John Spicer

Ethics of the Ordinary - A meeting run by the Royal Society of Medicine with the Royal College of General Practitioners

Ethics has long been recognised as an integral element of primary healthcare.1 Despite the ubiquity of ethical challenges and dilemmas in primary care, it remains a neglected domain in the world of bioethics. Accordingly, there have been calls to explore the ethical dimensions of primary healthcare.2,3 On 15 February 2011 the Royal Society of Medicine ran a conference in association with the Royal College of General Practitioners in order to fulfil this need. The conference aspired to create a lively discourse between interested practitioners such that they had the opportunity to share ideas, research and literature in the context of primary healthcare ethics. This aspiration was fully met and 70 people convened, including medical students, academics and seasoned practitioners who made use of the opportunity to share their thoughts and experiences, research ideas and projects. The focus was on ‘everyday ethics’ – the moral dimensions underpinning interactions and relationships between clinicians, patients and their families and the subtle but complex ethical dimensions of everyday life. The recent changes to GP training and requirements for revalidation, and changes in societal attitudes provide an urgent need for a solid foundation of a body of knowledge (both theoretical and empirical) and a community of scholars who are concerned with the ethics underpinning a vast majority of healthcare interactions. Two keynote speakers opened the event. Iona Heath, RCGP president, and Deborah Bowman, senior lecturer in medical ethics and law. Iona Heaths inspirational talk highlighted the experience of the particular and how the uniqueness of individuals, their encounters and their narratives cannot be forced into a procrustean framework of rules and generalities. She outlined her view of the challenges facing ethical practice in primary care and emphasised the key role of compassion. Deborah Bowman, drawing from her own qualitative research, highlighted the extraordinary in the ordinary and how bioethics has not captured the ethics of the ordinary. She emphasised the centrality of relationships and the roles of the GP as advocate, holistic practitioner and healer. We explored three themes in the workshops: research in primary care ethics, issues affecting training and issues in practice. There were also 15 poster presentations. These could be categorised into two broad themes: the clinician–patient (or teacher–student) relationship and ‘micro-ethics’,4 exploring personal and professional boundaries, the role of power, families, values and emotions in the relationship. The second theme was the exploration of the greater relevance and appropriateness of ethical paradigms other than the four principles, such as virtue ethics and feminist ethics for understanding and illuminating ethical problems, including rationing in healthcare.

Oregon and the UK: experiments in resource allocation

Decisions about how to spend money allocated to healthcare are complicated and merit a fully reasoned approach. Sources of moral justification for such decisions are examined and the innovative system engineered in the US state of Oregon described. Contrasts are drawn with the UK model and the conclusion is drawn that some public influence on such decisions is useful and should be explored.

University-linked localities.

In this article, we propose that reframing the old concept of ‘academic general practices’ as ‘university-linked localities’ will help to integrate the work of those leading commissioning, education, research and public health. It will provide a ‘playground’ for different disciplines to creatively interact for the benefit of all.

How primary care can contribute to good mental health in adults

Abstract The need for support for good mental health is enormous. General support for good mental health is needed for 100% of the population, and at all stages of life, from early childhood to end of life. Focused support is needed for the 17.6% of adults who have a mental disorder at any time, including those who also have a mental health problem amongst the 30% who report having a long-term condition of some kind. All sectors of society and all parts of the NHS need to play their part. Primary care cannot do this on its own. This paper describes how primary care practitioners can help stimulate such a grand alliance for health, by operating at four different levels – as individual practitioners, as organisations, as geographic clusters of organisations and as policy-makers.

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.

4th annual primary care ethics conference: Ethics education and lifelong learning

Primary care ethics is a field of study that has recently found new life, with calls to establish the relevance of ethical discussion in general practice, to gather a body of literature and to carve out an intellectual space for primary care on the academic landscape of bioethics. In this report, we reflect on the key strands of the 4th primary care ethics conference held at the Royal Society of Medicine, on a theme of ethics education and lifelong learning: first, to produce insights that have relevance for policy and practice; and second, to illustrate the idea that not only is ethics relevant in primary care, but primary care is relevant in medical ethics. Core themes included the advantages and disadvantages of prescriptive ways of doing ethics in education, ethical reflection and potential risk to professional status, the need to deal with societal change and to take on board the insights gained from empirical work, whether this is about different kinds of fatherhood, or work on the causes of moral distress in healthcare workers.

Tales of two European cities: primary care in actualité.

Comparisons between primary care settings in Europe are of particular interest since the RCGP adopted EURACT criteria in the new MRCGP curriculum. This article contrasts two everyday GP experiences between Italy and England. Themes of practice are shown to be common but systemic differences are evident and prevail. The reader is encouraged to reflect on these two aspects in the course of the article

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.

Integrated care in the UK: variations on a theme?

This short review compares the experiences of Scotland and Wales in developing integrated care with those of England, and to some extent Northern Ireland. It is a companion piece to two other articles published in this issue from Scotland and Wales.

Bach and clinical care: a proposition.

My purpose in this short piece is to suggest that, just possibly, listening to Bach can make you a better clinician. Arguably, listening to any music might make you a better clinician, but perhaps Bach has the edge.1 One doctor, for example, alluded powerfully to the role of Bach, and only Bach, in stilling the various conflicted thoughts crowding his head, when he wanted to think.2 No doubt others would offer similar sentiments. To do this I want to consider the Chaconne in D minor (from the 2nd violin partita), written for solo violin but often performed and recorded these days on the guitar. Johannes Brahms wrote that the Chaconne contained ‘a whole world of deepest thoughts and most powerful feelings’, on its face a pretty good statement of the material offered to us as general practitioners in long term relationships with patients. It is thought that Bach wrote the Chaconne as a response to the death of his first wife, a sombre expression of the grief he experienced. To most ears the music reveals love, anguish, death and fear: it is rich, clearly, in emotion. Thus to understand and reflect on the piece it is necessary to listen to it, quite evidently, and if listened to, what is heard? It is about 15 minutes long, just the same as an average sort of patient interaction in UK primary care, perhaps a little longer. It is more or less structured as a ‘passacaglia’ wherein the same sequence of notes is repeated; in this case about 70 times, and within a complicated series of variations. That sequence of notes is constructed into harmonies (where several notes are sounded together) which progress and change over time. It would be tempting to say that anything repeated 70 times may turn out to be tiring, taxing or uninventive. Of course, in Bachs hands this is never so: what we hear is an innovative and constantly renewed musical structure, simple in appearance but complex in its final presentation. Ask yourself what you hear in a consultation with a ‘complicated’ patient. There will be experiences, feelings, symptoms, reports of life events and relationships, among other things. It takes sensitivity to help the patient discuss all of this; and the skills of listening, clarifying and perhaps advising. Of these we might say that the listening is the most important of these skills: these aspects have been examined elsewhere in great detail and I suggest it is accepted prima facie. Various sources could amplify this area if the reader wishes it.3 Over time our conversations with patients like this can have a variable though repetitive structure, as the life events they encounter and their responses to them are rehearsed over and over with us. Helping such patients is often helping them to make sense of the connections between these events and their own responses, demanding an interpretive and listening skill. Learning to listen well can take many forms, and listening to music clearly offers a very different experience from listening to patients. Listening to music does not offer a concrete version of the world: it is an abstracted, intangible form, much dependent on cultural determinants. John Sloboda, a noted author in this field, wonderfully articulates the psychological mechanisms we use to interpret musical structure as we listen to it.4 Bachs Chaconne, as stated, is a powerful description of grief and it usually brings about similar emotional responses in people who listen to it. As such it can articulate emotions in those listeners that are of value in interpreting stories of emotions in our patients. Clearly there are degrees of skill in the construction of the music we choose to listen to, and I suppose it is part of my argument that listening to the Chaconne brings that emotional arousal about in a deeper or profound manner, than the cold emotions of a shimmering balladeer. So, in summary, when we as clinicians listen to something as profound as the Chaconne we are hearing the transmuted emotions of a great composer to which we respond emotionally and interpretively: we have two ways of responding. And that is just the same sort of task we face when listening to the stories of our patients, particularly the complex patients. I suggest the two areas of activity help each other. In putting these thoughts together I am indebted to Mike Lasserson, a long serving RCGP member and faculty officer in London, who powerfully described his inspiration in Bach and the Chaconne in particular.5 I share his enthusiasms, though not his skills, and hope at least some of the former have been articulated