Practical Ethics for General Practice

In 1982, Stephen Toulmin wrote an influential article entitled, ‘How medicine saved the life of ethics’.1 Moral philosophers, he suggested, were locked into complex, arcane debates of limited or zero interest to those outside the discipline. When, in the 1960s, they began to look at the ethics of medicine, they had to look at particular situations, individual cases, professional enterprises, and human relationships — the swampy lowlands of practical ethics, rather than the sunlight uplands of ethical theorising. Moral philosophy was saved from being shunted to the sidelines of academia by giving a substrate on which the discipline could work. Hence the burgeoning of bioethics and bioethicists over the past 20 years.

This book is part of that exponential growth. As the title suggests, it is a practical book. The authors, two Australian ethicists, describe four fictional practices in London, Bath, rural Yorkshire, and Glasgow, and use this as a device to generate situations and stories to illustrate ethical principles and dilemmas.

After a short introduction on ethical theories and approaches, there are chapters on trust, confidentiality, beneficence, justice, and autonomy, (although not a separate chapter on non-maleficence). They then cover ethical issues at the beginning and end of life, role conflicts, and finish with a section on the virtues of being a good doctor.

Examples are well chosen, in that they reflect common GP problems, as well as those of intimacy, gift-giving, and sexual involvement. Relevant law is covered where appropriate, with references to the 1967 Abortion Act, Gillick competence, Bolam, and the Human Rights Act. The ethical issues raised by preventive care and screening get a brief, but thoughtful, section. The chapter on justice and resource allocation in the NHS, an area on which more attention is continually being focused, gives a very clear exposition of the problem and philosophical approaches from differing theoretical viewpoints. I have a niggling feeling that in the NHS, the most demanding and vociferous patients, as well as well-funded single disease organisations, increasingly get a disproportionate share of the cake by putting pressure on everyone — receptionists, doctors, health authorities, politicians, and the media. Is this an inevitable consequence of the displacement of paternalism by consumerism?

Most of us who work as GPs seem to have got by without a detailed understanding of ethics, but there are reasons for thinking that, as a profession, we should look more closely at this area, both for established GPs and those in training. Ethics provides a framework for reflective practice, and can be used as a tool in significant event analysis. It opens up ways of discussing everyday problems and avoids the rigid thinking that can hamper an in-depth understanding of dilemmas. GPs are sometimes prone to tramline, inflexible ways of thinking. Increasingly, we need ethical flexibility to deal with the astonishing changes in technology and the ways that these affect our patients, the tools that we use, and the societal attitudes that we encounter in and out of the consulting room. My own view, for what it's worth, is that an approach founded on virtue ethics offers our best chance for the future here. It grounds ethics in the psychology of the doctor (Mark Sheehan, personal communication, 2004), and can acknowledge complexity, evidence and narrative, and professional skills as well as our traditions and history.

And our history has left us ethically confused. The General Medical Council's booklet, Good Medical Practice,2 is at heart deontological, in that it is founded on the duties of a doctor. It almost amounts to a book of rules. The Quality and Outcomes Framework of the new GMS contract is utilitarian, based on evidence that promotes the greatest good for the greatest number. Vocational training is still rooted in educating GPs to become good (if not perfect) general practitioners, arguably a virtue ethics approach.

Should we be worried that these are very different, intrinsically contradictory approaches? I think that we should. Perhaps, 20 years after Toulmin's article, we are realising that the roles have been reversed, and that we need ethics to save the life of medicine. Well done Australia.

• © British Journal of General Practice, 2004.