Case
Dr Sue Longford and Ms Margaret Wilmore have worked at the Southern Heights Family Practice for a number of years. Sue works as a general practitioner (GP) on a part-time basis and Margaret is the mainstay at the practice’s reception services. Margaret confides in Sue that she is concerned about the specialist cardiology care of her mother, Mrs Grey, who is 85 years of age. ‘She’s been seeing Dr Giles for 3 years now. He’s always running late and there are half a dozen patients in his waiting rooms. Last time, they couldn’t even find her a chair when we arrived. When I complained, one of the other patients gave Mum his seat. When she does eventually get to see him, he rushes things and seems to ignore her questions. Mum may be getting older, but she is very switched on and deserves to be listened to. He had her in and out of his room in 5 minutes even though she wanted to ask about the battery in her pacemaker as she’s had it for quite a few years now. I’d like her to change to another doctor, but you know what it’s like. Mum thinks it would be rude to ask her GP for a referral to someone else, so she won’t let me do anything about it.’
Dr Longford thinks hard. She has heard stories about Dr Giles’s care from other GPs. A patient who is new to the practice last year described an encounter with Dr Giles that left Dr Longford wondering about his competence. She would never refer any of her patients to him, but she has nothing firm on which to base her concerns.
What should Dr Longford say to Ms Wilmore?
Ethical framework for clinical practice
The unease which this case may trigger is a useful pointer to the presence of ethical issues. However, it may be more difficult to work out what the right thing to do is. We propose a framework for thinking about ethical issues that may help using this case study as an example.1 We must note at the outset that ethical analysis is not a magic bullet. It is rare that there are simple ‘yes/no’ or ‘right/wrong’ answers to ethical dilemmas, and working through an ethical decision framework cannot tell you exactly what to do. However, this process can help to identify where the ethical sticking points are, think systematically about the issues, identify a range of possible responses, and make a considered judgement about which option is preferable and why.2
Pinpointing the issues
The first step is to try to pinpoint the ethical issues. What are the challenging decisions here and why are they challenging?
Professional practice concerns
Ms Wilmore has raised potentially troubling allegations about the standard of care provided by her mother’s cardiologist. Questions to consider:
- How confident do you need to be before relaying concerns about a professional colleague?
- What obligations does Dr Longford have to act in this case, compared with similar concerns about a colleague in her practice?
- Should Dr Longford contact Mrs Grey’s GP directly rather than discussing matters with Ms Wilmore?
Another related concern arises as this query is from an employee of Dr Longford about a personal matter, rather than direct patient care. What is the status of this request and what mandate does Dr Longford have to act on behalf of Ms Wilmore’s mother?
Elder care issues
We will canvas elder care issues in the next paper in this series.
Considering perspectives
We suggest looking at the case from multiple perspectives after identifying as many ethical questions as possible (it is important to think creatively).
The patient’s perspective
What is important for the patient and what would be the best option for her? It is important to take Mrs Grey’s wishes and values into account, and it is clear that she cares about maintaining a cordial relationship with her GP. However, she may not realise that a request to change doctor is unlikely to put that relationship at risk. More importantly, Mrs Grey may be at risk of harm if her cardiologist is not providing an adequate standard of care. A second opinion would provide a review of her care and her GP may suggest a change of specialist if this is warranted. This recommendation may be more acceptable to Mrs Grey if it comes from her GP rather than her daughter.
The practitioner’s duties and obligations
What actions will demonstrate important ethical qualities (eg honesty, respect, trustworthiness, fairness, and beneficence) by the practitioner? This is slightly tricky as Mrs Grey is not Dr Longford’s patient and Mrs Grey’s GP is not an immediate colleague of hers. Nonetheless, doctors have obligations beyond those that are owed to their patients. This includes acting to avoid harm to the patients of doctors about whom there may be competence concerns, whether these are ‘known’ individuals (as is the case with Mrs Grey) or completely unknown patients. Questioning the competence of a fellow professional seems to be extraordinarily difficult. Reasons for this include fear of being seen as a whistleblower, lack of knowledge about support for impaired doctors and concerns that regulatory processes may be punitive rather than supportive.3
Dr Longford only has hearsay in this case, which does not reach the threshold for mandatory reporting.4 However, Dr Longford does have a responsibility not to ignore the issue. One option is to encourage Ms Wilmore to raise her concern about her mother’s care through the notification process at the Australian Health Practitioner Regulation Agency (AHPRA). Notifications may relate to behaviour or communication, as well as more serious issues. These can be made by third parties, including family members, other health professionals and patients.5
AHPRA encourages the reporting of concerns. Serious concerns will trigger a formal notification, while less serious ones are noted and the practitioner alerted. Therefore, a growing number of minor concerns can trigger further investigation.
Alternatively, Dr Longford may call the GP in charge of Mrs Grey’s care to discuss the concern and what action to take. This would give her further information about the apparent quality and appropriateness of the cardiologist’s standard of care.
The next stage in the ethical analysis will be to consider the consequences of different courses of action on the healthcare team and the community, as well as for the patient and practitioner. Supporting Ms Wilmore in registering her concern may help to avoid harm to Dr Giles’s patients. It may also trigger support for him prior to any adverse patient outcomes, and may lead to his successful return to competent practice if he is currently impaired.
Suggesting only a second opinion to Ms Wilmore, and doing nothing further about Dr Giles, may seem the easy option. However, in our view, this would be inconsistent with the duty of care as this extends beyond the patient immediately in front of you.
Review and reconsider
The final part of any ethical analysis is to review the favoured option, double check for unintended consequences, appraise the robustness of the reasons and consider how comfortable you would be explaining your decision to your peers and others whose opinion you respect. There are only ‘least worse’ options on some occasions, but even if this is the case, weighing these up in a thorough and systematic manner can help you to reach a justifiable decision.
Suggested action
We would advise Dr Longford to:
- Suggest to Ms Wilmore that her mother should ask her GP for a second opinion.
- Contact Mrs Grey’s GP directly to seek further information about the cardiologist’s standard of care.
- Encourage Ms Wilmore to notify AHPRA of her concerns.
Authors
Wendy Rogers BMBS, BA (Hons), PhD, MRCGP, FRACGP, Professor of Clinical Ethics, and ARC Future Fellow, Department of Philosophy and Department of Clinical Medicine, Macquarie University, Sydney, NSW. wendy.rogers@mq.edu.au
Annette Braunack-Mayer BMedSci (Hons), PhD, Head, School of Public Health, University of Adelaide, Adelaide, SA
Competing interests: None.
Provenance and peer review: Commissioned, externally peer reviewed.