Any properly conceived notion of health care will relate not only to facts (for example, I am breathing) but also to values (for example, it’s good to be alive). In our pluralistic world we have become scared of talking about our values and sought to retreat into facts, but this will not do. Medicine depends completely on judgements such as ‘state A is preferable to state B’, but such a statement requires values and can never be derived solely from facts. And it is here that science has a problem.
One cannot treat values in the same way as material objects. It was David Hume who first pointed out that values cannot be derived from facts. For example, Hume said that if you examine an action labelled as a vice you will not find the vice in the action itself, but only in the ‘sentiment of disapprobation which arises in you ’.
The role of facts is to define and understand the nature of our choices. We require values then to choose. So in an obvious case I prescribe amoxicillin to a patient with community-acquired pneumonia because I value the life of the patient above the life of the Strep. pneumoniae bacterium. Science cannot tell me which I should value most. Unfortunately most choices in medicine are not so easy.
Just to make things more complicated, while facts and values may well be different one cannot always make an absolute distinction between them. Consider the statement: ‘Torquemada was cruel.’ Am I proposing a factual claim, such as ‘torturing people is cruel’? Or am I passing an entirely subjective value-based judgement? Or, as RM Hare suggested, am I smuggling in a subjective judgement dressed up as if it were a fact? And if I am passing a value judgement rather than stating a fact, am I then saying that values are entirely subjective? Do they just depend on my preferences? If so, and if we feel that torturing people is wrong in our culture, would we be wrong to criticise it in another culture?
Values exist in the human world and not in the physical world itself. Facts and values in our human world, and therefore in our language, get entangled. Even though values cannot be derived from facts we cannot always separate them into two neat boxes. As Putnam asserts, it is generally best if we think of a fact/value distinction not a fact/ value dichotomy.
So how do values influence our use of facts in medicine? Aristotle first pointed to the need for values as well as science. As he put it:
‘... virtue makes us aim at the right mark, and practical wisdom makes us take the right means.’
Bill Fulford has pioneered a model of ‘values-based practice’. Fulford reminds us that human flourishing cannot be established from empirical observations of the material world only. Human flourishing can only be pursued by the use of values or value-laden concepts in bringing meaning to observable facts. Medicine needs values.
CPD further study and reflective notes
The notes in Boxes 1 and 2 will help you to read and reflect further on any of the brief articles in this series. If this learning relates to your professional development then you should put it in your annual PDP and claim self-certified CPD points within the RCGP guidelines set out at http://bit.ly/UT5Z3V.
Box 1. Reflective notes
What do you value most in your own life?
What do you value most in medicine?
How do we recognise and use patients’ particular values within the consultation?
Box 2. Further reading
Primary source: Fulford KWM, Peile E, Carroll H. Essential values-based practice. Clinical stories linking science with people. Cambridge: Cambridge University Press, 2012.
Further study: Putnam H. The collapse of the fact/value dichotomy and other essays. Cambridge (MA): Harvard University Press, 2002.
If your reading and reflection is occasional and opportunistic, claims in this one area should not exceed 10 CPD credits per year. However if you decide to use this material to develop your understanding of medical philosophy and ethics as a significant part of a PDP, say over 2 years, then a larger number of credits can be claimed so long as there is evidence of balance over a 5-year cycle. These credits should demonstrate the impact of your reflection on your practice (for example, by way of case studies or other evidence), and must be validated by your appraiser.
- © British Journal of General Practice 2014
