John Coggon: Can a conscience dictate?
26 Oct, 09 | by julietwalker
If I asked a physiologist to show me where her conscience is, I’m fairly sure she’d not be able to. Yet, it seems, a great many doctors appeal directly to their consciences, or at least wish to be free to do so. This is a little strange. If a patient says “God makes me do it” suspicions arise. So why should a doctor be at liberty to appeal to something beyond the empirically demonstrable? I work in “health law and ethics”, and see lauded the great march away from a “Bolamised” system, wherein clinical judgement counted (officially) for pretty much everything, and values that worked against such professional opinion could be subjugated in accordance with the maxim “Doctor knows best”.
The Burke litigation clarified (thankfully, in my view, though this is something unfashionable in circles I mix in) that physicians know their craft better than the layperson: it is not for me to tell my doctor what is “clinically indicated” in any given situation (eg heroin and single malts might be something I think are good for me, but my GP need not therefore legitimise my opinion with a prescription). It is not insurmountably controversial for doctors to claim expert knowledge; to assess a patient’s medical condition, and estimate the probable efficacy of various interventions. More controversial is a claim of knowledge of such ethereal matters as the scope and import of sanctity, dignity, and integrity. Why, in public healthcare anyway, should a doctor’s view on abortion, bear on what their patient is entitled to?
At a conference I’ve attended today at Keele University, conscientious objection in public life, including but not only in healthcare, has been put under the spotlight. And I’ve learned a lot. Lois Bibbings noted that historically conscientious objection has been open, to varying degrees, to people whose objection has a range of bases: religious, moral, political, and humanitarian. Most importantly, Bibbings made clear the importance of the socio-political context in which objection is made permissible. Her paper related to warfare, but if we make a case-study of the social structures that led to the “conscience clauses” concerning abortion and embryology, we might see that there is less about upholding deep matters of moral principle, and more about social and political compromise, in the spirit of English politics.
In the context of healthcare, it remains contested whether a professional’s conscience has a public role. Sheelagh McGuinness cautioned against a recurring theme in these arguments; the “demoralisation” of healthcare provision, and the possibility of slipping into an amoral, consumerist model. Kimberley Brownlee further demonstrated how public officials can not, in good conscience, or under proper moral scrutiny, always be beholden to the apparent rules of their offices; even in the context of the criminal justice system. The conference covered a great deal, in fascinating and provocative detail. One final point of note here was Stephen Pattison’s questioning of the relationship, if any, between conscientious objection and “whistle-blowing”. Informed by references to Judaeo-Christian theology, he noted a duality – between good and bad – in moral reasoning, and asked whether whistle-blowers, and, by parity of reason, conscientious objections, are saints or sinners.
In many ways, this felt more like the start of a debate than the end of it. I certainly felt there were lots of questions I’d like to find answers to: What is conscience in the first place? Where does eccentricity or prejudice stop and moral reasoning start? In a political compromise (or fudge), can we expect any sort of purity on this? And anyway, are some groups – such as the medical profession – so powerful that they can wield their consciences regardless of the views of others? I remain deeply sceptical of arguments about deep-seated “rational consensus”, and suspect it’s better that physicians wear their consciences on their sleeves, than carry them deep inside and publicly legitimise their decisions through spurious rationales.
John Coggon is a British Academy postdoctoral fellow in the School of Law at the University of Manchester.
John Coggans report states that conscience is beyond the empirically demonstrable, but so are first principles we all accept and without which we could`nt live eg. the glass is on the table, which is`nt provable but try living life without empirically unprovable truths. Conscience is our guiding light since we are goal directed free beings with a rational nature, and theere is such an enormous number of choices and some definitely harmful [ eg. to kill ]so it seems nature has endowed man with a moral compass. The discussion of a true and reliable conscience is another days work and eventually filters down to what is true and how one squares up to it. This is a very short reply to a very important subject.
Eugene Breen
October 29th, 2009 at 11:41 am
“…and suspect it’s better that physicians wear their consciences on their sleeves” - they do - that’s what the white coat is about.
And it is what the Hippocratic Oath is about. If that isn’t a public declaration of conscience then what would satisfy?
You say: “Sheelagh McGuinness cautioned against a recurring theme in these arguments; the “demoralisation” of healthcare provision, and the possibility of slipping into an amoral, consumerist model.” Putting aside the ambiguity of “demoralisation” (does it removing morals or lowering morale? - I assume you mean the former), can you elaborate on what she said? Why the need for caution?
Dr No
October 29th, 2009 at 3:21 pm
Hello, Dr No.
In fact - I probably shouldn’t have left this cryptic - the “demoralisation” point plays on the very ambiguity you discern, and is meant to refer to both meanings. McGuinness was working from research done by Jonathan Montgomery on this idea: briefly (and I hope not too crudely), if we try to remove morality from the practice of medicine (and healthcare more widely), we may wind up with a much worse model, demoralising the workers in the process (in both senses).
At least in regard to legal developments, there seems to be a move to much more “consumerist” picture. Although some may find this appealing, the caution lies in a fear that this will undermine many of the goods of healthcare provision.
My understanding of McGuinness’s paper is that we ought to allow some “moral space” (my words, not hers) for doctors, because, despite what some people will tell you, some matters really are ethically controversial, and telling a doctor that he/she is simply a service provider so ought to provide them no matter what is asking too much.
The question then becomes where do we draw the line? Forcing people to take part in abortion or euthanasia (where it’s legal) may be beyond the pale. But what about not treating people whose illnesses result from lifestyle choices you take a moral objection to? McGuinness argued that the difficulty of the line drawing exercise does not, of itself, recommend that we shirk the issue and deny doctors a right to conscientious objection.
Another interesting point from your post - I’m not sure all (or even that many) doctors are signed up to the Hippocratic Oath, are they? Even if so, conscientious objection bites where there is disagreement rather than agreement - ie, Dr Yes (if you’ll beg my pardon) might perform a proecedure, while Dr No will not.
Here the issue is not one of moral certainty, but of professional latitude given moral UNcertainty.
I think some theorists overstate their claims and make out that there is a much stronger moral consensus than in fact is the case. And I think part of allowing doctors some moral latitude in their practice obtains in acknowledging that some things may be permissible legally (or politically), but their moral standing remains contentious.
I hope this helps.
John Coggon
October 29th, 2009 at 4:54 pm
[...] comment referred to the opening paragraph of a post by John Coggon. He wrote: “If I asked a physiologist to show me where her conscience is, I’m fairly sure [...]
The Witch Doctor offends the BMJ! « The Witch Doctor
November 1st, 2009 at 12:42 am
Just because you cannot point to where your conscience lies does not mean it is not important. I cannot think of a more irrelevant introduction to the point your are trying to make which seems to be that doctors should not be free to follow their consciences.
Conscience is an ability or a faculty that distinguishes whether one’s actions are right or wrong. Following ones conscience would seem to be rather a good maxim for a doctor. And everybody else for that matter.
Dr Grumble
November 1st, 2009 at 2:01 am
Dr G:
Conscience is an ability or a faculty that distinguishes whether one’s actions are right or wrong. Following ones conscience would seem to be rather a good maxim for a doctor. And everybody else for that matter.
Ummm… not really. Isn’t there a danger that “conscience” is simply a socially-accepted way of talking about a lifetime’s worth of unexamined prejudices?
Iain Brassington
November 1st, 2009 at 1:02 pm
Hello, Dr Grumble.
Thanks for your comment - I must have been unclear in the blog because I agree with you that there is a legitimate and important role for conscience in healthcare (and, as you say, more broadly).
Some of my peers disagree, but I am entirely of the view that it is proper that the law allow a right of conscientious objection in some circumstances. What interests me is how one should distinguish the areas where there should be this right, and areas where there should not be.
An amoral NHS in which doctors become “operatives” with no latitude for free-thought or moral perspective is something I oppose.
If I had been arguing that conscience is unimportant, you’re right that the intro would have been silly (or at least not very persuasive as argumentation). But that’s not what I was doing.
John Coggon
November 1st, 2009 at 6:10 pm
Hello John,
Thoughtful blog on an important topic. If you’re interested here’s a link to a relevant paper I wrote on just this subject, published in last month’s JME. It certainly won’t answer all of your questions but may give you part of an idea as to why some of us who hold a conscientious objection think it is so important. Cheers.
http://jme.bmj.com/cgi/content/full/35/10/599
James Gerrard
November 2nd, 2009 at 3:26 pm