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Primacy of patient welfare or moral equality? The example of out-of-hours care

Stephen Buetow, Rachel E Davis

Abstract


Deeply embedded in medical professionalism, the principle of primacy of patient welfare puts patient interests first. Despite the greater inherent dependence of patients on physicians than of physicians on patients, this principle acts against the right of physicians to be viewed as moral equals and can harm physicians, patients and health system performance. Referring to the current crisis in out-of-hours care provision in the United Kingdom, this paper therefore recommends people‑centred care informed by a principle of moral equality. Virtuous action is deemed necessary to apply this principle. It involves using deliberative dialogue to consider equal moral interests equally, make binding decisions to satisfy the interests likely to maximize overall welfare, and ensure that those whose interests are least satisfied are not worse off than before. This action addresses situationally the taken-for-granted assumption that the interests of the patient necessarily trump the interests of others.


Keywords


Ethics, interests, moral equality, people-centred care, personhood, physician-patient relations, principle of primacy of patient welfare, social justice, virtue

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References


Birrell, I. (2013). A helpline in crisis and doctors who still refuse to put patients' interests before their own. Daily Mail. Available at:

http://www.dailymail.co.uk/news/article-2319960/NHS-111-helpline-crisis-doctors-refuse-patients-interests-own.html (last accessed 16 October 2013).

National Audit Office. (2006). The provision of out-of-hours care in England, London: The Stationery Office. Report no: HC 1041. Report no: HC 1041, Available at: http://www.nao.org.uk/wp content/uploads/2006/05/05061041.pdf (last accessed 16 October 2013).

Swick, H. (2000). Toward a normative definition of medical professionalism. Academic Medicine 75, 612-616.

Jones, R. (2002). Declining altruism in medicine. British Medical Journal 324, 624-625.

ABIM Foundation, ACP-ASIM Foundation & European Federation of Internal Medicine. (2002). Medical professionalism in the new millennium: a physician charter Annals of Internal Medicine 136, 243-246.

Emanuel, E.J. & Pearson, S.D. (2012). Physician autonomy and health care reform. Journal of the American Medical Association 307 (4) 367-368.

Epstein, R. & Street Jr., R. (2011). The values and value of patient-centered care. Annals of Family Medicine 9, 100-103.

Jotkowitz, A. & Glick, S. (2005). The physician charter on medical professionalism: a Jewish ethical perspective. Journal of Medical Ethics 31, 404-405.

Wendler, D. (2010). Are physicians obligated always to act in the patient's best interests? Journal of Medical Ethics 36, 66-70.

NHS England. (2013). Putting patients first. The NHS England business plan for 2013/14 - 2015/16, NHS England: Redditch. Available at: http://www.england.nhs.uk/wp-content/uploads/2013/04/

ppf-1314-1516.pdf (last accessed 16 October 2013).

Braddock III, C., Snyder, L., Neubauer, R. & Fischer, G. (2012). The Patient-Centered Medical Home: An ethical analysis of principles and practice. Journal of General Internal Medicine 28 (1) 141-146.

Canadian Medical Association. (2010). Health care transformation in Canada: Change that works. Care that lasts: Ottawa. Available at: http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Advocacy/HCT/HCT -2010report_en.pdf (last accessed 16 October 2013).

Benatar, S. & Upshur, R. (2008). Dual loyalty of physicians in the military and civilian life. American Journal of Public Health 98, 2161-2167.

Griffin, J. (1986). Well-being: Its meaning, measurement, and moral importance. Oxford, England: Clarendon Press.

Buetow, S. (2007). Non-attendance for health care: when rational beliefs collide. Sociological Review 55, 592-610.

Boudon, R. (2003). Beyond rational choice theory. Annual Review of Sociology 29, 1-21.

McAfee, N. (2004). Three models of democratic deliberation. Journal of Scientific Philosophy 18 (1) 44-59.

Singer, P. (1993). Practical Ethics. 2nd edn. New Jersey: Princeton University.

Cheraghi-Sohi, S., Hole, A., Mead, N., McDonald, R., Whalley, D., Bower, P. & Roland, M.O. (2008). What Patients Want From Primary Care Consultations: A Discrete Choice Experiment to Identify Patients' Priorities. Annals of Family Medicine 6 (2) 107-115.

Hardwig, J. (1990). What about the family? Hastings Center Report 20 (2) 5-10.

Post, S. (ed.). (2007). Altruism and health: Perspectives from empirical research. New York, NY: Oxford University Press..

Wallace, J.E., Lemaire, J.B. & Ghali, W.A. (2009). Physician wellness: a missing quality indicator. Lancet 374 (9702) 1714-1721.

Halbeslen, J. & Tathert, C. (2008). Linking physician burnout and patient outcomes: Exploring the dyadic relationship between physicians and patients. Health Care Management Review 33 (1) 29-39.

Sirovich, B., Woloshin, S. & Schwartz, B. (2011). Too little? Too much? Primary care physicians' views on US health care. Archives of Internal Medicine 17, 1582-1585.

Dyrbye, L., Massie, F., Eacker, A., Harper, W., Power, D., Durning, S., Thomas, M., Moutier, C., Satele, D., Sloan, J. & Shanafelt, T. (2010). Relationship between burnout and professional conduct and attitudes among US medical students. Journal of the American Medical Association 304 (11) 1173-1180.

Heath, I. (2013). Not safe in their hands. British Medical Journal 346, f1004.

Buetow, S. & Elwyn, G. (2008). The window mirror: a new model of the patient-physician relationship. Open Medicine 2 (1) E20-25.

World Medical Association. Medical ethics manual. (2009). 2nd edn. Available at: http://www.wma.net/en/30publications/30ethicsmanual/pdf/ethics_manual_en.pdf (last accessed 16 October 2013).

Rose, G. (1992). The Strategy of Preventive Medicine. Oxford: Oxford University Press.

Gillon, R. (1986). "The patient's interests always come first"? Doctors and society. British Medical Journal 292, 398-400.

Angell, M. (1993). The doctor as double agent. Kennedy Institute of Ethics Journal 3, 279-286.

Veatch, R. (1995). Abandoning informed consent. Hastings Center Report 25, 5-12.

World Health Organization. (2006). What is people-centred health care? Patient at the Centre of Care Initiative, WHO Regional Office for the Western Pacific: Geneva. Available at: http://www2.wpro.who.int/sites/pci/health_care.htm (last accessed 16 October 2013).

NHS England. (2009). NHS 2010–2015: from good to great: preventative, people-centred, productive., Department of Health: Redditch. Available at: http://www.official-documents.gov.uk/document/cm

/7775/7775.pdf (last accessed 16 October 2013).

NHS England. (2013). The NHS belongs to the people. A call to action, NHS England: Redditch. Available at: http://www.england.nhs.uk/wp-content/uploads/2013/07/nhs_belongs.pdf (last accessed 16 October 2013).

Patient-Centered Outcomes Research Institute (PCORI). (2012). Patient-Centered Outcomes Research Definition Revision. Response to Public Input. Consensus definition as of February 15, 2012, PCORI: Washington DC. Available at: http://www.pcori.org/assets/PCOR-Definition-Revised-Draft-and-Responses-to-Input.pdf (last accessed 16 October 2013).

Brooker, D. (2007). Person-centred dementia care. London: Jessica Kingley.

Dworkin, R. (2000). Sovereign Virtue: The Theory and Practice of Equality. Cambridge, MA: Harvard University Press.

Kant, I. (trans. Meiklejohn, J.M.D). (1899). Critique of Pure Reason. New York: Willey Book Co.

Rawls, J. (1971/1999). A Theory of Justice. 2nd edn. Cambridge, MA: Harvard University Press.

Anonymous. (2010). Locum doctors 'putting patients at risk'. BBC News South Scotland. Available at: http://www.bbc.co.uk/news/10453098 (last accessed 16 October 2013).

Anonymous. (1997). Locum doctors. British Medical Journal 314. Available at: http://www.bmj.com/content/314/7074/S2-7074 (last accessed 16 October 2013).

Beach, M., Inui, T. & Relationship-Centered Care Research Network. (2006). Relationship-centered care: a constructive reframing. Journal of General Internal Medicine 21 (Supplement 1) S3-S8.

MacIntyre, A. (1984). After Virtue: A Study in Moral Theory. 2nd edn. Notre Dame, IN, USA: University of Notre Dame Press.

Thomson, J. (1997). The right and the good. Journal of Philosophy 94 (6) 273-298.

Little, M., Gordon, J., Markham, P., Rychetnik, L. & Kerridge, I. (2011). Virtuous acts as practical medical ethics: an empirical study. Journal of Evaluation in Clinical Practice 17, 948 953.

Barilan, Y. & Brusa, M. (2013). Deliberation at the hub of medical education: beyond virtue ethics and codes of practice. Medicine, Health Care and Philosophy 16, 3-12.

Huddle, T. (2013). The limits of social justice as an aspect of medical professionalism. Journal of Medicine and Philosophy, 38, 369-387.

Ferlie, E. & Shortell, S. (2001). Improving the quality of health care in the United Kingdom and the United States: A framework for change. Milbank Quarterly 79, 281-315.

O'Malley, J. (2012). Out of hours and primary care. British Journal of General Practice 62, 176 177.

Habermas, J. (1990). Moral Consciousness and Communicative Action. Cambridge: MIT Press.

Kass, L. (1997). The wisdom of repugnance. New Republic 17-26.

Parsons, T. (1951). The Social System. Glencoe IL: Free Press.

Steiner-Grossman, P. (1997). The New People: Not Patients : A Source Book for Living With Inflammatory Bowel Disease. New York: Crohns & Colitis Foundation of America.

White, S. (2007). Equality. Cambridge, UK: Polity Press.




DOI: http://dx.doi.org/10.5750/ejpch.v2i3.794

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