Singling out the double effect - some further comment.

We comment on a paper published in the same issue of the London Journal of Primary Care. We applaud Bow's engagement with the ethical issues in a previous LJPC paper but argue that further work is needed to establish the everyday moral concerns of health care workers in primary care. We also suggest that the ethical distinction between advice and medication and devices may be artificial if both have an effect on a patient

Evaluating case studies of community-oriented integrated care.

This paper summarises a ten-year conversation within London Journal of Primary Care about the nature of community-oriented integrated care (COIC) and how to develop and evaluate it. COIC means integration of efforts for combined disease-treatment and health-enhancement at local, community level. COIC is similar to the World Health Organisation concept of a Community-Based Coordinating Hub - both require a local geographic area where different organisations align their activities for whole system integration and develop local communities for health. COIC is a necessary part of an integrated system for health and care because it enables multiple insights into 'wicked problems', and multiple services to integrate their activities for people with complex conditions, at the same time helping everyone to collaborate for the health of the local population. The conversation concludes seven aspects of COIC that warrant further attention

TIDieR-Placebo: A guide and checklist for reporting placebo and sham controls

Background Placebo or sham controls are the standard against which the benefits and harms of many active interventions are measured. Whilst the components and the method of their delivery have been shown to affect study outcomes, placebo and sham controls are rarely reported and often not matched to those of the active comparator. This can influence how beneficial or harmful the active intervention appears to be. Without adequate descriptions of placebo or sham controls, it is difficult to interpret results about the benefits and harms of active interventions within placebo-controlled trials. To overcome this problem, we developed a checklist and guide for reporting placebo or sham interventions. Methods and findings We developed an initial list of items for the checklist by surveying experts in placebo research (n = 14). Because of the diverse contexts in which placebo or sham treatments are used in clinical research, we consulted experts in trials of drugs, surgery, physiotherapy, acupuncture, and psychological interventions. We then used a multistage online Delphi process with 53 participants to determine which items were deemed to be essential. We next convened a group of experts and stakeholders (n = 16). Our main output was a modification of the existing Template for Intervention Description and Replication (TIDieR) checklist; this allows the key features of both active interventions and placebo or sham controls to be concisely summarised by researchers. The main differences between TIDieR-Placebo and the original TIDieR are the explicit requirement to describe the setting (i.e., features of the physical environment that go beyond geographic location), the need to report whether blinding was successful (when this was measured), and the need to present the description of placebo components alongside those of the active comparator. Conclusions We encourage TIDieR-Placebo to be used alongside TIDieR to assist the reporting of placebo or sham components and the trials in which they are used

Acute ethics: risk assessment and the Doctrine of Double Effect in a referral to on-call urology.

The Doctrine of Double Effect has been described as often used in medicine and surgery but is seldom described outside the palliative medicine context. This paper presents a possible clinically focussed illustration of the doctrine of double effect used in an acute urological setting. The authors describe the case of an elderly patient with significant dementia and haematuria who required anticoagulation. Implicit double effect reasoning may have helped the surgical team reach their initial decision with regard to a treatment plan, reconciling a duty to beneficence with a duty not to cause harm. This short case is offered as a stimulus for further discussion over the role of duty-based ethical reasoning in the acute surgical setting. It also highlights a possible need for more detailed case-analysis in identifying areas of interest in surgical ethics

Patient-centredness and consumerism in healthcare: an ideological mess.

In this paper we contrast two concepts that permeate political rhetoric concerning healthcare in the UK and elsewhere: patient centred care and consumerism. We outline their parallel histories and note that they appear to have different philosophical origins. Both concepts, however, are founded in the value or rights of the patient, whether as a person or as a buyer of services. As these concepts are variously defined or even misinterpreted, we note that this creates opportunities for their rhetorical use in ways that appear insincere. We outline the main problems with conflating patient centred care and consumerism, arguing that these rest on conceptually messy argument and incorrect or insincere definitions of consumerism. We further argue that consumerism is not compatible with a rationed healthcare service but patient-centred care arguably is

Patient-centredness and consumerism in healthcare: an ideological mess.

In this paper we contrast two concepts that permeate political rhetoric concerning healthcare in the UK and elsewhere: patient centred care and consumerism. We outline their parallel histories and note that they appear to have different philosophical origins. Both concepts, however, are founded in the value or rights of the patient, whether as a person or as a buyer of services. As these concepts are variously defined or even misinterpreted, we note that this creates opportunities for their rhetorical use in ways that appear insincere. We outline the main problems with conflating patient centred care and consumerism, arguing that these rest on conceptually messy argument and incorrect or insincere definitions of consumerism. We further argue that consumerism is not compatible with a rationed healthcare service but patient-centred care arguably is

Compassion in primary and community healthcare

Compassion is an attribute of a person’s affective understanding which seeks shared experience of the world’s ills and some alleviation of those ills’ effects. Compassion is cognitive, participative and alleviative. Compassion alleviates suffering by participating in it. Compassion’s cognitive content is shaped by the circumstances and beliefs of those concerned. Since present-day civic life is plural, primary and community healthcare workers’ compassionate understanding must grasp people’s diverse ways of perceiving health and illness. However, while taking patient perceptions seriously rightly excludes professional paternalism, it does not mean that compassion involves uncritical acquiescence to patient perceptions. What is required is a compassion suited for this ‘secular’ time when ultimate questions about human life and suffering have not been finally answered and in which diverse perceptions meet in sometimes critical conversation. Such conversation takes time. And so a lack of or misuse of time may result in failing to reach the goal of compassion and in doing injustice to some in favour of others. Compassion is not in opposition to justice but rather a constitutive feature of justice’s realisation. If both compassion and justice are to characterise practice, both a supportive organisational ethos and regular personal refreshment are required. Pointing to one rich source of refreshment, the motto of the Royal College of General Practitioners, cum scientia caritas, wisely emphasises the greatest of the three theological virtues, love

Genomic health data generation in the UK: a 360 view

In the UK, genomic health data is being generated in three major contexts: the healthcare system (based on clinical indication), in large scale research programmes, and for purchasers of direct-to-consumer genetic tests. The recently delivered hybrid clinical/research programme, 100,000 Genomes Project set the scene for a new Genomic Medicine Service, through which the National Health Service aims to deliver consistent and equitable care informed by genomics, while providing data to inform academic and industry research and development. In parallel, a large scale research study, Our Future Health, has UK Government and Industry investment and aims to recruit 5 million volunteers to support research intended to improve early detection, risk stratification, and early intervention for chronic diseases. To explore how current models of genomic health data generation intersect, and to understand clinical, ethical, legal, policy and social issues arising from this intersection, we conducted a series of five multidisciplinary panel discussions attended by 28 invited stakeholders. Meetings were recorded and transcribed. We present a summary of issues identified: genomic test attributes; reasons for generating genomic health data; individuals’ motivation to seek genomic data; health service impacts; role of genetic counseling; equity; data uses and security; consent; governance and regulation. We conclude with some suggestions for policy consideration

Emerging themes in the everyday ethics of primary care: A report from an interdisciplinary workshop

We report key themes arising from a postgraduate workshop organized by the King's Interdisciplinary Discussion Society (KIDS) held in April 2011. KIDS believe that health is a phenomenon that transcends disciplinary boundaries, and therefore issues relating to health care and medical ethics are best addressed with an interdisciplinary approach. The workshop, entitled 'Everyday Ethics and Primary Healthcare', included poster presentations and oral presentations from participants from a range of disciplines and occupational backgrounds which highlighted the challenges faced by primary health-care workers. Three common themes emerged: the impersonal and cumbersome work environment that can result from the encroachment of rationalizing tools; the tension between 'ethical practice as an ongoing sensibility' and 'ethical practice as "box-ticking"'; and the contested nature of what constitutes 'health'. Participants felt that the interdisciplinary perspective was helpful in elucidating the various ethical issues arising in primary health care

Should UK primary care be an early adopter of genomic medicine?

Genomics is the study of all the DNA in the genome, together with technologies that allow it to be read, analysed and interpreted. Powerful new genomic technologies now allow greater accessibility to the human genome which is, in turn, allowing the integration of genomic data into all aspects of healthcare: increasingly genomic data are being used for the diagnosis and treatment of disease, and in due course are likely to be used for the prevention of disease. At the 2017 RCGP Annual Conference, the topic of whether UK primary healthcare should be an early adopter of genomic medicine was the subject of a debate led by the RCGP committee on medical ethics (CoME). By publishing this paper, we hope that readers who were unable to attend the conference debate will have an opportunity to consider the arguments and take the discussion further, whether in correspondence or on social media