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It would be a pity to miss an early opportunity to consider how to build clinical ethics support into the structure of the new primary care groupings in the United Kingdom. Neither standard ethical precepts nor guidelines from national bodies like the General Medical Council1or the British Medical Association2 can cover all the intricacies and nuances of any given clinical situation. Best practice requires the interpretation and application of ethical principles in the local context, so primary care trusts will have to recognise, as acute trusts have started to do, that they have a responsibility to support clinicians and managers alike as ethical problems arise in their day to day work.
Primary care can draw on experience of clinical ethics support in secondary care, as well as on international experience, which is collated in a recent Nuffield Trust report on the subject3 and was the subject of a recent conference in London. Some 20 hospital trusts in the United Kingdom now have clinical ethics committees, which may help to bridge the interprofessional gap arising from different backgrounds in ethics approaches. Other trusts depend on guidance from retained ethicists or from university departments of ethics. Some make their clinical governance team, or professional advisory committee, responsible for providing clinical ethics support. However, a dedicated resource was the preferred option of the managerial and clinical leaders in the survey performed by the Nuffield Trust, 79% of whom perceived a need for clinical ethics support within their hospital. The report recommends that local research ethics committees, which are primarily decision making bodies, should not take on the mainly advisory role of clinical ethics support.3
It helps to be clear about what sort of service is required of the committee or individual designated to provide ethics support. Is the role proactive, interactive, or reactive? The first is best suited to a multidisciplinary committee, which can draw on its collective experience to consider the likely ethical dilemmas facing individual clinicians and the trust corporately. Committees can find and disseminate suitable frameworks for approaching such situations as rationing decisions or end of life dilemmas. The interactive role sees clinical ethics committees looking at the actual dilemmas that arise in the course of trust business or clinical practice and entering discussion with management and individual clinicians. This role predicates an independent committee able to consider difficult issues from an ethical standpoint, separately from clinical governance4or budgetary considerations.
The last, reactive, role, may best be considered in two contexts: immediate and delayed. Immediate reaction to the needs of a clinician or manager in an ethical predicament requires an accessible individual, like an ethicist or experienced clinical ethics committee chairperson, rather than a committee. Although it is unlikely that an “ethics flying squad” could support primary care clinicians in the consulting room or patients' homes, it is generally feasible to provide a hotline to experienced ethical counsel.
As for the delayed reactions, ethical dilemmas are a worthy topic for significant event reviews. Such reviews have been shown to be one of the most effective forms of learning,5 and promoting them is one way in which clinical ethics committees could discharge their educational function. Good significant event reviews need to be encouraged by providing skilled facilitation and paid time for employees to take part in them, and the learning needs to be shared among the wider audience of the primary care trust. Ideally patients should also be involved, as ethical dilemmas concern patients' rights, choice, and safety.
How else can primary care teams be supported educationally in the field of clinical ethics, and how can we train and educate ethical advisers and members of clinical ethics committees?6 Ethics is now an established part of undergraduate medical curriculums, and there are several educational initiatives in postgraduate and continuing professional education. For example, the North Thames deanery has run a successful series of courses on education for clinical governance that involve much consideration of the ethical dimension (S Heard, personal communication).
The Nuffield report raises questions about how clinical ethics committee members can be trained, and two main approaches are identified: training in ethical theory and training in the process of ethical deliberation. The major problems of formal ethics education are funding and availability. It is not unreasonable to suggest that primary care trusts should sponsor masters level education for an interested clinician when there is not a trained ethicist to support a clinical ethics committee, but once some professional support exists, training in ethical deliberation is probably more appropriate for a wide variety of professionals: education in ethical awareness and moral reasoning is not about what to think but how to think.
Effective postgraduate education in ethics is likely to happen best in small groups, in a multiprofessional setting, and to be based on reflective practice. Just as the educational strategy of considering patients' unmet needs and doctors' educational needs (PUNs and DENs)7 works on the principle that “you don't know what you don't know,”8 so critical appraisal in ethics needs to train in “you don't perceive what you don't perceive.” Forums for ethical discussion, involving both staff and patients, should be promoted throughout primary care sites, and diversity of opinion welcomed in an area where there can be no “rightspeak.”
The decision facing primary care trusts should not be about whether to incorporate clinical ethics support into the structure of the organisation, but how to do it. The organisational culture should promote and welcome ethics support, which should be independent and capable of critical appraisal of all the trust's activity.