Is it morally permissible for general practitioners to disclose their opinion on a woman's decision on abortion?

BACKGROUND: This paper considers ethical dilemmas arising where a patient asks their General Practitioner for advice and their personal opinion regarding whether or not to have an abortion. Patients often seek their General Practitioner's advice regarding treatments and procedures, which may occasionally lead to the General Practitioner facing a difficult dilemma of whether to share their personal opinion with their patient. As General Practitioners are more accessible as the first point of contact for patients and often have a closer relationship with them, they may be particularly exposed to such situations. Additionally, the significance of abortion as a sensitive topic and the fact the General Practitioner may have their own personal viewpoint on its morality may make it particularly difficult for them to know how to respond to such a request. MAIN TEXT: This paper explores the difficulties arising in such a situation and considers whether it could ever be ethically justifiable for General Practitioners to express their opinions on such a matter. We consider the duties of a doctor, and highlight the need for clearer guidance for healthcare professionals on managing tensions in their professional boundaries between their personal moral views and their professional responsibilities. A range of ethical viewpoints are considered to explore how a doctor might ap, in particular the principle of autonomy, virtue ethics, and consequentialism. CONCLUSIONS: This article recognises that a General Practitioner in a situation such as this faces many ethical challenges. We propose that offering their opinion to the patient where specifically requested may be morally justifiable. A virtue ethics approach in particular requires that the General Practitioner applies practical wisdom to make this decision, and where they do disclose their opinion ensure this is done so in such a manner that it does not harm the patient and promotes flourishing. We encourage GPs and other healthcare professionals to consider their own moral perspectives on sensitive issues such as abortion, and reflect on how their moral viewpoints have the potential to influence their practice. In doing so, we hope clinicians can be better should they be faced with a situation such as this.

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.

Patients' and carers' perspectives of palliative care in general practice: A systematic review with narrative synthesis.

BACKGROUND: General practitioners have overall responsibility for community care, including towards end of life. Current policy places generalists at the centre of palliative care provision. However, little is known about how patients and carers understand the general practitioner's role. AIMS: To explore patient and carer perspectives of (1) the role of the general practitioner in providing palliative care to adult patients and (2) the facilitators and barriers to the general practitioner's capacity to fulfil this perceived role. DESIGN: Systematic literature review and narrative synthesis. DATA SOURCES: Seven electronic databases (MEDLINE, Embase, PsycINFO, BNI, CINAHL, Cochrane and HMIC) were searched from inception to May 2017. Two reviewers independently screened papers at title, abstract and full-text stages. Grey literature, guideline, hand searches of five journals and reference list/citation searches of included papers were undertaken. Data were extracted, tabulated and synthesised using narrative, thematic analysis. RESULTS: A total of 25 studies were included: 14 employed qualitative methods, 8 quantitative survey methods and 3 mixed-methods. Five key themes were identified: continuity of care, communication between primary and secondary care, contact and accessibility, communication between general practitioner and patient, and knowledge and competence. CONCLUSION: Although the terminology and context of general practice vary internationally, themes relating to the perceived role of general practitioners were consistent. General practitioners are considered well placed to provide palliative care due to their breadth of clinical responsibility, ongoing relationships with patients and families, and duty to visit patients at home and coordinate healthcare resources. These factors, valued by service users, should influence future practice and policy development.

Bridging the education-action gap: a near-peer case-based undergraduate ethics teaching programme.

Undergraduate ethics teaching has made significant progress in the past decade, with evidence showing that students and trainee doctors feel more confident in identifying and analysing ethical issues. There is general consensus that ethics education should enable students and doctors to take ethically appropriate actions, and nurture moral integrity. However, the literature reports that doctors continue to find it difficult to take action when faced with perceived unethical behaviour. This has been evident in recent healthcare scandals, in which care has fallen below acceptable ethical standards, despite the presence of professional ethical guidelines and competencies. The National Foundation Training Programme forms the first 2 years of training for new UK doctors. We designed a Foundation Doctor (FD)-led teaching programme in which medical students were invited to bring cases and experiences from clinical placements for small group discussion facilitated by FDs. The aim was to enable students to act ethically in practice through developing moral sensitivity and moral identity, together with skills in ethical reasoning and tools to address barriers to taking ethical action. FDs were chosen as facilitators, based on the evidence that near-peer is an effective form of teaching in medicine and may provide positive role models for students. This article reviews the background rationale for the programme and its design. Important themes emerging from the case discussions are explored. Student and FD facilitator feedbacks are evaluated, and practical challenges to the implementation of this type of programme are discussed.

Vitamin D-mediated growth inhibition of an androgen-ablated LNCaP cell line model of human prostate cancer.

1,25-(OH)(2) vitamin D(3) (1,25-(OH)(2) D), the active metabolite of vitamin D, exerts antiproliferative effects on a variety of tumor cells including prostate. This inhibition requires vitamin D receptors (VDRs) as well as downstream effects on the G1 to S phase checkpoint of the cell cycle. Recent data raise the possibility that androgen plays a role in the antiproliferative effects of 1,25-(OH)(2) D in prostate cancer cells; however, this hypothesis has been difficult to test rigorously as the majority of prostate cancer cell lines (unlike human prostate tumors) lack androgen receptors (ARs). We utilized two different models of androgen-independent prostate cancer that express functional ARs and VDRs to evaluate a possible role of androgen in 1,25-(OH)(2) D mediated growth inhibition. We stably introduced the AR cDNA into the human prostate cancer cell line ALVA 31, which expresses functional VDR but is relatively resistant to growth inhibition by 1,25-(OH)(2) D. Neither ALVA-AR nor the control cells, ALVA-NEO, exhibited substantial growth inhibition by 1,25-(OH)(2) D in the presence or absence of androgen. This observation suggests that the basis for the resistance of ALVA 31 to 1,25-(OH)(2) D-mediated growth inhibition is not the lack of AR. The second model was LNCaP-104R1, an AR-expressing androgen independent prostate cancer cell line derived from androgen dependent LNCaP. 1,25-(OH)(2) D inhibited the growth of LNCaP-104R1 cells in the absence of androgen and this effect was not blocked by the antiandrogen Casodex. As was observed in the parental LNCaP cells, this effect was correlated with G1 phase cell cycle accumulation and upregulation of the cyclin dependent kinase inhibitor (CKI) p27, as well as increased association of p27 with cyclin dependent kinase 2. These findings suggest that the antiproliferative effects of 1,25-(OH)(2) D do not require androgen-activated AR but do involve 1,25-(OH)(2) D induction of CKIs required for G1 cell cycle checkpoint control.