By Bill (KWM) Fulford, Fellow of St Catherine’s College and Member of the Philosophy Faculty, University of Oxford, Emeritus Professor of Philosophy and Mental Health, University of Warwick, and Director of The Collaborating Centre for Values-based Practice, St Catherine’s College, Oxford.
In their use of conjunction – Markets and Meaning – Joshua Hordern and Andrew Papanikitas directly challenged us to face up to the complexity of the values driving the NHS.
The challenge is timely. Debate around the growing role of market forces in UK healthcare has all too often been narrowly adversarial, a markets or meaning debate reflecting the ‘my values right or wrong’ polarities of values monism. The challenge of the conjunctive ‘markets and meaning’ is, rather, what the moral and political philosopher Isaiah Berlin (1958) identified as the challenge of pluralism.
Values pluralism is what values-based practice is all about. Derived from mid-twentieth century Oxford analytic philosophical work on the logic (the meanings and implications) of value terms (Fulford, 1989), values-based practice starts from a premise of mutual respect and relies on good process (based on learnable clinical skills) rather than pre-set right outcomes, to support balanced decision making where complex and conflicting values are in play (Fulford, Peile and Carroll, 2012). Developed thus far most extensively in mental health, Ashok Handa (Tutor for Surgery in Oxford) and I have recently launched The Collaborating Centre for Values-based Practice at St Catherine’s College with the aim of extending values-based approaches into other areas of health and social care (see valuesbasedpractice.org).
There was much of values-based practice in Hordern and Papanikitas’ Markets and Meaning programme. Both their initial workshop in Oxford and the subsequent conference at the RSM benefitted from meticulous planning reflecting the values of positive care that values-based practice among other ways of working with values seeks to support. Both meetings were also effectively chaired to sustain an ethos of mutual respect consistent with the premise of values-based practice.
The outcomes of the programme, too, reflecting the way its constituent meetings were organized and chaired, were in important respects values-based. Among other distinctively values-based outcomes, delegates came away with a raised awareness of the range and complexity of the values bearing on contemporary healthcare practice; a recognition that different, even conflicting, stakeholder values, far from reflecting a failure of moral reasoning could be the basis for balanced decision making where values conflict; and an understanding that good process (as in commissioning) rather than prior convictions may be the key to striking the required balance in practice.
It is of course one thing to engage in values-based pluralistic thinking in a meeting and quite another to carry that thinking through into policy and practice. We should be clear about the difficulties here. Isaiah Berlin (above), while emphasizing the dangers of values monism, was pessimistic about the prospects for pluralism: it is in our very natures as human beings, he pointed out, to crave the certainties of values monism. Values-based practice moreover, as a resource for pluralistic thinking, has been focused, as the philosopher Sridhar Venkatapuram has pointed out (2014), mainly at the level of clinician-patient decision-making rather than at the population level where markets and meanings coincide. So all-in-all the odds are stacked against us!
In the announcement for their RSM meeting Hordern and Papanikitas say they have funding to extend their work if ‘there is sufficient reason to pursue a second year of the project’. I hope they will find ‘sufficient reason’ in the pluralism realized so effectively against the odds in their values-based Markets and Meaning programme.
References
Berlin, I., (1958) Two Concepts of Liberty. Oxford: Clarendon Press.
Fulford, K.W.M. (1989) Moral Theory and Medical Practice. Cambridge: Cambridge University Press.
Fulford, K.W.M., Peile, E., and Carroll, H (2012) Essential Values-based Practice: clinical stories linking science with people. Cambridge: Cambridge University Press
Venkatapuram, S. (2014) Values-Based Practice and global health. Chapter 11 in Loughlin, M (Ed) Debates in Values-based Practice: arguments for and against. Cambridge: Cambridge University Press
