Freedom of Conscience and the Needs of the Patient
Presented at the Obstetrics and Gynaecology Conference
Developments - New Boundaries
Banff, Alberta (November 9-12, 2001)
Sponsored by Department of Obstetrics and Gynecology, Faculty of Medicine,
University of Alberta, and the Department of Obstetrics and Gynecology,
Misericordia Hospital, Edmonton, Alberta.
. . .Today I am going to focus on the terms in the
title of this presentation - freedom, conscience, and needs - touching, in
one place, upon ethics, and concluding with a reflection upon faith and the
notion of moral neutrality. . .
The presentation on fetal surgery
caused me to reflect upon what might happen, some time in the future, if
surgery to correct a congenital abnormality were unsuccessful. How would
the surgeons or nurses who assisted respond, if they were asked, three
weeks later, to inject potassium chloride into the heart of their former
patient, in preparation for a genetic termination?
1 If one or two declined, for reasons of
conscience (as opposed to personal discomfort), might they jeopardize
their continued employment or opportunities for
The theme of this conference -
Developments - New Boundaries - reminds us that developing
technologies have the potential to deliver improved health care, but will
probably force you to deal with increasingly frequent or complex conflicts
of conscience in your work. It is becoming more important - not less - to
talk about freedom of conscience in health care.
Today I am going to focus on the
terms in the title of this presentation - freedom, conscience, and needs -
touching, in one place, upon ethics, and concluding with a reflection upon
faith and the notion of moral neutrality.
Three years ago there was a
conference of hospital pharmacists here. An ethicist put to the group the
hypothetical case of a 16 year old girl who goes to the town’s only
pharmacist for the morning-after-pill. In the ethicist’s scenario, the
pharmacist is morally opposed to dispensing the drug, there are no other
health care providers available, and no other town within a day’s
travel. When the assembled pharmacists could not reach a consensus on how
their luckless colleague should respond, the ethicist gave them the ‘correct’
answer. "From an ethical standpoint, regardless of your beliefs, in
that situation your responsibility is to the patient and patient care, to
address that patient’s needs."3
A nice, neat answer, but one that
illuminates the hidden faith of the ethicist rather than ethical
Loosely defined, a need is some
good that is essential for the good of the patient. If the
morning-after-pill is not a bona fide need, pharmacists are not
obligated to dispense it. On the other hand, if it is a bona fide
need, it is possible to argue that, at least in some circumstances, such
as those in the ethicist’s myth, pharmacists are obliged to
dispense it. The same principle applies to other medical procedures or
It all depends upon what one
means by "need", and this is where the faith of the ethicist
came in. He believed that the morning-after-pill was essential for the
good of the hypothetical 16 year old girl, and his ethical conclusion was
based upon that belief. Substitute some other morally controversial
procedure for the morning-after-pill, and you will see what I mean.
Let’s suppose what was wanted
was not the morning-after-pill but something else. I’m afraid that I
will have to get into something here that I’d really rather avoid:
apotemnophilia - the overwhelming desire to become an amputee for purposes
of sexual gratification or to conform to one’s self-image as someone
without a leg, or an arm, or other appendage.
Consider the case of Ronald
Brown. In 1998 Brown amputated the healthy lower leg of apotemnophiliac
Phillip Bondy, whose desire to become an amputee arose from a sexual
fetish. When asked by a journalist why he had cut off Bondy’s leg, Brown
explained that he was doing only what any good doctor would do; he was
responding to the needs of his patient.
5Consistent with the World Health
Organization’s definitions of health, Bondy no doubt perceived that the
amputation of his healthy lower leg would lead to an improvement in his
"mental and social well-being."
Had Brown been a competent surgeon, the amputation might have helped Bondy
to ‘realize his aspirations and satisfy his needs.’7
Unhappily, Brown was an incompetent butcher, and
Bondy died of gas gangrene two days after the operation.
8Was Brown - a defrocked
practitioner who with dubious qualifications as a surgeon9-
correct in his judgement that amputation of a healthy limb is an ethical
response to apotemnophilia?
That was the view of Dr. Robert
Smith of the Falkirk & District Royal Infirmary in Scotland. The year
after Bondy’s death, he disclosed that he had performed single leg
amputations on two apotemnophiliacs, whose desire for amputation was not
sexually motivated. The surgery was performed with the permission of the
Medical Director and Chief Executive of the hospital, in a National Health
Service operating theatre with NHS personnel, after consultation with the
General Medical Council and professional bodies.
10 Dr. Smith described it as "the most satisfying operation I have
and it is clear that he derived his satisfaction from his perception that
he had met the needs of his patients.
12If we take the ethicist’s
advice that one is obliged to address patients’ needs regardless of one’s
beliefs, and if we accept Dr. Smith’s view that the amputations did just
that, does this not imply that health care practitioners may be required
to perform or assist in such surgery, especially if one is the only
surgeon in an isolated community, and the patient may, if denied surgery,
resort to self-amputation with a chain saw or log splitter?
13 Should the medical
profession, if it advocates a policy of non-judgemental harm reduction,
not ensure that apotemnophiliacs have timely access to safe amputations?
The principles of bioethics seem
to support this conclusion. Clearly, Dr. Smith respected the autonomy of
his patients. Assuming that he adhered to the principle of informed
consent, no injustice was done to them. Nor did injustice arise from the
imposition of additional costs on the public health care system, since the
patients paid for the surgery. One could argue that this was a
particularly egregious example of the injustice of two-tiered health care,
but the argument is hardly conclusive, and could be answered simply by
adding elective amputations to the list of approved surgery. The patients
themselves would argue that the principle of non-maleficence was not
offended. On the contrary, they would assert that the amputations had a
It appears, then, that voluntary
amputation of healthy limbs is not inconsistent with the World Health
Organization’s definition of health, nor with bioethics principlism.
This was, perhaps, why professional and regulatory authorities in the
United Kingdom supported Dr. Smith. Yet all of this was quite lost on the
doctor who learned, at the last moment, that Brown wanted him to assist in
amputating a healthy limb. He told the patient (in a fit of ‘strong
paternalism’) "This isn’t right! You don’t want this!" and
stormed out of the room. 14
Conscientious objection in the raw, one might say. Or was he, as others
would have it, "imposing his values on the patient"?
Now, I am not asking you to
accept this or that view of the ethics of voluntary amputation. But I am
directing your attention to the way in which the definition of
"needs" controls subsequent ethical discussion, and - more
important - that our definition of needs depends entirely upon what we
believe to be conducive to human well-being.
This brings us to the essential
point. What is conducive to human well-being is determined by the nature
of the human person.15
We cannot agree upon what is good for the patient without first agreeing
upon that. That is what determines not only how we define the needs of the
patient, but how we approach every moral or ethical problem in medicine.
Doctors Brown and Smith believed that they did nothing contrary to the
essential nature of their patients by cutting off healthy limbs, and were
thus acting morally. The doctor asked to assist Brown had quite the
opposite view.What must be emphasized is that
when we cannot achieve a consensus about the morality of a procedure, it
is frequently because we are operating from different beliefs about the
nature of the human person. Disagreement is seldom about facts - the
province of science - but about what to believe in light of them - the
province of philosophy and religion. Hence the term "hidden
Unfortunately, this is frequently
obscured in scenarios like that proposed by the ethicist, which demand
that everyone accept the hidden philosophical or religious
faith-assumptions of the presenter in order to reach the ‘correct’
ethical conclusion. And if they refuse to abandon their own philosophical
or religious convictions in favour of those of the presenter, they are
likely to be accused of ‘imposing their morality’. To clear the air
during such discussions, it is frequently helpful to substitute a
different moral problem for the one being considered. Replace the
morning-after-pill with something more controversial - voluntary
amputations of healthy limbs - and reflect on how the change affects the
positions taken, and why.
Well, I suppose I have not precisely defined what is meant by the needs
of the patient. But, in what might prove to be an arduous dialogue, we
must start somewhere. To make a start, it is enough to point out what
must be attended to in discussion between moral strangers.
Ethics-as-tools and ethics-as-identity
Among the points that must be attended to is the distinction between what
Professor Frederic Hafferty and Dr. Ronald Franks have identified as
"ethics-as-tools and ethics-as-identity". How often have you heard someone
say, "I am personally opposed to X, but I can't let my personal morality
influence my public or professional responsibilities"?
This statement reflects, in the
words of Hafferty and Franks, "a view of ethics that frames ethical
principles as tools to be employed . . . something that can be
picked up or put down, used or discarded, depending upon the situation or
circumstances involved . . . an instrument for manipulation much like any
of the more technological tools medicine has at its
One keeps several ethical
toolboxes on the shelf by the back door: one for the home, one for the
office, another, perhaps, for the political arena. Use the right tool for
the right job, and don’t embarrass yourself and your colleagues by
bringing the wrong toolbox onto the ward. Hafferty and Franks observed
that this "rather limited and task-oriented view of ethics" is
the "prevailing sentiment, at least within the basic science faculty
of medical schools." 17
In contrast, a conscientious
objector does not instrumentalize moral and ethical norms, but internalizes
them. They are not tools for solving problems, but form part of his
identity. And a human person has only one identity, served by a
single conscience that governs his conduct in private and professional
life. We identify this as the virtue of personal integrity.
The ethics of the profession
Unfortunately, personal integrity is challenged by claims to moral
supremacy (if not absolute ethical infallibility) that are made, not only by
some ethicists, but by some professional organizations. This is reflected,
for example, in a statement that appeared in a controversial bulletin from
the Ethics Advisory Committee of the College of Pharmacists of British
The moral position of an
individual pharmacist, if it differs from the ethics of the profession,
cannot take precedence over that of the profession as a whole.
The bulletin demanded that
pharmacists who had conscientious objections to services refer patients to
someone who would provide them, "and in the end deliver these
services themselves if it is impractical or impossible for patients to
otherwise receive them."
The Ethics Committee listed a
number of services then available that might give rise to conscientious
objection. Consistent with our theme of New Developments - New
Boundaries, the Ethics Committee also put pharmacists on notice:
In future these services
might expand to include preparation of drugs to assist voluntary or
involuntary suicide, cloning, genetic manipulation, or even execution.
Yes, involuntary suicide.
The College Registrar continued the thought in correspondence, observing,
however, that "there are strong ethical arguments that could be made
against participating in . . .involuntary suicide
. . ." 20
But don’t be alarmed. This was,
the Registrar later explained, a slip of the pen. What was really meant
was "involuntary euthanasia".
Well, I suppose you needn’t be
concerned about euthanasia, voluntary or otherwise. In your field, you
deal with far less complicated and controversial issues: simple things
like genetic screening, cloning, embryo research, stem cells, diagnostic
ultrasound, life and death before birth, and so forth.
Are you not, all of you,
perfectly at ease in surrendering your conscientious convictions about
these things and accepting "the ethics of the profession" -
whatever those might happen to be, from time to time? After all, how can
one justify applying his personal or private morality in health care,
especially in public health care?
The question is framed so as to
portray conscientious objectors as narrow-minded, eccentric, and even
selfish, attempting to discredit them precisely because theirs is a
minority view. But this approach cuts both ways. The beliefs of many
conscientious objectors, while certainly personal in one sense, are
actually shared with tens of thousands, or even hundreds of thousands or
hundreds of millions of people, living and dead, who form part of great
religious, philosophical and moral traditions. If theirs is a ‘private’
morality, that of an early 21st century profession with several
thousand members is not less so.
The question does not turn on
privacy, but truth. If "the ethics of the profession" express a
truer moral vision than the ethics of the objector, then it is clear that
"the ethics of the profession" ought to prevail. Those who would
suppress the conscientious convictions of their colleagues should be able
and willing to explain first, why they are better judges of morality, and,
second, why their judgement should be forced upon unwilling colleagues.
Avoiding the issue by hiding behind noble sounding phrases like "the
ethics of the profession" will not do.
Freedom and autonomy
We have had an example of
"conscientious objection in the raw". How about freedom in the
buff, courtesy Christie Blatchford of the National Post, reporting on a
protest demonstration last month in downtown Toronto? Two minutes after
watching two protesters drop their trousers and defecate on a public
sidewalk, she encountered other protesters, faces concealed by balaclavas
and kerchiefs, dragging news and mail boxes into the street and throwing
them into traffic.
[A] grown man about my age
with long white hair and a beatific attitude burbled with delight and
remarked, because he simply could not help himself he was so
delighted, "Isn't it beautiful?" . . ."I meant
democracy," the man said. "I meant, isn't democracy
The story illustrates how the
concept of autonomy dominates our understanding of freedom. Freedom is
interpreted almost exclusively as freedom from: freedom from
constraint, from rules, from direction, from guidance, from immutable
principles - even from good manners.
This cultural obsession with autonomy introduces two complications into
discussion about freedom of conscience in health care.
First: just as some ethicists
reject freedom of conscience in health care in order to defend patient
autonomy, some health care workers defend conscientious objection as an
expression of professional autonomy. Both approaches are to be
rejected. As lawyer and social critic Iain Benson observes, conflicts
about involvement in a procedure cannot be settled by unilateral claims to
autonomy because the autonomy of two parties is involved. In such
conflicts, one applies principles of justice, not autonomy.
The second complication is a
tendency to politicize the concept of freedom of conscience. This occurs
because we habitually associate freedom with political freedom:
freedom from constraint by more powerful interests or the state. But this
political interpretation of freedom, so esteemed by the white-haired
gentleman in Toronto - and by others with more sense and better reasons -
is actually very narrow.
The more liberal and profound
interpretation of freedom is freedom for: for discerning the good
that needs to be done, for choosing the good, for doing good. This kind of
freedom is the condition necessary for the internalization of ethical and
moral norms that shape the identity of the person. This freedom is
liberating, but it is also confining, for it imposes an obligation to
distinguish true goods from false, higher goods from lesser. It demands
that one form convictions about what is truly good, and live accordingly.
One is not free to believe that truth doesn’t matter.
25And that is a source of conflict,
for the prevailing cultural sentiment is that truth doesn’t even exist.
Unless, of course, the protester
is defecating on my living room rug.
Well, I have failed to define the
needs of the patient, given you two different views of ethics and two
different notions of freedom. If you are not yet confused, be patient. I’m
about to describe three different ideas about conscience.
The first, and traditional view,
is that conscience is an intellectual faculty that judges whether an act
is morally good or evil. The conscience judges correctly only when the
judgement accords with objective reality and an objective standard of
morality. Thus, one is first obliged to ascertain relevant facts - say,
what correct science tells us about stem cells - and then determine what
objective moral principles apply.
This means, of course, that
conscience can err in two ways; it can be mistaken as to the facts, and it
can be mistaken in its choice of principles.26
In view of this, one must not act on a doubtful conscience, for if one
acts on a doubtful conscience, one will be morally responsible for any
evil that follows. Is the movement in the bush a moose or my hunting
partner? Clear up the doubt before pulling the trigger; 99% probability
isn’t good enough. Is deliberately killing an innocent human being in
order to put an end to his suffering a good or an evil thing to do? Clear
up the doubt before lethally injecting the patient. Some mistakes can’t
The obvious corollary is that one
may be prevented from acting on an erroneous conscience in order to
prevent harm to others.
The second, and probably the
prevailing understanding of conscience, is that it is an intellectual
faculty that independently constructs personal moral norms. One’s
conscience actually creates right and wrong. Conscience becomes the
great liberator, to which one appeals against any restrictive moral
precept on the ground that my conscience has determined that this is
"right for me," or at least "right for me in these
circumstances." Taken to its logical conclusion, this means that
conscience - which makes the rules about right and wrong - cannot
err, and we are left to deal with freedom of conscience as it was
understood by Adolph Eichmann and the "decent Nazi", Dr. Karl
Brandt, both of whom were hanged for their part in Nazi
The third idea about conscience
is that it is simply a faculty that senses one’s ‘comfort level’.
Whether comfort or discomfort is related to the morality of a procedure is
beside the point - especially when one does not want to offend one’s
colleagues. On the other hand, sacrificing one’s personal ‘comfort’
to help the patient can be portrayed as the noble thing to do - or,
perhaps, the only ethical thing to do. That was why you became a doctor,
wasn’t it? Again, one is not faced here with the possibility of error.
Feelings are never wrong.
Now, to be quite clear, the
Protection of Conscience Project understands conscience in the first
sense, which, as you have noticed, admits that conscience can err.
Nonetheless, we do not fear freedom of conscience, for objective reality
and objective moral standards provide both the means to determine that it
has erred, and the justification for limiting it when necessary.
On the other hand, people who
think that conscience creates right and wrong or merely monitors personal
comfort levels, quite logically fear freedom of conscience. Since their
understanding does not include the possibility of error, they acknowledge
no principle by which such freedom can be limited, and cannot conceive of
a society that could survive if conscience, as they understand it,
were to be let off its leash. Neither can I.
There is a consensus, then, that
freedom of conscience is not unlimited. The disagreement, when it arises,
is about how to fix its limits, and why. How are we to do this, especially
in a pluralistic society?
I believe that Dr. Morcos has made a start by offering this forum for discussion, and I
thank them for their invitation to speak. Constructive dialogue, with
particular attention to discovering the roots of disagreement, is
indispensable. That should continue.
Implicit and explicit faith
But constructive dialogue will
not take place unless we are prepared to recognize the faith-assumptions
of all parties in dialogue. I mentioned the key concept of the human
person, but there are other ‘articles of faith’. One of the most
widespread dogmas is that faith has no place in public and professional
life. Faith, so the argument goes, is unreliable and divisive because it
is unscientific, and must be confined to the strictly private sphere in
the interests of social harmony and progress.
But that human dignity exists -or
that it does not - or that human life is worthy of unconditional reverence
- or merely conditional respect - and the principles of beneficence, non-maleficence,
justice and autonomy, are all held on faith.
They may held by religious
believers as derived from divinely revealed truth, by principled moralists
(whether religious, atheistic or agnostic) who have derived them from
various sources, or by the indifferent, who have them from traditions they
do not understand. But in all cases we are dealing with belief, not facts
that have been or can be established by science.
So you are believers - all of
you. You believe that today is November 11th, because that is what you
have been told. You believe that something momentous occurred on this day
in 1918, because that is what you have been told. You believe that you
were born on a certain day in a certain place and in a certain year, to a
particular mother and father, because that is what you have been told. And
you believe in human dignity, equality and justice, but not because they
are scientific facts that have been established by experiment. The most
momentous decisions in life - to marry this particular man or woman, to
have children , to choose a life of service - are not only acts of love,
but great acts of faith. Banish faith from life and you will banish with
it the possibility of human society and much that contributes to human
So, we are believers, all of us.
Some of us profess explicit religious beliefs, others live by implicit
non-religious beliefs. But, "[e]veryone ‘believes’," writes
Iain Benson. "The question is what do we believe in and for what
The myth of moral
Finally, we will make no progress
in dialogue unless we abandon claims to moral neutrality.
Something that is good may be
done; so, too, may something that is morally neutral. Only if something is
evil is one obliged to avoid participation in it.
But the statement that a procedure is good, neutral or evil presumes a
moral standard against which the procedure has been measured, and a
conclusion that one may do X is necessarily based upon that moral
Thus, the dogmatic claim that
"secular ethics" or "the ethics of the profession" are
morally neutral is to be rejected not only as a fiction, but, to quote
Professor J. Budziszewski, as "bad faith authoritarianism . . . a
dishonest way of advancing a moral view by pretending to have no moral
You will note that I have not
attempted an apology for freedom of conscience, so you will not leave here
with slogans to brandish, a handy list of pros and cons or practical
advice on how to avoid being sued. Instead, I have offered a number of
observations and reflections on words that we too often take for granted,
and cause us to stumble: needs, ethics, freedom, conscience, and faith.
In preparing this presentation,
my goal has been to establish the foundation for constructive reflection
and respectful discussion over the longer term. Ultimately, I hope that
your discussions with colleagues will be more productive and your
disagreements more fruitful for having considered the points I have put
before you. Once more, I thank Dr. Morcos for providing this opportunity to speak, and I thank you
for your attention.
Robert "MDs face Internet restrictions: Prescription ban Canadian
first". The Calgary Herald 10 June, 2000. The practice is
endorsed by the College of Physicians and Surgeons of Alberta. Its
introduction followed a controversy about infant deaths at the Foothills
Marnie, "Personal Qualms Don’t Count: Foothills Hospital Now Forces
Nurses To Participate In Genetic Terminations." Alberta Report
Newsmagazine (now The Report) 12 April, 1999.
2. For an
analogous situation, see
Sean, Nurse Refused Employment, Forced to Resign: A Two Tiered System
of Civil Rights.
3. Thatcher, Chris, "The Pharmacy Conscience Clause:
Coming to Terms with an Ethical Dilemma." Canadian Pharmaceutical
Journal, March, 2000, P. 28.
4. Lawyer Iain
Benson, Executive Director of the Centre for Cultural Renewal, calls this
"the hidden faith of the new secularity." Benson IT. Notes
Towards a (Re) Definition of the "Secular". (2000) 33 U.B.C.
Law Review. 519-549, Special Issue: "Religion, Morality, and Law", P.
cosmetic surgery we do things all the time for which there is no need. We
are constantly rearranging what God gave us."
Paul, Why Did He Cut Off That Man's Leg? The Peculiar Practice of Dr.
John Ronald Brown.
6. In 1948 the
World Health Organization defined health as " a state of complete
physical, mental and social well-being and not merely the absence of
disease or infirmity." Quoted in Dugas, Beverly Witter and Emily R.
Knor, Nursing Foundations: A Canadian Perspective. Scarborough,
Ontario: Appleton & Lange Canada, 1995, P.9
is defined as the extent to which an individual or group is able, on one
hand, to realize aspirations and satisfy needs . . ." (World Health
Organization, 1984) Quoted in Dugas, supra, P.20
8. Ciotti, supra
graduated from the University of Utah School of Medicine in August, 1947,
and spent 20 years as a general practitioner before obtaining formal
surgical training. He failed to become certified by the American Board of
Plastic Surgery. In 1977 his licence to practise was revoked by the
California Board of Medical Quality Assurance for "gross negligence,
incompetence and practising unprofessional medicine in a manner which
involved moral turpitude." After losing licences to practise in
Hawaii, Alaska and St. Lucia he set up an unlicensed practice, living in
southern California and performing sex-change surgery in Mexico. He was
eventually jailed for 19 months for practising medicine without a licence.
He had resumed his unlicensed practice when Bondy was introduced to him. (Ciotti,
Sarah, "Controversy over UK surgeon who amputated healthy limbs".
The Lancet, Volume 355, Number 9202, 05 February 2000. Dr. Smith
waived his fee and the patients paid for the surgery.
News Internet Ventures, Surgical Questions Raised Over Amputations of
Two Healthy Legs.
have no doubt that what I was doing was the correct thing for those
patients . . . Following amputation, they both made a rapid and
satisfactory recovery without complications. At follow-up both patients
remain delighted with their new state." Ramsay, supra
Carl Elliott, discussing the phenomenon of apotemnophilia, reported that
one woman had unsuccessfully tried to induce gangrene in her legs, and was
considering other self-inflicted injuries -like lying under a train - that
would necessitate amputation. In researching his article he interviewed an
amputee who had used a log splitter to precipitate eventual surgical
Carl, "A New Way to be Mad". The Atlantic Monthly,
14. The patient
was apotemnophiliac Gregg Furth. The abrupt departure of the doctor forced
cancellation of the surgery, and by the time Brown had found a
replacement, Furth had changed his mind about amputation. He suggested his
friend, Bondy, as a substitute. Ciotti, supra.
15. One must
make a critically important distinction between human being and
human person.In Canadian law, human being
is defined by section 223 of the Criminal Code as a child who has
"completely proceeded, in a living state, from the body of its
mother". Canadian jurisprudence indicates that the term human
person and human being (as defined in section 223) are
synonymous. There are historical, legal and political reasons for this,
but I am not, in the present context, concerned with law. The subject here
is the relationship between science and philosophy.
It is the province of science to
determine when a human individual begins to be - that is, to exist.
The existence of a human being is a purely biological matter.
Standard texts on human embryology are clear on this point, and there is
no need to go into that here. (Carlson, Bruce M. Human Embryology and
Developmental Biology. St. Louis, MO: Mosby, 1994, P. 31; Moore, Keith
L. and T.V.N. Persaud, The Developing Human. Philadelphia: W.B.
Saunders Company, 1998, P. 2; Müller, Fabiola and Ronan O'Rahilly, Human
Embryology & Teratology. New York: Wiley-Liss, 1994, P. 19-20;
Larsen, William J.,Human Embryology. New York: Churchill
Livingstone, 1997, P. 1. See also
Dianne N., When do Human Beings Begin? "Scientific" Myths and
Scientific Facts. International Journal of Sociology and Social
Policy 1999, 19:3/4:22-47.
However, science cannot determine
what moral obligations are called forth by the existence of a human being.
Equally important, while science can establish that a human being is
in existence, it cannot determine that the individual is a human person.
That is a philosophical question, and science is not competent to decide
philosophical questions. Its correct and limited role is to provide
factual data that philosophers and ethicists incorporate into their
Frederic, PhD, and Ronald Franks, MD, "The Hidden Curriculum, Ethics
Teaching, and the Structure of Medical Education." Journal of
Academic Medicine, Vol. 69, No. 11, November, 1994, P. 862. The
identity considered by the authors is a professional identity, and,
to the extent that they separate personal and professional identities in
the same person, they actually adopt the "ethics-as-tools" approach that
they critique. Nonetheless, the author is indebted to them for their
insight, which is applied here in a manner that is probably different
from what they intended.
17. Ibid, P. 864
18. The notion
that one person can maintain two different moral identities was explored
by Robert Louis Stevenson in Dr. Jekyll and Mr. Hyde. "Though
so profound a double-dealer, I was in no sense a hypocrite; both sides of
me were in dead earnest; I was no more myself when I laid aside restraint
and plunged in shame, than when I laboured, in the eye of the day, and the
furtherance of knowledge or the relief of sorrow and suffering . . . I
thus drew steadily nearer to that truth by whose partial discovery I have
been doomed to such a dreadful shipwreck: that man is not truly one, but
truly two . . . others will outstrip me on the same lines; and I hazard
the guess that man will ultimately be known for a mere polity of
multifarious, incongruous and independent denizens." Stevenson,
Robert Louis, Dr. Jekyll and Mr. Hyde & The Merry Men and Other
Tales and Fables. Ware, Hertfordshire: Wordsworth Classics, 1999, P.
42. Also relevant here is the theory
of ‘doubling’ proposed by Robert Jay Lifton as an explanation for the
participation of German physicians in Nazi medical atrocities. While not
suggesting that they suffered from some kind of multiple personality
disorder, Lifton explores the process by which men, who, in their ‘personal
or private lives’, perhaps enjoyed reputations as caring, sensitive,
etc., could have committed atrocities in the discharge of their public
functions. His disturbing conclusion: (P. 427) "most of what Nazi
doctors did would be within the potential capability - at least under
certain conditions - of most doctors and of most people." Lifton,
Robert Jay, The Nazi Doctors: Medical Killing and the Psychology of
Genocide. Basic Books, 1986, P. 418-465.
19. College of
Pharmacists of British Columbia Bulletin, Ethics in Practice: Moral
Conflicts in Pharmacy Practice. March/April 2000, Vol. 25, No. 2, P.
5. For further information about the bulletin and related issues,
Report 2001-01, College of Pharmacists of British Columbia: Conduct of
the Ethics Advisory Committee 26 March, 2001 20. Letter from the Registrar of the College of
Pharmacists of British Columbia to the Project Administrator, 19 April,
21. Letter from the Registrar of the College of
Pharmacists of British Columbia to the Project Administrator, 9 May,
Christie, "Post-Sept. 11, clowns' antics deplorable: Protesters burn
U.S. flag, slash tires: 'This is what democracy looks like'".
Post, 17 October, 2001.
freedom from may be a condition necessary to pursue some good, as
when one must be free from some commitments in order to pursue
others. The point here is that our cultural obsession with autonomy
encourages the feeling that freedom is synonymous with escape and with
limitless possibilities. In contrast, writes Professor Robert Spitzer, S.J.,
"one feels unfree, hemmed in, or even enslaved when new
responsibilities are "imposed", or when one is forced to focus
on one course of action rather than another." Spitzer, Robert J.,
with Robin A. Bernhoft and Camille E. De Blasi, Healing the Culture: A
Commonsense Philosophy of Happiness, Freedom and the Life Issues. San
Francisco: Ignatius Press, 2000, P. 209-210) The author follows Professor
Spitzer, S.J., in his development of the theme of freedom from and
medicine where two people are involved, autonomy is always a two-way
street. Yes, the patient or "client" has his or her autonomy;
but so, too, does the practitioner. There is no good reason (except
perhaps one grounded in an anti-religious bias) to advocate that a
patient's autonomy should trump the autonomy of the professional
health-care worker just because the two views conflict. What is needed . .
. is an examination of how to accommodate conscience and religious views
within the contemporary technocratic and often implicitly anti-religious
paradigm of certain aspects of modern medicine. In case anyone has missed
it, the question of whether anything is "given" with respect to
human persons is going to be, in many cases, the issue in coming
decades as various issues in human genetics begins to unroll their
discoveries and possibilities into the various areas of society (medicine,
ethics and law included). An analytical framework of some sophistication
is necessary to ensure maximal respect for and accommodation of differing
views in society.""The real issue, where there
is a conflict of views between people regarding involvement with a
procedure or drug, is not settled by reference to one person’s
"autonomy" but by reference to another principle, that of
"justice" (defined as "rendering a person their due……").
For it is there, in the order of justice, that competing claims must be
reconciled in a manner that accords with the rule of law (including
professional ethics and respect for professional disagreement), the
provision of health-care and the developed understanding of a civil
Iain T., "Autonomy", "Justice" and the Legal
Requirement to Accommodate the Conscience and Religious Beliefs of
Professionals in Health Care. (Revised March 2001)
ignorant man is (in a way) free to think what he likes: increasing
knowledge will reduce that kind of freedom. At the moment, I am myself
free to believe anything I like about (say) brain surgery, or the
economics of Nicaragua. I am also, and for that reason, totally unable to
do anything about either of those important matters. If I chose to get
educated about either of them, the process would involve a progressive
diminution of my present glorious freedom of belief. I would thus become a
free man in fields where I am now crippled and helpless; but for this
freedom I would have to pay the price of accepting the determinate and
objective nature of reality in those fields and conforming my mind to it.
I would become more free in one way, and less free in another."
Derrick, Christoper, Escape from Scepticism: Liberal Education as if
Truth Mattered. San Francisco: Ignatius Press, 1977, P. 70-71.
J. Budziszewski identifies four ways in which these two kinds of errors
can come about: inexperience, insufficient skill in reasoning, inattention
and perversion of reasoning by corrupt habits, customs, impaired
dispositions, self-deception, etc. Budziszewski,
J., "Handling Issues of Conscience." The Newman Rambler,
Vol. 3, No. 2, Spring/Summer 1999, P. 3.
27. "I was
no more than a faithful, decent, correct, conscientious and enthusiastic
member of the SS and of the Reich Security Headquarters . . . I did my
commanded duty with a clear conscience and a faithful heart." -
Adolph Eichmann. Von Lang, Jochen and Sibyll, Claus (Ed.), Ralph Manheim
(Trans.), Eichmann Interrogated: Transcripts from the Archives of the
Israeli Police. New York: Farrar, Straus & Giroux, 1983, P.
289-290. "I have always fought in
good conscience for my personal convictions and done so uprightly, frankly
and openly." - Dr. Karl Brandt. The statement was made in June, 1948,
before he was hanged for his involvement in the Nazi euthanasia programme.
"Brandt is, more than any other doctor, the prototype of what I shall
call the ‘decent Nazi’. . . The ‘decent Nazi’ did much of the work
of the regime and was indispensable to Nazi mass murder." Lifton,
Robert Jay, The Nazi Doctors: Medical Killing and the Psychology of
Genocide. Basic Books, 1986, P. 117.
Iain T., "There are No Secular ‘Unbelievers’".
7, Vol. 4, No. 1, Spring 2000, P. 3.
29. The point being made here does not require an
exploration of the more complex approach to the morality of human acts
taken by Aristotle and St. Thomas Aquinas.
question of neutrality has been profoundly obscured by the mistake of
confusing neutrality with objectivity... neutrality and objectivity are not
the same... objectivity is possible but neutrality is not. To be neutral,
if that were possible, would be to have no presuppositions whatsoever. To
be objective is to have certain presuppositions, along with the
manners that allow us to keep faith with them. We presuppose that we
exist, that our students exist, and that we exist in a really existing
world. We presuppose that perception is not wholly illusion, and that the
consequent relation - - ‘if this, then that’ - - does correspond to
something in reality. We presuppose that nothing can both be and not be in
the same sense at the same time. We presuppose that good is to be done and
truth is to be known. We presuppose that we should never directly intend
harm to anyone. And so forth." Budziszewski,
J., "Handling Issues of Conscience." The Newman Rambler,
Vol. 3, No. 2, Spring/Summer 1999, P. 4.