The distinction Nurse Jodie Trammel (in the film Extreme Measures) makes about Luthan’s decision concerning which emergency patient should go to theatre first, ‘You made a moral choice, Guy, not a medical one’is false. Every medical judgement involves judging the facts and judging the values of a situation.
One may therefore expect that energy and resources in the study of medicine would be divided roughly equally between these two aspects; ethics and evidence studied with equal rigour and devotion, the value base and the evidence base seen as equally important. David Misselbrook’s editorial1 was necessary as it emphasised that this is far from true. Academic journals publish research which sheds light on the facts that underlie our practice, but usually give little attention to work shedding a similar light on our values. The BJGP to its credit has long published analytic work on ethical issues in general practice,2 but until now this has been an exception, and, as with most medical journals, review criteria and instructions to authors have been framed in the expectation (99% correct) that submissions would be empirical. Only the science, not the art of medicine is seen worthy of academic study.
The recognition that primary academic work on ethical issues in general practice is important and that the BJGP will publish it is therefore very welcome. However this alone will not redress the balance. As Papanikitas3 put it we need to build ‘a body of knowledge and a community of scholars’. With ethics as with empirical data we need not only primary research but also reviews which rigorously synthesise that research (and as with complex empirical data,4 how to do this is not straighforward) and tools such as ethical guidelines to help clinicians apply the outcomes of that work.
We also need to think deeply about what we teach young doctors about values and how they should acquire the necessary virtues. Again there is a mismatch; only one of 30 MRCGP curriculum statements5 explicitly addresses ethics and values-based medicine (although others ‘smuggle’ values in without analysis, sometimes not even acknowledging their existence). Unconscious ethical competence often leads GPs to act rightly, but in a morally complex and confused world it is not sufficient. As St Thomas Aquinas reminded us, ‘virtue is the habit of acting rightly, but also that habit must be according to reason’. Not only is the unexamined life not fully human, it is dangerous, because we may act wrongly because of hidden assumptions and prejudices.
The conferences promoted under the Ethics of the Ordinary6 banner and similar initiatives have demonstrated that a body of scholars who wish to give the ethics of general practice serious attention exists. But the occasional meeting is not sufficient. We need structures which make it easy to find research and reflection on these issues, and fora where they can be discussed. Can this be done through traditional academic means; meetings, poster presentations, journal articles, or mailing lists? Or as a scattered community do we also need to use information technology: internet gateways, online discussion groups, or electronic mailing lists? There is already a LinkedIn primary care ethics group7 and a Wikipedia article8 to which all are welcome to contribute; how should we build on these?
Who should lead this? Is this a job for the RCGP and the BJGP, universities or medical schools, or one of the bodies that traditionally support ethical debate — the Institute of Medical Ethics, the Nuffield Foundation, or the Society of Apothecaries? Should discussions be limited to general practice, or should we be involving nurses, midwives, and managers, who also make decisions on values in primary care; and/or medical specialists, whose work also includes much that is ordinary and often unexamined?
The BJGP has shown its willingness to support ethical debate; perhaps the next step is to discuss these questions in its online discussion area (http://www.rcgp.org.uk/bjgp-discuss).
Acknowledgments
Thanks are due to Paquita de Zeuleta, Rhona Knight, David Misselbrook, Andrew Papakinitas, and John Spicer (The Ethics of the Ordinary Steering Group) for their help in preparing this piece.
- © British Journal of General Practice 2012
