Notes and Annotated Reading Guide on
Values-Based Practice
Notes
These notes introduce the skills-based approach of values-based practice and outline how this fits with other disciplines in the developing field of values-based medicine.
What are Values? And what is their Relevance to Medical Decision-Making?
1) Values are wider than ethics. A helpful definition is provided by Sackett et al., in their training manual on evidence-based medicine: ‘By patient values we mean the unique preferences, concerns and expectations each patient brings to a clinical encounter and which must be integrated into clinical decisions if they are to serve the patient.’ (Sackett et al., 2000, page 1, emphasis in the original).
2) The common feature of values, and what makes them directly relevant to medical decision-making, is that they are ‘prescriptive’ or ‘action guiding’ (Hare, 1952). Thus, values are explicit in some areas of medical decision-making, for example in cost-benefit analyses as the basis of clinical guidelines (Brown et al., 2005). But the essential point is that whether explicit or implicit, values, as well as evidence, guide all decisions in medicine as in any other area (Hunink et al., 2001).
Again, Sackett et al., underline the importance of evidence and values working together with clinical expertise in all areas of medical decision-making: they write ‘When these three elements (best research evidence, clinical expertise and patient values) are integrated, clinicians and patients form a diagnostic and therapeutic alliance which optimises clinical outcomes and quality of life (Sackett et al., 2000, page 1, emphasis and parenthesis added).
What is Values-Based Medicine?
3) Values-based medicine is to values what evidence-based medicine is to evidence: just as evidence-based medicine offers resources for working more effectively with complex and conflicting evidence in medicine, so values-based medicine offers different although fully complementary resources for working with complex and conflicting values in medicine.
4) In addition to ethics, existing disciplinary resources for values-based medicine include decision theory, health economics, the social sciences (including medical anthropology), and the medical humanities (including medical history).
Why do we need Values-Based Medicine?
5) We need values-based medicine for essentially the same reason that we need evidence-based medicine, i.e. the increasing complexity of medical decision-making.
The need for evidence-based medicine arises from the increasing complexity of the evidence underpinning medical decision-making. Similarly, the need for values-based medicine arises from the increasing complexity of the values underpinning medical decision-making.
6) The increasing complexity of values in medicine is reflected, in particular, in
i) the growth in importance of such areas as ethics, clinical governance and quality assurance, and
ii) the extent to which patients themselves continue to feel that their ‘voice’ is not being sufficiently heard.
7) The growing complexity of values in medicine is due to a number of factors, some general to society as a whole (for example increasing multiculturalism), others specific to medicine. Factors specific to medicine include,
i) the increasing importance of the values of individual patients and families in medical decision-making (a key aspect of the ‘patient’s voice’, see above) alongside those of professionals,
ii) the growing importance of teamwork in medicine and the consequent interdependence in medical decision-making of the often very different values of different professional groups, managers and policy makers, and
iii) the increasingly wide range of treatment options opened up by advances in science and technology and the strongly value-laden nature of the issues that these bring with them (for example, in the area of assisted fertility).
What is Values-Based Practice?
8) Values-based practice is a new approach to working with complex and conflicting values in medicine based primarily on learnable clinical skills (Fulford, 2004; Woodbridge and Fulford, 2004).
The four skills areas of values-based practice are concerned with: 1) raising awareness of values and of differences of values, 2) reasoning about values, 3) knowledge of values, and 4) links with communication skills.
9) Values-based practice is based on theoretical work in a branch of Oxford analytic philosophy concerned with the meanings and implications of value terms (Fulford, 1989) together with empirical work in the social sciences (e.g. Colombo et al., 2003).
Further details of the theory and empirical research supporting the development of values-based practice are given in the Reading Guide.
The Development of Values-Based Practice in Mental Health
10) The development of values-based practice has been spearheaded by Warwick University and Warwick Medical School and we have maintained our lead in this area with a number of key initiatives (outlined below).
11) The skills training approach of values-based practice was developed originally in a partnership between Fulford’s programme in the Philosophy and Ethics of Mental Health (PEMH) in the Department of Philosophy, and a major mental health NGO, the Sainsbury Centre for Mental Health (SCMH).
The approach, which was piloted in training programmes with front-line staff, was published as a joint Sainsbury Centre for Mental Health/Warwick Medical School training manual, ‘Whose Values?’ (Woodbridge and Fulford, 2004). ‘Whose Values?’ was launched by the Minister, Rosie Winterton, at a joint Sainsbury Centre for Mental Health/Warwick Medical School conference in London in 2004 and has subsequently become the basis of a number of national policy, training and service development initiatives in mental health and social care. (See also, Reading Guide.)
12) Currently, Fulford is seconded part-time to the Department of Health as Special Adviser for Values-Based Practice. In this role he is leading on two major programmes,
Currently, Fulford is seconded part-time to the Department of Health as Special Adviser for Values-Based Practice. In this role he is leading on two major
programmes,
i) the development of training materials to support implementation of an amended Mental Health Act (launched in 2008) and with on-going work on its development specifically in relation to DRE (Delivering Race Equality).
Reference for training materials: Care Services Improvement Partnership (CSIP) and the National Institute for Mental Health in England (NIMHE) (2008) Workbook to Support Implementation of the Mental Health Act 1983 as Amended by the Mental Health Act 2007. London: Department of Health.
ii) the development of guidance on a shared approach to assessment in mental health and social care (launched in 2009) and with an on-going implementation programme.
Reference: The National Institute for Mental Health in England (NIMHE) and the Care Services Improvement Partnership (2008) 3 Keys to a Shared Approach in Mental Health Assessment. London: Department of Health.
Website: www.3keys.org.uk/downloads/3keys.pdf
The Lead taken by Warwick Medical School in extending Values-Based Practice to other Areas of Medicine
13) Warwick Medical School has maintained Warwick’s lead in values-based approaches by supporting a number of initiatives aimed at extending the skills-based training of values-based practice from mental health into other areas of medicine.
The long-term vision is to become the first centre of excellence for values-based practice with a research and educational programme developed with key partners nationally and internationally.
‘Partners’, on the model of values-based practice in mental health, includes representatives of three key stakeholder groups: i) researchers and clinicians, ii) patients and patient groups, and iii) policy makers.
14) A key recent initiative has been a joint Wellcome Trust/Warwick Medical School conference exploring the disciplinary resources and applications of values-based medicine.
The conference brought together representatives of the three stakeholder groups noted above: thus, delegates included, for example, Lord Patel of Bradford, David Pink, C/E of the Long-Term Conditions Alliance, and Andrew Dillon, C/E of NICE.
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15) Other Warwick Medical School initiatives in values-based practice include: 1) a new book series with Cambridge University Press, 2) pilot educational studies, 3) work on literature search methods for values (includes databases on diabetes, obesity, Alzheimer’s disease and primary care), and 4) values-based communication skills.
16) Warwick University and Warwick Medical School are particularly well placed to lead on the development of values-based practice through hosting a number of key related programmes: for example, BEME (an international organisation supporting Best Evidence in Medical Education), the Centre for the History of Medicine (Wellcome funded), key sections of The National Patients Library, the NHS Centre for Patient Involvement, and a successful Clinical Trials Unit with a particular interest in patient involvement.
Brown, M. M., Brown, G.C. and Sharma, S. (2005) Evidence-Based to Value-Based Medicine. Chicago: American Medical Association Press.
Colombo, A., Bendelow, G., Fulford, K.W.M. & Williams, S. (2003) Evaluating the influence of implicit models of mental disorder on processes of shared decision making within community-based multidisciplinary teams. Social Science & Medicine, 56: 1557-1570.
Fulford, K.W.M. (1989, reprinted 1995 and 1999) Moral Theory and Medical Practice. Cambridge: Cambridge University Press.
Fulford, K.W.M. (2004) Ten Principles of Values-Based Medicine. Ch 14 In Radden, J. (Ed) The Philosophy of Psychiatry: A Companion, pps 205-234.
Hare, R.M. (1952) The language of morals. Oxford: Oxford University Press.
Hunink, M.G.M. and Glasziou, P.P. (2001) Decision making in health and medicine: Integrating evidence and values. Cambridge: Cambridge University Press.
Sackett, D.L. Straus, S.E., Scott Richardson, W., Rosenberg, W., and Haynes, R.B. (2000) Evidence-Based Medicine: How to Practice and Teach EBM (2nd Edition). Edinburgh and London: Churchill Livingstone.
Woodbridge, K., and Fulford, K.W.M. (2004) Whose Values? A workbook for values-based practice in mental health care. London: Sainsbury Centre for Mental Health. (Available to the Advisory Board Meeting)
See also Reading Guide for further publications on values-based practice and related areas of values-based medicine.
Annotated Reading Guide on Values-Based Practice
Values-based practice is one of a number of new theoretical and practical tools for working with complex and conflicting values in medicine, collectively ‘values-based medicine’.
Values-based practice differs from, while being complementary to, other tools in the toolkit of values-based medicine, such as ethics and health economic theory,
This Reading Guide covers, 1) the theory and empirical base of values-based practice, 2) policy, training and service development initiatives in values-based practice in mental health and primary care, and 3) illustrative examples of some of the other tools in the toolkit of values-based medicine.
1.1 The theory underpinning value-based practice is based on work in linguistic analytic philosophy of the ‘Oxford school’ in the middle decades of the twentieth century on the meanings of key value terms, such as ‘good’, ‘ought’ and ‘right’. Examples include,
· The Language of Morals. Hare, R.M. (1952) Oxford: Oxford University Press.
· Descriptivism. Hare, R.M. (1963) Proceedings of the British Academy, 49: 115-134. Reprinted in Hare, R.M. (1972) Essays on the moral concepts. London: The Macmillan Press Ltd.
· On Grading. Urmson, J.O. (1950) Mind, 59: 145-169.
· The Object of Morality. Warnock, G.J. (1971) London: Methuen & Co Ltd.
For a recent collection building on the work of this period, see the American philosopher, Hilary Putnam’s (2002) The Collapse of the Fact/Value Dichotomy and Other Essays (Cambridge, Mass., and London, England: Harvard University Press).
1.2 The theory of values-based practice was developed by Fulford in his (1989 and subsequent reprints) Moral Theory and Medical Practice (Cambridge: Cambridge University Press) by applying the work of the Oxford school on the meanings of key value terms (‘good’, ‘ought’, etc, as above) directly to the meanings of key medical terms, ie the meanings of such terms as ‘illness’, ‘disease’, ‘disability’, ‘function’ and ‘dysfunction’.
This work is part of a wider philosophical research programme exploring the ways in which factual and evaluative elements of meaning are combined in concepts of disorder. See for example, foundational work in this area by the American philosopher, Christopher Boorse (eg. his Boorse, C. (1975) On the distinction between disease and illness. Philosophy and Public Affairs, 5: 49-68; and more recently Boorse, C. (1997) A Rebuttal on Health. Ch 1 in Humber J.M. and Almeder, R.F. eds, What is Disease? Totowa, New Jersey: Humana Press, pps 1-134.
The theory has been further developed in a number of chapters and journal articles, in particular,
· Teleology without Tears: Naturalism, Neo-Naturalism and Evaluationism in the Analysis of Function Statements in Biology (and a Bet on the Twenty-first Century). Fulford, K.W.M. (2000) Philosophy, Psychiatry, & Psychology, 7/1:77-94.
Fulford and others have examined the links between values-based practice and a number of specific areas of medicine including CAMHS, management, spirituality and other aspects of the medical humanities, ethics, diagnosis and neuroscience – see Warwick Medical School website www2.warwick.ac.uk/fac/med/study/cpd/subject_index/pemh/vbp_introduction/.
1.3 A key prediction of the theory of values-based practice - that the implicit values driving medical decision-making are often far more diverse than we recognise - has been tested by the British social scientist, Anthony Colombo, in a major study funded by the Nuffield Foundation. The results of the study were widely disseminated in both research and NGO journals - see, for example,
· Evaluating the Influence of Implicit Models of Mental Disorder on Processes of Shared Decision Making within Community-based Multi-disciplinary Teams. Colombo, A., Bendelow, G., Fulford, K.W.M., and Williams, S. (2003) Social Science & Medicine, 56: 1557-1570.
· Six Models of Mental Disorder: A Study Combining Linguistic-Analytic and Empirical Methods. Fulford, K.W.M. and Colombo, A. (2004). Philosophy, Psychiatry, & Psychology, 11/2, 129-144.
· Model Behaviour. Colombo, A., Bendelow, G., Fulford, K.W.M., & Williams, S. (2003) Openmind, 125: 10-12.
The methods developed in this study became the basis for one of the main areas of skills training for values-based practice (see next section).
2) Policy, Training and Service Development Initiatives in Values-Based Practice
2.1 Ten key principles of values-based practice, as a process-based approach to working with complex and conflicting values in medicine, are set out in detail in Fulford’s (2004) Ten Principles of Values-Based Medicine. Chapter 14 in Radden, J. (ed) The Philosophy of Psychiatry: A Companion.
The ten principles of values-based practice are illustrated in this article with a corresponding ten-part clinical history of a woman with manic-depressive disorder, ‘The Artist who Couldn’t See Colours’. This illustrates in particular how values-based and evidence-based approaches work together to support full partnership in medical decision-making between patients and clinicians.
2.2 The ten principles of values-based practice have been applied particularly in mental health and primary care in a series of policy, training and service development initiatives.
This work has been carried out in partnership with both service users and service providers and with institutional support from NGOs (including the Sainsbury Centre for Mental Health (SCMH), the Mental Health Foundation (MHF) and Turning Point in London, and the World Psychiatric Association) and from government departments (in particular the UK’s Department of Health).
2.3 Policy: A direct application of values-based practice to national policy in mental health and social care is The National Framework of Values for Mental Health, published by NIMHE in 2004 (http://nimhe.csip.org.uk/ValuesBasedPractise - also in hard copy in e.g. ‘Whose Values?’, see below).
NIMHE (the National Institute for Mental Health in England) is the body responsible for mental health policy implementation in England and Wales.
2.4 Training: The first training manual for values-based practice was developed in a partnership between the Sainsbury Centre for Mental Health and Warwick Medical School with the support of NIMHE.
Published as ‘Whose Values?’ (Woodbridge, K. and Fulford, K.W.M. (2004) London: The Sainsbury Centre for Mental Health), the training manual was launched at a conference in London by the Minister, Rosie Winterton, and, together with the NIMHE Values Framework, has subsequently become the basis of the service development initiatives outlined below.
Teaching and learning materials on values-based practice have now been published in a wide range of both professional journals and textbooks – see Warwick Medical School website noted above, section 1.2; also, the Royal College of General Practitioners (2005) Curriculum Statement: Ethics and Values Based Medicine at www.rcgp.org.uk/gpcurriculum/pdfs/ethicsAndVBPsfRCGPCouncilDec2005.pdf. In addition to the UK, training programmes in values-based practice have been developed in a number of European countries and in South Africa.
2.5 Service developments: Values-based national service developments in mental health and social care include,
The Ten Essential Shared Capabilities: A Framework for the Whole of the Mental Health Workforce. Department of Health (2004). The ‘Ten ESCs’, which are explicitly values- as well as evidence-based, in turn support a number of other policies including the National Workforce Strategy (Department of Health, 2004) and Community Development Workers (Department of Health, 2004).
· The development of training materials to support implementation of an amended Mental Health Act (launched in 2008) and with on-going work on its development specifically in relation to DRE (Delivering Race Equality).
Reference for training materials: Care Services Improvement Partnership (CSIP) and the National Institute for Mental Health in England (NIMHE) (2008) Workbook to Support Implementation of the Mental Health Act 1983 as Amended by the Mental Health Act 2007. London: Department of Health.
· The development of guidance on a shared approach assessment in mental health and social care (launched in 2009) and with an on-going implementation programme.
Reference: The National Institute for Mental Health in England (NIMHE) and the Care Services Improvement Partnership (2008) 3 Keys to a Shared Approach in Mental Health Assessment. London: Department of Health.
Website: www.3keys.org.uk/downloads/3keys.pdf
Internationally, values-based approaches to service development are included in the World Psychiatric Association’s Institutional Program on Psychiatry for the Person.
3.1 As noted above, values-based practice is only one tool in the toolkit of values-based medicine. This section illustrates some of the wide range of other disciplinary resources for working with complex and conflicting values.
3.2 Evidence-based medicine: The close links between values and evidence in medical decision-making are spelled out in the introduction to Sackett, D.L., et al.’s (2000) Evidence-Based Medicine: How to Practice and Teach EBM (2nd Edition). Edinburgh and London: Churchill Livingstone.
3.3 Decision analysis: Decision theory provides a mathematical approach to combining probabilities (based on evidence) with utilities (based on values). See e.g., Hunink, M. et al.’s (2001) Decision Making in Health and Medicine: Integrating Evidence and Values. Cambridge: Cambridge University Press.
3.4 Health economics: A variety of methods have been developed by health economists for factoring social and other values into healthcare policy. For an explicitly values-based approach, see Brown, M. M. et al.’s (2005) Evidence-Based to Value-Based Medicine. Chicago: American Medical Association Press.
3.5 Clinical ethics: As perhaps the most widely recognised values in medicine, ethical values, such as confidentiality and ‘best interests’, provide a framework for the diversity of individual values involved in clinical decision-making.
Such frameworks may take the form of codes of practice and guidelines as well as being incorporated into more general legal frameworks such as the Human Rights Act – see e.g. Lord Woolf’s address as Lord Chief Justice to the British Academy (15.10.2002) quoted in Hansard (28.10.2002, col. 607).
3.6 Medical humanities: As a rapidly evolving field covering many sub-disciplines, the importance of the medical humanities is increasingly widely recognized. For a thoughtful but critical review, see
· “The Medical Humanities,” for Lack of a Better Term. Campo, R. (2005) JAMA, Vol. 294, No. 9:1009-1011.
Within this wide field, narrative-based medicine, with its strong links with first-person accounts of the experience of illness by patients and carers, is a particularly rich resource for values-based medicine. See for example,
· Narrative Based Medicine: Dialogue and Discourse in Clinical Practice. Greenhalgh, T. Hurwitz, B. (1998) London: BMJ Books.
· Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust. Charon, R. (2001) JAMA, Vol. 286, No. 15:1897-1902.
· Healthcare Ethics and Human Values: An Introductory Text with Readings and Case Studies. Fulford, K.W.M., Dickenson, D. and Murray, T.H. (eds) (2002) Malden, USA, and Oxford, UK: Blackwell Publishers.
3.7 Other areas of philosophy: Values-based practice is the ‘philosophy into practice’ cutting edge of a new and rapidly expanding international field of cross-disciplinary work between philosophy and psychiatry. For a brief introduction and major textbook respectively, see,
· Past Improbable, Future Possible: the Renaissance in Philosophy and Psychiatry. Fulford, K. W. M., Morris, K. J., Sadler, J. Z., and Stanghellini, G. (2003) Chapter 1 (pps 1-41) in Fulford, K. W. M., Morris, K. J., Sadler, J. Z., and Stanghellini, G. (eds.) Nature and Narrative: an Introduction to the New Philosophy of Psychiatry. Oxford: Oxford University Press.
· The Oxford Textbook of Philosophy and Psychiatry. Fulford, K.W.M., Thornton, T., and Graham, G. (2006). Oxford: Oxford University Press.
The philosophy of psychiatry is important for the further development of values-based medicine as the source of new research with potential philosophy-into-practice applications in key related areas, notably tacit knowledge (the basis of professional skills) and individual judgement (as in clinical judgement). See in particular,