Clinical judgement and values Values

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Clinical judgement and values Values

• Dr Tim Thornton
• Lecturer in Philosophy
• Division of Medical Education

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Aims of the session

• To underline the way in which values (of
  clinicians and others) impact on medical practice
  in clinical judgements in Values-Based Practice
  (VBP to complement EBP).
• To outline some of the features of values and
  their difference from facts.
• To show how ethical reasoning is an aspect of
  values-based practice and how a proper
  understanding of it sheds light on the
  non-algorithmic nature of values based reasoning.
• To raise the issue of conflict of values.

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Sacket et al Evidence based medicine

• What is EBM?
• Evidence based medicine is the integration of
  best research evidence with clinical expertise
  and patient values.

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Sacket et al Evidence based medicine

• By best research evidence we mean clinically
  relevant research New evidence from clinical
  research and treatments both invalidates
  previously accepted diagnostic tests and
  treatments and replaces them with new ones that
  are more powerful, more accurate, more
  efficacious and safer.

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Sacket et al Evidence based medicine

• By clinical expertise we mean the ability to use
  our clinical skills and past experience to
  rapidly identify each patients unique health
  state and diagnosis, their individual risks and
  benefits of potential interventions, and their
  personal values and expectations

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Sacket et al 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.

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From Tomorrows Doctors

• 35. They must understand a range of social and
  cultural values, and differing views about
  healthcare and illness. They must be aware of
  issues such as alcohol and drug abuse, domestic
  violence and abuse of the vulnerable patient.
  They must recognise the need to make sure that
  they are not prejudiced by patients' lifestyle,
  culture, beliefs, race, colour, gender,
  sexuality, age, mental or physical disability and
  social or economic status.

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From NICEs introduction to Citizens Council

• NICE acknowledges that although its decisions are
  based on evidence they are set against a
  background of values and judgments. NICE wants
  the public from all parts of the community to
  give their views and opinions and provide a
  backdrop against which NICE and the independent
  Committees that advise it can develop their
  recommendations.

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Conflicting values raised in VBM / Medical Ethics
week

• Should intersex children be assigned a gender at
  an early age?
• Should infertility treatment be available on the
  NHS? If so what, if any, limits should be placed
  on patient selection?
• Should a 15 year old be allowed to decline life
  preserving treatment (dialysis)?
• Should the parents of a 16 year old girl with
  learning disability be allowed to request
  sterilisation for their daughter?

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What is the role of values in clinical judgement?

• Values are evident in moral aspects of clinical
  judgement.
• They play a role in shaping public policy.
• They underpin much of the work in transcultural
  medicine.
• They are most evident in disagreement in high
  profile cases.
• But they are widespread in everyday care.

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But how do values play a role in clinical
judgement?

• In general, clinical judgements are practical
  judgements about what to do.
• According to a traditional view, practical
  judgement rests on two feet
• Beliefs
• Desires / Pro-attitudes / Values.
• Only by a combination of these is an action
  motivated or explained.

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What is missing from this case of ordinary action
explanation?

• Why did he open the fridge? Because he wanted a
  cold beer.
• (And he believed there was cold beer in the
  fridge.)

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And from this explanation?

• Why did she add chilli to the sauce? Because she
  believed it would make it hotter.
• (And she desired / valued a hot sauce.)

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Action and the practical syllogism

• The pair of an appropriate belief and value
  implies a course of action.
• Straightaway he acts! (Aristotle)
• In explaining everyday actions, we implicitly
  fill in unstated elements from the practical
  syllogism. But they are necessary elements. (What
  if she hated hot food or he thought the fridge
  was empty?)

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So what has this to do with clinical practice
judgement?

• Choosing an action depends on both what we can do
  and what we want to and should do.
• Medical education concentrates (correctly) on the
  former (EBM). But the latter is also vital (VBM).
• Note the concern of NICE, the BMA, the GMC with
  the role of values in health care and practice.

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This is a modest view of the role of values in
diagnosis

• That is, it assumes that the belief side of the
  practical syllogism is value free. But is that
  so? Is diagnosis (as opposed to treatment)
  value-free?
• Psychiatric diagnosis involves terms like
  failure to conform to social norms conning
  reckless disregard etc.
• Indeed the very idea of (physical) illness /
  disease has been claimed to contain values.Not
  just any difference from the norm is illness /
  disease.

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Two first order differences between beliefs and
values

• Suppose two people disagree about the number of
  chairs in this room, what conclusions can we
  draw?
• Vagueness aside about the definition of chair, at
  least one person must be wrong about the number,
  must have miscounted in some way.

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The first first order difference between
beliefs and values

• Suppose two people disagree about the aesthetic
  value of the chairs in this room, what
  conclusions can we draw?
• On a plausible account, neither need be wrong,
  they just value different aspects of chairs
  (comfort, shape, price, practicality, utility
  etc).

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Example What is the fastest cake in the world?

• Scone!
• One may need to be told that scone Its
  gone implying speed. But whether or not one
  does, a difference of opinion about whether it is
  a good joke need not imply a mistake.
• We talk of different senses of humour.

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Divergence of values and facts 1

• We typically allow divergence of value to be a
  rational possibility implying no mistake.
• We typically take divergence of factual beliefs
  to imply a mistake.
• So VBM should face up to legitimate divergence of
  values (contrast the approach of EBM).

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Second difference The invisibility of values

• Where we do agree about values they can become
  invisible, submerged behind descriptive criteria.

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Compare

• What makes an apple a good / desirable / valued
  apple?
• What makes a piece of pictorial art good /
  desirable / valued?
• In the first case we can agree descriptive
  (non-evaluative) criteria. The same applies for
  clinical judgements in areas where we agree on
  the values.

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Five principles of VBM 1

• 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)

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Five principles of VBM 2

• VBM's "first call" for information is the
  perspective of the patient or patient group
  concerned in a given decision (the
  "patient-perspective" principle)
• In VBM, 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)