Books: Handbook of Primary Care Ethics

Back in the Devonian era when I was a medical student, ethics simply did not figure in the curriculum. Shortly before that a new law permitting abortion had been passed; renal transplants were becoming commonplace (cardiac transplants soon to follow); huge advances were improving survival of premature babies; and in vitro fertilisation was around the corner. But there was no felt need for undergraduates to learn about ethics. It wasn’t that ethical questions didn’t arise, but in the paternalistic atmosphere of the time doctors didn’t expect to be questioned, or to have to justify the grounds on which they made decisions. Universal agreement that we all need to understand and grapple with the moral dimension of medicine has forced the subject onto the syllabus everywhere. With that has come increasingly varied ways of examining medical ethics, together with a growing understanding that moral questions abound, and not just the big beasts of abortion, brain stem death, and euthanasia. It’s one of the many changes that have transformed medical practice in the last 50 years.

To emphasise the change, here is this book; 44 chapters by 49 authors, all 420 pages of it. As if to drive the point home, this is not a book of medical ethics in general: it’s only about ethics for primary care. After initial admiration at the editors’ completion of this task, one immediately looks to see how they have managed to fill the space. It’s all here: general principles, including the need for compassion; thoughts about complementary medicine; application in routine consultations; learning and teaching; mental health; children and older patients; research; multidisciplinary teams; narrative; and much else besides. Keeping up with the kind of work GPs are now called upon to do, the final section of the book deals with distributive justice, commissioning, self-care, and regulation.

As in any multi-author work there is some repetition, but the overall standard is high and consistent. There are some gems: a chapter on caring for families by the late Micky Weingarten; another by Paquita de Zulueta discussing our obligations towards migrants; a warning about teaching students in our practices; and a guide about the ethics of research in which Jonathan Ives advises any reader who ‘… is yet to be convinced of the need to pay attention to research ethics … to seek a new profession’.

In contrast there are places where the ethical content is less easy to discern. A chapter on benefits and harms seems, at first, to owe little to moral principles. Similarly one on musculoskeletal problems. There’s one chapter where the word ethics never appears. But the key to such content is there. In a chapter on ‘Fat politics and medical education’ Jonathon Tomlinson spells out that this is not directly about medical ethics, but about the ethical behaviour of primary care professionals, how it’s learnt, and how it can be improved. The editors supply the key to the book in their introduction. What we do is defined by the breadth of problems we deal with and the skills we use to solve them. The book tries to cover a range of topics as wide as primary care and reminds us, time and again, that there is a moral dimension to everything we do. It doesn’t matter much that some of the chapters seem a bit peripheral. They add to the overall message, and that does matter a great deal.

Does all the learning mean we are doing so much better than our forebears? I wish I knew. They had rough and ready ways of recognising and dealing with ethical matters. My own beloved teacher told me that if he saw any difficulty he always imagined the patient as a close relative and asked himself what that person would want. Even then I could see the weakness of such an approach. But recent medical experiences of friends and relatives suggest that many doctors still take too much for granted, such as assuming consent for investigations and referrals. Perhaps the general level of understanding is better. There does seem to be much more awareness of the need to respect patients’ autonomy. Understanding the need for compassion makes practice without it indefensible. Change does happen, though more slowly than we might want. This book won’t transform medical practice instantly but it adds its collective voice to the forces pulling us all in the right direction.

• © British Journal of General Practice 2019