From triple helix - winter 2016 - Wear your values [p05-07]
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Richard Vincent reflects on why we need to be clear about our values and our reasons for holding them.
The idea for the title of this article emerged after seeing an advertisement for eco-friendly jeans. By buying 'sustainable' denim, your purchase would not only bring sartorial excellence but would also proclaim values of global ecology and fair trade. These values, as the manufacturers hoped, could be a deciding factor in choosing their brand.
Values feature increasingly in the dialogue and presentation of organisations, authorities, and professional groups. They serve to define the key drivers and characteristics of their operation and, by implication, the desired attitudes and motivation of those who work within them. Our personal values, arising from our core beliefs, are the most energetic determinants of our behaviour. (1) They provide an internal guide to our choices in all situations. (2) They powerfully influence the attitudes and decision-making that become visible in our actions, our priorities and our relationships.
Values are described in various ways, though often only by a single word or brief phrase - altruism or working in partnership with a wider team, for example. (3) They vary in scope from broad ideals covering many situations, as in faithfulness or justice, to more specific applications, such as continuing improvement or timeliness. These latter examples often reflect behaviours that fall within a broader principle; for example, the value of punctuality could be seen as part of the more general value of respect. When used by organisations these more specific values can often be re-cast as goals or objectives. The boundaries of these various definitions seem rather porous, though all present behaviour judged to be ideal. 'Higher' values focus as much on our attitude to others as on the behaviours that they endorse.
In speaking about values it is usually implicit that they are good, portraying a high moral code and enabling individuals and communities to flourish. Such positive values - particularly those with wide application - can be considered virtues. In turn these can be built into a wise system of ethics set alongside systems based on rules (deontology), principalism or consequences (utilitarianism). (4) But values may also be potentially limiting with negative effects on our personal growth and peace as well as separation, doubt and mistrust in relationships with others. These adverse effects may well arise in practice if, for example, the values of popularity, control or wealth provide our overriding motivation.
We are encouraged to reflect on the personal values that shape our lives and our clinical practice. (5) Teasing them out, however, may be more difficult than expected. In the 'iceberg model' of NHS culture, (6) while behaviours and discourse stand out visibly above the water-line, the foundational beliefs, attitudes, and values that support them are darkly submerged. Searching for them requires heart and mind, curiosity and honesty; and it is befitting that we make the attempt in a spirit of prayer. Self-deception always crouches at our door, prompting us to list more noble values than those which, in reality, determine our day-to-day decisions, actions, and reactions.
One practical way to start an exploration of our values system is to use the acronym SALTED:
S - spending: on what do you spend your time and your money?
A - anger: what makes you most angry?
L - loss: what would you consider your greatest loss?
T - trust: when things are overwhelmingly threatening,whom or what do you really trust most?
E - energy: what energises you most?
D - delight: what causes you the greatest delight?
Another approach, particularly in relation to clinical practice, is to list the values and characteristics you would like to find in a perfect health professional, one whose help you are seeking for a difficult illness. Discovering how far you match up to these ideals will require time and honest reflection. Constructive comments on your work by a trusted team member could help. When this exercise was undertaken recently by a group of obstetricians, midwives and nurses in Sierra Leone they conjured up 33 personal values judged desirable in an ideal health professional. Interestingly, just three related to clinical skills while the remainder addressed personal attitudes or interactions with patients and staff.
Additional benchmarks against which to assess our professional values can be found in documents from the NHS, (7) the Royal Medical Colleges, the General Medical Council (8) and other professional bodies where values themselves are named or preferred professional behaviour is described (from which their underpinning values can be discerned).
Above and beyond these human writings lie the authoritative revelations of the God who made us. Throughout, the Bible exemplifies and calls us to live according to the values and pattern of the kingdom of God - in stark contrast to the norms of our fallen world. The Old Testament often presents rules to fashion his people into God-centered living; but love as the primary, over-riding and enabling value is certainly there too, not least in Deuteronomy and Leviticus (9) as quoted by Jesus in Matthew (10) as the summary of the Law and the Prophets.
What can we learn of Jesus' values from his words and actions?
In his epistle to the Romans (12) Paul expresses the dilemma we face while trying earnestly to live as Jesus' disciples. As his followers, we are committed to his values and seek his help fully to adopt them as the drivers of all our attitudes and actions. But contrary, negative or limiting values can so readily rise up in opposition. The nagging values of popularity or material success could easily displace our call to behave with altruism, integrity, humility and generosity. But where this happens we are not to despair but rather consider how our noble values have been hijacked, and then return to Jesus to seek his forgiveness and the power that enables his values to be expressed in all that we do.
In addition to the challenge of a values-conflict internally, our professional practice will afford many interactions with those whose values and priorities do not match our own. How we approach such discord in the organisations where we work necessitates drawing heavily on our core values of respect, kindness, justice, and mercy together with prayer for wisdom and the humility to seek the guidance of others where appropriate. And with the patients and relatives whom we attend, such an approach will also be required, particularly as we develop a therapeutic interaction that takes full account of their values and preferences as well as our own. (19)
An identity between our internal values and our external behaviour, without restriction or distortion, defines the value of integrity. It has been said that the closer this match can be achieved the more likely we are to be at peace, to have appropriate self-confidence, and to flourish. Integrity means doing the right thing even when nobody is watching. Some regard integrity as the crowning value on which all others depend since it makes plain by our behaviour the internal values that propel us.
So aim for integrity: take all your good values and wear them!
LOVE — with true altruism
RESPECT — without judgment
HUMILITY — servanthood, always
INTEGRITY — outside = inside
FORGIVENESS — repeatedly showing mercy
KINDNESS — everyone counts as family
FAITHFULNESS — even at personal cost
JUSTICE — on behalf of others
UNEXPECTED GENEROSITY — of spirit, goods, time, attention
RIGHTEOUSNESS — without self-congratulation
UNITY — while embracing differences
Richard Vincent is Emeritus Professor of Cardiology and formerly Associate Dean of the Brighton and Sussex Medical School.
1. What are values? Barrett Values Centre.
2. Definition: Values. Business Dictionary.
3. Royal College of Physicians of London. Doctors in Society: medical professionalism in a changing world. RCP; 2005
4. Misselbrook D. Virtue ethics - an old answer to a new dilemma? Part 1.
Problems with contemporary medical ethics. JRSM 2015;108:53 Misselbrook D. Virtue ethics - an old answer to a new dilemma?
Part 2. The case for inclusive virtue ethics. JRSM 2015;108:89
5. Slowther A, Peil E et al. RCGP Curriculum statement 3.3: Ethics and Values-Based Practice. RCGP; 2006 and Powers BW, Navathe AAS et al. Medical education's authenticity problem. BMJ 2014;358:8
6. Braithwaite J. A lasting legacy from Tony Blair? NHS culture change. JRSM 2011;104:87
7. NHS Choices. About the NHS: Principles and values that guide the NHS. NHS 28 May 2015. About NHS England: Our vision and purpose. NHS England.
8. General Medical Council. Good Medical Practice. GMC; 2013.
9. Deuteronomy 6:5; Leviticus 19:18
10. Matthew 22:37-40
11. Matthew 5:1-6:24; Philippians 2:1-11; Galatians 5:16-26
12. Romans 7:21-25
13. Hajjaj FM, Salek MS et al. Non-clinical influences on clinical decision-making: a major challenge to evidenced-based practice. JRSM 2010;103:178