context. The aim of setting standards in clinical governance is to determine the
best' treatment or approach to a condition and implement these findings across the whole of the NHS. These standards will be set b yconsidering the medical evidence and b yemplo ying a rigorous methodolog yto determine the best treat- ment scientifically. There is an implicit assumption that by establishing the quality of a treatment in this wa yit can be done without recourse to values or personal opinion. I want to consider this view that this method will tell us which treatments arebetter' scientificall yand argue that although medical science can make an
important contribution to treatment decisions, value judgements still come into
qualit yassessments and these should be explicitl yrecognised.
It could be argued that b yusing such a scientific methodolog yto set standards,
values can be eradicated completel yfrom this whole process. There is an implicit
strand running through the literature that b yusing such tools in setting standards,
decisions will be made on a more objective basis. Book titles such asThe Scientific
Basis of the Health Serviceconjure up images of a value free utopia. It is eas yto
suppose that as the evidence of effectiveness is improving, we are increasing our
knowledge base and thus decreasing the need for values. Medicine in both clinical
practice and research is concerned with establishing the facts of the matter, and
scientific method is often thought to be defined b yimpartialit yand objectivit y.
It is the objective nature b ywhich the evidence based medicine paradigm approaches the question of ``what are we doing'' and ``how can we do better'' that causes health care providers and funding agencies to increasingl yadopt this paradigm as a primar yprinciple.' [4] Underlying this position, that by employing the tools of evidence based medi- cine ,EBM), values can be eradicated from the standard setting process, are two assumptions: the improvement in medical evidence gives us a more accurate picture of which treatments work, and the use of systematic reviews can provide us with mechanisms that enable us to gain accurate knowledge of these findings. These findings are then implemented in clinical practice; because the findings are thought to be objective it is inferred the decision is objective too ± values have no role to play. Given this understanding, by using high quality evidence standard setting decisions can be made on ascientific' basis and therefore are supposedly
open to less interpretation. As Kleinet al.note, this appears to allow decision-
makers, `the prospect of less pain, [and] less responsibilit yfor taking difficult
decisions' [5].
So, b ythe application of the methodolog yof EBM, can bodies aiming to set
national standards of service provision decide what is the best treatment without
recourse to an yvalue judgements? I will argue that this is not possible for two
reasons. First, the ver yterm effectiveness is a subjective one in that it incorporates
important value judgements. Second, even if what is the best treatment could be
proven scientificall yand objectivel y, we would still need to use value judgements
to help tell us how to use that information. I will deal with these points in turn.
11.12.1 Effectiveness and value judgements
To sa ya treatment is effective, and hence of better qualit y, incorporates non-
242 Nursing Law and Ethics