Primary care ethics
International Journal of Integrated Care, 10 December 2007 - ISSN 1568-4156
Book review
Primary care ethics
Edited by Deborah Bowman and John Spicer
Oxford, New York: Radcliffe Publishing, 2007, pp 208,
ISBN 978 1 85775 730 9
Prasuna Reddy, Convenor Ethics, Law & Professional Development School of Medicine, Deakin University Director Health Services Research Flinders & Deakin Universities Australia

Primary Care Ethics is one of those books that healthcare professionals will share with their colleagues because it brings together a range of experiences that are often discussed informally with their peers, but rarely addressed in clinical training. It is not intended as a textbook of medical ethics, but rather a series of essays that are insightful, thought provoking, and informative in raising awareness of the complex issues we face in our practice, and application of theories and concepts in understanding our decision-making. Reading the chapters is like eavesdropping on an intelligent conversational debate among healthcare practitioners.

Several chapters of the book are concerned with the relationships between healthcare professionals and their patients. Acknowledging that trust is considered a cornerstone of relationships, Paquita de Zulueta discusses several models of the doctor–patient relationship that are linked to trust. She notes that models founded on reciprocity, narrative and virtue are better explanations for understanding the interactive relationships between doctors and their patients, and raises concerns about the potential collision course of the primacy of individual patient autonomy and the paternalistic model that emphasises beneficence. Margaret Lloyd takes up this theme in several case examples where there may be a conflict between respecting patient autonomy and acting paternalistically. She asks whether increasing emphasis on individual autonomy harms the doctor–patient relationship.

Personal autonomy is a theme that runs through John Spicer's case illustration of a generic patient whose lifestyle choices may be responsible for his current illness, and ethical justification for interventions based on paternalistic clinical decision-making. He asks whether healthcare professionals in primary care should use the ascription of personal responsibility as a criterion for delivery of allocation of care.

In a chapter on human rights in primary care, Katherine Wright touches on several common dilemmas in primary care: issues of confidentiality and information-sharing; the right to treatment and resource allocation; and disputes between health professionals and patients' families. Respect for autonomy as a principle in medical ethics is discussed in another chapter on ethical considerations of a primary care team charged with the responsibility for community care of elderly patients with dementia. The authors conclude that ethical discussion in the care team is of high importance.

Peter Toon has written an excellent chapter on virtue ethics and uses stories provided by healthcare professionals to illustrate ways of developing primary care ethics. The stories have real examples of challenges faced by doctors, and the insights gained from the group in exploring their implications. Ann King tackles a topic that is not often addressed in medical ethics: interprofessional working relationships including moral issues arising from interprofessional conflict.

The later chapters in Primary Care Ethics are rich in philosophical and practical analyses of professional issues. Jim Price and Deborah Bowman discuss the ethical aspects of clinical decision-making within the framework of complexity theory. The use of a case study helps put some of the ideas embedded in the theory into a comprehensible format. Andrew Dicker writes an engaging chapter on whether doctors should observe a moral duty to care for themselves. He states that the injunction to put the interests of patients first, even before the doctor's own interests, is not only presenting an ambiguous and manipulative message, the injunction is also hypocritical. This chapter is well worth reading for the power of the arguments about the emotional defences of doctors. Deborah Bowman raises interesting debate around the issue of accountability in medicine. She focuses on differing perceptions about competence and performance of doctors, and conflicts of interest in practice.

In their chapter on developing ethics education and support in primary care, Anne Slowther and Michael Parker note that while many of the ethical issues will be common among doctors in a variety of healthcare settings, there are key differences between primary and secondary care that will have important implications for the ways in which ethical issues are addressed and the types of ethics support that are appropriate. This chapter provides good information for clinical supervisors about how ethics informs clinical practice at individual, team, and organisational levels.

The editors of Primary Care Ethics, in their concluding chapter, draw out some of the major themes addressed in the book, including issues of personal autonomy; the position of the clinician in relation to the professional behaviour of colleagues; and uncertainty, which they note to be a constant and under-discussed phenomenon in primary healthcare.

A major strength of this book is the way that uncertainty is recognised as an intrinsic part of the work of practitioners in primary care. Many books on medical ethics can leave the healthcare practitioner in a state of despair: some provide prescriptive guidelines about how one can (or should) be an ethical practitioner; others provide a confusing array of case studies or ethical dilemmas with no guidelines. Primary Care Ethics has an engaging set of authors who are not shy of offering opinions, but the editors seem to have taken trouble to ensure there is a balance of theory, ideas, possible solutions, and case material set in the real-life situations of practitioners. Although the focus of the book is on primary care, the ethical issues discussed are pertinent to primary care, public health, and various forms of integrated care. Health and social care services often differ in terms of culture, professional roles and responsibilities, and clinical or service approaches. However, ethical issues discussed in Primary Care Ethics such as trust in the doctor–patient relationship, patient autonomy and consent, accountability in medicine, interprofessional relationships and confidentiality, are all applicable to the healthcare enterprise.