Neuroscience and Values: A Case Study Illustrating Developments in Policy, Training and Research in the UK and Internationally

Simon in the International Classification of Diseases

Simon’s story was first published by the British psychologist, Mike Jackson (1997), in a study of delusion and spiritual experience. Simon, it would seem, had a delusional perception (the revelations in his ‘suns’ or wax seals) which in the ICD (International Classification of Diseases, World Health Organization, 1992) suggests a diagnosis of schizophrenia or other psychotic illness. Yet, Simon (along with many others in Jackson’s study) was much empowered by his experiences; he won his court case; went on to become a successful lawyer and always considered his experiences to be deeply spiritual in nature.

Simon in the Diagnostic and Statistical Manual

If Simon’s own understanding of his experiences is in conflict with the ICD, it is consistent with the DSM (the Diagnostic and Statistical Manual, American Psychiatric Association, 1994). Thus, the DSM includes, in addition to traditional symptom-based diagnostic criteria, what it calls ‘criteria of clinical significance.’ For a diagnosis of schizophrenia in the DSM, therefore, Simon would have to show not only the relevant symptoms (to satisfy Criterion A), but also a deterioration in social and/or occupation functioning (to satisfy Criterion B, the relevant criterion of clinical significance (p285). To the extent, then, that Simon’s occupational functioning was actually enhanced by his experiences, he failed to satisfy Criterion B and hence did not, despite satisfying Criterion A (the symptom-based criterion), have schizophrenia at all according to the DSM, but a spiritual experience.

Facts and values in the Diagnostic and Statistical Manual

It might be thought that the success of the DSM in providing a more face-valid interpretation of Simon’s experiences than the ICD reflects its more explicit evidence-base (American Psychiatric Association, 1994, p XV). Closer inspection, however, suggests to the contrary that the key to the DSM interpretation is its more explicit values-base. Consider Criterion B: it requires both a change in functioning (a matter of fact) and a change for the worse (which is a matter of values).

DSM thus makes explicit what many have argued is implicit in psychiatric diagnostic concepts generally, namely that they are deeply value laden (Fulford, 1989; Sadler, 2005). The question that arises, then, is what interpretation should be placed on this.

Interpretations various

The value-laden nature of psychiatric diagnostic concepts is capable of a number of different interpretations (Fulford, 1989). In the psychiatry/antipsychiatry debates of the 1960s and 1970s, for example, psychiatrists such as R.E. Kendell (1975), [and Singh and Singh recently (2009)], argued that the relevant values would disappear as future scientific advances established biological correlates of psychological abnormalities, whereas so-called antipsychiatrists, by contrast, claimed that these same values showed mental disorders to be irreducibly and regardless of future scientific advances, a matter of ‘morals not medicine’ (Szasz, 1960); and in the now very large literature on concepts of disorder, there have been many subsequent attempts to find a middle ground between what I have called elsewhere the ‘values in versus values out’ extremes of these early positions by delineating, in one way or another, what is taken to be a value-free element of their meanings (Fulford, 2000).

I do not have space here to do justice to these different interpretations (but see Fulford, 1989, chapter 1). The issues raised by the psychiatry/antipsychiatry debate are important however, not just theoretically but because they go to the heart of diagnosis and treatment in the practice of psychiatry, and I return to these issues below. First, however, I want to introduce briefly a very different way of understanding the prominence of values in psychiatric diagnosis that we owe to the work of R M Hare and others in the Oxford ‘school’ of analytic philosophy. As we will see, this work, although originally abstract and theoretical in nature, directly underpins the practical tools of values-based practice.

Hare on values

As a former White’s Professor of Moral Philosophy in Oxford, R M Hare (Hare, 1952, 1963) worked with J L Austin (Austin, 1956-7), Geoffrey Warnock (Warnock, 1971), J O Urmson (Urmson, 1950) and others in what is called analytic ethics. What this means is that rather than focusing on substantive moral questions (‘is this or that action right or wrong?’), this group of philosophers focused on the logic (the meanings and implications) of value terms (‘what does it mean to say that this or that action is right or wrong?’).

This all sounds rather abstract and indeed like mathematics analytic philosophy is abstract. Yet, also like mathematics, it is the abstract nature of analytic ethics that makes it a powerful approach when combined with an empirical discipline like psychiatry (think here of the power of mathematics when combined with observational physics). In the present case, there is a key point that we can take particularly from Hare’s work that explains the more value-laden psychiatric diagnosis and thereby provides the theoretical grounding for the applied tools of values-based practice.

Values visible

The key point to take from Hare’s work in the present instance can be summed up in the slogan ‘visible values = diverse values.’ The essence of Hare’s argument, as the Figure illustrates [Figure 1], is that all value term, including such generic value terms as ‘good’ and ‘bad,’ may come to appear value-free and thus more like factual terms, where the values they express are largely agreed or settled upon.

Figure 1

Good Strawberry and Good Picture

Hare’s example, shown in the left-hand side of the Figure, was of ‘good strawberry,’ this being a use of the value term ‘good’ in which it carries largely factual meaning, namely that the strawberry in question is red, sweet and grub-free, etc. This is essentially because most people have shared values when it comes to strawberries, that is, that strawberries should be red, sweet and grub-free, etc., and hence, this factual meaning has become attached by association to the use of the value term ‘good strawberry.’ Conversely, ‘good’ used of pictures, as in the right-hand side of the Figure, over which people’s values vary widely, has no shared factual meaning and thus retains overtly evaluative connotations.

Visible values in psychiatric diagnostic concepts

Returning now to the medical concepts, an exactly parallel argument explains the relatively value-laden nature of psychiatric diagnostic concepts compared with concepts of bodily disorder. Again, this is illustrated by the Figure 1. In a direct parallel with Hare’s argument about value terms in general, we see that psychiatric diagnostic concepts are relatively value-laden, neither because psychiatry is a matter of ‘morals not medicine’ (as the anti-psychiatrists suggested, as above), nor because of the supposed underdevelopment of psychiatric science (as Kendell and others believed), but because the values involved in diagnostic judgments in psychiatry, in contrast with the corresponding judgments in bodily medicine, are particularly diverse (Fulford, 1989, chapter 5).

Thus, the criteria for good and bad heart functioning, for example, paralleling ‘good strawberries,’ are largely settled and agreed upon, and this is true by and large of all the areas with which (acute) bodily medicine is primarily concerned. By contrast, however, the areas with which psychiatry is primarily concerned–emotion, desire, belief, motivation, sexuality and so forth–are all areas in which our values, paralleling ‘good pictures,’ are highly diverse.

Values-based practice: The theory

Again, I do not have space here to go into the arguments for and against this interpretation in detail. Nonetheless, it is important to note a number of theoretical points to the extent that these bear on the issues for diagnosis and treatment in psychiatry raised by the debate about mental illness (as outlined above).

The is-ought debate in philosophy

Like all research-led disciplines, the logic of values remains an area of on-going debate and Hare’s analysis is far from being universally accepted. Indeed, it falls within a 200-year debate in philosophy about the logical relationship between factual and evaluative meaning (the so-called ‘is-ought’ debate), a debate that continues to this day (see for example, Putnam, 2002).

Abnormality

The issues in the ‘is-ought’ debate in philosophy are reflected in those raised in the psychiatry/antipsychiatry debate about the concept of mental illness (noted above) and in the modern extension of that debate to concepts of disorder in general (Fulford, 2003). The key issue for practice is whether abnormality of functioning, whether in psychiatry or indeed in any other area of medicine, although ostensibly a value-laden notion can be defined (at least in part) value-free (Fulford, 1989 and 2000).

We can see the importance of the concept of abnormality in the central role that Criterion B, as a criterion of social/occupational dysfunction, played in the differential diagnosis in Simon case. Whether we took Simon to be suffering from a psychotic disorder or going through a religious experience turned, in the DSM, on deciding not just whether his social/occupational functioning had changed (this being a matter of fact) but had changed for the worse (this being a matter of values). So applied to Criterion B, and by extension to the wider problem of the nature of abnormal psychological (or any other) functioning, the debate about concepts of disorder becomes a debate about whether the requisite value judgments can be replaced by (or redefined in terms of) one or more facts.

Values-in vs values-out in diagnosis and treatment

This is where different interpretations again become relevant. One view (the view that I characterised elsewhere as the ‘values-out’ view, Fulford, 2000) is that we should either exclude values or at the very least work toward a consensus as the basis of consistent diagnostic criteria and treatment guidelines. This is a common sense view with many credible advocates (such as R. E. Kendell, no less, as above) and again, I cannot do full justice to the many variations on the values-out approach here (but see Fulford, 2003).

The values-out approach, however, whatever its merits, remains promissory on it, proving possible to exclude values. This is proving difficult in practice (witness the prominence of values in the DSM; Sadler, 2005) and may be impossible in principle (Fulford, 1998). It is also not risk free; consensus on all values too easily slides to enforced consensus with all its inherent risks of the abusive practices to which psychiatry has been so peculiarly subject throughout its history (Fulford et al., 2003).

The alternative ‘values-in’ approach is to accept that diversity of human values is indeed part of the clinical challenge faced by psychiatry and to work with rather than against it. This is what values-based practice as described further below seeks to do.

Values-in vs values-out in science

A further reason for seeking a values-out solution to the problem of dealing with the diversity of human values in psychiatric diagnosis is the belief that these are somehow prejudicial to the hard science agenda of establishing the biological correlates of psychological abnormality. Again, this is a concern with credible advocates and merits fuller treatment than I can give to it here.

Values-based practice, however, whatever may be true of its alternatives, is very much a partner to science in medicine. At the level of diagnosis and treatment values-based practice provides a key link in clinical decision-making between on one hand, the generalisable knowledge derived from science and reflected in evidence-based practice, and on the other hand, what evidence-based practitioners themselves have identified as the ‘unique values’ of individual patients (Sackett et al., 2000, page 1).

At the level of research, it clarifies the relevant research questions. Simon’s story again makes the point. There are clear research questions to be answered about the different causal processes involved in producing what we might call well-functioning psychotic experiences (as in Simon’s case) as distinct from the more familiar badly functioning psychotic experiences (as in the case of disorders such as schizophrenia). Delineating the different (presumably very different) causal pathways involved is important not only theoretically but also as the basis of developing more effective treatments. But the research required to delineate these two causal pathways has to start, like comparable research in any other area of medicine, from clear clinical differentiation of the phenomena in question. This in turn requires good clinical skills. And good clinical skills, as we will see in the next section, are the foundation of values-based practice.

Values-based practice

Values-based practice is one of a growing number of new disciplines contributing to more effective ways of working with values in medicine (Fulford, 2004). A distinctive feature of values-based practice, and one that makes it particularly relevant to tackling problems involving diversity of values, is that it starts from and celebrates the importance of the uniqueness of the individual. Unlike ethics, therefore, which seeks to determine ‘right outcomes,’ values-based practice relies on ‘good process,’ in particular good clinical skills, as the basis of balanced decision-making where values conflict.

There are ten key elements of the process of values-based practice (Fulford and Woodbridge, 2004). As just noted, values-based practice is primarily skills-based (see below). But also important are (1) an appropriate service model (values-based practice depends on a person-centred and multidisciplinary service structure), (2) strong links between values-based and evidence-based approaches and (3) partnership between service users and service providers in clinical decision-making. A full account of these ten elements, together with a detailed case history of ‘The Artist who Couldn’t See Colours,’ is given in my (Fulford, 2004) Ten Principles of Values-Based Medicine. Further case studies illustrating the applications of values-based practice in other areas of medicine besides psychiatry are given in the launch volume for a new series from Cambridge University Press on values in medicine, Essential Values-based Practice: Linking Science with People (Fulford, Carroll and Peile, forthcoming).

As noted in the text, the Story of Simon was first published by Mike Jackson as part of his DPhil thesis and subsequently in Jackson, 1997. The analysis of this and similar case histories outlined here was first published in Jackson and Fulford, 1997.