Divided loyalties and ambiguous relationships

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 ambiguity things about the relationships involved that would be better sorted out. Finally the author looks at situations in which physicians are systematically exposed to irresoluble ambiguity.

KIE: Using examples from occupational medicine, sports medicine, and clinical trials, Toulmin discusses two of the moral conflicts he believes are common to all professions: conflicts of obligations and divisions of loyalties. Conflicts of obligation are inherent in all medical practice, the author argues, and cannot be resolved by balancing claims, but only by choosing one obligation over another. Conflicts of loyalty result when a physician's relationships "to two or more individuals, or to two or more institutions, become irreconcilable in ways that force him to choose between them." Along the spectrum of loyalties lie multiple loyalties and ambiguous loyalties, and the latter, if unresolved, create moral ambiguities. Toulmin concludes by identifying characteristics of contemporary American medicine that make it likely that the dilemmas of conflicts of obligation, divided loyalties, and ambiguous relationships will persist.