Primary Care Ethics

Deborah Bowman

• Publisher: CRC Press
• Year: 2018
• Print ISBN: 9781138460058
• eBook ISBN: 9781315345086
• Edition: 1
• Topic: Medicine
• Subtopic: Family Medicine & General Practice

Relevant for the entire primary care team, this book provides a diverse range of perspectives on current topical issues. Healthcare ethics is a subject of increasing interest, especially when it related to some of the challenging themes regularly discussed in the media. Until now there has been little useful literature for those in primary care, where ethical problems are often experienced with a unique set of issues. Primary Care Ethics is rigorous and academic, while remaining highly accessible for the full range of practitioners. Moral and legal aspects are clearly distinguished throughout, and the theme-based approach is stimulating and original. In providing greater depth and breadth in this subject than has been available previously, the book is both practical and thought-provoking, and essential reading for everyone, whether in academic, training or practice-based primary care.

Chapter 1

Truth, trust and the doctor–patient relationship

Paquita de Zulueta

It is trite to describe the health professional’s relationship with his or her patient as a relationship of trust, yet the description encapsulates the very heart of the relationship.

Margaret Brazier and Mary Lobjoit¹

Introduction

‘Trust’ is such a small word, yet it holds such significance. But what is trust? It eludes definition, yet, instinctively, most of us have a clear sense of what it is, and, in particular, when it is lacking. We know and value its importance – indeed necessity – in everyday life, as in medicine, but we may have difficulty articulating precisely why. We notice it much as we notice air – only when it becomes scarce or polluted.

Trust has been described as ‘the truly mysterious, barely known entity that holds society and ourselves together, the “dark matter” of the soul’² or as ‘the God particle […] the fuel, the essence, the foundation of general practice’.³ The Oxford Shorter Dictionary defines ‘to trust’ as ‘to have faith or confidence in; to rely on or depend upon’ – a definition that fails to capture the complexity and richness of the concept.

I shall be examining the extent to which trust underpins the doctor–patient relationship; what promotes trust and what undermines it in this context. I shall focus on the relevance of truthfulness in the promotion of trust between patients and their GPs. My further aim is to clarify the philosophical foundations for the variety of models representing the doctor–patient relationship and to choose the one that best encompasses and fosters trust. I shall not be examining the metaphysics of truth, albeit a subject of great interest and recently explored by two modern philosophers, Bernard Williams⁴ and Simon Blackburn.⁵ I am aware that by narrowing the scope of the enquiry, I will omit issues relevant to trust – a multi-faceted phenomenon – yet hope that the enquiry will nevertheless yield fruitful insights.

If we stop to consider how people would function in the absence of trust, we soon realise that ordinary life would be impossible. We regularly put our trust in others (and machines made by others) when we undertake banal activities such as driving a car, asking for directions, drawing money from a cash point, posting a letter, confiding in a friend, having our hair cut or buying books from an Internet-based retailer such as Amazon. Trust pervades our daily life and gives us a degree of predictability and confidence. In the end, we have to place our trust in others to engage with the world. Without trust we are doomed to self-imprisonment.

Those who break our trust, not only betray us, but threaten the very fabric of civilised society. In Dante’s Inferno, traitors went directly to the innermost circle of Hell, closest to Satan himself. As O’Hara says:

Perhaps Dante’s instincts are sounder than ours: perhaps those who betray trust are doing serious and dangerous violence to the foundations of society. Minor betrayals, individually less shocking than the crimes we see in our newspaper headlines, make us less capable of getting on with each other, of living the lives we want to lead.⁶

Ruth Etchells also argues that a culture that accepts ‘personal perfidy’ – the acceptance of breaches of trust – generates mistrust and cynicism about professional and public matters nowadays, as it did in Elizabethan times.⁷ And yet, as Annette Baier reminds us, trust is neutral, and ‘exploitation and conspiracy, as much as justice and fellowship, thrive better in an atmosphere of trust’.⁸

I shall be focusing on personal trust as distinct from social trust. Individuals gain personal trust and institutions social trust.⁹ To give an example: in present-day Iraq, interpersonal trust may be high between relatives or a tribal group, but social trust low for the institutions governing law and order. To give another example, trust in a doctor may be high, but low for the NHS generally. The distinction has been discussed and refined by several sociologists, including Niklas Luhmann, who distinguishes between trust in persons and confidence in institutions.¹⁰ Trust in persons requires the ontological freedom of the other – it becomes ‘the generalised expectation that the other will handle his freedom, his disturbing potential for diverse action, in keeping with his personality – or, rather with the personality which he has presented and made socially visible’.¹¹

Both forms of trust are necessary to reduce complexity and keep chaos at bay. To trust is to venture into the unknown. Confidence (or reliance), in contrast, is based on past performance, the ability to impose sanctions in case of ‘betrayal’ and the power to check up on the actions of the other in the future.¹² The current regulatory frameworks evidently are attempts to increase confidence, but may not necessarily increase trust.

The context

Trust dominates the news and politics. Arguably, the word has been degraded by overuse in recent times. Following the invasion of Iraq by American and allied forces in March 2002, the English media have referred to trust and its betrayal on countless occasions. The Hutton Inquiry¹³ revealed an anatomy of deceit. Those under scrutiny provided a broad palette of every shade of deception: from evasion to concealment, to partial disclosure, to deliberate non-disclosure, and thence to sophistry, half truths, distortions, and, eventually, to frank lies. The Inquiry gave evidence of how people can intentionally mislead others by manipulating facts and theories to suit their own agendas. Albeit not directly relevant to the doctor–patient relationship, Hutton and other allied inquiries provide us with a useful lexicon for dishonesty and deception, and also remind us of the potential for abuse by those in power.

Medicine in recent times has also experienced a crisis in trust. The discovery that the GP Harold Shipman was a mass murderer and the GP Dr Green a paedophile, the revelation of negligent and arrogant practitioners such as the gynaecologists Rodney Ledward and Richard Neale, and the scandals at hospitals in Bristol and Alder Hey all conjoined to seriously undermine the public’s trust in the medical profession. This mistrust was worsened by the discovery that professional self-regulation was found to be seriously deficient and that safeguards to protect vulnerable individuals were insufficient or absent. A number of inquiries followed, resulting in a shake-up of the General Medical Council (GMC), and a (bewildering) number of bodies were set up to monitor and manage clinical performance. In addition, doctors now have compulsory annual appraisal, clinical audit and five-yearly revalidation (the methodology still to be agreed at the time of writing). These changes are discussed in detail in Chapter 10. A new age of accountability is born. And yet, as the philosopher Onora O’Neill reminds us, accountability cannot replace trust. She argues that the new ‘accountability culture’ creates more administrative control, relentless demands to record and report, detailed conformity to procedures and protocols, and the setting of readily measurable and controllable targets. This culture creates ‘perverse incentives’, distorts the ‘proper aims of professional practice’, and undermines institutional autonomy. Slavish adhesion to extrinsic incentives – remunerated vaccination targets and 48-hour accessibility are examples of this in general practice – has generated criticism and fuelled mistrust that the medical profession is not pursuing the intrinsic requirements of being ‘good doctors’. We have the paradox that an increase in accountability may actually reduce and undermine trust.

The pursuit of ever more perfect accountability provides citizens and consumers, patients and parents with more information, more comparisons, more complaints systems; but it also builds a culture of suspicion, low morale, and may ultimately lead to professional cynicism, and then we would have grounds for public mistrust.¹⁴

Some would argue that this has already happened. And all that is achieved is that trust is shifted onto other individuals empowered to monitor the professionals – but why should they be any more trustworthy? Meanwhile, the public questions whether doctors are pursuing public health targets and other prescribed ends for the public good or for their own benefit, and doctors question (usually amongst themselves) whether they really are likely to benefit their patients. Choice, not fate, is placed on the shoulders of patients, who have to undertake greater responsibility for failure, of making bad choices. Their only safeguards are those regulatory mechanisms for increasing confidence, and the reliance on the behaviours and attitudes set by socially sanctioned roles.

The relevance of role

How immutable are these socially sanctioned roles and the role of the doctor in particular? In her book, Rules, Roles and Relations, Dorothy Emmet defines role as the ‘name for a typical relation in which a typical action is expected’.¹⁵ In our roles, we subsume much of our subjectivity, and adopt a persona. But doctors cannot prevent their own personal style or core beliefs from seeping through; otherwise they would conform to fully predictable and uniform patterns of behaviour, which evidence would suggest they clearly do not. Personal and role relationships overlap and the persona cannot be banished from the person or vice versa. Emmet goes on to say that we should not adopt too rigid a view of the persona:

If we press the ‘mask’ metaphor and take so mechanical and literal a notion of the persona that it becomes just something through which the right sorts of noises sound (personant), we shall never catch the conversation-like nuances by which role performances are also found to be relationships between people.¹⁶

Seligman suggests that role can be viewed as a stable state within a social system, complete with its normative role expectations, or it can be seen as a process – role-making rather than role-taking – emerging out of interaction and reciprocity, and less determined by systemic constraints. This more fluid and negotiable perception of role allows greater freedom, but less certainty.¹⁷ Patients cannot rely on a bedrock of role predictability from their health professionals. The public’s expectations of the GP’s role may conflict with that of GPs, creating tensions. Furthermore, GPs may experience role conflict and seek to spend more time with their families whilst pressures mount for them to be available 24/7, even for trivial complaints. Ev...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Foreword
• About the editors
• List of contributors
• Acknowledgements
• Introduction
• 1 Truth, trust and the doctor–patient relationship
• 2 Autonomy and paternalism in primary care
• 3 ‘But it’s not my fault!’ Are we responsible for our health?
• 4 Human rights in primary care
• 5 Ethical considerations in the primary care of the elderly demented patient
• 6 Setting boundaries: a virtue approach to the clinician–patient relationship in general practice
• 7 Interprofessional teamworking: a moral endeavour? An exploration of clinical practice using Seedhouse’s ethical grid
• 8 Complexity, guidelines and ethics
• 9 Should doctors observe a moral duty to care for themselves?
• 10 Fallible, unlucky or incompetent? Ethico-legal perspectives on clinical competence in primary care
• 11 Ethics support and education in primary care
• 12 Final thoughts: conclusions and endnotes
• Index