Wednesday, 7 November 2012

Values Based Practice and authoritarianism

I have been to the third of a three day conference / workshop on EBM and VBP organised by Michael Loughlin and Phil Hutchinson (pictured) at MMU, Cheshire. My talk, assembled sadly (and rudely because Rupert Read had to respond to it) at the last minute, started from a single comment in Bill Fulford's reply to a commentary I had written on VBP for a special issue exited by Michael. In it, I suggested that one can think of Fulfordian VBP as a conjunction of three claims.

1: Values are implicated in diagnosis as well as treatment
2: Principles are insufficient for value judgements
3: The emphasis is on good process rather than right outcomes

I then expressed doubts about the consistency of the third procedural claim with the idea that VBP is proposed with normative force. Instead, I suggested that one can have pretty much everything one wants by combining the first two with a particularist model of value judgements in which value judgements aim to track real evaluative particulars inhering in situations. But, I suggested in the commentary, a diagnosis of why Bill had not himself adopted this version.

If there is sufficient agreement about values then codifications – whether ethical or legal or other – can contingently be formulated. But the explanation for such agreement is not that there are real values out there that command the agreement of right thinking people. That approach – particularism – which I favour perhaps smacks of authoritarianism and, in the context of medicine, may recall the dangers of totalitarian psychiatry. [Thornton 2011: **]

And indeed Bill agreed with this worry and hence motivation in his, as yet unpublished, reply.

[A]uthoritarianism in the guise of totalitarian psychiatry (the imposition of a pre-set view of ‘good outcomes’) was the basis of some of the worst abuses of medical practice in the twentieth century [Fulford draft reply]

The phrase ‘imposition of a pre-set view of “good outcomes”’ might carry either of two meanings, however. It might mean the imposition of a prejudiced view by powerful people. That would fit the label 'authoritarian'. But it would not justify the rejection of the particularist in favour of the liberal view. Or it might mean that the process of deliberation of VBP answers to, is disciplined by, a or the right or good outcome. But if the latter, why think that responding to independently existing good outcomes is authoritarian? And can we understand VBP without ‘authoritarianism’?

One motivation for that might be drawn from Rorty's assimilation of the authoritarianism of religious abasement to the objectivity of taking empirical and value judgement as answering to a worldly 'other'. Here is McDowell's summary of Rorty's view (to which Rorty does not object).

The sense of sin from which Dewey freed himself was a reflection of a religious outlook according to which human beings were called on to humble themselves before a non-human authority. Such a posture is infantile in its submissiveness to something other than ourselves. If human beings are to achieve maturity, they need to follow Dewey in liberating themselves from this sort of religion of abasement before the divine Other. But a humanism that goes no further than that is still incomplete. We need a counterpart secular emancipation as well...
What Rorty takes to parallel authoritarian religion is the very idea that in everyday and scientific investigation we submit to standards constituted by the things themselves, the reality that is supposed to be the topic of the investigation. Accepting that idea, Rorty suggests, is casting the world in the role of the non-human Other before which we are to humble ourselves. Full human maturity would require us to acknowledge authority only if the acknowledgement does not involve abasing ourselves before something non-human. The only authority that meets this requirement is that of human consensus. If we conceive inquiry and judgment in terms of making ourselves answerable to the world, as opposed to being answerable to our fellows, we are merely postponing the completion of the humanism whose achievement begins with discarding authoritarian religion.
[McDowell 2000: 109-10]

This view is motivated by a number of other views which are not closely connected to VBP. For example, Rorty's antirepresentationalism rules out not only views within the philosophy of mind but more generally views about the relation of thought and world and hence the need instead for solidarity rather objectivity. But even if one did not take a view on that, one might still think that value judgements are affected and infected by a deep contingency. It is only because of contingent features of our natures and cultures that we are in any position to make the judgements we do. Further, value judgements can be hard in this sense: even having deployed very thorough argument and debate, there seems to be no guarantee of agreement on ethical matters. There are echoes in this of Fulfordian VBP.

So one way to motivate a rejection of authoritarianism in VBP, construed merely as the idea of being disciplined by some sort of right or good outcome, is to take note of the underlying contingency of value judgements and to conclude from this that the idea of objectivity in this area makes no sense.

If so, however, there is an alternative to be found in what McDowell goes on to outline. The key idea is that neither the underlying contingency nor the idea that value judgements are hard rules out objectivity.

One aspect of the immaturity that Rorty finds in putting objectivity rather than solidarity at the focus of philosophical discourse is a wishful denial of a certain sort of argumentative or deliberative predicament. On the face of it, certain substantive questions are such that we can be confident of answers to them, on the basis of thinking the matter through with whatever resources we have for dealing with questions of the relevant kind (for instance, ethical questions)... But even after we have done our best at marshalling considerations in favor of an answer to such a question, we have no guarantee that just anyone with whom we can communicate will find our answer compelling. That fact - perhaps brought forcibly home by our failing to persuade someone - can then induce the sideways glance, and undermine the initial confidence. Rorty's suggestion is that the language of objectivity reflects a philosophical attempt to shore up the confidence so threatened, by wishfully denying the predicament. The wishful idea is that in principle reality itself fills in this gap in our persuasive resources.  Any rational subject who does not see things aright must be failing to make proper use of humanly universal capacities to be in tune with the world.  If we fall into this way of thinking, we are trying to exploit the image of an ideal position in which we are in touch with something greater than ourselves – a secular counterpart to the idea of being at one with the divine – in order to avoid acknowledging the ineliminable hardness of hard questions, or in order to avoid facing up to the sheer contingency that attaches to our being in a historically evolved cultural position that enables us to find compelling just the considerations we do find compelling.
Here too we can make a separation. This wishful conception of attunement with how things really are, as a means of avoiding an uncomfortable acknowledgement of the limitations of reason and the contingency of our capacities to think as we believe we should, can be detached from the very idea of making ourselves answerable to how things are. We can join Rorty in deploring the former without needing to join him in abandoning the very idea of aspiring to get things right... [McDowell 2000: 112]

So this suggests two ways of thinking about VBP and authoritarianism. One can reject the latter, construed as a commitment to right outcomes independent of any particular instance of the process of deliberation, and put the emphasis on process or solidarity and motivate it by invoking something like Rorty's rejection of abasement to the Other. One can appeal to this in the case of value judgements in particular because of their connection to the contingencies of human subjectivity and the omnipresence of hard judgements.

But, if so, one will need to shore up that picture against the objection that it does not follow from those motivations alone. That is, one can combine the first two elements of VBP, which I outlined at the start, with a denial of a constitutive role of process and maintain that even in VBP value judgements are disciplined by evaluative particulars. One way to fill this out is to borrow McDowell's sketch in which the realm of values is in a transcendental harmony with our subjectivity. One needs to have a particular kind of mind and life to have one's eyes open(ed) to this tract of reality, as McDowell might say. (So the independence of process and outcome is at the level of instances. ) Such an alternative is at least available to VBP at the cost of adopting, and defending, a particularist metaphysics of values.

That is to set out two approaches with their distinct costs. But it still seems to me that there is reason to favour the latter. The first reason is the objection that proposing or supporting VBP itself presupposes a value which does not seem simply to await the VBP process. The second is that VBP aims at a balance of values and, third, is a skill. But surely not just any balance - such as one imposed by force - will do, but the right, or at least a good, outcome? And a skill requires some conception of discipline if it can be practiced. So I still think that a particularist reading of VBP is to be preferred over the more radical, liberal sense.

Interestingly, Rupert Read agreed with the critical thrust but thought that there would be no logical space for the modest particularist modification I proposed. Rather, once proceduralism was replaced with a thought that any form of VBP was held in place only at the cost of some substantial value judgements then a critical assessment and justification of them would have to take account of the point and context of healthcare. So the replacement account would inflate to stop nowhere short of a teleological account of a flourishing orientated medicine: FlOM. Wary of substantial theory building, I was not sure I wanted to sign up yet for such a utopian reworking of VBP. But I will wait to see how he and Phil articulate and develop FlOM.

McDowell, J. (2000) ‘Towards rehabilitating objectivity’ in Brandom, R.B. Rorty and his critics Oxford: Blackwell
Thornton, T. (2011) ‘Radical liberal values based practice’ Journal of Evaluation in Clinical Practice 17: 988-91