INTRODUCTION
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:
Consciously avoiding judgements other than those which are clearly ‘medical’ and therefore ending any discussion which is not about medical treatment. This position itself ignores the value-laden nature of medical decisions.
Deferring to guidelines and the law even when this seems wrong.
Relying solely on specialist advisors (for example, from an indemnity body, or some kind of ethics consultant).
We 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.
Personal 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 or regulatory bodies have rightly determined to be beneficial or the correct approach. The values ascribed to clinicians, even with respect to compassion, have been challenged as unrealistic and too burdensome in the stressed healthcare workplace.1,3
One interpretation of these two positions is that it is unfair to patients and unfair to GPs (or other clinicians) for any ethical deliberation to take place at the bedside or in the consulting room. Clinicians should do as asked by the patient and the governing or regulatory bodies in line with established professional duties. If they do more or less it is in their own time and at their own risk.
GPs may also unconsciously avoid making ethical judgements, by deferring completely to patient choice, by accepting certain moral positions as self-evident, by equating the law with morality, and by conflating moral and empirical questions.
PARADIGM CASE
We use a published scenario where a clinician finds themselves in a position of moral authority because this brings with it an invitation to make a conscious ethical judgement. Accordingly, we discussed a paradigm case from the primary care ethics literature with broad similarities to cases we had all encountered. The key feature of the case is the request for advice that goes beyond the strictly medical. It is taken from a chapter on professional boundaries in a primary care ethics sourcebook which we recommend to any GP seeking to reflect on their professional boundaries.4
A young doctor, previously unknown to you, is discharged from hospital with her first baby, who has severe anoxic brain damage. Her pharmacist husband is clearly distraught and cannot accept this event. You are asked to advise.
You judge that this is going to destroy the parents’ relationship and strongly advise the possibility of arranging adoption. It is accepted. (They then have two brilliant children and successful careers).4
Toon suggests that the GP in the case is acting virtuously as a wise friend, possibly based on knowledge of the child’s predicted needs or experience of similar situations in family medicine. We ask ourselves, is the situation one in which a GP should advise? (Should an opinion only be offered if asked for?) Or should any discussion outside the purely medical be avoided. Doctors offering advice ‘outside their remit’ may be criticised for inappropriate interference with advice inappropriately imbued with medical authority. Conversely, clinicians may do their patients a disservice if they deliberately decline to exercise ethical judgement out of an affectation of clinical impartiality.5 It seems clearly within a ‘doctor remit’ to recommend that a patient stops smoking, but the remit becomes fuzzier when talking about social care; for example, whether to start a family.
ANGELS RUSH IN WHILE FOOLS SHOULD FEAR TO TREAD
Difficult ethical judgements are seldom welcome. They take time, get in the way, can be emotionally distressing, and bear legal ramifications. So there are plenty of ‘selfish’ reasons to try and ‘bounce’ them. To deal with them another time, to hope another clinician will deal with it, passing the buck along, either through time or up the hierarchy. Insofar as these reasons dominate, they should be resisted. However, there is virtue in recognising one’s own inexperience and seeking appropriate help.
We should acknowledge the difficulty of ethical engagement. GPs and other primary care clinicians work in relative isolation compared with their colleagues in secondary care.6 Primary care clinicians have poorer access to ethics education and support than their hospital colleagues.7 In the workplace, unrealistic values are ascribed to clinicians.2 Opening ethical decision making to scrutiny can be a perceived vulnerability for GPs.8 Gillies9, cites the Fragility of Goodness:
‘Events beyond our control may affect, for good or ill, not only our happiness or success or satisfaction, but also the central ethical elements of our lives: whether we manage to act justly in public life, whether we are able to love and care for another person, whether we get a chance to act courageously.’10
CONCLUSION
While we recognise that even ‘clearly medical’ cases have a moral component worthy of reflecting on, the above case provides a reasonable scenario for a discussion about whether to avoid making an ethical judgement. As such it and cases like it have significant educational value. Consciously avoiding involvement in ethical judgements could be criticised as moral cowardice, unconsciously avoiding involvement by an unreflective approach to practice could also be criticised as moral laziness.
Clinicians and other healthcare professionals need to be sensitive to ethical issues but also aware that such issues require decisions to be made (even if it is the decision to do nothing). Accordingly, an important role for ethics education may be a better understanding of moral agency.11 A question worth asking is ‘Do I have a role in the decision-making process and what is it?’. Ethical reflection and ethically informed action can be considered aspects of good leadership, as well as a part of good clinical care.
Notes
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The authors have declared no competing interests.
- © British Journal of General Practice 2016