The doctor’s dilemma

To the Editor: In From the Editor’s Desk in the 20 November 2006 issue of the Journal, Van Der Weyden acknowledged the 100th anniversary of the first performance of George Bernard Shaw’s play The doctor’s dilemma, and the fact that both society and medical practice have since changed dramatically in the ensuing century. He then asked: “. . . what is the modern doctor’s dilemma?”1

Contemporary Australian medical practice faces challenges posed by changes in community and government expectations, free market policies, workforce shortages and infrastructure changes, so this question should not be regarded as rhetorical. Answers to it will depend to some degree on the type of medical practice under consideration and where it is situated geographically, but to get the ball rolling, I suggest that in respect of general practice anywhere in Australia, a significant set of dilemmas surround notions of responsibility.

Traditionally, general practitioners have held responsibilities primarily to individual patients. With increasing emphasis being placed, appropriately, on preventive and screening activities, to what extent should GPs’ responsibilities be extended to the community as a whole, and how should any such extension be resourced? Given that the interests of individuals and communities will not always be in accord, how might the resulting conflicts of interests best be managed? And, to increase the complexity of such considerations, to what extent ought responsibility to patients extend to responsibility for patients?

Another dilemma for doctors in respect of responsibility relates to identifying the boundaries between altruism and martyrdom. To what extent should health care professionals be expected to put the interests of their patients or of the community before those of themselves and their families?

To extend the notion of responsibility further, and with the GP’s role as patient advocate particularly in mind, to what degree should health care professionals be active against social injustices which impinge on their patients’ health?

I know that in responding to the Editor’s question I have posed another set of questions, none of which are easily answered — if they could be, they would not be dilemmas. However, acknowledging and clarifying these questions is the first step towards answering them, and also towards preventing much community misunderstanding.