Abstract 1
Teaching and Learning Ethics in General Practice training
A number of authors have expressed concerns about the lack of “a body of knowledge and a community of scholars”1 in the moral philosophy of primary care. One aspect is that few GP trainers have training in the rational analysis of ethical problems, and so are not well equipped to teach their trainees how to tease out the issues they face. UK trained doctors receive some formal education in ethics as part of their undergraduate training, although the nature of this varies between students and medical schools; many international graduates do not. Thus some trainees will have considerable ethical expertise, others may have little more than an impression of the Duties of a Doctor2 and Beauchamp and Childress’s Four Principles. 3
Initially the MRCGP curriculum4 included a statement on ethics and value based care, but this has now been removed since it is felt that ethical issues should be covered throughout the curriculum. An analysis of the curriculum suggests moral relativism, emotivism and/ or positivism may underlie its attitude to ethical analysis.
In this presentation questions about the role of philosophical medical ethics in GP training and its implications for teaching the teachers, for curriculum and timetable design and for assessment will be explored:
- Do GPs need the technical skills of moral philosophy to practice well, or can they be “unconsciously competent” in this area? How are competence, reflection and reflexivity related?
- Should ethics be identified as a specific area of the curriculum or, since all aspects of medicine have a moral component, should it be a thread across the whole curriculum?
- What should be the relationship between ethics and law in the GP curriculum?
- Is facing a moral problem which you have no satisfactory way of addressing a cause of psychological distress in clinicians, and does this contribute to low morale and burn out?
- What is the relationship between learning and teaching the intellectual skills of moral analysis and the personal qualities, virtues or “competences” needed to flourish as a health care practitioner?
- To what extent are these intellectual skills and personal qualities innate and how much can they be taught?
- What aspects of ethical competence can be assessed and how should they be assessed?
- What knowledge, skills and virtues do GP teachers (trainers and programme directors) need to help their trainees learn what they need to learn about ethics and law?
Although the discussion will largely focus on GPs, another important issue is what common ground there is between GPs, other medical practitioners, other practitioners in health care (nurses, midwives, health visitors, managers, PAMs, in both primary and secondary care ) and with social work and social care; and how those who offer the patient perspective can contribute to this process.
The presentation is intended to be a starting point for a discussion both during the session and afterwards, and the session will conclude with a consideration of options for taking this discussion forwards.
References
1Papanikitas A. and Toon P., (2011), Primary care ethics: a body of literature and a community of scholars?J R Soc Med, 104, 94 – 96
2 GMC (2014) Duties of a Doctor http://www.gmc-uk.org/guidance/good_medical_practice/duties_of_a_doctor.asp
3 Beachamp TL & Childress JF (2008) Principles of Biomedical Ethics 6th Edition OUP Oxford
4 RCGP (2014) GP Curriculum Overview http://www.rcgp.org.uk/gp-training-and-exams/gp-curriculum-overview.aspx
Abstract 2
Practitioners in most areas of healthcare face the death of their patients with varying degrees of frequency, and like all aspects of health care this raises issues of values as well as of fact; most centrally the question “what is a good death?”
It is often stated that we live in a “death averse society”[1] [2], and this has an impact on how and whether we are prepared to talk about death. The meaning of a good death is most often discussed in the context of the argument about the pros and cons of voluntary and involuntary euthanasia and assisted suicide or issues of palliative care[3] [4]. For health professionals there is a huge emphasis on the importance of resuscitation decisions, when and how to discuss them[5], but this is only one small aspect of dying, and it often feels as if the purpose of the discussion is to protect the practitioner rather than to benefit the patient.
Yet these and other practical questions can only be answered rationally within the context of a more general understanding of the place of death in life and in society. Death is inevitable, something which all of us (including clinical health care practitioners) will face both for ourselves and for those close to us sooner or later, and we need to be clear on our values if we are to act rightly when we encounter it. This means considering issues such as:
How does a good death fit into a good (flourishing) life?
When is death an enemy and is it ever a friend?
Is death always a defeat or can it be a triumph?
When is death premature?
Is there more to a good death than the avoidance of pain and suffering?
What personal qualities do practitioners and patients need to face death well?
This presentation will draw upon ideas and images from a wide variety of sources – poetry, art, literature, the language of obituaries and funeral orations and history as well as ideas from moral philosophy in an attempt to understand the fragmented moral discourse[6] about death in our society and suggest how we can work toward an underlying concept of and what constitutes a good death. A typology of attitudes to death will be sketched out and an virtue ethic approach to death outlined.
References
1. Leedy SA & Lewis R Making the case for hospice care to a death averse society http://www.slideshare.net/StephenLeedyMDFAAHPM/ice-to-eskimos-making-the-case-for-hospice-care-to-a-death-averse-society
2. Balaban, RB A Physician’s Guide to Talking About End-of-Life Care J Gen Intern Med. Mar 2000; 15(3): 195–200. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495357/
3. NHS (2014) Euthanasia and Assisted Suicide http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495357/
4. NHS (2014) End of Life care http://www.nhs.uk/carersdirect/guide/bereavement/pages/accessingpalliativecare.aspx
5. GMC (2014) End of life care: When to consider making a Do Not Attempt CPR (DNACPR) decision http://www.gmc-uk.org/guidance/ethical_guidance/end_of_life_DNACPR_decision.asp
6. MacIntyre A After Virtue 2nd Edition1985 Duckworth, London
Biography
Peter Toon was a GP for thirty years. He also held academic posts at UCL, Queen Mary University of London and the GP Deanery, working mainly on postgraduate and continuing education. He has written academic papers on the ethics of medical reports, preventative health care and virtue ethics in medical practice, as well as his major works “What is Good General Practice”, “Towards a Philosophy of General Practice” and most recently “A Flourishing Practice?”. He has recently retired and now lives in Canterbury and Avignon, dividing his time between the practices of moral philosophy, gardening, cookery, and music.
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