Power and Responsibility

New doctors who begin practising will be well-versed in their ethical responsibilities. Preparation for finals and applications for foundation year jobs require students to engage with, and demonstrate, their ethical knowledge and how they apply that knowledge in practice. Yet, until graduation, students have few formal responsibilities.

Once the celebrations of finals and the novelty of introducing oneself as “doctor” have passed, the realities of medical practice can be a shock. For many, survival rather than ethical sophistication are the order of the day. Duty of care narrows to the list of tasks accumulated at the behest of seniors. Responsibility becomes burdensome rather than a privilege.

To be ethical is easy in the abstract: ethical dilemmas in the lecture theatre and seminar room often appear to be deftly resolvable. However, the realities of ethical practice are more demanding, which is why some doctors make poor ethical decisions.

For most junior doctors, ethical questions do not relate to the life and death crises that often dominate ethics teaching. The issues are more mundane. Yet, it is their very ordinariness that makes those challenges fundamental to, and at the heart of, what it means to be an ethical doctor.

In a properly organised foundation post, the boundaries of appropriate and inappropriate work, both in terms of content and load, will be defined and regulated. However, it is possible that even the best-run foundation post will bring ethical challenges relating to the shift in responsibility and the particular features of the clinical teams with whom one is working. Consider the experiences of Dr H.

Case Study

Dr H was excited when she began her F1 job at a busy district general hospital located on the outskirts of a large city. Dr H is of the opinion that her consultant, Dr S, is a skilled clinician. However, she has become concerned about some of the interactions between him and his patients, particularly during ward rounds where he rarely acknowledges or discusses their care with them.

One morning, while Dr H is part of a large ward round comprising a dozen people, Dr S reviews the care of a patient who has been admitted for investigations following an unexplained “collapse”. He proposes that the patient have an echocardiogram, an exercise stress test, and begin treatment for hypertension. Dr H notices that Dr S does not explain his decision to the patient.

Later, Dr H is asked by the nursing staff to see the patient who has become distressed and refuses to go down for investigations because he “has no idea what is going on”. Dr H visits him, but the patient will “only talk to the main man – the consultant”. Dr H knows that Dr S has an outpatient clinic followed by a research meeting off -site.

What should DR H do?

One practical approach would be for Dr H to sit with the patient and perhaps rectify the situation by apologising for his distress, explaining what is happening and seeking his consent to proceed. However, even if Dr H has the skills and sensitivity to manage the situation, it will still involve her making several ethical compromises. The patient has explicitly requested to see the consultant; he may agree to see Dr S later, but he is clearly unhappy about the extent to which Dr S has involved him in his care.

Moreover, Dr H’s existing concerns about the way Dr S interacts, or rather doesn’t interact, with patients are greater than this particular patient’s concerns. By seeking to manage the situation, Dr H is making a choice not to engage with an ethical issue that affects the care of her team and strikes at the heart of the therapeutic relationship.

There may be good reasons for not wishing to tackle the wider issue: Dr H may feel that she is too junior to speak out; she may be unsure whether her concerns are legitimate; she may feel that she has responsibility but no power; or she may be keen to preserve her relationship with her consultant. Nonetheless, if Dr H chooses to do no more than merely contain the crisis, she is making a significant ethical choice and one that has implications for patient care.

Dr H should view this as an opportunity to tackle something that is difficult and is likely to recur in her career, namely speaking out or disagreeing with a colleague. Just as it takes practice to hone skills in cannulation or lumbar punctures, it takes practice to learn how to challenge, question and constructively disagree with someone whose approach is compromising patient care.

OUR ADVICE: POWER AND RESPONSIBILITY

The pressure of the clinical workload means that mistakes are inevitable, but a distinction needs to be made between matters of personal conduct and poor performance, and where a doctor’s performance may be affected by a health issue (eg depression, substance abuse etc).

GMC guidance says you should support colleagues who have problems with performance, conduct or health, but action should be taken if this compromises patient care. The GMC recommends that you raise your concerns to the medical director or a senior colleague. Local guidelines will be in place to deal with these situations should they arise. If in doubt, contact your MDO (Medical Defence Organisation) for specific advice.

Challenging a senior colleague is probably one of the hardest things you may have to do in your career, so if you have concerns, contact Medical Protection as soon as possible and a dedicated medicolegal consultant will support you through the process.

Professor Deborah Bowman is Professor of Bioethics, Clinical Ethics and Medical Law at St George’s University of London.