It’s unethical for general practitioners to be commissioners

Sir,

I agree with Mark Sheehan . I also think he makes a bad case for a
good cause.

The most celebrated ethical frameworks will have no problem with the
accumulation of the roles of commissioner and provider. The obvious
conflict is integral to the ethical posture, in the balance

-Between doing good while not doing harm;

-Between respect for the autonomy of the particular patient while
upholding justice for a population of patients.

While the balances above are specified in a principled approach, they
are also implicit and integral to the sort of judgements relevant to
virtue ethics and utilitarian frameworks.

However, the discomfort generated by this accumulation of roles
remains. It was already visible in the separation of commissioning and
provider arms of PCO's. Therefore it deserves attention.

The issue is about the role of justice and autonomy in the ethical
reasoning. Interestingly, there is an International meeting in Bochum end
of March about Justice and Modern Healthcare (http://www.ruhr-uni-
bochum.de/malakow/bmbf-conf/) and the European Society for the Philosophy
of Medicine and Healthcare also has Justice as the main theme for its
annual conference (http://espmh.org).

I approach this issue as the balance between patient centred, act-
related values (beneficence and non-maleficence) which are typically
negotiated within the relationship between competent people; against more
abstract, attitude-related values (autonomy and justice) which are
typically assessed against conceptual standards external to the private
relationship. The latter are aptly described as political issues.

It is a frequent fact that the pursuit of real improvements in human
life brings about deeper alienation from our core interests. Examples were
described by such diverse people as Karl Marx: while "he sees that
liberalism is a great improvement on the systems of prejudice and
discrimination which existed in the Germany of his day (...) such
politically emancipated liberalism must be transcended on the route to
genuine human emancipation." It is from here that "Marx argues that not
only is political emancipation insufficient to bring about human
emancipation, it is in some sense also a barrier." (Wolff, 2010, p. #2.1).

We may also look at Barry Schwartz' "Paradox of Choice" (Schwartz,
The Paradox of Choice, 2003) or his brilliant TED talk about this
(Schwartz, Barry Schwartz on the paradox of choice, 2006) to understand
how the current paradigm of individual freedom became a source of
alienation: the increase in opportunity costs, arising from the
multiplicity of choices, may achieve a negative net result for the
chooser, whatever the choice made. Thus, in exercising our freedom under a
model designed to improve it, we become alienated from our freedom, the
result no longer being a robust expression of the freedom we purport to
exercise.

So what about GP's commissioning and providing for their patients? My
point is that it may tick all the boxes in everyone's ethical assessment,
it may be just, caring, considerate, expedient and whatever ethical tick
boxes one may wish for. But will the outcome of this process be a robust
expression of what General Practice is about? I really doubt it will.

Will it enhance the affirmation of human emancipation within the
encounter between doctor and patient - between two human beings meeting
under the ethos of a caring, therapeutic relationship? Ok, this is my
personal take on what General Practice is about, but please substitute for
your own. If this model enhances your core outcomes, then it is probably a
good model. If it does not, why are we accepting to have our core ethos,
our core attitudes and concerns, redesigned by stealth?

I believe we are heading for an efficient model, ticking all the
appropriate boxes, but producing an outcome in which we become alienated
from our core values and which we may have difficulty recognising as the
expression of what we are.

------

Schwartz, B. (2006, September). Barry Schwartz on the paradox of
choice. (K. Stoetzel, Ed.) Retrieved January 22, 2011, from TED.com:
http://www.ted.com/talks/barry_schwartz_on_the_paradox_of_choice.html

Schwartz, B. (2003). The Paradox of Choice. New York: HarperCollins
Publishers.

Wolff, J. (2010). Karl Marx. In E. N. Zalta (Ed.), The Stanford
Encyclopedia of Philosophy (Summer 2010 ed.).