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Values are those things that we ﬁnd valuable or are able to ﬁnd value in. From the earliest times, medicine and health care have been fundamentally concerned about, and permeated by, values. Philosophers have classiﬁed values in a range of ways, but there is some agreement that we can hold values which are to do with liking (subjective values) and with usefulness (instrumental values). Rather more controversially, some have proposed a class of values that are intrinsic (values which are independent of notions of liking or use). Values are acquired in multiple ways, and one of the fundamental purposes of health care professional training is the instilling of values. This is likely to result in differences between the values of medical and health care professionals on the one hand and the public that they seek to serve on the other. This difference is played out and raises difﬁculties in both the purpose and practice of medicine and health care.
Values lie at the heart of the medical and health care enterprise and reactions to its successes and failures (Kennedy 1981). Doctors and other health care professionals possess and are encouraged to develop particular values: patients bring their own sets of values to consultation and treatment; wider society has values-based expectations of medical and health care systems expressed through mechanisms of policy making and governance.
Values in medicine and health care have a long provenance. While conceptions of what is valuable change over time (Jonsen 2000), those interested in exploring the nature and form of values in health care are faced with an enduring complexity. What do we ﬁnd valuable and why? Are my conceptions about what is of value different to yours, and if so for what reason? Is there a particular value or set of values that are (or ought to be) present in the practice of health care and medicine? If so, what is its nature? If not, what are the implications for those who have an interest (whether as practitioners, patients, or concerned onlookers) in these ﬁelds?
The Historical Development Of Values In Medicine, Medical Ethics, And Bioethics
In the West, the beginning of medical practice, and medical ethics, is often associated with the Hellenic period. Hippocrates (from about 460 BCE to 370 BCE) has his favor as the “founding father of healers” accredited to him partly because of his expression of medicine’s values involving at least in part the avoidance of harm and the production of beneﬁt (Bynum 2008, p. 5).
During the Middle Ages, treating the sick and caring for the poor and needy became an expression of piety in both the East and West, a symbol of grounding religious belief in a real and demanding world. This is visible through examination, for example, of Buddhist and Christian traditions. Thus the actions of treatment and caring embodied the values of these and other religious traditions. Indeed, in an important way the value of health became a direct manifestation of goodness in the world, and disease and illness appeared as demonstrations of worldly corruption and sin (Thomas 1997).
The central place of values in understanding what it is that those involved in health care are seeking, and how they should conduct their search, continued into the eighteenth and nineteenth centuries, and the phase of exponential scientiﬁc discovery presaged by the Enlightenment. The rapid development of pathology during this period can be understood in part as an ethical enterprise rooted in values. For example, tuberculosis (TB), endemic in the nineteenth century, and its causative pathogen – the tubercle bacillus – were seen as possessing moral signiﬁcance; the ﬁght against TB was a crusade, at the heart of which were values (Tomes 1997).
The arrival of the twentieth century, and the growing sense of ambivalence and even concern about the power of medicine and the exercise of medical practice, led to the gradual transformation of medical ethics into the new ﬁeld of bioethics. This was partly because of a belief that bioethics would provide a more robust challenge to medical power and control (Jonsen 2000). Yet still, at the heart of this relatively new project, and the broad ﬁeld of human endeavor that it attempts to scrutinize, lie values central to humanity, and understanding what it is to be human: health itself, of course, but also values such as freedom, autonomy, respect, beneﬁt, caring, and a wide range of others.
Values: Definition And Clarification
Values are those things that we ﬁnd valuable or are able to ﬁnd value in. Such a broad deﬁnition, however, is not of enormous help, at least partly because it is clear that we ascribe different degrees of importance to the range of things that each of us ﬁnds to be of value. Thus philosophers have been concerned to describe and analyze the nature of values much more carefully.
It is generally agreed that some of the values we hold are values of liking or preference, while others are more fundamental and constitute what might be called necessary values (Downie et al. 1996). Someone might prefer (value), for example, the color green, while another person might have a preference for red. Green and red may become more than values of preference if they are associated with what we might well consider to be the necessary value of driving carefully and with respect for the Rules of the Road. We are required, among these rules, to stop at red lights and move off when they change to green. Thus in this context red and green represent a value that is necessary, instead of simply being colors to which we might attach a value of preference.
We may well want to argue that, as opposed to the value of preference, the necessary value is something that should be widely shared and therefore become a necessary social value (Downie et al. 1996). On the other hand, it might be thought strange if someone were to argue for a value of preference being widely shared by others. (Although of course this might incidentally be the case.) Broadly, then, we could suggest that values of preference may or may not have wide social relevance: while necessary values clearly should have such relevance.
However, this conclusion yields a difﬁculty in that it provides little ground for asserting which particular values ought to be elevated to the status of necessary. Here, a slightly more detailed tripartite classiﬁcation of values could be considered to be helpful. Among others, Dworkin (1995) argues that values can be subjective: instrumental: and intrinsic. Subjective values correspond to values of liking or preference identiﬁed above. But the notion of instrumental and intrinsic value begins to develop conceptions of why certain things hold value for us.
Again according to Dworkin and others, instrumental values are those things that we ﬁnd valuable because they possess utility. Of course, it is possible through careful thinking to identify why someone holds a certain thing as valuable in a liking or subjective sense. A train enthusiast, for example, could possibly explain their affection in terms of the aesthetic experience of gazing at the beauty of steam engines, or the intricate design of railway systems, which might appeal to their sense of, and preference for, design and order. But someone who merely travels on trains – a daily commuter, say – is most likely to identify the railway system as something that has instrumental value because it holds usefulness for her. (It gets her to or from work.)
Finally, intrinsic values are those things that we ﬁnd valuable beyond conceptions of subjective preference, or utility; they are things that we hold valuable for their own sake. These are the sorts of values that, if we hold them, we would most likely want others to do so as well. Thus they may well assume a normative character and importance. An example of a value that might possibly be intrinsic is freedom. (The qualiﬁcation is present here because, as will be described later in this research paper, there has been some debate in the ﬁeld of applied ethics about the realism of constructing a class of values deemed to be intrinsic.)
As the example above demonstrates, this means of describing values, of making divisions into the subjective, instrumental, and intrinsically valuable, should not be taken to imply completely discrete classiﬁcations (Dworkin 1995). It is possible to imagine a person holding something as valuable because they like that thing, it has utility for them, and (arguably) it can be divorced from thoughts of preference or use. Freedom, say, is something that, if its holder stops to think about it, they will ﬁnd that they like (on most occasions it may simply seem odd if we were to believe otherwise), that is useful to them (it enables them to function and achieve their purposes in the world), and that they cannot reduce solely to these kinds of conceptions and would want others to possess in equal measure (at least if they are reﬂectively and compassionately human).
The Acquisition Of Values
Values are acquired in a range of ways and from a variety of sources. Their acquisition involves a complex interplay between the individual and their context (Green and Tones 2010). The nature of the values that individuals acquire and possess depends not only on who they are but how they have been formed: by their culture, social class, family background and education, among other things. Moreover, both individuals and the world around them are constantly changing (e.g., people age), meaning that the values they possess may alter over time. There is now a wide international literature, much of it empirically based, that charts conceptions of health and related issues on the part of people and communities from a range of different contexts and cultures. This literature can in part be understood as description of the health and health-related values of so-called lay people.
It therefore follows that different people possess different values (or at least different conceptions of a particular value) (Seedhouse 2001). Given the nature of values acquisition, it can also be said that because health care professionals undergo a very particular and distinctive formation, the values that they possess will be equally distinctive. Indeed, one of the functions of health care professional education is to instill the values of that profession (say, medicine) into the character and persona of the individual seeking to enter it (Becker et al. 1977).
This process of values acquisition on the part of health care professionals in training is complex and involves a frequently highly subtle interplay between what is formally taught through the curriculum and informal methods of initiation and socialization. The net result is that after having undergone training to become a doctor, for example, the person concerned is capable both of doing the job (having acquired the necessary knowledge and understanding) and of holding and demonstrating, even if not explicitly, the values associated with that job, and the sort of person who does it. The two things are enmeshed with each other. A doctor, say, both holds a body of medical knowledge and expertise and at the same time regards these things as fundamentally valuable, to be protected and promulgated.
The arduousness and distinctiveness of the process of values acquisition through health care professional education ensures that the values of the profession concerned are upheld and very strongly embedded in that particular professional culture. This process and its outcomes also make it very likely that the values of the professional on the one hand and the values of the “lay” person on the other will be different, at least in some respects.
Health Care And The Public-Professional Values Gap
Differences in the type and nature of values held by health care professionals and the people who they serve are therefore inevitable. In much day-to-day health care, these differences can be negotiated and managed. However, this daily management and negotiation sometimes falters or even fails. It does so in two different kinds of ways: one dramatic but nevertheless relatively rare, the other more constant and pervasive.
Health Care “Scandals” And The Public-Professional Values Gap
The gap in values between health care professionals and the public they are supposedly seeking to serve is exposed dramatically in the cases of so-called health care scandals. The origins and nature of such “scandals” are highly variable and range from individual malpractice to systemic failure (Stanley and Manthorpe 2004). At their heart, however, they frequently feature a gap in perception between practitioners on the one hand and patients on the other about what is deemed to be valuable. This gap can often be traced to a belief that the values of the profession (say, the value of professional knowledge) should, above all else, be unquestioningly protected. The Bristol Heart Babies, an eventually highly publicized case that unfolded at the Bristol Royal Inﬁrmary in the United Kingdom (UK) during the 1990s, essentially arose because the doctors concerned were not prepared to admit to the failures of the procedures that they were using, even though the mortality rates of the babies and very young children that they were operating on and caring for were far higher than they should have been (Kennedy 2001).
Bristol is just one demonstration of the power of professional values and how badly their enactment in practice can go wrong. “Scandals” in health care are a global phenomenon. When they emerge, they (rightly) receive signiﬁcant levels of attention and sometimes have impact in terms of the ways in which professional values are promulgated and maintained. This impact is often demonstrated through attempts somehow to make those who hold such values more “accountable.” (The Bristol Heart Babies case, e.g., led to changes in the way that doctors’ practice was regulated in the UK, with a shift to some extent from self-regulation to scrutiny of the profession by “outsiders.”) To this extent, the exposure of “scandals” and the inquiries and actions that inevitably result are an important part of the social construction and reconstruction of values.
The Public-Professional Values Gap And Conceptions Of “Health”
Somewhat less noticed but much more frequent and ultimately having a signiﬁcantly greater degree of pervasiveness is the gap in orientation between health care professionals and their public around what is arguably the central value of health care, namely, health itself.
From the deﬁnitions and clariﬁcation already presented in this research paper, “health” can be understood as possessing both subjective and instrumental value (Seedhouse 2001). Some people pursue health (perhaps in the sense of physical activity and participation in sports) because they like to do so. Most people – the great majority – like being healthy and have a subjective preference for avoiding illness. (There would perhaps be a morbid curiosity on the part of many about those who did not, although the hypochondriac is not an uncommon phenomenon, and there are certain kinds of more acute mental health problems where illness is welcomed.) Equally, most people can see that being healthy holds utility for them in that it allows them to get on with their lives, make a living, and so on. It is these kinds of subjective and instrumental conceptions of the value of health that pervade many “lay” accounts of health and illness (Green and Tones 2010).
Practitioners and policy makers, especially in the areas of health promotion and public health, also have a tendency to think of health as an intrinsic value (Downie et al. 1996). In these kinds of accounts of health, while the value is not necessarily seen as an end in itself (although it sometimes appears that this is the case), it is certainly viewed as an overriding imperative toward which those involved in health care must somehow ceaselessly work. Notions of subjectivity and use thus become less important than the fundamental value of health. While such conceptions are not uncommon among those professionally involved in health, “lay” accounts of health, as has been indicated, tend much more toward the pragmatic.
“Health” As An Intrinsic Value?
The difﬁculty with this gap between professional and “lay” conceptions of the value of health, with the former perhaps often viewing “health” as somehow intrinsic, is twofold. In the ﬁrst place, professionals may be making a mistake in believing that there is indeed a class of values that can be labeled “intrinsic” and into which the value of health would fall. In the second place, this mistaken classiﬁcation leads to problems of intention and action on the part of health care professionals.
With regard to the ﬁrst of these two difﬁculties, philosophers in particular have tried, but struggled, to determine what would be the basis for such a class of values. Some have argued that the class comprises those values we can recognize as fundamental from an impersonal or objective point of view (Williams 2002). Others have suggested that intrinsic values are those that, if we consider them, form the basis for the kind of life that is worth living (Audi 2004).
There is a signiﬁcant contrast between the ﬁrst, “general recognition” argument, and the second, “experience of worthwhile living,” one. General recognition of the existence and importance of intrinsic value depends on an impersonal view of the nature of the world, the values it contains, and which of these should be promulgated. An individual need not have direct experience of the value or lack of it in order to determine its worth and believe that it should be promoted. On the other hand, if someone were to believe that a value was intrinsic because it was one of the things that formed the basis of worthwhile living, then they must (even if simply by proxy) have had experience of that value. This contrast between the two arguments suggests that while they might mingle and coalesce in the empirical world, as theoretical arguments they are separate.
However, the difﬁculty is that neither is especially convincing in identifying what things might actually constitute an intrinsic value (that is to say, the kinds of things that actually have such value, a value irreducible to thoughts of preference or use). An individual might hold that the value of health is fundamental in the “general, impersonal recognition” sense, but it is hard to see how they could do so without reference to, especially, a sense of the use of health in their beliefs. Even more so, the “experience of worthwhile living” argument for the existence of intrinsic value cannot be conducted without a sense that there has to be purpose (utility) in the experience of health.
To imagine in relation to either argument that it leads to divorce from use or preference leads to difﬁculty in understanding the place of health in the world. Health is not a value that is simply there, an immutable presence. It is instead a value that is present in greater or lesser degrees and is lost or preserved or increased through human work and endeavor, and in any case its nature is contested and disputed. This actual state of affairs in the empirical world moves inquiry back to the idea that a general, and generally accepted, class of values that should be seen as intrinsic is hard to arrive at and that viewing the contested value of health as one of a class that in any case is difﬁcult to derive is problematic.
Some involved in applied ethics have expressed anxiety about the problems involved in constructing and justifying a class of values that could be viewed as intrinsic (Baird-Callicott 2005). The assertion here is that there must be values that are more than simply things of use or preference, because our intuitive humanity believes this to be so. One does not, for example, see the value of one’s family wholly in terms of liking their company, or the useful social support that they provide. But perhaps, as Baird-Callicott (2005) argues, this is where the proper nature of intrinsic values lies; they are those things that, for us, outstrip preference or use.
This leads to the second problem related to the gap between “lay” and professional conceptions of the nature of health as a value. This problem emerges from the intentions and actions of health care policy makers and professionals. The tendency of such people to see health as an intrinsic value, something that those involved in the health care ﬁeld should be striving to increase simply because it is so fundamentally important and beyond considerations of preference or utility, has led to particular kinds of declarations and action (especially with regard to public health).
These actions and declarations are based on the premise that health should be pursued as an overall social objective with little (or even no) reference to the circumstances of particular individuals, communities, or populations; health is simply something that is worth pursuing and promoting just because it is an intrinsic value (Downie et al. 1996).
The difﬁculty with this kind of direction on the part of policy makers and health care professionals stems directly from the problems that philosophers have had in constructing a class of values believed to be intrinsic. If “general, impersonal recognition” and “experience of worthwhile living” arguments for the nature of a putative class of values fall away, what is left is that it is comprised of those things that, after all due consideration, outstrip (for the individual) thoughts of liking or use. Yet exactly what these kinds of values are cannot be prescribed or predicted; judgments on their nature have to be arrived at by the person concerned.
The implication of this is that for some, “health” may have the appearance of intrinsic value, while for others it may not. Much depends on individual circumstances, beliefs, and purposes – the kinds of things that have been described above as being the powerful formulators of conceptions of health and its value in the ﬁrst place. So health only has intrinsic value if that is how it is formed and held by individuals. With regard to the general question of the gap between the separate conceptions held by “lay” people on the one hand and by health care professionals on the other, about the nature of health and health care-related values, this causes the emergence of a particular difﬁculty. The problem is that if appraisal of health or a health care-related value as having intrinsic value lies with the individual, there can be no possibility of the pursuit and promotion of health being an overriding social objective. This kind of intention and direction might only be possible if such values were intrinsic in ways proposed by the “impersonal recognition” and “worthwhile living” arguments described. Philosophers consistently run into trouble with these kinds of arguments for the nature of intrinsic value.
This research paper has described the historical development of values in medicine and health care. Such development is best understood as having been integral to and enmeshed within these practices, and consideration of the practices, from the earliest times. Values have been deﬁned and described. In particular, distinction and clariﬁcation has been drawn between values that are about preference (liking or subjective values), instrumental values (values of use or utility), and intrinsic values. The acquisition of values has been described. Values are acquired in multiple ways from a range of different sources, as well as changing and developing over time. Because of this, health care professionals are bound to acquire and possess a set of “professional values” that are different, at least to some degree, from the values of the “lay” public that they seek to serve.
There is then at the very least the potential for a “gap” between the values of health care professionals (and policy makers) and “lay” people. This manifests itself relatively infrequently in the emergence of health care “scandals.” But it also appears more consistently and pervasively in everyday health care policy and practice, especially in the ﬁeld of public health. The tendency of professionals and policy makers to conceive (even if not explicitly) of health as an intrinsic value is problematic. This is partly because it is hard to construct and argue for a class of such values in the ﬁrst place and partly because the only reasonable ways of understanding both the nature of intrinsic value and the nature of health as a value militate against the notion of health possessing value in an intrinsic sense.
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