The limits of primary care
The limits of primary care

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The limits of primary care

2: Moral dilemmas

It is clear from the account of Jim and Marianne's lives that they need some help. But do they deserve help? Some of our course testers had very strong reactions to the inclusion of drug users in a course about health and social care. Here is one typical response:

I am not sure that Jim and Marianne and people like them deserve this sort of attention. Their problems were self-inflicted. It must have cost someone (we taxpayers?) a lot of money to rehabilitate them, yet they wasted the opportunity, cadged more money off Marianne's parents, stole from honest members of the community, and then expected to be bailed out by the NHS. Are there no limits to the obligations we all have to support people who seem determined to waste their lives, and damage the lives of others as they do so?

Do you share this attitude? It represents a clear challenge to the idea that everyone has rights to health and social care services simply because they happen to be resident in a community.

This question is one we could debate in abstract terms, but it takes a very concrete form when practitioners have to make decisions about resources, eligibility and priorities. Because I take a particular interest in drug users in my work as a GP, I have some experience of facing the issues. I explore some of them in the extract below, entitled Snowballs and Acorns: Medicine by impact.

Snowballs and Acorns: Medicine by Impact [Tip: hold Ctrl and click a link to open it in a new tab. (Hide tip)]

Activity 2: Tough decisions

Read the extract above. Concentrate on the dilemmas I faced in considering what to do when called out by Julia to examine her child. As this block is about communities, look at the question from two perspectives:

  1. the GP's obligations to the individual

  2. the GP's obligations to the community

and, under these headings, list the considerations involved in coming to a decision about taking Julia and her family on to the practice list.



Obligations to the individual Obligations to the community
Sick child, no fault of his own Family will be expensive to treat, means fewer resources to spend on other (more deserving?) patients
Holistic view of Julia's situation suggests she needs help Doctors should focus on things they can treat rather than trying to take on the troubles of the world
Julia is asking for help for the first time, responding to an empathetic doctor Should not reward a deviant who has brought her troubles on her own head
May be an opportunity to stop this family sliding deeper into the mire May be a constant drain on public money with no real return
No other agencies available to offer support Democratically elected local authority has taken the decision to withdraw helping agencies; doctor should go with this consensus

In theory, everyone has the right to register with a GP practice, and expect treatment – something we examine in more detail below. There are other things to think about too.

  • It is not just Julia whose welfare is at stake: her children may be at some kind of risk. Any health or social care worker in contact with Julia's family will have to be aware of the Children Act 1989 principle that ‘the child's welfare is paramount’ (Department of Health, 1989a), and act accordingly. In the case of the GP this will mean checking with the health visitors attached to the practice, and asking them to visit. They will be obliged to take action if Julia is not providing the care that a ‘reasonable parent’ should supply under the circumstances.

  • In this sort of situation a GP may be professionally liable if things were to go wrong and the child became seriously ill as a result of negligence.

  • On this occasion my own needs, and those of my family, had to be put aside, but neither a GP nor any other health or social care worker can sustain this level of commitment to the welfare of others indefinitely.

  • In the Reader chapter I also reflect on why I am attracted to work with drug users. Is it solely out of altruism, or does this aspect of my work feed an unworthy personal need? And does that matter?

This chapter shows that just one small encounter can present a practitioner like me with a whole host of moral dilemmas. It is well nigh impossible to draw hard and fast rules when every case is different, and when personal as well as professional issues come into play. Legal requirements, such as the Children Act, mean that the question is not just a matter of individual judgement.

Moreover, such decisions have to be made not only at the face-to-face level, but in planning how to use limited resources.

Activity 3: Rationing resources

As a member of a health authority responsible for purchasing health services you are faced with a contracting budget. Given a choice between retaining an eight-bed drug rehabilitation centre (where someone like Julia could get treatment) and setting up four additional beds for acute psychiatric care, which would you choose?


This dilemma was faced by one health authority in 1997. The decision was to close the drug rehabilitation centre in favour of financing acute psychiatric care. Did you make the same choice?

If you did make the decision that Jim and Marianne, Julia and her children, are less deserving than people with acute psychiatric conditions, where would you draw the line? At treatment for motorists who drink or drive recklessly; cyclists who do not wear helmets; smokers; people who eat too much fatty food, or indulge in sports like ski-ing or horse riding, which carry a high risk of injury?

If you knew that a place in prison, where many drug users spend time, costs up to £30,000 a year, would that influence your decision?


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