A note on the ethics of the ordinary in primary healthcare

Andrew Papanikitas* is deputy editor of the BJGP. He is on twitter @gentlemedic
Peter Toon is a retired GP writer and virtue ethicist
Paquita De Zulueta, is Hon. senior lecturer in medical ethics and law at Imperial College and recently retired GP. She is on twitter @PdeZ_doc
David Misselbrook is senior ethics advisor for the BJGP
John Spicer* is a South London GP, ethicist and medical educator. He is on twitter @johnspicer3

This week’s BJGP Life articles (see bottom of article for what is coming up) will have an ethical or philosophical flavour, as BJGP Life launches a new column: Ethics of the ordinary (EotO) is a regular column that explores ‘ethical and moral concerns relevant to general practice and primary care.’

There are many reasons why primary care generates ethical and philosophical issues. Patients are likely to be meaningfully autonomous -fully clothed and fully conscious, more empowered to contest medical ideas of best interests and risk.¹ Primary care teams look after entire families, and generally do not discharge patients who choose not to comply with their recommendations. They can be left to look after patients deemed ‘untreatable’ by secondary care services.² They often have a holistic understanding of patients’ backgrounds, life stories and values acquired from longer term relationships built on trust and familiarity. And there is just so much general practice happening out there that involves moral complexity. A patient attends during a full surgery, distraught over a marital breakdown – how much time should you give them? Can this teenager be in a consensual relationship with their few-years-older partner? Should we be motivated by compassion or duty? Should we delay the initial COVID-19 vaccination programme because of possible risks? The issues are as endless and everyday as general practice itself. And it is a poorly kept secret that ethics teaching in undergraduate and postgraduate medical education is often delivered by general practitioners.³

Some cases involve much discussed ‘ethical dilemmas,” such as those concerning abortion or end of life care, or arise from societal or technological changes such as assisted fertility or advances in genomic medicine. But many raise everyday and ordinary issues which are ‘unsexy‘⁴ from a popular or academic perspective because they are not associated with a new technology, a change in the law or a moral panic. Dramatic and technology-driven ethical issues also clearly affect community and primary care settings. Issues and conflict may also arise in the interface between teams, whether they are located in hospitals or community settings.⁵

The ethics of the ordinary is a reference to the of issues and decisions found in everyday practice.^6,7,8 It may be that the public interest, or academic funding, or political gaze, have moved on. It may be that that undramatic instances still raise moral questions worth answering. EotO relates to all healthcare settings (not just general practice and not just those which are patient-facing).

EOTO has also been embodied as a mundane revolution in UK primary care, by groups of British GPs and allied academics in a variety of disciplines. Admiring the relative success of clinical ethics committees in hospitals and national groups⁹ like the Genethics Forum and the UK Clinical Ethics Network, some set up discussion groups,¹⁰ others contacted their local hospital ethics committee with their dilemmas.¹¹ We called for a body of knowledge and community of scholars to support primary healthcare^12,13 and ran a series of conferences at the Royal Society of Medicine over a decade, with support from the Institute of Medical Ethics, The University of Oxford and the RCGP.^14,15 A large group of us wrote an award-winning handbook of primary care ethics,¹⁶ cited in the RCGP curriculum. The BJGP ran an A-Z of medical philosophy – explicitly inviting readers to use the ideas in reflecting on their own professional lives.¹⁷ During this period the RCGP committee on medical ethics has been a presence at the RCGP annual conference, running sessions on (inter alia): shared decision-making, part-time working, sponsorship, guidelines and conflicts of interests as well as tackling artificial intelligence and genomic medicine in primary care.¹⁸

The references below represent the range and evolution of issues raised, and a collegial community which is far from homogenous in world view and intellectual tradition. You will see familiar authors from past and present, and we invite the wider BJGP and BJGP life community to join us in this discourse. We will include both solicited and reasonably argued unsolicited work in the EotO column. EotO will not shy away from controversial or divisive topics, and collegial discussion in the comments is encouraged. Please ensure that debate is respectful, and founded on reasonable arguments and facts.

What to expect the week commencing 14th February 2022 on BJGP Life:

• On Wednesday, Felicitas Selter, Kirsten Persson, and Gerald Neitzke discuss the similarities and differences in animal and human euthanasia as a source of moral distress for the practitioner.
• On Thursday, Helen Burn explains that because legalised physician-assisted dying would likely involve GPs, GPs should think about their views on the issue.
• On Friday, Matthew Davis and Ana Worthington argue that the arguments in favour of the recent Assisted Dying Bill at its second reading in the UK House of Lords are based on flawed evidence.
• On Saturday, Koki Kato introduces us to phenomenology as an approach to understanding patient-centred care, using his own illness-experience as a worked example.
• On Sunday Samar Razaq reflects on truth, medical opinion and the scholarship in the age of Twitter.

All this week’s BJGP Life articles have been recently independently submitted (none were commissioned). We hope that they generate discussion and collegial debate.

References

1. Brody H. The essence of primary care, p. 56-61 in The Healer’s Power. New Haven: Yale University Press. 1992
2. Pellegrino E. The healing relationship: the architronics of clinical medicine, in Shelp EA, ed. The clinical encounters: the moral fabric of the patient-physician relationship. Reidel, Dordrecht 1983
3. Misselbrook D (2012) The BJGP is open for ethics. Br J Gen Pract, DOI: https://doi.org/10.3399/bjgp12X629964
4. Butcher F (2011), The appeal of ‘unsexy’ ethics, https://wellcome755.rssing.com/chan-8434298/latest-article2.php (accessed 12/2/22)
5. Wiles K et al, Ethics in the interface between multidisciplinary teams: a narrative in stages for inter-professional education, London J Prim Care (Abingdon). 2016; 8(6): 100–104. doi: 10.1080/17571472.2016.1244892
6. Papanikitas A and Toon P, Last but not least: the ethics of the ordinary, Br J Gen Pract, 2010; 60 (580): 863-864. https://bjgp.org/content/60/580/863.full
7. Cyril et al, Ethics of the ordinary: a class response, Br J Gen Pract, 2012; 62 (595): e143-e146. DOI: https://doi.org/10.3399/bjgp12X625283
8. Gardner J et al, Emerging themes in the everyday ethics of primary care, Clinical Ethics 2011; 6 (4):211-214 doi: https://doi.org/10.1258/ce.2011.011034
9. Peile E. Supporting primary care with ethics advice and education, BMJ, 2001; 323(7303): 3–4. doi: 10.1136/bmj.323.7303.3
10. Evans Patel G, King A, and Spicer J, Healthcare ethics: learning in the workplace, Work Based Learning in Primary Care 2006; 4: 57–64 https://www.researchgate.net/publication/321318915_Healthcare_ethics_Learning_in_the_workplace accessed 12/2/22
11. Sokol D (2009), Who wants to be the flu GP? http://news.bbc.co.uk/1/hi/health/8135658.stm (accessed 12/2/22)
12. Papanikitas A, Toon P. Primary care ethics: a body of literature and a community of scholars? Journal of the Royal Society of Medicine. 2011;104(3):94-96. doi: https://doi.org/10.1258/jrsm.2010.100353
13. De Zulueta P. (2008) Welcome to the ethics section of the London Journal of Primary Care London Journal of Primary Care, doi: https://doi.org/10.1080/17571472.2008.11493183
14. Papanikitas A, et al. (2011) Ethics of the ordinary: a meeting run by the Royal Society of Medicine with the Royal College of General Practitioners. London Journal of Primary Care, doi: https://doi.org/10.1080/17571472.2011.11493331
15. Papanikitas A et al, 4th annual primary care ethics conference: ethics education and lifelong learning London J Prim Care (Abingdon). 2014; 6(6): 164–168. doi: https://doi.org/10.1080/17571472.2014.11494369
16. Jewell D, Brave new ethics, Br J Gen Pract 2019; 69 (681): 200. doi: https://doi.org/10.3399/bjgp19X702053
17. Misselbrook D (2013) An A-Z of medical philosophy. Br J Gen Pract, doi: https://doi.org/10.3399/bjgp13X660841
18. Papanikitas A. (2016) Education and debate: a manifesto for ethics and values at annual healthcare conferences. London Journal of Primary Care 8:6, pages 96-99. https://doi.org/10.1080/17571472.2016.1244152

Featured image: From the classroom to the clinic, by Andrew Papanikitas