By Daniel Sokol
Cases of swine flu are expected to increase sharply in coming months
As the swine flu pandemic claims more victims and anxious patients visit their GP practice in ever-increasing numbers, GPs around the country are facing an ethical dilemma.
Many hospital doctors speak ill of GPs, accusing them of knowing nothing about the ear, or the throat, or the shoulder, or whatever their specialty deals with.
Some also are jealous about their pay and their lifestyle.
Their work, however, is vital though rarely glamorous.
They don't drill into skulls, place tubes down patients with blocked airways or switch off life-support machines.
Unlike the hospital doctors, they don't have fancy toys that will show a fractured bone or a bleeding brain in great detail.
They may deal with a demented elderly lady who's had a fall, a psychiatric patient who hears voices, or a 14-year-old girl asking for contraceptives.
In the consultation room, alone with the patient, they often make difficult decisions.
A few days ago, some GPs asked for some ethical advice.
According to guidance from the Department of Health, their practice had to pick a "pandemic flu lead" who would be responsible for dealing with flu patients.
As one GP put it, "a rubbish job"
Aside from the added responsibility, this doctor is likely to be in greater contact with flu patients and at higher risk of contracting the disease.
The greater the exposure, the greater the risk.
Perhaps unsurprisingly, no-one jumped at the opportunity. It is, as one GP put it, "a rubbish job".
The GPs wanted a fair way of picking the flu doctor.
I first spoke to a GP I knew to find out what happened in her practice.
She smiled and told me she was chosen as the flu lead because she lived closest to the practice.
If public transport went down, she could walk to work.
She was not thrilled at the prospect and expressed concerns about her school-aged sons and getting attacked by desperate patients and relatives in need of Tamiflu.
The Royal College of GPs, anticipating the possibility of public unrest, advises practices to review their security arrangements.
The predicament of the GPs reminded me of a true story often used in the teaching of ethics.
If the strength of our competing duties is morally important, a single doctor with no children may have a greater obligation to be the flu lead than a married doctor with three young children
In 1841, a ship struck an iceberg in the Atlantic and began to sink. Forty-one passengers crammed on to a lifeboat.
A few hours later, the first mate on the lifeboat told his eight crewmen to throw passengers overboard as the overcrowded boat was sinking. All would die otherwise.
How should they select the unfortunate victims?
He told the crew not to part man and wife and to spare the women.
They pushed 16 passengers into the water.
The situation for the GPs is different in many ways but the analogy is nonetheless helpful. The best option is to seek a volunteer. With good infection control, the risks are small.
The practice could also entice volunteers with 'risk pay', as they did in Toronto during the SARS epidemics, or offer other benefits.
But what if no one steps forward? Is it ethical to pressure someone to be the flu lead? Is it ethical to flout the guidance and not have a flu lead at all, leading to poorer patient care?
Duty of care
At this point, some readers may protest and accuse the doctors of failing in their duty of care.
Isn't this what they are trained and paid to do?
The doctors' reply might go something like this: "Yes, we have a duty of care and 99.9% of the time we discharge that duty, but these are exceptional circumstances.
"Some of us have very young children at home, others have frail, elderly parents in need of assistance; why should our duty of care to patients trump our duties of care to loved ones?"
If the strength of our competing duties is morally important, a single doctor with no children may have a greater obligation to be the flu lead than a married doctor with three young children.
Yet, how would this work in practice? Is a six-year-old daughter "worth more" than a five-year-old daughter? Is a 90-year-old parent worth more than a toddler? Is a girlfriend of 10 years worth less than a wife of five years?
Will there be a committee to decide on these matters and, if so, how would it check that candidates were telling the truth?
On the lifeboat, the first mate initially suggested a lottery to decide who should stay on the boat.
Perhaps that be a suitable system for our GPs?
The advantages are clear: it's quick, simple, objective and treats everyone equally.
The disadvantages are that it may select the GP who lives furthest away, with a pregnant wife and two young children.
One possibility would be to exclude people like the GP just mentioned; another would be to share the burden and appoint several flu doctors.
Do readers have a solution to this dilemma?
It is easy for the public and the media to fix their attention on the swine flu patients and their anxious relatives, but as the pandemic intensifies and the medical profession becomes more deeply involved, we should spare a sympathetic thought to the flu clinicians across the country and indeed the world.
Whether they freely adopted the role or drew the short straw, their commitment to our welfare will come at some cost to themselves and their loved ones.
• Dr Daniel Sokol is a medical ethicist at St George's, University of London.