London Journal of Primary Care 2011;4:72–6
# 2011 Royal College of General Practitioners
Ethics
Everyday ethics: learning from an ‘ordinary’ consultation in general practice Caroline Allison GP and MSc Student, Department of Public Health and Primary Care, King’s College London, UK
Why this matters to me In daily practice, I encounter situations in which the use of an ethical framework is helpful in reflecting on the decisions I make. This article takes a ‘constructed’ clinical encounter based on my experiences and aims to analyse the issues arising with
reference to the relevant literature. I conclude by putting forward my own resolution and ideas for the future. Any similarity between this case and particular person, living or deceased is purely coincidental.
ABSTRACT The author uses a constructed case to analyse some of the ethical decisions that UK general practitioners face in everyday settings. A variety of ethical frameworks and empirical primary healthcare literature are used to demonstrate how ethical tools may be used by clinicians in primary healthcare to reflect on their decisions in practice. The GP
consultation context can make ‘on the spot’ ethical decisions difficult and varied. Keywords: autonomy, clinical decision making, ethics, Four Principles, justice, primary care, resource allocation
During a busy afternoon clinic ... During a busy afternoon clinic at a suburban health centre, a man (Dr X) attended with several demands. He was a 65-year-old, retired pathologist. He had a history of liver disease, hypertension, chronic depression and haemorrhoids. He was followed up at six-monthly intervals by a consultant-led hospital hepatology team. I had not met him before and I was relatively new to the practice at this stage. He wanted to discuss three things. The first was that he had been measuring his blood pressure at home and had become concerned that it was higher than it should be. He wanted to add another medication, and was asking for a specific drug from a class of medications that were not part of our local or national guidelines for managing hypertension. Not only was I concerned by my unfamiliarity with prescribing this drug, especially given his complicated medical past, but also, when I looked up the drug in the British National Formulary, despite having licence for use in
hypertension, it was not without a variety of serious side effects. Its cost profile from the local prescribing formulary also showed that it was considerably more costly than the guideline drugs. This prompted an apprehensive response from me based on my instinct for caution. My hesitation was met with frustration by the patient, who had predicted my response and was ready to vocalise a criticism that ‘the newer qualified doctors always try to avoid taking responsibility’. We put this to one side, temporarily, and pursued his other two requests. The second was that he wanted a longer prescription for his antidepressant medication instead of the two months usually issued. He had been using it for over seven years. It was documented that he refused referral to psychological therapies and had been placed on the antidepressant without trial of more frequently used drugs. He was frustrated by having to ‘report in’ to the GP every two months to request his repeat tablets,
Everyday ethics
which he had no intention of changing. Moving on to his final point, without engaging the second, in order to cover all of his agenda, he joked that on a lighter note, he wanted a cream for his haemorrhoids. However, the requested cream was an unusually highstrength version from a class of low-potency steroid creams (hydrocortisone), which was not favoured by the local formulary due to its high cost, and was not recommended by dermatologists. When I acknowledged this to the patient he was aware of the cost involved, but my offering him an appropriate alternative led to a threat that should his haemorrhoids worsen he would be making a complaint. By this stage, I had spent double the time allocated to me per patient for a consultation. I resolved to negotiate carefully to a mutual agreement. I checked his blood pressure and adjusted his current blood pressure medication accordingly, agreeing to write to the hepatology consultant to ask for his opinion on the specific drug request. I gave him a three-month prescription of antidepressant and asked him to see me again to engage with him further on looking into future ways to help with his depression. I ‘gave in’ and issued the expensive hydrocortisone cream with the fear of worsening his haemorrhoids and triggering a complaint, despite knowing that the alternative offered could not have been any less effective from a pharmacological perspective. I drew the consultation to a close expressing that I was sorry that his requests had met with discussion rather than simple action, but that I hoped he could understand the reasons for this, especially given his work within the NHS. He expressed that he had paid his dues to the state and had earned the right to be able to choose his medication at this stage.
Using ethical ideas to reflect on the consultation I now turn to unravelling this consultation from an ethical perspective to gain insight into my reactions and actions, and how best to approach situations like this again with more confidence and moral rationing. There are two main ethical issues that I want to discuss. The first is fair resource allocation. The patient requested two unusual and expensive medications, and a longer issue of antidepressant for which he would have to pay ‘less for more’. The extended time taken for the consultation was also a resource issue, as my time was cut short for dealing with other people’s medical problems. The second ethical issue is that of patient autonomy. Dr X had clear knowledge and ideas about what he wanted for his health, and he wanted the freedom to exert these.
73
This article therefore discusses the issues surrounding resource allocation and patient autonomy in primary care, and attempts to apply this knowledge at a consultation level. This article does not evaluate healthcare resource rationing from an economics perspective.
Ethical theory Both issues can be approached using a variety of ethical theories.1 The main ethical frameworks include consequentialism or more specifically utilitarianism, based on the ideas of Bentham and Mill, deontology, the Four Principles and virtue ethics. Utilitarian decisions are those in which the consequences maximise human happiness, or the morally right action is that with the best foreseeable consequences. Duty-based ethics (or the deontological approach) has its origins with Kant. Deontology approaches the action as morally right if it is in accord with the moral rule or principle. Four Principles plus scope analyses decisions based on patient autonomy, beneficence, non-maleficence and justice.2 A final example is virtue ethics developed from Aristotle’s views, which define a ‘morally good’ act as that which would have been chosen by a virtuous person, favouring acts of generosity or kindness.3 These core approaches can be applied to the areas of ethical interest, starting by looking at resource allocation, issues of money and time. NHS policy is that there should be equal access to healthcare based on equal need, free at the point of delivery.4 This leaves the GP with a tension between being the gatekeeper for the NHS and being the patient’s advocate. Awareness of the patient’s social and psychological context, within the environment of the GP surgery makes decisions on rationing easily open to coercion or negotiation, or the GP may be led to using resources in a biased fashion if they allow the most vocal patients to dictate terms.5 I primarily use the Four Principles to reflect on this case.
Using the Four Principles The Four Principle theory is helpful here because a deontological or utilitarian approach does not easily incorporate all the aspects required to make the decision and there is no overwhelming duty which offers the right or wrong solution. The action requires a balanced argument between allowing the patient to come to their own decisions about their care (autonomy) with the promotion of what is best for the patient (beneficence), whilst avoiding any harm
74
C Allison
(non-maleficence) with ultimate consideration for fair distribution of resources (justice). For example, my patient requested expensive medication and wanted to address three complicated issues, which all demanded time. This led to an unfair distribution of ‘healthcare’ directed at him. On reflection, I could not justify giving him the hypertensive medication because overall I felt that this was not in his best interests as it was an off-guidelines drug which could potentially cause harm (beneficence and non-maleficence). The patient’s right to choose (autonomy) needed to be in line with safety, and therefore I was able to weigh these principles in favour of withholding prescription, which was also in harmony with justice principles. Interestingly, the outcome was different when I issued the expensive steroid cream. Perhaps there was less at stake for beneficence and non-maleficence, and the patient’s explicit use of his autonomy (threatening complaint) ‘stacked up’ the pressure against ideas of justice or beneficence as reasons to withhold. This highlights that the context of a GP consultation can make ‘on the spot’ ethical decisions difficult and varied. Berney et al 5 analysed GP discussions about ethical dilemmas and concluded that the patient’s social and psychological criteria were significant components in decision making. The GPs in Berney et al’s study admitted that their own relationship with the patient affected outcomes. GPs are in a vulnerable position if they are only able to hold back the NHS purse strings when there is more at stake than just the expense or fairness of rationing. The duty to ‘make the care of your patient your first concern’or being a virtuous clinician (generosity) are at risk of overriding the principles of justice.6
Resource allocation and ethical conflict This controversy is highlighted in cases in which care may have been withheld or refused when cost is at the root of the decision. One such case is that of ‘Child B’ in which an expensive, second, bone-marrow transplant was withheld from a 10-year-old child who was suffering from terminal end-stage leukaemia. The decision was justified on the medical grounds that treatment would be futile at this point and so not costeffective. This was unsuccessfully challenged by the child’s father, leading to public outcry and debate. One discussion on the case suggested that money and human values were not equal, and proposed that one solution for mutual understanding was for more public involvement.7,8 The argument for shared decision making is promoted in a discussion by BogdanLovis.9 This approach involves making a shared decision in which all the evidence is placed in context,
including aspects of resource allocation, to make a default ‘frugal’ option, with the best outcome correlating the patient’s and society’s best interests. There is recognition that there are limits to resources at the point of decision making, and engaging the public with this concept is a critical step towards understanding. The evidence for consumer involvement in healthcare development was reassessed by a Cochrane intervention systematic review involving six trials.10 Unfortunately, this showed that there was little research to isolate the effectiveness of consumer involvement in developing healthcare policy. There is a need to assess public involvement directly in managing the rationing of medical decisions. Perhaps if I had stepped back from my consultation and explained fully to the patient the pharmacological argument in light of the costs and effectiveness of the more potent steroid cream, I might have engaged better and challenged his autonomy with more insight and from a less-threatened perspective. The rationing of healthcare took an interesting political turn recently with the coalition government’s White Paper,4 in which GPs have been explicitly given the task of forming consortia to commission healthcare. GPs must negotiate issues of cost-cutting (justice) with best patient care (beneficence/non-maleficence). It will remain a challenge to GPs to find ways to engage the public in understanding resource allocation in order to make fair policy and service development. This White Paper focuses on ‘putting patients at the heart of everything’, which links with the second ethical issue of patient autonomy. How do we incorporate respect for a patient’s right to choose with rationing healthcare? There is a tendency for patients to be attracted by the latest technology and medication, at high cost. GPs might be at risk of ‘manipulating autonomy’ depending on how they negotiate the options. The White Paper states that ‘patients will have more choice and control, helped by easy access to the information they need about the best GPs and hospitals. Patients will be in charge of making decisions about their care.’ The White Paper only later acknowledges that ‘doctors and nurses must be able to use their professional judgement about what is right for a patient, with decision making in the hands of professionals and patients (shared decision making)’ (Department of Health4, pp. 3, 13). Practical consultation-level management is therefore thrown into the familiar conflict, resting on the judgement of the GP to reach an ethical decision with their patient.
Dr X’s autonomy In this case, Dr X wanted the right to choose his own hypertensive medication and steroid cream. This is based on the premise that he was a competent adult,
Everyday ethics
who had some expert knowledge having been a pathologist. He believed that he had a greater right to choose, given that he had ‘done his bit’ for the NHS. With the Four Principle ethical approach, the overall ‘right decision’ rests in weighing up each of the four elements, as explained earlier. For example, I allowed acting in his ‘best interest’ to outweigh his autonomy in respect to the issuing of the hypertensive drug. This was based on beneficence (doing good by remaining within national guidelines), non-maleficence (avoiding serious side effects) and justice. Remaining within clinical guidelines, however, is an ethical issue in itself.11 His autonomy outweighed the outcome towards prescribing his requested expensive steroid cream. Perhaps a virtuous ethical approach fits analysis of this specific point; in each aspect of the decision making I wanted to behave as a virtuous physician. Rogers found that GPs operated decision making with a variety of levels for ‘respecting autonomy’.12 She analysed GP consultations with patients complaining of back pain and requesting different management options, including the request for narcotic analgesia, X-rays, complementary therapies and time off work. She found that the outcome depended on the individual GP’s attitude towards the patient’s right to autonomy. Rogers acknowledged that the justification for denying or limiting requests was often based on a form of ‘non-maleficence’. Interpreting patient autonomy was being placed in the biopsychosocial context of the consultation in order to make decisions. If patients demand specific care or treatment they should be fully informed of the risks and benefits of their option. This is a deontological approach to autonomy; the doctor’s ‘duty’ is to provide information that is up-to-date and evidence based.6 I believe that enabling autonomy goes hand in hand with enabling informed consent. If patients want to choose, they must also expect to take on responsibility or consequence for the part they play in the decision.5 Perhaps this is where the social responsibility for limited resources links back in and must be realised.
Conclusions This reflection has focused on issues arising from a consultation that provoked areas of conflict between the patient and doctor. There were questions of how much autonomy a patient should have in making clinical decisions, and how the GP manages the fair allocation of resources. I have focused mainly on the Four Principles approach to analysing my actions. These areas of discussion are ‘hot topics’ for GPs in the current climate of government proposals for change in the recent White Paper. I have argued that overall
75
decisions are weighed within the context of the individual consultation and outcomes can vary. The GP must juggle exposure to several pressures. In my case, these included expert knowledge, emotional pressures and time allocation. I hope that GPs will aim to work with patient demands in an open manner, in order to embrace autonomy within a context of fairness. In the above case, this is likely to involve requesting a second consultation with the patient, given the time required for discussion. Increased reflection, especially for the GP new to practice, may also be indicated when faced with patient requests for unfamiliar procedures or medications. Easier access to high-quality information and collaboration with professional colleagues may be needed to fairly direct care, especially for complicated cases. For the government’s proposal of shared decision making to work in reality, there needs to be shared understanding between the clinician and the ‘professional patient’, incorporating responsibility sharing along the way, and ultimately acceptance from both sides that best interests must be in line with both the patient and society. I do not believe that this is an easy task and it will involve a change in approach to ‘option giving’. This article has highlighted the aspects of this case that were in ethical conflict. It also signposts current literature which reflective practitioners my find relevant to a case like this. REFERENCES 1 Hope T, Savulescu J and Hendrick J. Medical Ethics and Law. The Core Curriculum. London: Churchill Livingstone Elsevier, 2003. 2 Gillon R. Four principles plus attention to scope. BMJ 1994;309:184. 3 Gillies J. Ethics in primary care; theory and practice. InnovAit 2009;2(3):183–190. 4 Department of Health. White Paper. Equity and Excellence: Liberating the NHS, 2010. Available at: www.dh. gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAnd guidance/DH_117353 5 Berney L, Kelly M, Doyal L, Feder G, Griffiths C and Jones I. Ethical principles and the rationing of health care: a qualitative study in general practice. British Journal of General Practice 2005;55:620–625. 6 General Medical Council. Good Medical Practice: Duties of a Doctor. London: GMC, 2006. 7 Burgoyne C. Distributive justice and rationing in the NHS: framing effects in press coverage of a controversial decision. Journal of Community & Applied Social Psychology 1997;7:119–136. 8 Price D. Lessons for health care rationing from the case of child B. BMJ 1996;312:167–169. 9 Bogdan-Lovis E and Holmes-Rovner M. Prudent evidence-fettered shared decision-making. Journal of Evaluation in Clinical Practice 2010;16(2):376–381. 10 Nilsen ES, Myrhaug HT, Johansen M, Oliver S and Oxman A. Methods of consumer involvement in
76
C Allison
developing healthcare policy and research, clinical guidelines and patient information material (Review). Cochrane Database of Systematic Reviews 2006; 3, Art. No: CD004563. DOI: 10.1002/14651858.CD004563. pub2 11 Rogers W. Are guidelines ethical? Some considerations for general practice. British Journal of General Practice 2002;52:663–669. 12 Rogers W. Whose autonomy? Which choice? A study of GPs’ attitudes towards patient autonomy in the management of low back pain. Family Practice 2002;19:140– 145.
13 Slowther A, Ford S and Schofield T. Ethics of evidence based medicine in the primary care setting. Journal of Medical Ethics 2004;30:151–155.
ADDRESS FOR CORRESPONDENCE
Dr C Allison, Hillyfields Medical Centre, 172 Adelaide Avenue, London SE4 1JN, UK. Email: caroline. [email protected] Submitted 22 March 2011, accepted for publication 28 March 2011
Read and comment on this article online at www.londonjournalofprimary care.org.uk/
# 2011 Royal College of General Practitioners
Ethics
Everyday ethics: learning from an ‘ordinary’ consultation in general practice Caroline Allison GP and MSc Student, Department of Public Health and Primary Care, King’s College London, UK
Why this matters to me In daily practice, I encounter situations in which the use of an ethical framework is helpful in reflecting on the decisions I make. This article takes a ‘constructed’ clinical encounter based on my experiences and aims to analyse the issues arising with
reference to the relevant literature. I conclude by putting forward my own resolution and ideas for the future. Any similarity between this case and particular person, living or deceased is purely coincidental.
ABSTRACT The author uses a constructed case to analyse some of the ethical decisions that UK general practitioners face in everyday settings. A variety of ethical frameworks and empirical primary healthcare literature are used to demonstrate how ethical tools may be used by clinicians in primary healthcare to reflect on their decisions in practice. The GP
consultation context can make ‘on the spot’ ethical decisions difficult and varied. Keywords: autonomy, clinical decision making, ethics, Four Principles, justice, primary care, resource allocation
During a busy afternoon clinic ... During a busy afternoon clinic at a suburban health centre, a man (Dr X) attended with several demands. He was a 65-year-old, retired pathologist. He had a history of liver disease, hypertension, chronic depression and haemorrhoids. He was followed up at six-monthly intervals by a consultant-led hospital hepatology team. I had not met him before and I was relatively new to the practice at this stage. He wanted to discuss three things. The first was that he had been measuring his blood pressure at home and had become concerned that it was higher than it should be. He wanted to add another medication, and was asking for a specific drug from a class of medications that were not part of our local or national guidelines for managing hypertension. Not only was I concerned by my unfamiliarity with prescribing this drug, especially given his complicated medical past, but also, when I looked up the drug in the British National Formulary, despite having licence for use in
hypertension, it was not without a variety of serious side effects. Its cost profile from the local prescribing formulary also showed that it was considerably more costly than the guideline drugs. This prompted an apprehensive response from me based on my instinct for caution. My hesitation was met with frustration by the patient, who had predicted my response and was ready to vocalise a criticism that ‘the newer qualified doctors always try to avoid taking responsibility’. We put this to one side, temporarily, and pursued his other two requests. The second was that he wanted a longer prescription for his antidepressant medication instead of the two months usually issued. He had been using it for over seven years. It was documented that he refused referral to psychological therapies and had been placed on the antidepressant without trial of more frequently used drugs. He was frustrated by having to ‘report in’ to the GP every two months to request his repeat tablets,
Everyday ethics
which he had no intention of changing. Moving on to his final point, without engaging the second, in order to cover all of his agenda, he joked that on a lighter note, he wanted a cream for his haemorrhoids. However, the requested cream was an unusually highstrength version from a class of low-potency steroid creams (hydrocortisone), which was not favoured by the local formulary due to its high cost, and was not recommended by dermatologists. When I acknowledged this to the patient he was aware of the cost involved, but my offering him an appropriate alternative led to a threat that should his haemorrhoids worsen he would be making a complaint. By this stage, I had spent double the time allocated to me per patient for a consultation. I resolved to negotiate carefully to a mutual agreement. I checked his blood pressure and adjusted his current blood pressure medication accordingly, agreeing to write to the hepatology consultant to ask for his opinion on the specific drug request. I gave him a three-month prescription of antidepressant and asked him to see me again to engage with him further on looking into future ways to help with his depression. I ‘gave in’ and issued the expensive hydrocortisone cream with the fear of worsening his haemorrhoids and triggering a complaint, despite knowing that the alternative offered could not have been any less effective from a pharmacological perspective. I drew the consultation to a close expressing that I was sorry that his requests had met with discussion rather than simple action, but that I hoped he could understand the reasons for this, especially given his work within the NHS. He expressed that he had paid his dues to the state and had earned the right to be able to choose his medication at this stage.
Using ethical ideas to reflect on the consultation I now turn to unravelling this consultation from an ethical perspective to gain insight into my reactions and actions, and how best to approach situations like this again with more confidence and moral rationing. There are two main ethical issues that I want to discuss. The first is fair resource allocation. The patient requested two unusual and expensive medications, and a longer issue of antidepressant for which he would have to pay ‘less for more’. The extended time taken for the consultation was also a resource issue, as my time was cut short for dealing with other people’s medical problems. The second ethical issue is that of patient autonomy. Dr X had clear knowledge and ideas about what he wanted for his health, and he wanted the freedom to exert these.
73
This article therefore discusses the issues surrounding resource allocation and patient autonomy in primary care, and attempts to apply this knowledge at a consultation level. This article does not evaluate healthcare resource rationing from an economics perspective.
Ethical theory Both issues can be approached using a variety of ethical theories.1 The main ethical frameworks include consequentialism or more specifically utilitarianism, based on the ideas of Bentham and Mill, deontology, the Four Principles and virtue ethics. Utilitarian decisions are those in which the consequences maximise human happiness, or the morally right action is that with the best foreseeable consequences. Duty-based ethics (or the deontological approach) has its origins with Kant. Deontology approaches the action as morally right if it is in accord with the moral rule or principle. Four Principles plus scope analyses decisions based on patient autonomy, beneficence, non-maleficence and justice.2 A final example is virtue ethics developed from Aristotle’s views, which define a ‘morally good’ act as that which would have been chosen by a virtuous person, favouring acts of generosity or kindness.3 These core approaches can be applied to the areas of ethical interest, starting by looking at resource allocation, issues of money and time. NHS policy is that there should be equal access to healthcare based on equal need, free at the point of delivery.4 This leaves the GP with a tension between being the gatekeeper for the NHS and being the patient’s advocate. Awareness of the patient’s social and psychological context, within the environment of the GP surgery makes decisions on rationing easily open to coercion or negotiation, or the GP may be led to using resources in a biased fashion if they allow the most vocal patients to dictate terms.5 I primarily use the Four Principles to reflect on this case.
Using the Four Principles The Four Principle theory is helpful here because a deontological or utilitarian approach does not easily incorporate all the aspects required to make the decision and there is no overwhelming duty which offers the right or wrong solution. The action requires a balanced argument between allowing the patient to come to their own decisions about their care (autonomy) with the promotion of what is best for the patient (beneficence), whilst avoiding any harm
74
C Allison
(non-maleficence) with ultimate consideration for fair distribution of resources (justice). For example, my patient requested expensive medication and wanted to address three complicated issues, which all demanded time. This led to an unfair distribution of ‘healthcare’ directed at him. On reflection, I could not justify giving him the hypertensive medication because overall I felt that this was not in his best interests as it was an off-guidelines drug which could potentially cause harm (beneficence and non-maleficence). The patient’s right to choose (autonomy) needed to be in line with safety, and therefore I was able to weigh these principles in favour of withholding prescription, which was also in harmony with justice principles. Interestingly, the outcome was different when I issued the expensive steroid cream. Perhaps there was less at stake for beneficence and non-maleficence, and the patient’s explicit use of his autonomy (threatening complaint) ‘stacked up’ the pressure against ideas of justice or beneficence as reasons to withhold. This highlights that the context of a GP consultation can make ‘on the spot’ ethical decisions difficult and varied. Berney et al 5 analysed GP discussions about ethical dilemmas and concluded that the patient’s social and psychological criteria were significant components in decision making. The GPs in Berney et al’s study admitted that their own relationship with the patient affected outcomes. GPs are in a vulnerable position if they are only able to hold back the NHS purse strings when there is more at stake than just the expense or fairness of rationing. The duty to ‘make the care of your patient your first concern’or being a virtuous clinician (generosity) are at risk of overriding the principles of justice.6
Resource allocation and ethical conflict This controversy is highlighted in cases in which care may have been withheld or refused when cost is at the root of the decision. One such case is that of ‘Child B’ in which an expensive, second, bone-marrow transplant was withheld from a 10-year-old child who was suffering from terminal end-stage leukaemia. The decision was justified on the medical grounds that treatment would be futile at this point and so not costeffective. This was unsuccessfully challenged by the child’s father, leading to public outcry and debate. One discussion on the case suggested that money and human values were not equal, and proposed that one solution for mutual understanding was for more public involvement.7,8 The argument for shared decision making is promoted in a discussion by BogdanLovis.9 This approach involves making a shared decision in which all the evidence is placed in context,
including aspects of resource allocation, to make a default ‘frugal’ option, with the best outcome correlating the patient’s and society’s best interests. There is recognition that there are limits to resources at the point of decision making, and engaging the public with this concept is a critical step towards understanding. The evidence for consumer involvement in healthcare development was reassessed by a Cochrane intervention systematic review involving six trials.10 Unfortunately, this showed that there was little research to isolate the effectiveness of consumer involvement in developing healthcare policy. There is a need to assess public involvement directly in managing the rationing of medical decisions. Perhaps if I had stepped back from my consultation and explained fully to the patient the pharmacological argument in light of the costs and effectiveness of the more potent steroid cream, I might have engaged better and challenged his autonomy with more insight and from a less-threatened perspective. The rationing of healthcare took an interesting political turn recently with the coalition government’s White Paper,4 in which GPs have been explicitly given the task of forming consortia to commission healthcare. GPs must negotiate issues of cost-cutting (justice) with best patient care (beneficence/non-maleficence). It will remain a challenge to GPs to find ways to engage the public in understanding resource allocation in order to make fair policy and service development. This White Paper focuses on ‘putting patients at the heart of everything’, which links with the second ethical issue of patient autonomy. How do we incorporate respect for a patient’s right to choose with rationing healthcare? There is a tendency for patients to be attracted by the latest technology and medication, at high cost. GPs might be at risk of ‘manipulating autonomy’ depending on how they negotiate the options. The White Paper states that ‘patients will have more choice and control, helped by easy access to the information they need about the best GPs and hospitals. Patients will be in charge of making decisions about their care.’ The White Paper only later acknowledges that ‘doctors and nurses must be able to use their professional judgement about what is right for a patient, with decision making in the hands of professionals and patients (shared decision making)’ (Department of Health4, pp. 3, 13). Practical consultation-level management is therefore thrown into the familiar conflict, resting on the judgement of the GP to reach an ethical decision with their patient.
Dr X’s autonomy In this case, Dr X wanted the right to choose his own hypertensive medication and steroid cream. This is based on the premise that he was a competent adult,
Everyday ethics
who had some expert knowledge having been a pathologist. He believed that he had a greater right to choose, given that he had ‘done his bit’ for the NHS. With the Four Principle ethical approach, the overall ‘right decision’ rests in weighing up each of the four elements, as explained earlier. For example, I allowed acting in his ‘best interest’ to outweigh his autonomy in respect to the issuing of the hypertensive drug. This was based on beneficence (doing good by remaining within national guidelines), non-maleficence (avoiding serious side effects) and justice. Remaining within clinical guidelines, however, is an ethical issue in itself.11 His autonomy outweighed the outcome towards prescribing his requested expensive steroid cream. Perhaps a virtuous ethical approach fits analysis of this specific point; in each aspect of the decision making I wanted to behave as a virtuous physician. Rogers found that GPs operated decision making with a variety of levels for ‘respecting autonomy’.12 She analysed GP consultations with patients complaining of back pain and requesting different management options, including the request for narcotic analgesia, X-rays, complementary therapies and time off work. She found that the outcome depended on the individual GP’s attitude towards the patient’s right to autonomy. Rogers acknowledged that the justification for denying or limiting requests was often based on a form of ‘non-maleficence’. Interpreting patient autonomy was being placed in the biopsychosocial context of the consultation in order to make decisions. If patients demand specific care or treatment they should be fully informed of the risks and benefits of their option. This is a deontological approach to autonomy; the doctor’s ‘duty’ is to provide information that is up-to-date and evidence based.6 I believe that enabling autonomy goes hand in hand with enabling informed consent. If patients want to choose, they must also expect to take on responsibility or consequence for the part they play in the decision.5 Perhaps this is where the social responsibility for limited resources links back in and must be realised.
Conclusions This reflection has focused on issues arising from a consultation that provoked areas of conflict between the patient and doctor. There were questions of how much autonomy a patient should have in making clinical decisions, and how the GP manages the fair allocation of resources. I have focused mainly on the Four Principles approach to analysing my actions. These areas of discussion are ‘hot topics’ for GPs in the current climate of government proposals for change in the recent White Paper. I have argued that overall
75
decisions are weighed within the context of the individual consultation and outcomes can vary. The GP must juggle exposure to several pressures. In my case, these included expert knowledge, emotional pressures and time allocation. I hope that GPs will aim to work with patient demands in an open manner, in order to embrace autonomy within a context of fairness. In the above case, this is likely to involve requesting a second consultation with the patient, given the time required for discussion. Increased reflection, especially for the GP new to practice, may also be indicated when faced with patient requests for unfamiliar procedures or medications. Easier access to high-quality information and collaboration with professional colleagues may be needed to fairly direct care, especially for complicated cases. For the government’s proposal of shared decision making to work in reality, there needs to be shared understanding between the clinician and the ‘professional patient’, incorporating responsibility sharing along the way, and ultimately acceptance from both sides that best interests must be in line with both the patient and society. I do not believe that this is an easy task and it will involve a change in approach to ‘option giving’. This article has highlighted the aspects of this case that were in ethical conflict. It also signposts current literature which reflective practitioners my find relevant to a case like this. REFERENCES 1 Hope T, Savulescu J and Hendrick J. Medical Ethics and Law. The Core Curriculum. London: Churchill Livingstone Elsevier, 2003. 2 Gillon R. Four principles plus attention to scope. BMJ 1994;309:184. 3 Gillies J. Ethics in primary care; theory and practice. InnovAit 2009;2(3):183–190. 4 Department of Health. White Paper. Equity and Excellence: Liberating the NHS, 2010. Available at: www.dh. gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAnd guidance/DH_117353 5 Berney L, Kelly M, Doyal L, Feder G, Griffiths C and Jones I. Ethical principles and the rationing of health care: a qualitative study in general practice. British Journal of General Practice 2005;55:620–625. 6 General Medical Council. Good Medical Practice: Duties of a Doctor. London: GMC, 2006. 7 Burgoyne C. Distributive justice and rationing in the NHS: framing effects in press coverage of a controversial decision. Journal of Community & Applied Social Psychology 1997;7:119–136. 8 Price D. Lessons for health care rationing from the case of child B. BMJ 1996;312:167–169. 9 Bogdan-Lovis E and Holmes-Rovner M. Prudent evidence-fettered shared decision-making. Journal of Evaluation in Clinical Practice 2010;16(2):376–381. 10 Nilsen ES, Myrhaug HT, Johansen M, Oliver S and Oxman A. Methods of consumer involvement in
76
C Allison
developing healthcare policy and research, clinical guidelines and patient information material (Review). Cochrane Database of Systematic Reviews 2006; 3, Art. No: CD004563. DOI: 10.1002/14651858.CD004563. pub2 11 Rogers W. Are guidelines ethical? Some considerations for general practice. British Journal of General Practice 2002;52:663–669. 12 Rogers W. Whose autonomy? Which choice? A study of GPs’ attitudes towards patient autonomy in the management of low back pain. Family Practice 2002;19:140– 145.
13 Slowther A, Ford S and Schofield T. Ethics of evidence based medicine in the primary care setting. Journal of Medical Ethics 2004;30:151–155.
ADDRESS FOR CORRESPONDENCE
Dr C Allison, Hillyfields Medical Centre, 172 Adelaide Avenue, London SE4 1JN, UK. Email: caroline. [email protected] Submitted 22 March 2011, accepted for publication 28 March 2011
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