Some of the Tools in the Values Toolkit
This section provides a brief introduction to a selection of tools in the values toolkit of health and social care covering
- Ethics, law and regulation
- Decision analysis
- Health economics
- Evidence-based medicine
- Narrative-based medicine
- Medical Humanities
The selection aims to illustrate the rich variety of resources available for working with values. It is though far from exhaustive. Each of the examples described merits much longer treatment and there are many others that have important roles to play. Some of these, with particular and close links to values-based practice, are covered elsewhere in the Reading Guide: see for example communication skills and multidisciplinary teamwork; also sections on leadership, management and spiritualty in Read More about Policy and Service Development, Practice Guidance and Commissioning of Services. But there remain nonetheless many omissions.
Please contact us if you have suggestions for improving and extending this part of the Reading Guide including links to more extensive guides on these or other topics.
Ethics, Law and Regulation
As perhaps the most widely recognized values in health care, shared ethical values, such as confidentiality and ‘best interests’, together provide limiting frameworks for the diversity of individual values involved in clinical decision-making.
These frameworks take different forms. In values-based practice locally derived frameworks of shared values are the basis for balanced dissensual decision-making in individual cases. In contemporary regulatory ethics, shared values take the form of codes of practice prescribing general rules governing right behavior supported by sanctions. Codes of practice are in turn closely linked to other important tools in the values toolkit such as law and regulation.
A model for how ethics, law and the balanced decision-making of values-based practice come together is described in the next section Links between Other Tools and Values-based Practice. New work on the links between ethics, law and regulation is noted in Research and On-going Development.
Principlism and case-based reasoning
Frameworks of shared ethical values are the basis of ethical principlism in Tom Beauchamp and James Childress’ seminal book Principles of Biomedical Ethics. The four principles they describe are the widely shared healthcare values (sometimes called ‘prima facie principles’) of autonomy, beneficence, non-maleficence (do no harm) and justice. The reasoning skills of values-based practice include using these four principles (or other similar frameworks) to highlight otherwise neglected values bearing on a given situation.
Beauchamp, T. L. and Childress, J. F. (2012) Principles of biomedical ethics. 7th edn. Oxford University Press: New York.
Principlism, as a form of top-down reasoning, is helpfully complemented by the bottom-up approach of case-based reasoning (or casuistry). For an example of the difference that a brief exercise in case-based reasoning can make to a difficult clinical consultation, see
Fulford, K.W.M., Peile, E., and Carroll, H (2012) ‘Teenage Acne: widening our values horizons’. Values-based practice element 4, reasoning about values. Ch 5, pps 55 – 64 in Fulford, K.W.M., Peile, E., and Carroll, H Essential Values-based Practice: clinical stories linking science with people. Cambridge: Cambridge University Press
Many other varieties of similarly case-sensitive forms of ethics are also important in healthcare. Clinical ethics for example, practical ethics and translational ethics, all offer approaches that are complementary to rule-based ethics
Hébert, P. (2009) Doing Right: A Practical Guide to Ethics for Medical Trainees and Physicians, 2nd edition. Oxford University Press
Gupta, M. (2011) Values-based practice and bioethics. Journal of Evaluation in Clinical Practice, 17, 992–995.
Foddy B., Kahane G., and Savulescu J. (2013) Practical Neuropsychiatric Ethics. chapter 69, pps 1185 – 1201 in Fulford KWM, Davies M, Gipps R.G.T., Graham G, Sadler J, Stanghellini G, Thornton T (eds). The Oxford Handbook of Philosophy and Psychiatry. Oxford: Oxford University Press.
The relationship between clinical ethics and values-based practice is among the topics explored in Michael Loughlin’s Debates in Values-based Practice.
Discipline specific ethics, reflecting the diversity of professional values (nursing ethics, medical ethics, etc), are an important part of the values toolkit. Recent profession-oriented publications combining ethics with values-based practice include
Williamson, T., and Daw, R., (2013) Law, Values and Practice in Mental Health Nursing A Handbook. Open University Press
Note also Alastair Morgan and colleagues’ forthcoming co-written book
Morgan A, Felton A, Fulford K. W. M, Kalathil J and Stacey G. (forthcoming 2015) Values and Ethics: an Exploration for Mental Health Practice. Palmgrave Macmillan
Ethics and service user research
Paralleling the rise of discipline specific ethics there has been a growing awareness of the need for an ethics specifically of service user engagement. Jan Wallcraft, for example, manager of SURGE (Service User Research Group for England) has written extensively on these issues.
Williamson, T., and Daw, R., (2013) Law, Values and Practice in Mental Health Nursing A Handbook. Open University Press
The service user research group NSUN (National Service User Network) has developed key principles of service user involvement.
The National Service User Network’s National Involvement Standards 4Pi are published at http://www.nsun.org.uk/assets/downloadableFiles/4pi.-ni-standards-for-web.pdf
David Crepaz-Keay’s work provides an important empirical basis for assessing the quality of service user involvement
Crepaz-Keay, D., (2014) Effective Mental Health Service User Involvement Establishing a consensus on indicators of effective involvement in mental health services. D Prof thesis. London: Middlesex University
Jayasree Kalathil and colleagues’ resource of first-hand service user accounts includes an important exploration of the ethics of how service user narratives are employed in research contexts
A review of Personal Narratives of Madness compiled by Jayasree Kalathil and colleagues is available on-line in the website resource supporting the Oxford Handbook of Philosophy and Psychiatry www.oup.co.uk/companion/fulford
These and other resources for service user research are described further in Read More about Policy and Service Development, Practice Guidance and Commissioning of Services (see Strengthening the Service User Voice).
Virtue and other ethics
Further resources for ethics in healthcare are provided by the variety of ethical theories: utilitarianism is important for resource issues, for example, virtue ethics for education, and deontology for rights and responsibilities and the links between ethics and law. An early exploration of the rich variety of ethical theories and their applications in healthcare are explored in the edited collection
Fulford, K.W.M., Gillett, G.R., and Soskice, J.M. (1994) (eds) Medicine and moral reasoning. Cambridge: Cambridge University Press
This includes an article by the bioethicist William May spelling out some of the largely forgotten resources for virtue ethics in healthcare education from mediaeval theology
May, W.F. (1994) The virtues in a professional setting. Ch. 7 in Fulford, K.W.M., Gillett, G.R., and Soskice, J.M. (eds) Medicine and moral reasoning. Cambridge: Cambridge University Press, pps 75-90.
Decision theory provides a quantitative approach to combining probabilities (based on evidence) with utilities (based on values).
Miriam Hunink, Professor of Clinical Epidemiology and Professor of Radiology at the Erasmus University Medical Center, Rotterdam, and colleagues offer an explicitly integrative values-plus-evidence based approach
Hunink, M.,G., Weinstein, M. C., Wittneberg, E., Drummond, M.F., Pliskin, J.S., , Wong, J.B., and Glasziou, P.P.(2cnd edition 2014) Decision Making in Health and Medicine: Integrating Evidence and Values. Cambridge: Cambridge University Press.
Jack Dowie, Professor Emeritus of Health Impact Analysis in The London School of Hygiene and Tropical Medicine, is among those who have developed decision support tools based on decision analysis. http://www.annalisa.org.uk
Dowie’s ‘Annalisa’ website offers lively interactive visual representations allowing clinicians and patients to explore together how the available evidence interacts with individual preferences in deciding between different treatment options.
Health economists have developed a variety of methods for factoring social and other cost-benefit values into healthcare policy. The most familiar of these is the QALY (or Quality Adjusted Life Year).
Melissa and Gary Brown, both Professors of Ophthalmology, and Sanjay Sharma’s Evidence-Based to Value-Based Medicine offers an explicitly values-based approach.
Brown, M. M., Brown, G.C. and Sharma, S. (2005) Evidence-Based to Value-Based Medicine. Chicago: American Medical Association Press.
Melissa Brown is President and Chief Executive, and Gary Brown is Director of Medical Economics, of the Center for Value Based Medicine
The UK Department of Health ran a program in value based pricing with the aim of extending cost-benefit calculations for healthcare interventions beyond traditional effects and side effects to include a wider range of values such as quality of life and return to work.
VALUE BASED PRICING (VBP) – How the NHS will purchase drugs www.2020selection.co.uk/images/pdfs/value-based-pricing.pdf
This program adopted a model of value-based pricing used in commerce the essential feature of which is setting prices according to the values of the end-recipient (consumer or customer)
Evidence and values are often portrayed as antithetical. Values for example may be equated with bias in research; and values are sometimes called in aid as a counter to the demands of evidence.
In values-based practice by contrast, as also in decision analysis and health economics, values and evidence are complementary side-by-side partners in decision-making.
The complementary nature of values-based and evidence-based approaches is reflected in the Two Feet Principle of values-based practice. The clear separation however implied by this principle oversimplifies the relationship between them. Values-based practice is not evidence-free: it depends in part on Knowledge of Values. Neither is evidence-based medicine values-free. Science itself is not value free: the James Lind Alliance in Oxford (http://www.lindalliance.org) was set up specifically to bring patient priorities more effectively into the selection of research topics. And every stage in the process of developing evidence-based guidelines is deeply values-laden
We are grateful to Professor Peter Littlejohns for this slide. Peter was at the time (2009) Clinical and Public Health Director at NICE and responsible for the guideline program
For further aspects of the relationship between evidence-based and values-based practice see Links between Other Tools and Values-based Practice
Narrative-based medicine has a number of points of contact with values-based practice
- A focus on first-person accounts of the experience of illness by individually unique patients and carers
- Close attention to individual meaning and significance
- Acknowledgment that the perspectives of narrator and listener may be different
- Recognition that understanding is an interpretive (and essentially linguistic) act
- A holistic approach incorporating generalized research evidence alongside individual narrative
Illustrative of a now extensive literature is
Greenhalgh, T. Hurwitz, B. (1998) Narrative Based Medicine: Dialogue and Discourse in Clinical Practice. London: BMJ Books
Greenhalgh, T. Hurwitz, B. (1999) Why Study Narrative? British Medical Journal; 318(7175): 48–50.
Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust. Charon, R. (2001) JAMA, Vol. 286, No. 15:1897-1902
HEXI (the Oxford Health Experiences Institute) provides an on-line resource of (mainly) patient narratives across a wide range of medical conditions http://hexi.gtc.ox.ac.uk
As a rapidly evolving field covering many sub-disciplines the importance of the medical humanities is increasingly widely recognized. Indeed a key challenge for the field is to define just exactly what medical humanities covers.
Literature and art are clearly relevant fields. But so also are other disciplines traditionally regarded as being among the humanities, such as theology, philosophy (underpinning for example values-based practice) and history. The Warwick historian of medicine Mathew Thomson has characterized medical history as the ‘history of medical values’ (personal communication).
For a thoughtful but critical review, see
Campo, R. (2005) “The Medical Humanities,” for Lack of a Better Term. JAMA, Vol. 294, No. 9:1009-1011