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General Practice and Ethics: Uncertainty and Responsibility
  1. Jane Macnaughton
  1. Director, Centre for Arts and Humanities in Health and Medicine, University of Durham

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    Edited by Christopher Dowrick and Lucy Frith, London, Routledge, 1999, 196 pages, £14.99.

    This book approaches its subject in two parts. Part I considers themes and principles relating to ethical decision making in general practice. The themes are those of uncertainty, responsibility (the problems of divided responsibility between the individual patient and the wider community), evidence-based medicine, patient-centredness and postmodernity. The “four principles” approach to ethics is discussed and ethico-legal problems are considered. Part II intends to relate these themes to four topics: prescribing, depression, advance directives and research in general practice. Except in the first chapter of Part II, on prescribing, by Colin Bradley, there is in fact little relationship between the principles and themes of the first part of the book and the consideration of topics in the second. However, the book does not claim to present a coherent approach to the subject but to be a series of discrete essays by different authors on related themes.

    Some unifying themes emerge in part I of the book. Those of the subtitle are explored mainly by Christopher Dowling in the initial chapter and he has an interesting analysis of the kinds of strategies general practitioners (GPs) adopt—consciously and subconsciously—to minimise the stress dealing with uncertainty might cause. One strategy is that of shifting responsibility for decision making onto the patient under the guise of “patient-centredness”. However, being patient-centred does not mean giving out antibiotics over the phone to a patient who asks for them for a sore throat, as Dowling suggests. That seems to me more like consumerism. I don't know how helpful most GPs will find Dowling's suggested methods for resolving the problems created by uncertainty: using probability theory, decision analysis, and the “weighted average principle”. The approach of sensible clinical judgment, exemplified in the resolution of his clinical example, seems to me to be simpler and safer.

    The theme of patient-centredness is taken up again in chapter five, but I would have expected in this book to have had more discussion of other ways of seeing the doctor-patient relationship and specifically for there to have been more questioning of the current orthodoxy of patient-centredness. There may have been a shift away from an old kind of paternalism but the suggestion that it is possible for a doctor to achieve “whole person” understanding is also paternalistic.

    The best two chapters of the book are an intelligent and balanced critique of evidence-based medicine by Lucy Frith and an account of ethico-legal dilemmas in general practice by Len Doyal. Doyal considers the specific problems of applying the principles of respect for autonomy and confidentiality within the context of general practice and these problems are given a detailed exposition here. This chapter, along with that by Lucy Frith, would form a good basis for general practitioner trainer-registrar tutorials on these subjects.

    Doyal's chapter is an exception to one problem with much of the book: that there is not sufficient emphasis on what is distinctive for GPs about the problems discussed. This is particularly so in the chapters on confidentiality and postmodernity. I also find it difficult to understand why the editors chose advance directives as one of their four topic areas in Part II as this does not sit easily in a book on GP ethics. This problem is balanced by the fact that the book is largely written by practising GPs, and the examples they give help to cut through some of the theorising which may be impenetrable to most GPs.

    Disappointingly, there is no mention of the reorganisation of the National Health Service (NHS) which has introduced a new collective working environment for GPs in the form of primary care groups (PCGs). New ethical problems may develop in this context relating to constraints imposed by PCG budgets and divided loyalties between the GP's own practice and the wider population served by the PCG. Other members of the primary health care team are hardly mentioned, and there was a need, in particular, to consider the issue of the increasing autonomy of practice nurses and the issue of nurse prescribing.

    This book will not, therefore, appeal to non-GPs in primary care, but it will certainly be of use to GPs and I would recommend practice libraries to buy a copy. It is of most use at the postgraduate level, for trainers and registrars, and may be helpful in forming the focus for tutorials on the subjects raised.