There is a constant stream of articles in the medical and the general press pointing out some moral problem or other with healthcare.
Just recently, the Daily Telegraph warned that ageism in the NHS might be causing the elderly to suffer more, and the Daily Mail regularly reports missed cancers and syndromes that GPs fail to spot, while BBC News ran a blog questioning whether GPs were ‘under threat of extinction’.
The view that healthcare is facing a moral crisis, in general or in specific ways, is often seen in terms of professionalism. The Royal College of Physicians a few years ago suggested that in society in general ‘the ideals we equate with professionalism are in decline’. This and other analyses of the state of medical care suggest a number of factors that are contributing to this decline.
Some are specific to medicine, such as changes in working practices leading to loss of continuity of care, diminution of personal responsibility, loss of medical team structure and leadership by example, and an NHS ‘blame culture’.
Factors affecting society more widely include rising consumerism, risk aversion and a decline in stability and continuity of relationships and the trust that this builds.
And in the end to make the case that healthcare faces a moral crisis, perhaps only one reference is necessary – the Francis Report.
Sharing our practices
The influential virtue ethicist Alasdair MacIntyre, however, thinks that the problem lies deeper than this.
In his book After Virtue he suggested that our society has experienced a fundamental breakdown in the framework of our moral understanding, and that this is the underlying cause of the moral problems and uncertainties we face and which he argues affect all areas of our life, not just healthcare.
MacIntyre believes that to resolve this problem our society needs a shared narrative, a shared tradition, and a shared world view for which shared social activities with traditions, or ‘practices’, are a central support.
One of MacIntyre’s ‘practices’ is medicine. The aim of my new book, A Flourishing Practice?, is to try to see whether MacIntyre’s analysis of our situation and his suggested solutions can in fact be applied to healthcare, and whether they might help resolve these problems in professionalism and the pervading sense of moral crisis.
Looking at healthcare in this way help us deal with problems of morale, recruitment and retention in general practice, as well as reconciling political and public health demands on our time what our patients want and expect, and helping us to work with our patients in ways which contribute to our wellbeing as well as theirs.
In consultations GPs are often torn between meeting QOF targets based on public health values, in terms of the greatest good of the greatest number, and doing what their patients-as-customers want them to do.
We face conflicts when patients, adopting the consumerist values now enshrined in the NHS Constitution, insist on antibiotics for sore throats. If we want to offer evidence-based treatment we must refuse.
But we are burdened with conflicting duties to our patients, society and the NHS, and we face legal and managerialist sanctions if we fail to find a middle ground.
If instead of trying to satisfy these conflicting we could focus on working in partnership with patients then perhaps these problems could be avoided. MacIntyre was pessimistic about piecing together a shared moral tradition but I am less so, particularly when it comes to healthcare.
Dr Peter Toon is the author of A Flourishing Practice?. He has previously practiced as a GP in Canterbury.