Promoting the valuable? – Medical technology, bioethics and philosophy: the case of tandem mass spectrometry
If we would live in Candide’s best of all worlds, technology would have only good effects on the things we value. But of course we are not living in such an ideal world, whence technology affects human values, both positively and negatively. Medical ethics or, more broadly and more accurately, bioethics has acknowledged the importance of medical technology in the context of death, suffering, pain, disease and health. Various approaches have emerged in bioethics, ranging from the most dominant approach, i.e. principle ethics with its emphasis on autonomy, beneficence, non-maleficence, and justice, to casuistry, pragmatism, virtue ethics and care ethics. All approaches seek to grapple the impact of medical technology on human life in terms of right or wrong, appropriate or inappropriate, praiseworthy or blameworthy, good or evil. All approaches converge on the view that technology per se is not the problem, but its potential for promoting or threatening human values and human life. The technological imperative to mould decisions for care delivery on the basis of technical opportunities should be replaced by the ‘human imperative’ to use medical technology in such a way that technology contributes to good care and good life. The issue of what we can do has to be turned into the issue what we should do. Thus, bioethics adds to the classic three criteria of Medical Technology Assessment (MTA) or more broadly Health Technology Assessment (HTA), i.e. effectiveness, safety, and cost-effectiveness, a fourth criterion, the normative assessment of technology. Depending on the chosen ethical approach, normative aspects of medical technologies and care will be interpreted differently. In case of ‘good death’ or ‘good dying’, Hippocratic ethics, for example, emphasizes the ideal of a ‘painless’ death, principle ethics focuses on the ideal of a ‘self-chosen’, autonomous death, and care ethics stresses the ideal of ‘dying in a caring environment in congruence with the life story of the patient’. Depending on the chosen ideal, different normative aspects will be signified, whence criteria as outcome, risk, cost, quality of life and well-being will be differently operationalised. However differently this ‘ideal’ of good dying, or other valuable targets in health care, is conceptualised, the underlying notion is that next to effectiveness, safety and costs, technology can be assessed as ‘how it contributes to good life’.
Scholars in the fields of philosophy of technology and science and technology studies have criticized bioethics because of their ‘naïve’ views on medical technology: the valuing of technology merely seems to start with the use of technology by humans. The naïve view assumes that there is nothing intrinsically good or bad ‘inside’ technology; technology is neutral in that respect, just as a knife can be used to do something good, e.g. cutting during a life saving surgery, or something bad, e.g. cutting someone’s throat. Oral contraceptives, for example, are neutral: in one context these drugs can contribute to the emancipation of women, in another context can these drugs be used to enforce women to reduce the number of children or to have sex against their will. None of these effects are ‘enclosed’ within these drugs themselves: what these drugs do depends on the question whether the drugs come into ‘good’ or ‘bad’ hands. Humans are the problem, not technology. The sophisticated view, however, holds that technology and use are interwoven. Some ways of using technology are ‘enclosed’ within technology; other ways of using some kind of technology are excluded because of its architecture. Technology contains so-called ‘scripts’, comparable to the scenario of a movie or an opera, in which the users are prescribed what to say or to do. Thus, bioethics has not only to deal with humans, but also with medical artefacts: what are they doing with us as humans, what kind of norms are enclosed, what sort of choices are enabled or excluded, what kinds of responsibilities are delegated, enforced or shifted through these artefacts? The question then becomes in what ways medical technologies are ‘good’ or ‘bad’, ‘virtuous’ or ‘vicious’. The aim then becomes to develop ‘good’ and ‘virtuous’ technologies.
Certainly, these are important questions. Science and technology studies have enriched the picture of technological development by showing that technology development is in fact a continuous, flexible and malleable process. At each point in this process there is an ‘open end’, providing moments for choice, opportunities for adaptation of technology, and possibilities for steering social life. In this way science and technologies studies show that deterministic views on technological development, either technological implying that ‘technology develops autonomously, in the sense that the technological train speeds up like a Juggernaut’ or social implying that stakeholders such as government, business, professionals or science are determining the direction of technological development, are false. Technology, human life and society are developing, interwoven parts of a co-evolutionary process.
Nevertheless, the opposition between bioethics and science and technology studies is grossly over-stated. Technology is an important subject of bioethics. The pragmatist turn with its emphasis on practices, localities and contingencies, has taken place in bioethics as well. And normative views in science and technology studies, although mostly implicitly forwarded, of developing ‘good’ or ‘virtuous’ as part of our technological culture, are held in some fields of bioethics as well. Feminist and care ethics, for example, reject the distinction between the ‘cool, calculating, and rational approach of technology’ and the ‘warm, engaged, and caring treatment’ in health care, stressing that technology is an important means through which care, attention, responsibility and inter-human relationship are shaped.
Instead on focusing whether values are ‘in’ technologies or humans, whether the emphasis should be on good and bad technologies or on good and bad hands, I will focus on the notions of good and bad, that is on values. Framed in this way, the naïve and the sophisticated view of technology both share the assumption that basic to technology is ‘promoting something valuable’. I will explore this thesis in this paper in more detail. First, I will review some major developments in bioethics with an emphasis on the development of value pluralism and the pragmatic turn claiming that, broadly speaking, the notion of developing good and virtuous technologies presuppose a specific view on values and valuing. Second, I will further explore this view by analysing the teleological structure of the concept of value. Third, I will sketch the contours of an alternative view on value and valuing using the philosophical framework of Scanlon.
As an illustrative example I will take the case of tandem mass spectrometry (MS/MS), a new technique in newborn screening, which can be used to detect many rare disorders in newborns at the same time. At this moment it is estimated that about 30 very rare disorders can be detected in a single test, that is, in a single rapid assay with only one small sample of blood (which is taken anyway to test on phenylketonuria (PKU), congenital hypothyreodism (CHT), and adrenogenital syndrome (AGS), as is common practice in the Netherlands). This new technique of newborn screening has led to a fundamental debate about the principles of population screening in newborns, even to the extent that a transition is envisaged from the ‘old’ philosophy to a ‘new’ philosophy. The sketched views on values and valuing will be used to see whether a fresh look at this debate on a paradigmatic shift in newborn screening is possible. Though this is a specific case, the exploration of the views on values and valuing is applicable to a wide range of medical technologies, from high-tech to low-tech, from ‘hard’ technologies – apparatus, surgical procedures, etc. – to ‘soft’ technologies – guidelines, protocols, etc.
-the emergence of bioethics as principle ethics: technology as a ‘threatening’ force (technology as an ‘intrusion’ in human life and health care)
-the emergence of a more balanced view looking at both positive and negative aspects of technology
-the pragmatist turn
-different views on autonomy
-broadening of values relevant to technologies: good care, good professional, etc.
-technologies as part of human life and culture: the coordination model (technologies as regulators of normative tasks)
-health care and MTA as responsibility practice
Conclusion: the underlying structure in the field of bioethics with regard to technology is that basic to technology is ‘promoting something valuable’, this requests a further exploration of what is means to be valuable and to be promoted, that is to get a deeper understanding of the teleological structure of values.
[to be elaborated]
Philosophers of technology have pointed out that technology (or more broadly technological action or thinking) has a certain ‘unity’, which defies the complexity, diversity and profoundness of the sociocultural embeddedness of technology. This ‘unity’ of technology (or technical rationality) is its ‘teleological’ or ‘functional’ structure implicating goals and means, functions and structures, power and control. A hammer serves the goal of driving a nail in the wall, a drug serves the goal to relief people from pain or to treat disease, a bridge serves the goal of easy and quick transportation, to cite some examples. In all cases important values in human life are involved: home comfort, regain of health, and moving around in one’s world. The teleological structure implicates that to discern something as good is equivalent with a valuable good to be promoted. At this point I will not raise the question whether this teleological structure is ‘inside’ the technology or whether it is assigned ‘to’ or imposed ‘on’ technology. Heidegger, Habermas, and Borghman, for example, have claimed the former position, whereas Searle claims the latter position. Here is at stake whether this teleological structure is specific to technology (or more broadly to science and instrumentalism). I will claim this not to be the case. Values also (might) have a teleological structure.
Let me first underline the importance of this issue to bioethics and STS. The deep issue here is that bioethics and STS both claim that specific to technology is the separation of ends and means, which as a consequence, limits the range of values considered regarding technology and helps to delegate the development of technologies towards scientists and engineers and the use of technologies towards society at large.
However, what I want to claim is that values can have a teleological structure as well. The term ‘values’ can be used in a broad sense ranging from moral values of right and wrong (justice, equity, fidelity) to non-moral values related to works of nature, art, music, science and technology. Here I will focus on the good as how we want the world to be and the right as how we may or must do, but this is a matter of practice, not of principle. More specifically, I will focus on pain, suffering and death as bad things in the world and the treatment of pain, the relief of suffering and the prevention of death as right actions to do. I will take the example of pain, suffering and death as extreme negatively valuable things to occur to people, particularly so because life-threatening and life-devastating diseases form an important niche for new medical technologies such as tandem mass spectrometry.
Let me draw an example of the ethics of newborn screening and new technology, in particular tandem mass spectrometry (MS/MS). The question is: should we do it? – if presuming that we can do it and that we can afford it. The question is whether there is a benefit and whether the possible harm in screening is much more than offset by the potential benefit. In their classic paper on screening Wilson and Junger have listed ten points for considering the acceptance or rejection of any population screening technique, of which six are related to ‘The condition sought should be an important health problem”. The following quotation is one, albeit a very dominant and prominent answer from the field of tandem mass spectrometry: “The disorder, so individually rare, might not be considered to constitute ‘an important health problem’ or to occur frequently enough to justify screening the whole population. However, another way to look at frequency and seriousness would be to consider newborn screening, up to a point, as package. If a simple sample can be used for a number of tests, then the rarity of some of the individual disorders will not matter if the whole aggregate of disorders occurs frequently enough to justify a mass screening programme. Currently, in many newborn screening programmes, around one baby per thousand tested has one of the disorders sought overall”. Separately, each rare disease might not represent a ‘real’ benefit – only to be decided on a case-by-case method -, but combined together, with many more rare diseases to come, they clearly represent a benefit, that is, a cluster of serious diseases to be treated or alleviated. This is not debated; the technology seems to be highly promising and hopeful. The crux of the debate, however, is ‘whose benefit’ is sought. Here is how Wilcken phrases the issue: “The screening process is supposed to confer a benefit, and the implications are, benefit to the baby. Is benefit to the family enough, when there is no benefit to the baby tested? That might be so if the baby will go on to an impaired childhood, before dying, as benefit to the family will also certainly benefit the child during his (her) life. This could occur, for example, with Duchenne muscular dystrophy, a presently untreatable disorder for which there are a number of optional screening programmes offered. But if the disorder is quickly fatal, then there will be no obvious benefit to the baby. But nor should there be deemed to be any harm, since the screening sample collected would be used for disorders which more clearly fit the criteria for screening. So if there is clear benefit to the family, this seems like a non-issue, but does cast considerable doubt on whether effective treatment is a sine qua non for disorders included in a screening programme. A benefit to the family when there is no benefit to the baby however would not seem contraindicated if there is no harm to the baby, and as the MS/MS new born screening tests have the possibility to diagnose a number of disorders simultaneously, to exclude one because there might be no benefit to the baby, although parents could benefit, flies in the face of common sense”.
Wilcken’s remarks about ‘what flies in the face of common sense’ seem to reflect the appeal of moral teleology: whose benefit should we strive for, that of the baby or of the family? Certainly, this is a profound issue. The proposal to consider not (exclusively) the interests of the newborn is a profound break with traditional screening practice. The Institute of Medicine (IOM) stated in 1994 that in neonatal screening there should be a “clear benefit to the newborn”. The UK ‘Science and Technology Committee’ pointed out in 1995: “We recommend that there should be no mass screening (…) in childhood unless a treatment for the disorder exists”. The Dutch Health Council did and still does hold the same position. Scientists who are in favour of tandem mass screening claim that this view is outdated and that it does not fit with technological developments in screening. Instead of focussing on the individual, the newborn child, one should acknowledge, “in neonatal screening, the beneficiary is the family”. Policy positions are shifting, in many countries there are pilots and various instances already tandem mass spectrometry screening programs enacted. In the United States, but also in various European countries, there is a strong lobby of patient organisations and parent groups who urge to utilize maximally the potentialities of these new screening techniques and who claim that a fast diagnosis is always better, if not for the child itself, then in any case for the parents and their family. This issue is not new as such. It has been heavily debated with regard to potential screening of Duchenne Muscle Dystrophy (DMD). Since neonatal screening was proposed in 1975, this has been the subject of immense discussion, precisely on the question in what sense the lack of possible treatment or prevention should affect the balancing of benefits and costs for the participants.
This issue is complex. Many questions come to the fore: How to enact informed consent? How to consider the possible benefits of preventing diagnostic lag time and misinterpretation of early symptoms? How to evaluate therapeutic improvement without cure? How to consider possible limitations of the ‘package’ of rare diseases, some perhaps treatable and others not? How to evaluate possible benefits of parents to ‘prepare themselves’, practically and emotionally, for a life with a seriously diseased child? My aim here is not to argue pro or const any of the possible answers to be given on these difficult questions, although I will provide an answer on the principle question whether to benefit the child or the parents. My point is to understand why there exists such a ‘feeling of urgency’ and what the moral structure of the debate is.
Let me outline the features of the teleological structure of values. Firstly, in case of pain, suffering and death and, consequently, the actions to alleviate or prevent them, a self-evident response is that these are bad things and highly valuable actions. Stated in this way, the major implication of this teleological conception of values is the idea that to be bad is simply ‘to be prevented’ (or to be good is ‘to be promoted’). This idea has an extremely natural, even inescapable appeal. If so, then it becomes easily explainable why a technological imperative is so attractive, appealing and powerful in medicine. The use of medical technology seems to be entrapped in a teleological structure from two sides: from technology itself as well as from the values at stake. In the case of tandem mass spectrometry, the diseases concerned are life devastating metabolic disorders, which affect deeply the life of newborn children, whence the lives of their parents and families. Preventing such a bad thing to occur in our world has a natural appeal to us
Second, values do seem to have a two-part argumentative structure. Pain, suffering and death are state of affairs with a ‘dys’-value of certain strength, whence they are a matter of ‘to be prevented’. They are value-attached states, which simply occur or not, and when they occur they provide the human being with reason to do what will promote or prevent their fulfilment. In case of death, for example, the strength of the ‘dys’-value is so great, that we are willing to do anything – that is, even at a high cost – to prevent it. Third, due to the ‘strength’ part of this teleological structure, the ethical argumentation boils down to balancing the strengths of competing values. On this view, when our values conflict, then this idea of balancing competing values will seem to be the general form of ethical decision-making with the central focus on the issue whether to benefit the child or the family. Now certainly, this is the deeper structure of the debate on tandem mass spectrometry, although I will show later on that this is not the only possible way to look at the debate. Fourth, the teleological structure is not exclusive: any value can be weighed. It is true that very often a limited set of values is at stake in such a teleological structure, but this is only a practical point. Thus, Wilcken might be rebutted by the argument that the range of values she takes into account, seems to be rather limited. Narrative ethics could claim to focus on stories of people’s lives showing other values at stake. Care ethics could claim that other aspects of autonomy are important, e.g. authenticity, inter-human relationship, attention. Feminist ethics could bring forward valuations of dependency relations in families or politics. However, even if a wide range of values would have been taken into account – social, aesthetic, religious, etc. –, once taken up into a teleological structure, the argumentative pattern would be the same: what values should be promoted, how should different values be ‘weighed’, how valuable should tandem mass spectrometry be considered? Fifth, this teleological structure is neutral to any ethical view, be it consequentialist or deontological (or perhaps otherwise, e.g. virtue ethics). The ‘weighing’ might be done in some utilitarian, metrical framework; it might be done as well in some deontological framework, preferring some sort of value or underlying principle. In fact, the debate on tandem mass spectrometry is phrased within the framework of principle ethics. Although there might be no benefit to the child, since there is no harm to the child and the benefit done to the parents and the family is so great, the principle of doing the benefit to the family might prevail. If so, some argue, the principle of autonomy, as reflected in the request of informed consent, may be ‘overridden’ as well. Others argue that this stance would be disproportional, whence they propose either to hold both principles equally or to let the principle of autonomy, hence informed consent, prevail.
After having outlined the teleological structure of the promoting of good and the preventing of bad, one might ask what alternative view exists. Let me first recast the major point of this teleological structure of values. On this view it is held that what we have reason to do (or not to do), is to act so to realize those state of affairs that are best (or prevent those that are worst), that is those states in the world that have the greatest (or least) value. What I will argue for is that when we consider values, it becomes quite implausible to hold that (all) our thinking about value can be cast in this teleological form. Instead of asking ‘how valuable’ things are, the other approach is to ask ‘how to value’ things. Many values in our lives, e.g. friendship, children, love, music, art, or professional work seem to be highly valuable things, but certainly not things ‘to be promoted’. It would be highly strange to claim that the primary reason to be loyal to one’s friends or to make them happy is to ‘promote’ the friendship. On the contrary, being loyal to one’s friends or to make them happy belongs intrinsically to what it means to ‘be a friend’. If not, then indeed one could say to promote friendship is to betray one friend in order to make several new ones, or in order to bring it about that other people had more friends. As Scanlon says, “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. It is an advantage of the present account that it calls attention to this aspect of our ideas of value, one that is easily concealed by the assumption that the primary question about the value of something is how great that value is”.
Now, this account of knowing how to value something instead of knowing how valuable something is seems to be very awkward in the case of pain, suffering or death. Somehow medicine seems to defy this sort of valuation structure. How could one ‘value’ pain, suffering or death except as exclusively negative? Since pain and death are moral concepts with such low intentional, evaluative content, as with any (negative) experiential states, these states of affairs should be prevented anyway. However, even then questions of valuations intrinsically related to such negative states can be asked. For example, in case of death there are other questions than just whether death is bad or how bad it is: how should we think about the value of life knowing that it is finite; what attitude should we adopt: Fear? Resignation? Such questions might seem to be remote from the issue of preventing inborn metabolic disorders. But are they? From other areas in medicine, e.g. dementia, palliative care, coma, mentally and handicapped children, we know such questions are morally relevant and inescapable. This alternative view becomes the more evident when we consider promoting good instead of preventing bad. Preparing parents on ‘having a seriously disabled child’, for example, would count as doing good, but surely there will be different ways of filling in what good parenthood means, different ways of how to value what is good and what is right to do.
I have discerned two views on values and valuing: how valuable things are and how to value things. The question is whether this distinction provides new insights into the debate on tandem mass spectrometry.
Let me first explicate what is at stake in the debate. The most important value at stake here is not doing something good but preventing something bad. The diseases concerned are devastating metabolic disorders which affect deeply the life of newborn children, whence the lives of their parents and families. Preventing such a bad thing to occur in our world has a natural appeal to us. As human beings, our relation to such devastating diseases lies in being able to prevent them from occurring, or to make their occurrence less likely. Yet, this is not the same as doing some good, such as ‘preparing the family, practically and emotionally, to bear the future of their suffering’. Surely, this is a good thing to do and, as such, good things to do can be promoted. Why? The general answer to this question is to claim that this helps to promote good parenthood. If a rapid diagnosis is provided and a cumbersome walkthrough in the health care system is prevented, parents might feel assured and well prepared, it helps them to get on with their life and to face the difficult problems with their child in the near future. It promotes their well-being. In this respect, the parents are the targets of the doing good, whence the moral problem develops into a conflict of the benefit of the child versus the parents.
However, it is not a conflict on the same level. The word ‘benefit’ is quite misleading in that respect. It is the preventing something bad to the child versus promoting something good to the parents. The teleological structure of preventing something bad is extrapolated to any state of affair, which has a (positive) value, whence is therefore a matter of being ‘to be promoted’. Yet, there is an important difference. As Sidgwick has emphasized, we may have impersonal reasons to relieve other people’s pain and suffering but not to promote every aim that they have. Even if one would acknowledge this difference, the view can still be held that since there is neither benefit nor harm to the child, the benefit to the parents might prevail. Even then, one cannot hold that providing the test is the only way to do good. Further justification has to be done and additional subtleties of argumentation will arise. However, it is not my intention here to provide this kind of argumentation. I want to shift the focus on what is at stake.
The alternative way of looking at the debate is not the question of doing good either to the child or to the parents, but that of how to value parenthood or what it is to be a good parent. Someone who values parenthood will take himself or herself to have reasons, first and foremost, to do those things that are involved in being a good parent: to care for one’s child, to be concerned with the child’s interests, to try to stay in touch, to spend time with the child, and so on. On this view it would be very odd to say that in order to promote parenthood one should promote the interest of the child, and it would be even stranger to say that there is a conflict between parenthood and the best interests of the child, let alone one should prevail parenthood above the best interests of the child. Now suppose that parents who are in favour of choosing the mass screening test claim that they are doing it in the best interest of the child – say that they want not to let the child suffer unnecessary diagnostic tests, not let the child be in pain or insecurity, hope that some therapy might be found in the near future, perhaps even that being themselves insecure parents excludes being a good parent, or whatever -, then these claims encompass reasons which are involved in being a good parent. If this is the case, then there seems to be no conflict at all, the doing good is intrinsically interwoven with being a good parent for this child, although the benefit of the child might be in the near future, not at the time of birth. Then, the discussion should be about how the interests of the child are being served best.
I am not saying that is the right interpretation of the case. I am only claiming that starting by fundamental values, being a good parent, being a good family member, questions arise which aim at the best interest of the child, precisely because caring for one’s children intrinsically belongs to being a good father, good mother, or good carer. I simply want to present a broader framework in which the issues of tandem mass spectrometry can be discussed. This approach might not help directly in taking decisions but it points into directions of broader and deeper questions, which should be answered before taking any decision.
I have provided an account of two ways of valuing: the distinction between how valuable things are and how to value things. Let me discuss some possible objections to this distinction and then conclude with some final points.
First, it might be claimed that much, or perhaps all, what is claimed in pragmatist ethics, including the pragmatist stance in science and technology studies, is precisely to shift the issue of how valuable something is towards the issue how to value life or death. Indeed, various proposals in medical ethics to conceive of moral deadlocks as ‘dilemmas’, ‘tragedies’, or ‘life stories’, seem to exploit such a view. Ethical problems might be unsolvable, but through continuous, repetitious discussing, interpreting, and storytelling, the tragically aspects of such moral problems achieve meaning and significance. It is not about choices and solutions, but the way one shapes his or her life and provides meaning. Isn’t this clearly representative for how to value things? I don’t think so. I accept that pragmatist ethics, particularly hermeneutics, narrative ethics and care ethics provide a major under stream in ethics with a clear emphasis on the different ways one could value life, death and many other things in humanity. Still, these fields do offer normative claims how to contribute to a ‘good’ or ‘virtuous’ life.
Second, the ‘broadening’ of the range of values by pragmatist ethics will not help, since the point is how values are framed. The goal of developing ‘good’ or ‘virtuous’ technologies might indeed imply other values to be promoted; the intentional structure remains teleological. Third, accepting the former arguments it could be claimed that even if the dividing line falls within pragmatist ethics, surely principle ethics is exclusively connected to a framework of balancing and weighing values. I reject this argument, because it is based on a defective view of principle ethics. It might be so that principle ethics is predominantly ‘hooked up’ at a framework of balancing values, this is a matter of practice, not of principle. In fact, I have explicated the alternative view of how to value things fairly reasonable within a principle ethical framework, not as a matter of principle, but for the sake of the argument.
Fourth and finally, one could claim that this is an irrelevant issue. The issue is precisely what values should be promoted (or prevented) in order to develop good and virtuous technologies. Hence, one should proceed forward in providing satisfactory answers to the difficult questions, not a broadening or deepening of the issues. This argument does not hold. In fact, I think the situation is reverse. Most importantly, satisfactory answers to such questions cannot all be read off from a proper assessment of how bad or how good a thing it would be to do in various ways at various points in one’s life. In fact, judgments of ‘balancing’ or ‘outweighing’ are best considered as flowing from and shaped by a set of more general attitudes and by a much broader evaluative framework.
The most important point, however, is that values are not the key concept of ethical assessments of technologies or other ‘valuable’ things in our world. The key concepts are the kinds of actions and attitudes to things we do want to call for and our reasons for doing so. These are the inputs into the valuing process with values being the output. To value something, Scanlon claims, “is to take oneself to have reasons for holding certain positive attitudes toward it and for acting in certain ways in regard to it. Exactly what these reasons are, and what actions and attitudes they support, will be different in different cases. They generally include, as a common core, reasons for admiring the thing and for respecting it, although ‘respecting ‘ can involve quite different things in different cases. Often, valuing something involves seeing reasons to preserve and protect it (as, for example, when I value a historic building); in other cases it involves reasons to be guided by the goals and standards that the value involves (as when I value loyalty); in some cases both may be involved (as when I value the U.S. Constitution)” (p. 95). So, being valuable involves there being reasons to act or to respond in a wider variety of ways than any teleological conception can hold. Values are not starting points, but conclusions of practical reasoning. Yet, it remains important to understand that to conclude whether something is of value not only involves merely knowing that it is valuable or how valuable it is, but also how it is to be valued, whether the ‘something’ involved concerns the technologies or the hands of human beings.