Ethical issues in the first five years
By Dr Rhona Knight, 16 June 2011
Questions of ethics pose complicated problems to GPs on a daily basis, says Dr Rhona Knight.
Big medical ethics cases commonly hit the headlines and as the saying goes, hard cases make bad law. Examples of such stories include 'First successful saviour sibling treatment for the UK'1 and 'We are happy and don't want to die, say patients locked in their bodies'.2
Yet if you talk to GPs, these difficult and complicated cases are rare in everyday practice - they are the ethics of the extraordinary. But it is the ethics of the ordinary that pose problems faced on a daily basis and affect doctors in the first five years onwards.3
'Ethics of the Ordinary' was the title of a conference organised by the Royal Society of Medicine in association with the RCGP in February 2011.4
Everyday ethical issues
Take a minute to think: in your last surgery, what ethical issues did you have to contend with? I had a call from an irate husband wanting information about his wife who had just been admitted to hospital. I had the QOF box pop-up indicating I should carry out a patient health questionnaire on a patient who had come with two other problems that were her priority. I had to decide whether to put a one-off high BP reading into the notes as free text or coded.
This does not include the other times that the computer tells me there is a cheaper medication than the one I want to prescribe.
Nor does it include the decision of whether to offer a chaperone to all four patients who have a 10-minute appointment for a vaginal examination.
Dealing with problems
In the first five years of practice, four key ideas can help you to identify and handle common ethical questions in the consultation. These can be extended more broadly to the ethical matters of practice. They are:
1. Identify the ethical matters and dimensions of the consultation
2. Identify the relevant facts
3. Explore the relevant values
4. Decide a justifiable way forward with the patient
These four stages are illustrated in a tool that I have developed and used to teach medical ethics over a number of years: the ethical cycle.
Medical education is full of cycles that promote reflective practice and facilitate learning from practical experience.
Initially, using the ethical cycle can feel like learning to ride a bike: rather clunky and unstable. However, if used to reflect on the matters you encounter that occur more frequently in practice, it can aid the development of a more intuitive approach, of a professional wisdom.
In the same way you learn to recognise clinical problems, make diagnoses and develop shared management plans more fluently in the first five years of independent practice, so too you can recognise and manage the ethical problems in practice more smoothly.
In ethical as well as in medical decision-making, doctor and patient are experts. The patient is the expert in the experience of illness and in their own views and values. The doctor brings professional expertise. Bringing the expertise of patient and doctor together is part of the art of consultation.
1. Identify the ethical issues and dimensions of the consultation
This requires you to be ethically aware. Consent and confidentiality questions are usually easy to pick up, but remember that things like payments for performance, where the focus on box-ticking is often about practice income and not about quality of patient care, have ethical dimensions too.
2. Identify the relevant facts
The necessary facts can be numerous. Take a 13-year-old requesting contraception. If you wish to be an ethical doctor practising good medicine, the list of what you need to find out can seem never-ending.
3. Explore the relevant values
These include the values of the patient and, often, their family. Doctors need to be aware of their own values and those of the profession, as outlined by the GMC.5
They also need to be aware of the values of the practice and the primary care organisation, for example, in prescribing, and of what the law says.
4. Decide a justifiable way forward with patient
Using these facts and values, a shared decision needs to be made that doctors can justify to themselves, their profession and, if necessary, the courts.
Exploring the ethics of the ordinary may not make headlines. It does, however, help to develop the practical ethical wisdom that all GPs need.
- Dr Rhona Knight is a GP and member of the RCGP Ethics Committee
1. Walsh F. First successful saviour sibling treatment for UK. www.bbc.co.uk/news/health-12055034
2. Daily Mail. 24 February 2011; 10
3. RCGP. New professionals. First5. www.rcgp.org.uk/new_professionals/first5.aspx
4. RCGP. Ethics of the ordinary. www.rsm.ac.uk/academ/evb02.php5. GMC. Regulating doctors, ensuring good medical practice. www.gmc-uk.org/guidance/ethical_guidance.asp
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