Open Access Open Access  Restricted Access Subscription or Fee Access

Another argument for values-based medicine

Miles Little, Wendy Lipworth, Jill Gordon, Pippa Markham


There is a contemporary dialectic concerning the status of evidence-based medicine, criticising it for being ‘scientistic’, epistemologically inconsistent, rigid and dismissive of non-numerical sources of knowledge. A host of alternative frameworks has been proposed, including values-based medicine, narrative medicine, patient-centered care and person-centered medicine. Person-centered medicine is amongst the most persuasive and well-argued models. Miles and Mezzich  have argued in a major article that person-centered medicine employs theories of personhood to elaborate and justify its epistemology and praxis. At the same time, they claim that person-centered medicine is an ‘emergent’ concept that needs no base or foundation to justify it. We believe, however, that without some foundational values to underpin the status claimed for personhood, the arguments for person-centered medicine are incomplete. We therefore propose a set of foundational values ­­– survival, security and flourishing – that underpin individual and social functioning transculturally. While these values are the same in all cultures, their expressions differ from culture to culture. Importantly, our notion of values is only modestly foundational. Modest foundationalism recognises that foundational propositions are only ‘warrantable assertions’ that may very well change in time and place. Foundational values in this sense are pragmatic and heuristic in kind and not normative. We enter a plea for their recognition in the form of the values-based medicine we describe.

Full Text:



Miles, A. & Mezzich, J.E. (2011). The care of the patient and the soul of the clinic: person centered medicine as an emergent model of modern clinical practice. International Journal of Person Centered Medicine 1 (2), 207-222.

Goldenberg, M.J. (2006). On evidence and evidence-based medicine: Lessons from the philosophy of science. Social Science & Medicine 62, 2621-2632.

Grossman, J. (2008). A Couple of the Nasties Lurking in Evidence-Based Medicine. Social Epistemology: A Journal of Knowledge, Culture and Policy 22 (4), 333 - 352.

Kerridge, I., Lowe, M. & Henry, D. (1998). Personal paper: Ethics and evidence based medicine. British Medical Journal 316 (7138), 1151-1153.

La Caze, A. (2008). Evidence-Based Medicine Can’t Be…. Social Epistemology: A Journal of Knowledge, Culture and Policy 22 (4), 353-370.

Lipworth, W., Carter, S. & Kerridge, I. (2008). The "EBM movement": where did it come from, where is it going, and why does it matter? Social Epistemology: A Journal of Knowledge, Culture, and Policy 22, 425-431.

Miles, A. & Loughlin, M. (2011). Models in the balance: evidence-based medicine versus evidence-informed individualized care. Journal of Evaluation in Clinical Practice 17, 531-536.

Timmermans, S. & Angell, A. (2001). Evidence-Based Medicine, Clinical Uncertainty, and Learning to Doctor. Journal of Health and Social Behavior 42 (4), 342-359.

Timmermans, S. & Kolker, E.S. (2004). Evidence-Based Medicine and the Reconfiguration of Medical Knowledge. Journal of Health and Social Behavior 45, 177-193.

Tonelli, M.R. (2006). Integrating evidence into clinical practice: an alternative to evidence-based medicine. Journal of Evaluation in Clinical Practice 12 (3), 248-256.

Worrall, J. (2002). What Evidence in Evidence-Based Medicine? Philosophy of Science 69 (3), S316-S330.

Kalina, M., Tinkoff, G. & Fulda, G. (2011). Massive postpartum hemorrhage: recombinant factor VIIa use is safe but not effective. Delaware Medical Journal 83 (4), 109-113.

DeLaughery, E.P., Lenfesty, B. & DeLoughery, T.G. (2011). A retrospective case contro study of recombinant factor VIIa in patients with intracranial haemorrhage caused by trauma. British Journal of Haematology 152 (5), 667-669.

Chapman, A.J., Blount, A.L., Davis, A.T. & Hooker, R.L. (2011). Recombinant factor VIIa (NovoSeven RT) use in high risk cardiac surgery. European Journal of Cardiothoracic Surgery Epub ahead of print.

Friederich, P.W., Henny, C.P., Messelink, E.J., Geerdink, M.G., Keller, T., Kurth, K.H., Büller, H.R. & Levi, M. (2003). Effect of recombinant factor VII on perioperative blood loss in patients undergoing retropublic prostatectomy: a double-blind placebo-controlled randomised trial. Lancet 361, 201-205.

Dutton, R.P., Parr, M., Tortella, B.J., Champion, H.R., Bernard, G.R., Boffard, K., Bouillon, B., Croce, M.A., Dimsits, J., Holcomb, J.B. Leppaniemi, A., Vincent, J.L., Hauser, C.J. & CONTROL Study Group. (2011). Recombinant activated Factor VII safety in trauma patients: Results from the CONTROL trial. Journal of Trauma 71 (1), 12-19.

Ilyas, C., Beyer, G.M., Dutton, R.P., Scalea, T.M. & Hess, J.R. (2008). Recombinant Factor VIIa for warfarin-associated intracranial bleeding. Journal of Clinical Anesthesiology 20, 276-279.

Yank, V., Tuohy, C.V., Logan, A.C., Bravata, D.M., Staudenmayer, K., Eisenhut, R., Sundaram, V., McMahon, D., Olkim, I., McDonald, K.M., Owens, D.K. & Stafford, R.S. (2011). Systematic review: Benefits and harms of in-hospital use of recombinant factor VIIa for off-label indications. Annals of Internal Medicine 154, 529-540.

Yank, V., Tuohy, C.V., Logan, A.C., Bravata, D.M., Staudenmayer, K., Eisenhut, R., Sundaram, V., McMahon, D., Olkim, I., McDonald, K.M., Owens, D.K. & Stafford, R.S. (2011). Systematic review: benefits and harms of in-hospital use of recombinant Factor VIIa for off-label indications. Annals of Internal Medicine 154, 529-540.

Logan, A.C., Yank, V. & Stafford, R.S. (2011). Off-label use of recombinant factor VII in U.S. hospitals: Analysis of hospital records. Annals of Internal Medicine 154, 516-522.

Avorn, J. & Kesselheim, A. (2011). Editorial: A hemorrhage of off-label use. Annals of Internal Medicine 154, 566-567.

Karkouti, K. & Levy, J.H. (2011). Comment: The off-label use of recombinant activated factor VII. Annals of Internal Medicine [cited 2011 18 August 2011]; Available from:

Hayanga, A.J. (2011). Replies: Trends in the use of Factor VII in cardiac surgery. Annals of Internal Medicine [cited 2011 18 August 2011]; Available from:

Miller, C.G. & Miller, D.W. (2011). The Real World Failure of Evidence-Based Medicine. International Journal of Person Centered Medicine 1 (2), 295-300.

Penston, J. (2011). The irrelevance of statistics-based research to individual patients. International Journal of Person Centered Medicine 1 (2), 240-249.

Raman, R. (2011). Evidence-based Medicine and Patient-centered Care: Cross-Disciplinary Challenges and Healthcare Information Technology-enabled Solutions. International Journal of Person Centered Medicine 1 (2), 279-294.

Walsh, B. & Gillett, G. (2011). A post-structuralist view of evidence-based medicine (EBM): what EBM contributes to philosophy. International Journal of Person Centered Medicine 1 (2), 223-231.

Walsh, B. & Gillett, G. (2011). Is Evidence-based Medicine positivist? International Journal of Person Centered Medicine 1 (2), 232-239.

Fulford, K.W.M. (2007). Values-based medicine: delusion and religious experience as a case study in the limits of medical-scientific reduction. In: The Science of Morality, (Ed. G. Walker) London: Royal College of Physicians.

Fulford, K.W.M. (2010). Bringing together values-based and evidence-based medicine: UK Department of Health Initiatives in the 'Personalization' of Care. Journal of Evaluation in Clinical Practice 17 (2), 341-343.

Little, M. (2002). Humanistic medicine or values-based medicine? What's in a name? Medical Journal of Australia 177 (6), 319-321.

Petrova, M., Dale, J. & Fulford, K.W.M. (2006). Values-based practice in primary care: easing the tensions between individual values, ethical principles and best evidence. British Journal of General Practice 56 (530), 703-709.

Charon, R. (2001). Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust. Journal of the American Medical Association 286 (15), 1897-1902.

Greenhalgh, T. & Hurwitz, B. (eds). (1998). Narrative Based Medicine: Dialogue and Discourse in Clinical Practice. London: BMJ Books.

Cassell, E.J. (1997). Why should doctors read medical books? Annals of Internal Medicine 127 (7), 576-578.

Laine, C. & Davidoff, F. (1996). Patient-centred medicine: A professional evolution. Journal of the American Medical Association 275 (2), 152-156.

Montgomery, K. & Little, M. (2011). Enriching patient-centered care in serious illness: a focus on patients' experiences of agency. Milbank Quarterly 89 (3), 381-398.

Engel, G.L. (1962). The nature of disease and the care of the patient: the challenge of humanism and science in medicine. Rhode Island Medical Journal 45, 245-251.

Engel, G.L. (1977). The care of the patient: art or science? Johns Hopkins Medical Journal 140 (5), 222-232.

Engel, G.L. (1978). The biopsychosocial model and the education of health professionals. Annals of the New York Academy of Sciences 310, 169-187.

Little, M. (1995). Humane Medicine, Cambridge: Cambridge University Press.

Henry, S.G., Zaner, R.M. & Dittus, R.S. (2007). Viewpoint: Moving beyond evidence-based medicine. Academic Medicine 82 (3), 292-297.

Upshur, R. (2002). If not evidence, then what? Or does medicine really need a base? Journal of Evaluation in Clinical Practice 2, 113-119.

Warren, M.A. (1997). Moral Status: Obligations to Persons and Other Living Things, Oxford: Oxford University Press.

Locke, J.(1689). An Essay Concerning Human Understanding. Oxford: Clarendon Press. (1957).

Kant, I. (1797). The Metaphysics of Morals. Cambridge: Cambridge University Press. (1996).

Michaels, M.D. (1989). The Chaos Paradigm. Organization Development Journal 7 (2), 31-35.

Marks-Tarlow, T. (1995). The fractal geometry of human nature. In: Chaos Theory in Psychology and the Life Sciences,(Eds. R. Robertson & A. Combs), pp. 275-283. Lawrence Erlbaum Associates: Mahwah, NJ.

Bourdieu, P. (1984). Distinction: A Social Critique of the Judgement of Taste, Cambridge, Mass: Harvard University Press.

Bourdieu, P. (2008). Outline of a Theory of Practice, Cambridge: Cambridge University Press.

Olafson, F.A. (1995). What is a Human Being? - A Heideggerian View, New York: Cambridge University Press.

Webb, D.J. (2011). Value-based medicine pricing: NICE work? Lancet 377 (9777), 1552-1553.

Quintelier, K., Van Speybroeck, L. & Braeckman, J. (2010). Normative Ethics Does Not Need a Foundation: It Needs More Science. Acta Biotheoretica 59 (1), 29-51.

Gert, B., Culver, C.M. & Clouser, K.D. (1997). Bioethics: A Return to Fundamentals, New York: Oxford University Press.

Alston, W.P. (2006). Beyond "Justification": Dimensions of Epistemic Evaluation, Ithaca, NY: Cornell University Press.

Junger, E. (1934). On Pain, New York: Telos Press. (2008).

Améry, J. (1980). At the Mind's Limits: Contemplations by a Survivor on Auschwitz and its Realities, Bloomington and Indianapolis: Indiana University Press.

Sen, A. (1993). Capability and well-being. In: The Quality of Life, (Eds.M. Nussbaum & A. Sen), pp. 30-53. Oxford:Clarendon Press.

Hart, S.L.(1971). Axiology--theory of values. Philosophy and Phenomenological Research 32 (1), 29-41.

Rescher, N. (2010). Axiogenesis: An Essay in Metaphysical Optimalism, Lanham, Maryland: Lexington Books.

Sagoff, M. (1986). Values and Preferences. Ethics 96 (2), 301-316.

Flanagan, O., Sarkissian, H. & Wong, D. (2008). Naturalizing ethics. The evolution of morality: adaptations and innateness. In: Moral Psychology (Vol 1), (Ed. W. Sinnott-Armstrong), pp. 1-25. Cambrdige, Mass: MIT Press.

Dewey, J. (1948). Reconstruction in Philosophy. Boston: Beacon Press.

Dewey, J. (1941). Propositions, Warranted Assertibility, and Truth. The Journal of Philosophy 38 (7), 169-186.

Connolly, W.E. (1974). Terms of Political Discourse. Lexington, Mass.: D C Heath.

Gallie, W.B. (1956). Essentially Contested Concepts. Proceedings of the Aristotelian Society 56, 167-198.

Gallie, W.B. (1956). Art as an Essentially Contested Concept. The Philosophical Quarterly 6 (23), 97-114.

Gray, J. (1978). On Liberty, Liberalism and Essential Contestability. British Journal of Political Science 8 (4), 385-402.

MacIntyre, A. (1973). The Essential Contestability of Some Social Concepts. Ethics 84 (1), 1-9.

Nussbaum, M. (1995). Non-relative virtues: An Aristotelian approach. In: The Quality of Life, {Eds. M. Nussbaum & A. Sen), pp. 242-269. Oxford: Clarendon Press.

Nussbaum, M.C. (1988). Non-Relative Virtues: An Aristotelian Approach. Midwest Studies In Philosophy 13 (1), 32-53.

Daniels, N. (1980). Reflective equilibrium and Archimedian points. Canadian Journal of Philosophy 10, 83-103.

Daniels, N. (1996). Justice and Justification: Reflective Equilibrium in Theory and Practice. Cambridge: Cambridge University Press.

DePaul, M.R. (2001). Balance and Refinement: Beyond Coherence Methods of Moral Inquiry. London: Routledge.

Little, M. (2000). Ethonomics - the ethics of the unaffordable Archives of Surgery 135, 17-21.

Mann, G.G. (1988). Ethonomics: An Enquiry into the Nature and Causes of the Wealth of Individuals. Ascot, Berkshire: Springwood Books.

Alison, F., Hodkinson, H., Hodkinson, P. & Unwin, L. (2005). Learning as Peripheral Participation in Communities of Practice: A Reassessment of Key Concepts in Workplace Learning. British Educational Research Journal 31 (1), 49-68.

Gabbay, J., le May, A., Jefferson, H., Web, D., Lovelock, R., Powell, J. & Lathlean, J. (2003). A case study of knowledge-management in multi-agency consumer-informed 'communities of practice': implications for evidence-based policy development in health and social services. Health 7 (3), 283-310.

Wenger, E. (1998). Communities of Practice: Learning, Meaning and Identity. Cambridge: Cambridge University Press.



  • There are currently no refbacks.