It’s a complex world in primary care, and it changes medical ethics!

By Sanjiv Ahluwalia, Rupal Shah & John Spicer.

In this post, we want to challenge to the idea that ethical decision making exists independently of context or of the interactions that influence us. We propose that social complexity offers an alternative perspective to our existing normative frameworks; a perspective which validates our subjective experience of the unpredictability of relationships, the emergent nature of understanding and which acknowledges the influence of context on our moral choices.

Primary care suits the paradigm of social complexity. Our own experience of working as doctors is that relationships with patients in general practice are longitudinal, grounded in dialogue, vary over time, involve differing spaces (from the consulting room to patients’ homes) and are influenced by the mode of communication employed (for example, telephone, video or face to face consultation). We have noticed that both patient and clinician continuously reframe their own narratives to maintain a sense of coherence, and this has an impact on the moral decisions that are made. Social complexity theory offers a framework which permits abstracted knowledge and ideas to be incorporated into the interaction between individuals whilst acknowledging the inevitable unpredictability of the consultation and its potential for transformative change.

Heesoon Bai proposes that established ethical frameworks range between two ends of a spectrum – from those that regard ethical principles as being abstracted and universal; to those that disregard universality and promote a relativistic perspective. She suggests that both extremes ignore our lived experience, disregarding the way in which moral values change through time and space and reflect (and are reflected in) the way the world is set-up. We endorse her view.

The premise that we can define ethical and behavioural standards independently of context, time and relationships is partly responsible for the proliferation of procedures and processes, inspections, payment regimes and reporting requirements imposed upon the delivery of healthcare in the UK over the past 30 years. The development of these ideas and their translation into “performance management”, “patient safety tools”, “professional regulation” and “quality improvement approaches” are often experienced as being disconnected to the reality of practice, with little apparent reflection on their collective impact on clinician or patient experience.

We explore the key concepts in complexity theory, their relevance to working in primary care, and showcase the relation they have to ethical issues, through an in-depth analysis of an interaction between a patient and their GP. Whether this blog generates scepticism or resonance, we hope that by engaging with it (and the associated article) you will be inspired to respond and thereby create new ways of thinking, challenging and being challenged. In doing so, you will have participated in the invisible processes of human interaction that social complexity seeks to make explicit.

Paper title: Moral Flux in primary care: the effect of complexity

Authors: John Spicer, Sanjiv Ahluwalia and Rupal Shah


1- St George’s, University of London, Institute of Clinical and Biomedical Education

2- Health Education England [London Team]

3- Health Education England [ Professional Support Unit]

Competing interests: None declared

Social media accounts of post author(s): @johnspicer3 and @ahluwaliasanjiv

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