The values and ethical commitments of doctors engaging in macroallocation: a qualitative and evaluative analysis

Using practical wisdom to facilitate ethical decision-making: a major empirical study of phronesis in the decision narratives of doctors

Background

Medical ethics has recently seen a drive away from multiple prescriptive approaches, where physicians are inundated with guidelines and principles, towards alternative, less deontological perspectives. This represents a clear call for theory building that does not produce more guidelines. Phronesis (practical wisdom) offers an alternative approach for ethical decision-making based on an application of accumulated wisdom gained through previous practice dilemmas and decisions experienced by practitioners. Phronesis, as an ‘executive virtue’, offers a way to navigate the practice virtues for any given case to reach a final decision on the way forward. However, very limited empirical data exist to support the theory of phronesis-based medical decision-making, and what does exist tends to focus on individual practitioners rather than practice-based communities of physicians.

Methods

The primary research question was: What does it mean to medical practitioners to make ethically wise decisions for patients and their communities? A three-year ethnographic study explored the practical wisdom of doctors (n = 131) and used their narratives to develop theoretical understanding of the concepts of ethical decision-making. Data collection included narrative interviews and observations with hospital doctors and General Practitioners at all stages in career progression. The analysis draws on neo-Aristotelian, MacIntyrean concepts of practice- based virtue ethics and was supported by an arts-based film production process.

Results

We found that individually doctors conveyed many different practice virtues and those were consolidated into fifteen virtue continua that convey the participants’ ‘collective practical wisdom’, including the phronesis virtue. This study advances the existing theory and practice on phronesis as a decision-making approach due to the availability of these continua.

Conclusion

Given the arguments that doctors feel professionally and personally vulnerable in the context of ethical decision-making, the continua in the form of a video series and app based moral debating resource can support before, during and after decision-making reflection. The potential implications are that these theoretical findings can be used by educators and practitioners as a non-prescriptive alternative to improve ethical decision-making, thereby addressing the call in the literature, and benefit patients and their communities, as well.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-021-00581-y.

Can mobile health apps replace GPs? A scoping review of comparisons between mobile apps and GP tasks

Background

Mobile health applications (mHealth apps) are increasingly being used to perform tasks that are conventionally performed by general practitioners (GPs), such as those involved in promoting health, preventing disease, diagnosis, treatment, monitoring, and support for health services. This raises an important question: can mobile apps replace GPs? This study aimed to systematically search for and identify mobile apps that can perform GP tasks.

Methods

A scoping review was carried out. The Google Play Store and Apple App Store were searched for mobile apps, using search terms derived from the UK Royal College of General Practitioners (RCGP) guideline on GPs’ core capabilities and competencies. A manual search was also performed to identify additional apps.

Results

The final analysis included 17 apps from the Google Play Store and Apple App Store, and 21 apps identified by the manual search. mHealth apps were found to have the potential to replace GPs for tasks such as recording medical history and making diagnoses; performing some physical examinations; supporting clinical decision making and management; assisting in urgent, long-term, and disease-specific care; and health promotion. In contrast, mHealth apps were unable to perform medical procedures, appropriately utilise other professionals, and coordinate a team-based approach.

Conclusions

This scoping review highlights the functions of mHealth apps that can potentially replace GP tasks. Future research should focus on assessing the performance and quality of mHealth apps in comparison with that of real doctors.

Ethics education and moral decision-making in clinical commissioning: an interview study

BACKGROUND

Clinical commissioning involves ethically challenging decisions about health resource allocation. However, commissioners come from a range of professional backgrounds with varying levels of training and expertise in ethical decision-making. Hence, they may lack the relevant training and resources to feel fully prepared for this increasingly demanding role.

AIM

This study aims to provide insight into how prepared commissioners feel in making ethical decisions; what ethics learning needs they might have; and how these might be addressed.

DESIGN AND SETTING

This qualitative interview study explored the experiences of commissioners working for clinical commissioning groups (CCGs) in England.

METHOD

Eighteen participants were interviewed between December 2017 and July 2018 using a purposive sampling approach to participant selection. Transcriptions were coded and analysed using the constant comparative method of thematic analysis.

RESULTS

Most participants had not received ethics training in preparation for, or during, their commissioning role, and reported difficulties identifying and analysing ethical issues. Participants often felt uncomfortable about decisions they were involved in, attributing this to a number of factors: a sense of moral unease; concerns that CCGs' decision-making processes were not sufficiently transparent; and that CCGs were not fully accountable to the population served.

CONCLUSION

Commissioners face complex decisions involving ethical issues, and associated moral unease is exacerbated by a lack of ethics training and lack of confidence in identifying and analysing these. This study shows a clear need for additional support and ethics training for commissioners to support them in this area of decision-making.

Procedural justice and the individual participant in priority setting: Doctors' experiences

In this study we describe, synthesise, and discuss the experiences and views of doctors who participate as technical experts in health care priority setting, reflect on the ethical significance of the challenges to procedural and distributive justice they encounter, and propose an empirically derived practical approach to improving the fairness of the process. Between August 2015 and July 2016 we conducted semi-structured face-to-face interviews with 20 doctors in NSW, Australia, purposively selected on the basis of their participation in macroallocation. Participant selection, data collection, and analysis were carried out according to the principles of grounded moral analysis, an empirical bioethics methodology closely based on grounded theory. The doctors we interviewed attached ethical significance to a broad range of procedural concerns that militated both against the prospect of distributive justice and against their own wellbeing: unfair access to opportunities to participate in macroallocation, sexist behaviours and structures, rewards for rule-breakers, cynical and insincere practices, waste, duplication, and inefficiency, and being taken for granted. On the basis of our data, we hypothesise that the institutional conditions for macroallocation do not support the care of medical participants in deliberations. Evaluating our findings against the 'accountability for reasonableness' framework of Daniels and Sabin, we expose as incompatible with the conditions for procedural justice processes that treat participants in macroallocation unfairly or cause them to have moral unease about the justice of the enterprise. We suggest a supplementary procedure that positions commitment to the care and just treatment of participants as a foundation of any macroallocation procedure.