Andrew Papanikitas

Should GPs avoid making ethical judgements

While considering a problematic case in a case-based discussion we found ourselves asking the question, should GPs and other frontline clinicians allow themselves to become involved in ethical judgements? Given the position that every decision has a moral aspect of some kind, is this even possible? We surmise that the conscious avoidance of ethical judgement may take place in the following ways: nnWe were aware that publications in the clinical ethics literature suggested that conscience and compassion were problematic concepts in health care for clinicians.1,2 While these address compassion and conscience, they are possibly interpreted as clinicians ought not to make ethical judgements, or enact human values beyond those strictly stipulated by the job.nnPersonal conscience (at least with regard to conscientious objection) has been challenged on the basis that ethical deliberation should not take place in the clinical encounter and clinicians should offer whatever the governing …

Patient-centredness and consumerism in healthcare: an ideological mess

Two concepts appear to permeate political rhetoric concerning healthcare in the UK and elsewhere: patient-centred care and consumerism. Concerned that these two important ideas should not get conflated in public debates about healthcare, we outline their different philosophical origins and note their differences and similarities. We would argue that both can be used in ways that are muddled or insincere, with important implications for healthcare delivery.

Self-awareness and professionalism

Professionalism is a key component of good general practice, and self-awareness is a key component of professionalism. Being self-aware means understanding your own fitness to practice as a GP. It is a critical skill for ePortfolio reflections and appraisals, as it is a critical skill for good practice. In this article I will offer an approach to professional self-awareness through a set of four questions: What are my goals? What are my beliefs? What are my values? and What is my condition?

Everyday clinical dilemmas

Everyday clinical dilemmas in general practice may not always be recognised as involving ethical challenges. Such cases will typically make the GP feel a bit uncomfortable and uncertain. Ethics is often seen as relevant to abstruse and complicated cases, such as cases concerning genetic testing for Huntingdon’s chorea or the reckless patient with a contagious disease. Complicated cases present relatively rarely, are recognisable and prompt us to readily seek advice from colleagues. This article offers four everyday clinical cases that illustrate ethical challenges to encourage not only thought and discussion about these cases, but also about similar cases that will present commonly to GPs and may be the subject of case-based discussions within ePortfolios or appraisal.

Education and debate: a manifesto for ethics and values at annual healthcare conferences

Abstract In this paper I discuss the ways in which the conference stream ethics and values manifested at the 2015 RCGP Annual Conference in Glasgow, and the ways in which it is planned for the 2016 RCGP Annual Conference in Harrogate. The 2015 RCGP had plenaries, oral presentations, breakout symposia, a debate, and a poster stream. I briefly discuss each in turn before offering a manifesto (a public statement of aims and proposed policy) for ethics and values at healthcare conferences. It is my hope that others will critique this, flesh it out further and even consider how ethics and values relate to conferences for healthcare workers of various specialities. A conference provides opportunities for ethics and values discussion that are potentially distinctive from any other kind of forum. Because conferences offer the potential for knowledge and attitudes to be revisited and revised, issues can be ‘unsettled’ in a way that permits different perspectives to be more fully discussed.

Singling out the double effect - some further comment.

Abstract We comment on a paper published in the same issue of the London Journal of Primary Care. We applaud Bow’s engagement with the ethical issues in a previous LJPC paper but argue that further work is needed to establish the everyday moral concerns of health care workers in primary care. We also suggest that the ethical distinction between advice and medication and devices may be artificial if both have an effect on a patient.

‘The House of God’: reflections 40 years on, in conversation with author Samuel Shem

The House of God is a seminal work of medical satire based on the gruelling internship experiences of Samuel Shem at the Beth Israel Hospital. Thirteen ‘Laws’ were offered to rationalise the seemingly chaotic patient management and flow. There have been large shifts in the healthcare landscape and practice since, so we consider whether these medical truisms are still applicable to contemporary National Health Service practice and propose updates where necessary: People are sometimes allowed to die. GOMERs (Get Out of My Emergency Room) still go to ground. Master yourself, join the multidisciplinary team. The patient is the one with the disease, but not the only one suffering. Placement (discharge planning) comes first. There is no body cavity that cannot be reached with a gentle arm and good interventional radiologists. Fit the rule to the patient rather than the patient to the rule. They can always pay you less. The only bad admission is a futile one. If you don’t take a temperature you can’t find a fever and if you are not going to act on it, don’t do the test. Show me a BMS (best medical student) who ONLY triples my work, and I’ll show you a future Foundation Year 1 doctor (FY1) who is an asset to the firm. Interpret radiology freely, but share your clinical findings with the radiologist and in a timely fashion. Doing nothing can be a viable option. These were developed in conversation with Samuel Shem, who also offers further insight on the creation of the original laws.

Evaluating case studies of community-oriented integrated care

Abstract This paper summarises a ten-year conversation within London Journal of Primary Care about the nature of community-oriented integrated care (COIC) and how to develop and evaluate it. COIC means integration of efforts for combined disease-treatment and health-enhancement at local, community level. COIC is similar to the World Health Organisation concept of a Community-Based Coordinating Hub – both require a local geographic area where different organisations align their activities for whole system integration and develop local communities for health. COIC is a necessary part of an integrated system for health and care because it enables multiple insights into ‘wicked problems’, and multiple services to integrate their activities for people with complex conditions, at the same time helping everyone to collaborate for the health of the local population. The conversation concludes seven aspects of COIC that warrant further attention.

Inside general practice ethics: guidelines ‘and’ ‘of’ or ‘for’ good clinical practice

Abstract The RCGP conference, like other annual healthcare conferences offers a protected space for reflection on ethical aspects of practice. This paper presents a summary and discussion of a fringe session led by the RCGP Committee On Medical Ethics at the 2017 RCGP annual conference in Liverpool. Well thought-out rules offer a potential solution to the burden of responsibility for making every single decision from first principles. But guidelines can be difficult to follow, too numerous to know, may conflict with each-other and may not be appropriate in all circumstances. Delegates at this meeting discussed barriers to good guideline development and implementation, perceptions of medicolegal risk in non-adherence, aspects of benefit, harm and justice in guideline use and ethical guidelines. Delegates found it easier in the meeting to critique clinical rather than ethical guidelines. There was broad agreement that understanding how to practice in relation to guidelines represented a learning need in general practice education.

Shared decision making: a need for honesty?

In this analysis we challenge the conceptual honesty of ‘shared decision making’, arguing that, although it is held up as an ideal decision-making standard, it is used too often to describe (and justify) decision-making practices that are not shared at all. This is problematic because, if the legitimacy of a decision relies on it being ‘shared’, but it is not in fact shared, the decision loses legitimacy, or is falsely legitimised by the appearance of being shared. We argue that the realities of clinical practice mean that genuinely shared decision making is not completely impossible but difficult to achieve in a sincere and just manner. We articulate an intentionally controversial stance, with the aim of generating thought and debate.nnShared decision making has been offered as a way of better respecting patient autonomy, leading to management plans or actions that are in tune with patient values and therefore improving concordance. It provides a platform for respecting autonomy while avoiding abandoning patients to their autonomy, by giving them information without assistance in interpretation; this allows them to arrive at informed decisions that are in accord with their beliefs, values, and preferences. This ideal accords with the deliberative model of the clinician/patient relationship put forward by Emmanuel and Emmanuel being morally preferable to a paternalistic or informative/commercial relationship.1nnIn arguing that shared decision making is the pinnacle of patient-centred care, Barry and Edgman-Levitan describe it in the following terms: ‘… the clinician offers options and describes their risks and benefits, and the patient expresses his or her preferences and values. Each participant …