Values Based Medicine is a twin sister framework to Evidence Based Medicine. It is one of the responses to the growing complexity of the values involved in health-related decision making, just as Evidence Based Medicine is a response to the growing complexity of facts.

The framework was developed originally by Bill (K.W.M.) Fulford. It builds on his work in the philosophy of psychiatry, in particular the application to conceptual issues in mental health of the work of R. M. Hare and others in the “Oxford School”, on the descriptive and normative meaning of terms.

Values Based Practice is the theory and skills-base for health-related decision making where legitimately different, and hence potentially conflicting, values are implicated. In Values Based Practice, conflicting values are balanced by means of 'good' process, and not by a predetermined hierarchy of values or priority of perspectives.

A greater engagement with the patients' values is not simply morally desirable. It is also expected to contribute to improved health outcomes. The underlying assumption is that if health-benefiting decisions are made with respect for values as well as evidence, following a process in which values have been explored, clarified and balanced, such decisions are more owned and more likely to be acted on.

How values based is current clinical practice?

The good intentions to take patients’ values into account are certainly there. However, they are not always effectively realised. Values are explored and factored into the decision-making process less frequently than health professionals (or health policy makers, or researchers) believe they are. Here are some of the reasons: 

• if values are presumed to be shared - and this tends to happen whenever values are not openly conflicting - they will remain unexplored. For example, if a doctor strongly believes that the benefits of a certain drug are more desirable than its side effect are undesirable, she may assume that this is a shared view, just ‘the way things are’. She then has no reason to enquire after the preferences of her patients.
• values may be difficult to elicit. For example, it may be difficult to bring out concerns about a certain treatment’s negative effects on sexual function, as many patients will find this too personal to discuss.
• the power balance in a patient-health professional encounter is such that patients rarely volunteer their values.  

          Working with values is also difficult because:   

• although values can sometimes be elicited in their most abstract form, as pronouncements about ‘autonomy’, ‘dignity, ‘loyalty’, most of the time they come through in wishes, preferences, perceptions, choices, expectations, hopes, fears, etc. Such phenomena are shaped by identity-defining values, but are also strongly responsive to contextual effects. This makes it difficult to identify the deeply personal component in them.

• the values involved in health-related situation are not necessarily easy to define in a way that patients and other stakeholders can simply apply their own values onto a matrix of possibilities. For example, it is debatable whether drugs in depression make one a less autonomous person, by putting him or her under the influence of external agents, or a more autonomous one, by rendering him or her capable of making decisions unconstrained by a disease process.

• conflicting values may be very difficult to reconcile without a sense of substantial loss. For example, an artist may need to choose between the creative potential of his bipolar emotional spectrum and a feeling of greater control and social acceptance achieved under treatment.

• there may be a wide gap between what is said and believed about the values one holds and what comes through in behaviours. For example, health professionals may believe that they are not discriminating against elderly or minority patients, while the length and contents of their consultations with such patients suggest otherwise.

What Does Values Based Practice Contribute to Values Based Medicine?

Many disciplinary areas produce knowledge of health-related values - health psychology, medical sociology, the medical humanities, health economics, health decision making, clinical ethics, etc. Research in each of these areas of Values-Based Medicine can help identify types and ranges of health-related values, provide theoretical explanations of how such values develop and what influences they respond to, and suggest practical approaches to working with them for the purposes of improved clinical practice, health policy making and medical education.

Research is, however, only one possible way of learning about health-related values. Representations and explorations of values can be found in the arts, humanities, and everyday discourse. Sources from all these fields complement research-based knowledge of health-related values.  They also form the basis of powerful educational tools.

The theory of Values Based Practice provides a conceptual framework for bringing together findings, representations, tools and sources - and for facilitating their translation into a knowledge base and working tools for clinical practice, healthcare research, health policy making and medical education.  

At a practical level, the process of values based practice, in particular as it draws on learnable clinical skills, contributes to balanced medical decision making that is both evidence based and also responsive to the values of the individual patient and others concerned in a given clinical situation.

How does Values Based Practice relate to frameworks of similar assumptions and concerns?

Values Based Practice is one of a number of frameworks (such as patient-centred care, shared decision making, narrative-based medicine, mindful practice) that aim to make health care more attentive to the patient as a unique individual. There are certainly multiple pathways to the same goal.

Values Based Practice provides a cross-cutting set of practical tools for each these approaches to person-centred care because all of them depend (among other things) upon understanding an individual patient’s values and being able to integrate them with the values of others in clinical decision making.

A further contribution of Values Based Practice comes from its very broad underlying conceptual framework. The concept of ‘values’ allows for a large number of factors in health-related decision making to be captured; for a wide range of disciplines to find common ground on which to exchange ideas; and for values-based approaches to be applied successfully in many different contexts in healthcare (i.e. in addition to clinical decision making between patients and families with health professionals, decisions in such areas as management of services and overall policy development).  

It is likely that Values Based Practice and the other frameworks and disciplines contributing to Values Based Medicine will often converge on findings, approach and messages. Together they all aim to contribute to decisions that are owned by the patient as reflecting their wishes, concerns and other values, are feasible in view of his or her psychological make-up and the constraints of their individual situation, are based on the available evidence, and hence are likely to maximise the number of improved health outcomes.