The global COVID-19 pandemic has exposed the fragility of national and international healthcare organisations, and tested the morality and integrity of health care across the world. On the frontline of care, physicians and healthcare workers were exposed to risks and poorly protected, with burnout rates high, moral injury substantial, and many contemplating leaving the profession.1 Would reflection on the ethics of family medicine provide a means of re-engaging with the meaning of being a family doctor? Does this have wider implications for ethics education around the world? Inspired by the joint conference of the World Organization of Family Doctors (WONCA) and the Royal College of General Practitioners in London in 2022, we consider these questions and invite a global cross-disciplinary dialogue.
THE RELATIONSHIP BETWEEN FAMILY MEDICINE AND BIOETHICS
There are a variety of narratives that connect family medicine with the professional education of doctors more broadly, with a particular emphasis on ethics. Brody argues that patients in the community setting are much more empowered to foster respect because they are more likely to be in a position of choice and dignity with the ability to demand respect.2 Doyal emphasises the opportunities and complexities of continuity in the patient–clinician relationship,3 while Pellegrino wryly observes that the community doctor may be required to maintain a clinical relationship even when all biomedical and specialist therapies have been exhausted.4 The complexities of family medicine and public health within a western ethic that privileges the autonomous choices of the individual are well-documented features of primary care. The continuity, complexity, and uncertainty of primary care invite consideration of virtue-based approaches to ethics, though time pressures in ambulatory care and increasingly fragmented systems are eroding the ethical base of practice.5
The main criticisms of this account could be that it is situated in a largely global North, Western-democratic, individualistic, capitalist, Judeo–Christian worldview. The issue of whose voice and whose values are heard is an important one, sometimes expressed as a question of epistemic justice. The disciplines of philosophy and bioethics are certainly going through this in response to criticisms of Eurocentrism and colonialism.6
A more cynical and simplistic narrative is that moral elements of professionalism are ‘softer’ and can be delegated to practitioners less committed to the rigours of bioscience research. On this account, ethics and professionalism, sociology and psychology are the academic ‘scraps from the table’ that hospital-based academics were happy to defer to others while they got on with more well-funded biomedical research. This account is complicated by the ‘gold rush’ in bioethics, where funding for research focuses on experimental treatments and technologies as part of the evaluation of these, or the perception that other questions in health care are ‘settled’ or less likely to result in an influential policy change.7 This experience may vary by jurisdiction and can also be explained as a tension between different foci of clinical gaze in different professions, such as whether there is a greater emphasis on biomedical or psychosocial aspects of health and illness.
This brings us to the main question in front of us today: does the nature of family medicine make it particularly well-suited to address ethical questions, and to guide medical students through ethical learning? Moreover, could this be expanded into a global primary care (ethics), transcending local differences in both primary care and ethics approaches? To answer these questions we must consider whether we can agree on a shared approach to family medicine and, following from this, shared values.
WHAT ARE THE SHARED VALUES?
The WONCA Tree produced by the Swiss College of Family Medicine8 emphasises a holistic approach to the patient in family medicine, as well as an orientation towards continuity, accessibility, and community. The Declaration of Astana reaffirms the importance of an inclusive and effective approach, focusing on justice, solidarity, and sustainability in primary care.9 Even if we could all agree on these defining characteristics of family medicine, it is not easy to translate them into ethical values with global relevance. The most widely used framework in this sense will probably be Beauchamp and Childress’ four principles, encompassing autonomy, beneficence, non-maleficence, and justice. However, a disproportionate focus on autonomy in the past may mean this framework is again tailored to a Western individualistic world view. The four moral attitudes of a care ethical approach seem more appropriate to a global family medicine context, turning to attentiveness, responsibility, competency, and responsiveness,10 although a Judeo–Christian perspective underlies this framework. The seven values suggested as a basis for global health ethics (respect for all human life, human rights, equity, freedom, democracy, environmental ethics, and solidarity) may provide a solution to an impasse on shared values.11 This does not mean that we can or should reach global agreement on ethical dilemmas in family medicine, such as end-of-life treatment or truth-telling, but we may be able to agree on shared values underlying the profession and on how to unite moral disagreement with a respectful patient approach.
The strength of family medicine may lie in local community programmes rather than in a forced global mindset. However, we cannot deny that several emergent ethical challenges will require a global point of view. Climate change is one such example. The introduction of AI technology in low- and middle-income countries may also require a global approach, as it comes with the promise of solving long-standing health inequalities but holds risks of paternalism, dehumanised care, and algorithmic bias, potentially deepening the equity gap.12 These examples show the increasing importance of developing a strong global primary care definition and ethics.
COSMOPOLITAN ETHICAL SKILLS FOR FAMILY MEDICINE LEARNERS: STARTING A CONVERSATION
In medical curricula, ethics has a variety of meanings, all associated with the notion of acting rightly, and the knowledge and skills required to enable this. Which ethical skills can or should family medicine instil in medical students and specialist trainees? First, the ability to identify ethical issues in the daily practice. Rather than focusing on an ethical deficit that needs to be corrected, at least some of the teaching could focus on examples of clinicians successfully coping with everyday ethical challenges. Second, the ability to analyse these issues in a meaningful way by applying sense-making frameworks, discussing them with colleagues, introducing interdisciplinary approaches, and contributing to policy and literature. Third, to expand the sensitivity of the profession to community-thinking into a global awareness — when considering the emerging ethical challenges discussed above, we argue this will be of increasing importance. Cosmopolitanism, Benatar and Upshur observe, is an ethical perspective that dates back to antiquity, in particular to Stoic accounts regarding humans as citizens of the world.5 A common theme is that humans have affiliations with each other regardless of nation of birth, identity, family relationships, or political and religious allegiances.11
We want to start a conversation and ask what values we need to inform our practice — how do we get to them (shared and unshared)? We invite a cross-cultural dialogue in family medicine ethics that is inclusive of non-Western approaches. We invite discussion across professions, mindful that much of the world’s medicine and primary health care is not delivered by a variety of clinicians. Ethical preparedness for the global issues of today and tomorrow requires this discourse.
Notes
Provenance
Commissioned; not externally peer reviewed.
Competing interests
Andrew Papanikitas is Deputy Editor of the BJGP. All authors are currently involved in the WONCA Working Party on Ethical Issues and have research and teaching interests in the ethics of primary health care.
- © British Journal of General Practice 2022
