John Coggon: Can a conscience dictate?

john coggonIf 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.