Dutch Masters and social determinants

In these days of difficulty, we … everywhere must and shall choose the path of social justice, the path of faith, the path of hope, and the path of love toward our fellow man.

Franklin D. Roosevelt

Recently I was lucky to attend a wonderful exhibition at the Museum of Fine Arts in Boston, Mass.¹ The show, “Class Distinctions—Dutch Painting in the Age of Rembrandt and Vermeer,” is organized into rooms based on 3 social classes—the wealthy, the middle class, and the poor. A fourth room features paintings in which the classes mingle.

The show reveals that the Netherlands in the early 17th century was in many ways much like our own society today, complete with a “one percent”—the rich merchants and princes of the House of Orange—and a large underclass divided into the “deserving” (poor because of, for example, a disability) and the “undeserving” poor (poor because of their own moral failings). Not surprisingly, the first room contains paintings by some of the greatest painters who ever lived, such as Vermeer, Rembrandt, and Hals. Among this part of the collection are almost life-sized vanity portraits of some of the wealthiest people of the time. Also not surprisingly, since the poor could not afford to commission the great artists of the day, the third room contains a smaller number of paintings by lesser-known artists. Several of the pictures portray almshouses. In general the portraits of the least of Holland’s citizens are unflattering.

Where were the physicians in 17th-century Holland? In what room, and among which classes, do we find them? In the second room, among the middle class, is a beautiful painting of a barber-surgeon by Isaak Koedijk, painted around 1650. It shows the surgeon kneeling before an equally middle-class–looking patient, dressing a leg wound.

Where do we find physicians, especially family physicians, situated today? Although socioeconomically we still occupy the middle and upper classes, the unequal and inequitable lives of our patients and the adverse health effects of social disadvantage are an increasing part of the reality of our daily work lives. Although there are sceptics among us,² there is overwhelming evidence of the adverse health effects of poverty and, conversely, the health and economic benefits of greater equality in society.³ How do we family physicians respond to these challenging inequities? Where can we seek ethical guidance?

Furler and Palmer from the Primary Care Research Unit at the University of Melbourne in Australia grappled with these questions in an important paper published in 2010.⁴

They advocate for active engagement with social health inequalities in everyday primary care. They also argue that commonly drawn upon normative ethical theories such as utilitarianism and deontology, and the four bioethical principles—respect for justice, beneficence, non-maleficence and autonomy—still keep social health inequities as an elephant in the room.⁴

Instead, they contend that the 3 forms of togetherness described by sociologist Zygmunt Bauman—being-aside, being-with, and being-for—can help us to understand and develop a response to health inequities, especially if we can develop the ideal ethical relationship of being-for our patients in the broadest context.⁴ Furler and Palmer argue: Developing the relation of being-for ... need not be overwhelming for clinicians faced with a full waiting room of patients and the responsibility and seeming impossibility of acting on the social and societal forces embodied in each .... Being-for does not ignore the critical exchanges that must occur as day to day illness care proceeds, rather it provides a way of being together that infuses these. For the physician it demands a reflexive awareness of the way they may contribute to shaping the encounter, sensitivity to questions that might bring foreclosure, limit responses and create silence. It also demands that patients too come to recognize the physician with their uniqueness and alterity.⁴

It has been said that data prove but stories convince. The January cover of Canadian Family Physician, and the photo essay inside (page 68), is the first in an ongoing series of portraits of communities across Canada grappling with some of the inequities and challenges pervading society— from poverty, to social isolation and deprivation, to being able to deliver your baby in your own rural or remote community, to being able to die in your own home. In each story, a family physician is the point of entry, but it is the cocreated response of the family physician and the larger community that is the focus of the stories, by award-winning writer and poet Sarah de Leeuw, and the accompanying photographs. We hope that over time this collection of covers and stories will help us in being-for our patients.

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