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vknphysique Group

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Sebastian Perez
Sebastian Perez

Divided Loyalties

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.

Divided Loyalties

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.

DIVIDED loyalties. I guess that's a fancy way of saying we're feeling pulled in two directions--sometimes more! When, for example, you want to do what your friends are doing, but you also know you should obey your parents' wishes. It can be pretty confusing. So, what do you do?

As I continued praying, the divided loyalty that had disturbed me so much was resolved. The relationship faded naturally away as we gradually went our separate ways. I knew that I had done the right thing in this case, because right before my friend and I stopped dating he told me why he enjoyed our relationship. He said he enjoyed going out with me because he wasn't expected to drink, do drugs, and have sex. He said he had learned from this that he could exclude these activities from his dating experience.

What my friend sensed when we dated was his real selfhood, which is spiritual, made in God's image and likeness. And, you know what? He liked that selfhood--so did I. He liked what he was beginning to think and express for the first time in years. For, you see, my friend, too, had a divided loyalty. He had been pulled in two different directions for a long time. The belief that he was a mortal dominated by a mortal body (and had to act like it) was trying to pull him away from learning more of the

We can all have divided loyalties to resolve. But perhaps the biggest decision we come across in our experience is whether to give our loyalty to matter or Spirit. It sure seems like we are made of matter. In reality, though, as Christ Jesus showed us, our selfhood is entirely spiritual. We are made in the image of God, who is Spirit. As we understand our genuine, spiritual identity, we see that we are always governed by our eternal Father-Mother God.

Divided loyalties are a much bigger issue than one individual against another, or parents against children. They show us that we need to choose between matter and Spirit. But when we learn that it is God who demands our loyalty, we see that we can always turn to Him in prayer. We don't need to struggle with divided loyalties, since man is already spiritual, loyal to God, good, above all.

An even morepowerful experience of split loyalties happens when parents argue in front ofchildren, criticizing and negating each other, whether generally or morespecifically. That leaves the child in the untenable position in those momentsto choose one parent over the other. Grandparents or other relatives can alsoset children up to be torn in their loyalties by speaking negatively tochildren about one parent or the other.

If oneparent understands and follows these recommendations and the other parent doesnot, it is important for the one parent to confront the other parent outside ofthe earshot of the child, stating firmly that it is critical not to put kids inthe middle where their loyalties are split. If the other parent refuses,outside help is probably needed to allow the child/children to have a safeplace to process their feelings, regain their power and address their fears.

If yourex-spouse puts your children in situations where they experienced splitloyalties, are you able to have an adult conversation with him/her, bringing uphow painful it was for the children to experience this?

It may seem surprising that one of our most well-known founding fathers, Benjamin Franklin, had a Loyalist son. In fact many families were divided during the Revolution, with some members choosing to rebel against British rule and others remaining loyal to the King. Benjamin Franklin and his son, William Franklin, prominently exemplified these divided loyalties. How did this rift occur, and were they ever reconciled?

From the moral point of view, most dual-agent situations are best seen as cases of conflicting loyalties or clashing duties. The doctor must choose one duty over another (Macklin, 1982). Perhaps most problematic are situations in which the patient assumes (because of the weight of the professions' patient-centered ethic) that the doctor is working for the patients' best interest. A psychiatrist in a prearraignment examination might be able to elicit more information then a police interrogation simply by presenting a trusting demeanor. But if the message is not "I am here to help you," then the purpose of the examination should be directly stated. An administrative evaluation in a student health service should clearly state, "You are being evaluated at the request of the dean, who will receive a report of my findings." A health professional should not give the impression that everything a person says is confidential if that is not the case.

While cases in psychiatry and mental health have received the most attention, this attention has increased awareness of the problem of divided loyalties in virtually all areas of healthcare. A quick literature search for "divided loyalties" on the Internet returns results from the following specialties: nursing (Winslow; Dinc and Ulusoy; Chao; Tabik, 1996), ophthalmology (Addison), sports medicine (Sim), occupational medicine (Walsh), physical therapy (Lurie; Bruckner), military medicine (Howe; Camp; Pearn; Hines), transplant medicine (Bennett; Tabik, 1994), clinical researchers (Miller), aviation medicine (McCrary), infectious diseases, obstetrics (Plambeck), student health and those doing administrative evaluations and disability evaluations (Lomas and Berman), and house physicians and residents (Morris; La Puma), as well as psychiatrists, forensic psychiatrists and physicians, and child psychiatrists and pediatricians. Issues of privacy, especially the privacy of medical records, cut across all disciplines in the information age, as do issues of cost containment, reimbursement, and healthcare funding. While all these disciplines face situations of divided loyalties, perhaps nowhere is the conflict more dramatic than it is in nursing, where loyalties have undergone a transformation from loyalty to the individual physician for whom and with whom a nurse works, to the healthcare institution that employs the nurse, to patients more generally, and finally to the principles of medical ethics that inform the values of all professions.

Extreme cases put the more mundane cases into perspective. Psychiatrists in the former Soviet Union (as well as in other Eastern European countries and in the People's Republic of China) have come under scrutiny for hospitalizing political dissidents and labeling them psychiatrically impaired (Bloch and Reddaway). Physicians in the military governments of Latin American have (perhaps under coercion themselves) cooperated with the torture of political prisoners, a situation that also occurred in South Africa during the period of apartheid. Nazi physicians conducted experiments in concentration camps that would have previously been unimaginable, giving rise to the safeguards of informed consent now required (Drob; Lifton, 1976, 1986). Nazi doctors acted completely contrary to their own moral and professional commitments, serving the ideology of the state and not their patients. These historic lessons make the need to examine divided loyalties all the more urgent.

In cases of controversial religious movements, distressed families have sought help from mental health professionals to "rescue" and "deprogram" their children from such groups or cults. The mental health professional may be caught in a divided-loyalty dilemma between family values and religious liberties, possibly medicalizing religious conversions and then treating them as illnesses (Post). On the other hand, vulnerable young people may be particularly susceptible to coercive group pressure, and mental health professionals have traditionally acted in the "best interest of the child" for autonomous growth and development.

The question of divided loyalty can readily arise in matters of confidentiality. Mental health professionals cherish confidentiality as a prerequisite for psychotherapeutic work, but what is an appropriate limit to confidentiality when a patient reveals plans that might endanger others? This question came dramatically to public attention in 1974, when Tatiana Tarasoff, a college student, was murdered. Lawsuits were subsequently brought by the student's parents against the university, the campus police, and the psychotherapist who had failed to warn Tarasoff of threats made against her life by a fellow student (and patient of the therapist) who had fallen in love with her and whose love was unrequited. The therapist had alerted campus police to the danger his patient posed, but they arrested him, found him harmless, and released him.


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