As Moral Imperatives in Primary Care

By Karen Faith, BSW, MEd, MSc

Alex, Paula and Dr. Ben

Alex was a feisty, independent man who suffered from several chronic conditions. After a bad fall at the age of 84 years he required more supportive care. Alex agreed with his daughter Paula that he should move into a retirement setting. Once in residence, Alex became a patient of Dr. Ben, a visiting physician. Prior to this, Alex had assembled a patchwork of medical care, which included various specialists and, when needed, doctors at a local walk-in clinic. This arrangement had been less than optimal, and resulted in regular complications with medications and several short hospital admissions.

Dr. Ben consulted with Alex’s specialists, asked for help with acquiring needed community care resources and established a working relationship with the residence care coordinator. This was to become a complicated care situation. Dr. Ben’s approach to primary care with patients like Alex was to establish a collaborative care team. He found an ally in Paula. She followed-up on medical recommendations, helped to monitor Alex’s medication regimen, and coached her father to accept more support and to use assistive devices to avoid future falls. The residence care coordinator also became a pivotal member of the care team. Dr. Ben depended on the nurse’s ability to monitor Alex’s health and medications, and to notify him of any concerns. Eventually, Alex’s health declined further. It was clear that his medical and support needs exceeded
the team’s ability to safely care for him. Alex agreed to long-term care.

As Alex’s primary-care physician, Dr. Ben had established relationships that enabled him to guide Alex, his daughter and the care team in decision-making. His role required the skills of team leadership, effective communication, timely sharing of pertinent health information and compassionate support. Implicit in Dr. Ben’s actions, decisions and behaviours were values consistent with the “ethics of care.”

Ethics of care

This article explores what is meant by “ethics of care” and how this ethics perspective may be implicit in the way that primary care is being envisioned for the future. The ethics of care perspective grew from a branch of philosophy with a “strong focus on experiences and relationships traditionally associated with women and their care work.”

The moral obligation of care providers extends beyond clinical skills. According to the ethics of care interpersonal skills are crucial in supporting compassionate patient care while at the same time maintaining one’s commitment to protect the patient’s personal liberty, well-being and freedom from harm. Central to this philosophical perspective is the emphasis on relationships. Patients are understood within their context, life experience and network of affiliations. Care is delivered through sustained communication and shared accountabilities across a network of care settings and providers.

Medical ethics has been dominated by a traditional principle-based approach, with autonomy as a guiding concept. An ethics of care perspective emphasizes that although autonomy will always be a leading ethics principle, it does not ultimately reflect the way most people live their lives. People’s health care choices are significantly influenced by their network of affiliations, as well as by the cultural and economic aspects of their life experiences. Therefore, a justice orientation to ethics that emphasizes individual liberty and freedom from coercion does not suffice if patients are to be understood within their life context and relationships.

Dr. Danielle Martin, vice president of Women’s College Hospital in Toronto, has spoken on improvements that are needed in primary care, stating that the focus must return to emphasizing sustained, caring and committed relationships with patients. To achieve this continuum of care, she suggests that systemic improvements are necessary to enhance collaboration, communication and integration throughout the network of health care services. In her view, physician–patient interactions are a potential “source of healing” for the patient. Accordingly, she argues against patient care becoming primarily dependent on intermittent walk-in clinic visits because, in her view, a physician’s care or treatment approach to patients should be “more than just a transaction.”

A patient’s health issues and care goals are best understood over time and through sustained physician–patient relationships. Hippocrates reportedly stated to one of his students, “Let your best means of treating people be your love for them, your interest in their affairs, your knowledge of their condition and your recognized attentiveness to them.”

The present and future

Is there a reason to be concerned that primary care may have veered away from these ancient values of medicine? Author Robert Levine of Yale University School of Medicine has written that traditional, principle-based ethics places an overarching emphasis on individual rights and medical legal considerations that he regards as the “ethics of strangers.” In an article published in 1987, he stated: “We teach an ethics of strangers rather than one more suitable for intimate relationships as the one we wish to foster between patient and personal doctor.”

It has been suggested that this view of health care and health care ethics that emphasizes individual rights over the moral benefits of forming caring relationships over time may have influenced patients to see primary care in much the same as any service provided to them as consumers. From this view, primary care becomes a means through which to address “immediate (and infrequent) problems in a timely manner” as opposed to “more comprehensive whole-person care” supported through a sustained doctor–patient relationship.

Admittedly, health care has become increasingly complex. The demands on primary-care physicians as healers, gatekeepers and health advocates are formidable and stressful. Within the ethics of care perspective, the well-being of both the patient and the care provider is of moral concern. Opinion leaders are calling for a new model of primary care that is better suited to addressing the current challenges faced by providers, and that more effectively meets the needs of various patient populations. Given today’s economic and political challenges and the shifting demographics in Canadian health care, it is no longer reasonable to expect primary-care physicians to practice in a patient-centred and relationally focused way without systemic enhancements such as interprofessional team supports. Improvements are needed to enhance patient experiences throughout the continuum of care. The complexities facing primary-care physicians who try to meet the health care needs of patients such as Alex are well known and documented. Patients with faltering health will typically transition through a complicated system of care, in which gaps in services and the communication of information are routinely encountered. Primary-care providers have long held that safe, quality patient care is hindered within a system burdened by a “silo syndrome.”

An ethics of care orientation and principle-based ethics are important moral compasses for those who provide primary care. The changes being proposed by opinion leaders such as Dr. Martin
also reflect the core moral concepts found in the ethics of care. The ethics of care teaches us that the well-being of patients, as well as those providing their care, is of moral significance.

These obligations not only require a just, caring and effective health care system, but also one built on shared accountabilities supported through the values of respect and collaboration.

Karen Faith BSW, MEd, MSc, is a bioethics consultant, writer, public speaker and member of the Joint Centre for Bioethics at the University of Toronto. She has served on staff at the Sunnybrook Health Sciences Centre and currently works with regional and community-based health care organizations. Karen has spoken nationally and internationally on ethics in health care.