Clinical Ethics Consultation. Theories and Methods, Implementation, Evaluation

It seems somehow odd to review an edited collection of essays on clinical ethics consultation (CEC), a phenomenon largely identified (in the literature at least) with hospital medicine. One might ask if such a phenomenon is necessary in primary care. British GPs seem a fairly self-reflective profession. After all, the Balint movement in the UK appears to have been largely confined to general practice education.¹ A small article on the difficulties of maintaining confidentiality in RCGP News² can result in an august and furious response in the BJGP's pages³. Yet ethics is a word perceived as hard, bookish, for academics, according to the chairman of the RCGP ethics committee no less.⁴ So why might a text looking at theories and methods of ethics support, its implementation, and its evaluation be of interest to those working in primary care?

Everyday, ordinary primary healthcare has also traditionally been of less interest both to tabloid newspapers and to bioethics.^5–7 Refreshingly, the editors of Clinical Ethics Consultation have embraced this ‘everyday’ concern. In his chapter on ethical decision-making in nursing homes, Bollig laments that despite the high frequency of ethical issues occurring in nursing homes ‘all round the world, every single day,’ they are often overlooked or neglected, probably due to their ordinariness. Elsewhere Stuber describes the moral distress felt by a nurse who struggles to watch over 36 patients whilst deciding whether she can safely get a person with diarrhoea to the toilet every 30 minutes. To protest against work conditions carries a risk of unemployment, and the ward is already understaffed. Stuber uses the case to describe the difficulties that work conditions place on the moral definition of a profession. This is a point Iona Heath has been making for some decades in her arguments that GPs should not be both patient-advocates and fund-holders.⁸

Whether it is in a Balint group, an appraisal, or other reflexive exercise, guided introspection may be viewed warily by British GPs. Opening up behaviour to ethical scrutiny can raise the fear that behaviour will be deemed by peers to be deficient, that one will fall foul of ‘ethicality’.^9,10 In the final chapter Schildmann and Vollman quote a definition of ethicality as ‘practices consistent with ethical norms and standards’.

They cite the promotion of ethicality as one possible outcome by which CEC can be evaluated. In her chapter on facilitating reflection on professional norms, Stuber suggests that people do not reflect on the values that are commonly taken to constitute part of their professional competence. General physicians and GPs find help useful in facing ethical difficulties but reported having used the available services infrequently, and, paradoxically, doctors with greater confidence in their knowledge of ethics were more likely to have used available services.¹¹ When read alongside Stuber's insight, the situation is faintly reminiscent of Tudor-Hart's inverse care law, where people with the greatest health needs were the least likely to access healthcare.¹² Whether this was a problem of non-availability of services or a lack of ability to access those services,¹³ the analogy may apply to postgraduate ethics education and ethics support in primary care.

Ethics education,^11,14,15 allows GPs to engage with support and scholarship, and this book draws on a number of approaches that lend themselves to community of general practice scholars. Whether there is not enough postgraduate education in this area, or simply not enough support for its uptake is a matter that warrants further discussion. As a source text this volume has much to offer.