Primary care ethics: a body of literature and a community of scholars?

‘Primary care ethics has acquired a definitive place on the “bioethics map”’.¹

Ethics has long been recognized as an important aspect of primary healthcare.² But what are the ethical issues in primary care? How do GPs and other members of the primary healthcare team make moral decisions? How should they decide which actions are good, or right in a moral sense? And why is this important for academia, education and practice?

The ethics of the ordinary

Value choices are made in every healthcare encounter. How long to spend with each patient, how to phrase a medical report, when to recommend a cheaper rather than a more expensive drug; whether to give in to a patient's desire for investigation or treatment when the clinician's judgement or the evidence base is against it; these and many other decisions in primary care involve value judgements. Ethical decisions in primary care may seem less dramatic than those in high-tech medicine, but their cumulative impact is profound because there are far more of them. Most healthcare encounters take place in primary care; approximately 400.3 million in England in 2008.^3,4 Also, because primary care is often the first step in a patient journey, small decisions (such as when to refer) may make big differences later on.⁵

The context of primary care value judgements is different from secondary care. Patients often stay with the same practice for many years, allowing large amounts of information to be gathered and personal relationships to develop. Patients see the same clinician for a variety of problems, at once or at different times. Often whole families see the same clinicians, who may also be their friends and neighbours. These factors affect how moral decisions are made in primary care, and raise ethical dilemmas which are less common in secondary and tertiary medical care.^6,7 Decisions are affected by patient's values and those of their families, community and culture, and society in general, as well as those of health professions and individual clinicians. The transfer into the community of services previously provided in hospitals may be associated with the transfer of ethical dilemmas previously only encountered in hospital settings.⁸ Most bioethical literature, however, deals with tertiary medicine; much less attention is paid to the concerns of GPs and other primary care team members.⁹

The need for a body of knowledge

UK GPs may be influenced by various externally applied ethical approaches. The General Medical Council's codes of conduct, Good Medical Practice,¹⁰ and Good Medical Practice for General Practitioners¹¹ are essentially deontological, founded on the duties of a doctor, and almost amount to a book of rules. The Quality and Outcomes Framework of the GP contract is utilitarian, based on evidence of what promotes the greatest good for the greatest number. Vocational training is still rooted in concepts of professional growth and development, aimed at producing life-long learners; arguably rooted in virtue ethics.¹² Gillies and others have argued that an approach which focuses on each individual situation is needed.^13,14

There have been few major studies on how ethical decisions are made in the primary care setting. Over 20 years ago an international survey suggested that British, US and Canadian GPs tend to make ethical decisions on a case-by-case basis rather than prioritizing patient autonomy or patient welfare when these came into conflict.^15,16 In a much smaller qualitative study Berney et al.¹⁷ found GPs' acceptance of general moral principles (such as the importance of patient autonomy) does not imply coherence in applying these principles to rationing decisions.

There is a shortage of theoretical work exploring ethical aspects of common problems in primary care, such as writing medical reports, rationing decisions for individual patients, and protecting confidentiality in small communities and groups with different cultural values. There is little in-depth published qualitative data exploring how UK GPs recognize and reconcile ethical issues. The little empirical research on such issues is mostly quantitative, leaving many unanswered questions about the reasoning behind decisions made by GPs. There have been international calls¹⁸ for ‘Those interested in and conducting empirical research in health care ethics to consider expansion beyond the “traditional” into the ethics of everyday practice of clinical medicine’. Qualitative bioethics research in UK General Practice can illuminate ethical, legal and policy debates by promoting an understanding of what ethical frameworks and strategies are used (implicitly and explicitly) in justifying decisions not just about issues in abstract but also in specific cases in practice.

Supporting education and practice: an urgent need

GPs in recent times have been encouraged to be aware of their values and how these affect their practice.^19,20 The conceptualization of General Practice ethics as ‘values-based’ is reflected in RCGP curriculum statement 3.3.^19,20 Ethical issues in the new MRCGP include: abortion, chaperones, confidentiality, euthanasia, rationing, and whistle-blowing, as part of section 2.2: Ethical aspects of general practice'. Section 2.4: Justifying and clarifying personal ethics takes in to account the fact that a person's espoused values and their real-life behaviour can often differ.²¹ This curriculum is a set of benchmarks for aspiring GPs in the UK which also has implications for those currently in practice. It has a special relevance at a time when changes to the NHS mean that General Practitioners may have to accept, at the very least, corporate responsibility for rationing decisions.²²

These changes to GP training and proposals for revalidation as well as changes in society at large, make it urgent to develop a body of knowledge (both theoretical and empirical) and a community of scholars concerned with the ethical aspects of the vast majority of healthcare interactions²³ which take place in primary care.

Footnotes

DECLARATIONS —

Competing interests The authors have both been involved with the ‘Ethics of the Ordinary’ meeting, held at the Royal Society of Medicine in association with the Royal College of General Practice on 15 February 2010. This inaugural meeting aims to foster a community of scholars and a body of knowledge in the field of primary care ethics. For more information see http://www.rsm.ac.uk/academ/evb02.php

Funding None

Ethical approval Not applicable

Guarantor AP

Contributorship Both authors contributed equally