Here is an second version of the paper that David Morris and I are writing.
Values Based Practice, Social Policy and
the Service User identity
Introduction
‘Values Based Practice’ (VBP) might be the
name of any approach that paid due and serious attention to the role of values alongside
facts in good healthcare. But it has also become the name of a particular
approach to working with diverse values in healthcare pioneered by the
psychiatrist and philosopher KWM (Bill) Fulford. In this paper, we will take it
to mean the latter.
Although drawing on a substantial
philosophically framework, VBP is, itself in one key respect, theoretically
minimalist. That is, aside from some framework values, the violation of which
would undermine the very possibility of VBP, the work of managing diverse
values is not determined or dictated by antecedent principles. Its ‘principles’
are more pointers or reminders. Nor is it even driven by the goal or telos of a
right outcome but is instead guided by the idea of following a good process.
The task of managing a legitimate diversity of values is left to a process of
discussion by those who have a stake in the outcome, a discussion the shape of
which is left deliberately open-ended. Whilst there are some pointers to guide
the debate, there are few – though not no – ground rules.
But whilst it is plausible that the
application of VBP to clinical decisions with particular identified patients or
health service users, and a particular team of health professionals provided by
the contingent circumstances of care, can be theoretically minimalist (though
whether it can be as minimalist as it is taken by Fulford to be is open to
question [see Thornton 2011]), its application to health and social policy
cannot escape some substantive antecedent commitments.
A key question concerns the identity of
service users in the context of social policy. By contrast with the paradigmatic
case of clinical decision making, this identity cannot be taken for granted.
But ‘not taking it for granted’ means, in this case, that it cannot be settled prior to some judgements about relevant
values, judgements thus prior to and outside the application of VBP. We will
use a vignette – the case of Mrs E – to illustrate the possibility that the
proper answer to the question ‘Who is the user of a service or policy?’ may be,
not an individual or even agglomeration of individuals, but a social network.
Neglect of this through assuming that service users are individuals risks
neglect of social capital.
We will also caution against conceiving of
the service user identity in the policy case on the model of that of paradigmatic
clinical decision making. At the risk of slipping into jargon: the service user
identity should not be thought of essentially, or exclusively. It is an
identity relative to context. But determining who the service user is in any
given context depends on a piece of values-based reasoning. So if VBP proper
presupposes an answer to this question before it can start such reasoning is
not part of VBP but rather something more fundamental.
Values
Based Practice and clinical decision making
Values Based Practice stands in opposition
to an implicit or inchoate traditional view of the relation of facts and values
in medical care. On this traditional view, medical diagnosis is a
matter of getting the facts right independent of any values. Values come into play in guiding – alongside good evidence based
medicine – treatment and management. And when they do, they are codified in a
set of principles, a proper understanding of which form a kind of moral
calculus.
VBP rejects both of these aspects of the
traditional view. Values are implicated in diagnosis as well as
treatment. And any moral principles to which we might appeal are insufficient to guide good
practice. The arguments for the first element need not concern us in any detail
here [see Thornton 2007: 62-73; Thornton 2011]. But they have to do with the
idea that illness in general is an evaluative notion. Illness is bad for the
sufferer and that notion of badness is essentially evaluative. (Thus VBP is
committed to the failure of programmes to reduce the notion of illness to
value-free notions such as a failure of biological or proper function. But,
first, there is grave doubt as to whether the pattern of explanation in which
functions are deployed really is value-free [See Thornton 2000]. Second, even
the foremost contemporary philosopher of psychiatry who defends the use of
failure of function to capture the idea of disorder explicitly combines that
with the value, harm, to analyse
illness and disease [Wakefield 1992, 1999].)
The
second step to articulate Values Based Practice is the rejection of both the
sufficiency and the fundamental importance of moral principles in guiding medical practice. The first follows
from a feature which is present even in Tom
Beauchamp and James Childress’s attempt to relate medical ethical
reasoning to a set of principles [Beauchamp and Childress 2001].
Principles
of Biomedical sets out four general principles to guide medical
ethical reasoning: autonomy, beneficence, non
maleficence and justice. As
is familiar, these four do not derive from any single higher
principle and can conflict. Beauchamp and Childress describe two methods for
dealing with such conflicts: specification and balancing. Specification is a way of deriving more concrete
guidance from the fairly abstract higher level principles. It ‘is a process of reducing the indeterminateness
of abstract norms and providing them with action guiding content. For example,
without further specification, do no harm is an all-too-bare starting point for
thinking through problems, such as assisted suicide and euthanasia. It will not
adequately guide action when norms conflict.’
[Beauchamp
and Childress 2001: 16]
Balancing
and complements specification thus: ‘Specification
entails a substantive refinement of the range and scope of norms, whereas
balancing consists of deliberation and judgement about the relative weights or
strengths of norms. Balancing is especially important for reaching judgements
in individual cases.’ [Beauchamp and Childress 2001: 18]
Neither balancing nor specification simply
unpacks the content of the principles themselves. Nor, like deductive
nomological explanation in the physical sciences, do they combine general
principles with particular circumstances in a deductive argument. Both require an
extra element of judgement. Thus even according to the Four Principles
approach, the four principles are not sufficient for medical ethical judgement.
Values
Based Practice goes further than this, however. Although it concedes that there
can be sufficient agreement about some values that they can codified to provide
the basis for ethical codes and guidelines and other agreed elements for
any thinking about healthcare,
these remain just a small part of the values that have to be taken account of
in guiding medical practice which include individual preferences, desires,
wishes, firmly held faith and convictions and so forth.
By
stressing this multiplicity, it stresses the standing possibility of
disagreements and clashes in thinking about particular circumstances. But
if values are ubiquitous and if, agreed framework aside, disagreement is both
to be expected and legitimate, how can the process of assessing the competing
‘pulls’ of different values be managed? To repeat, within the framework,
guidance by principles is of limited use. There are three key suggestions.
First, rather than aiming to arrive at the
right outcome in a conflict, VBP aims instead at there being a good process.
That is, it rejects the idea that a particular accommodation of values might be
the right result in any particular context in favour of a method. Correctness,
if it applies at all, applies to the method followed. Fulford summarises this
idea thus: ‘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)’ [Fulford 2004: 206].
Second,
‘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)’ [ibid: 206]. This again reflects the idea that correctness attaches
not to an endpoint but to a process. Thus there is equal stress on methods of raising
awareness of values by attention to language use (the ‘values-blindness’
principle) and for improving knowledge of other people’s values (the ‘values-myopia’
principle).
Fulford
characterises VBP using ten principles or pointers.
Ten
Principles of Values Based Practice
1:
All decisions stand on two feet, on values as well as on facts, including
decisions about diagnosis (the ‘two feet’ principle)
2:
We tend to notice values only when they are diverse or conflicting and hence
are likely to be problematic (the ‘squeaky wheel’ principle)
3:
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)
4:
VBP’s ‘first call’ for information is the perspective of the patient or patient
group concerned in a given decision (the ‘patient-perspective’ principle)
5:
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)
6:
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)
7:
A rich resource of both empirical and philosophical methods is available for
improving our knowledge of other people’s values (the ‘values-myopia’
principle)
8:
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)
9:
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)
10:
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)
Despite
these pointers, however, Values Based Practice is theoretically
minimalist. That is not to say that it is not based on theoretical
considerations. It draws heavily on Fulford’s analysis of the evaluative nature
of diagnosis which in turn is based in the ordinary language analysis pioneered
in Oxford in the 1950s and 1960s, especially Hare’s early work on the logical
properties of value terms [Fulford 1989; Hare 1952]. But that theoretical
articulation is used to defend a theoretically-light approach to forming value
judgements.
By contrast with what Fulford calls
‘quasi-legal medical ethics’, in which value judgements are derived from a rich
body of principles or the equivalent of case law, VBP leaves them to a process
of exploration, self- and other-knowledge and discussion. It accepts
‘dissensus’ as a likely outcome. It is a liberal approach to the values in
question. Aside from the framework values, all and any values have equal merit
prior to the process of local debate.
But that theoretically minimalism
is made possible in part by taking one thing for granted. As the fourth pointer
says: VBP’s ‘first call’ for
information is the perspective of the patient or patient group concerned in a
given decision (the ‘patient-perspective’ principle). That principle militates
against a slippage of discussion into a paternalist imposition of values on, or
against, the patient or service user. But it assumes that the question of who
is the patient or service user can be decided independently of the application
of VBP to value judgements. This is a reasonable assumption in the paradigmatic
case of clinical decision making where the identities of patients, clinicians
and other members of a healthcare team are fixed by local contingencies. But
things are more complicated in the case of the identity of ‘users’ of a policy.
Values
based practice, social policy and service user identity: the underlying logic
In clinical decision making, Values Based Practice can start from the
particular patient and his or her clinical team. Thus the question of who is
the patient or service user can, to a first approximation, be taken for granted
prior to the application of VBP. But that is not true to anything like the same
extent in cases to which VBP may be extended and applied: the investigation and
evaluation of social policies concerning healthcare.
In the case of the application of Values Based Practice to a particular patient
and their pre-existing clinical team, the question ‘Who is the service user?’
is not, typically, a pressing problem. But what of the case of the assessment
of existing or the development of new health and social policies?
The
problem in a nutshell is this. Any practical health or social care policy has a
number of effects or consequences, both positive and negative. A policy
designed to reach members of a community unwilling to report their mental
health problems, for example, might have such people as its service users. But
if it addressed them by addressing families, then healthy family members might
also be count as service users. And if the aim were to improve social inclusion
within the community, other members of the community might count as service
users. Given that VBP prioritises the ‘patient or patient group concerned in a
given decision (the ‘patient-perspective’ principle)’ this raises the question:
who should count as the patient or service user in such complex cases?
This is not to say that such a question is
unanswerable. But answering it will involve assessing the competing claims of
different potential groups for priority. Since that is an evaluative (as well
as a factual) matter it might have been thought that it could be settled by an
application of Values Based Practice. But it
turns out that VBP presupposes a prior answer to it. In other words, the
question of service user identity is an evaluative matter which, whilst vital,
cannot be addressed by VBP as it is applied to clinical decision making.
Although
we have outlined the problem as one of principle (VBP both requires but cannot
assume an answer to the question of service user identity before its application), there are also practical problems which
follow from assumptions which are typically
made about the likely identity of service users. One problem is that the
potential therapeutic value of social networks
in particular go unnoticed and thus their worth is neglected. We will
illustrate this through the following detailed vignette (though name s and
details have been changed to ensure anonymity).
The case of Mrs E
Consider
the case of Mrs E, a woman of 96, living, as she has since 1920, in an
un-modernised Edwardian house in inner London. Though she has no significant
cognitive impairment or difficulties with communication, Mrs E has breast
cancer, diabetes, arthritis and hypertension (resulting episodically in serious
nose-bleeds and fainting) for which she requires some eight forms of medication
daily. She lives alone having been long widowed and has a daughter of 60 who
lives 250 miles away and whose scope for maintaining contact is hampered also
by her own health problems. Mrs E’s mobility and hence her self-care is
severely limited by her arthritis. She can feed herself but cannot prepare food.
She can dress herself but with such difficulty that she usually remains in her
night clothes throughout the day. With its original coal fired heating and
plumbing system, her only access to hot water in the summer months, when the
boiler is off, is by way of a kettle, so she cannot bath or shower for much of
the year. Mrs E is frail. Life is a daily struggle to retain independence. That
she has retained it in these circumstances is due to the specific and extensive
commitment of a neighbour who has provided daily assistance with personal care
for some years – and who has de facto become
Mrs E’s carer – a number of other neighbours who provide informal support and
help with specific tasks as required and two established friends, each of whom
visit monthly.
The
members of this network are crucial to Mrs E. They have used their own agency
to optimise her resilience, scope for independence and hence agency in two key
ways. Firstly, in having been responsible for securing Attendance Allowance,
‘Telecare’ and adaptations to the home environment (including installation of
the stair lift by which means Mrs E is able to get to bed) they have
articulated and secured otherwise unmet practical needs and financial
entitlements. Secondly, they have established a form of social engagement based
on shared identity. One of the two established friends is, as Mrs E herself has
always been, a keen gardener and so shared gardening narratives have become a
critical aspect in shaping over time a form of support which is reciprocally
informative, appreciative and, therefore, sustainable. In addition, through the
multiple dimensions of shared experience associated with their engagement with
Mrs E and each other, this network has generated new and diverse forms of
knowledge and accordingly, collective identity. In addition to being the group
of individuals who support Mrs E, they might be considered with Mrs E to constitute a form of neighbourhood capital both with
continuing potential for mutual support based on the needs of Mrs E herself,
and, in the context of what may be thought of as the ‘core economy’ [Cahn 19**]
of the locality, with emergent potential for the wellbeing of other members of
the community and therefore, the community itself.
In
relation to Mrs E though, while this network has therefore been instrumental in
enabling her independence, it has reached the limits of its capacity to meet a
level of personal need that deepens a little each week and has sought advice
from the local Adult Social Care Department. Until this point, the only health
or social care service which Mrs E had received was that provided, as required,
by her GP and a Community Nurse working from the Practice. The Social Worker
who visits Mrs E is experienced and specialises in older people. She sees her
role as one of assessing the individual needs of Mrs E, as a putative service
user, against a criterion framework for service entitlement. In part because of
the effectiveness with which she has utilised the network interventions to
date, Mrs E fails to meet any of the criteria for a service to be provided.
Moreover, the social worker’s professional modus
operandi provides no space for an account either of the impact of the
decision on the network or of its contribution to date and in the future.
Fidelity to an individualised or
personalised definition of who the service user is has eliminated the need
to understand the problem systemically as one in which a number of people are,
in effect, joined to the challenge of meeting individual need. In excluding any
evaluation of the inter-dependency impact that these relationships, for all
their complexity, might represent, we see an approach to seeking to protect
individual independence which contains the means for its own failure, with all
that this entails for the costly and inevitable demise of Mrs E’s health and
wellbeing.
To
privilege the identity of an individual community member as service user as the
key organising principle in the design of services that incorporate a values
perspective may be necessary to reframing the way in which power is seen and
used in the relationship between professional service provider and recipient.
It is certainly the sine qua non for
a service seeking to be consonant with the precepts of contemporary policy on
personalisation. As the example has shown, however, it can also reinforce a
conceptualisation of this relationship as bilateral: one in which some nominal
redistribution of power takes place between two players in a clinical
engagement rather than one that draws on the rich capital that a systemic
approach can engender if it brings to bear instead the ‘real life’ analysis of
social possibility revealed in the multiple identities of people who may – or
may not use services.
The
case of Mrs E reveals one danger in a too hasty assumption about the identity
of the users of a health or social policy. A typical focus on individuals
neglects the importance, and value, of social networks which might properly be
thought of as users of services. Such networks, however, need not themselves be
mere agglomerations of individuals but may be structured and supported by
social relations.
Such a
case contrasts with the paradigmatic view of VBP applied in a clinical setting
in which the question of who is the service user seems, at least, more clear
cut. That is not true, we have suggested, of the policy case. But it might be
assumed that identifying service users in the latter case can be modelled on
the former through a slippage between the idea of identifying service users to
the idea of a service user identity. (Think of the difference between using the
word ‘identity’ to mean having an answer to the question ‘Who is the tallest
person in the room?’ and using it to mean the self-conception that someone
might have. The tallest person may not think of themselves as the tallest
person, their height may be of no importance to them.) So it might be thought
that there is a shortcut to picking out who the service users are of a mental
health policy, eg., from the community of service users, those who take on that
as their identity. There are, however, reasons to be wary of the very idea of a
service user identity which we will now outline.
The
contingent perils of a service user identity
We will outline four reasons to be
cautious of the idea that a community of service users can be picked out through
a service user identity.
First,
the very idea of a service user identity, based on shared experience could, ironically,
limit relationships with other disadvantaged communities whose own
complementary claims could be an resource. To privilege the collective voice of
common interest over other perspectives and communities may encourage such
communities to turn inwards.
Second,
it circumscribes the context within which individual capabilities can be
understood and appreciated. Behind the case for equity of opportunity is an
implicit argument for the recognition of capability. The right to participate
is driven by an assertion of personal capability to participate. A
categorical approach to defining community may place limits on the way in which
its members and their diverse capabilities, both individual and shared, will be
expressed and perceived externally, thereby limiting the effect of that aspect
of empowerment concerned with the proper recognition of what people can do.
This links to the third problem.
Third,
in practice, the right to be equally valued irrespective of difference is
likely to be realised only in a social context in which the capabilities of people
with disability are recognised and the potential for defining people
principally in terms of disability are eradicated. The positive perception of
disability necessary to actions that support empowerment are associated with
the idea that the nature and value of an individual’s activity should be seen
as a function of their multiple identity. A service response to the needs of
people with disability which incorporates their role as citizens with
contributory assets alongside that of service users with needs, is conditional
on the notion of multiple identity being understood by public agencies. This
understanding may not be best served by retaining, as the basis for service
organisation, a model of community characterised by a singular definition of
membership especially in a service environment governed by a contemporary
concern with community health and civic engagement.
Fourth, the potential for individual recovery, whether defined at the
level of the individual or at a population level, is usually calibrated against
an assessment of the response of other people. For example, how successful a
person with a mental illness might be in holding down a job in an open plan
office is likely to depend on an assessment made of the anticipated or actual
response of office colleagues (‘the work community’), while policy on
employment for people with mental health problems is likely to take this into
account, deploying study data (or not!) in which examples of such individual
experience is aggregated as an evidence base for the existence, and therefore
policy relevance, of stigma and discrimination as factors to be considered in
service model development. It is
important therefore to give these external social accounts some descriptive
weighting in order to advance social recovery prospects and, to the extent that
such discourse is conducted within the conceptual framework of ‘the community’
(which is the case for policy and practice in public mental health as well as
that for services), it is important to provide for an understanding of
community perspectives associated with ‘the other’ that has some equivalence to
those associated with that of illness experience.
Service
user centrality and theoretical minimalism
As we outlined in the first section, when
Values-Based Practice is applied to individual clinical cases, it is
theoretically minimalist. With the parties to a clinical decisions identified,
VBP imposes a background of shared values – necessary for it to function at all
– but then leaves the management of rational and legitimate disagreement about
values to a discussion in which highlighting the values involved, including
hidden and implicit values and communication skills play a central role. By
adopting a form of theoretical minimalism, VBP can avoid having to settle
contentious global debates about competing moral theories and approaches.
Providing that there is sufficient agreement about framework values, VBP can
leave the discussion of competing values to a local context. The particular
participants can examine their values relevant for the particular decisions
concerned.
Such discussion is not, however, entirely
free. A safeguard against paternalism is the ‘patient-perspective’
principle: the ‘first call’ for information is the perspective of the patient.
But, as we have argued, the combination of this principle and theoretical
minimalism cannot be carried over in to the context of health and social policy.
Identifying
the claims of groups to count as service users, to count as having more say
than others, cannot be taken for granted. If not, it must itself be subject to
a value-laden debate and judgement. If VBP is identified with a minimalism,
then this issue cannot be settled by VBP alone. If it is not so identified,
then the application of VBP to policy debate will call for a more structured
approach to weighing the opinions and values of those who may be affected. The
cost of the application is giving up minimalism. Some values will have more
values than others.
There is, however, a benefit from this
cost. We will illustrate this by refrring back to two earlier sections. First,
in the discussion of Mrs E, we highlighted the danger of assuming that the
proper answer to the question ‘Who is the service user?’ picks out an
individual or even an agglomeration of individuals. In some cases, at least, a
better answer may be that a social network or community is the service user
(where one distinction between an agglomeration and network is that individuals
can enter or leave the latter without changing its identity).
Second, in the penultimate section, we
drew attention to some contingent but typical dangers from approaching the
question of the identity of service users in the policy case with the same
simple mindedness which seems to work for the paradigmatic clinical case. If
one thinks of service users as those picked out by having a service user
identity – as a particular community fixed prior to potential policy
developments – then this will encourage the isolation and permanence of that
community. But if instead, identifying the service user community or
communities depends on the policy under scrutiny and its particular
consequences, these dangers can be diminished.
To count as a service user – relative to a
particular policy – will depend on fitting a role, or characteristic. This
follows from the idea that so counting will flow from an argument which will have to be couched in general terms such as why
having such and such a role puts one in a position to have an expertise in so
and so. Thus a sufferer from a mental illness may also be a tax paying citizen,
a family member, a carer, a member of a particular ethnic grouping etc. Thus
the individual can properly count as a member of any number of differing
communities relevant to a policy initiative and thus merit a number of
different voices.
Thus service user identity may include
social networks as well as individuals and can be shifting and multiple rather
than fixed and single. Neither of these corrections to the paradigmatic case is
inconsistent with the main thrust of VBP: with the claim that values play a key
role in debate about health and social care in a way that reists codification
in ethical principles. But since both kinds of debate about identity are grounded
in reasoning concerning the, sometimes
competing, values in play, they are inconsistent with the assumption that
service user identity can be assumed before
VBP is put into play.
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