Values In Canadian Health Policy Analysis: What Are We Talking About?

Key Implications for Decision Makers

  • Values are like atoms. Values seem to be everywhere, like atoms - all-pervasive, extremely important, yet often invisible. We always think with them, but there are occasions when we must also think about them. This report offers "periodic tables" for locating specific types of values for policy analysis and understanding their relationship to each other. The frameworks challenge some popular views of values in health policy, and suggest in particular that:

    • Values are not just preferences.
    • Values are not just individuals' deep-rooted beliefs.
    • Individual and collective values are made of different, incommensurable substances.
    • Weighing values tells us little about what to do with them.

  • And values are also like onions. Studying policy values critically leads the policy analyst through layers of reasoning that is definitional (that is, what values are important, what values are like, where values are found) as well as instrumental (that is, what should we do with values and how).

  • Strive for the big picture and critique its parts. Values can be found in many actors (individuals, communities, humanity, the human species) and may take many forms (ideas, words, actions). They also can play several roles in policy arguments (means, ends, embodiments, representations). Rigorous and meaningful policy analyses of values will: (1) seek multiple sources of information, (2) pay attention to imagery, and, (3) interpret each source of values information critically, in awareness of its characteristic limitations.

  • Reading between the lines is necessary and difficult. Values rhetoric is artful and complicated. Analysts must critically interpret values statements - as well as silences - in context to discern their true meaning.

  • Evidence is not value-free. This imperative to read between the lines extends to the interpretation of research evidence. Value-laden choices guide the training of researchers, posing research questions, selecting methods for answering research questions, providing the resources to pursue the answers, distilling the answers into facts to be reported, and creating an audience for research reports.

  • From platitudes to policies. Stakeholders disagree over whether declared values have real meaning, provide real guidance, confer real responsibility and accountability. Values, unlike goals, do not necessarily entail specific policies. Our relationship with values involves developmental aspects (for example, creating, cultivating, changing values); philosophical aspects (for example, apprehending possible values, critically interpreting values), and discursive aspects (for example, conversing, deliberating, and persuading).

Executive Summary

Introduction

In health policy and politics, stakeholders talk a great deal about "values," but do not always clarify what they mean. They consequently may talk about different things without even realizing it. This study addressed the following questions:

  • What do Canadian health reform documents call "values"?
  • How do Canadian health reform documents invoke values?
  • How do scholars define values and where do they find them (in individuals, groups, societies)?
  • What are some lessons for policy analysis?

Values in Canadian health reform documents

We conducted a qualitative content analysis of 36 Canadian health reform documents published from 1990-1999, analyzing how their authors address and discuss values. We found from this that Canadian health reformers call a great variety of things "values" in their writings, including: the Canadian health system itself, health states, equity, access, economic viability, and relationships. Further, these values describe concepts that are quite different from each other, such as goodness, physical entities, principles, specific goals, or attitudes and feelings.

Few documents reflect on the meaning or definition of values. However, most do invoke values. For instance, almost all documents presented a list of a few "tenets countable by hand" with which to frame their reform proposals, such as "10 guiding principles," "9 vision statements," "7 major directions for change," etc. Values also appear in litanies (e.g., "quality, access, efficiency, and accountability"). These lists provide convenient reference but in themselves have limited impact on the reader. Values are balanced with qualifiers such as "appropriate" or "reasonable" that themselves imply values; they are also often balanced against each other as tradeoffs. Negative values are seldom called "values," and authors do not distinguish their relative positions in terms of being "for" a value that others are "against" (e.g., if some support equity, this does not mean that others promote inequity per se). Finally, missing values tell a mysterious tale: when an author fails to declare a particular value, it may mean either that the value is not prized or that it is so deeply held that it is taken for granted.

Values in the scholarly literature

In parallel to the content analysis of Canadian health reform documents, we conducted a scholarly review and synthesis of values theories found in a wide variety of academic disciplines. From this review we developed two synthetic frameworks for policy analysis: one for finding values for empirical study, and one for finding values in policy reasoning.

The importance and definition of values. The idea of values appeals to us for various reasons that are, in themselves, values. Our urge to talk in terms of values may stem from the search for a technical (as opposed to moral) basis for policy norms, a respect for individuals or diverse cultures, a sense that empirical facts or economic calculations neglect what is important, or other reasons. There are many competing definitions of values in the social sciences and humanities. And, contrary to popular conceptions, all facts contain values. Values generate and mould facts, as well as affect their meaning and dissemination.

Locating values for empirical study. To study values empirically, we must start with some idea of where to look for (locate) values and how to recognize them. The literature in various disciplines proposes many places and actors where values may be found, including individuals, communities, humanity, or the human animal. Further, each of these actors may manifest values in various kinds of expressions, including their ideas (thoughts, philosophies), words, or actions. Together, these two dimensions generate several possible values locations, each of which in turn implies a distinctive method for study (experiment, interpretation, survey, philosophizing, etc.). Scholars offer a range of ideas about the nature of values and where to find them, as well as methods for studying them. Because of this complexity, a more comprehensive picture of current values may emerge from multiple, rather than single, methodological approaches.

Locating values in policy reasoning. In policy reasoning, values are often discussed not only in terms of who possesses them and how they are expressed, but also as "means versus ends". Values as ends speak to decision making that involves identifying what is ultimately important and envisioning what is desirable in the long term, rather than to making concrete choices or taking action. Values as means, on the other hand, are used to implement the end values. They pertain to decision making that involves making choices or taking action; they are less concerned with what ultimately matters and more concerned with what must be done. They are viewed as less morally-based than ultimate values, more concrete, and more debatable. Policy makers address values as end on occasion (for example, in priority setting or strategic planning exercises), but values as means continually (for example, in their choice of instruments for carrying out their missions). Between these two value types lie values that either represent or embody the means and ends values. It is important to note that any given value (for example, health, justice, user charge prohibitions) does not occupy a natural place on this spectrum, but rather is placed there (and is held in its place) through careful argument.

Lessons

Values are like atoms. Values seem to be everywhere, like atoms - all pervasive, extremely important, and hard to examine without special tools. We always think with them, but there are occasions when we must also think about them. Two frameworks in the report offer rough "periodic tables" for locating specific types of values for policy analysis and understanding their relationship to each other. This analysis challenges some popular views of values in health policy, and suggests that:

  • Values are not just preferences.
  • Values are not just individuals' deep-rooted beliefs.
  • Individual and collective values are made of different, incomparable substances.
  • Weighing values tells us little about what to do with them.

And values are like onions. Studying policy values critically leads the policy analyst through layers of reasoning that involves descriptive reasoning (that is, what values are important, what values are like, where values are found) as well as instrumental reasoning (that is, what should be done with values and how).

Strive for the big picture and critique its parts. Values can be found in many actors (individuals, communities, humanity, the human species) and may take many forms (ideas, words, actions). They also can play several roles in policy arguments (means, ends, embodiments, representations). Rigorous and meaningful analyses of values will: (1) use multiple sources of information and will understand the relative contribution of each source to the "bigger picture (2) pay attention to imagery and other techniques used by authors, and (3) interpret each source of information critically, being aware of its limitations.
Reading between the lines is necessary and difficult. The rhetoric used when discussing values is artful and complicated. Analysts must critically interpret values statements ¾ as well as silences - in context to discern their true meaning.

Evidence is not value-free. This imperative to read between the lines also applies to the interpretation of research evidence. Values influence all of these researcher choices: researcher training, posing research questions, selecting or developing methods for answering research questions, providing the resources to pursue the answers, distilling the answers into facts to be reported, and creating an audience for research reports.

From platitudes to policies. Stakeholders disagree over whether declared values have real meaning, provide real guidance, and confer real responsibility and accountability. Values, unlike goals, do not necessarily entail specific policies. Our relationship with values involves developmental aspects (for example, creating, cultivating, changing values); philosophical aspects (for example, apprehending possible values, critically interpreting values), and discursive aspects (for example, conversing, deliberating, and persuading).