Thoughtful Health Care: Ethical Awareness and Reflective Practice


David Seedhouse

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    About the Author

    David Seedhouse is a widely-read writer on the philosophy of health care. He has written or edited 15 books, including the best-selling Health: The Foundations for Achievement and Ethics: The Heart of Health Care. David is a Visiting Professor at the University of Derby, UK, and Western Sydney University in Australia. David is also the creator of the Values Exchange – an online community for reflection and debate about ethical and social issues, used in many universities internationally, and also by the NHS in the UK. A version of the Values Exchange is connected to this book, and all readers are encouraged to sign in and enjoy the creative conversations.


    This book has emerged out of a tumultuous two years of working and personal life. I have not had the luxury of a sabbatical from university or business, or any other part of a very busy existence, so the book is no doubt less well researched than it could be – but it is the very real product of a very real life.

    As usual, I don’t have anyone else to blame for its errors and omissions, but I do have to thank my colleagues at Sage Publishing for their very professional support and encouragement, and for their willingness to trial the Values Exchange (my business) as an online adjunct to their textbooks. I am also deeply grateful to Vanessa Peutherer for her belief in me as a writer and human being, and for her considerable part in the creation of Thoughtful Health Care. Almost all the examples in the book are hers, and they lend it a reality and practical depth that I would not otherwise have been able to achieve.

    Publisher’s Acknowledgements

    The publishers would like to thank the following individuals for their invaluable feedback on the proposal and chapters of the book:

    • Dr Silvana Bettiol, University of Tasmania, Australia
    • Dianne Burns, University of Manchester, UK
    • Benny Goodman, Plymouth University, UK
    • Angela Hudson, University of the West of England, UK
    • Gillian Rowe, Plymouth University Partnerships, UK
    • Nick Wrycraft, Anglia Ruskin University, UK
    • Wendy Wright, University of the West of Scotland, UK

    Praise for the book

    Though my discipline is not health care but risk management, the writings of David Seedhouse have enlightened my thinking and influenced my worldview in invaluable ways. A practical approach underpinned by a coherent philosophy is what we need, and David delivers yet again in this latest work.

    Professor David Ball, Middlesex University, UK

    David Seedhouse has produced a strikingly honest view of where health policy makers have gone wrong but more importantly suggests an approach and ways health care professionals of the future can improve the quality of care for patients This is an interesting book that I was keen to read and didn’t disappoint. David Seedhouse provides some challenging ideas that will make readers reflect on and question their assumptions. This is a must purchase book for undergraduate nurses.

    As a trainee nurse in the optimistic 90s we were encouraged to challenge practice and question ideas. In the decades that followed we were then told to blindly follow targets regardless of the reasons for them. Currently the NHS is in crisis and badly needs leaders. David Seedhouse’s excellent book reignites that spirit of curiosity and sets the challenge for health care practitioners to really look at what is health and how in moving forward do we best provide a services that delivers the best health care.

    Nick Wrycraft, Anglia Ruskin University, UK

    David Seedhouse is a well-known and respected author in this field and in this book delivers a corrective to the current well-meaning but erroneous views on such things as values based recruitment and the 6Cs. Any health care worker thinking critically and wanting to articulate why certain practices and values are not up to the mark would do very well in reading this. The writing style is very accessible without dumbing down. Key ideas are illustrated and examined through very appropriate case studies and think stops. This should be core reading in any nursing programme.

    Benny Goodman, Plymouth University, UK

    An excellent book from a trusted author. This is a really useful source of information for nurses and student nurses which encourages much discussion and debate. The writing style is engaging and the reader certainly engages in the thought provoking toolkit and practical examples.

    Wendy Wright, University of the West of Scotland, UK

    This critically insightful and seriously thought provoking text challenges readers to critically reflect upon and carefully consider ‘the values delusion’ within contemporary health care settings. Pulling no punches, Seedhouse presents a refreshing and sometimes scathing attack on some of the superficial ways in which ‘values’ are viewed across many sectors.

    Dianne Burns, University of Manchester, UK

    This thought provoking book contests the ideas of values and ethical awareness that are inherent in health and social care settings today. The reader is encouraged to reflect on established perspectives and reframe views. It is very accessible and broad in its appeal. I would recommend to all health and social care professionals.

    Angela Hudson, University of the West of England, UK

    When every organisation – from the NHS to CocaCola – has its list of platitudinous ‘core values’, on which all its practices are allegedly ‘based’, Seedhouse’s penetrating scepticism is not only refreshing but urgently needed. This book is wilfully contentious – for the most part legitimately so. Seedhouse cares less about convincing us he is right on any given issue, much more about encouraging the genuine, critical thinking and practice that organisations agree, in principle, we need, but which so many of their structures inhibit.

    Michael Loughlin, Manchester Metropolitan University, UK

    Introduction: The Goblin In The Meadow

    Iggy’s a two-year-old black labrador. He’s a knowing dog, highly attuned to his environment. When he’s outside, his face twitches incessantly. His whole body’s alert. His eyes see the world differently from ours. He hears and smells more than we do. He has no words to describe his experience – he just experiences.

    Iggy’s standing in a meadow in high summer, taking it all in: tall grasses, poppies nodding, butterflies, swooping birds, nature’s quiet sounds, woodland behind – and above that, blue sky, drifting clouds, a gentle breeze and all of it swaying in some mysterious harmony. An amazing landscape. Full of colour, possibility, unknown paths, new adventures.

    Then a rat hurtles from a burrow and darts past. Iggy’s transfixed. The amazing landscape vanishes – only the rat exists for Iggy now. He chases it madly but the rat escapes into a bolthole. Iggy barks fiercely. Tries furiously to dig his way in. Waits. Barks some more. The rat’s gone. Iggy turns away. After all there are bees in the meadow. And wasps. And endless other mysteries. There’s a whole unknown world waiting in the meadow.

    Now there are people in the meadow. Happy people at first. But look. Coming out of the undergrowth. It’s a goblin, a scary goblin. The humans are transfixed for a split second. The amazing landscape vanishes – only the goblin exists now. The people chase it madly but the goblin escapes into a bolthole. They shout fiercely. Then they turn away – they’re going to get weapons. They tell everyone they know about the goblin. They come back to the meadow and watch for it. Soon enough they fence the meadow off. Put signs up. Beware of the goblin. Go back. Danger. And the amazing landscape stays vanished. It’s where the goblin lives. That’s all that matters now.

    The central theme of this book – you might even say the only theme – is that like Iggy, we humans should always be aware of the whole meadow, not just the part where crowds of us have gathered (1).

    This book was originally intended to be an introduction to values-based health care for students and professionals. Good values are increasingly seen as essential to best practice, so a book explaining exactly what they are and how they can be effectively applied seemed an obviously good idea. Not only that, but a decade earlier I had written a scholarly textbook about values-based decision making for the caring professions, and built a website for reflective practice called the Values Exchange. It seemed a perfect fit.

    Yet the more I thought about values the more it became apparent that our current understanding of them is inadequate.

    There is a widely-held view that values are solid, meaningful, stable attitudes. On this view a ‘compassionate person’ will have the same characteristics as another ‘compassionate person’, will behave with ‘compassion’ in all circumstances, and will have associated values – like ‘honesty’ and ‘respect’ –which fit snugly with her ‘compassion’. Understood like this, values can be defined in a simple way, can be readily detected from what people say and do, can be taught, and can be listed in mission statements to inspire consistent behaviours.

    This reading of values has become so popular that the NHS bases its entire Constitution on its own set of values; almost all institutions and businesses proudly declare their values on their websites and office walls; students and practitioners are taught or persuaded to adopt certain values and not others; and prospective health professionals have their values assessed at interview –and may even be denied work if these values are found wanting.

    Envisaged this way, values are like simple commands on memory sticks. Insert a memory stick containing the code for ‘integrity’ into a person’s brain and voila – she’s programmed to act ‘with integrity’ in every circumstance.

    Trouble is, as soon as you examine real-life situations, this cosy understanding of values disintegrates. Values do inform our decisions to an extent, but in a much more vague and erratic fashion than we assume. ‘Compassion’, for example, might have one meaning to one person and a conflicting meaning to another. To Samantha ‘compassion’ might be the ability to empathise, to Benjamin ‘compassion’ may mean acting against a patient’s wishes in their best interests. To Jules it might be ‘compassionate’ to assist a terminally ill person to end their life, to Andy it may be ‘compassionate’ to do everything he can to prevent the dying patient committing suicide: legitimate versions of ‘compassion’, leading to totally opposite actions.

    How can a memory stick be programmed for ‘compassion’ if ‘compassion’ can inform logically incompatible choices?

    Not only that, but there is massive evidence – both from academic research and everyday life – that we are much more inconsistent in our choices and actions than we like to think. Dependent on what’s happening in our daily lives, our emotional state, our level of knowledge, who we are friendly with, who we are working with, how busy we are, how stressed we are and so on, we may one day act according to one version of ‘compassion’, and contradict it the next.

    The Official View is that values are fundamental drivers of our behaviours, but with just a little reflection it’s obvious that our choices are formed by more powerful forces: by our peers, friends and colleagues, by our biology, by our psychology (and its errors), by our personalities, by our cultures, by our personal histories, by our education, by our environment and countless other factors.

    How can the Official View be so at odds with what every thoughtful person knows from normal life experience? How can so many apparently intelligent people be so wrong about the nature of values? What is it that’s blinding us to the depth of people’s thought processes, loyalties and decision making? Why do so many of us need to simplify the richness of life by substituting myths for reality?

    The more I thought about it the more I saw the Official View of values as a form of delusion – once you look at it closely, it’s hard to think of it as anything else. Then I wondered, is this delusion unique to health care or is it everywhere in human life? What does the delusion consist of, what are its implications, how in particular does it impact on health care and – most important of all – can we escape it? Can we become more aware of ourselves, more conscious of the perplexing nature of life, and more accepting of inconsistency if that is the way things really are? If we can see past at least some of our delusion, will it enable us to be more sensitive and helpful to other people?

    These are big questions, but I hope this book goes at least a little way toward answering them. It begins in a straightforward fashion, examining the way values are understood in health care, and showing by analysis and example that this understanding is mistaken – in fact it’s almost completely wrong. Then, in an attempt to get closer to the bottom of things, we embark on an unusual – but I hope entertaining – investigation into a range of social phenomena: from risk, schools, rights and progress to the news-media and even the survival strategies of plants.

    We are driven to make sense of the world. In order to do so we stick as many labels on it as we can, but the more complex and ingrained our labelling systems become the more we lose sight of everything we haven’t or can’t label. We believe our labels are true, and we are all too easily convinced that the rules and policies we make up would somehow exist even if we didn’t.

    Worse still, our labels make it appear as if the world is made up of separate parts or packets, when really everything is profoundly connected.

    Our worst delusion is to imagine that we can improve the social world by trying to change it as we see and define it, rather than work with its astonishing intricacies, as best we can. Things are just not as simple as they seem.

    Thoughtful Health Care offers a Toolkit for thoughtful practice in complex reality. Though it’s easier to offer catchy lists of key words and simplistic appeals to ‘put patients first’ – if reality is more complicated than we like to think it is, trying to change it as if it’s straightforward is just not going to work. Accordingly, the Toolkit is rich and varied, and requires intelligence and perception to use. It’s more a compendium of insights than a set of spanners, but it’s surely less deluded than the official alternatives. With effort and practice the Toolkit offers much-needed support for health workers and students currently overwhelmed and frustrated by disconnected codes, missions, rules and checklists.

    Overall, Thoughtful Health Care offers a timely reminder that there’s so much more to working life than obediently following the latest rules and policies. All health workers have a rich blend of knowledge, experience and intuition. They work with other complex people, most of whom have temporary or permanent vulnerabilities – creating an unpredictable mix of action and reaction. While rules and codes and disciplinary reviews may help promote consistency of care to a small extent, these highly specific labels frequently undermine creativity, curiosity, kindness and – ultimately – the capacity to respond to each person as a unique individual.

    Each of my earlier books, one way or another, was designed to help health workers think more systematically about their work and purposes. These texts were meant to be accessible to any reader, yet flicking through their pages I can see why some of my work has been misunderstood, and why parts of it might turn off readers who prefer quick fixes and certainties over philosophical rigour. Though they may be clear enough to the initiated, they do contain a fair bit of technical detail, which I have left out of Thoughtful Health Care. However, if you are sufficiently keen to want the theoretical arguments which underpin the present book, I recommend Health: The Foundations for Achievement; Ethics: The Heart of Health Care; and Health Promotion: Philosophy, Prejudice and Practice (2, 3, 4). If not, just enjoy the book you have in your hands at the moment.

    In Thoughtful Health Care, I have tried to write a different sort of book, in a different style from my more scholarly essays. Here, I simply aim to empower any interested reader with the sense that if something looks or feels dodgy it very probably is. Whenever this applies to you, the book will give you food for contemplation, and a few techniques that will help you question incongruity, even if only to satisfy yourself.

    Thoughtful Health Care is meant to be a pleasant, absorbing read, with a variety of examples drawn from many areas of life, not just health care. It’s intended to be treasured (ideally) – a reflective retreat for when you’re overwhelmed with rules for rules’ sake; or perhaps working in unintelligent systems with people who don’t seem to care as much as you do. Or maybe when you have to deal with dumb unkindness, and it’s damaging you, not to say others.

    I have in mind a reader who would relish a quiet, thoughtful conversation with a moderately educated, unafraid man – perhaps shutting his or her door after a dispiriting day, sipping a coffee or a gin, and thinking quietly, ‘At least I’m not alone in my thoughts and concerns. Despite the fact that I’m part of a very small minority, I’m not entirely wrong. I have a point, whatever they say.’

    Thoughtful Health Care does not abandon logic or robust reasoning; it just doesn’t make a meal of it. Even Chapter 1 – which is the most scathing about the latest absurdities amok in the NHS – is meant as a humourous journey. Thoughtless attempts – however well-meaning – to improve the world with codes, ‘values-based recruitment’, and lists of words all beginning with the same letter, are merely the over-confident assertions of people out of their intellectual depth. Seemingly all the reason in the world won’t help them see this, so I suggest you stand back with a wry smile while doing all you can to make a difference, on your own terms, according to your own sense of integrity and moral commitment.

    While Thoughtful Health Care draws on parts of my previous work, it does have something new to offer. It points to a constant choice we all have: you can look at the world as if it’s an uncertain, mostly mysterious place where you learn continually, or you can look at it as if everything they tell you is true. I know which I prefer, and if you feel the same you will find much support in its pages.

    This is a very personal book, which is pretty much forbidden territory in academia. But then every book, and every piece of research for that matter, is personal, however much it’s disguised. So why pretend otherwise?

    I’ve written Thoughtful Health Care primarily in order to communicate. And by far the most important part of any human communication is communicating yourself to others. Just as everything else in the world is inseparably connected, the author is never separate from what he writes. Nor is he separate from his readers, each of whom creates a unique reading experience as they blend their worlds with the words on a book’s pages.

    David Seedhouse Wolverley, England

    (Note: This book uses a dedicated Values Exchange: The Values Exchange is a set of educational tools designed to promote self-awareness, awareness of others and to develop skills in critical thinking. It is also an extensive online learning community, which every reader of this book is invited to join.

    Issues to reinforce the book’s themes, to challenge the reader, and to build the community are peppered throughout the book. Simply sign in as instructed then respond to as many issues as you like.)

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