By Nir Ben-Moshe.

Conscientious objection in medicine has become a topic of heated debate in recent years, but answers to the question of what justifies such objections in medicine have proven to be elusive. According to the two primary justifications found in the literature, conscientious objection in medicine is justified either out of respect for the moral integrity of the objector or because we should tolerate different moral points of view. However, surely not all forms of moral integrity should be respected. For example, Adolf Eichmann is reported to have followed the dictates of his conscience when implementing the final solution. But if Eichmann claims that his moral integrity will be compromised if he does not execute the final solution, we would not want to say that not allowing him to do so threatens his status as a moral person. So what we need is an objective understanding of morality, rather than morality as perceived by the person, in order to forge an interesting connection between moral integrity and moral personhood, and that is not provided in the literature on conscientious objection in medicine.

Toleration of different points of view won’t suffice either, if this approach assumes that conscience merely expresses a commitment to acting morally: the commitment could be subjective in the sense that the agent is committed to morality as the agent understands morality—again, consider Eichmann claiming that he is committed to morality—and thus it is not clear why this is worthy of respect. The underlying problem, I believe, is that the integrity and tolerance approaches to conscientious objection share the assumption that the truth of conscience’s claims is irrelevant to their justification

In my paper, “The Truth Behind Conscientious Objection in Medicine” in Journal of Medical Ethics, I develop a new framework for conscientious objection in medicine that is based on the idea that conscience can express true moral claims, an idea that is manifested in Gandhi’s declaration that “in matters of conscience, the law of majority has no place,” and in Luther King’s declaration that “an individual who breaks a law that conscience tells him is unjust […] is in reality expressing the highest respect for law.” I draw and build on one of the historical roots, found in Adam Smith’s impartial spectator account, of this idea.

In particular, the standard set by an impartial spectator is the standard of a fully-informed, impartial, and modestly idealized spectator who views the situation from a neutral perspective and whose responses constitute the morally appropriate and inappropriate. Accordingly, I argue that when a medical professional is reasoning from the standpoint of an impartial spectator, her claims of conscience are true, or at least approximate moral truth to the greatest degree possible for creatures like us, and should thus be respected.

This type of account provides a novel justification for conscientious objection in medicine by appealing to the simple idea that a conscientiously objecting agent might be getting things right, while society is getting them wrong, and it does so by utilizing a standard of correctness that we can all share and that is thus fitting to liberal democracies. Moreover, the account advances the debate regarding both the integrity and toleration criteria. For proponents of the integrity view, it offers a way of forging a connection between moral integrity and moral personhood: if moral personhood is constituted by the standpoint of the impartial spectator, then moral integrity should be respected insofar as it conforms to this standpoint. For proponents of the toleration view, it provides an objective conception of the commitment to morality, namely, a commitment to morality from the standpoint of the impartial spectator.

In my reliance on the impartial spectator, I am arguing for an impersonal conception of conscience, which diverges from the personal accounts of conscience that are generally defended in the literature. Some readers might find this troubling, especially in connection with religious conscientious objections. After all, an account that appeals to the authority of the impartial spectator is not conducive to justifications based on other normative authorities, such as scripture or tradition.

However, insofar as the religious objector’s claim is moral in nature, he could justify it by appealing to the standpoint of the impartial spectator, instead of scripture/tradition. Indeed, note that the religious objections we tend to accept in medicine—e.g., objections to performing abortions—could have been formulated as moral objections within the impartial spectator framework, and those that we do not tend to accept—e.g. objections to treating gay patients—could not have been thus formulated. Now, one might still worry that since most conscientious objections are made on religious grounds, my Smithian account of conscience is not relevant for how conscientious objections in medicine are actually formulated. However, we are interested in the justification of conscientious objection in medicine, not a description of how conscientious objections in medicine are, as a matter of fact, put forward. Therefore, it might be the case that current practices in regard to conscientious objection in medicine will need to be radically revised.

Paper title: The Truth Behind Conscientious Objection in Medicine

Author: Nir Ben-Moshe

Affiliations: University of Illinois at Urbana-Champaign

Competing interests: None to declare

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