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II. The Concept of Values
III. Values and Human Needs
IV. Value Issues in Biomedical Practice
V. Fluidity of Values
VI. Moral Values
VII. Values and Human Action
VIII. Values in Society and Culture
IX. Critical Reflection on Values
X. Public Value Syntheses
Though values are integral to human experience, it is only in modern societies that they have gained an explicit place in ethics. In traditional societies, values generally operate as components of the common culture that are taken for granted. Their moral discourse focuses on the rules that define primary human obligations and on notions of moral excellence. Values first acquire ethical importance where individuals have wide choices about how they are to live their lives. These choices lead to a plurality of value perspectives whose competing claims may appear to express little more than subjective preferences. The challenge to ethics, then, is to devise ways of assessing values critically in relation to normative moral discourse.
In European civilizations, wide value choices were first opened up by the rise of capitalism and of liberal democratic states. In this context, value considerations are never far removed from market dynamics or from basic principles of human liberty. Although class and status factors bar many from the benefits of these modern social formations, their impact on human life remains pervasive, compelling us for the sake of social order to accommodate various value orientations.
II. The Concept of Values
We take note of the realities in our world that matter to us. Values are concepts we use to explain how and why various realities matter. Values are not to be confused with concrete goods. They are ideas, images, notions. Values attract us. We aspire after the good they articulate. We expect to find our own good in relation to what they offer.
Because values are linked to realities we experience, they have an objective reference. They disclose features in our everyday world to which we attach special importance. Positive values are balanced by disvalues. Disvalues express what we consider undesirable, harmful, or unworthy about particular phenomena. They identify realities that we resist or strive to avoid. Virtually everything we experience has valuative significance: objects, states of affairs, activities, processes, performances, relational networks, and so on.
Values are linked to acts of valuation (Scheler). For every value that appears, there is a corresponding valuative orientation (Husserl). This orientation may not be fully self-conscious; still less is it an expression of critical judgment. It is, nonetheless, the subjective basis for the appearance of values. Without valuing subjects, there can be no such thing as values.
In an elemental sense, values are disclosed by feelings (Ricoeur). Explicit value language comes later, if at all. How do I know that health is good? I know because I feel good when I am healthy. The positive feeling signals the presence of value. How do I know that a performance of Shakespeare’s Hamlet is good? Even an informed aesthetic judgment has an affective basis: I was moved by it. In being moved, I apprehend value. My primal awareness of value becomes explicit as I identify the features in a phenomenon that draw me to it. Human languages furnish a rich vocabulary for conversations about values.
The correlation between values and valuative acts does not imply that values are purely subjective or that they are merely secondary embellishments of empirical fact. On the contrary, the notion of an empirical reality devoid of all valuative meaning is itself an abstraction. As our perceptions disclose an object’s reality, so our affections disclose its worth (Ricoeur). By means of perceptions and affections, we apprehend facets of the realities we encounter. Apart from corresponding acts of consciousness, however, nothing whatever can appear.
III. Values and Human Needs
Values are intimately related to human needs and desires (Niebuhr; Ogletree; Ricoeur). We value realities that satisfy basic needs and fulfill deeply felt aspirations. We associate disvalues with realities that threaten or diminish human well-being. Human well-being is only part of the story. With a growing environmental consciousness, value discussions embrace nonhuman life forms as well, perhaps creaturely well-being as a whole. Human life then gains its value within a natural world that has intrinsic worth. Religious communities honor a world-transcending center of values from which all lesser values derive their significance.
There are as many kinds of values as there are regions of experience where we distinguish good or bad, better or worse, beneficial or harmful: sensory values, organic values, personal values, interpersonal values, social values, cultural values, and spiritual values (Scheler). Social values can be differentiated into economic, political, legal, associational, and familial subsets. Cultural values embrace religious, moral, cognitive, and aesthetic interests (Parsons). The formal value types all contain values and disvalues. Notions of creaturely well-being are implied if not stated.
IV. Value Issues in Biomedical Practice
Virtually all kinds of values figure in biomedical practice. Organic values are basic: life, health, vigor, bodily integrity. The purpose of medicine is to save lives and to promote healing. Yet the ill and injured are never merely “patients,” organisms suffering treatable maladies; they are persons with dignity who have their own life plans (May, 1991; Ramsey). Personal values, therefore, qualify organic values. Patients as persons may in no case be subjected to medical procedures without informed consent. Ideally, they participate actively in their own healing.
Organic values are inherently problematic. Our impulses press us to strive for life, strength, and agility. Yet these strivings are limited by our vulnerability to illness, injury, disability, and, finally, certain death. Modern medicine inclines us to define the limits of organic life not as natural features of finitude but as problems to be solved. This tendency requires us to make value judgments about the boundaries of medical intervention. Medical practices inattentive to these boundaries can deprive the dying of the personal space they need to achieve closure in their life pilgrimages.
At this point, organic values are qualified by more encompassing value commitments. Such commitments can help us to accept life’s limits, acknowledge goods more noble than our own survival, and endure sufferings and disappointments with grace and wisdom. Life, death, health, and illness are never purely physiological; they are moral and spiritual as well. Healthcare must also have moral and spiritual as well as physiological dimensions (Cousins; May, 1991; Nelson and Rohricht).
Professional and economic values intersect medical practice in similar ways. Physicians have specialized knowledge that equips them to provide socially valued services. They enjoy social status as professionals who maintain standards for medical practice. In this role, they are public guarantors of prized social values (May, 1983). Physicians in the United States offer services for fees, primarily through third-party payments. Accordingly, medical practice is also a market transaction, and physicians are businesspeople with economic interests. The stake in economic values qualifies professional devotion to patient well-being.
The organization of healthcare profoundly conditions its operative values. Modern medicine requires sophisticated technologies affordable only to large medical centers. These institutions, usually constituted as corporations, dominate medical practice in the United States. The technologies they use are typically produced and supplied by global corporations. The income they receive derives largely from corporate employee-benefit plans and from insurance firms that service them. Health-related industries have become a major component of the economy, perhaps inappropriately overriding the legitimate claims of other social goods. Powerful economic and political interests support the continued growth of medical enterprises with little regard for wider social ramifications.
Because the desire for quality medical services is urgent, intense public debate surrounds federal policies that bear upon the organization, regulation, and funding of healthcare. The struggle is to determine appropriate government roles for the oversight and financing of biomedical activities. In this struggle, conflicting political values intersect healthcare practices as public actors respond to constituent interests. Similar sociocultural analyses could be directed to the roles played in the healthcare system by values resident in families, religious communities, research institutes, medical colleges, the legal system, the media, and the arts. Ethical studies of the intersection between biomedical practices and social processes uncover a volatile mix of conflict-laden value issues.
V. Fluidity of Values
Values are not only pervasive but also fluid. Any concrete experience harbors many values and disvalues, none of which is definitive or self-contained. Illness can be a physical malady, a ruthless disruption of personal plans, an economic disaster, an opportunity for self-discovery, a moment of human bonding, an occasion for medical virtuosity, or a case study in biomedical research (May, 1991). Each of these meanings captures some of the values that belong to a particular experience. As attention shifts, one set of values continually flows into another.
Our terminology for values is similarly fluid. The word health can be used descriptively; it also identifies an important value. Justice can designate a basic moral principle; it can refer equally to a value worthy of promotion in social arrangements. The term objective may characterize “value-free” inquiry, but it also designates a cognitive value.
Because of their fluidity, values resist schematic classification. Attempts to construct comprehensive value schemes do, however, have heuristic significance. They heighten awareness of the range of our valuative connections with our world, and they stimulate reflections on what belongs to human well-being (Hartmann; Perry; Scheler).
VI. Moral Values
Within the value field, we can isolate a subset of moral values. Moral values cluster around personal identity, interpersonal relationships, and the makeup of groups, associations, social institutions, whole societies, and even the global community (Scheler). Numerous values—dignity, integrity, mutual respect, loyalty, friendship, social cohesion, fairness, stability, effectiveness, inclusiveness—are moral in import. Anthropocentric values are supplemented and corrected by the moral claims of animals and, more broadly, by the moral claims of the environment, a self-sustaining ecosystem. Even religious devotion to the divine life has moral dimensions, for the faithful are obliged to honor God as the final bearer of value.
Moral values enjoy precedence within the value field because they identify the basic loci of all valuing experience— that is, valuing subjects in relationship. Where moral values are secure, we can cultivate a wide array of values. Where moral values are in danger, all values are at risk.
Even so, in our responses to concrete cases we regularly rank some nonmoral values above specifically moral ones. Faced with a health emergency, our regard for life itself, an organic value, surpasses normal preoccupations with human dignity, a moral value. We do what we can to save a life! At the same time, we know that life as such is but one value among many. Prolonging human life can never, therefore, be the primary goal.
Similarly, human beings can often best advance their own good through value commitments that transcend specifically moral considerations. Cognitive, aesthetic, and especially spiritual values finally stand higher than moral values in most value schemes because they bestow significance on existence in its travail and woe. Yet these values still require for their realization valuing subjects who are bearers of moral value.
We normally discuss moral values in terms of rights and duties. Rights identify claims that others properly make on us. These claims intersect our value-oriented projects and disclose our duties. A physician’s professional judgment about a course of therapy is subject to the patient’s informed consent. The abortion debate hinges on differing assessments of fetal rights against a pregnant woman’s right to choose.
Duties consist of obligations and prohibitions. Obligations specify what we must do no matter what else we might also hope to accomplish. Hospital emergency rooms must treat seriously injured persons regardless of whether they can pay, offering such care as a part of normal operations. Prohibitions specify what we must not do regardless of larger objectives. We must not use human beings as research subjects without their consent no matter how important the research may be.
It is for the sake of moral values that basic rights and duties are binding. We may set such mandates aside only when extraordinary measures are required to safeguard the values they protect. For the sake of human dignity, physicians are normally obliged to do all they reasonably can to sustain the lives of their patients. Precisely for the sake of human dignity, however, this obligation loses its force when further medical interventions would only prolong the dying process.
VII. Values and Human Action
Value awareness gains practical importance in terms of action (Ricoeur). We adopt courses of action that promise results favoring our prized values; we act to inhibit developments that endanger our values. Values guide decision making, disposing us to choose one course of action over another. We justify our decisions in terms of the values they are designed to promote.
Matters do not always turn out as we expect. We may lack the skill, the power, the influence, or the knowledge to achieve our objectives. In medical practice, few surprises follow the skilled application of routine therapies proven to be effective for treating particular ills. Physicians do not stay within safe territory, however. They regularly confront medical problems that they cannot diagnose with confidence and for which there are no known clinical responses with assured results. Medical outcomes frequently fall short of human hopes. They include side effects whose disvalues outweigh desired values. “Side effects” belong to action consequences even when they do not reflect our intentions.
When our actions affect the actions of others, uncertainty increases. Other people may not react as we expect. They may misunderstand our intentions or respond carelessly. We may misread their value commitments. Perhaps the relevant network of human interactions is so vast and complex that it surpasses what we can grasp. Here, too, the outcomes may not fit our values. Prediction is most reliable for highly routine actions with widely understood purposes. It is least reliable for novel initiatives, such as new directions in policy.
Because we cannot fully control or predict the consequences of our actions, the fit between actions and values is inexact. This inexactness carries over into value assessments. We may readily name the values that attach to desired outcomes. Before we can evaluate a course of action, however, we have to consider the uncertainties. We have to weigh the disvalues that could accompany significant miscalculations. Considerations of value differ from discussions of duty by virtue of the inexact fit between values and action. Duty refers not to the likely outcomes of actions but to actions as such, which are largely in our power. It specifies ground rules that order human activity. In general, we may pursue a larger vision of the good only within constraints set by these ground rules. In its early stages, biomedical ethics properly gave precedence to the delineation of basic moral duties.
The fit between values, action, and action consequences remains close enough, however, that values must figure in the ethical examination of action. I am accountable to myself and others not simply for the conformity of my actions to rules that define my duties but also for values and disvalues that reside in the results of my actions. In decision making, I project the likely outcomes of actions I am considering and I weigh probabilities that qualify my projections. I also bring into view risks of unpleasant surprises. Practical reflection on values depends on substantial knowledge of the social dynamics that structure action.
VIII. Values in Society and Culture
In traditional societies, the most crucial value issues are largely settled. To be viable, a society requires a shared set of reasonably cohesive values. This shared value cluster composes the society’s moral identity. It is expressed in many ways within the common culture: public rituals, speeches, novels, paintings, school textbooks, standard histories, and scholarly investigations.
Modern societies with market economies and liberal democracies are not able to sustain comprehensive value syntheses. At best, they promote what John Rawls calls a “thin” theory of the good—that is, elemental goods that all are presumed to need and want whatever else they might also desire (Rawls). Within the framework of basic goods, such societies host a multiplicity of concrete value orientations, reflecting the diverse priorities of individuals and groups within the society. Some question whether we can sustain even a “thin” theory of the good without a widely shared, substantive value synthesis fostered in basic social institutions (MacIntyre). The disintegration of traditional cultural values tends to undermine interest in the common good. Private preoccupations with individual advantage and “interest group” politics then displaces public discourse about the good of the society as a whole. Likewise, political battles are fought without the restraints of civility necessary to social order. Value theory becomes urgent when basic values are in dispute. Its task is not only to advance critical investigations of persistent value disputes but also to show how various value streams within a pluralistic society can contribute to the good of all.
IX. Critical Reflection on Values
The scrutiny of values has four crucial layers: (1) the reflective identification of our operative values; (2) assessments of the fit between these operative values and considered judgments about creaturely well-being; (3) analyses of value relations in order to identify compatible and incompatible values sets; and (4) imaginative constructions of value syntheses capable of ordering life priorities in personal, communal, and social contexts.
The investigation of values begins with description. We seek to become self-conscious about the values we prize, taking note of value commitments ingrained in stable life patterns and ongoing institutional involvements. The descriptive task is informed by historical studies of normative traditions and of social developments leading to current practices. As we make our operative values explicit, we are often stimulated to reorder our priorities. We recognize that existing arrangements do not reflect our convictions about what matters most in life.
The relation that values have to basic human needs suggests a second step in value studies. British utilitarians and American pragmatists sought to test our presumptive values by empirical investigations (Bentham; Dewey). Their aim was to discover life practices and value attachments that truly accord with primary human needs. Much human-science research functions as value inquiry of this sort, shedding light on value patterns that tend to promote human well-being in contrast to those that finally prove dysfunctional. Historical, philosophical, and theological reflections can also inform such inquiry. For ethics, the challenge is to clarify the contributions empirical studies can make to the critical assessment of values and to incorporate those contributions into constructive philosophical and religious thought. The third step is an analysis of value relations. Not all values are compatible with one another, at least not in practical terms. We cannot both affirm free speech and shield people from all offensive public expressions. We cannot protect the environment without constraining market freedoms. Likewise, we cannot guarantee everyone healthcare that fully utilizes the most advanced medical technologies while also controlling aggregate healthcare costs. Critical thought examines values in terms of their fit with one another. It dramatizes the necessity of choices among different sets of values. We bypass some values and endure relative disvalues for the sake of value combinations that reflect considered priorities. The crucial step in the critical study of values is the imaginative construction of coherent value syntheses capable of guiding action. Because modern societies harbor a multiplicity of value perspectives, attempts to determine value priorities take place in several contexts.
Individuals develop a mature moral identity by clarifying the connections and priorities that order personally cherished values. Value syntheses are no less vital for families, special-interest associations, and religious bodies. These collectives gain moral, and perhaps religious, identity through shared value commitments. Organizations that give concrete form to economic, legal, political, and cultural institutions are themselves more effective when they make their defining values explicit.
Coherent sets of values are not easily achieved or sustained. They enjoy the greatest authority when they emerge as critical appropriations and transformations of normative value traditions within contemporary life settings. Because of the complexity of experience, value syntheses can never fully overcome areas of ambivalence or wholly resolve internal strains. Within limits, we can accommodate value conflicts that we acknowledge and honor. Such conflicts may even stimulate creativity. Within comprehensive value syntheses, value priorities normally run in two contrary directions. Elemental sensory, organic, and economic values enjoy priority over higher political, cultural, and spiritual values in the sense that they furnish the conditions necessary to the appearance of the higher values. Political, cultural, and spiritual values enjoy priority over more basic sensory, organic, and economic values in the sense that they bestow meaning and significance on the more elemental values. Moral values play the mediating role because they identify the loci of value experience. These contrasting modes of priority can shed light on concrete values conflicts.
X. Public Value Syntheses
A basic value of modern societies is the protection of private spaces for people to pursue diverse visions of the good. Social cohesion rests, then, on minimal agreements that allow individuals and groups to live together in their diversity. In the United States, the prevailing value synthesis combines liberal democratic principles and principles of free-market capitalism. Enduring controversies concern the nature and extent of appropriate government intervention in market processes. Less clearly articulated are images of a greater national community embracing many races, cultures, and religions. The latter images are countered by persisting patterns of racism, ethnocentrism, and religious intolerance.
In biomedical ethics, the most urgent challenge is to form a public value synthesis that can guide healthcare reform. Though difficult disputes remain, there is considerable agreement that a good system will guarantee basic care for all, maintain acceptable standards of quality, foster an active partnership between patients and physicians, take account of the defining values of those who give and receive care, sustain advanced biomedical research, hold total costs to manageable levels, and protect contexts for personal preferences and individual initiatives in delivering and receiving care. These values—especially the contention that all people must have access to basic medical services—all have important moral dimensions.
Any workable system will include value trade-offs. It will require a reexamination of standards of quality care, a balance between healthcare needs and other social goods, and a workable mix of economic incentives and government regulations that maintains discipline within the system while allowing space for individual initiatives. Any system will also confront limits. Moral creativity requires imaginative responses to limits in the promotion of creaturely well-being.
Because of the subtleties involved, bioethics cannot easily incorporate notions of value and valuation into deliberations about basic human duties. Yet values pervade human experience. They even shape our perceptions of the obligations and prohibitions that set constraints on our actions. As we examine more comprehensively the moral issues that reside in biomedical practice, the more we will discover the necessity of systematic value assessments. Critical value studies will tend as well to force a shift in the dominant structure of moral reasoning, from the linear logic of the syllogism to the more nuanced process of weaving multiple value considerations together into an illuminating pattern of moral understanding. While the resulting judgments may appear less precise and decisive, they will probably be more true to life.
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