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An ethical dilemma…what is the right thing to do?

An ethical dilemma…what is the right thing to do?

I have been a GP partner in the same practice for 28 years. Focused on the practical aspects of the here and now of everyday clinical care. Ethics seems like a remote privilege for clever people in academic departments.

Ethical theories give us a structure for understanding what is the right thing to do in a given set of circumstances.

The NHS was set up in 1948 in a welfare state as a utilitarian construct which has not changed. The right thing to do being the thing that benefits the most number of people within a finite budget.

For this to work it requires us as individuals to behave in a utilitarian way, if your problem is worse than mine, you can go first, I trust the professionals to make the best decisions and recognise that things can go wrong.

Society has changed, people have been actively encouraged to become consumers. If I want something and can afford it, I shall have it. Our definition of the right thing to do has become egocentric, ie what is best for me.

The egocentric approach rejects the passive acceptance of what is on offer. Individuals make their own risk decisions regardless of the impact upon another person. Trust is placed more upon oneself than on the judgement and benevolence of others.

Neither utilitarianism nor egocentricity is relatively better or worse than the other. But the problem for the clinicians in the NHS is that the planners plan in a utilitarian way and clinical practice is now based upon an egocentric culture, drives up demand and breaks the budgets.

This ethical dilemma plays out in the consulting room, on the ward, in the clinics and emergency departments.

If I said you have a 1 in 10 chance of having cancer, would you like me to do some tests? I guess you would, but what if it was 1 in 100 chance, or 1 in a 1000? The tests are free by the way. NICE guides us to a 3 in 100 risk level. In a practicing lifetime doctors will meet patients with a 1 in 1000 chance and its not NICE that the patient takes to court when their cancer has been missed!

I was trained to work in a utilitarian system in which GPs managed clinical uncertainty through long term relationships with patients and their communities and being able to use the passage of time as a diagnostic tool. In an egocentric society, clinical practice is based upon fear, we are taught to protect ourselves through tests and second opinions, in pursuit of clinical precision.

This is the behaviour which is increasing demand, it is probably not good for patients and threatens the existence of the NHS.