Abstract
Values-Based Medicine (VBM) is the theory and practice of clinical decision-making for situations in which legitimately different values are in play. VBM is thus to values what Evidence-Based Medicine (EBM) is to facts. The theoretical basis of VBM is a branch of analytic philosophy called philosophical value theory. As a set of practical tools, VBM has been developed to meet the challenges of value diversity as they arise particularly in psychiatry. These challenges are illustrated in this paper by a case study of the differential diagnosis between delusion and religious experience. In a traditional model of scientific medicine, such challenges would be expected to become less pressing with advances in medical science. Philosophical value theory suggests, to the contrary, that scientific progress, through opening up an ever-wider range of choices, will increasingly bring the full range and diversity of human values into play not just in psychiatry but in all areas of medicine. The future, then, for medicine, is an integrated model in which VBM and EBM are equal partners in a genuinelyhuman discipline.
Zusammenfassung
Values-Based Medicine (VBM), eine Medizin, die auf Werte gegründet ist, ist die Theorie und Praxis klinischer Entscheidungsfindung in Situationen, wo Werte ins Spiel kommen, die aus guten Gründen voneinander abweichen. VBM ist also im Verhältnis zu Werten, was Evidence-Based Medicine (EBM) im Verhältnis zu Fakten ist. VBM hat ihre theoretische Basis in einem Zweig der analytischen Philosophie, der so genannten philosophischen Wertetheorie. VBM wurde als ein praktisches Instrumentarium entwickelt, den Herausforderungen gerecht zu werden, vor die uns besagte Wertevielfalt stellt, besonders in der Psychiatrie. Diese Herausforderungen illustrieren wir in diesem Beitrag anhand einer Fallstudie über die differentielle Diagnose von Wahnvorstellungen und religiöser Erfahrung. In einem traditionellen Modell wissenschaftlicher Medizin würde man erwarten, solche Herausforderungen würden durch Fortschritte in den medizinischen Wissenschaften allmählich abgebaut werden. Dagegen deutet die philosophische Wertetheorie darauf hin, dass wissenschaftlicher Fortschritt das Spektrum der Möglichkeiten zwar immer mehr erweitert, dabei jedoch zunehmend die ganze Breite und Vielfalt menschlicher Werte ins Spiel bringen wird, nicht nur in der Psychiatrie, sondern in allen Bereichen der Medizin. Die Zukunft der Medizin liegt also in einem integrierten Modell, in dem VBM und EBM gleichwertige Partner in einer wirklichen Humanwissenschaft sind.
Résumé
La médecine basée sur les valeurs (VBM, values based medicine) est une théorie et une pratique de prise de décision médicale dans des situations faisant intervenir de façon légitime différentes valeurs. La VBM est aux valeurs ce que la médecine basée sur les faits (EBM, Evidence based medicine) est aux faits concrets. La base théorique de la VBM est une branche de la philosophie analytique appelée Théorie des valeurs philosophiques. La VBM a été développée comme jeu d’instruments pratiques pour venir à bout de la diversité des valeurs telles qu’elle survient en particulier dans le domaine de la psychiatrie. Ces défis sont illustrés dans le présent article par une étude de cas sur les différences de diagnostic entre l’illusion et l’expérience religieuse. Dans le modèle traditionnel de la médecine scientifique, on pourrait s’attendre à ce que ces questions deviennent moins pressantes à mesure que la science médicale progresse. La théorie des valeurs philosophiques suggère au contraire que le progrès scientifique, bien qu’il ouvre un éventail toujours plus important de possibilités, fera de plus en plus intervenir toute la gamme et toute la diversité des valeurs humaines, non seulement dans la psychiatrie, mais dans tous les domaines médicaux. Ainsi l’avenir de la médecine réside-t-il dans un modèle intégré considérant la VBM et l’EBM comme les partenaires égaux d’une discipline éminemment humaine.
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Notes
Recent research shows that delusional perceptions and other symptoms originally thought to be pathognomonic of schizophrenia may occur in other psychotic conditions. Psychiatry differentiates these conditions by related features, e.g., dementia by impaired memory etc.; mania by elevated mood, flight of ideas, etc. Simon’s story makes an excellent test case for differential diagnosis with trainee psychiatrists!
Simon also had another relevant symptom from the ICD list called “thought insertion”. For a more complete version of Simon’s case history see Jackson and Fulford (1997).
Kendell (who sadly died recently) wrote his 1975 paper as a direct rejoinder to Szasz’s sceptical attack on the concept of mental illness. He took his definition of disease from work in respiratory medicine (Campbell et al. 1979); the “biological dysfunction” approach was developed further by the American philosopher, Christopher Boorse (1975), drawing on the distinction between disease and illness, and applying it to mental illness (Boorse 1976). Boorse has subsequently presented a more detailed account of his model (Boorse 1997). The American social worker and philosopher, Jerome Wakefield, has produced a spirited defence of this model with DSM particularly in mind. For recent philosophical moves in this debate, including articles by Szasz, Wakefield and Fulford, also Chris Megone and Tim Thornton, see a special issue of the journal Philosophy, Psychiatry, and Psychology (March 2001).
I develop the details of the arguments supporting this interpretation from philosophical value theory in Fulford (1990). This includes an analysis of the relationship between the patient’s experience of illness and medical knowledge of the causes of disease, and a detailed account of the applications of philosophical value theory to particular kinds of psychopathology. I extend the theory in Fulford (1999, 2000b). The fact/value, or description/evaluation, distinction continues to come under attack in a debate stretching back at least as far as the eighteenth century British Empiricist philosopher, David Hume (Putnam 2002). The applications of philosophical value theory to our understanding of the “language of medicine” are (largely) independent of the position taken on the issue at the heart of this debate, viz., as to whether the distinction can be driven all the way back, to “pure” facts/descriptions and “pure” values/evaluations. For a contribution from the philosophy of psychiatry to the debate, via the phenomenology of delusion, see Fulford (1998, 1991).
Some of those most directly concerned with the development of EBM have emphasised the importance, alongside explicit evidence, not only of implicit knowledge (based on experience) but also of patient’s values in clinical decision-making. Sacket et al. (1997) emphasise that all three have to come together if we are to establish a “new alliance” between patients and professionals in healthcare. Nonetheless, the practice of EBM has thus far been almost exclusively concerned with explicit evidence.
EBM and VBM are thus a good deal closer than the traditional stand-off between science and values might suggest. There are also differences, of course. A key difference is that where EBM is based on objective knowledge, VBM is based on subjective understanding. The aim of science, as the American philosopher Thomas Nagel put it, is a view from nowhere (Nagel 1986). This is its strength. It is also the justification for placing meta-analyses of RCTs at the top of the “evidence hierarchy” in EBM (Straus 1999). Such meta-analyses, in seeking a view from everywhere, hope to approximate to the view from nowhere! But VBM, in being concerned with human values, aims to get as close as possible to the particular value perspectives of those concerned in a given situation. Again, there is no conflict here. The aperspectival ambitions of EBM and the perspectival ambitions of VBM provide complementary resources for clinical decision-making. In their differences, then, as in their similarities, VBM and EBM are partners in clinical decision-making.
Many philosophers, as previously noted, have attacked the very distinction between fact and value. A particular criticism of philosophical value theory, as exemplified by the work of R.M. Hare, is that it is impotent practically (e.g. Williams 1985). Medicine shows this criticism to be misplaced. Like mathematics, philosophical value theory, just in being an analytic discipline, has to be applied in a practical context if it is to have practical effect. But also like mathematics, it is its status as an analytic discipline that makes it a particularly effective tool when it is so applied.
References
American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders, 4th edn. American Psychiatric Association, Washington, DC
Andreasen NC (2001) Brave new brain: conquering mental illness in the era of the genome. Oxford University Press, Oxford
Bloch S, Reddaway P (1997) Russia’s political hospitals: the abuse of psychiatry in the Soviet Union. Gollancz, London
Boorse C (1975) On the distinction between disease and illness. Philos Public Aff 5:49–68
Boorse C (1976) Wright on functions. Philos Rev 85:70–86
Boorse C (1997) A rebuttal on health. In: Humber JM, Almeder RF (eds) What is Disease? Humana, Totowa, New Jersey
Campbell EJ, Scadding JG, Roberts RS (1979) The concept of disease. Brit Med J 2:757–762
Colombo A, Bendelow G, Fulford KWM, Williams S (2003) Evaluating the influence of implicit models of mental disorder on processes of shared decision making within community-based multi-disciplinary teams. Soc Sci Med 56:1557–1570
Dickenson D, Fulford KWM (2000) Thinking skills: ethical reasoning and problem solving in psychiatric ethics. In: Two minds: a casebook of psychiatric ethics. Oxford University Press, Oxford
Fulford KWM (1990) Moral theory and medical practice. Cambridge University Press, Cambridge
Fulford KWM (1991) Evaluative delusions: their significance for philosophy and psychiatry. In: Supplement 14, delusions and awareness of reality. Brit J Psychiat 159:108–112
Fulford KWM (1998) Mental illness (concept of). In: Chadwick R (ed) Encylopedia of applied ethics. vol 3. Academic, San Diego, pp 213–233
Fulford KWM (1999) Nine variations and a coda on the theme of an evolutionary definition of dysfunction. J Abnorm Psychol 108(3):412–420
Fulford KWM (2000a) Philosophy meets psychiatry in the twentieth century—four looks back and a brief look forward. In: Louhiala P, Stenman S (eds) Philosophy meets medicine. Helsinki University Press, Helsinki, p 114–131
Fulford KWM (2000b) Teleology without tears: naturalism, neo-naturalism and evaluationism in the analysis of function statements in biology (and a bet on the twenty-first century). Philos Psychiat Psychol 7(1):77–94
Fulford KWM (2004) Ten principles of values-based medicine. In: Radden J (ed) Companion to the philosophy of psychiatry. Oxford University Press, New York (in press)
Fulford KWM, Benington J (2004) VBM2: a collaborative values-based model of healthcare decision-making combining medical and management perspectives. In: Williams G (ed) Medical and management perspectives in child and adolescent psychiatry. Oxford University Press, Oxford (in press)
Fulford KWM, Bloch S (2000) Psychiatric ethics: codes, concepts, and clinical practice skills. In: Gelder M, Lopez-Ibor JJ, Andreasen N (eds) New Oxford textbook of psychiatry. Oxford University Press, Oxford, pp 27–32
Fulford KWM, Dickenson D, Murray TH (eds) (2002) Healthcare ethics and human values: an introductory text with readings and case studies. Blackwell, Malden, USA
Fulford KWM, Williamson T, Woodbridge K (2002) Values-added practice (a values-awareness workshop). Mental Health Today, October, pp 25–27
Fulford KWM, Morris KJ, Sadler JZ, Stanghellini G (2003) Past improbable, future possible: the renaissance in philosophy and psychiatry. In: Fulford KWM, Morris KJ, Sadler JZ, Stanghellini G (eds) Nature and narrative: an introduction to the new philosophy of psychiatry. Oxford University Press, Oxford
Hare RM (1952) The language of morals. Oxford University Press, Oxford
Hope T, Fulford KWM, Yates A (1996) The Oxford practice skills course: ethics, law and communication skills in health care education. Oxford University Press, Oxford
Human Rights Watch/Geneva Initiative on Psychiatry (2002) Dangerous minds: political psychiatry in China today and its origins in the Mao era. Human Rights Watch, New York
Jackson MC (1991) A study of the relationship between spiritual and psychotic experience. Dissertation, Oxford University
Jackson MC (1997) Benign schizotypy? The case of spiritual experience. In: Claridge GS (ed) Schizotypy: relations to illness and health. Oxford University Press, Oxford
Jackson M, Fulford KWM (1997) Spiritual experience and psychopathology. Philos Psychiat Psychol 4:41–90
Kendell RE (1975) The role of diagnosis in psychiatry. Blackwell, Oxford
Nagel T (1986) The view from nowhere. Oxford University Press, Oxford
Philos Psychiat Psychol (2001) Philos Psychiat Psychol 7(1)
Putnam H (2002) The collapse of the fact/value dichotomy and other essays. Harvard University Press, Cambridge, Mass
Sacket et al (1997) Evidence-based medicine: how to practice and teach EBM. Churchill Livingstone, London
Sims A (1997) Commentary on “spiritual experience and psychopathology”. Philos Psychiat Psychol 4(1):79–82
Straus SE, McQuay HJ, Moore RA, Sackett DL (1999) A proposed patient-centred method of delivering information about the risks and benefits of therapy: the likelihood of being helped versus harmed. J Int Clin Psychopharmacol (Full) ID:2966
Szasz TS (1960) The myth of mental illness. American Psychologist 15:113–118
Warnock GJ (1971) The object of morality. Methuen, London
Williams B (1985) Ethics and the limits of philosophy. Fontana, London
Wing JK, Cooper JE, Sartorius N (1974) Measurement and classification of psychiatric symptoms. Cambridge University Press, Cambridge
World Health Organisation (1992) The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. World Health Organisation, Geneva
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Fulford, K.(. Neuro-ethics or neuro-values? Delusion and religious experience as a case study in values-based medicine. Poiesis Prax 2, 297–313 (2004). https://doi.org/10.1007/s10202-004-0061-x
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DOI: https://doi.org/10.1007/s10202-004-0061-x