General Practice and Ethics

Christopher Dowrick, Lucy Frith

• Publisher: Routledge
• Year: 2012
• Print ISBN:
  9780415164986
• eBook ISBN:
  9781134710119
• Topic: Medicine
• Subtopic: Ethics in Medicine

Explores the ethical issues faced by GPs in their everyday practice, addressing two central themes; the uncertainty of outcomes and effectiveness in general practice and the changing pattern of general practitioners' responsibilities.

Part I

Themes

Chapter 1

Uncertainty and responsibility

Christopher Dowrick

[A]t once it struck me what quality went to form a Man of Achievement, especially in Literature, and which Shakespeare possessed so enormously—I mean Negative Capability, that is, when a man is capable of being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason…

John Keats (1817)

In this chapter I wish to explore what appears to be a major problem for general practitioners in our work with patients, namely the uncomfortable juxtaposition of uncertainty and responsibility. I shall begin by exploring some of the levels and degrees of uncertainty which exist in ordinary general practice. I shall then describe a set of pragmatic strategies which most of us use to reduce our sense of uncertainty on the one hand, and a second set of strategies which we may use to reduce our sense of responsibility on the other hand. Next I shall discuss the extent to which philosophical concepts drawn from the field of logic—in particular probability theory and decision analysis—can guide our decision making in areas of clinical uncertainty. I shall argue that these can be helpful in specific areas of diagnosis and management. However, they are often limited by our tendency to adopt heuristic (‘rule of thumb’) biases and, more importantly, they cannot assist us in making decisions in the context of conflicting value systems. In situations of unresolved conflict Levi's ‘weighted average principle’ may offer us some useful guidance. Finally, I suggest that, far from being an unwanted burden for general practitioners, the tension between uncertainty and responsibility may be an important and necessary motivating force.

LEVELS OF UNCERTAINTY

During a study of doctors and patients on a metabolic research unit in Canada, Renee Fox proposed three basic types of uncertainty affecting physicians: incomplete mastery of available knowledge; limitations in current medical knowledge; and the consequent difficulty of ‘distinguishing between personal ignorance or ineptitude and the limitations of present medical knowledge’ (Fox, 1959). She also noticed the strategies that the physicians used to cope with the stresses of such uncertainty—‘counter-phobic grim joking’, wagering behaviour when predictions were hazardous and devising magical techniques to enable them to carry out their tasks with confidence and poise. Katz (1988) has characterized these behaviours as a disregard of uncertainty, an attitude which may result from simple denial, from traditional ideas about the ethical conduct of physicians towards patients or from a sense of the proper exercise of one's professional responsibilities. I think that the uncertainties confronting general practitioners are considerably more complex than this, and our methods of disregarding them consequently tend to be more varied and subtle.

At the same time we (usually) carry with us a sense of a duty to care and do our best for our patients. No matter how patient-centred we may be, how sophisticated our abilities to devolve decision making to or share it with our patients, we believe that it matters what we think and do, that to a greater or lesser degree we do have the power to make things better or worse for patients, even if ‘only’ to affect how they feel about themselves and their health, and that we must exercise this power in the best possible way.

We are often uncertain about diagnoses. What problems are going to be presented to us by the next patient who comes through the door of the consulting room? We may not be sure whether his fatigue, headache or abdominal pain is the start of a serious and life-threatening condition or will prove to be caused by a straightforward and self-limiting viral infection. It is also often unclear what our patients’ perceptions of their problems may be, what ideas they have about how their problems should be managed and what other hidden or complicating psychosocial agendas they may have.

In many cases presented to us there will be room for debate about the best management options. Should we prescribe antibiotics for otitis media or antidepressants for mild to moderate depression? Should we refer patients with prostatic symptoms to a urologist early or indeed at all? There may be a discrepancy between the best and the available manage-ment options, for instance in the care of the frail elderly or patients with severe and enduring mental illness. Nor can we be confident that even the best and most comprehensively researched treatment options—such as prescribing aspirin for the secondary prevention of myocardial infarction—will achieve substantial improvement in health of the particular individual patient in front of us.

At more fundamental levels we may be uncertain about the nature of our professional role: are we biomedical scientists, holistic physicians, social workers or health service administrators? We may also be aware that there are conflicting epistemological paradigms—biomedical, psychosocial, political or spiritual, for example—within which we can seek to explain our patients’ problems, and that the paradigm within which we operate will affect the type of action we adopt.

The varying levels of uncertainty can be summed up as follows:

Diagnosis	range
	severity
	patient's expectations
	complicating factors
Management	best options
	available options
	efficacy of options
Paradigms	biomedical
	psychosocial
	political
	spiritual, etc.

During the course of a recent routine morning surgery I saw eighteen patients. Eight of them had upper respiratory problems, five were depressed, two each had cardiac and musculoskeletal problems, and there were also requests for my help with impetigo, abdominal pain, contraception and a life insurance form.

After each consultation I made brief notes about any aspects which had caused me uncertainty. In six cases—including abdominal and musculoskeletal pain—my diagnosis was provisional at best. For at least ten of the eighteen patients I was not fully confident about the management options I recommended, ranging from the prescription of antibiotics for an upper respiratory tract infection to a focused psychological intervention for complex marital problems. With six patients I was uncertain about which knowledge paradigm was most appropriate. I found Richard Markham the most troubling of these cases.

Richard is a 59-year-old married man who has worked all his life in a brass foundry. His work is highly specialized and a source of great pride, particularly his contribution to the sculpture of a figure on horseback which is prominently displayed in a city centre churchyard. He came to see me to review ongoing problems with his knees. He reported that the pains in his knees were still there though they had improved since he reduced his working week to three days. I informed him that the X-ray we organized on his last visit has shown no abnormality.

He has two other problems which concerned me. He was extremely anxious, and I suspect probably also depressed. He clearly finds coming to the doctor a very stressful experience and does so as rarely as possible. He is also in a high-risk category for cardiac disease. He had a myocardial infarction when he was 31, has a strong family history of ischaemic heart disease, drinks at least five pints of beer a night and is overweight as well as anxious. Blood tests ordered after his last visit revealed high cholesterol levels and suggested physical damage from his alcohol intake. His blood pressure on this occasion was raised at 180/105. Richard is trying to reduce weight, but is very reluctant to reduce his alcohol intake.

It is clear from a biomedical perspective that in order to reduce his risk of cardiac disease Richard should reduce or stop his consumption of alcohol, and that his musculoskeletal problems will be mitigated if he reduces his hours of work. But a psychosocial approach identifies alcohol as one of his main sources of pleasure and relaxation. And his work has been his main source of personal identity. Which is more important, the quality or the quantity of his life? My uncertainty here is which paradigm to adopt, rather than what advice to give within an assumed biomedical paradigm.

Being uncertain is not a problem if we do not have to act. Having responsibility is not a problem if we know what to do. But if we have to act in a situation when we do not know what to do—that is more difficult. To what extent can ethics help us to address and minimize this difficulty?

PRAGMATIC STRATEGIES TO REDUCE UNCERTAINTY

There are several methods which general practitioners adopt—whether consciously or not—to minimize uncertainty or else to reduce the stress that it may generate. I do not wish to suggest that these methods are intrinsically unethical or wrong, but rather to offer a tentative taxonomy as a basis for critical observation and reflection.

Within consultations general practitioners have a tendency to set limits on the legitimacy of problems presented by patients. We use their initial cues to channel encounters towards a small number of preconceived specific diagnostic and management strategies and interpret any later information received within those terms. We may then ignore ‘extraneous’ information—particularly relating to psychological and social problems—and fail to respond to or follow patients’ verbal agendas (Campion et al., 1992). A study of principals in the former Mersey region found that they were most likely to consider acute physical problems as appropriate or relevant to their knowledge and skills, while social issues were considered least appropriate. It concluded that general practitioners probably work to a bio(psycho) rather than a biopsychosocial model of health care (Dowrick et al., 1996).

The majority of general practitioners now work in groups with three or more partners (Fry, 1992). Within such groups there is a tendency for doctors to develop special interests, such as asthma, diabetes or mental health. This may happen overtly, after a decision within the practice that one partner should set up a chronic disease clinic. It may also build up by custom and practice over time, with impetus from both partners and patients. A doctor with a particular interest in depression, for example, may receive internal referrals of complicated cases from partners, which will inevitably take up a significant proportion of her time. Receptionists may also steer patients in her direction, and patients themselves will over time tend to gravitate towards her for help with that particular type of problem. The net result is that the likelihood of that doctor seeing a depressed patient during a routine surgery is much higher than usual, thus reducing her level of uncertainty about the range of potential diagnoses and treatment options which she needs to consider.

Financial considerations may also be used to reduce uncertainties in clinical work. It is perfectly legitimate—although ethically dubious—for general practitioners to concentrate their interests and efforts on those aspects of their clinical work which generate the most income. The 1990 GP Contract, for example, has encouraged some doctors to maximize their list sizes in deprived areas, and focus their attention on achieving the highest targets for immunization and cervical cytology and other fee-for-service programmes (Dowrick et al., 1995). The debate within British general practice over core and non-core functions (RCGP, 1996) is also germane to this issue. By specifying the types of problem general practitioners should treat as part of general medical services, and itemizing other tasks for which extra payments should be negotiated, the profession is overtly setting limits on the uncertainty within which it is prepared to operate.

To summarize, a taxonomy of pragmatic strategies to reduce uncertainty could be as follows:

In the consultation	select patient cues for response
	bio(psycho) model
In the practice	develop specializations
In the profession	financial orientation
	core and non-core services

PRAGMATIC STRATEGIES TO REDUCE UNCERTAINTY

It is of course possible for general practitioners to alter the other side of the equation by reducing the level of responsibility we assume for the problems presented to us by our patients. Referral behaviours, patient centredness and our professional culture can all be used in this way. As with the taxonomy of strategies to reduce uncertainty, my argument is not that these are unethical per se, but that they can be used to abdicate responsibilities which arguably we should retain.

If we are not sure about diagnosis or management we can refer. In the past the most common route of referral was ‘upwards’ to hospital consultants, providing a major means of shifting responsibility for problems that we found complicated or difficult to manage. Although the overall proportion of cases referred in this direction has remained relatively constant at about 10 per cent (Fry, 1992), there has been a change in the threshold for referral. The increasing sophistication of investigative options available to general practitioners and the pressure to shift care and resources from secondary to primary care mean that we tend to work up cases more comprehensively than in the past before involving our specialist colleagues, and therefore retain more responsibility for diagnosis and management.

However, the expansion of primary health care teams has provided many more opportunities for us to refer ‘sideways’, to district nurses, physiotherapists or counsellors, for example. While this has many major advantages for effective patient care, there are also potential ethical hazards. Access to these colleagues is usually much more rapid than to a hospital outpatient clinic. They are also likely—either through their terms of employment or a sense of professional subordination—to be amenable to our direct control and influence. We may therefore at times be tempted to ask them to shoulder an excessive burden of responsibility for both diagnosis and management of patients, in a context where it is difficult for them to refuse to do so.

As general practitioners we place great emphasis on the importance of being patient centred, of listening carefully to our patients’ concerns, their views about the nature of their problems and their opinions about the best methods of managing them (Byrne and Long, 1975). Ethically this concept appears impeccable. It embodies respect for the individual, patient empowerment and a commitment to developing the patient's sense of her ability to manage her own health and disease.

Patient-centredness can, however, merge imperceptibly into a withdrawal of responsibility, a refusal by the doctor to apply himself to an adequate degree of thought and decision making. An extreme but uncomfortably widespread example is the telephone encounter between patient and receptionist in which the patient announces he has tonsillitis and needs an antibiotic and the doctor simply writes a prescription for penicillin to be picked up later. Another common scenario involves the patient with non-spec...

Table of contents

• Front Cover
• General Practice and Ethics
• Professional Ethics
• Title Page
• Copyright
• Contents
• Notes on contributors
• General editor's foreword
• Acknowledgement
• Introduction
• Part I Themes
• PART II Topics
• Index