Values Based Practice: the theory
If ethical principles are insufficient to guide good healthcare, how should we respond to the conflicting values often present? One approach is called ‘Values Based Practice’ (VBP). It is the practical counterpart of the analysis of values in medicine proposed by Bill Fulford and discussed in Conceptual Issues in Nursing.
The main emphasis in VBP is that clinical decision making is not sufficiently guided by a framework of ethical rules and regulation, important as such a framework is, but depends also on learnable clinical skills to respond in a balanced way to a far broader range of diverse values. Values Based Practice thus shifts the emphasis in clinical decision-making from ‘right outcomes’, defined by ethical rules and regulation, to ‘good process’. It provides a skills-based approach to balanced decision-making where, as is often particularly the case in mental health, complex and conflicting values are in play.
Ten Principles of Values Based Practice
All decisions stand on two feet, on values as well as on facts, including decisions about diagnosis (the “two feet” principle)
We tend to notice values only when they are diverse or conflicting and hence are likely to be problematic (the “squeaky wheel” principle)
Scientific progress, in opening up choices, is increasingly bringing the full diversity of human values into play in all areas of healthcare (the “science driven” principle)
VBP’s “first call” for information is the perspective of the patient or patient group concerned in a given decision (the “patient-perspective” principle)
In VBP, conflicts of values are resolved primarily, not by reference to a rule prescribing a “right” outcome, but by processes designed to support a balance of legitimately different perspectives (the “multi-perspective” principle)
Careful attention to language use in a given context is one of a range of powerful methods for raising awareness of values (the “values-blindness” principle)
A rich resource of both empirical and philosophical methods is available for improving our knowledge of other people’s values (the “values-myopia” principle)
Ethical reasoning is employed in VBP primarily to explore differences of values, not, as in quasi-legal bioethics, to determine “what is right” (the “space of values” principle)
In VBP, communication skills have a substantive rather than (as in quasi-legal ethics) a merely executive role in clinical decision-making (the “how it’s done” principle)
VBP, although involving a partnership with ethicists and lawyers (equivalent to the partnership with scientists and statisticians in EBM), puts decision-making back where it belongs, with users and providers at the clinical coal-face (the “who decides” principle)
But is it plausible to replace aiming at the right outcome with simply having a good process of deliberation? Is that merely subjective and if so is that a bad thing? And what of the value of using VBP is the first place? How, according to VBP’s own approach, would its own value be determined?
Reading extract from:
Fulford, K.W.M. Ten Principles of Values-Based Medicine. The Philosophy of Psychiatry: A Companion. Ch. 14. J. Radden. New York, Oxford University Press, 2004, 205 – 234