Skip to main content

Ethics Case Consultation in Primary Care: Contextual Challenges for Clinical Ethicists


The development of ethics case consultation over the past 30 years, initially in North America and recently in Western Europe, has primarily taken place in the secondary or tertiary healthcare settings. The predominant model for ethics consultation, in some countries overwhelmingly so, is a hospital-based clinical ethics committee. In the United States, accreditation boards suggest the ethics committee model as a way of meeting the ethics component of the accreditation requirement for payment by Health Maintenance Organizations (HMOs), and in some European countries, there are legislatory requirements or government recommendations for hospitals to have clinical ethics committees. There is no corresponding pressure for primary care services to have ethics committees or ethics consultants to advise clinicians, patients, and families on the difficult ethical decisions that arise in clinical practice.

Hide All

1. Slowther A, Hope T, Bunch C, Woolnough B. Clinical Ethics Support in the UK. Current Position and Likely Development. London: The Nuffield Trust; 2001.

2. Joint Commission for Accreditation of Health Care Organizations (JCAHO). Comprehensive Manual for Hospitals. Chicago, JCAHO; 1996.

3. Carbonelle S, Schmitz P. Ethical function in Belgian Hospital Ethics Committees: Historical overview. In: Lebeer G, Moulin M, eds. Ethical Function in Hospital Ethics Committees. Biomed 2 working papers. Brussels: Universite Libre de Bruxelles; 2000:39–45.

4. Hurst S, Reiter-Theil S, Slowther A, Pegoraro R, Danis M. Should ethics consultants help clinicians face scarcity in their practice? Journal of Medicial Ethics 2008;34:241–6.

5. In Re Quinlan. 70 NJ 10, 355 A(2d) 647 (1976); President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Decisions to forgo life sustaining treatment: A report on the ethical, medical and legal issues in treatment decisions. Washington DC: U.S. Government Printing Office; 1983:155–70.

6. Slowther A, Johnston C, Goodall J, Hope T. Development of clinical ethics committees. British Medical Journal 2004;328(7445):950–2.

7. Andereck WS. Development of a hospital ethics committee: Lessons from five years of case consultations. Cambridge Quarterly of Healthcare Ethics 1992;1(1):41–50; Brennan TA. Physicians and futile care: Using ethics committees to slow the momentum. Law, Medicine and Health Care 1992;20(4):336–9; Cohen CB. Interdisciplinary consultation on the care of the critically ill and dying: The role of one hospital ethics committee. Critical Care Medicine 1982;10:11–84; Reiter-Theil S. The ethics of end-of-life decisions in the elderly: Deliberations from the ECOPE study. Best practice & research. Clinical anaesthesiology 2003;17(2):273–87; Connelly JE, DalleMura S. Ethical problems in the medical office. JAMA 1988;260(6):812–5; Schneiderman LJ, Gilmer T, Teetzel HD, Dugan DO, Blustein J, Cranford R, et al. Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: A randomized controlled trial. JAMA 2003;290(9):1166–72.

8. Braunack-Mayer AJ. What makes a problem an ethical problem? An empirical perspective on the nature of ethical problems in general practice. Journal of Medical Ethics 2001;27(2):98–103; Bremberg S, Nilstun T. The variety of ethical issues in everyday practice. European Journal of General Practice 2001;7:143–7; see note 7, Connelly, DalleMura 1988; Viens DC. Moral dilemmas experienced by nurse practitioners. Nurse Practitioner Forum 1994;5(4):209–14.

9. UK Clinical Ethics Network. Clinical Ethics Committees; available from (last accessed 12 May 2008).

10. Pellegrino ED. The social ethics of primary care: The relationship between a human need and an obligation of society. Mount Sinai Journal of Medicine 1978;45(5):593–601.

11. Doyal L. Ethico-legal dilemmas within general practice. In: Dowrick C, Frith L, eds. General Practice and Ethics: Uncertainty and Responsibility. London: Routledge; 2000.

12. Brody H. Transparency: Informed consent in primary care. Hastings Center Report 1989;19(5):5–9.

13. Dickman RL. Family medicine and medical ethics—A natural and necessary union. Journal of Family Practice 1980;10(4):633–7; Smith H. Medical ethics in the primary care setting. Social Science and Medicine 1987;25(6):705–9.

14. Rogers WA. Beneficence in general practice: An empirical investigation. Journal of Medical Ethics 1999;25(5):388–93; Rogers WA. Whose autonomy? Which choice? A study of GPs' attitudes towards patient autonomy in the management of low back pain. Family Practice 2002;19(2):140–5.

15. Bremberg S, Nilstun T, Kovac V, Zwitter M. GPs facing reluctant and demanding patients: Analysing ethical justifications. Family Practice 2003;20(3):254–61; see note 8, Viens 1994.

16. Hermsen M, Ten Have H. Decision-making in palliative care practice and the need for moral deliberation: A qualitative study. Patient Education and Counselling 2005;56(3):268–75.

17. See note 8, Braunack-Mayer 2001.

18. See note 8, Braunack-Mayer 2001; see note 7, Connelly, DalleMura 1988; see note 8, Viens 1994.

19. See note 7, Connelly, DalleMura 1988.

20. Ayres PJ. Rationing health care: Views from general practice. Social Science and Medicine 1996;42(7):1021–5.

21. See note 7, Connelly, DalleMura 1988; see note 8, Viens 1994.

22. Carman D, Britten N. Confidentiality of medical records: The patient's perspective. British Journal of General Practice 1995;45(398):485–8.

23. See note 4, Hurst et al. 2006.

24. Beauchamp TL. Methods and principles in biomedical ethics. Journal of Medical Ethics 2003;29(5):269–74.

25. Agich GJ. Joining the team: Ethics consultation at the Cleveland Clinic. HEC Forum 2003;15(4):310–22.

26. American Society for Bioethics and the Humanities (ASBH). Core Competencies for Health Care Ethics Consultation. Glenview, Il: ASBH; 1998.

27. See note 26, American Society for Bioethics and the Humanities 1998.

28. Reiter-Theil S. The Freiburg approach to ethics consultation: Process, outcome and competencies. Journal of Medical Ethics 2001;27(Suppl. 1):i21–3; Singer PA, Pellegrino ED, Siegler M. Clinical ethics revisited. Biomed Central Medical Ethics 2001;2:E1; West MB, Gibson JM. Facilitating medical ethics case review: What ethics committees can learn from mediation and facilitation techniques. Cambridge Quarterly of Healthcare Ethics 1992;1(1):63–74.

29. See note 26, American Society for Bioethics and the Humanities 1998:15.

30. Slowther A. Ethical decision-making in primary care. 2004. DPhil thesis. Bodlean Library, University of Oxford.

31. Busby A, Rauh JR. (). Implementing an ethics committee in rural institutions. Journal of Nursing Administration 1991;21(12):18–25; Niemira DA. Grassroots grappling: Ethics committees at rural hospitals. Annals of Internal Medicine 1988;109:12–3.

32. Hoy J, Feigenbaum E. Making the case for ethics consults in community mental health centers. Community Mental Health Journal 2005;41(3):235–50.

33. MacRae S, Chidwick P, Berry S, Secker B, Hebert P, Shaul RZ, et al. Clinical bioethics integration, sustainability, and accountability: The hub and spokes strategy. Journal of Medical Ethics 2005;31(5):256–61.

34. Agich GJ. What kind of doing is clinical ethics? Theoretical Medicine 2005;26(1):7–24.

Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Cambridge Quarterly of Healthcare Ethics
  • ISSN: 0963-1801
  • EISSN: 1469-2147
  • URL: /core/journals/cambridge-quarterly-of-healthcare-ethics
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Full text views

Total number of HTML views: 5
Total number of PDF views: 20 *
Loading metrics...

Abstract views

Total abstract views: 243 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 20th November 2017. This data will be updated every 24 hours.