John Goldie is a retired GP and medical educator.
At 9.02 on a Monday morning, the idea of the autonomous clinician starts to unravel. A patient at reception is angry because they can’t get an appointment. Another asks why their referral hasn’t arrived. The receptionist absorbs both with a calm that looks effortless but isn’t.
In my room, the computer crashes. A registrar appears with a safeguarding question. The phone rings. The system freezes. And yet I am still expected to be the autonomous clinician: rational, self-contained, accountable. It is a powerful image. It is also a misleading one.
Moral agency is not exercised in isolation but through negotiation, shared responsibility, and emotional labour.
General practice is relational at its core. We work through constant interaction with patients, reception staff, nurses, colleagues, and managers. Moral agency is not exercised in isolation but through negotiation, shared responsibility, and emotional labour. Ethical models that ignore this fail to describe the world in which general practice happens.
Autonomy mattered. It challenged paternalism and defended patient choice. But it no longer captures the moral complexity of contemporary primary care. The consultation is no longer a simple encounter between two people. Templates, prompts, and digital systems shape what can be said and done. Burden of Treatment Theory has shown how much of care is co-produced between patients, clinicians, and systems rather than delivered by individuals alone.¹ Reception staff remain the front line of access and emotional triage, while GPs carry accountability for outcomes that are jointly produced.
If autonomy is the wrong starting point, what might replace it?
One alternative is to begin with relationships. Confucian role ethics offers a useful lens—not as abstract philosophy but as a way of naming what many of us already recognise. Rather than asking what isolated individuals owe one another, it asks how moral responsibility arises from the roles we inhabit and the relationships we sustain.²
Seen this way, a GP participates in a web of roles: colleague, mentor, learner, listener, gatekeeper, boundary setter. Ethical practice is cultivated through everyday actions—how we open a consultation, hand over responsibility, manage disagreement, and repair ruptures. The moral life of a practice is made up of these repeated acts—what Confucian thinkers call li, the rituals that sustain relationships.³
This perspective brings reception work into clearer view. Often described as “administrative,” it is profoundly moral. Receptionists shape access, dignity, and fairness long before a patient reaches a clinician. They manage distress, anger, and scarcity on behalf of the system. If general practice has a moral centre, it sits as much at the reception desk as in the consulting room.
Consider a GP pausing before leaving the consultation room to call the patient, straightening their posture, greeting the patient by name with warmth and respect. None of these actions are required, yet together they create a predictable, humane rhythm that helps the patient feel safe and valued. This small choreography is li: micro-practices that sustain trust and hold the relationship itself.
Autonomy mattered. It challenged paternalism and defended patient choice. But it no longer captures the moral complexity of contemporary primary care.
This framework understands hierarchy not as licence but as obligation. Those with greater power owe greater attentiveness and care to those more vulnerable—patients, registrars, junior staff. This echoes care ethics, which emphasises responsibility and interdependence over individual autonomy.⁴⁻⁵ It is not paternalism, but recognition that power carries responsibility.
It also shifts how we understand accountability. Instead of asking, “Who is to blame?” we might ask, “Where did the relationship break down?” The focus moves from individual fault to collective repair, reflecting the realities of practice, where harm more often arises from frayed systems and stretched relationships.
There remain moments when responsibility narrows to one person: a safeguarding decision, a sudden deterioration, a disclosure that allows no time to seek advice. In these moments, the clinician must act, drawing on judgement and moral courage. Relational ethics does not dissolve this responsibility—it situates it. Individual accountability remains, but it is held within the moral life of the practice.
Releasing the myth of the autonomous clinician is quietly protective. It invites collaboration, shared responsibility, and mutual support. And it offers a more realistic starting point: If general practice strains at 9.02 on a Monday morning, it is not because clinicians lack autonomy, but because relationships are stretched to their limits. Any ethical framework worthy of our work must begin there.
Deputy editor’s note – see also by John Goldie: https://bjgplife.com/the-surgery-that-thinks/
References
- May C, Eton DT, Boehmer K, et al. Rethinking the patient: using Burden of Treatment Theory to understand the changing dynamics of illness. BMJ. 2014;349:g6680.
- Ames RT. Confucian Role Ethics: A Vocabulary. Hong Kong: Chinese University of Hong Kong Press; 2011.
- Ames RT, Rosemont H Jr. The Chinese Classic of Family Reverence: A Philosophical Translation of the Xiaojing. Honolulu: University of Hawai‘i Press; 2009.
- Tronto JC. Caring Democracy: Markets, Equality, and Justice. New York: NYU Press; 2013.
- Kleinman A. The Soul of Care: The Moral Education of a Husband and a Doctor. New York: Penguin; 2019.
Featured photo by Andrew Moca on Unsplash
