{"id":1414,"date":"2011-12-16T22:47:00","date_gmt":"2011-12-16T21:47:00","guid":{"rendered":"https:\/\/blogs.bmj.com\/medical-ethics\/?p=1414"},"modified":"2011-12-19T10:03:04","modified_gmt":"2011-12-19T09:03:04","slug":"a-conscience-claus-with-claws","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/medical-ethics\/2011\/12\/16\/a-conscience-claus-with-claws\/","title":{"rendered":"A Conscience Clause with Claws"},"content":{"rendered":"

There’s a flurry of papers on conscientious objection in the latest JME<\/em>: Giles Birchley argues, taking his cue from Arendt, that conscientious objection has a place in medicine\u00a0here<\/a>; Sophie Strickland’s paper on medical students’ attitude to conscientious objection (which I mentioned<\/a> in July)\u00a0is here<\/a>; and Morten Magelssen wonders when conscientious objection should be accepted here<\/a>.<\/p>\n

All this is coincident with the recent passing of the “Protection of Life” Bill<\/a> by the American House of Representatives.\u00a0 This also has a significant clause about conscientious objection: I’ll come to that \u00a0in a little while.<\/p>\n

Magelssen claims that conscience is important for integrity, and there is a social interest in protecting integrity.\u00a0 His position is that objections should be accepted if<\/p>\n

1. Providing health care would seriously damage the health professional\u2019s moral integrity by (a) constituting a serious violation\u00a0(b)\u00a0of a deeply held conviction.<\/p>\n

2. The objection has a plausible moral or religious rationale<\/p>\n

3. The treatment is not considered an essential part of the health professional\u2019s work<\/p>\n

4. The burdens to the patient are acceptably small ((a)\u00a0The patient\u2019s condition is not life-threatening; (b) Refusal does not lead to the patient not getting the treatment, or to unacceptable delay or expenses (c) Measures have been taken to reduce the burdens to the patient)<\/p>\n

5. The burdens to colleagues and healthcare institutions are acceptably small<\/p><\/blockquote>\n

As elaboration, he claims that\u00a0“[a]n objection does not have a plausible rationale if it is based on erroneous factual premises”.\u00a0 I worry a little about this: some false statements are implausible (the insistence of the man who works down at the chip shop that he’s Elvis, for example), but others are not (“The Higgs Boson has a mass in the region of 300 GeV” is probably false, but was until recently – until we had a reason to believe it <\/em>false – <\/em>a perfectly plausible thing to say); still others are implausible but actually true (“An electron exists in all theoretically possible states simultaneously, but measurement will yield a result corresponding to just one of them”: hence Schr\u00f6dinger’s cat paradox).\u00a0 It’s a slightly puzzling thing to say in respect of conscientious objection, too: there might be any number of religious positions that forbid doing A<\/em>, even though they’re mutually incompatible and so, at most, only one can be true; but, presumably, if we take conscientious objection seriously, it doesn’t hinge on the actual truth of what a person believes.\u00a0 At the same time, how are we to deal with a person’s earnest statement along the lines that his religion forbids A<\/em>, when other members of the religion disagree?\u00a0 It’s true that he believes it forbidden; we need to be able to separate the truth of “I believe this to be forbidden” and “This is forbidden”. \u00a0Failure to do that would mean there’d be no way to work out what was plausible.<\/p>\n

And, while it might be true of decent societies that they\u00a0allow moral dissent (Magelssen talks about democracies, but I see no reason to suppose that you can’t have a\u00a0decent\u00a0non-democracy),\u00a0I’m also a little wary of making too easy a leap from this to medicine.\u00a0 After all,\u00a0you\u00a0don’t get a choice about living in a society of some kind; but\u00a0noone forces you to\u00a0enter medicine, and even less are you forced to enter a particular speciality.\u00a0 If you object to, say, terminations, then it’s not crazy to suppose that you probably ought to stay\u00a0out of obs and gynae, career-wise.<\/p>\n

Birchley’s paper is concerned precisely about career dynamics, and claims that a right to object based on an ayenbite of inwyt<\/a><\/em> is important in hierarchical institutions such as hospitals: it allow juniors to demur from the demands of their seniors, taking into account that those seniors might have become less likely to recognise legitimate ethical concerns over the course of the process of becoming senior.\u00a0 Thus<\/p>\n

a right to object conscientiously protects individuals from participation in immoral acts they lack the institutional power to challenge effectively.<\/p><\/blockquote>\n

There’re aspects of the paper that seem uncomfortably close to Kass’ “wisdom of repugnance”, and so are likely to attract substantially the same kind of objection – especially the claim that the voice of conscience is not the voice of reason, and is not subordinate to it. \u00a0The claim that “the revulsion that manifests in the voice of conscience is resolutely immune to reason” comes alongside a claim that that voice of conscience can still be challenged by reflection, and that “it is reflection on our experiences, rather than appeals to reason, that will provide that challenge” – but I’m unsure how mere reflection has any normative power: without some kind of regulator, all we’re saying is, “First I thought this<\/em>, then I thought that<\/em>, and I still do”. \u00a0To go beyond that, you need something normative – and reason seems like a reasonable plug to fill the gap.<\/p>\n

Anyway: on to the American legislation.\u00a0 The Bill states that<\/p>\n

No funds authorized or appropriated by [the Paitient Protection and Affordable Care] Act \u2026 may be used to pay for any abortion or to cover any part of the costs of any health plan that includes coverage of abortion, except\u2013
\n(A) if the pregnancy is the result of an act of rape or incest; or
\n(B) in the case where a pregnant female suffers from a physical disorder, physical injury, or physical illness that would, as certified by a physician, place the female in danger of death unless an abortion is performed, including a life-endangering physical condition caused by or arising from the pregnancy itself.<\/p><\/blockquote>\n

The Paitient Protection and Affordable Care Act<\/a> is a major plank of Obama’s healthcare reforms.\u00a0 That the provisions outlined above have been suggested isn’t really much of a surprise.\u00a0 However, the PL Bill continues to require that<\/p>\n

A Federal agency or program, and any State or local government that receives Federal financial assistance under this Act (or an amendment made by this Act), may not subject any institutional or individual health care entity to discrimination, or require any health plan created or regulated under this Act (or an amendment made by this Act) to subject any institutional or individual health care entity to discrimination, on the basis that the health care entity refuses to–
\n(A) undergo training in the performance of induced abortions;<\/p>\n

(B) require or provide such training;<\/p>\n

(C) perform, participate in, provide coverage of, or pay for induced abortions; or<\/p>\n

(D) provide referrals for such training or such abortions.<\/p><\/blockquote>\n

Life Site News<\/a> talks about this clause in terms of “strengthened conscience rights for health care providers”; CNS News<\/a> frames it in terms of “protect[ing] health care providers who are opposed to abortion for moral or religious reasons”.\u00a0 A cursory reading might lead us to interpret this as a fairly common-or-garden conscience clause; but what’s important not to forget is that not all terminations of pregnancy are elective: some of them are required in order to save the life of the pregnant woman.<\/p>\n

For this reason, there would seem to be a coherent moral position that says that it’s one thing to allow people to opt out of performing elective terminations; but quite another to allow them to opt out of performing any terminations whatsoever, or to opt out of training in how to provide them.\u00a0 You might think that the deliberate ending of a human life for elective reasons has no place in medicine; but even if you do think that, it’s a long way from thinking that the equivalent procedure in an emergency situation has no place in medicine. \u00a0Yet the Bill does seem to allow medics to refuse to participate in terminations even when the mother’s life is at stake<\/em>. \u00a0And so it’s not a common-or-garden conscience clause after all.<\/p>\n

Ophelia Benson notes that<\/a> “the legislation would make it legal for health care providers \u2013 including hospitals, not just individuals \u2013 to refuse to do abortions even to save the woman\u2019s life”, and\u00a0enjoins us<\/a> to “[n]otice the complete failure to mention that this ‘strengthening’ means legalizing the refusal to do an abortion to save a woman\u2019s life<\/em>“. \u00a0I think she’s on to something; and it’s in this sort of context that Magelssen’s paper is troubling. \u00a0As I just suggested, it’s not obvious that someone who voluntarily goes into medicine can legitimately claim the kind of “protection” that the Bill provides: granted that sometimes saving a life may require terminating a pregnancy (and there’re even Catholic theologians who’ll accept the permissibility of removing an innocent threat), not to learn how to do it seems like a massive dereliction of duty, and not one that’s easy to square with the ethos<\/em> of medicine. \u00a0And if you’re working in a discipline where you’re tolerably likely to have to perform a termination, but object to doing so… well, you’ve chosen the wrong discipline. \u00a0Maybe dermatology or nephrology or immunology would be more up your street.<\/p>\n","protected":false},"excerpt":{"rendered":"

There’s a flurry of papers on conscientious objection in the latest JME: Giles Birchley argues, taking his cue from Arendt, that conscientious objection has a place in medicine\u00a0here; Sophie Strickland’s paper on medical students’ attitude to conscientious objection (which I mentioned in July)\u00a0is here; and Morten Magelssen wonders when conscientious objection should be accepted here. […]<\/p>\n

Read More…<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1240,968,511,443,591,2022],"tags":[],"class_list":["post-1414","post","type-post","status-publish","format-standard","hentry","category-blogosphere","category-clinical-ethics","category-in-the-news","category-jme","category-life-and-death","category-reproduction"],"yoast_head":"\nA Conscience Clause with Claws - Journal of Medical Ethics blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2011\/12\/16\/a-conscience-claus-with-claws\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"A Conscience Clause with Claws - Journal of Medical Ethics blog\" \/>\n<meta property=\"og:description\" content=\"There’s a flurry of papers on conscientious objection in the latest JME: Giles Birchley argues, taking his cue from Arendt, that conscientious objection has a place in medicine\u00a0here; Sophie Strickland’s paper on medical students’ attitude to conscientious objection (which I mentioned in July)\u00a0is here; and Morten Magelssen wonders when conscientious objection should be accepted here. 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