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JME Online First, published on June 4, 2015 as 10.1136/medethics-2015-102797 Commentary
Conscientious objection and medical tribunals Alberto Giubilini CONSCIENTIOUS OBJECTION Professionals have a prima facie obligation to do what their profession requires. This is an uncontroversial principle. Equally uncontroversial is that our conscience is essential to our moral integrity. On any account of conscience (whether religious, philosophical or psychological), conscience encompasses core and selfidentifying moral beliefs.1 2 Therefore, there is also a prima facie duty to respect conscience. The issue of conscientious objection in healthcare is the issue of whether and how to strike a balance between these two prima facie duties when they conflict with each other, for example, when doctors have a conscientious objection to abortion.
THE PROBLEM OF GENUINENESS: MEDICAL TRIBUNALS ARE USELESS One problem is that sometimes objection to abortion is not genuinely conscientious. For example, in Italy some doctors who are formally conscientious objectors in public hospitals perform illegal abortions in private clinics.3 Unfortunately, it is extremely difficult to pick out such cases. We might introduce ‘medical tribunals’ that assess the genuineness of conscientious objection. According to Christopher Cowley,4 however, such tribunals would be useless, because nothing could constitute evidence for genuineness. For example, Cowley says that the fact that a doctor behaves like a good Catholic in her private life (eg, she goes to Church every Sunday) is no evidence that her objection to abortion is genuinely based on religious conscience. I agree with Cowley on this point, but not for the same reasons he offers. Cowley’s reason is that “opposition to abortion is not so essential to being a Catholic” (as opposition to war is to being a Quaker); therefore, behaving like a good Catholic does not prove that a conscientious objection to abortion is genuine. I agree on the conclusion, but Cowley’s premise is false. The impermissibility of abortion is indeed an essential principle in the life of a good Catholic. Abortion is Correspondence to Dr Alberto Giubilini, Centre for Applied Philosophy and Public Ethics (CAPPE), Charles Sturt University, Barton, 10-12 Brisbane Avenue, Canberra, ACT 2600, Australia; [email protected]
considered by the Catholic Church an ‘unspeakable crime’,5 and the Cathechism of the Catholic Church affirms that those who procure abortions are subject to excommunication.6 Cowley reports that most UK Catholic doctors do not oppose abortion. But this only means that they are not good Catholics; it does not mean that opposition to abortion is not essential to being a Catholic. Because there are many not-so-good Catholics, it is possible that a doctor behaves like a proper Catholic in her private life but objects to abortion for non-moral reasons, using her religion as an excuse. A medical tribunal could not identify such doctors. There are other ways in which a tribunal could assess the genuineness of conscientious objection. For example, conscientious objectors might be required to accept a significant salary cut. If they are willing to pay this price, then we have more reasons to trust their objection is genuine. However, it could be replied that, given the fundamental value of conscience, people should not be required to pay a price for it. I hence grant this general point to Cowley: it is impossible for a tribunal to assess whether a conscientious objection is genuine without undermining the basis on which a right to conscientious objection is claimed in the first place, namely the fundamental value of conscience. If we assume a right to conscientious objection in healthcare, we have to grant the right to anyone who claims to have a conscientious objection, other things being equal (eg, the objection does not pose any threat to the life of the patient). Tribunals are useless.
THE PROBLEM OF REASONABLENESS: MEDICAL TRIBUNALS ARE UNNECESSARY Cowley rightly suggests that conscience claims need to be genuine, and ‘independently worthy of respect’, which he takes to be equivalent to ‘reasonable’. But Cowley suggests that also in this case a medical tribunal would be of no use. I think he is right, but only if we accept his very low standard of reasonableness. Cowley includes in the domain of the reasonable objections based on religious beliefs, such as the objection of a Catholic doctor to abortion, but excludes what he
considers ‘superstitious’ or ‘unintelligible’ beliefs, such as the objection to working on Friday 13th. It is not clear what criterion Cowley is using for this distinction. Many Jews object to working on Saturdays, and Jewish doctors might want to stick to their religious prescription exactly like many Catholic doctors want to stick to their religious prescription not to perform abortions. Both are genuine ‘conscientious’ objections, for what we know. So one might wonder what makes the objection to working on a certain day (either Friday the 13th or Saturdays) less intelligible than the objection to performing abortion. Cowley suggests that something is reasonable as long as it cannot be disproved. As he writes, “it is very hard to ‘prove’ what sort of moral status the foetus has. (There are of course other loci of disagreement in the abortion debate, mostly involving similarly unprovable claims on both sides.)”. This criterion, however, sets the bar for reasonableness extremely low, and seems to allow many superstitious views into the domain of the reasonable. There are an infinite number of propositions that are ‘unprovable on both sides’. On the basis of this very low requirement, Cowley claims that a tribunal would not be able to assess which of two conflicting claims regarding the morality of abortion is more reasonable than the other. However, the real problem seems to me to be of a different kind. The problem is that with a very low standard of reasonableness, assessing reasonableness would be so easy as to render a tribunal useless. A tribunal would consider reasonable almost every conscientious objection. In any case, my argument and Cowley’s argument support the same practical conclusion: by adopting Cowley’s low standard of reasonableness, a tribunal would be of no use. If we assume a right to conscientious objection in healthcare, we should grant the right to everyone who claims to have a conscientious objection based on some moral or religious belief, other things being equal. Tribunals are unnecessary.
CONCLUSIONS: WHEN MEDICAL TRIBUNALS ARE NEEDED Cowley is only concerned with the problem of how to assess different cases of conscientious objection, “given that British doctors are allowed to conscientiously object to abortion”. However, his conclusions about the uselessness of medical tribunals have interesting implications regarding the permissibility of conscientious objection. If we allow conscientious objection in healthcare, and if we consider anything that cannot be
Giubilini A. J Med Ethics Month 2015 Vol 0 No 0
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
1
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Commentary disproved as reasonable ground for objections, we need to allow conscientious objection in all cases in which doctors claim to have a conscientious objection, other things being equal. Conscientious objection to abortion would be as worthy of respect as conscientious objection to working on certain days of the week or to anything else, other things being equal.7 I wonder whether Cowley would be prepared to accept this conclusion. If not, we should either reject the assumption that conscientious objection is permissible at all, or find a more rigorous standard for distinguishing between permissible and impermissible objections. If we can do the latter, we might well need medical tribunals. Competing interests None declared.
2
Provenance and peer review Commissioned; internally peer reviewed. To cite Giubilini A. J Med Ethics Published Online First: [ please include Day Month Year] doi:10.1136/ medethics-2015-102797
2 3 4
Received 20 April 2015 Accepted 17 May 2015 5
▸ http://dx.doi.org/10.1136/medethics-2015-102692
6 7
J Med Ethics 2015;0:1–2. doi:10.1136/medethics-2015-102797
Sulmasy D. What is conscience and why is respect for it so important? Theor Med Bioeth 2008;29:135–49. Minerva F. Conscientious objection in Italy. J Med Ethics 2015;41:170–3. Cowley C. Conscientious objection and healthcare in the UK: why tribunals are not the answer. J Med Ethics Published Online First: 17 Apr 2015. doi:10.1136/medethics-2015-102692 Ioannes Paulus PP II, Evangelium Vitae, 1995. https:// w2.vatican.va/content/john-paul-ii/en/encyclicals/ documents/hf_jp-ii_enc_25031995_evangelium-vitae. html (accessed 20 Apr 2015). Cathechism of the Catholic Church. Vatican City, Libreria Editrice Vaticana, 1993. Giubilini A. The paradox of conscientious objection and the anemic concept of conscience. Kennedy Inst Ethic J 2014;24:159–85.
REFERENCES 1
Wicclair M. Conscientious objection in health care. An ethical analysis. New York: Cambridge University Press, 2011.
Giubilini A. J Med Ethics Month 2015 Vol 0 No 0
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Conscientious objection and medical tribunals Alberto Giubilini J Med Ethics published online June 4, 2015
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JME Online First, published on June 4, 2015 as 10.1136/medethics-2015-102797 Commentary
Conscientious objection and medical tribunals Alberto Giubilini CONSCIENTIOUS OBJECTION Professionals have a prima facie obligation to do what their profession requires. This is an uncontroversial principle. Equally uncontroversial is that our conscience is essential to our moral integrity. On any account of conscience (whether religious, philosophical or psychological), conscience encompasses core and selfidentifying moral beliefs.1 2 Therefore, there is also a prima facie duty to respect conscience. The issue of conscientious objection in healthcare is the issue of whether and how to strike a balance between these two prima facie duties when they conflict with each other, for example, when doctors have a conscientious objection to abortion.
THE PROBLEM OF GENUINENESS: MEDICAL TRIBUNALS ARE USELESS One problem is that sometimes objection to abortion is not genuinely conscientious. For example, in Italy some doctors who are formally conscientious objectors in public hospitals perform illegal abortions in private clinics.3 Unfortunately, it is extremely difficult to pick out such cases. We might introduce ‘medical tribunals’ that assess the genuineness of conscientious objection. According to Christopher Cowley,4 however, such tribunals would be useless, because nothing could constitute evidence for genuineness. For example, Cowley says that the fact that a doctor behaves like a good Catholic in her private life (eg, she goes to Church every Sunday) is no evidence that her objection to abortion is genuinely based on religious conscience. I agree with Cowley on this point, but not for the same reasons he offers. Cowley’s reason is that “opposition to abortion is not so essential to being a Catholic” (as opposition to war is to being a Quaker); therefore, behaving like a good Catholic does not prove that a conscientious objection to abortion is genuine. I agree on the conclusion, but Cowley’s premise is false. The impermissibility of abortion is indeed an essential principle in the life of a good Catholic. Abortion is Correspondence to Dr Alberto Giubilini, Centre for Applied Philosophy and Public Ethics (CAPPE), Charles Sturt University, Barton, 10-12 Brisbane Avenue, Canberra, ACT 2600, Australia; [email protected]
considered by the Catholic Church an ‘unspeakable crime’,5 and the Cathechism of the Catholic Church affirms that those who procure abortions are subject to excommunication.6 Cowley reports that most UK Catholic doctors do not oppose abortion. But this only means that they are not good Catholics; it does not mean that opposition to abortion is not essential to being a Catholic. Because there are many not-so-good Catholics, it is possible that a doctor behaves like a proper Catholic in her private life but objects to abortion for non-moral reasons, using her religion as an excuse. A medical tribunal could not identify such doctors. There are other ways in which a tribunal could assess the genuineness of conscientious objection. For example, conscientious objectors might be required to accept a significant salary cut. If they are willing to pay this price, then we have more reasons to trust their objection is genuine. However, it could be replied that, given the fundamental value of conscience, people should not be required to pay a price for it. I hence grant this general point to Cowley: it is impossible for a tribunal to assess whether a conscientious objection is genuine without undermining the basis on which a right to conscientious objection is claimed in the first place, namely the fundamental value of conscience. If we assume a right to conscientious objection in healthcare, we have to grant the right to anyone who claims to have a conscientious objection, other things being equal (eg, the objection does not pose any threat to the life of the patient). Tribunals are useless.
THE PROBLEM OF REASONABLENESS: MEDICAL TRIBUNALS ARE UNNECESSARY Cowley rightly suggests that conscience claims need to be genuine, and ‘independently worthy of respect’, which he takes to be equivalent to ‘reasonable’. But Cowley suggests that also in this case a medical tribunal would be of no use. I think he is right, but only if we accept his very low standard of reasonableness. Cowley includes in the domain of the reasonable objections based on religious beliefs, such as the objection of a Catholic doctor to abortion, but excludes what he
considers ‘superstitious’ or ‘unintelligible’ beliefs, such as the objection to working on Friday 13th. It is not clear what criterion Cowley is using for this distinction. Many Jews object to working on Saturdays, and Jewish doctors might want to stick to their religious prescription exactly like many Catholic doctors want to stick to their religious prescription not to perform abortions. Both are genuine ‘conscientious’ objections, for what we know. So one might wonder what makes the objection to working on a certain day (either Friday the 13th or Saturdays) less intelligible than the objection to performing abortion. Cowley suggests that something is reasonable as long as it cannot be disproved. As he writes, “it is very hard to ‘prove’ what sort of moral status the foetus has. (There are of course other loci of disagreement in the abortion debate, mostly involving similarly unprovable claims on both sides.)”. This criterion, however, sets the bar for reasonableness extremely low, and seems to allow many superstitious views into the domain of the reasonable. There are an infinite number of propositions that are ‘unprovable on both sides’. On the basis of this very low requirement, Cowley claims that a tribunal would not be able to assess which of two conflicting claims regarding the morality of abortion is more reasonable than the other. However, the real problem seems to me to be of a different kind. The problem is that with a very low standard of reasonableness, assessing reasonableness would be so easy as to render a tribunal useless. A tribunal would consider reasonable almost every conscientious objection. In any case, my argument and Cowley’s argument support the same practical conclusion: by adopting Cowley’s low standard of reasonableness, a tribunal would be of no use. If we assume a right to conscientious objection in healthcare, we should grant the right to everyone who claims to have a conscientious objection based on some moral or religious belief, other things being equal. Tribunals are unnecessary.
CONCLUSIONS: WHEN MEDICAL TRIBUNALS ARE NEEDED Cowley is only concerned with the problem of how to assess different cases of conscientious objection, “given that British doctors are allowed to conscientiously object to abortion”. However, his conclusions about the uselessness of medical tribunals have interesting implications regarding the permissibility of conscientious objection. If we allow conscientious objection in healthcare, and if we consider anything that cannot be
Giubilini A. J Med Ethics Month 2015 Vol 0 No 0
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
1
Downloaded from http://jme.bmj.com/ on November 15, 2015 - Published by group.bmj.com
Commentary disproved as reasonable ground for objections, we need to allow conscientious objection in all cases in which doctors claim to have a conscientious objection, other things being equal. Conscientious objection to abortion would be as worthy of respect as conscientious objection to working on certain days of the week or to anything else, other things being equal.7 I wonder whether Cowley would be prepared to accept this conclusion. If not, we should either reject the assumption that conscientious objection is permissible at all, or find a more rigorous standard for distinguishing between permissible and impermissible objections. If we can do the latter, we might well need medical tribunals. Competing interests None declared.
2
Provenance and peer review Commissioned; internally peer reviewed. To cite Giubilini A. J Med Ethics Published Online First: [ please include Day Month Year] doi:10.1136/ medethics-2015-102797
2 3 4
Received 20 April 2015 Accepted 17 May 2015 5
▸ http://dx.doi.org/10.1136/medethics-2015-102692
6 7
J Med Ethics 2015;0:1–2. doi:10.1136/medethics-2015-102797
Sulmasy D. What is conscience and why is respect for it so important? Theor Med Bioeth 2008;29:135–49. Minerva F. Conscientious objection in Italy. J Med Ethics 2015;41:170–3. Cowley C. Conscientious objection and healthcare in the UK: why tribunals are not the answer. J Med Ethics Published Online First: 17 Apr 2015. doi:10.1136/medethics-2015-102692 Ioannes Paulus PP II, Evangelium Vitae, 1995. https:// w2.vatican.va/content/john-paul-ii/en/encyclicals/ documents/hf_jp-ii_enc_25031995_evangelium-vitae. html (accessed 20 Apr 2015). Cathechism of the Catholic Church. Vatican City, Libreria Editrice Vaticana, 1993. Giubilini A. The paradox of conscientious objection and the anemic concept of conscience. Kennedy Inst Ethic J 2014;24:159–85.
REFERENCES 1
Wicclair M. Conscientious objection in health care. An ethical analysis. New York: Cambridge University Press, 2011.
Giubilini A. J Med Ethics Month 2015 Vol 0 No 0
Downloaded from http://jme.bmj.com/ on November 15, 2015 - Published by group.bmj.com
Conscientious objection and medical tribunals Alberto Giubilini J Med Ethics published online June 4, 2015
Updated information and services can be found at: http://jme.bmj.com/content/early/2015/06/04/medethics-2015-102797
These include:
References Email alerting service
This article cites 3 articles, 1 of which you can access for free at: http://jme.bmj.com/content/early/2015/06/04/medethics-2015-102797 #BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
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