Evidence-based practice, realism, person-centered care, decision support tools, abuses of psychiatry
I am grateful to Tim Thornton and John Sadler for the opportunity to provide a brief coda on values-based practice to this special issue of Philosophy, Psychiatry, & Psychology.
The papers collected here represent an important contribution to the rapidly expanding literature on values-based and evidence-based approaches and I cannot do justice to them individually. Rather, I want to focus on a theme that runs through the collection as a whole, namely that in contrast with evidence-based practice, values-based practice is, in a word, 'anti-realist.' The implication is that this is a limitation of the approach. I want to suggest, by contrast, that it goes to the very heart of what is significant about values-based practice both theoretically, and, perhaps still more important, practically.
Realism takes many forms philosophically: It is evident in this collection, in particular, in various references to cognitivism. So understood, then, realism about values amounts to the substantive claim that I can 'know what is right' in much the same sense that I can 'know what is yellow.' Correspondingly, the anti-realism of values-based practice stems directly from its origins in analytic philosophy, specifically the mid-twentieth century Oxford School of linguistic analytic philosophy as exemplified by the work of J. L. Austin (1956/7), R. M. Hare (1952, 1963) and G. J. Warnock (1971). Values-based practice, like the Oxford School, is anti-realist to the extent that it is analytic rather than substantive in orientation. Values-based practice is also anti-realist to the further extent that, following the Hare line rather than that of Warnock, it maintains the logical separation of description and evaluation. In the latter respect, it is important to add, the theory of values-based practice depends only on there being, as Hilary Putnam (2002) has put it, a distinction rather than an out-and-out dichotomy between description and evaluation.
Among other schools of analytic philosophy, a particular virtue of the Oxford School is its focus on ordinary language. Much criticized by some, this is just the focus that is required for philosophical work in a practical discipline like psychiatry—it is within the ordinary language use of everyday practice in mental health and social care that the many practical difficulties arising from such concepts as that of mental disorder arise (Fulford 1990). Notwithstanding, therefore, its [End Page 183] analytic rather than substantive underlying theory, values-based practice, in being derived from work in the Oxford School, is exactly where 'the action is at,' so to speak.
This is one reason, then, why values-based practice, as a new approach to working with complex and conflicting values, offers a really practical approach as a partner to evidence-based practice in psychiatry. Neither approach gives answers as such, both being about good process rather than pre-judged right outcomes. Evidence-based practice gives us a process for factoring complex and conflicting evidence into medical decision-making; values-based practice gives us a different but fully complementary process for factoring complex and conflicting values into medical decision-making. (Fulford, forthcoming)
The Oxford School takes us further, however. Warnock (1989), in his philosophical biography of Austin, notes that it was always Austin's intention that linguistic analysis should work in partnership with empirical disciplines including, by implication, evidence-based practice. Sadly, Austin died relatively young, but we have carried this idea forward in the development of values-based practice. Thus, a key early research program in the development of values-based practice brought together the analytic work on values and models of disorder in my Moral Theory and Medical Practice (Fulford 1989) with the empirical studies of the social scientist, Anthony Colombo (Colombo et al., 2003; Fulford and Colombo, 2004). Similarly, early developments in training (as in the training manual Whose Values? [Woodbridge and Fulford, 2004]), in policy (the NIMHE Values Framework [available from: http://www.nimhe.csip.org.uk/silo/files/nimhe-values-frameworkpdf.pdf]) and in research (on assessment in mental health [Fulford...