THIS issue's column arose from an email exchange with the Summons commissioning editor. He asked if I might consider writing something about the proposed reorganisation of the NHS or would I consider the topic “too political”. In so asking, he prompted me to return to a fascinating question – what is the relationship between ethics and policy?
The governance and practice of healthcare is an ethical matter. The values that underpin the organisation and delivery of healthcare are unavoidable and moral in character. Professionals and patients don’t interact in a vacuum but in the complex machinery of the NHS as envisaged by its political masters.
Yet, healthcare and its ethics often seek and claim a position of moral neutrality. The convention for a disinterested perspective begins early. At my own institution, which trains only future clinical professionals and scientists, there are no Conservative, Labour or Liberal Democrat Societies and political affiliation, if it exists, seems to be expressed privately rather than overtly amongst the student body. In some situations, that is desirable: the therapeutic relationship would likely be compromised by stridently and inappropriately expressed personal opinions. However, the work that doctors, dentists and other clinicians do daily is an inherently political business in that the provision of healthcare is the enactment of policy. And that policy has a moral dimension: it is predicated on particular values and it has far-reaching effects on the practice of millions.
I imagine many readers, even the avowedly apolitical, have fantasised about the ways in which the NHS could be improved. Many more have probably groaned as successive secretaries of state seek to impose their reforming vision on healthcare. Those fantasies and groans may seem at first glance to be nothing more than a healthy reflex to political meddling, but they warrant closer attention. For such responses demonstrate two ethical points. First, the vast majority of healthcare professionals care about how healthcare is provided. Second, there is a relationship between how individuals aspire to serve patients and how policy influences that daily work. In other words, clinicians can be politically disinterested but never uninterested.
What then is the ethical significance of the most recent proposals for NHS reform? First, professionals must acknowledge that political reform has a moral dimension. Whether one agrees with the specific recommendations, it is worth reflecting on the ethical assumptions embedded in the proposed changes. What do the proposals assume about fairness, equitable access, the role of the clinician and distributive justice?
Having identified the moral foundations on which the proposals are built, it is time to return to ethical basics. How will the proposed reforms inform that which is the daily bread of clinical practice? What are the implications of the proposals for the therapeutic relationship? Will the virtuous doctor or dentist differ in the newlyenvisaged NHS or are the virtues of altruism, service and inclusivity secure? How will conflicts of interest be conceptualised and understood in a new world of GP commissioning and multiple providers? What skills and competencies should medical and healthcare education develop in those new to the clinical professions and are they unaltered by the changing political landscape?
These questions can be met with widely variable responses. That does not matter. Indeed, a range of response and divergence of opinion are usually beneficial for the quality of ethical debate. The point is that these are questions for everyone working as a healthcare professional to consider. Whether you are excited by the prospect of flexing commissioning muscle as a GP, believing it will secure better care for your patients, or uneasy about what you perceive as the conceptualisation of healthcare as a product for trade, time spent reflecting on the reasons for your position is time well spent. For those who resist the dichotomous approach and refuse either to wholly embrace or wholly reject the proposals, taking time to consider the underlying ethical dimension to policy change is instructive.
Whatever your response to Andrew Lansley’s proposals, it reveals something about your moral compass and the ways in which you believe healthcare should be practised. It is via the medium of policy that fundamental ethical questions are raised. These questions matter because they are not often explicitly considered yet they shape every moment of our practising lives: what we believe the aims of healthcare to be, how the clinician–patient relationship should be, what it means to serve the public sector, the ways in which limited resources are distributed and what makes a 'good' doctor or dentist.
Politics was famously said to be the art of the possible. Whether you consider the secretary of state’s proposals to be possible is a matter of ethics not merely political machinations in parliament. A considered response is essential.
Deborah Bowman is a senior lecturer in medical ethics and law at St George’s, University of London