Education and debate: a manifesto for ethics and values at annual healthcare conferences

Abstract In this paper I discuss the ways in which the conference stream ethics and values manifested at the 2015 RCGP Annual Conference in Glasgow, and the ways in which it is planned for the 2016 RCGP Annual Conference in Harrogate. The 2015 RCGP had plenaries, oral presentations, breakout symposia, a debate, and a poster stream. I briefly discuss each in turn before offering a manifesto (a public statement of aims and proposed policy) for ethics and values at healthcare conferences. It is my hope that others will critique this, flesh it out further and even consider how ethics and values relate to conferences for healthcare workers of various specialities. A conference provides opportunities for ethics and values discussion that are potentially distinctive from any other kind of forum. Because conferences offer the potential for knowledge and attitudes to be revisited and revised, issues can be ‘unsettled’ in a way that permits different perspectives to be more fully discussed.


Introduction
In this paper I discuss the ways in which the conference stream 'ethics and values' manifested at the 2015 RCGP Annual Conference in Glasgow and is planned for the 2016 RCGP Annual Conference in Harrogate. The 2015 conference boasted plenaries, oral presentations, breakout symposia, a debate, and a poster stream. The 2016 conference will include a poster stream and a fringe event on the ethics of flourishing and survival. I briefly discuss each in turn before offering a manifesto (a public statement of aims and proposed policy) for ethics and values at healthcare conferences. It is my hope that others will critique this, flesh it out further and even consider the role of conferences in postgraduate ethics and healthcare education more broadly.

Issues raised in the plenary lectures
At the 2015 RCGP Annual Conference, plenary sessions had a strong moral flavour: Human rights lawyer Shami Gregory (RCGP Committee on Medical Ethics), two professors of medical law, Hazel Biggs from Southampton and Charles foster from Oxford depolarised the debate by arguing that there is space for professional expertise and respect for patient autonomy. They discussed the issue that patient choices are influenced by a number of factors, making 'true' autonomy quite a difficult concept with implications for clinical practice. Debate was more polarised among the audience with points such as the distinction between needs and desires and limitations on medical influence being usefully rehearsed. Conversations about meaningful patient choice and shared decision-making continued beyond the session. Previous ethics debates at the conference have included thorny issue such as how to deal with financial conflicts of interests such as sponsored education and unpacked the issues implicit in shared electronic patient healthcare records. [4] Unfortunately the debate 'Who knows best -the patient or the clinician?' was concurrent with a symposium on 'flourishing practice' , forcing the delegates to choose. The symposium was led by Peter Toon and in connection with his new book. [5] Peter Toon and assembled delegates asked what the virtues and internal goods of practice might be. Internal goods include things like mastery of a skill and distinguished from external goods such as status or money. They highlighted many of the reasons why GPs do not feel that they are flourishingsuch as lack of time and work pressures squeezing out opportunity for reflection.
The, 'Inside GP ethics' workshop began with brief presentations from the Chair of the ethics committee (Simon Gregory), a senior educator involved in teaching ethics (John Spicer), and a GP-philosopher whose emphasis has been on virtue ethics (Peter Toon). The discussion included issues such as ethical aspects of the trainee in difficulty and broader discussion about the place of philosophy in clinical thinking. The brief presentations offered delegates a taste of what thinking was being done in their professional organisations and educational bodies, and what relevant support for clinicians those organisations were offering -including the work of the RCGP and postgraduate education organisations such as Health Education England). The discussion offered an opportunity for the RCGP Ethics Committee and educators in the room to hear learn about the issues affecting delegates in their clinical, educational and managerial roles.

The 2015 poster stream
The call for posters elicited contributions including: empirical work on patient choice regarding place of death (the winning poster in the category), the ethical puzzle of clinician self-care, and issues for clinical practise arising from ethnic diversity. A fun poster Chakrabarti discussed the importance of human rights and civil liberties [1] and reminded the delegates that healthcare professionals constituted a politically influential group, often involved in exposing human rights abuses in the UK and abroad. Talking about why he wrote his 1978 bestselling medical novel, 'The House of God. ' Samuel Shem (aka Professor Stephen Bergman from New york University) discussed the threat of healthcare workers' disconnection from each-other and from vocation itself. [2] Shem controversially talked about how his generation of medical students publically protested against the Vietnam War and suggested that if doctors felt that a contract was not fair or safe, they ought to strike. Crimewatch presenter, Nick Ross suggested that crime should be treated epidemiologically, like a disease. [3] Professor frede Olesen from Aarhus University offered biologically and empirically founded arguments for the importance of good clinician-patient relationship. These plenaries expose delegates to discussions that are taking place in society that clearly might influence but might not explicitly feature in the day to activities of a healthcare worker. They also offer delegates the potential to respond to what they hear, by questioning the speaker, by recognising reasons to engage with an issue (for example through political action) or by discussion with colleagues how to make the best of a changing world (links to two of the talks at the conference and a similar talk by Samuel Shem are listed below).

Videos podcasts linked to the above plenaries
Professor frede Olesen from Aarhus University discussing the healing power of the doctor-patient relationship -in biomedical terms. See video: https://www.youtube. com/watch?v=bpGvHZfBGd8 Shami Chakrabarti discussing the importance of legal protection of human rights and resulting civil liberties. See video: https://www.youtube.com/ watch?v=bpGvHZfBGd8 Samuel Shem aka Professor Stephen Bergman from New york University discussed why he wrote, 'the House of God' and human disconnection in healthcare as a source of distress. http://torch.ox.ac.uk/ interview-professor-stephen-bergman

Breakout sessions
Three breakout sessions which explicitly concerned the ethics and philosophy of healthcare practice all filled their conference venues (these are each briefly described below).
The RCGP Committee on Medical Ethics' debate asked 'Who knows best -the patient or the clinician?' This highlighted the difficulty in defining honest and meaningful patient-centred choice. Chaired by Professor Simon with a serious message applied UK General Medical Council ethical standards to doctors in the television science-fiction programme Star Trek. Public expectation of the medical profession is potentially shaped by the characterisation of doctors in popular media. Many of the Star Trek doctors behaved in very paternalistic ways -The authors noted that most ethical doctor in the programme was not human but an artificial intelligence, who developed person-centred skills with time and experience. At least one of the posters, which asked whether GPs should avoid making ethical decisions was subsequently published in the British Journal of General Practice. [6] The future -2016 and beyond There is clearly appetite among practitioners for ethical discussion and debate at the RCGP conference. This has the potential to improve clinician welfare and decision-making though making resources available when clinicians face a dilemma. The RCGP Conference offers a protected space where issues can be considered at a remove from clinical pressures (for example, the time delegates spend at a conference is generally protected from demands to attend to immediate patient needs or workplace administration), with the luxuries of time and available expertise. The 'Energising primary care' conference at Harrogate will have a poster section for ethics and values and a fringe meeting to discuss an topic of ethical moment: The ethics of survival and the ethics of flourishing. There has been much talk about resilience and survival, and hard choices, rhetorical gaps and going extra miles in general practice. Statements about how to generate excellence in primary healthcare coexist alongside open letters from overwhelmed practitioners contemplating early retirement. flourishing, virtue and excellence can seem like aspirations of the ivory towers of academia rather the swampy lowlands of practice. At worst, rhetoric of excellence can seem like a recipe for moral failure. And yet general practice and primary care need energising -this includes a philosophy of practice whatever that might be. Members of the RCGP ethics committee and invited panel members will host an open discussion on the ethics of everyday general practice. We will ask: Should we concentrate on surviving or flourishing? Ought we to think about both? What are the ways that that such ideas are helpful or unhelpful in practice? How can we best energise the ethics of general practice and primary healthcare in the 21st century? This fringe meeting is intended as an open discussion conducted under Chatham House rule (A rule of anonymity where delegates are free to discuss the content of a meeting but without naming colleagues or their institutions. In theory this allows a more frank discussion that is illustrated by real experiences).

From is to 'ought'
An ethics and values stream at a primary care (indeed any general healthcare conference) should comprise: (1) Representation on the conference management committee. This can serve at least two key purposes: to represent relevant interests to the conference committee and to represent the conference to groups that might participate. In 2015 the representative was drawn from the organisation's own ethics committee. The expectations of representative to be a conduit and not just to tout their own interests should be clear. Most professional groups have an ethics committee that filters issues of societal and professional moment. This is a resource for both selecting an issue for discussion and sourcing good speakers. (5) An 'Ethics at the frontline' session: in 2015 the RCGP ethics committee led such a session and drew a full lecture room. This offers delegates and faculty the opportunity to start a conversation. Ethics committee members should attend such a meeting, which should be a safe space conducted under Chatham House rule (see above) and an opportunity to horizon-scan for ethical issues in practice. (6) Other opportunities to share learning and raise issues should be highlighted. Louhiala et al.
have maintained an online ethics support network which reports back to and is the focus of a symposium at the finnish Medical Association annual conference. [7] Dunn et al. developed an online interactive casebook for Singaporean clinicians that has been used and adapted in several other countries. [8] There are also informal social media networks such as the Primary Care Ethics LinkedIn Group -an intermittently active community of about 400 academics, educators, policymakers stakeholders and clinicians. [9]