Marianne Boenink

Co-referaat paper Rein Vos: Promoting the valuable? Medical technology, bioethics and philosophy: the case of tandem mass spectrometry

Workshop Ethics & Technology, UT 30 & 31 januari 2004

Marianne Boenink, Universiteit Twente

Introduction:

Rein Vos’s paper is both wide-ranging and complex; it offers nothing less than a reconsideration of what ethical reflection is all about and how it should proceed. This is wide-ranging indeed; it is probably more than asked for in the context of this conference. I must admit that my first reaction when I read it, was that it does not really tackle issues specific for medical technology, perhaps not even for technology in general. The paper makes a rather general claim about the teleological structure implied by most thinking about values, and thus has implications for ethical reflection on any domain. However, Vos’s point (noted in passing) that technology may be trapped in a teleological structure from two sides, that is, from the side of technology as well as from the side of values, is certainly relevant to philosophers of technology, and so is his proposal for grappling with ethical issues in a technologcial context.

As to the complexity: I found it difficult to grasp the argument, let alone its implications, at once. I was very glad, therefore, to be asked by the organizers of this conference to summarize the line of argument and the most important points for those who haven’t read the paper – summarizing your paper turned out to be very helpful to grasp it myself. So, let me first give you the main points of the paper as I see them.

Summary of line of argument and most important points

The paper starts with the observation that ethical reflection on medical technology mostly circles around the question how to assess technology’s contribution to the good life. Vos wants to bring into view an assumption shared by all views alike: the idea that technology is promoting something valuable (p. 4), and that therefore ethical technology assessment should focus on the values promoted (whether by technology itself or by its users). This assumption in turn presupposes, according to Vos, a specific view on values and valuing which is that values are, just like technology, teleological in structure.

Vos contends that almost all ethical theories imply that values have a teleological structure, that is, that “something is good if it is to be promoted, and something is bad if it is to be prevented” (7)

When a value is seen as something to be promoted (or prevented), two more implications seem to follow:

- the activity of valuing consists of two parts: perceiving something as (un)desirable and concluding that action should be taken to promote or prevent it

- values can be seen in terms of strength, so ethical reasoning is a form of balancing the respective strenghts of competing values (8)

Vos’s most important objection to the teleological framework is that not all values are things to be promoted/prevented; thus, not all ethical reflection can be cast in teleological form (9). He exemplifies this by pointing to the value of friendship: friendship is a good, but should not be promoted at all costs.

The alternative approach Vos suggests, is based on Scanlon, who in a rather Wittgensteinian turn of phrase has written that “understanding the value of something is not just a matter of knowing how valuable it is, but rather a matter of knowing how to value it – knowing what kinds of actions and attitudes are called for” (10) Vos argues that ethical reflection should focus on how to value, that is, on what it means to value something (on the actions and attitudes to things we want to call for) (13), not on the balancing of values. Values are the output, the conclusion of practical reasoning, not the input, he concludes (14).

The difference between this approach and the teleologcial frame is illustrated by the debate on tandem mass spectrometry. I will not go into this here, because the line of argument is clear enough without.

After this summary (which I hope Vos can endorse), let me give some comments. I will first comment on some of the theoretical issues, and then go on to investigate why the alternative approach might be worthwhile and connect it to my own research.

I On values and valuing: theoretical points

The line of argument sketched before, seems to me to ask for clarification on several points. Let me list them before I will discuss some of them more elaborately:

1. Most importantly: what do you mean exactly with the ‘teleological structure of values’?

2. If we agree about this terminology, than the question that is central to your argument arises: is this structure to be found in all values or only in some?

3. Do all theories presuppose this structure?

4. I wonder whether and why it is problematic to presuppose such a teleological structure?

Finally, we may ask how convincing the proposed alternative is. I will focus here first on question 1, 2 and 4 and then go on to discuss the merits of Vos’s alternative.

ad 1: What do you mean exactly with the ‘teleological structure of values’?

I had some real difficulty to understand what you mean with this expression, so let us look at the way it is presented in your paper. The claim that values might have a teleological structure is introduced after a discussion of the teleological structure often ascribed to technology. In the technologcial context this teleological structure is characterised as “implicating goals and means, functions and structures, power and control” (4). This rather loose description is followed by a more specific one: “The teleological structure implicates that to discern something as good is equivalent with a valuable good to be promoted.”(4) This latter formulation returns when the teleological sturcture of values is discussed (p. 7): “the major implication is the idea that to be bad is simply ‘to be prevented’ (or to be good is ‘to be promoted’.”

This seems to me a rather imprecise and far-reaching definition of ‘teleological’. Imprecise, because traditionally, something has a teleological character if it is oriented towards some good or a goal. Defined in this way, it is not difficult to see that most technologies are teleological in structure indeed. However, it is much more difficult to understand why values would be teleological, since they are mostly understood as the goods (or bads) referred to in this definition. It does not make much sense to say that a value like friendship or health is oriented towards a good or a goal, unless it is a value that is instrumental towards some other good. However, we might have reason to say that the activity of valuing is teleological, that is, valuing might be oriented to the realization of the value in kind. Thus, there seems to be an important difference to be observed between values and valuing.

ad 2. Is this teleological structure something which can be seen in all valuing (! not in all values) or only in some?

Even if we concede that to value something as good is usually to imply that it should be promoted, we may wonder what this means. If to promote something is to realize it wherever possible, the general thesis is clearly untenable. As Vos’s example of friendship shows, valuing friendship is not equivalent with wanting as much of it as is possible. On the contrary, if we want to promote this specific friendship, the possibilities for other friendships may be limited.

But Vos’s argument that more is not always better, seems to me not to probe deep enough. It is not just that some values, such as friendship, have a specific character which would make their unlimited promotion quite silly. The phrase ‘to be good is to be promoted’ (or prevented) is too unqualified for all other values as well. As most of you will probably agree, human life is full of different, often conflicting values. Promotion of one value will often interfere with the possibilities to realize other values. This is recognized even by the principle-approach in medical ethics, however simplistic: autonomy should not be promoted in an unqualified way, because it may reduce the possibilities to realize benificence or justice as well. These goods are valued in a prima facie way, but not necessarily promoted at all times and in all kind of situations. So, if we want to continue to speak of the teleological character of valuing, this character should be understood to be more qualified; to value a good is at most to have a disposition to promote it.

So:

- I agree with Vos that not all valuing is teleological, if by teleology is meant that valuing something is to be equated with promoting a good. To value something is to have a disposition to promote it. This weaker understanding of the teleological character of valuing may be justifiable for all goods, even for friendship.

ad 3. - do all theories presuppose this structure?

I just touched on this question, so my answer here will be brief: contrary to what Vos implies, the qualified nature of valuing is recognized in many ethical theories, at least in those who acknowledge that there is more than one good in human lives, such as principlism, virtue ethics, hermeneutics, narrative ethics, as well as in some versions of utilitarianism and deontological ethics. Thus, the unqualified teleological presupposition is not as widely accepted as Vos suggests. Moreover, some of these perspectives seem to frame ethical questions in the way Vos proposes. In modern versions of virtue ethics, for example, it is not uncommon to focus on the ‘how-question’, that is, on attitudes and actions, instead of on the weighing of values.

However, as a discussion of whether this alternative approach is as new as Vos suggests would not leave much time to discuss the merits of the approach, I will not go into this here.

ad 4. - Why it is problematic to presuppose valuing is teleologically structured?

Vos says remarkably little about his reasons for rejecting the teleological assumption completely. His main argument is that it does not do justice to values like friendship, love, children and art. But if this is the only argument, the presupposition might still be very useful in other cases! Moreover, as I argued before, the unqualified version of the assumption is not convincing and not desirable. The qualified version, however, might have its merits.

There is, however, an argument against the qualified teleological approach that is not mentioned explicitly by Vos. This argument is especially relevant to ethics of technology. The teleological approach (whether unqualified or qualified) seems to presuppose that values are stable entities, never-changing concepts that may be realized in historically and culturally different ways, but that they are not touched themselves by the means used to realize them. This assumption is falsified, I think, by our experience of valuing. Technology seems to me continually to change not so much the goods we value, but their meaning. For example, parenthood has been an important value in most human societies up to now, but what it means to be a good parent is changed by the existence of technologies like tandem mass spectrometry.

Seen in this perspective, there is certainly good reason to shift the focus from ‘values’ to ‘what it means to value’ when thinking about ethics and technology. To show why and how your alternative approach may be illuminating this issue, I want to discuss some observations from my own research.

II How to value: an example

Without going into too much detail here, my own research focuses on the question how people (mostly women) who are part of family with a high prevalence of breast cancer, deal with the possibility (offered by DNA diagnostics) to get to know their personal genetic risk of breast cancer. I spoke to about 10 women who thought they might have a high genetic risk for breast cancer. I observed their consultations with a clinical geneticist and interviewed them twice (once before their first consultation and again after about 1 year).

One of my findings was that many women find it difficult to decide whether they want to have a DNA-test, not because they are not sure whether they want to have this information, but because opting for a DNA-test implies that family-members who have been (or are) ill should be tested first. As the clinical geneticist told them, a DNA-test is more informative if the findings can be linked to the prevalence of the disease in the family. Therefore, to produce a meaningful test result, testing should start with those in a family who have suffered from or are still suffering from breast cancer; if a mutation is found, then healthy family-members can be tested as well for this mutation. Thus, to get to know their own genetic risk, healthy women should bother one or more family members first.

If we try to interpret this situation in terms of values, we might say that what is at stake here, is (at least) your own health (or, more precise: knowledge about your health risks), the well-being of the family members involved, and family relationships. The technology involved (DNA diagnostics for breast cancer) seems to enforce us indeed to weigh these values against each other. The women themselves often framed the issue in this way when asked how they decided whether to opt for a DNA-test or not. For example, most women, when asked in the first interview why they wanted to consult a centre for clinical genetics, pointed to health and family relations as values that were important to them, and as DNA-diagnostics as a means to realize these values.

Implicitly, however, they interpreted both health and family relations in terms different from those used before the rise of DNA-technology already. By learning about their health risks, they would be able to take measures to control their health more effectively, to prevent early death and thus be a responsible wife and mother.

In the second round of interviews it became even more apparent how technology shapes both values and the way we value. One woman then told me that she had not taken any action yet because the aunt whom she had to ask for help, was diagnosed with breast cancer for the second time some weeks after this woman’s first consult with the geneticist. She did not want her own worries to interfere with or complicate her aunt’s efforts to battle her disease, nor to burden their relationship by introducing this issue at this moment. Being informed about the procedure of DNA-diagnostics, her view of what it would mean to promote family relationships had changed again.

So: an interpretation in terms of balancing pre-existing values clearly is not very helpful if the meaning of values is continually shifting under the influence of technology. An interpretation in terms of ‘how to value’ may be more fitting indeed, because it focuses attention on how the meaning of values changes by technological developments. Vos seems to allude to this argument when he writes that values are the output, not the input of practical reasoning. In my view, however, this is too radical. If values were not the input, we would not know where to look in our attempt to investigate how to value. It seems to me more appropriate to say that values are input as well as output of the process of valuing, and that valuing in a technological environment leaves hardly any value unchanged.

III Ethics and technology: which way to go?

To sum up: I hope it has become clear that I do think the proposed shift from ‘which values’ to ‘how to value’ is (mind the word!) valuable – that is, I have a disposition to promote it. However, my reasons for doing so are somewhat different from those mentioned by Vos.

Moreover, I think it is valuable for ethics of technology especially, because ethical assessment of technology is easily caught in discussion of which values technology enables us to realize, whereas it may be more important to ask how technology influences our perception of what it means to value a specific good.