PS:It falls to the editor of a to assume responsibility not just for the determined editorial slant of a magazine, journal or newspaper, but also to attempt on behalf of its readers, to draw together the various strands of discussion and argument (hopefully) in one coherent narrative or postscript at the end – a difficult and challenging task at the best of times!
Many of the preceding pages have been spent discussing the existential issues of quality and professional performance against a backdrop of inadequate financing and quite discouraging cancer statistics widespread across most parts of sub-Saharan Africa.
The practice of medicine worldwide is governed by the supreme ethical principle of ‘best interests’. Invested in the role of the doctor, is the custodian and gatekeeper’s responsibility to ‘do no harm’. This responsibility presupposes a ‘duty of care’, the basis of any presumption of liability on the part of a medical practitioner and the principle upon which a claim of professional negligence may be hinged.
In order to establish liability on the part of a doctor (or other healthcare professional), there are 3 important tests that must be satisfied:
- That a duty of care was owed to the patient
- That the said duty was breached
- Causation – That as a direct result of the breach, the patient suffered harm
A historic assumption of autonomy, which has for several years caused a sizeable number of medical colleagues to fall foul of the requirements above, and entrenched culture of deference towards the medical profession has in recent years, receded significantly in favour of greater transparency and increased public engagement with service users and stakeholder members of the wider society.
This has been the case in medical practice consultations, even in sub-Saharan Africa. Berwick (2016) in his seminal paper discussing the 3rd Era for Medicine and Healthcare, describes an epic collision of two eras with incompatible beliefs.1
While healthcare services in many western countries are indeed struggling to come to terms with the responsibilities of a new ‘moral era’ of practice (Era 3 – with less managerial encumbrances, less performance management and endless failed incentives), the conflict within healthcare systems located in sub-Saharan Africa and across many low and middle-income countries, is definitely between an existing culture of assumed ‘nobility’ – the right to undeserved public trust and professional self- regulation (Era 1) versus the advancing need for greater transparency, increased public accountability and enhanced professional regulation standards (Era 2).
As in most parts of Europe and the western world, the post-World War II ideal of the UK National Health Service (NHS) has evolved considerably from a position of ‘almost complete autonomy’ to a more equal, less paternalistic ‘partnership’ between health professionals and their patients.2 This irreversible shift in balance is based almost entirely upon a framework of mutual and professional accountability existing within a framework of performance-based regulation of the healthcare delivery industry.3
Every system has its beginnings. “The Citadel”, A.J Cronin’s prodigious 1937 account that deals extraordinarily with issues of medical ethics in the pre-war years, provides useful insight into the prevailing culture of practice and the experiences of practitioners and service users in the period preceding the early days of the now-esteemed NHS, as well as the perception and role of the local General Practitioner (GP) in this nascent period of history.
Reflecting on the ethical responsibility of the practising clinician, Savulescu (1995) argues in favour of a more proactive “rational, non-interventional” form of paternalism, acknowledging the nature of medicine as a “moral practice” (and of doctors as “moral agents”) with a professional responsibility to
make evaluations and value judgements of patients’ best interests, and to argue “rationally” in favour of these judgments as a way of preserving patient autonomy and the rights of individuals to make quality decisions concerning their own health.4
A clearly defined acknowledgement of the rights of patients, standardised adoption of evidence-based treatment guidelines and a programme of sustained coordinated investment in private and public-sector healthcare under the regulatory control of centralised authorities are all factors that have contributed to a paradigm shift in approach to healthcare provision in Europe and most parts of the western world.
Significant disparities observed in the health and socioeconomic fortunes of low and middle-income economies are largely explained by differences in approach to the requirements of these principal factors. A system of robust governance across all relevant sectors will be crucial to sustaining our socioeconomic development in the years ahead.
“…You must take reasonable care to avoid acts or omissions which you can reasonably foresee would be likely to injure your neighbour. Who then in law is my neighbour? The answer seems to be persons who are so closely and directly affected by my act that I ought reasonably to have them in contemplation as being so affected when I am directing my mind to the acts or omissions which are called in question.”
– Lord Atkin in the case of Donoghue v Stevenson (1932) AC 562
1. Berwick DM. Era 3 for Medicine and Health Care. JAMA. 2016;315(13):1329–1330. doi:10.1001/jama.2016.1509
2. Klein R. ‘The state of the profession: the politics of the double bed’, British Medical Journal (BMJ) 1990;301:700-2
3. Emanuel LL. ‘A professional response to demands for accountability: practical recommendations regarding ethical aspects of patient care’. Ann Intern Med 1996; 124:240–9
4. Savulescu J. ‘Rational non-interventional paternalism: why doctors ought to make judgments of what is best for their patients’, Journal of medical ethics, 1995; 21: 327-331