Abstract
Whether practiced by ethics committees or clinical ethicists, medical ethics enjoys a solid foundation in acute care hospitals. However, medical ethics fails to have a strong presence in the primary care setting. Recently, some ethicists have argued that the reason for this disparity between ethics in the acute and primary care setting is that primary care ethics is distinct from acute care ethics: the failure to translate ethics to the primary care setting stems from the incorrect belief that acute care ethics can be applied to the primary care setting. In this paper, I argue that primary care ethics and acute care ethics are species of the same ethical genus, and that the ethical differences are not ones of kind but of circumstance. I do this by appealing to the role obligations that underlie acute care and primary care clinicians’ medical ethical obligations and the shared institutions that ground those obligations.
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Notes
Medical systems may have concerns that extend past primary care to secondary care clinics as well. These concerns are important, but secondary care is already more like acute care than primary care. If primary care can be shown to be of the same ethical genus as acute care, I am confident that secondary care can as well.
Is the genus-species relation the correct relation to use in describing the relation between medical ethics and primary/acute care ethics? It’s possible that casting the relationship as primary and acute care ethics being two subspecies of the same species would be appropriate: perhaps, it is easier to tie two subspecies together than two species or easier for two subspecies to interact with each other than two species. Which relation one picks, I believe, does not change the fundamental relation that exists between medical ethics, on the one hand, and primary and acute care ethics on the other hand. Thus, I invite the reader to read in her/his preferred relation for the rest of the paper. Thank you to an anonymous reviewer, Anna Perinchery-Herman, Doug Moore, and Stephanie Hull for helpful clarification on this point.
This claim, in and of itself, is not incredibly controversial. Strict consequentialists might reject it since they think that all of one’s duties consist in maximizing/satisficing the good and this is a natural obligation. However, they would also reject that primary care ethics is sui generis, so they are not my primary target.
There is a larger controversy in the background here about whether all special obligations must be voluntarily taken on or whether one can have a special obligation to someone without ever voluntarily taking it on—think, for example, of an obligation to one’s child. My argument does not depend on one of these sides being correct and is consistent with both. Thus, I shall set this aside.
Of course, embedding need not stop there. For example, the Premier League is embedded in the institution of soccer more generally. In this case, one might say Özil is a midfielder playing soccer for the Premier League in Arsenal. There may be multiple orders of embedding for any role one inhabits.
Thank you to an anonymous reviewer for this helpful example.
This is, indeed, a controversial assumption, as I’m sure some would say that one’s role-obligations could potentially outweigh one’s natural obligations. I am committed to the claim that this is false, but defending it is outside the scope of this paper. This will simply be a critical assumption of the paper, but given its defense in the literature, I take it to be reasonable.
Of course, one can imagine scenarios in which I do possess such an obligation such as when someone’s life is on the line, but I presume most do not play chess under these scenarios.
Or, at least, their moral significance is not tied to medical ethics and the ethicist need not concern herself with them.
I want to thank a participant in the ACHE 2020 research symposium for discussion on this topic.
I want to thank Elizabeth E. Magill for bringing this problem to my attention in a prior version of this paper.
Though, one must remember, acute care facilities do sometimes deal with the issue of whether to fire a patient. See D’Arrigo (2013). Thanks to an anonymous reviewer for this helpful example.
Thank you to an anonymous reviewer for raising this important objection.
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Acknowledgements
Thanks to the participants at the ACHE 2020 research symposium for their helpful comments and questions. Thanks to Elizabeth E. Magill for helpful comments on earlier versions of this paper. Thank you also to Anna Perinchery-Herman, Doug Moore, Stephanie Hull, and Ash Navabi for their invaluable discussion on several different topics within this paper.
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Perinchery-Herman, S. Primary Care Ethics is Just Medical Ethics: A Philosophical Argument for the Feasibility of Transitioning Acute Care Ethics to the Primary Care Setting. HEC Forum 35, 73–94 (2023). https://doi.org/10.1007/s10730-021-09451-x
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DOI: https://doi.org/10.1007/s10730-021-09451-x