Ethics in General Practice

A Practical Handbook for Personal Development

Anne Orme-Smith, John Spicer

• Publisher: CRC Press
• Year: 2018
• Print ISBN: 9781857753288
• eBook ISBN: 9781315348513
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

A working understanding of medical ethics is becoming ever more important to all practising doctors. There are many ethical issues which present, often unexpectedly, to healthcare professionals which can seem impossible to resolve. This is an introductory text for everyday general practice. Key issues and relevant legal aspects are illustrated with examples and case histories, and the book is structured so particular topics can be found with ease. For added benefit, chapters have pointers for further reflection and analysis, references to journal articles and useful reading lists. The book can be used as a resource for group discussion or by individual general practitioners including GP registrars and their trainers.

CHAPTER ONE

Learning about ethics:
why is it important?

Learning about ethics has only recently been recognised as being of high priority in medical training: some of our current population of doctors have sworn the Hippocratic Oath, but most have not. Some had exposure to moral and ethical thinking in medical school, but most did not. Some doctors studied humanities or other non-scientific disciplines before medicine, but most did not. The situation is changing, and the newer generations of doctors will have greater time given as undergraduates to ethical and legal matters.¹ These important subjects are now part of the core undergraduate curriculum.²

Why is it important to study such an ephemeral subject as ethics, where it could be said that discussion and debate lead nowhere and there is no one unequivocal ethical solution to a problem? For example, where an ethics module is included within the medical curriculum, how could such an expenditure of time and resources be justified? There are some cogent arguments against such a proposal. It could be said that there are no universally applicable rules in ethics, that it is a mish-mash of opinions. In any given situation, there may be so many conflicting issues that decision making would be made too complicated if we took all of them into consideration. Introducing ideas of equality and autonomy, which then pull in opposite directions, would make it impossible to accommodate everyone’s interests. It sounds good in theory, but is likely to be time-consuming in practice. We could argue that there is nothing wrong with a pragmatic system governed by the use of experience, intuition and common sense.

The bulk of medical teaching trains doctors to work according to evidence-based clinical protocols for diagnosis and treatment. Introducing an ethical dimension into everyday medical practice requires them to look at their work from another perspective.³ Apart from the educational advantage of expanding the boundaries of medical training, there is the probable beneficial impact on patient care. There might be a better chance of recognising the full range of issues in any given situation that would promote a wider choice of options for action. Insight and awareness of the deep-seated attitudes and prejudices that influence decisions increases the likelihood of flexibility of approach rather than emotional entrenchment. This could provide impartiality with the probability of better outcomes for the patient. Credibility may be strengthened, patient care improved, and well-reasoned decisions can be openly defended.

In the past, when paternalism reigned, with doctors making decisions on behalf of their patients, supposedly having their best interests in mind and following Hippocratic guidance of beneficence and non-maleficence, the ethical content of patient care could be reduced to the minimum. The application of philosophical theory and the existence of conflicting attitudes had little part to play; there needed to be a considerable element of trust in the medical profession by patients and the public. Attitudes have changed, paternalism is replaced by partnership where patients autonomy is recognised. People are in general better informed about healthcare and have a better understanding of the standards they can expect. Trust remains a crucial component of the doctor-patient relationship but it is based on a fuller mutual understanding and on a more equal footing than prevailed in the past.

It would be a mistake to make too many assumptions about peoples understanding. For many the doctor is the one with the expertise and the answers to their problems and, as such, is invested with a certain amount of power in the relationship. It is easy for the doctor to accept this role and make most decisions on his patients behalf. Advances in medicine make it difficult to provide information to patients in an accessible form; it could be said that a little knowledge would provoke more anxiety than none at all. When should information be given, how much, and can it be guaranteed that the patient has understood?

Virtually all GP consultations have an ethical dimension, which may be more or less obvious. Ultimately, the patient is better served by a GP who considers this dimension as an integral part of each interaction with a patient.

What is meant by ‘medical ethics’?

Ethics has been defined as:

the philosophical study of the moral value of human conduct and of the rules and principles that ought to govern it; ... a code of behaviour considered correct especially that of a particular group, profession or individual.⁴

We could say that in order to know how to behave in an ethical manner we need to use a background of moral philosophy from which we deduce certain principles on which we ought to act. This is in contrast to the opinion that we can organise our professional behaviour using pre-existing human qualities that tell us by instinct how to make the right decisions, or by so-called professional self-regulation.

When we approach the subject of medical ethics we are in the arena of deciding what is the right course of action as opposed to wrong. For example, is it right or wrong to give a certain treatment, to withdraw it, to choose one treatment rather than another, or to look for disease before evaluating symptoms? In this, medicine is no different from any other profession: moral choices will arise for consideration and will need to be weighed in the balance.

Yet it is because healthcare in our society is of fundamental importance that the actions of healthcare professionals and choices made by patients are exposed to critical assessment. Using the words right’ and ‘wrong’ in this context might suggest that clear cut answers can be found by a process of analysis. Is this so?

Consider the following case.

Alan is 43 and drinks heavily. His GP has known him and his family over many years. He is being prosecuted by the police for driving with an illegal quantity of alcohol in his body. He comes to see his GP for help, saying his asthma prevented him blowing properly into the alcometer used by the police.

It is not difficult to see that there are many conflicting pressures here. The GP will have a duty to do the best for Alan and his family but will also be conscious of a duty to assist the law in process, as exemplified by the police prosecution. She will be aware of the needs of confidentiality when making reports to court, but might also feel that Alan should ‘get his deserts’ as an ordinary citizen too. She might worry over Alans family, who will be the poorer when he loses his job that depends on his ability to drive. An understanding of medical ethics will help Alans GP to find the best course of action and to answer the question: what ought to be done?

Ethics, morals and the law

The words ethical and moral are used frequently in this book. Both refer to behaviour - good and bad, right and wrong. In moral terms, what is the right decision going to be? This might seem a daunting task, as Alans GPs problem exemplifies. However, we do have sources of guidance. One obvious one is the law, which is often poorly understood by doctors but can sometimes be helpful.

Betty is a cantankerous lady who constantly finds fault with what members of the primary healthcare team try to do to help her. She has multiple physical problems that the GP, community nurses and physiotherapists grapple with as best they can. Their best never seems to be good enough. One day she comes to see the doctor and asks for copies of all her computer records over the last year. She wont say why.

The GP is ambivalent about this unexplained request, unsure as to whether she ought to comply. What is she to do?

The answer is straightforward if uncomfortable. Statute law is uncompromising⁵ and the GP must provide Betty with the records, within certain clearly defined limits (see also Chapter 3).⁶ Is there an ethical basis for this law? The relevant statutes here are an expression of autonomy, the principle that exemplifies the fact that patients ought to have dominion over their own affairs, including information held by doctors about them. This principle disallows paternalistic behaviour by doctors, and says that people should be agents of their own destiny.

It is arguably the most important principle in medical ethics today, and we will be addressing it in greater detail in succeeding chapters. Much of our law in this country, including these statutes, is codifying the moral principle of autonomy. It converts what we take, morally, as being a right action into an obligatory one, with the force of law. It is important to remember that for most of the time doctors will not have the law to instruct them in non-clinical decision making, as with the problem posed to Alans GP.

Moral theories

Man has always struggled with distinguishing ‘right’ decisions from those that are ‘wrong’. The discipline of moral philosophy is founded on this struggle and its content feeds modern considerations of medical ethics.

Ethics, historically, is a branch of philosophy, the study of beliefs and values. Philosophy deals mostly in theory, though interestingly enough, in an article praising applied philosophy, one author has suggested that the true philosophers of today reside in hospitals and laboratories (to which we could add GP surgeries).⁷

We will be considering these four main moral theories in this book:

• virtue
• duty
• utility
• rights

which are four different ways of answering the question ‘What is the right thing to do?’

Like all theories, moral theories are only speculative. They cannot be disproved or proved, and in the medical context they represent a way of analysing particular problems. For those with a scientific background, such as most doctors, this does not come naturally. Generally, scientists prefer to ascribe truth to a proposition that can be proved objectively rather than to a speculative one.

Recent years have seen a trend towards justifying doctors’ actions in diagnosis or treatment on evidential grounds-evidence-based practice. Whilst this is laudable, it is a different process from moral reasoning which deals in uncertainties and logical analysis.

The moral theories listed above are broad strands of thought in moral philosophy and they underpin most modern-day medical ethics, even if they have ancient roots. Let us have a closer look at them.

Virtue ethics can be traced back to Aristotle. The theory is that people with certain intrinsic good character traits make good decisions, and we should aspire to exhibit such qualities. For the soldier, that might be bravery or fortitude, for the parson, truthfulness and temperance. It is arguable what virtues a modern healthcare professional should have: perhaps determination, consistency and a sense of humanity. Modern moral philosophers have reawakened interest in virtue ethics and there are rich sources of further reading for the interested GP.^8,9

That there should be duties in medical practice may seem obvious, but one needs to ask why that should be so. This moral theory holds that we have obligations to each other based upon respect for one another’s person. The theory is associated mainly with the German philosopher, Kant, who formulated what he described as the categorical imperative, defining our duty to each other as human beings. One version of this is that people should always be regar...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Foreword
• Preface
• Acknowledgements
• 1 Learning about ethics: why is it important?
• 2 Professional duties: ‘Trust me, I’m a doctor’
• 3 Confidentiality: ‘Your secret is safe with me’
• 4 Screening in primary care: whose risk is it anyway?
• 5 Matters of the mind
• 6 The elements of consent: information and understanding
• 7 Fertility: making babies - the haves and the have-nots
• 8 Children: ‘When will I be old enough?’
• 9 A good death: ethics and humanity at the end of life
• 10 Resource allocation: needs and wants
• 11 Looking forward: the advance of ethics in general practice
• Appendix 1 The Hippocratic Oath1
• Appendix 2 A modern Hippocratic Oath
• Appendix 3 Duties of a doctor1
• Appendix 4 The Human Rights Act 1998
• Glossary
• Further reading
• Index