximization of these goods is just
and should be promoted. Rawls is concerned, in part, that the circumstances
into which one is born are random and that some win and some lose in the
birth lottery. Circumstances will dictate, for example, whether one is born to
a wealthy, aristocratic family, or to a sharecropper family—think, feudal lord
T …
There is an old saying about being “born with a silver spoon in his mouth.” References to silver
spoons appear in the songs of the Gershwins though Creedence Clearwater Revival and the
Beatles to Lily Allen. What these silver spoons have in common is a reference to persons who
are born into inherited wealth, privilege, and a life of ease. Their starting point in life lacks the
struggle that others acquire by virtue of their own perhaps plastic spoon starting point that
these musicians sing about. John Rawls’ theory is concerned about the lack of fairness of social
starting points, the social position to which one is born. Rawls tries to soften the blow to persons
born to disadvantaged positions by insisting that the least well off in society ought not suffer
in circumstances where the rich get richer. He does not oppose the rich getting richer but insists
that if the rich get richer, justice as fairness demands that the poor must become better off too.
10 • Guide to Nursing's Social Policy Statement • Chapter 1. Social Contract Theory
versus serf. In addition, some will be born who can run faster and jump higher,
sing better, write better, or think more abstractly—think Kobe Bryant or Albert
Einstein. The natural lottery determines not only the circumstances into which
one is born but also the abilities that one is born with—randomly and arbi-
trarily. For Rawls, these natural assets and endowments are to be used in such
a way that they benefit all. So those with better social circumstances or with
stronger natural abilities may use their natural assets to improve their own lot,
so long as in doing so it contributes to the good of the less well off in society.
As Rawls states, “those who have been favored by nature, whoever they are,
may gain from their good fortune only on terms that improve the situation of
those who have lost out.”
36
Rawls’s highly abstract theory of justice addresses the conditions that must
exist prior to establishing a social contract, for only these conditions will in
the end make for a social contract that is just and fair. These conditions would
prevent the creation of Rousseau’s first description of the social contract gone
wrong by placing limits on political and social organization that are necessary
to create a just society. Rawls’s concept of justice as fairness, as well as Kant’s
perspective on autonomy as rational self-legislation, receive considerable atten-
tion in the bioethics literature as well as the nursing ethics literature, specifically
in considerations of respect for patient autonomy (patient self-determination),
access to health care, and the structure of healthcare systems.
Feminists, Critical Race Theorists, and Social Outliers: In-Groups and Out-Groups
The focus of this chapter is on the rights, privileges and obligations of nursing
that are generated by its social contract rather than on critiquing social con-
tract. Even so, it would be unwise to bypass some of the substantive critique
that has been lodged against it, particularly because it has implications for
those who are socially disadvantaged, and ultimately affects ways in which one
may think about health disparities.
Social contract theory has not escaped critique by feminist and critical race
theorists or those who work in the domain of intersectionality. Critical theories,
as a category, engage in social criticism to the end of social change. They go
beyond being descriptive or explanatory to actually seeking change. Critical
race theory, a subtype of critical theory, specifically examines society at the
intersections of race, law, culture, and power. Intersectionality is often used
by critical theorists to examine the interconnections of socially constructed
categories (such as race, ethnicity, class, gender) and socially constructed prej-
udices (such as racism, sexism, ageism, homophobia, handicapism, xenopho-
bia, classism, and the like) and how they create social-structural systems of
oppression, domination, discrimination, and disadvantage. That is, they look at
how social constructs intersect and are used to create or perpetuate structural
injustices.
37,38
Chapter 1. Social Contract Theory • Guide to Nursing's Social Policy Statement • 11
Feminist theorists have provided a range of potent critiques of the contract
theories of Hobbes, Locke, Rousseau, and Rawls, and of Kant and others as
well. Carole Pateman,
39
Eva Kittay,
40
Annette Baier,
41
Jean Hampton,
42
Jean
Elshtain,
43
Virginia Held,
44
Joan Tronto, and Susan Okin
45
are prominent
among the many feminist theorists who have critiqued social contract the-
ory.
46
Their critiques have been of sufficient substance that they are now taken
into account by contemporary “contractarians” (whose roots are in Hobbes)
and “contractualists” (whose roots are in Rousseau), both of whom advocate
contract theory. While there are several somewhat differing critiques, they do
intersect, working together to provide a holistic critique.
Pateman is a leading critic of social contract theory. Her critique is extensive,
nuanced, and complex. For our purposes here the thrust of her argument is
that “the classic theorists had left a legacy of problems about women’s incor-
poration into, and obligation within, civil society that contemporary arguments
failed to acknowledge.” She argues that “the social contract presupposed the
sexual contract, and that civil freedom presupposed patriarchal right.”
47
Her
essential point is that “contract is seen as the paradigm of free agreement. But
women are not born free; women have no natural freedom. …Sexual differ-
ence is political difference; sexual difference is the difference between freedom
and subordination.”
48
The first part of her argument is that the original contract was made by men
and constructed in such a way as to privilege men and to grant men freedom.
It was at the same time a contract that brought women under the domination
of men as a contractual norm that reflected the social norms of the day. She
proceeds to discuss a variety of ways in which women are made unequal and
denied voice by the social contract:
The original pact is a sexual as well as a social contract: it is sexual
in the sense of patriarchal—that is, the contract establishes men’s
political right over women—and also sexual in the sense of estab-
lishing an orderly access by men to women’s bodies [through the
T …
Critical theories, as a family of theories, engage in a reflective assessment and critique of society
and culture. The tools of critical theories are composed of a wide range of both social sciences and
humanities. A theory is a critical theory to the extent that it seeks “emancipation from slavery,”
acts as a “liberating…influence,” and “is not just a research hypothesis which shows its value in
the ongoing business of men; it is an essential element in the historical effort to create a world
which satisfies the needs and powers of human beings.”
71
Critical theory is not simply analysis and
critique. It is also possessed of a reformist bias, often with a social justice concern at its heart.
Critical theory, whether feminist-, race- or abilities-focused (see also pg. 94), has an agenda:
the critique of society and culture in order to change the world to move it toward meeting the
needs of
all
humankind.
12 • Guide to Nursing's Social Policy Statement • Chapter 1. Social Contract Theory
marriage contract]. …Contract is far from being opposed to patriar-
chy; contract is the means through which patriarchy is constituted.
49
Thus women are denied freedom from the start of the social contract. But
she goes further:
Patriarchal civil society is divided into two spheres, but attention
is directed to one sphere only. The story of the social contract is
treated as an account of the creation of the public sphere of civil
freedom. The other, private, sphere is not seen as politically relevant.
Marriage and the marriage contract are, therefore, also deemed
politically irrelevant.
50
She and other feminists note that social contract consigns women and wom-
en’s work—caring—to the private sphere, the sphere of “dependency care”
51
or “intimate labor” that is hidden from view and poorly compensated or not
compensated at all.
52
Tronto observes that women in the 18th century sought
new public roles that “had to be contained and were contained by arguing that
women naturally belonged within the household. Another side of this picture
is also important: the locating of moral sentiments within the household.”
53
She asserts that women’s desire to act in the social sphere, coupled with their
capacity to reason, could not be contained and so threatened the status quo.
By framing a social construct of differing spheres and types of activity for men
and women, women were able to be contained: “Women were creatures of
sentiment, best exercising their virtue in the context of the household. …As
women became increasingly identified with feeling, men were increasingly left
free to be identified with reason. It was a small leap, then, for Kant to exclude
women and to ensconce men within the possibility of fully and true moral
life.”
54
From here it easy to imagine where this went in terms of the place of
nurses and nursing in society.
Women are subordinated in the original male-constructed social contract,
relegated to the hidden sphere in society, and their labors are devalued. In
addition, as the purveyors of care and caring work, women fall outside of
the rationalistic Kantian configurations of the moral life. For Kant, autonomy
consists in rational self-legislation. Women, socially identified with sentiment,
not reason, did not fulfill the Eurocentric “perspective of masculinity” that
philosophers of the 18th and 19th centuries were promulgating. Christine
DiStephano, in her 1991 book Configurations of Masculinity, demonstrates
that a number of important modern moral philosophers developed their theo-
ries with a normative understanding of “mankind” that contained a normative
understanding of masculinity.
Chapter 1. Social Contract Theory • Guide to Nursing's Social Policy Statement • 13
Taking a somewhat different approach, Tronto, Held, Baier and other femi-
nist theorists working in “care ethics” maintain that the disinterested, dispas-
sionate, disembodied, universal person of Rawls, Kant, and others does not
provide an adequate account of our moral, social or political obligations and
that the State of Nature of contract theories does not give an adequate account
of humanity. For example, for Hobbes, persons in the state of nature are radi-
cally individual without affiliative–affectional ties, and driven by fear. Even as
a logical and fictional construct, it is an inadequate view that leaves out affec-
tional bonds, caring for one another, dependency, and more. Held maintains
that “various philosophers claim that even morality itself is best understood in
contractual terms” but that
As expressions of normative concern…contractual theories hold out
an impoverished view of human aspiration. To see contractual rela-
tions between self-interested or mutually disinterested individuals as
constitution the paradigm of human relations is to take a certain his-
torically specific conception…as representative of humanity. And it
is, many feminists are beginning to agree, to overlook or to discount
in very fundamental ways the experience of women.
55
While social contract does not specify a system of ethics or duties, it none-
theless contains normative elements that impinge upon prevailing theories of
ethics and their relationship to nursing, as well as the way that nursing con-
ceives its moral concepts, values, ideals and obligations. For example, nursing
ethics necessitates a view of the person—one that is not adequately explained
by the social contract theories. That is, a central moral claim of nursing is that
the patient is a person of worth and dignity, deserving of care and compassion,
T …
Social concern for the ways in which society’s social structures advantage some and disadvan-
tage others is a matter of dawning awareness. In the 1800s, issues of the position of African-
Americans and women surfaced—and persist. Society did not, then, have an awareness of the
ways in which older adults, persons with disabilities, some immigrants were disadvantaged by
the status quo. That awareness would not dawn until some decades later. The critique of social
contract theory is that it either omits some minority groups from the contract or it fixes some
groups in a subordinate position within the social contract. Pateman, Kittay, Baier, Hampton,
Elshtain, Held, Tronto, Okin and others (see that discussion starting on page 11) have all cri-
tiqued social contract theory for its subordination of women within the contract. Mills extends
the feminist critique to include the ways in which the social contract disadvantages racial minori-
ties. Silvers and Francis extend the critique even farther to explore ways in which social contract
disadvantages persons with disabilities, “outliers in society.” Women, racial and ethnic minorities,
persons with disabilities—these are social minorities. They are not necessarily numeric minorities;
however social minorities they are differentiated, defined, and in both covert and overt ways,
disadvantaged by the social contract. Perhaps one day the light of awareness will next dawn for
the nation’s largest minority: minors.
14 • Guide to Nursing's Social Policy Statement • Chapter 1. Social Contract Theory
without regard for personal attributes or socioeconomic status. The social
contract theories look to avoid strife, protect property, etc., and contain a
descriptive and restricted view of human desires or interactions, but not a full
descriptive view of persons per se. That is, they only describe one aspect of
the person (e.g., self-interest, fear, envy, etc.) and do not give a full account of
humanity individually or collectively. Tronto’s work is of particular note in that
it attempts to make a political argument for an ethic of care, in effect to modify
if not radically change the boundaries between politics, morality, and caring
practices, in effect to change the social contract.
56
Charles Mills, inspired by Carole Pateman’s Sexual Contract, extends a similar
critique based on race, that he terms the Racial Contract:
But the peculiar contract to which I am referring, though based on
the social contract tradition that has been central to Western polit-
ical theory, is not a contract between everybody (“we the people”),
but between just the people who count, the people who really are
people (“we the white people”). So it is a Racial Contract.
57
As feminist theorists note the exclusion of women from the social contract
(though some beginning changes in that contract have been acknowledged),
so too, Mills notes the exclusion of a number of people groups and issues from
the social contract:
The “Racial Contract,” then, is intended as a conceptual bridge
between two areas now largely segregated from each other: on the
one hand, the world of mainstream (i.e., white) ethics and political
philosophy, preoccupied with discussions of justice and rights in the
abstract, on the other hand, the world of Native American, African
American, and Third and Fourth World political thought, histori-
cally focused on issues of conquest, imperialism, colonialism, white
settlement, land rights, race and racism, slavery, jim crow, repara-
tions, apartheid, cultural authenticity, national identity, indigenismo,
Afrocentrism, etc. These issues hardly appear in mainstream political
philosophy, but they have been central to the political struggles of
the majority of the world’s population. Their absence from what is
considered serious philosophy is a reflection not of their lack of seri-
ousness but of the color of the vast majority of Western academic
philosophers.
58
Using Pateman and Mills as a foundation, Silvers and Francis posit that per-
sons with disabilities also become outliers in social contract theory:
Chapter 1. Social Contract Theory • Guide to Nursing's Social Policy Statement • 15
Commentators concerned about justice for women and racial
minorities have argued that social contract theory is inherently
flawed. Far from offering a firm foundation on which to build com-
prehensive concurrence about justice, these critics contend, the con-
tract model enables mutual agreement only within the boundaries
of an “in-group/out-group” frame. Pateman, for example, has argued
that the contract model reaches only a restrictive mutuality that
privileges men and denies recognition to women. Mills has similarly
claimed that contract theory positions African Americans at a disad-
vantage where justice is concerned. These authors contend that the
social contract model places “outliers,” either individually or collec-
tively, in “out-groups” beyond the reach of equal justice. More recent
versions of the “outlier problem” charge that social contract theory
stands between people with disabilities and justice.
59
Kittay, Jennings, and Wasunna emphasize the failure of social contract theory
to take account of dependency. Their particular concern is for long-term care,
especially long-term care of frail elderly persons; they question the adequacy
of social contract to support dependency care in general and the needs of the
frail elderly specifically:
As a result of feminist scholarship, we have come to understand that
the invisibility of human dependency and dependency care is in part
a product of a private–public distinction that places a premium on
the public and relegates issues of dependency to the private domain.
But we can ask if the private/public distinction is itself a product of
our deep denial of the inevitability of human dependency. Within
the theoretical literature and political life of the Western industri-
alized nations, at least, we are captives of the myth of the indepen-
dent, unembodied subject—not born, not developing, not ill, not
disabled and never growing old—that dominates our thinking about
matters of justice and questions of policy.
60
T ...
The world’s most perfect, amazing, and useful mobile phone with the world’s most perfect,
amazing, and useful apps is of little use to real people if the engineers do not take into account
the fact that humans drop things, that winters are cold, summers are hot, and children throw
things down the toilet. The most perfect electronics have to be able to withstand the use and
abuse of real humans in a real environment. Their development for humans cannot ignore human
reality. Intersectionality and intersectional theories try to take account of real humans and
human reality by looking at factors that intersect and influence one another—like race, class and
gender. Any study of social contract and nursing must consider real nurses and the real world of
nursing–particularly its intersections with gender, culture, and power.
16 • Guide to Nursing's Social Policy Statement • Chapter 1. Social Contract Theory
Thus, the discourse continues from successive formulations and reformula-
tions of social contract theory to its critique by feminists, critical race theorists,
and intersectionalists concerned about persons with disabilities or the frail
elderly—and nurses. What begins as an abstraction, a fiction with no direct
application, in the end has implications for the real-life professional concerns
of nurses.
Social Contract and Health Care: Medicine Is Not Nursing
A social contract applies to the whole of society and its members. However,
there seem to be levels of social contract. As examples of the appropriation of
social contract to a global health setting, Kittay, Jennings and Wasunna, as
noted above, address long-term care of the frail elderly as a global contractual
issue, and Ooms and colleagues, write about “a global social contract to reduce
maternal mortality.”
61
In general social contract is applied to one nation and its
people. And yet, as we note in Pateman and Mills, there is a range of large,
unwritten social contracts for segments of society, including the marriage con-
tract, the sexual contract, the racial contract—and somewhat more circum-
scribed social contracts contract between society and professions. In the realm
of economics and finance, Donaldson and Dunfee make a distinction between
macro- and microcontracts, but the microcontracts refer to smaller economic
communities, not to professions.
62
There is no clear discussion of the move-
ment from a social contract with the whole of society to these smaller contracts
with specific groups within society in the healthcare literature. Despite the lack
of theoretical justification in the literature for that development, both medicine
and nursing have long laid claim to a social contract with society.
Medicine in the United States began to form as a modern profession earlier
than nursing. Until such time as a guild is formed, an occupational group cannot
speak of a social contract. For medicine, this occurred in the mid-1800s; mod-
ern nursing in the United States began to coalesce as an occupational group
in the later 1800s and more especially after the formation of the American
Nurses Association (ANA) in 1900 and the establishment of its offices in the
1920s. There is, in the first code of ethics of the American Medical Association
(AMA), founded in 1847, an implicit understanding that a social contract exists
T …
Both medicine and nursing talk about having a social contract; meaning a contract with society.
Social contract
is a also metaphor for a general social arrangement. Social contract does not have
provisions; it is not specific in the sense of, say, sales or rentals or service contracts. However, like
any everyday contract, there are two parties involved (nursing and society) and both parties have
to do something to meet their contractual obligations. Here, society contracts with “nursing” to
provide health care, and nursing contracts with society to set its own standards of practice and
education.
Chapter 1. Social Contract Theory • Guide to Nursing's Social Policy Statement • 17
between medicine and society. Chapter III, article 1, section 1 of the AMA
Code of Medical Ethics (1847) states:
As good citizens, it is the duty of physicians to be ever vigilant for the
welfare of the community, and to bear their part in sustaining its insti-
tutions and burdens: they should also be ever ready to give counsel to
the public in relation to matters especially appertaining to their profes-
sion, as on subjects of medical police, public hygiene, and legal medi-
cine. It is their province to enlighten the public in regard to quarantine
regulations,-the location, arrangement, and dietaries of hospitals,
asylums, schools, prisons, and similar institutions, - in relation to the
medical police of towns, as drainage, ventilation, &c., - and in regard
to measures for the prevention of epidemic and contagious diseases;
and when pestilence prevails, it is their duty to face the danger, and to
continue their labours for the alleviation of the suffering, even at the
jeopardy of their own lives.
63
This section of the 1847 Code of Medical Ethics indicates the physician’s
wider responsibilities beyond those owed to an individual patient. Other ele-
ments commonly associated with a social contract are found elsewhere in
that AMA Code of Medical Ethics. However, medicine, elsewhere, has explicitly
adopted social contract as the model of physician–society relationship. Wynia
asserts that social contract had a particular appeal to American medicine:
It was the American medical profession that, in the mid-19th cen-
tury, created the first national set of ethical and practice standards.
Eventually, similar standards were almost universally accepted,
thereby creating the modern concept of the medical profession.
American physicians were primed for the task of creating a full-
fledged profession for several reasons. Perhaps most important was
the Americans’ attraction to the notion of a social contract—a notion
conceived by French, English, and Scottish Enlightenment thinkers,
but implemented most fully in the young American republic, created
by rebels against inegalitarian classism. In the United States, people
were to relate as equals. Social relations were to be built upon more-
or-less explicit contracts between willing parties, not such nebulous
notions as noblesse oblige or gentlemanly honor. This way of thinking
led to the desire to specify the terms of social relations. In medicine,
this specification would take the form of a written code of ethics.
64
Cruess and Cruess, who have written extensively on social contract in medi-
cine, have identified three sets of expectations based on “three interlocking soci-
etal components…patients and patient groups as well as the ‘public’…health-care
18 • Guide to Nursing's Social Policy Statement • Chapter 1. Social Contract Theory
managers, the state, government…departments…and the…medical profession
and ‘professional bodies.’”
65
They develop a list of societal expectations of med-
icine as well as medicine’s expectations of society, deriving the list from their
definition of a profession. Government’s expectations of medicine are:
• Assured competence of physicians
• Morality, integrity, honesty
• Compliance with healthcare system—laws and regulations
• Accountability: performance, productivity, cost-effectiveness
• Transparency in decision-making and administration
• Participation in team health care
• Source of objective advice
• Promotion of the public good
Medicine’s expectations of government are:
• Trust sufficient to meet patient’s needs
• Autonomy sufficient to exercise judgment and self-regulation
• Healthcare system: value-laden, equitable, adequately funded and
staffed, reasonable freedom within system
• Role in developing health policy
• Monopoly through licensing laws
• Rewards: nonfinancial (respect, status), financial
66
T -…
One attribute of professions is that they are self-policing to ensure that those who avail them-
selves of the professional’s service will are getting competent service and will not be harmed.
Self-policing, however, has been failing abysmally. The bioethical emphases on respect for patient
self-determination, informed consent, and patient voluntariness arose as a response to the Nazi
medical atrocities of World War II. These were brought to light in 1947, at the trial of 27 Nazi phy-
sicians (Annas and Grodin, 1992). Horrific, radically evil, and often lethal experiments were con-
ducted on non-consenting human prisoners. Nurses participated in the conduct of unconscionable
medical experimentation on unwilling prisoners, and were complicit in the medical killings in Nazi
Germany (Froth, 2013a; 2013b). In 1966, Henry Beecher published his landmark paper on ethics in
human research in the United States (Beecher, 1966). He identifies twenty-two medical research
projects that were conducted from prestigious universities and published in respected medical
journals, that were deeply, even frighteningly, ethically questionable. Nurses were directly and
indirectly involved in a number of these experiments as well. Self-policing remains an ideal.
Chapter 1. Social Contract Theory • Guide to Nursing's Social Policy Statement • 19
As would be true of nursing as well, the terms of these expectations are
articulated in the profession’s code of ethics and practice/education standards.
Social contract, a profession’s ethics, and its standards of education and practice
are interrelated but far from coextensive.
Nursing too employs the device of a social contract to explicate its rela-
tionship with society, including the expectations of nursing by society and
those that nursing has for society. A set of reciprocal expectations for nursing
and society can be drawn from Nursing’s Social Policy Statement, the Code
of Ethics for Nurses with Interpretive Statements, the definition of nursing, the
metaparadigm concepts of nursing, and the nursing literature on nursing as a
profession, ethics, and caring. Medicine and nursing differ in a wide range of
professional, philosophical, ethical, social, and political respects, yet, because
they both interact with health and illness (and each other), there is both overlap
and difference between the lists. The difficulty of extrapolating expectations
from a definition of profession, as Cruess and Cruess have done, is that such
definitions have been critiqued as being descriptive, rather than normative, in
which case the list that is generated is tautological. We shall look at the con-
cept of profession in the next chapter, but for now we turn to the reciprocating
expectations between society and nursing.
The 16 Elements of the Social Contract: Reciprocal
Expectations Between Nursing and Society
Nursing’s social contract can be expressed in terms of 16 elements of recipro-
cal expectations: nine compose professional societal expectations of nursing,
seven nursing’s of society. Together, these elements constitute the social con-
tract between nursing and society.
Society’s Expectations of Nursing within the Social Contract
Within the social contract, society has expectations or for the obligations that
nursing must meet as a profession. Much of society’s faith in nursing rests upon
its perceived and real faithfulness in meeting these obligations. Insofar as nurs-
ing meets these expectations, social trust is built. Were nursing to fail to meet
these expectations, society would have several avenues of action to pursue,
such as rescinding some of nursing’s privileges, increasing the regulation and
oversight of the profession, or taking control of portions of professional activity
previously under the autonomous control of the profession. Nursing, however,
gives evidence both of meeting these expectations and of a high level of social
trust: “For the past 13 years, the public has voted nurses as the most honest
and ethical profession in America in the Gallup poll. This year [12/2014], 80
percent of Americans rated nurses’ honesty and ethical standards as ‘very high’
or ‘high,’ 15 percentage points above any other profession.”
67
20 • Guide to Nursing's Social Policy Statement • Chapter 1. Social Contract Theory
That trust has been hard won. While it relies upon the belief that nurses
are honest and uphold ethical standards, that reliance is meaningless unless
the public also believes that nurses know what they are doing and that they
exercise competence and skill. Honesty, ethical standards, and competence are
a part of the societal expectations of nursing. More specifically, those expecta-
tions include the following general expectations.
1. Caring Service: That nursing care will be given with compassion and will
preserve the dignity and recognize the worth of patients without prejudice.
From this flows an expectation of patient participation in care decisions
and self-determination. Caring will extend to all who need nursing, for the
“protection, promotion, and optimization of health and abilities, prevention
of illness and injury, alleviation of suffering through the diagnosis and
treatment of human response, and advocacy in the care of individuals,
families, communities, and populations.”
68
2. Primacy of the Patient: That the patient’s needs and interests supersede
those of the institution or the nurse. Conflicts of interest are to be resolved
in favor of the patient. The trustworthiness of the nursing profession and
its individual members rests upon the primacy of the patient’s care, needs,
and interests. Professional organizations may seek to benefit nurses but
are expected to hold societal and nursing, or patient and nurse, interests
in balance: nursing may not gain at the expense of the patient or society.
3. Knowledge, Skill, and Competence: That the profession will ensure the
knowledge, skill, and competence of those newly entering practice and
those in practice, at every level and in every role. This requires that the
profession establish standards for education and practice, oversee educa-
tion through accreditation, and address error, incompetence, unethical,
unprofessional, or impaired practice.
4. Hazardous Service: That members of the profession will provide nurs-
ing care under conditions not customarily expected of those outside the
profession. This includes exposure to pathogens, contagion, infectious and
communicable disease, perseverance under difficult conditions such as
weather emergencies and powergrid failures, and caring for patients who
are combative or violent.
5. Responsibility and Accountability: That nursing and nurses will be
accountable and responsible for practice, transparent when lapses occur,
engage in self-regulation and peer-review, and establish and oversee pol-
icies for the profession.
Chapter 1. Social Contract Theory • Guide to Nursing's Social Policy Statement • 21
6. Progress and Development: That the profession will incorporate knowl-
edge development from the humanities and scientific advances; expand the
knowledge base of the profession through theory development, research,
scholarship, and innovation; and contribute to the larger sphere of scien-
tific knowledge beyond nursing.
7. Ethical Practice: That the profession will promulgate, affirm, and uphold
a code of ethics, to which individual nurses are expected to adhere. That
code of ethics will set forth the moral obligations, values, virtues, and ide-
als of the profession that inform and guide and are incumbent upon the
nurse and nursing organizations.
8. Collaboration: That nursing will contribute its distinctive perspective and
voice to the wider healthcare conversation, collaborating with other health
professions and disciplines to address the health needs of society.
9. Promotion of the Health of the Public: It is expected that nurses will
address the problems faced by individual patients including issues of
health disparities and that nursing will be involved with and lead in
health-related issues important to society. In some instances nursing will
be in the vanguard of emerging health-related issues. Nursing will partic-
ipate in the promulgation of healthcare policy at regional, state, national,
and global levels. Protection of the public through advocacy also includes
whistleblowing.
Nursing’s Expectations of Society within the Social Contract
Contracts are agreements between two parties, thus there are reciprocal obli-
gations or expectations. Just as society has expectations of nursing within the
social contract, nursing has expectations of society within that same social
contract. Those expectations include the following.
10. Autonomy of Practice: That society will authorize nursing to practice
within its scope and standards in identifying and addressing the health
needs of the patient, whether individual, family, community, or the nation.
This also includes the autonomy to educate its practitioners. Social trust is
an aspect of autonomy of practice; nursing expects social trust.
11. Self-governance: That society will extend the authority to professional
self-regulation of practice in accord with state nurse practice acts (NPAs).
This includes setting the nursing profession’s priorities for the health of
the nation; establishing scope, standards, and certification processes; inter-
acting with international health-related bodies; and accrediting nursing
schools and programs.
22 • Guide to Nursing's Social Policy Statement • Chapter 1. Social Contract Theory
12. Title and Practice Protection: That society will promulgate law that gov-
erns nursing including maintaining and administering licensing examina-
tions, and granting licensure that is mandatory, not permissive. Society will
also protect the title “Registered Nurse,” and prevent encroachment upon
nursing practice.
13. Respect and Just Remuneration: That society will accord the nursing
profession respect, support for the profession in research and education
funding, and a voice at the table. Society will support claims to a just wage
and humane work conditions for nurses.
14. Freedom to Practice: That nurses will have the authority and freedom
to practice nursing to the full extent of their education and preparation,
including expanded roles and innovative venues, consistent with state
NPAs. That restraints upon nursing that restrict its legitimate practice will
be removed.
15. Workforce Sustainability: That society will develop, implement, and
support a strategic plan to address workforce shortages, workforce sustain-
ability, and workforce capacity. This includes expanding access to nursing
education and creating structures for upward educational mobility.
16. Protection in Hazardous Service: That society will provide legislative
and other means to require organizations to minimize risk to nurses in the
face of hazardous service. Nurses are expected to engage in service that
carries risks to health above what is expected of the general public.
These 16 elements together constitute the social contract between nursing
and society. These categories have some overlap, and could be reconfigured
and titled differently, but this nonetheless remains the content of the social
contract. An extended discussion of the social contract itself would necessitate
taking each of these 16 elements and expanding them. We will not pause to do
that here, but instead will continue to explore the essential conceptual build-
ing blocks that lay the foundation for understanding the relationship between
nursing and society.
Nursing’s Social Policy Statement turns its attention to a number of these
elements of the social contract. First, it identifies the functions of ANA as “the
professional organization that performs an essential function in articulating,
maintaining, and strengthening the social contract that exists between nursing
and society, upon which the authority to practice nursing is based.”
69
Of the
16 elements of nursing’s social contract, Nursing’s Social Policy Statement very
briefly addresses ethical practice, collaboration, the knowledge base of practice,
and autonomy of practice. Its greatest attention is given to the scope of nursing
Chapter 1. Social Contract Theory • Guide to Nursing's Social Policy Statement • 23
practice, standards of practice, and the regulation of professional nursing. It
does not address all of the elements of nursing’s social contract.
Society has a need for caring activity in health and illness; it authorizes a
social group called nursing to meet that need. In doing so, it accords nurs-
ing specific privileges and expectations within the social contract. The broad
obligations of nursing are articulated in ANA’s definition of nursing as “the
protection, promotion, and optimization of health and abilities, prevention of
illness and injury, alleviation of suffering through the diagnosis and treatment
of human response, and advocacy in the care of individuals, families, commu-
nities, and populations.”
70
Nursing engages in an extraordinary range of activities to live out these
defining attributes—and in doing so, to meet the needs of society.
Gedankenexperimente: Some Thought Experiments
for Nurses about Social Contract Theory
The practical applicability of social contract theory is not immediately evident.
As an abstract conceptualization, it is not directly applicable to nursing practice
(or to other professional disciplinary practices other than, say, philosophy or
the history of ideas); yet it has implications for nursing that are profound both
for the ways in which we think about nursing, and for the practice of nursing
in terms of its engagement with society. It has particular relevance to nursing’s
concern for the social causes of health disparities. Social contract theory raises
a number of crucial philosophical, theoretical, and ethical questions for nursing
that make useful thought experiments both for self-reflection and to clarify how
larger conceptual schemata might interact with nursing theory or practice. For
example:
• What is nursing’s view of person (and human nature), health, soci-
ety, and nursing (the metaparadigm concepts) versus the under-
standing of these concepts within social contract theory?
• Does one’s view of human nature affect how one conceives of sick-
ness, health, or suffering?
• Is social contract theory an adequate explanation of nursing’s rela-
tionship to society?
• What dimensions of social contract theory might be troubling for
nursing?
• As a discipline that engages in caring practices, does nursing socially
devalue its own practices?
24 • Guide to Nursing's Social Policy Statement • Chapter 1. Social Contract Theory
• Does social contract afford nursing, as a female-dominated profes-
sion, a place at the table?
• Is the social status or social location of nursing affected by social
contractarianism?
• Of those whom nursing serves, who is left out of the social contract
and how?
• Is the contractarian emphasis on individuality, rationality, self-deter-
mination, and the protection of property inimical to nursing’s empha-
sis on caring?
• Is the Kantian autonomy and rationality ultimately compatible with
nursing ethics?
• Following Tronto, how might the social contract/politics be changed
to incorporate and value caring, an ethic of care, and caring
practices?
• Is there a global social contract and, if so, what are its parameters,
both in general and specifically for health professions, health profes-
sional education, and global health?
• Does social contract have the best fit as a description of nursing’s
relationship with society?
• Are there alternative theoretical structures for the social and political
relationship of professions (nursing) to society that more fully incor-
porate nursing values?
• Given that social contracts evolve and differ both over time and
across nations and cultures, is there an elemental or basic social con-
tract that might include all nurses?
It is important to think about questions such as these in order to formulate
a clear and thoughtful perspective on the place of nursing in society and any
tensions that may exist between prevailing social contractual views of nursing
and the values and ideals that nursing holds dear.
Chapter 1. Social Contract Theory • Guide to Nursing's Social Policy Statement • 25
ENDNOTES
All URLs provided are accurate as of May 29, 2015.
1
American Nurses Association (ANA), Nursing’s Social Policy Statement: The Essence
of the Profession (Silver Spring, MD: ANA, 2010).
2
American Nurses Association (ANA), Nursing: Scope and Standards of Practice
(Silver Spring, MD: ANA, 2010).
3
American Nurses Association (ANA), Code of Ethics for Nurses with Interpretive
Statements (Silver Spring, MD: ANA, 2015).
4
Note that many of these ancient or early works are in the public domain and are
readily available, gratis, in full-text online.
5
Plato Crito, Public Domain Book. http://classics.mit.edu/Plato/crito.html.
6
Richard Kraut, Socrates and the State (Princeton, New Jersey: Princeton University,
1984).
7
Plato, Republic, trans. Robin Waterfield (New York: Oxford University Press,
1993).
8
Epicurus, Principle Doctrines, trans. Robert Drew Hicks (Internet Classics Online,
2009).
9
See also: http://classics.mit.edu/Epicurus/princdoc.html.
10
Thomas Hobbes, Leviathan, ed. Richard Tuck, Cambridge Texts in the History of
Political Thought (Cambridge, UK: Cambridge University Press, 1992). See also:
Thomas Hobbes, The Leviathan (Corvallis, OR: Oregon State University, n.d.)
http://oregonstate.edu/instruct/phl302/texts/hobbes/leviathan-contents.html.
11
Hobbes, Leviathan (1990), 70. Spellings have been modernized.
12
Ibid.
13
Ibid., 80.
14
Ibid.
15
John Locke, Two Treatises of Government, ed. Peter Laslett, Cambridge Texts in the
History of Political Thought (Cambridge, UK: Cambridge University Press, 1988).
16
Ibid., 79.
17
Ibid., 87.
18
Ibid.
19
Ibid., 79.
20
20 Ibid.
21
Jean-Jacques Rousseau, The Basic Political Writings, ed. and trans. Donald A.
Cress, 2nd ed. (Indianapolis: Hackett Publishing, 2011).
22
Ibid., 72.
23
Ibid., 77.
24
Ibid., 87.
25
Ibid., 164.
26
Ibid., 163.
26 • Guide to Nursing's Social Policy Statement • Chapter 1. Social Contract Theory
27
J. Maxwell, personal correspondence with the author (May 26, 2015).
28
Bryan Garner, ed., Black’s Law Dictionary, 10th ed. (Eagan, MN: Thomson West,
2014) 736–37.
29
United States Constitution, Preamble. Full U.S. Constitution available at http://
www.archives.gov/exhibits/charters/constitution_transcript.html.
30
John Rawls, A Theory of Justice (Cambridge, MA: Harvard/Belknap Press, 1972).
31
Ibid., 3.
32
Ibid., 14–15.
33
Ibid., 123.
34
Ibid., 44, 78.
35
Ibid., 75.
36
Ibid., 87.
37
Sheryl Reimer-Kirkham, “Nursing Research on Religion and Spirituality through a
Social Justice Lens,” Advances in Nursing Science 37, no. 3 (2014): 249–57. See
also: Jamie Rogers and Ursula Kelly, “Feminist Intersectionality: Bringing Social
Justice to Health Disparities Research,” Nursing Ethics 18, no. 3 (2011): 397–
407; and Kimberly van Herk, Dawn Smith, and Caroline Andrew, “Examining
Our Privileges and Oppressions: Incorporating an Intersectionality Paradigm into
Nursing,” Nursing Inquiry 18, no. 1 (2011): 29–39.
38
Kimberlé Crenshaw, “Demarginalization of the Intersection of Race and Sex:
A Black Feminist Critique of Antidiscrimination Doctrine, Feminist Theory
and Antiracist Politics,” University of Chicago Legal Forum, 140 (1989). See
also: 139–67; Crenshaw, “Intersectionality: The Double Bind of Race and
Gender,” Perspectives, Spring 2004: 2; and Ashley Crossman, “Critical Theory:
An Overview,” About.com, n.d., http://sociology.about.com/od/Sociological-
Theory/a/Critical-Theory.htm.
39
Carole Pateman, The Sexual Contract (Cambridge, UK: Polity Press, 1988). See
also: Pateman, “God Hath Ordained to Man a Helper”: Hobbes, Patriarchy and
Conjugal Rights,” British Journal of Political Science 19, no. 4 (October 1989):
445–63; Pateman, The Problem of Political Obligation: A Critique of Liberal Theory
(Cambridge, UK: Polity Press, 1985); and Pateman, Participation and Democratic
Theory (Cambridge, UK: Cambridge University Press, 1970).
40
Eva Kittay, Bruce Jennings, and Angela Wasunna, “Dependency, Difference and
the Global Ethic of Longterm Care,” Journal of Political Philosophy 13, no. 4
(2005): 443–69. See also: Eva Kittay and Ellen Feder, ed., The Subject of Care:
Feminist Perspectives on Dependency (Lanham, MD: Rowman & Littlefield, 2002).
41
Annette C. Baier, Moral Prejudices: Essays on Ethics, (Cambridge, MA: Harvard
University Press, 1995).
Chapter 1. Social Contract Theory • Guide to Nursing's Social Policy Statement • 27
42
Jean Hampton, Hobbes and the Social Contract Tradition (Cambridge, UK:
Cambridge University Press, 1988). See also: Hampton, “Two Faces of
Contractarian Thought,” in Contractarianism and Rational Choice; Essays on David
Gauthier’s Morals by Agreement, ed. Peter Vallentyne (Cambridge, UK: Cambridge
University Press, 1991), 31–55; and Hampton, “Feminist Contractarianism,” in
A Mind of One’s Own: Feminist Essays on Reason and Objectivity, ed. Louise M.
Antony and Charlotte E. Witt, 2nd ed. (Boulder, CO: Westview, 2002), 337–68.
43
Jean B. Elshtain, Public Man, Private Woman (Princeton, NJ: Princeton University
Press, 1981).
44
Virginia Held, “Noncontractual Society: A Feminist View,” in Science, Morality and
Feminist Theory, ed. M. P. Hanen and K. Nielson, Canadian Journal of Philosophy
Supplement (Calgary, CA: University of Calgary Press, 1987), 111–37.
45
Susan M. Okin, Justice, Gender and the Family (New York: Basic Books, 1989).
46
Mari J. Matsuda, “Liberal Jurisprudence and Abstracted Visions of Human Nature:
A Feminist Critique of Rawls’ Theory of Justice,” New Mexico Law Review 16,
no. 3 (Fall 1986): 613–30. See also: David Boucher and Paul Kelly, “The Social
Contract and Its Critics: An Overview,” in The Social Contract from Hobbes to
Rawls, ed. D. Boucher and P. Kelly (London: Routledge, 1994), 1–34; Diane
Coole, “Women, Gender and Contract: Feminist Interpretations,” in Boucher and
Kelly, Social Contract, 191–210; Carol Gilligan, In a Different Voice: Psychological
Theory and Women’s Development (Cambridge, MA: Harvard University Press,
1982); Crawford B. Macpherson, The Political Theory of Possessive Individualism:
Hobbes to Locke (Oxford, UK: Oxford University Press, 1962); John S. Mill, The
Subjection of Women, in On Liberty and Other Essays, ed. John Gray (Oxford, UK:
Oxford University Press, 1998) 469–582; and Ruth Sample, “Why Feminist
Contractarianism?” Journal of Social Philosophy 33, no. 2 (2002): 257–81.
47
Pateman, Sexual Contract, x.
48
Ibid., 6.
49
Ibid., 2.
50
Ibid., 3.
51
Kittay, Jennings, and Wasunna, “Longterm Care,” 443.
52
Rhacel Parreñas and Eileen Boris, Intimate Labors: Cultures, Technologies, and the
Politics of Care (Stanford, CA: Stanford University Press, 2010).
53
Joan Tronto, Moral Boundaries: A Political Argument for an Ethic of Care (New York:
Routledge, 1993), 54.
54
Ibid., 55–56.
55
Held, “Noncontractual Society,” 194–95.
56
Tronto, Moral Boundaries, 54.
57
Charles W. Mills, The Racial Contract, (Ithaca, NY: Cornell University Press, 2014),
3.
58
Ibid., 4.
59
Anita Silvers and Leslie Francis, “Justice through Trust: Disability and the ‘Outlier
Problem’ in Social Contract Theory,” Ethics 116, no. 1 (October 2005): 40–41.
28 • Guide to Nursing's Social Policy Statement • Chapter 1. Social Contract Theory
60
Kittay, Jennings, Wasunna, “Longterm Care,” 445.
61
Gorik Ooms et al., “A Global Social Contract to Reduce Maternal Mortality: The
Human Rights Arguments and the Case of Uganda,” Reproductive Health Matters
21, no. 42 (2013): 129–38.
62
Thomas Donaldson and Thomas Dunfee, “Toward a Unified Conception of
Business Ethics: Integrative Social Contracts Theory,” Academy of Management
Review 19, no. 2 (1994) 252–84.
63
American Medical Association, Code of Medical Ethics of the American Medical
Association (Chicago: American Medical Association, 1847), 105.
64
Matthew K. Wynia. “The Short History and Tenuous Future of Medical
Professionalism: The Erosion of Medicine’s Social Contract,” Perspectives in
Biology and Medicine, 51, no. 4 (Autumn 2008): 567.
65
Richard Cruess and Sylvia Cruess, “Expectations and Obligations: Professionalism
and Medicine’s Social Contract with Society,” Perspectives in Biology and Medicine
51, no. 4 (Autumn 2008): 583.
66
Ibid., 586.
67
“Public Ranks Nurses as Most Honest, Ethical Profession for 13th Straight
Year (12/18/14),” NursingWorld.org, 2014, http://nursingworld.org/
Nurses-MostHonestEthicalProfession.
68
“What is nursing?” NursingWorld.org, http://www.nursingworld.org/
EspeciallyForYou/What-is-Nursing.
69
ANA, Nursing’s Social Policy Statement, 6.
70
Ibid.
71
Max Horkheimer, Critical Theory (New York: Seabury Press, 1972) 246.
