60 Primary care ethics
Ms. G is 17 years old and needs a physical examination prior to participating in high school sports. Her physician, Dr. M, has been the primary care clinician for Ms. G and her parents for the last 10 years. During Ms. G’s last annual visit, Dr. M engaged her in a routine discussion about sex, birth control, abstinence, and safety. Ms. G asked questions but denied any sexual activity. Dr. M counseled Ms. G to continue the discussion with her mother. At today’s clinic visit, Ms. G reports that she has been sexually active for a few months and would like to start birth control. Additionally, she is worried because her menstrual period is a little late and she complains of some abdominal discomfort and a vaginal discharge. Ms. G is adamant that Dr. M does not reveal her sexual activity to her parents.
Mr. H is 47 years old and has hypertension and high cholesterol, despite an active exercise regimen and healthy eating habits. He has a strong family history of hypertension. His mother had a stroke at age 57 and is disabled. Mr. H supports his mother as well as his wife and their three young children. He refuses to take medication, either for his blood pressure or for his elevated cholesterol. He mentions that he has “no faith in medications” and that his mother was taking appropriate medication when she had a stroke.
What is primary care ethics?
To understand the ethics of primary care, it is important to delineate the unique characteristics of primary care. Some view primary care as the cornerstone of the healthcare system, providing “most care for most people, for most conditions, most of the time.” Primary care is, ideally, accessible, patient-centered, continuous and comprehensive (Starfield, 1998). Each of these characteristics has a moral dimension.
Accessibility suggests that primary care clinicians are readily available to serve as the usual point of initial contact with the healthcare system. Depending upon the setting in which they work, they may be faced with a tremendous range of patients. Accessibility often implies that the primary care clinics are physically in the local community, giving clinicians insight into patients’ life experiences.
Patient-centered care incorporates patients’ values, goals, preferences, and needs. It “sees patients first as people, with hopes, fears, lives, jobs, families, and relationships, over and above any health problems that may be presented” (Rogers and Braunack-Meyer, 2004). Primary care that involves patients as partners in decision making is likely to be more effective. The challenge for clinicians is to manage values and goals that may be contrary to good health or to the clinician’s own values.
Continuous care may provide an opportunity for clinicians and patients to know one another both in sickness and in health, but it also includes the challenges of maintaining a therapeutic relationship. This can contribute to making the clinician–patient relationship ethically complex.
Comprehensive care requires that clinicians address any number of presenting physical, social, or psychological problems, in addition to providing preventive care. When referral to specialty care is necessary, the primary care clinician may need to manage conflicting recommendations while keeping an eye on the “big picture” with the patient.
Primary care clinicians encounter ethical issues on a regular basis in their routine care of patients. However, traditional bioethics scholarship and teaching has highlighted specific high-intensity ethics topics usually encountered in hospital and tertiary care settings. Tertiary care is characterized by subspecialized and highly technical “rescue” medicine. There has been much less emphasis on the ethically significant nature of primary care practice. This chapter examines ethics in the particular setting of primary care, focusing on the ethical content of primary care practice and offering some guidance when such issues are encountered.
Why is primary care ethics important?
Ethical issues in primary care are important both because they are frequent and because they can affect the quality of care. Although precise estimates are unavailable, the prevalence of ethical issues is high in the primary care setting, in part because that is where most patients receive most of their healthcare. The overwhelming majority of healthcare encounters take place in clinicians’ offices. For patients aged 65 and older, office visits occur 20 times more frequently than hospitalizations; in childhood, there are 40 to 60 office visits per hospitalization (Fryer et al., 2003).
Moreover, ethical issues are commonplace in primary care office visits. While there are few studies on the nature and prevalence of ethical issues in the outpatient clinic, Connelly and Dalle Mura (1988) reported that, in one outpatient office practice, ethical problems were present for 30% of the patients and in 21% of the office visits. The most common ethical problems for the patients were costs of care (11.1%), psychological factors that influence preferences (9.6%), competence and capacity to choose (7.1%), refusal of treatment (6.4%), informed consent (5.7%), and confidentiality (3.2%). Ethical problems were more common in patients over 60 years of age.
Consequently, primary care clinicians face a multitude of ethical issues every day. While many of the ethical issues raised in tertiary care may involve intense and dramatic choices, there is usually a structure, such as a hospital ethics committee, to assist the clinician in analyzing and resolving issues. However, in the outpatient setting, such structures are unlikely to be available and clinicians may be more isolated. Therefore, in order to meet the overriding ethical obligation to deliver appropriate care to patients, it is essential for clinicians to understand the ethical issues that arise in this setting and to develop a sensible approach to addressing them.
How should clinicians approach primary care ethics in practice?
Towards preventive ethics in primary care
Preventive ethics necessitates anticipating the ethical issues common in primary care and promoting clinic practices and standards that help to minimize avoidable problems (Forrow et al., 1993; McCullough, 1998). The defining characteristics of primary care (accessible, comprehensive, patient-centered, and continuous) suggest opportunities for preventive ethics. In many instances, policy and legal structures exist in this regard. For example, while primary care clinicians strive to offer patient-centered care that reflects patients’ desires and values, patients sometimes make requests that are inappropriate. Professional standards and clinical guidelines help guide the clinician in properly responding to many requests for unreasonable care (Brett, 2000).
In addition, continuity of care stresses the importance of maintaining a therapeutic clinician–patient relationship. There are circumstances, however, in which this relationship becomes ineffective or detrimental and the clinician must find a means to end the relationship. The ethical guidelines for ending a doctor–patient relationship usually center on avoiding abandonment and ensuring continuity of care with another provider (American College of Physicians, 2005). Professional societies may offer specific legal guidelines (American Medical Association, 2003; College of Physicians and Surgeons of Ontario, 2000).
When legal or policy guidelines are not clear or specific enough to provide a preventive approach,clinicians can work to establish relevant clinic policies and practices. Some target areas that may benefit from such an approach are listed in Table 60.1 .
Responding to ethical issues in primary care
Despite the best preventive efforts, ethical issues will arise and a systematic approach to responding to them is necessary. The complex nature of primary care can make it difficult to define a clear and consistent process for managing ethical conflicts. In many situations, using the systematic approach proposed by Jonsen et al. (2002) provides a reasonable structure for analysis. Specifically, they suggest that complex ethics cases be analyzed in terms of four key questions. What are the medical facts affecting the dilemma? What are the patient’s preferences? What impact will a decision have on the patient’s quality of life? What are the other contextual features (including patients’ values, family issues, legal issues) that affect the decision?
Establishing the medical facts around a case that involves difficult ethical issues is very effective in helping to identify the range of reasonable ethical options. Making sure that all parties involved share an understanding of the relevant medical features can often resolve or at least minimize the extent of the conflict. Once the medical aspects of an issue are clear, the patients’ preferences are explored. The clinician can bring the ethical issue to the patient, explain the nature of the conflict, and ask the patient for guidance on the range of possibilities. When primary care has been comprehensive and continuous, the clinician is in an excellent position to understand the multiple dimensions of patients’ preferences, including the influence of personal history, family, and community. Although always valid, family and community influences can be overwhelming and the clinician may have to work to protect patients’ autonomous decisions about preferences.
This combination of clarifying the medical facts and helping the patient to define preferences is the key to resolving most conflicts. The next step is to identify the impact of possible choices on the patient’s quality of life. Primary care clinicians often have unique insight into the quality of life for their patients, addressing both long-term knowledge of the patient’s life circumstances and awareness of the patient’s social and physical environment. Finally, other external factors that affect an ethical conflict should be considered. These include legal questions, family needs and values that may be different from the patient’s values, community standards and constraints, resource issues, and other issues that may limit or influence the feasibility of morally acceptable options.
This method works well as a means to structure the necessary information about an ethical issue in a logical and consistent manner. Many cases can be resolved just by sorting and arranging the relevant ideas and working with the patient to share understanding. For persistent problems, clinicians can seek advice from neutral colleagues or local professional organizations.
The cases
Ms. G presents a good example of the value of preventive ethics. Most jurisdictions allow a sexually active teen to request and receive confidential care for sexually transmitted diseases, pregnancy, as well as psychiatric services. Adolescent access to confidential contraceptive services is also common. At the same time, there is substantial variation in rules regarding a clinician’s option to inform parents when it is deemed to be in the best interest of the adolescent. Furthermore, clinicians are not always bound to provide confidential care to adolescents, even when legally available. Regardless, it would be prudent for the clinic to develop and present a very clear policy about confidential adolescent visits. A clinician who is not comfortable providing confidential care to teens can make that clear and redirect teen patients to a local free clinic or some other provider. In Ms. G’s case, the medical facts are clear. The patient’s preferences are likewise clearly stated, although the clinician can revisit the patient’s request for confidential care, particularly to identify her concerns. Why is she afraid to discuss this with her parents? Is there any history of violence or abuse from a parent, sibling, relative, neighbor, or other person? Was the sexual experience consensual? Are there older siblings or other adults who can help? Would it be helpful if the clinician presented the problem to her parents? Quality of life issues are also important. If the patient is pregnant, what are her goals and to whom can she turn for help and support? The contextual factors at play may involve the position of this teen in her family and community, the physician’s own values with regard to contraception and adolescent sexuality, and the legal issues around providing care to minors. If the clinic offers confidential care to teens, it seems fair to make sure that parents are apprised of this policy early in the course of care. In this case, there is no explicit information regarding whether the clinic had a prior policy regarding these issues. If it did not have, and make available, a policy directing sexually active teens elsewhere for family planning care, the patient can reasonably expect to receive care at this clinic. It follows that the clinician is bound to respond personally to the current crisis even if he is uncomfortable providing confidential care. Assuming this is the case, if the clinician is unsuccessful in counseling Ms. G to share her problems with her family, it may be necessary for him to provide confidential care initially while continuing counseling. If necessary, the clinician may need to find another local clinic that has an established practice of confidential family planning services.
The case of Mr. H, involving non-adherence to medical therapy, is a common and perplexing ethical issue that may pit the ethical principle of respect for autonomy against beneficence. There are no simple methods to avoid the ethical challenges of non-adherence, nor are there simple responses. The medical facts are reasonably clear; Mr. H has a significant history that puts him at risk for stroke, a condition that he wants to avoid. Medications are generally helpful, although cannot guarantee favorable results, as Mr. H has established. The clinician should ensure that the patient understands the potential benefits of medication as well as the risks of stroke given his history. Careful discussion of side effects that may be troubling Mr. H should be part of the discussion with him. There may be other concerns that Mr. H has not raised, such as the cost of the medications or his use of complementary medications. Alternatively, he may still be coming to terms with his mother’s illness and needs an opportunity to reflect on her disability and what caused it. The clinician may need to revisit this discussion repeatedly to elicit all relevant issues, since the patient’s preferences are not very clear in this picture. Mr. H refuses medications but works hard to stay healthy. He has important experience with the aftermath of a stroke. His non-adherence seems in conflict with his other behaviors. It is likely that there are other factors affecting his behavior. There may be important quality of life concerns related to medication use. Contextual factors are notable; Mr. H’s family responsibilities are weighty and may be causing anxiety. One of the most well-recognized benefits of primary care is its focus on a long-term relationship between clinician and patient. The clinician can revisit Mr. H’s non-adherence over time, supporting his efforts at maintaining health while continuing to look for acceptable medical therapies.