On occasion when I have asked medical students or GP trainees what they understand about medical ethics, I have had an answer that goes something like, ‘Oh … it’s beneficence, non-maleficence, autonomy … and the other one.’ But what about ‘the other one’? This is justice, the oft-neglected notion that we should treat equals equally and unequals unequally according to morally appropriate differences. Justice is the invisible elephant in primary care’s consulting room. It can easily be forgotten or deliberately sacrificed as other duties and responsibilities are nearer to us within physical space, obligation, or preference. These other considerations can make us fail to recognise the bigger and more complex picture of primary care.
On the BJGP Life site we have a series of articles on the Ukraine conflict in relation to primary health care. A sense of justice here speaks to the idea that those fleeing catastrophe and conflict, and those who are unable to, are also worthy of consideration. We have a sense that it is appropriate to allocate some time, interest, and resources to them (as I have previously argued — it helps if we see them as us).1
Featuring in this issue is the response to the unequal and different needs of refugees, with Aaron Poppleton and colleagues examining these particular needs.2 Book reviews of the novel Go, Went, Gone3 and the dramatic and instructional memoir Frontline: Saving Lives in War, Disaster and Disease4 embody this commitment to global health.
Intergenerational justice starts with looking after children — ours and the world’s. Richard Armitage, our de facto ‘correspondent in the Ukraine’, discusses the impact of the conflict on child health.5 Intergenerational justice into the future also features as Nada Khan reminds us that future generations depend on us not killing their world.6
JUSTICE, RIGHTS, AND PERSONHOOD
In the UK and in the present we consider the rights and need of our healthcare workforce in the UK and the education and welfare needs of trainees. Adam Kay’s book and television drama This is Going to Hurt: Secret Diaries of a Junior Doctor can not only be seen as bleakly comic drama, but also serves a way of restoring testimonial justice to junior doctors. As Yathu Maheswaran7 astutely observes, many of the problems highlighted are still present in training settings in both hospital and community, and responding to these is a duty and a skill for trainees and trainers alike.
In a narrative that invites change, Maria Victoria Bovo and John Launer8 share the testimony of a doctor suffering from long COVID with compassion and profound empathic generosity for colleagues who fail to be sympathetic to her plight. Vasu Sivarajasingam argues that there should be preferential health care for healthcare workers, though this may be justified on grounds other than fairness, such as health clinicians being able to care better for patients.9
Testimonial justice requires that we take moral distress seriously, whether this be junior doctors being asked to act beyond their usual experience in an emergency or doctors taking on an emotionally difficult and ethically divisive role such as euthanasia. Felicitas Selter and colleagues approach understanding moral distress in this setting by comparing human medicine with veterinary medicine in a case study of comparative medical ethics.10
Ultimately, to treat a person justly we must first recognise that they are a person. Emma Ladds11 describes how her personhood is recognised through a bunch of tulips and a caring word from a patient, setting this against the expectations of being a second-generation GP. Does the identity trump the person? Roger Jones’s review12 of A Fortunate Woman: A Country Doctor’s Story examines a new book out this month that follows a rural GP in the same setting (the Forest of Dean) as featured in John Berger’s A Fortunate Man: The Story of a Country Doctor . Perhaps unlike Berger’s book, Fortunate Woman allows the GP and her patients to speak for themselves, and is the better for it. Trish Greenhalgh reviews a long COVID self-help guide that could help patients and clinicians alike. In the absence of adequate resources for the treatment of the condition, this book is welcome.13
As should now be evident, justice comes in many flavours: distributive, legal, testimonial, intergenerational, and so on. And rather than ‘the other one,’ it is a core value of primary health care.
- © British Journal of General Practice 2022
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