Thoughtful Health Care

Ethical Awareness and Reflective Practice

David Seedhouse

• Publisher: SAGE Publications Ltd
• Year: 2017
• ISBN:
  9781526414519
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

Thoughtful Health Care offers a timely antidote to a Health Care climate dominated by endless rules, regulations, mission statements and codes of practice.

David Seedhouse explains how simplistic labelling, mindless targets and empty slogans have created a delusion of control and efficiency, obscuring actual patient and carer realities. Using thought-provoking examples from health care and beyond, the book advocates the restoration of thoughtfulness, creativity, and independence in health work. By reading this book, students and practitioners alike will be aided in developing their decision making and critical thinking skills, and ultimately serve those in their care better and with more honesty. The book ends with a powerful and practical toolkit that can be used thoughtfully and effectively by every open-minded health worker.

Thoughtful Health Care is for any health worker committed to caring with ethical awareness and practical sensitivity.

1 The Values Delusion

The Official View of Values

There’s a widely accepted view of values, shared across many sectors of society, which goes something like this.

1. Values can be clearly differentiated from each other.
2. Values can be held and exhibited both by individuals and organisations.
3. Values can be clearly identified as consistent drivers of individual and organisational behaviours.
4. Values expressed as single words are understood in the same way by everyone who reads or hears them.
5. Lists of different values – often known as ‘values statements’ – can consistently guide the actions of individuals and organisations.
6. People can and should be recruited according to their values.
7. If an organisation professes the right values, it will make the right decisions.
8. Lists of values help us tell the difference between right and wrong.

This way of thinking of values is so commonplace, at first it’s hard to see anything wrong with it. Yet it’s mistaken in every respect, as careful inspection of any official values statement will reveal (5). For example, take the NHS Constitution, which offers the authorised list of ‘principles and values that guide the NHS’ (6).

According to Principle 1:

The NHS provides a comprehensive service available to all

This principle applies irrespective of gender, race, disability, age, sexual orientation, religion, belief, gender reassignment, pregnancy and maternity or marital or civil partnership status. The service is designed to diagnose, treat and improve both physical and mental health. It has a duty to each and every individual that it serves and must respect their human rights. At the same time, it has a wider social duty to promote equality through the services it provides and to pay particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population.

Several words in this paragraph are ‘Big Values’ words: ‘duty’, ‘respect’, ‘human rights’, and ‘equality’. Together they seem to make an impressive point. Yet when you think about it, Principle 1 doesn’t actually make sense.

The principle says the NHS will treat everyone equally and respect their human rights. It also says it will pay more attention to the most disadvantaged sectors of society, since the NHS has a duty to help the least well-off people. However, if you have limited resources (which is always the case in the NHS) and you want to give a greater proportion of these to the least advantaged people, you can’t offer the same service to everyone equally, so you can’t respect everyone’s rights in the same way. It’s like saying, here’s an apple pie: everyone in our society has an equal right to the same size piece. However, the people in Poortown are thinner than everyone else so – in the interests of equality – it’s only fair to make the better off people’s slices smaller, in order to give more to the thin people.

You can’t have it both ways. You can’t say everyone has the right to the same size slice of pie and at the same time say that some people have a right to a bigger slice, when there’s only so much pie to go around. There’s a gigantic clash of values in Principle 1, which its authors somehow failed to notice: ‘equal rights and treating everyone identically’ versus ‘unequal rights and treating people differently’.

It’s quite an achievement to generate a deep-seated philosophical conundrum in the first paragraph of an official declaration. But while this might be a useful discussion point for a university seminar, it’s entirely unhelpful in health service practice. If I’m an NHS manager responsible for distributing resources in line with NHS ‘principles and values’, and I want to use Principle 1 to guide me, I’m stuck in an impossible bind. Do I give everyone an equal slice of the pie or don’t I?

What I think the NHS should be saying in Principle 1 is that it wants to create a more equal society, and will therefore offer more to the neediest people to try to bring them closer to the better off people – which means that the rights of better off people will sometimes have to be overridden. This does make sense and could, with much more detail, be applied in practice. However, as it stands, Principle 1 flatly contradicts one of the tenets of ‘the Official View’:

Official View 5. Lists of different values – often known as ‘values statements’ – can consistently guide the actions of individuals and organisations.

Generally speaking, in addition to their vagueness of meaning, lists of values exhibit three related types of problem – theoretical, practical and ethical. Theoretical problems occur when, as with Principle 1, the itemised words and claims are incompatible in the abstract, and therefore could never be used to guide practice. Practical problems arise when the theory hangs together, but where what is claimed is happening isn’t actually happening. And ethical problems happen when controversial outlooks are put forward as if everyone is bound to agree with them.

Principle 4 in the Constitution exemplifies all three types of problem:

The NHS aspires to put patients at the heart of everything it does

It should support individuals to promote and manage their own health. NHS services must reflect, and should be coordinated around and tailored to, the needs and preferences of patients, their families and their carers. Patients, with their families and carers where appropriate, will be involved in and consulted on all decisions about their care and treatment. The NHS will actively encourage feedback from the public, patients and staff, welcome it and use it to improve its services.

To say that NHS services must reflect the needs and preferences of patients, their families and their carers is a very big claim. Of course, it sounds perfectly reasonable at a glance, but to deliver on it consistently, all the needs and preferences of all patients and families must be met. However, in our complex social environment this simply cannot be so. There are countless examples where meeting the needs and preferences of one patient will prevent or even act against meeting the needs and preferences of another – this is just the way things are: not allowing smokers to smoke in hospital grounds, preventing windows opening to stop injury while reducing ventilation, banning flowers on wards in case of allergies, prohibiting clinicians sitting on patients’ beds to reduce infection while limiting human contact, giving everyone breakfast at the same time regardless of when they usually eat, refusing to operate on one needy patient in favour of another needy patient who would benefit more – all these are examples of inevitable conflict between needs. And everyone knows that the needs and preferences of patients, families and carers are very often at odds: patients want one thing and their families want another, carers recommend a treatment and the patient doesn’t want it. What is a need to one person can be a burden to another.

How, in the case below, can you – or anyone else working in the health service – possibly meet the needs and preferences of all patients, each member of their family and their carers, in a fair and equal manner?

Stop & Think One: The Curry Conundrum

Ahmed, a 65-year-old married man, is a voluntary in-patient in the Acute Mental Health Unit. He has been admitted for assessment and treatment of severe depression. Ahmed moved to England from southern India 20 years ago with his family. On admission, Ahmed is found to be underweight and he reports a moderate loss of appetite (anorexia) which has increased during his stay on the Unit and been present since his depressive symptoms have worsened. During his stay on the ward, on open questioning, it is established that Ahmed enjoys eating his wife’s homemade curry but dislikes hospital food on the whole, which seems to have contributed to a steady, continual loss of weight.

You are the health worker on duty. You have spoken to Ahmed and encouraged him to fill in his daily menu choice, to allow him to choose what he would like to eat. Ahmed continues to be unmotivated and seems disinterested, but fills the form in anyway. He has also been referred to the dietician for advice by the Registered Nurse on duty.

At meal time, that evening, you notice that, as usual, Ahmed has not eaten any of the food which has arrived from the kitchens, and despite encouragement, asks you to take his tray away, with his food untouched. You report this to the nurse in charge and document your evaluation in Ahmed’s notes.

At visiting time you are surprised to notice that Ahmed is sat with his wife and is visibly eating curry and rice with his hands, in front of everyone, in the day room. Some of the staff and patients verbalise feeling uncomfortable as a result of this behaviour, saying it is ‘unhygienic’ and ‘repulsive’. These statements are made, despite the fact that Ahmed, as part of his culture, sees nothing wrong with eating his curry with his hands: as he says, ‘it tastes better’ and his family regularly eat in this way at home, as do well over 1 billion people around the world.

It is evident that Ahmed’s wife has snuck food in for him, against the hospital policy, which states that due to legal obligations, to comply with the Food Safety Act 1990 and associated legislation and the risks of food poisoning, relatives and patients are unable to bring in meals containing cooked meat as they may support the growth of pathogenic bacteria.

What would you do in this scenario?

Do you agree with the proposal below?

It is proposed that you continue to allow Ahmed to consume his wife’s curry with his hands, in the communal area.

Add your response on the Values Exchange: http://thoughtful.vxcommunity.com/Issue/think-stop-one-curry-conundrum/23053

(Case originally posted by Vanessa Peutherer, VX Learning Facilitator)

One of the main ethical problems with simplistic values statements is the repeated attempt to use them to deliver Official View 8:

Official View 8. Lists of values help us tell the difference between right and wrong.

For example, the first sentence of Principle 4 is written as if it’s obviously right:

[The NHS] should support individuals to promote and manage their own health.

But why should the NHS ‘support individuals to promote and manage their own health’? Why shouldn’t the NHS look after people unconditionally – whether or not they want to manage their own health?

If I’m living in a damp flat, badly educated and unemployed, over fifty with few prospects, and I decide to smoke cigarettes to make myself feel better, am I a bad person for not ‘promoting and managing’ my own health? Maybe I am promoting my health by smoking, since it helps me cope and makes me happy? Since ‘health’ is not defined in the NHS Constitution, it’s not clear.

Have I failed in my ethical duty to promote my own health if I’m miserable, lost and getting by in an ‘unhealthy’ way? Or does the NHS Constitution place unreasonable expectations on me in a situation where few of my circumstances are of my own making? Where does this value judgement –that people ought to manage their own health – come from, and how is it justified? It’s certainly not a neutral position, and it definitely requires defending.

All the other principles have theoretical, practical and ethical difficulties too. They are bound to because they’re grandiose and removed from the messy reality we all have to live in.

Consider other principles.

Access to NHS services is based on clinical need, not an individual’s ability to pay

Actual practice is much more complicated than this. For example, some health authorities will fund certain treatments while others will not...