Values-based Medicine Research Articles

Values-Based Medicine Is an Ethical Concept for Implementing the Ethical Principles in Daily Practice.

Values-based medicine (VsBM) is an ethical concept, and bioethical framework has been developed to ensure that medical ethics and values are implemented, pervasive, and powerful parameters influencing decisions about health, clinical practice, teaching, medical industry, career development, malpractice, and research. Neurosurgeons tend to adopt ethics according to their own values and to what they see and learn from teachers. Neurosurgeons, in general, are aware about ethical codes and the patient's rights. However, the philosophy, concept, and principles of medical ethics are rarely included in the training programs or in training courses. The impact of implementing, observing the medical ethics and the patients' value and culture on the course, and outcome of patients' management should not underestimate. The main principles of medical ethics are autonomy, beneficence, nonmaleficence, justice, dignity, and honesty, which should be strictly observed in every step of medical practice, research, teaching, and publication. Evidence-based medicine has been popularized in the last 40-50years in order to raise up the standard of medical practice. Medical ethics and values have been associated with the medical practice for thousands of years since patients felt a need for treatment. There is no conflict between evidence-based medicine and values-based medicine, as a medical practice should always be performed within a frame of ethics and respect for patients' values. Observing the principles of values-based medicine became very relevant as multicultural societies are dominant in some countries and hospitals in different corners of the world.

Engaging Patients with Depression in Treatment Continuity.

When conceptualising engagement with treatment, it may be useful to contrast ‘disease’, which refers to underlying psychobiological dysfunction, with ‘illness’, which describes the experience of the person with that disease. Knowledge of disease, as well as understanding of illness, including patients’ explanatory models of symptoms, may be useful in facilitating shared decision-making. Ideally, physicians are able to integrate evidence-based medicine with values-based medicine by combining the best research evidence with patients’ unique needs and preferences. This, in turn, requires taking a systematic approach to the assessment of a range of domains (i.e. symptom profile, clinical subtype, severity and comorbidity) in individuals with depression, and individualising treatment accordingly. While data are now available from a range of randomised clinical trials addressing treatments for depressive symptoms, it is also notable that a decrease in symptom severity does not necessarily correlate with an increase in functioning, which highlights the need to monitor patients for the effect of treatment on a range of outcomes including comorbid anxiety, emotional responsiveness, and sleep quality. Importantly, recent epidemiological data emphasise the importance of persistence with treatment; most patients with major depression who persist with treatment eventually feel helped.

Response-Forty-Seven Years Later: Further Studies in Disappointment?

This paper provides a commentary on "Vascular amputees: A study in disappointment" (Little et al. 1974) and its significance in the development of the disability rights movement, as well as the movements for values-based medicine and person-centred health and social care.

Peut-on compter sur le care pour soigner le cure en psychiatrie ? À propos des troubles thymiques dans la clinique du jeune adulte

What can we find in the diagnostic of bipolar disorders that interests the international psychiatry at the end of the 20th century? Nosography is simplified in response to the search of increasingly accurate neuropharmaceutical targets and to strengthen the efficiency of chemical therapies. Nevertheless, while it is essential to pursue the improvement of antidepressant treatments, should one still accept to lose any semantic reference to depression and mood disorders under the label of bipolarity? In the DSM-III (1980), “depressive disorders” had been assimilated to “bipolar disorders”, and the classical syndromic opposition between “endogenous” and “exogenous” depressions, treasured by the French psychiatry, seems to have disappeared in benefit of a split between “major depressive disorder” (isolated or recurrent) and “minor depression” (chronical or dysthymic). In the DSM-5 (2013), there is a distinction between “disruptive disorder with mood dysregulation” and “persistent depressive disorder”, which, in turn, includes major depression, characterized and chronic, as well as the dysthymic disorder, both of them differentiated previously in the DSM-IV (1994) and IV TR (2000). In this context, melancholia is reduced to its least expression in a sub-category of “major depression”, which can, in turn, present “melancholic” or “dysthymic features”. From this evolution of the DSM, could we infer that international psychiatry is gradually coming back from its excess of technical atomization of the human being and the reduction of psyche to an organic body? Is contemporary psychiatry distancing itself from the contemporary questions raised by the need to integrate subjectivity and intersubjectivity in care practices and scientific research? At the end, could melancholia possibly be the only clinical-theoretical model making sense and preserving some internal consistency? Would this concept transcend time, places and disciplines, in clinical medical practice as well as in human and social sciences, in literature and arts alike? Some considerations on the evolution of the categorisation of depression in psychiatry will introduce the clinical vignette of a patient with a “bipolar disorder” label. This diagnostic – (im)posed after acting-out during a hospitalization – had the effect of breaking down the therapeutic binomial between the psychiatrist and the psychoanalyst – in place for ten years – on the hypothesis of a border-line diagnostic close to psychosis. This was a traumatic disorganization, marked by thymic movements of despair and elation that became overwhelming for the therapeutic trio itself. On the patient side, it became possible to redynamise the cotherapeutic process – although at a high price – due to a massive regression needing a radical reorganization of the frame of treatment and a reorientation of the initial diagnostic towards melancholia. The shared experience of an authentic “manic-depressive” relationship – helping and saddened – between the therapeutic staff, as well as the implementation of a setting of institutional packing, both facilitated the yield of incestual and psychotizing maternal imagos incorporated in early childhood. These were embolized in the patient's body as well as in the staff, and were masked by the excitation discharged through the suicide attempts. Time has come to relativize classical biomedical approaches centered on the “cure” versus socioethical approaches based on “taking care” of the person, which is being valued by the care movement at an international level (Glatignol, 2013). In other words, it is a matter of getting back to a medicine “funded on values” (values-based medicine VBM) and the subjective experiences (individual and collective alike) versus the limits of medicine exclusively based on evidence (Evidence-based medicine EBM) and objective facts.

A Consideration of both Means and Ends: Values-Based Medicine and the Problem of Changing Values

Values-based medicine (VBM) represents the most influential and sophisticated attempt to theorize the place of values within medical practice. It responds to competing value perspectives through a balancing procedure, termed “dissensus,” which seeks to keep multiple values in play. We argue, however, that VBM focuses on a static and cross-sectional picture of values, and does not provide an account of how values may change over time. We promote reasoning about values as an additional means of resolving conflicts within health care, which can manage dynamic values. We advocate for Hilary Putnam’s influential conception of the entanglement of fact and value to form the theoretical basis for values reasoning, which could operate alongside the balancing procedures advocated by VBM.

Pourquoi la visée du rétablissement en santé mentale implique une priorisation de la dimension éthique ?

The prospect of recovery requires to stop being centered on the disease and its course, in order to be now centered on the person and his or her future. It implies building a project, aiming at an accomplished life, and therefore making existential choices, which is a matter of ethical reflection. This makes self-determination one of the principles of the recovery process, which must be respected by the person and by those who accompany him or her. This orientation towards recovery means a change of purpose of care and support practices, which in turn implies a transformation of these practices that should be guided by the principles and values of the recovery process. The current movement of values-based medicine can be a useful resource for balancing the two foundations of care practices: knowledge and values.

Today´s medical self and the other: Challenges and evolving solutions for enhanced humanization and quality of care.

BackgroundRecent scientific developments, along with growing awareness of cultural and social diversity, have led to a continuously growing range of available treatment options; however, such developments occasionally lead to an undesirable imbalance between science, technology and humanism in clinical practice. This study explores the understanding and practice of values and value clusters in real-life clinical settings, as well as their role in the humanization of medicine and its institutions. The research focuses on the values of clinical practice as a means of finding ways to enhance the pairing of Evidence-Based Medicine (EBM) with Values-based Medicine (VBM) in daily practice.Methods and findingsThe views and representations of clinical practice in 15 pre-CME and 15 post-CME interviews were obtained from a random sampling of active healthcare professionals. These views were then identified and qualitatively analyzed using a three-step hermeneutical approach.A clinical values space was identified in which ethical and epistemic values emerge, grow and develop within the biomedical, ethical, and socio-economic dimensions of everyday health care. Three main values—as well as the dynamic clusters and networks that they tend to form—were recognized: healthcare personnel-patient relationships, empathy, and respect. An examination of the interviews suggested that an adequate conceptualization of values leads to the formation of a wider axiological system. The role of clinician-as-consociate emerged as an ideal for achieving medical excellence.ConclusionsBy showing the intricate clusters and networks into which values are interwoven, our analysis suggests methods for fine-tuning educational interventions so they can lead to demonstrable changes in attitudes and practices.

First Thoughts on a New Era for JACM.

First Thoughts on a New Era for JACM.

Theorising personhood: for better or for worse

Person-centered medicine is emerging as one of the most formidable critiques of evidence-based medicine. One of its claims to priority over patient-centered care, humane medicine, narrative-based medicine and values-based medicine is its attention to the philosophy of personhood. While it defines personhood in widely accepted terms, using adjectives employed by Cassell, such as ‘embodied, purposeful, thinking, feeling, emotional, reflective, relational’, it offers no examination of the numerous debates and disagreements about personhood. In particular, it has not so far explored the tension that exists between the neo-Lockean account of persistent psychological attributes, such as intention, cognition and rationality and the ‘animalistic’ account that ascribes personhood to human existence, to the human body and brain. Nor has it examined the significance of personhood as an emergent property of human beings imbedded in cultures and societies. Medical ontology is basically realist and its epistemology empiricist. Person-centered medicine faces the task of translating a contested, emergent concept into something realistic and empirically examinable, if it is to persist and have pedagogical purchase. Schectman’s ‘person-life view’ may provide a starting point for conceptualisation and teaching and respect is a relationship that underpins an understanding of personhood, but other guidelines will be needed. Some relevant suggestions are made in this article.

Psychiatrie et médecine fondée sur les valeurs

Some scholars, assessing psychiatry as still scientifically immature, call it to join the project of a medicine-based purely on facts as the Evidence-Based Medicine may be the current model. However, there is a classical contrast between the facts – that would be the realm of science – and the values: psychiatry seems to be desperately infiltrated by values as the concept of mental disorder highlights it. We present here the Values-Based Medicine (VBM) developed by the psychiatrist and philosopher K.W.B. Fulford. By contrast with the EBM, the VBM acknowledges the irreducible role of values in medicine. Far from being a symptom of immaturity, the values load inherent to psychiatry mirrors the complexity of its field. In the VBM, taking into full consideration the values becomes the driving tool for the decision-making (complementary to the EBM). By the very advances in science, all the medical fields will increasingly have to take into account the complexity of values. We underline the convergence of the VBM with other conceptual frameworks that have emerged around the concepts of recovery, care, person-centred practice and narrative medicine.

Promoting networks between evidence-based medicine and values-based medicine in continuing medical education

BackgroundIn recent years, medical practice has followed two different paradigms: evidence-based medicine (EBM) and values-based medicine (VBM). There is an urgent need to promote medical education that strengthens the relationship between these two paradigms. This work is designed to establish the foundations for a continuing medical education (CME) program aimed at encouraging the dialogue between EBM and VBM by determining the values relevant to everyday medical activities.MethodsA quasi-experimental, observational, comparative, prospective and qualitative study was conducted by analyzing through a concurrent triangulation strategy the correlation between healthcare personnel-patient relationship, healthcare personnel's life history, and ethical judgments regarding dilemmas that arise in daily clinical practice.In 2009, healthcare personnel working in Mexico were invited to participate in a free, online clinical ethics course. Each participant responded to a set of online survey instruments before and after the CME program. Face-to-face semi-structured interviews were conducted with healthcare personnel, focusing on their views and representations of clinical practice.ResultsThe healthcare personnel's core values were honesty and respect. There were significant differences in the clinical practice axiology before and after the course (P <0.001); notably, autonomy climbed from the 10th (order mean (OM) = 8.00) to the 3rd position (OM = 5.86). In ethical discernment, the CME program had an impact on autonomy (P ≤0.0001). Utilitarian autonomy was reinforced in the participants (P ≤0.0001). Regarding work values, significant differences due to the CME intervention were found in openness to change (OC) (P <0.000), self-transcendence (ST) (P <0.001), and self-enhancement (SE) (P <0.019). Predominant values in life history, ethical discernment and healthcare personnel-patient relation were beneficence, respect and compassion, respectively.ConclusionsThe healthcare personnel participating in a CME intervention in clinical ethics improved high-order values: Openness to change (OC) and Self Transcendence (ST), which are essential to fulfilling the healing ends of medicine. The CME intervention strengthened the role of educators and advisors with respect to healthcare personnel. The ethical values developed by healthcare professionals arise from their life history and their professional formation.

Evidence-based medicine and values-based medicine: partners in clinical education as well as in clinical practice

The best clinical decisions are based on both evidence and values in what is known as the 'two-feet principle'. Anecdotally, educationalists find teaching clinicians to become more evidence based is relatively simple in comparison to encouraging them to become more values based. One reason is likely to be the importance of values awareness. As values-based practice is premised on a mutual respect for the diversity of values, clinicians need to develop the skills to ascertain patient values and to get in touch with their own beliefs and preferences in order to understand those at play in any consultation. Only then can shared decision-making processes take place within a shared framework of values. In a research article published in BMC Medicine, Altamirano-Bustamante and colleagues highlight difficulties that clinicians face in getting in touch with their own values. Despite finding that healthcare personnel's core values were honesty and respect, autonomy was initially low ranked by participants. One significant aspect of this work is that this group has demonstrated that the extent to which clinicians value 'autonomy' and 'openness to change' can both be positively influenced by well designed education.

Value judgements and conceptual tensions: decision-making in relation to hospital discharge for people with dementia

We reflect, using a vignette, on conceptual tensions and the value judgements that lie behind difficult decisions about whether or not the older person with dementia should return home or move into long-term care following hospital admission. The paper seeks, first, to expose some of the difficulties arising from the assessment of residence capacity, particularly around the nature of evaluative judgements and conceptual tensions inherent in the legal approach to capacity. Secondly, we consider the assessment of best interests around place of residence, which demonstrates significant conceptual tensions. In addition, ‘best interests’ raise issues around the perception of risk and the perceptions of the family and crucially involve the notions of autonomy and trust. Finally, we not only gesture at some practical considerations based on insights from values-based medicine, but also make the suggestion that we require tighter functional assessments of residence capacity coupled with broader judgements about best interests.

Values‐based medicine and modest foundationalism

Philosophically, values refer to the basic commitments that justify judgements, beliefs and practices, both at the community and personal levels. The study of these kinds of values is axiology. We suggest that all people subscribe to three foundational values - survival, security and flourishing - and that these foundational values are expressed by way of concepts, systems, principles and practices that may differ substantially from culture to culture. Values can stand on their own as foundational justifications for health care and medicine. Many ethical quandaries can be better understood, even though they may remain unsolved, by reference to the foundational values that people can agree upon. This version of values-based health care has strong claims to prior logical status as a justification for the whole enterprise of health care, and values-based medicine is a part of this larger domain.

Ethics of the ordinary: a class response

In a previous issue of the BJGP , Papanikitas and Toon use a fictional narrative to illustrate the ethical components of an ordinary consultation.1 We discussed the narrative as a class as well as the questions posed by the authors, and would like to showcase our discussion as a way to decrypt some of the moral decisions and value judgements in this case. As a set of signposts to the ethical principles we have used Gillies’ InnovAIT paper.2 This paper sets out key ethical frameworks in relation to RCGP curriculum statement 3.3 on ethics and values-based medicine.3 The class consisted of five qualified GPs, one senior house officer in medicine, one bioinformatics graduate, and one researcher for a think-tank. The class were all taking part in an optional MSc module in ethics law and professionalism as part of an MSc degree in primary healthcare or a Master of Public Health degree at King’s College London. We conducted the discussion by Chatham House Rule, so all authors contributed, but no one voice is identified here. The class facilitator was Andrew Papanikitas, one of the authors of the previous BJGP narrative. We are all too aware that our discussion is not comprehensive and would welcome correspondence, either with us directly (via the corresponding author) or in the pages of this Journal. The scenario is one where the last patient on a Friday afternoon asks for a private referral to a clinic for consideration of bariatric surgery. We note that the patient would not qualify for an NHS referral, and that the GP in the scenario is in a hurry to get to a social engagement. The authors ask how the doctor reconciles his ‘legitimate’ (class emphasis) plans for an evening out with the needs of his patient. In discussion …

Another argument for values-based medicine

There is a contemporary dialectic concerning the status of evidence-based medicine, criticising it for being ‘scientistic’, epistemologically inconsistent, rigid and dismissive of non-numerical sources of knowledge. A host of alternative frameworks has been proposed, including values-based medicine, narrative medicine, patient-centered care and personcentered medicine. Person-centered medicine is amongst the most persuasive and well-argued models. Miles and Mezzich [1] have argued in a major article that person-centered medicine employs theories of personhood to elaborate and justify its epistemology and praxis. At the same time, they claim that person-centered medicine is an ‘emergent’ concept that needs no base or foundation to justify it. We believe, however, that without some foundational values to underpin the status claimed for personhood, the arguments for person-centered medicine are incomplete. We therefore propose a set of foundational values – survival, security and flourishing – that underpin individual and social functioning transculturally. While these values are the same in all cultures, their expressions differ from culture to culture. Importantly, our notion of values is only modestly foundational. Modest foundationalism recognises that foundational propositions are only ‘warrantable assertions’ that may very well change in time and place. Foundational values in this sense are pragmatic and heuristic in kind and not normative. We enter a plea for their recognition in the form of the values-based medicine we describe.

The slide to pragmatism: A values-based understanding of ‘dangerous’ personality disorders

This paper reports on a qualitative study of UK mental health practitioners’ experiences of working with the contested condition, dangerous and severe personality disorder (DSPD). Our interviews focused on the issues of treatability, risk assessment and decision-making in multi-disciplinary teams. We discuss the approach of values-based medicine (VBM) as a useful framework for interpreting the data: respondents cited both explicit values (based on occupational training) and implicit values (based on personal beliefs and subjective perceptions). There was evidence of conflicting values – within individuals, between occupational groups, and between individuals in occupational groups – which led to widespread uncertainty and caution about whether and how those with ‘dangerous’ personality disorders could be treated. These disputes were resolved by a ‘slide to pragmatism’, whereby practitioners, reluctantly acknowledging their own empowerment in the process, sought to make whichever choice was least risky for their own professional reputation, and most pragmatic, given the resources available.

Ethical aspects of personality disorders

To review recent literature around the controversial diagnosis of personality disorder, and to assess the ethical aspects of its status as a medical disorder. The diagnostic currency of personality disorder as a psychiatric/medical disorder has a longstanding history of ethical and social challenges through critiques of the medicalization of deviance. More recently controversies by reflexive physicians around the inclusion of the category in the forthcoming revisions of International Classification of Diseases and Diagnostic and Statistical Manual of Mental Disorders classifications reflect the problems of value-laden criteria, with the diagnostic category being severely challenged from within psychiatry as well as from without. The clinical diagnostic criteria for extremely value-laden psychiatric conditions such as personality disorder need to be analyzed through the lens of values-based medicine, as well as through clinical evidence, as the propensity for political and sociolegal appropriation of the categories can render their clinical and diagnostic value meaningless.

Knowledge and the Justification of Values in Values-Based Medicine

This paper critically evaluates central themes of values-based medicine (VBM). First, I discuss the 'non-descriptivist' conception of value judgments at the heart of VBM. According to it, no inferences can rationally be drawn from factual criteria to value judgments and the inferences that are naturally formed are a matter of human psychology. I argue, however, that it is an essential feature of value judgments that they are themselves subject to normative assessment. This implies an important role for an evaluatively rich notion of psychology. Second, I discuss the role of 'dissensus' in VBM and argue that, although value judgments need not converge, the processes for exploring conflicting values must, themselves, be normatively assessable. Third, I examine how these aspects interact in complex real cases such as the case study of Diane Abbot.

The Value of 'Value'

Values-based medicine derives from an approach first introduced into the philosophy of psychiatry, which aims to demonstrate that the reality of mental illness is not inconsistent with the scientific status of medicine. Associated primarily with the work of K.W.M. Fulford, the argument is that practitioners need to be ethical anti-descriptivists if they are to avoid the authoritarianism of evidence-based medicine, which overlooks the fact that genuine value conflicts can arise during all clinical encounters, and that psychiatry is just the most explicit area in which these occur. This paper takes a philosophically therapeutic line and argues that, by reducing values to the status of preferences, antidescriptivism undermines the value of 'value' and leaves the practitioner with a reduced ability to discern and negotiate genuine conflicts of value. The conclusion is that patients should be respected, not as instantiations of preferences but as valuers ; and that this requires practitioners to become more cosmopolitan and sympathetic, not more theoretically sophisticated.