Commentary: The Fragmentation of Value
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Description
The conflicts between disparate values, claims, and interests described in Stephen Toulmin's paper are not limited to the professions. They belong to a broader category of practical and moral problems that merits attention: the problems created by a disparity between the fragmentation of value and the singleness of decision. Members of the professions serve the interests of their clients in ways that cannot be immediately and directly evaluated by the clients, because they involve special knowledge and uncertainty and delay in the achievement of results. Therefore clients cannot regulate professional activity in detail. Professional codes are designed for the conspicuous self-regulation of such activities and services, so that the public can submit to professional ministrations with reasonable confidence. If the justification for that confidence is sometimes doubted in the case of medicine, it is because the public recognizes the variety of claims on a physician, from within and without, and sees that the patient's interests have a great deal to compete with. A realistic professional code will reflect these conflicts. It may tum out, however, that they are not most fairly dealt with by a system of professional self-regulation. Leaving aside the economic interests of physicians, the main competitors of the individual patient's interests are medical research and medical education, both of which serve the interests of future patients but may involve risk and sacrifice of comfort to the one who is serving as a subject. Some such distribution of burdens is necessary, but its shape is too often determined by factors like poverty and ignorance. Some people have no choice about the terms under which they will undergo medical treatment. There is a case for external regulation both of how patients may be used for research and training, and of which patients are thus used. But I am going to discuss the problem of practical conflict more generally, with only occasional reference to the biomedical professions. By a practical conflict I do not mean merely a difficult decision. Decisions may be difficult for a number of reasons: because the considerations on different sides are very evenly balanced; because the facts are uncertain; because the probability of different outcomes of the possible courses of action is unknown. A difficult choice between chemotherapy and surgery, when it is uncertain which will be more effective, is not an example of what I mean by practical conflict, because it does not involve conflict between values which are incomparable for reasons apart from uncertainty about the facts. There can be cases where, even if one is fairly sure about the outcomes of alternative courses of action, or about their probability distributions, and even though one knows how to distinguish the pros and cons, one is nevertheless unable to bring them together in a single evaluative judgment, even to the extent of finding them evenly balanced. An even balance requires comparable quantities. The strongest cases of conflict are genuine dilemmas, where there is decisive support for two or more incompatible courses of action or inaction. In that case a decision will still be necessary, but it will seem necessarily arbitrary. When two choices are very evenly balanced, it doesn't matter which choice one makes, and arbitrariness is no problem. But when each seems right for reasons that appear decisive and sufficient, arbitrariness means the lack of reasons where reasons are needed, since either choice will mean acting against some reasons without being able to claim that they are outweighed. Whether the conflict is a true dilemma or just a decision involving disparate values, it seems reasonable to propose, as Toulmin does, that to deal with it one must establish priorities among the conflicting claims. However, it is not clear how this can be done, or even what form the priorities would take. (It is unlikely, for example, that an absolute ranking of values into an order of precedence could be correct: even if X usually takes priority over Y, some large weight of Y will outweigh some small weight of X.) And the problem cannot even be addressed until we know more about the claims or values that give rise to the conflicts we are trying to resolve. My own view is that a general system of priorities, whether or not it involves the reduction of apparently disparate values to a common denominator, is not the appropriate method for dealing with these problems. But I shall argue for the point only after saying something about the sources of practical conflict, and how they can be classified.
Source Publication
Knowledge, Value and Belief
Source Editors/Authors
H. Tristram Engelhardt, Jr., Daniel Callahan
Publication Date
1977
Recommended Citation
Nagel, Thomas, "Commentary: The Fragmentation of Value" (1977). Faculty Chapters. 1328.
https://gretchen.law.nyu.edu/fac-chapt/1328
