Values, Ethics and Health Care


Peter Duncan

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    I would like to thank my colleagues in the Department of Education and Professional Studies, King's College London, for their continued support. Once more I am especially grateful to Alan Cribb and Margaret Sills for helping me to organise a period of study leave during which I was able to think a lot about the subject matter of this book, and ultimately to write a significant part of it.

    Zoe Elliott-Fawcett and her colleagues at Sage have been a great help, right from the stage where the initial ideas for this project developed.

    I am grateful to the anonymous reviewers of both the original proposal and the draft manuscript for their very useful advice and comments.

    The students with whom I have worked over the last few years at King's College London have helped me greatly, not least by constantly reminding me through our discussions of the ambiguity and difficulty that is almost always inherent in the practice of health care. Their experience, and the examples that they have helped to generate, have been central in allowing me to understand what I have come to call ‘ordinary’ health care as in actual fact being quite extraordinary.

    Finally, and most importantly, I would like to thank Jane for all the support she gives me, in all kinds of different ways.


    This book rests on the broad but essential claim that the whole enterprise of health care is fundamentally to do with values and ethics. Unless we have a concern with questions of ethics and values, our conception of health care, and our interest in practice, is incomplete. This claim is not in any sense a new one. Indeed, part of this book's project is to do with charting the history of the claim, and how (as well as why) arguments have been developed to support it.

    In the context of the powerful and exciting history of values and ethics in health care, I am trying in this book to do a number of particular things, which I want briefly to outline at its beginning before actually attempting to do them.

    First, I am trying to explore the nature of values in the health care context. I am particularly interested in two things here. One is the nature of the value of health itself. Given that one of our working assumptions about health care might be that its purpose is to produce more ‘health’, we are often remarkably unclear about what we may mean by this. If the purpose of health care is ‘more health’, yet we are not quite sure of what we understand by that, we lay ourselves open to confusion, dispute (with others who possess alternative understandings) and ultimately dilemmas of ethics in our practice. The history of dispute about the nature of health is probably as good a demonstration as any that we will never be able to reach harmonious agreement about the nature of health as a value. However, if we side-step it altogether, we run the very real risk of being unable to progress very far at all in our explorations of values and ethics in the health care context. So it forms an essential first step in this book, along with my other interest at this point – how and why we develop the health and health care-related values that we actually have. My own view is that they develop in large part through our working, or training to work, in health care, and if this is so, such an idea has major implications for our beliefs and judgements about what we should be doing and why we should be doing it.

    The second thing I am trying to do is to understand these values that develop in and from our health care persona and practice as drivers of work and ethics in the field. My interest here is largely (although not entirely) in what throughout this book I will call ‘ordinary’ health care. This is the everyday practice that those working, or training to work, in health care are most likely to be involved in. It includes things like giving advice, arranging care, supporting people trying to change their health behaviour, and so on. There are two reasons for my focus on the ethics of ‘ordinary’ health care. The first reason, obviously, is that this is the kind of practice most health care workers will be involved with most of the time – and which, at least on occasions, is perhaps thought of as being routine and not worth submitting to ethical examination. Second, against this possible thought, I want to claim that the ‘ordinary’ in health care is very often quite extraordinary. If we think of the apparently simple act of giving advice to a patient, say, there are so many layers to consider: her beliefs, values and attitudes as well as our own; the institutional context in which the advice-giving takes place; the social context framing it all, and so on. This is what makes ‘ordinary’ health care so extraordinary and, in my view, so difficult to deliberate upon. When I talk of ‘ordinary’ health care, then, I am not in any sense doing so pejoratively.

    In this focus on ‘ordinary’ health care, my intention is not to deliberately exclude what many people might actually more often see as ‘extraordinary’ health care situations – ‘life and death’ problems such as abortion, euthanasia, genetic engineering, and so on. Indeed, my argument in support of a fundamental concern for values and ethics in health care begins in part with a study of the particular ‘extraordinary’ health care situation of assisted suicide. Clearly, there is an essential social need to discuss and deliberate on ‘life and death’ in health care. But for the reasons I have given above, this is not my main intention here.

    The third particular thing that this book tries to do is to cast a concern with values and ethics in health care as one that is (or should be) shared across occupations and professions. This is a book about values and ethics in health care, not in nursing or occupational therapy or health-related social work or any other particular health care occupation. Again, there are reasons for this. I want to demonstrate that the values and ethics-related ‘agenda’ in health care is a shared one. It seems especially important to do this at a time when there is much focus on interdisciplinary and multidisciplinary learning and political attempts are being made (rightly or wrongly) to break down professional barriers. Of course, throughout the book I will be using examples that draw on particular professional contexts or experiences – those of nursing, say. This is because, for better or worse, we tend to organise and understand the world of health care through professional and occupational divisions of one sort or another. But the claim and argument of this book is that there is much more for us to share (occupationally and professionally) with regard to values and ethics in health care than there is to divide.

    In attempting to do these things, there is also at least one thing that I am trying to avoid. I want to avoid this book becoming a one-sided explication of theory, or of problems in practice. In one sense, I suppose that somebody could argue that it has to be so. After all, I am writing and you are reading. I am deciding on direction and you are following. But in an important way my intention is for the book to be as unlike this as possible. Throughout the text there are questions, points for thought and examples that are my attempt to engage in shared dialogue and thinking with you, albeit within the constraint and limits of the writer-reader divide. But my effort towards establishing a dialogue is a genuine one because I believe that the questions I am posing, the thoughts I am trying to stimulate and the reasoning and reflection I am trying to encourage, is not the writer's responsibility alone. Progress in trying to understand the questions and difficulties that we will discuss has to be shared simply because it cannot be made by oneself.

    What I hope to come up with in this book are some possible ways of starting to think about questions of values and ethics in health care. These might be thought of as frameworks within which debate can take place. My intention is to try to encourage you to work with my frameworks, or to begin to develop your own conceptions of what is required to try to understand problems in this area. What I am doing, if you like, is to supply some scaffolding poles and planks and start to put them up in a particular way so that they fit my understanding of what needs to be built. But you might want to bring along more or different poles and planks, or rearrange the ones that we already have, to fit your own understanding.

    A few final clarifications are needed. First, at certain places in the text I have put words or phrases into bold type to indicate that this is a key term or topic under consideration at that point of the book. Second, as I suggested above, the ‘Q’ (Question) and ‘Thinking About…’ features are both intended to promote shared dialogue and thinking. However, within this broad intention they have different purposes. ‘Q’ features ask you to apply yourself to a particular question raised by the text, which I then generally go on to explore in what follows. ‘Thinking About…’ features are intended to provoke wider reflection, perhaps moving beyond the boundaries of the text itself. Third, the book begins with a series of case studies and continues right the way through with examples that in turn are provided to support thinking, discussion and questioning. The case studies are all taken from ‘real life’. This is also true of most of the examples, as they have been generated through discussions with students and colleagues, with whom I have been involved over a number of years, about their own experiences of working in or studying health care and its practices. (I have anonymised examples as appropriate.) For this particularly, I would like to re-iterate the thanks I offered to all these people in my earlier acknowledgements.

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