Ethical dilemmas in general practice

General practice teams are regularly faced with ethical issues and dilemmas from bioethical dilemmas (including end-of-life care and pregnancy termination) to more simple concerns such as receiving gifts from patients.

The Royal Australian College of General Practitioners (RACGP) Standards for general practices 5th edition (the Standards) requires general practices to implement a system to document situations that present ethical dilemmas and the actions taken. The actions could include discussing the ethical dilemma with a colleague or with the GPs medical defence organisation. 

The Standards stipulate that documentation of a discussion about an ethical dilemma with a medical defence organisation must be kept separate from the patient’s health record, ideally in a separate medico-legal file.

The regularity and complexity of these dilemmas is the reasoning for the inclusion of the ethical dilemmas Indicator C2.1 > E > Our clinical team considers ethical dilemmas within the Core Standard 2: Rights and needs of patients.

Examples of situations for healthcare services or general practices which could result in ethical dilemmas include:

• Emotionally charged situations (terminal illness, euthanasia, unwanted pregnancy)
• Patient-practitioner relationships – family, friends and relationships (patient comes from a culture in which it is considered wrong to tell patients that they are dying. Being unclear on how to respond to a family’s request to conceal the truth from a dying patient.)
• Professional differences (criteria for referrals, outcomes of assessments, timeliness of interventions) 
• Reporting to the state’s driver licencing authority that a patient is unfit to drive
• Reporting an impaired colleague to AHPRA
• Caring for ‘undeserving’ patients (a patient who will not follow their treatment plan as directed, or offering transplant options to an alcoholic)
• Not being able to treat a patient with life-sustaining therapy due to the patient’s personal beliefs or family beliefs, and
• Breaking patient confidentiality if aware that the patient and/or their health status is harming others.

Ethical dilemma scenario

This scenario, or something similar, is experienced at one time or another by most general practice doctors and staff. To support practice teams with meeting the RACGP accreditation requirements, in the situation of ethical dilemmas such as this one, they are required to follow the actions listed under the heading ‘Meeting indicator C2.1 > E.’

Joe C, a 78-year-old male who immigrated to Australia over 40 years ago from an Eastern culture, has been treated at Family Practice since 1986. He and his wife came to his appointment, with his symptoms including painful urination and lower back/pelvic pain. The doctor completed a physical examination took some blood tests and said he would give him them a call when the results came in. 

The results came back with elevated levels that were a concerning sign of prostate cancer. The doctor called Joe’s contact number and his wife answered stating Joe was unavailable. The doctor said it was important for Joe to come back in to get referrals for a biopsy and ultrasound to confirm a diagnosis. Joe’s wife indicated she did not intend for Joe to come back in and refused to participate in an open discussion of the high possibility of the illness with either her or Joe.

Ethical study – truth-telling of a patient’s diagnosis across cultures

In western countries, approximately 80–90% of patients are given the truth about their diagnosis, whereas, in other cultures, figures can range from 0 to 50%.

In Japan, Southern and Eastern European countries such as Spain, Italy, and Estonia, there is a lower level of disclosure than in western countries. In Italy for example, the opportunity to not reveal information to the patient is evaluated by physicians, and while truth-telling attitudes have evolved in recent decades, there is still some cultural resistance to these changes.

Studies have indicated that it is more common for family members to act on the behalf of the patient and often will make the decision not to disclose the prognosis to the patient, causing an ethical dilemma for their practitioner.

In contrast to Western individualistic cultures, most traditional Eastern cultures place more emphasis on the collective role of the family in decision-making.

In China, for instance, the longstanding influence of Confucian philosophy has established “harmony” as an essential and important social value. Individual and family harmony is believed to be essential for both the prosperity of a family and a nation, thus death is a taboo subject. Chinese believe that discussing or thinking about death or death-related concepts or approaching a dead body will hasten death. For example, hospitals rarely have a floor numbered ‘4’ since the pronunciation of ‘4’ in both Mandarin and Taiwanese is similar to that of ‘death’.

Meeting indicator C2.1>E

To meet the RACGP Standards 5th edition indicator C2.1>E practices must document any ethical dilemmas that have been considered, and the outcome and solution.

To achieve this, practices could:

• Develop a policy and procedure which explains how the clinical team must manage ethical dilemmas
• Discuss ethical dilemmas at team meetings
• Provide a buddy or mentoring system in which ethical dilemmas and solutions for the clinical team to consider and discuss, or
• Display a notice in the waiting room listing ethical dilemmas that practitioners sometimes encounter, and how they generally deal with them.

Resources

• AGPAL eLearning: Cultural Learning – Module 1: Introduction to Cultural Competency. Available to all AGPAL and QIP clients at no cost.
• Code of Conduct for registered health practitioners – AHPRA Aboriginal and Torres Strait Islander Health Practice Board of Australia
• AMA Code of Ethics
• Ethical dilemmas policy and procedure – WAPHA Practice Assist