SOC.Sci. Med. Vol. 23. NO. a. pp. 753-787. 1986 0273-9536,86 53.00 + 0.

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Printed in Great Britain. All nghts reserved CopyrIght C 1986 Pergamon Journals Ltd

DIVIDED LOYALTIES AND AMBIGUOUS RELATIONSHIPS

STEPHEN TOULMIN
Committee on Social Thought, University of Chicago, 5801 Ellis Avenue, Chicago, IL 60637, U.S.A.

Abstract-The author argues that conflicts of obligation may, but need not, give rise to issues of divided
loyalties. Given this, the question then becomes under what circumstances and conditions a simple internal
conflict may escalate into the problem of divided loyalties or fiduciary ambiguities. After discussing
conflicts of obligation, it is asserted that loyalties are divided only when the demands of the various
relationships involved are irreconcilable. As this is an extreme, the major problematic issues fall, then.
in between, on multiple loyalties and ambiguous loyalties. How and where multiple loyalties arise. and
under what conditions they may become ambiguous loyalties lead to the recognition that moral problems
are created by leaving in ambiguitythings about the relationships involved that would be better sorted
out. Finally the author looks at situations in which physicians are systematically exposed to irresolubl:
ambiguity.

Key wordsdivided loyalties, bioethics, medical ethics, ethics

Professionals in any field of service face moral
conflicts of several different kinds, ranging from
simple conflicts of obligation, through multiple and
ambiguous relationships to outright divisions of loy-
alty; and many of these are illustrated in the material
presented in this set of articles. I shall here begin by
drawing a first distinction, between the two extremes:
namely, conjicts of obligation and divisions of loyalty.
The efforts involved in facing and overcoming
normal moral conflicts of obligation (I argue) may,
but need not, give rise to issues of loyalty also. As a
result, the serious moral issue is under what circum-
stances, and on what conditions, something that
began as a simple internal conflict, within the proper
exercise of professional responsibilities, may escalate
into a larger question of divided loyalties or fiduciary
ambiguities.
Within the practice of any profession, situations
must often be faced and dealt with which involve
straightforward ethical conflicts: situations in which
any professional, whether doctor or teacher, journal-
ist or computer engineer, is subject to two or more
concurrent obligations, which pull him in different
ways. This happens in two kinds of case. In one kind,
the professional (‘he’ for short) finds himself tom
between the demands of his professional situation
and other, outside claims, e.g. those of family. He
must then use his judgment in deciding, for instance,
at what point personal duties, arising (say) from the
fact that his father is dying, are so grave as to
override his professional duties toward a client in
need, and so justify him in pleading a ‘crisis’ and
suspending his practice. But, in another kind of case,
he may find himself, instead, pulled two ways be-
tween different types of claim both of which arise
within his practice.
The possibility of such internal conflicts of obli-
gation has been built into the practice of medicine
ever since the time of Hippocrates, whose oath had
the physician swear to serve, not merely his immedi-
ate patient, but also ‘the art.’ At the present time, this
second kind of conflict shows up most strikingly in
the moral quandaries attending the conduct of ran-
783
dom clinical trials. (At the stage at lvhich the
effectiveness of a novel, life saving treatment is
approaching the point of appearing ‘proven.’ but has
not yet met the fullest and most rigorous demands of
statistical demonstration, the physicians conducting
the trials may be torn between the respective claims
of the art, which require continuing the experiment to
the point of ‘proper proof,’ and of those research
subjects/patients who are on the placebo and may be
‘condemned to death’ if the experiment is not sus-
pended.) But it can arise in less critical or dramatic
ways, also. A patient’s symptoms may be ambiguous,
in ways that would call for alternative but incompat-
ible modes of treatment; a patient may, quite inno-
cently, make requests to the physician which offend
against his professional conscience; or a physician
may, without any pretence or deceit, have obligations
to an alternative client (e.g. an insurance company)
whose claims may run counter to the true needs of the
subject under examination.
About these straightforward conflicts of obligation,
only two philosophical points need making here.
First: ever since Socrates, clear headed moral analysts
have recognized that no single obligation of this kind
imposes on our conduct anything more than a pre-
sumptive, all-other-things-being-equal claim. This is
the point that Sir David Ross had in mind when he
wrote of ethical rules as carrying only prima facie
obligation; and the point is not much affected by
claiming that the rules or obligations in question are
‘absolute;’ for absoluteness can be claimed on behalf
of more than one such rule or obligation. and it is
only a matter of time before a situation arises in
which the two absolute rules pull in opposite ways.
(In traditional moral theology, indeed. the term
‘absolute’ itself meant simply ‘leaving aside the un-
avoidable exceptions,’ i.e. the same as Ross’s ‘prima
facie.‘)
In the second place, it does little good either in
theory or in practice to shut our eyes to these conflicts
of obligation, or pretend that they can always be
resolved without someone or something coming out
the loser. Some philosophers are determined to dem-
784 STEPHEN
onstrate. against the evidence of (e.g.) Aristotle’s
.Vicomachenn Ethics. that ethical problems may be
resolved by the use of some algorithm, or criterion,
which will always give us unambiguous answers,
however ambiguous the circumstances at first appear.
To argue in this way, however, is to deny the very
possibility of moral tragedies; and that in turn is to
trivialize the actual course of human life, by de-
stroying its potential for moral depth. So all such
philosophical theories are open to the challenge that
they are self discrediting, in that they deny some of
the most evident features of the very problems that
they profess to explain. A similar tendency exists in
the practical realm, equally: some writers are deter-
mined to demonstrate that no actual working situ-
ation can ever involve the professional in a true
conflict of obligation. This claim has been made
many times, e.g. for occupational medicine, or in the
case of medical research. Yet although, in general
terms, the problems facing practitioners in such fields
need involve no formal conflicts of intention, their
actual conduct in particular cases may still have to
steer a way between conflicting substantial demands.
So much, then, about conflicts of obligation, by
way of introduction to the thornier issues, of loyalty
and trust: to make the transition easier, let me begin
by underlining a first crucial point. I asserted at the
outset that professional conflicts of obligation may
escalate into issues of loyalty, but need not do so.
What makes the difference, in this respect, is the
degree of mutual understanding between physician
and patient or, more generally, between professional
and client. Where the patient wholly trusts the physi-
cian’s bona jides and devotion to his concerns, the
fact that he is faced by serious and difficult conflicts
of obligation need not be a source of any distrust or
anxiety. On the contrary: to the extent that the
physician has rightly won that trust, the patient will
rely on him to exercise his discretion equitably, i.e. to
apply his ability and conscience as best he knows
how, in dealing honestly with the situation, and
finding the least damaging way to resolve the
conflicts.
Why should this rather simple point be open to any
doubt or misunderstanding? A number of reasons
may be suggested, of somewhat different kinds. To
begin with, as Alasdair MacIntyre and Sam Gorovitz
have argued, many people approach physicians
nowadays with unrealistic ideas and exaggerated
expectations. Having failed to grasp that an element
of fallibility cannot be avoided, even in the most
c,rnscientious of medical practice, they assume that
the doctor is guaranteeing to alleviate their complaint,
i.e. that the maxim prima non nocere amounts, at the
very least, to an implicit contract never to injure a
patient, however tricky his case may be. Such false
expectations, of course, affect the quality of the
mutual trust and understanding between the patient
and the physician; and, faced with the unhappy
consequences that can sometimes flow in actual fact
from the best exercise of a scrupulous and fully
informed medical judgment, the patient may infer
that his trust in the physician had been misplaced.
Perhaps the physician did not have his mind on the
job; perhaps he was simply out for ‘the quick buck;’
perhaps he advertised himself as having competences
Tovrwx
he did not really possess; or perhaps his loyalties were
really directed elsewhere in any event, Medical
.tfalpractice.l
But (I suspect) other more complex issues are also
involved, which call for a more careful look at the
idea of ‘loyalties’ in general, and particularly at the
circumstances in which we would say that loyalties
were ‘divided.’ In the most typical case of divided
loyalties. an individual’s previously legitimate and
compatible relationships. either to ~Y‘Oor more indi-
riduals, or to two or more institutions, home irrecon-
cilable in ways that force him to choose between
them. In the years 1910 to 1913, for example, there
were hundreds of people in Britain and Germany who
had one parent from the other county, and many of
them even held dual citizenship. The outbreak of the
First World War in August 1914 placed these individ-
uals in the prototypical position, of having their
loyalties divided as between their two parents’ re-
spective native countries; and this division had the
effect of subjecting them to irreconcilable demands at
the same time, and in the same respecr.
Notice that, in the typical case of divided loyalties,
more is involved than the simple fact that some
individual stands in multiple relationships to different
individuals or institutions. Life rarely allows us the
luxury of standing in one-and-only-one relationship
to one-and-only-one person or institution. Most of us
live in multiple relationships, to family. to profession,
to church and so on, without this automatically
landing us in trouble; and the few exceptions to that
general statement (e.g. a hermit) are untypical enough
to be set aside. Nor is it enough that these multiple
relationships subject us to several specific and tempo-
rary demands, between which we must fmd some way
of arbitrating, as in the case of ‘contlicts of obli-
gation.’ Our loyalties are ‘divided’ only where the
demands of the various relationships are fully and
generally irreconcilable, because the continuing
claims to which some of them expose us require US to
abjure those of the others.
Straightforward everyday conflicts of obligation,
and deeper longterm divisions of loyalty, are however
only the extremes of a spectrum; and some of the
notions that are most relevant to the present dis-
cussion fall in between these extremes. Here, we
should look at two of these in particular: that of
multiple loyalties, and that of ambiguous loyalties.
Indeed (I would argue) one of the central issues that
we should be addressing is the question:
On what conditions do multiple loyalties become also
ambiguous loyalties? And what precautions should we take
to guard against the risks of such ambiguity?
Once again, there are those who would like to believe
that, either in theory or in practice (or both) ambig-
uous or divided loyalties can be either eliminated, or
ruled out. In their view, multiple loyalties can always
be reconciled, and can be prevented from subjecting
us to irreconcilable demands, still less forcing US to
make an outright choice between rival institutions.
In an ideal world, no doubt, all our working
institutions, and the whole society, would command
the loyalties of individuals unambiguously. In that
case, the problems of balancing off and reconciling
the multiple loyalties to which people would remain
 Divided loyalties
subject, even there, could safely be left to their
personal discretions, in accordance with Burke’s
maxim about the demands of ethics--“what human-
ity. reason and justice tell me I ought to do.” In short,
there would be no occasion for loyalties to be divided,
or for the peculiar difficulties that divided loyalties
create.
But this remains an ideal or aspiration, not a
statement about the world we actually live in: still
less, about the way in which ethical problems actually
arise for people within institutions whose modes of
operation are something less than ideal. Actual soci-
eties, by contrast, may fail to command our loyalties
clearly enough for our courses of moral action to be
clear and whole hearted. Even the life and career of
Edmund Burke himself was testimony to this fact:
Oliver Goldsmith described him as a man:
Who. born for the Universe, narrow’d his mind. And
parry gave up what was meant for mankind.
Nor is this problem a new one created by the
complexity of modem industrial society, as Soph-
ocle’s Antigone reminds us. Rather, Creon puts for-
ward on behalf of the State claims whose moral
authority Antigone cannot accept, since bowing to
them would require her to ‘narrow her mind’ in a way
incompatible with proper regard for family piety and
obligations.
In our present context, the issue of moral ambiguity
thus faces us with two central problems. These are,
first, to explain how, and under what circumstances,
the demands of less-than-perfect institutions may
make relations between a physician and a patient-
particularly, the loyalty of the physician to the
patient-morally ambiguous; and, second, to con-
sider how we can best minimize the resulting
difficulties. The two issues are connected. In any
context, things remain ambiguous only for so long as
they are left ambiguous: where there are initial ambi-
guities, these can be cleared up. Suppose, for example,
that I go to a physician for medical tests in con-
nection with an insurance application, and I am
tempted to take advantage of the situation to ask him
for advice: he can then explain to me that, in this
context, his business is to advise the insurers, not me,
and I will do better to consult my usual doctor.
Similarly, in the wartime military, there is usually
no real ambiguity, and little real problem. Only the
very naive would suppose that a doctor in military
uniform, working in a field hospital or dressing
station like those depicted in M*A*S*H, was in just
the same position as a family physician in peacetime,
civilian life. So long as an army doctor does not
pretend to be a normal civilian M.D., therefore, all
may be well. But this requirement is sometimes more
easily stated than satisfied. In a peacetime base, the
medical corps keeps its hand in by providing regular
medical service, not merely to the serving personnel,
but also to their families; and this can create under-
standable problems.
We encountered similar ambiguities, and similar
problems, in the case of sports teams. Still, a profes-
sional player should not be confused about the
position of the team physician, or make the mistake
of treating him in ecery respect as a normal private
physician. If he does so, he may well end up in a
and ambiguous relationships 785
problematical position; but he will do so by his own
fault. When he finds himself, as a result, in trouble
over (say) his contract or his use of illegal drugs, it
will at that stage be too late-and also quite unfair-
for him to complain that the physician’s position was
ambiguous. Everyone involved knows that a football
team physician has multiple loyalties to deal with;
and that, on occasion, the team’s standing and per-
formance may well be a ‘higher loyalty,’ which
justifies his treating a player’s confessions with a
somewhat lesser degree of confidentiality than is
demanded in a normal family practice. So what else
is new?
About problems of these kinds, two general things
can be said. In the first place, all of them are human
problems of a quite familiar kind: they are the
problems that always arise in close knit communities,
within which people interact in multiple ways. In such
to
a context, one person may well have occasion to ask
another, “In speaking to me as you are doing-about
how I decide who to sell my house to-are you
talking as a personal friend, as my minister of
religion, or as chairman of the zoning commision?”
These issues are best dealt with by clarifying them;
and, in this case, once we know where we stand. there
is no longer any reason for complaint. The only
people whose conduct can then leave us with sranding
reasons for complaint are those people-surely not
unknown-who exploit their multiple roles and
duties to manipulate their neighbors, in the interest of
their own self aggrandizement.
This brings us to the second general point. The key
issue is well stated in Robert Gellman’s article, when
he writes about ‘fair information practices,’ i.e. the
requirement that anyone who gives information, in
conditions where the confidence is only qualified or
partial, should have a chance to know how his
confidences are liable to be used. (The basis for this
argument can be found in Aristotle’s remarks in the
Ethics, on the subject of philia-a term whose full
sense is not well captured by the usual translation,
‘friendship.’ Our ethical obligations arise always
within the human relationships in which we find
ourselves. There is no general way of defining what
anybody ‘ought’ to do in particular cases, regardless
of how he stands in relation to all the other parties
involved: on the contrary, those relationships are the
heart of the matter.) So, in our own discussion, the
term ‘ambiguity’ is a well chosen one: moral prob-
lems are created, chiefly, by leaving in ambiguity things
about the human relationships involved that would
be better sorted out, and cleared out of the way.
Are there any circumstances, then, in which it is
impossible to sort out, and resolve ambiguities about,
the loyalties of professional practitioners; or, at the
very least, to indicate how, and why, they can quite
properly have multiple loyalties? Clearly enough, the
answer to that question is, yes. We do, indeed know
of such circumstances; and the question is whether, at
the present time, professional physicians in the
United States are systematicalIy placed in situations
that expose them to such irresoluble ambiguities.
Irresolubly divided or ambiguous loyalties are, of
course, no accident: rather, they refIect divided or
ambiguous social or historical situations. So the
best-perhaps, the only-way of elucidating our
756 STEPHEN TOULMIS

question is through a case by case analysis, given in Coast, whose very mixed labor force is still largely
terms drawn from social history. Here, I can only unorganized. (These variations arise from the histor-
outline a few sample instances in which this difficulty ies of the regions and industries concerned, from
is, or has recently been. a special problem for Amer- differences in the nature of the actual work, and
ican doctors. possibly from other factors, about which social
(1) To begin with, it is not for nothing that many historians do not fully agree.)
of the moral questions raised by bioethics became So, the relationships and roles that are open to any
particularly acute during the Vietnam War. In the cadre of professionals whose work places them be-
Second World War, there was little ambiguity about tween the two millstones of management and labor,
loyalties. Leaving aside the special problems of con- as happens to occupational physicians, may also be
science that affected a few Americans of German or expected to vary greatly depending on where, and in
Japanese origin, most Americans shared both a com- what kind of industry, those professionals are em-
mon repugnance for Hitler and Tojo, and a common ployed; and with them the character and acuteness of
conviction that they had to be defeated; and this the ethical problems to which their work exposes
consensus served to define ‘higher’ loyalties which them. It is one thing to keep your conscience and
everyone could recognize without difficulty. So, when reputation clear-to reconcile your proper loyalties
a military physician in World War II patched up a to all parties, and to be seen to do so-if you are a
wounded soldier and sent him back into action, he factory doctor in Silicon Valley; but. if you work in
did not have to explain the basis for his actions: both the West Virginia minefields and are answerable to
he and the soldier were ‘in this thing together,’ and both Consolidated Coal and the United Mine Work-
understood what had to be done. No such happy ers, that is quite another story.
consensus, by contrast, united either Americans in (4) Meanwhile, physicians are also affected by the
Vietnam, or their civilian counterparts back home. general bureaucratization of modem society. Living
When a country becomes caught up in what is widely in the Prussian state, Max Weber foresaw the growth
perceived as ‘an unjust war,’ people inevitably find of those large administrative structures that have
their loyalties torn and ambiguous; and physicians come to dominate our lives; and he foresaw also the
and other professionals are, in this respect, in no ethical problems that would be created as a result. In
different a situation from anyone else. So if, in dealing with these structures, citizens-now renamed
Vietnam, there were occasions when doctors on ‘consumers’ to mark their diminished social
active duty found themselves in more serious moral function-are afflicted by an impotence which under-
conflict than their World War II counterparts, e.g. mines their confidence in the bonafides of the author-
over how to handle the individuals who passed ities, in their role as ‘providers.’
through their hands, that fact was just one more Notoriously, contemporary medicine had been
consequence of the wider ambiguity over the entire taking the same road. The individual patient or
American involvement in the Vietnam conflict. ‘health care consumer’ who turns up in a hospital
(2) A similar ambiguity currently affects relations emergency room, and is sent from clinic to clinic for
between children and parents in this country. We live diagnosis and treatment, is barely aware of being a
in a time when ideas about those relations are in flux, ,party to any ‘human relationship.’ Instead, Alasdair
and people from varied regions and backgrounds MacIntyre remarks, he feels like a package; while the
have quite different ideas about the age at which clerks who check him into and out of each clinic, and
growing children are entitled to full autonomy and confirm that he possesses the documents needed for
confidentiality in dealing with there personal lives. the hospital’s ‘reimbursement,’ behave toward him in
Such questions are professionally important for, e.g. just the same way as any Weberian functionary. This
doctors involved in providing psychiatric services to is not to criticize the clerks, physicians, or anyone else
students in universities, or those who may be ap- involved. As Weber knew, ‘routinizing’ adminis-
proached by young women clients for birth control tration at first increases its efficiency: this is true of
and abortion counselling. Issues of this kind are made modern hospitals also. But, as Weber also knew, a
only the more acute and contentious by the lack of price has to be paid for that increase in efficiency; and
any public consensus about the ages of adolescence this price is largely paid in the corrosion of human
and maturity, or about the extent to which the law relations and the ethical problems so created.
can be asked to protect the rights and duties of (5) Aside from general factors that affect all mod-
parents to retain control over, and responsibility for, ern societies, some special ones are particularly rele-
the conduct of their children. In this respect, the vant to the United States today. Let me mention
physicians are simply ‘caught in the middle.’ three of these briefly in conclusion. First, of course,
(3) To some extent, this is also the fate of oc- there is the standing contrast in institutions and
cupational physicians. In their case, however, we traditions between America and Japan: all of the
might expect the differences between different indus- major problems in medical ethics are refracted
tries and regions of the country to be even more through this contrast. Even in straightforward
marked. The tone of relations between labor and patient-physician situations (I am told) much less
management has for a long time differed strikingly, as attention is paid in Japan to questions of informed
between the basic mining and extraction industries of consent and the like-by placing himself in the hands
U.M.W. country in the Appalachians, whose workers of a doctor, a Japanese patient gives trust which is
are largely of British origin; the secondary manu- expected to be unquestioning-so it would be highly
facturing industries in the IMidwest with many Ger- instructive to have a Japanese commentary on the
man and East European workers, typified by the auto moral ambiguities involved in the practice of (say)
workers; and the newer electronics plants on the West occupational medicine or sports medicine.
 Divided loyalties and ambiguous relationships
Secondly, the profession of medicine is not immune
to the racial issues that have played so large a part
in recent American history; nor are those issues
irrelevant to current discussions in philosophical
ethics. On the contrary, John Rawls’ emphasis on a
‘compensatory’ element in the theory of justice argu-
ably represents less a timeless contribution to the
analysis of a perennial concept than it does a timely
amendment to our ethical conceptions, in response to
the problems of mid-twentieth century America. Fur-
thermore, those racial issues are part of a larger
change, that has affected the whole temper of the
American social and political debate since the mid
1960s. Before 1965, or thereabouts, we were still
living in the time of consensus politics, of which
Lyndon Johnson was the last great master; and
nobody was embarassed to hear political issues dis-
cussed in terms of phrases like ‘national goals.’ Since
the late sixties, we have moved into a phase of
adversary politics, in which the ‘goals’ of political
action are defined, rather, in sectional, particularistic
terms-as the goals of Blacks, or women, or the
handicapped, or the Grey Panthers. This element,
too, has helped to undermine people’s trust in any
authority, including the authority of physicians; and
so aggravates the moral choices and decisions facing
the doctor in the course of his practice.
Finally, let me grasp a disagreeable but unavoidable
nettle. One last factor also has aggravated all of the
medical profession’s ethical problems, and this must
be put on the record. Doctors complain about a
miasma of public mistrust, to which they feel unjustly
exposed; and their natural convictions about their
787
own good intentions makes this response under-
standable. Without any commentary or judgment. it
has to be said that some of their clients regard these
‘good intentions’ as hypocrisy. They are strongly
aware of the wide disparities of income that separate
physicians-and some other professionals-from
most of their clientele; and they notice how much
energy such professional organizations as the A.M.A.
give to the task of *protecting’ the economic interests
of the profession.
In this connection, I will make just one closing
remark. Aristotle argued, in the Nicomachean Ethics,
that a full and open moral relationship was possible,
only between two people who were on a sufficiently
equal level. There was, in his view, no way in which
unequals-whether master and slave, Greek and Bar-
barian, or father and son-could enter into a re-
lationship of the kind that was possible for two ‘large
spirited human beings’ of the same rank and status.
And there is little doubt that he would have
been prepared to say the same thing about rich and
poor.
Economic disparities tend to have the same corro-
sive effect on personal relationships as social in-
equalities; and, in doing so, they undermine the
chances of any full and equal moral relations. Justly
or unjustly, the efforts of the A.M.A. to promote the
jinunciuf position of its members may thus be having
the unwanted side effect of undercutting their moral
position. If that is so, the problems of ‘divided
loyalties, ’ ‘conflicting obligations,’ and notably that
of ‘ambiguous relationships,’ are liable to be afflicting
the medical profession for some time to come.