We have thus shown experimentally that the two paradigms, EBM and VBM, can be converted into an EBM-VBM binomial through CME intervention. (Figures , , , , , and Tables and ).
Our results demonstrate that the healthcare personnel participating in a CME intervention in clinical ethics improved high-order values Openness to Change and Self-Transcendence, as observed through a concurrent triangulation approach (Figures and and Table ). Quantitative analysis showed that even if core values, such as honesty and respect, remained unchanged after educational intervention, other important values for the healthcare professional-patient relationship were changed (for example, justice, autonomy, love and charity). Moreover, the representations of values found in the qualitative analysis are compatible with the preceding results (compassion, justice, beneficence). In both cases, deontological and aretological values are susceptible to change in such a way as to fulfil the healing aims of medicine [2
Ethical discernment is a daunting task from the perspective of integral ethics, which seeks the good of the patient by integrating the three characteristics of action: as a moral agent, as a process to be evaluated from the perspective of rights and duties, and with respect to the consequences of the action. This approach ensures that healthcare professionals exercise their hierarchy of values (Figure and ).
Following Lozano, dilemmas can arise from different areas; different values and different kinds of ethics take precedence. Values consider the good that is to be achieved through a practice. However, when several of these values are in conflict and a decision cannot be reached, virtue becomes central in solving an ethical problem; the character, practical wisdom and experience of the practitioner are important resources for ethical deliberation (Figure ) [7
CME must focus on four areas to strengthen the EBM-VBM binomial: The first area is extensive knowledge of the pathophysiology of disease and availability of real therapeutic alternatives (EBM). The second area is knowledge and awareness of values (VBM). The third one is development of an ability to analyze and discern ethical dilemmas (VBM), and the fourth area is communication skills (VBM) [44
In this study, we validated our instrument (a value hierarchy in clinical practice) and identified the opportunity for CME intervention. Figure demonstrates that participants recognized that, to act fully as providers of medical assistance, advisors and educators, the most important values are honesty, respect and autonomy. These values are similar to those enumerated in the literature [46
]. These specific roles lend a multi-dimensional character to the patient-healthcare professional relationship. Our results (Table ) show that the most established role in this group of professionals is that of a provider of medical assistance; however, the CME intervention successfully developed bridges and networks to improve the practitioners' performance in the role of educator and adviser.
A notable outcome of our CME clinical ethics course is that it created awareness among physicians and healthcare professionals of how their decisions are made and the values that are at stake (Figures , , , , , ). Moreover, the intellectual exercise involving several ethical perspectives ensured that healthcare professionals deliberated in a comprehensive and thoughtful manner (Figures , , , , , ).
We propose that an integral approach to ethics similar to the one described by Polo [40
] is the solution to the increasing number of ethical dilemmas in medicine. Such an approach considers three features of ethical discernment: 1) The best decision is an integrated one that does not spring from isolated principles but one that allows the moral agent to consider due processes in a given context, as well as his/her own virtues in determining a course of action [14
]. Therefore, deontological, aretological and utilitarian criteria may overlap in decision making.
2) These criteria emphasize different issues involved in an ethical dilemma. A deontological criterion focuses on the fulfilment of general and comprehensive rules. A focus on virtue is more capable of addressing the immediate context. Moreover, a value such as efficiency should not be neglected in the healthcare professions. However, the specific configuration of the dilemma and the moral character of those involved will reveal which criteria should be prioritized in a process of wide reflexive equilibrium [47
3) The most important criterion for decision making is the respect for the universal trait of human dignity, even if those who address this dilemma conceive of it in different manners. Dignity supports the individual in acting conscientiously and making his/her own life choices [49
It is of the utmost importance to keep in mind the primacy of those affected by the decisions, ethical values and discernment of healthcare personnel. However, the decisions made by healthcare personnel not only affect patients but also the decision-makers themselves. These decisions determine what kind of person and professional one becomes, how sensitive one is towards others, and how attentive one is towards one's own needs. The best decisions justifiably solve a dilemma by integrating different ethical theories related to human actions. An integrated ethics approach is essential in medicine because medicine is concerned with the person and his/her interests, needs, vocation, virtues and transcendence.
In a nutshell, we can say that the CME intervention favors the creation of networks between EBM and VBM from a philosophical, epistemic, axiological and practical point of view. From the philosophical point of view, we were able to recover the ends of medical practice, namely: healing, curing and caring, the recognition of the person as central to healthcare. This is evident in Table where after the CME intervention; the representations and beliefs of the healthcare personnel were modified, and exhibited a more thorough understanding of the philosophy of medicine. From the epistemic point of view, the epistemic values that are related with medical attention were strengthened. Simultaneously, we perceived increased knowledge related to integral ethics. This can be seen in Table and Figures , , , , , , where the physicians' roles were more balanced. The promotion of personal growth through the exercise of values, such as autonomy, love, justice and freedom, could be seen. These values were rediscovered and used to improve the patient-healthcare personnel relationship. Both the quantitative (Figures , , , ), and the qualitative (Figures and , and Table ) analyses show the construction of links between EBM and VBM. From a practical perspective, tools for ethical discernment were provided, discursive spaces to reflect and critically analyze ethical dilemmas in clinical practice were created.
In ethical discernment, the use of clinical vignettes to picture situations with moral dilemmas proved useful. In these exercises autonomy stands out, it was a value previously overlooked and it became relevant for the healthcare personnel after the CME intervention. Additionally, ethical committees as guarantors of the humanization of healthcare were consolidated, while the promotion of a professional environment directed by academic, ethical and social excellence was encouraged. Strengthening values-based medicine automatically strengthens the EBM-VBM binomial given that they become more balanced. This is clearly shown in the present study. We are looking forward to continuing with the next phase of this project, which involves carrying out participant observation of the active healthcare personnel in medical units, in order to follow up on these results in the long term. This study is one of the first to explore the axiology of clinical practice. Different values and representations may be found depending on the studied population; however, we consider that the empirical method used to explore the representations of these professionals opens a window of opportunity for CME insofar as it strengthens the already-existing values among healthcare personnel; and at the same time, it promotes values that are missing but essential to an effective patient-healthcare personnel relationship. One dimension of medical responsibility involves being attentive to the values that need to be exercised. López Quintás [51
] explains that this attentiveness requires certain value-sensitivity: an ability to discover and recognize the fertility that values have in our lives, when they offer authentic possibilities for personal growth.