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external morality suggests a clear link between the values imparted in a professional
context and their influence within that environment.
There is evidence which supports this thesis. Andre (1992) suggests that during medical
training student doctors reconstruct their view of the world so that patients become
merely bodies. Andre refers to research demonstrating that students become
conditioned to leave behind emotional responses to suffering and pain, and grow more
cynical, less humanitarian, and more contemptuous of patients (1992, p. 148). The
values that medical culture and education imparts to students are influential in their
medical practice. Research also demonstrates that medical and institutional cultures
may be influential on decision making. For example, physicians are more likely to
withdraw therapy from supporting organs which have failed through natural rather than
iatrogenic reasons (Christakis & Asch, 1993). Or put another way, if you have
sustained some kind of disease or injury as a result of care or treatment given to you for
treatment of your original medical complaint, you are more likely to be actively treated
than if you presented with the same complaint from natural causes. Escher, Perneger
and Chevrolet (2004) established that doctors’ decisions to admit patients to intensive
care may be influenced by patients’ personalities or the availability of hospital beds.
These examples demonstrate how values imparted from medical culture and health care
institutions influence treatment decisions.
The complete picture
So far in this chapter I have considered a variety of potential mechanisms influencing
the instrumentality of values in decision making; the passions, biological responses,
cultures, society, and professional contexts. To consider any one of these explanations
for the instrumentality of values in isolation is insufficient. Return to the very basic
visual representation of decision making depicted in the introductory chapter.
The depiction of reasoning developed earlier in this chapter has now established a far
more complex picture of the instrumentality of values in decision making. When all of
the explanations are integrated, a multi-layered representation of decision processes is
constructed. Consider the following more thorough representation.
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