BeyHealth Quarterly Journal (BHQJ) BHQJ 2018: 001:1 (May 2018) - Page 39

Postscript In Defence of Healthcare Medical ethics and the question of a duty of care Tokunbo Shitta-Bey MBBS, MSc, MBA, MRCGP This has been the case in medical practice Dr Tokunbo Shitta-Bey is a family physician and academic General Practitioner. He is Chief Executive of BeyHealth Consulting and Editor of the BeyHealth Quarterly Journal. PS: It falls to the editor of a publication to assume responsibility not just for the determined editorial slant of a magazine, journal or newspaper, but also to attempt on behalf of its readers, to draw together the various strands of discussion and argument (hopefully) in one coherent narrative or postscript at the end – a difficult and challenging task at the best of times! Many of the preceding pages have been spent discussing the existential issues of quality and professional performance against a backdrop of inadequate financing and quite discouraging cancer statistics widespread across most parts of sub-Saharan Africa. The practice of medicine worldwide is governed by the supreme ethical principle of ‘best interests’. Invested in the role of the doctor, is the custodian and gatekeeper responsibility to ‘do no harm’. This responsibility presupposes a ‘duty of care’, the basis of any presumption of liability on the part of a medical practitioner and principle upon which a claim of professional negligence may be hinged. In order to establish liability on the part of a doctor (or other healthcare professional), there are 3 important tests that must be satisfied: 1. That a duty of care was owed to 2. That the said duty was breached 3. Causation – That as a direct result medical colleagues to fall foul of the requirements above, and entrenched culture of deference towards the medical profession has in recent years, receded significantly in favour of greater transparency and increased public and stakeholder members of the wider society. Issue 1 | MAY 2018 | best interests, and to argue describes an epic collision of two eras with rights of individuals to make quality decisions incompatible beliefs. 1 concerning their own health. 4 While healthcare services in many western A clearly defined acknowledgement of the countries are indeed struggling to come to rights of patients, standardised adoption of terms with the responsibilities of a new ‘moral evidence-based treatment guidelines and era’ of practice (Era 3 – with less managerial a programme of sustained coordinated encumbrances, less performance management investment and endless failed incentives), the conflict within healthcare under the regulatory control of in private and public-sector healthcare systems located in sub-Saharan centralised authorities are all factors that have Africa and across many low and middle-income contributed to a paradigm shift in approach to countries, is definitely between an existing healthcare provision in Europe and most parts culture of assumed ‘nobility’ – the right to of the western world. undeserved public trust and professional self- Significant disparities observed in the health regulation (Era 1) versus the advancing need for and socioeconomic fortunes of low and greater public middle-income economies are largely explained accountability and enhanced professional by differences in approach to the requirements regulation standards (Era 2). of these principal factors. A system of robust As in most parts of Europe and the western governance across all relevant sectors will be transparency, increased world, the post-World War II ideal of the UK crucial to sustaining our socioeconomic National Health Service (NHS) has evolved development in the years ahead. considerably from a position of ‘almost complete autonomy’ to a more equal, less paternalistic ‘partnership’ between health professionals and their patients. 2 This irreversible shift in balance is based almost entirely upon a framework of mutual and professional accountability existing within a framework of performance-based regulation of the healthcare delivery industry. 3 Every system has its beginnings. “The Citadel”, A.J Cronin's prodigious 1937 account that deals extraordinarily with issues of medical the now-esteemed NHS, as well as the A historic assumption of autonomy, which has users way of preserving patient autonomy and the the experiences of practitioners and service for several years caused a sizeable number of service the 3rd Era for Medicine and Healthcare, users in the period preceding the early days of harm with Berwick (2016) in his seminal paper discussing insight into the prevailing culture of practice and of the breach, the patient suffered engagement patients’ “rationally” in favour of these judgments as a ethics in the pre-war years, provides useful the patient make evaluations and value judgements of consultations, even in sub-Saharan Africa. perception and role of the local General Practitioner (GP) in this nascent period of history. Reflecting on the ethical responsibility of the practicing clinician, Savulescu (1995) argues in favour of a more non-interventional” proactive form of “rational, paternalism, acknowledging the nature of medicine as a “moral practice” (and of doctors as “moral agents”) with a professional responsibility to “…You must take reasonable care to avoid acts or omissions which you can reasonably foresee would be likely to injure your neighbour. Who then in law is my neighbour? The answer seems to be persons who are so closely and directly affected by my act that I ought reasonably to have them in contemplation as being so affected when I am directing my mind to the acts or omissions which are called in question.” - Lord Atkin in the case of Donoghue v Stevenson (1932) AC 562 REFERENCES 1. Berwick DM. Era 3 for Medicine and Health Care. JAMA. 2016;315(13):1329–1330. doi:10.1001/jama.2016.1509 2. Klein R. ‘The state of the profession: the politics of the double bed’, British Medical Journal (BMJ) 1990;301:700-2 3. Emanuel LL. ‘A professional response to demands for accountability: practical recommendations regarding ethical aspects of patient care’. Ann Intern Med 1996; 124:240–9 4. Savulescu J. ‘Rational non-interventional paternalism: why doctors ought to make judgments of what is best for their patients’, Journal of medical ethics, 1995; 21: 327-331 39