Justice for gatekeepers.

Fundholding schemes in UK general practice force doctors to consider the moral implications of gatekeeping. The view that doctors can avoid involvement in rationing is unrealistic and ignores the doctor's duty to act justly. Rather, doctors need to cultivate the virtue of justice, while health-care systems should encourage just action and not create temptations.

After bioethics and towards virtue?

The place of philosophical medical ethics in medical education and clinical practice has recently been questioned. Although partially valid, the criticisms do not warrant abandoning the enterprise. Instead a reappraised model, based on Aristotelean concepts of intellectual and moral virtue is suggested.

Ethical aspects of medical certification by general practitioners.

As well as acting as personal physicians, general practitioners are often asked to provide medical certificates, enabling patients to obtain benefits. In these cases doctors may act for the state, for other institutions or individuals, or as an advocate on the patient's behalf in a dispute. The ethical basis of this activity differs from the therapeutic doctor-patient relationship. Difficulties are particularly likely to arise when doctors are called on to combine the roles of therapist and certifier. Although this is often convenient and saves money, the damage to confidentiality and to the primary therapeutic relationship which may result must be weighted against this. The limitations of such certificates should also be borne in mind. Fairness and the preservation of the therapeutic doctor-patient relationship are best served by restricting the role of the personal doctor to the provision of clearly defined factual information on which others, who may be medical or non-medical, can make the final judgement.

Boxing clever.

KIE: This is the first contribution to a new JME column, "At the coalface," to which readers are invited to relate ethical problems they have encountered in their work. An adolescent patient requested that the author, a general practitioner, certify that he was medically fit to box. Toon attempted to dissuade him from boxing by explaining its dangers. When the boy persisted, the physician rapidly considered the ethical principles involved in the encounter and decided to "wash his hands" by telling his patient that if "he insisted on damaging his, or someone else's brain, then he must find another medical accomplice."^ieng

Teaching medical ethics symposium. A student-led approach to teaching.

It is increasingly agreed that ethics has a place in undergraduate medical education. There is, however, debate about how it should be taught, and by whom. We present our experience of teaching ethics in a general practice module over six years. During this period there has been a shift from a teacher-centred to a student-centred approach in which students choose ethical issues to explore within a framework provided. The issues raised are discussed with examples, and the future directions of our ethics teaching outlined.

The doctor, the patient and the relative: an exploratory survey of doctor-relative relationships.

The contacts which doctors have with their patients' relatives are important, and raise interesting and sometimes difficult ethical issues. In order to develop hypotheses about doctor-relative relationships, a sample of 18 general practitioners in east London were interviewed. Their views are summarized in this paper, and from them a number of hypotheses concerning these relationships are proposed. Further research will be needed to test these hypotheses.

Audit of work at a medical centre for the homeless over one year.

An audit of one years' work at a voluntary health care service for the homeless involving doctors, a chiropodist, nurses and social workers was carried out. It was found that although certain health problems are more common among the homeless than in the general population, the range resembles that in any general practice. However, registration with general practitioners was much less common among the homeless than in the general population, and a high proportion of referrals to hospital did not lead to appropriate treatment. The value of a special primary health care service for the homeless is discussed.

The need to respond and cardiac cycle effects: an alternative hypothesis.

Lacey and Lacey have proposed that stimulation by sensorimotor events produces a discrete burst of vagal activity which alters the length of the cardiac cycle in which such an event falls, and the length of the subsequent cycle, according to the point in the cycle in which the stimulus occurs. To test this hypothesis an experiment was conducted with 24 subjects in which they received three types of trials. These were signalled reaction time tests with a 5-s foreperiod, signalled reaction time tests during which subjects were instructed to sit still and stop breathing, and 5-s periods of immobility. Lacey and Lacey's results were only partially replicated in that no cardiac effect for the beat concurrent with the imperative stimulus was observed, but an effect similar to the one which they describe was found for the beat subsequent to the imperative stimulus. Cycle effects not predicted by the Laceys' hypothesis were found during the beat in which the cycle occurred and the subsequent beat. An alternative explanation of these phenomena is proposed which fits both their data and those of this study. Rather than being a consequence of a burst of vagal activity produced by the stimulus as they suggest, such cycle effects may reflect an underlying monotonic change in the heart rate.

Serving two masters: a dilemma in general practice.

General practitioners are the custodians of large quantities of confidential information, and they are often asked to use this to furnish reports for third parties. The implications of consenting to the disclosure of information for such purposes are frequently ill understood by patients. If there is a possibility that such disclosure may disadvantage the patient, the doctor should discuss the matter personally with the patient before releasing any information.

KIE: Two British general practitioners propose guidelines for their colleagues in responding to a patient's written authorization for disclosure of confidential information to third parties. They warn that such authorization is frequently neither free nor informed--usually it is a condition of employment or insurance and obtained without an explanation of the information sought or how it will be used. Physicians are advised to protect the patient's interests by ensuring that the consequences of disclosure are understood and by suggesting an independent medical opinion or even reconsideration of the application. The authors contend that there is no professional obligation to provide reports and that, in some situations, a refusal may be proper. However, any report given must be accurate and truthful.