Primary care ethics

Primary care ethics is the study of the everyday decisions that primary care clinicians make, such as: how long to spend with a particular patient, how to reconcile their own values and those of their patients, when and where to refer or investigate, how to respect confidentiality when dealing with patients, relatives and third parties. All these decisions involve values as well as facts and are therefore ethical issues. These issues may also involve other workers in primary healthcare, such as receptionists and managers.

Primary care ethics is not a discipline; it is a notional field of study which is simultaneously an aspect of primary health care and applied ethics. De Zulueta argues that primary care ethics has ‘a definitive place on the ‘bioethics map’, represented by a substantial body of empirical research, literary texts and critical discourse (2, 9, 10). The substantial body of research referred to by De Zulueta (9) has a tendency to be issue-specific, such as to do with rationing(11), confidentiality, medical reports, or relationships with relatives.

Much of the literature on primary care ethics concerns primary care physicians. The term primary care physician is synonymous with family practitioner, or general practitioner; meaning a medically qualified clinician who is the first point of access to health care, with general responsibilities which may but do not necessarily include child health or obstetrics and gynaecology. Other primary care clinicians; nurses, physiotherapists, midwives, and in some situations pharmacists may face similar issues, and some (confidentially, prioritisation of patients) may also involve administrative staff. In some healthcare systems primary care specialists may also encounter many of these issues.

Although the ethical decisions made in primary care are often as less dramatic than those in high-tech medicine (1), their cumulative effect may be profound (2), because of the vast number of health care encounters which take place in primary care, (approximately 400.3 million in England in 2008 alone (3, 4) ). Each of these involves ethical judgements, occasionally difficult, often straightforward; often deliberate but more often unconscious. Also, since primary care is often the first step in the patient journey, small decisions made then may make big differences later on. Most of the bioethical literature however deals with tertiary medicine, and much less attention is paid to the daily concerns of primary care physicians and members of the primary care team (5).

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