All for one and one for all?

CONTINUING my occasional and unlikely series of ethical reflections prompted by sporting endeavours (others’ not mine), the Tour de France is a rich seam to mine.

You may consider this a feeble attempt to justify hours watching cyclists in stunning French landscapes by reframing it as ‘research’. You wouldn’t be the first. You might be especially suspicious if you know that I also devoured the documentaries Unchained and Mark Cavendish: Never Enough, changing the algorithm for my recommended viewing irrevocably. However, there are fascinating questions that arise about an age-old ethical problem: balancing individual and collective interests.

Those who know more about the Tour than me (i.e. almost everyone) emphasise that it is a team sport. The riders wearing a coloured or polka dot jersey on the podium at curiously Stepford-like presentations would not be there without the team. That makes sense. Victory is not possible without the domestiques, participants who attack and weaken competitors, the riders who protect their leaders and experts advising on marginal gains.

As with everything on the Tour where nothing happens by accident – except accidents – the balancing of individual and collective interests is calculated. Leaders and prospects for each stage are identified in advance, roles are understood and team norms established. Those who break agreements, explicit or implicit, are represented as problematic.

Unchained portrayed Wout Van Aert’s decision to leave Jonas Vingegaard after a mechanical issue during stage 5 of the 2022 Tour as an errant display of self-interest. Unsurprisingly perhaps, Van Aert saw it differently. Sometimes, the calculation of interests encompasses reciprocity – as when the team director instructed Vingegaard to allow Van Aert, who had protected and served his leader’s interests, to win the 2022 time-trial. Although, reciprocity was possible only when overall victory was secure.

I think about healthcare as I watch these negotiations, wondering about the moral assumptions embedded within. Like the Tour, we are often reminded that healthcare is a team endeavour. NHS recruitment campaigns stress the numbers of roles that contribute to patient care. Ethical practice is, one might assume, no place for individual ego. Yet it also requires articulating difference, holding personal boundaries, a sense of self and the capacity to challenge when needed.

It is not necessarily desirable to serve the collective unconditionally and unquestioningly. Individuals will see their own and others’ interests differently, including in relation to resource allocation, duties of care, working conditions, practice priorities, patients’ individual and group needs, health inequalities and clinical outcomes.

The system within which individuals and teams work has an interesting and sometimes confusing approach to individual and collective interests. Competition to study medicine and other healthcare subjects is fierce, often creating, consciously or unconsciously, a perfectionist disposition in which individuals continue to strive to succeed.

At qualification, choices of jobs and access to specialty training are often shaped by individual performance. Those who have illness or caring responsibilities may need to apply for ‘special circumstances’ or find themselves justifying why they were unable to incorporate additional achievements, such as research or extra-curricular achievements alongside their academic study. Membership and postgraduate examinations as well as career progression will pull people towards their individual interests even as they prepare their answers to interview questions about team-work.

Culture and implicit norms about the individual and the collective within healthcare are complex too. As the history of whistleblowing in the NHS, and reporting following the case of Lucy Letby at the Countess of Chester Hospital NHS Foundation Trust demonstrate, individuals often encounter considerable resistance to speaking up and raising concerns. Individual responsibilities can be weaponised by threats of referrals to regulators, or more subtly by isolation or criticism.

Hierarchies may substitute for open reflection on the negotiation of individual and collective interests. Group-think can be misrepresented as the collective interest. The power to determine what constitutes a legitimate interest and how that interest is weighed against others is rarely explicitly considered as part of the ethical balancing of the individual and collective that is inherent and universal in healthcare.

The ”all for one and one for all” motto is an idealistic account of healthcare, cycling and perhaps life. How we perceive, engage with and respond to the negotiation of our individual and collective interests is personal, shifting and subjective. It is shaped by our personalities, preferences, relationships, circumstances and aspirations. The balancing of the individual and collective is complex and may reveal the messy, surprising and hidden parts of ourselves. No wonder perhaps that we prefer to muddle through the tensions, implicit norms, moral assumptions and mixed expectations of individuals, teams, organisations and systems.

To anyone prepared to pause and reflect on their own approach to, and experience of, navigating individual and collective interests, I say “Chapeau!”

Deborah Bowman is Emeritus Professor of Bioethics, Clinical Ethics and Medical Law at St George’s, University of London