Instruments of Power: The Opioid Risk Tool, Foucault, and the Values Assessment Approach

Abstract

The clinical encounter between the clinician and the patient is the central, pivotal node ofthe healthcare domain. As such, there is a significant ethical onus on the clinician to assure that the practices they use during this encounter are in alignment with their ethical commitments to their patients. Most practices undergo either a formal or an informal validation procedure, and sometimes those validation procedures neglect or under-emphasize the role of ethics and of potential unintended consequences (Messick, 1989). Even practices that were validated in good faith and according to accepted standards may cause patient harm. Samuel Messick has stated that the validity of a practice depends as much on its ethical impact and the potential negative consequences it may incur as it does on its quantification and that these aspects are often neglected (Messick, 1989). This project is underpinned methodologically by Michel Foucault’s problematization approach (Foucault, 1990, 1995) and applies it to a widely accepted clinical practice called the Opioid Risk Tool (ORT) (Webster & Webster, 2005). The ORT is used as a critical case (Flyvbjerg, 2006; Yin, 2011) to show how problematization can critically interrogate a practice in ways that reveal some of its tacit biases and possibilities for causing patient harm that thus may pose potential ethical conflicts for the clinician. Problematizing the ORT then leads to the creation of the Values Assessment Approach (VAA) as a way to problematize other proposed clinical practices. The VAA is a novel approach that can offer clinical communities theopportunity to critically assess any proposed practice in a democratic and deliberative way in order to determine whether that practice is in alignment with the ethical commitments of the clinician community and what to do if ethical misalignments are revealed through applying this process.