"NO MORE CHRISTIAN DOCTORS"
Part 6: Avoiding authoritarian 'solutions'
The centrality of the human person
Full Text
The definitions of "health" and "harm" are determined by underlying
beliefs about the nature of the human person.1 There can be no agreement
about what is beneficial or harmful for the patient without first agreeing
upon that. A definition or belief about the human person is necessary to
assess benefits and harms, and thus shapes the approach to every moral or
ethical problem in medicine.
These beliefs may take scientific and medical information into account,
but they are not and cannot be scientific, since questions about human
personhood are beyond the scope of science.2 An underlying non-scientific
'belief system' thus inescapably informs the practice of all physicians,
including their notions of "health" and "harm."
Explicit faith, hidden faith
When people cannot achieve a consensus about the morality of a procedure,
it is frequently because they 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. Such underlying beliefs are frequently
unexamined. Hence, when a public and practical expression of a religious
belief generates a conflict between a religious believer and a secularist,
the conflict often arises because of a clash between the explicit faith of
the religious believer and the hidden faith of the secularist.
In such
situations, precisely because the faith-assumptions of the secularist are
not explicit (and may not be recognized even by the secularist) , the
controversy is often erroneously portrayed as a conflict between believers
and non-believers: between religious belief and science ('real' facts):
between religious belief and reason ('real' knowledge): or between religious
belief and the secular (the 'real' world).
Forms of rationalism, scientific materialism and secularism that claim
exclusive access to reality deny the capacity of conscience or religion to
grasp what is real. The assumption here may be that reason (and perhaps only
reason employing empirical science) is "the only valid way of human knowing,
and, consequently, the only appropriate tool to explore non-scientific
questions, such as profound ethical issues."3 Thus, conscience and religion
are relegated to the purely subjective, personal sphere, because it is
assumed that they produce "mere" belief, which must give way before "real"
knowledge produced by forms of rational enquiry in which conscience and
religion play no part.4
Such an outlook involves a truncated view of reality, for human dignity,
justice, equality, courage, prudence, mercy, beneficence, non-maleficence,
and love - to name but a few realities that most people acknowledge- are not
amenable to the methods of empirical science nor adequately approached by
means of reason alone.5
An understanding of any of these things involves belief. They may be
religious beliefs held to be divinely revealed, the beliefs of principled
moralists (whether religious, atheistic or agnostic) who derive them from
various sources, or the beliefs of the indifferent, who absorb them from
traditions they do not understand, or Facebook. But controversies on all such subjects
arise from differences in belief, not conflicts between belief and
scientific facts, or between superstition and knowledge, or between myth and
reality.6
Impossible demands
Hence, the demand that physicians must not be allowed to act upon beliefs
is unacceptable because it is impossible; one cannot act morally without
reference to beliefs. Relevant here is a comment by Professor Margaret
Somerville. "In ethics," she writes,"impossible goals are not neutral; they
cause harm."7
The demand that physicians must not be allowed to act upon "personal" or
"religious" beliefs heard with increasing frequency and stridency in public
discourse - is equally unacceptable. The demand, framed in this way, with an
emphasis on "personal" or "private" morality, is an attempt 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 or private 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 those who differ with
them is not less so.
Avoiding authoritarian 'solutions'
Of greater interest in the present context are the sometimes explicit
accusations that physicians who act on "personal" beliefs are narrow-minded,
eccentric, and even selfish. Such allegations provide an additional reason
for caution, for they too often reflect an attitude more appropriate to a
totalitarian state than to a liberal democracy: that physicians have a duty
to do what they believe to be wrong, that they must always set aside their
own conscientious convictions in order to conform to the expectations of the
patient, or the profession, or the state, the better to serve as an
instrument to achieve ends chosen by others.
But Madame Justice Bertha Wilson, in R. v. Morgentaler, stressed
that "an emphasis on individual conscience and individual judgment . . .
lies at the heart of our democratic political tradition."8 She insisted that
an individual must never be treated as a means to an end - especially an end
chosen by someone else, or by the state. One of her reasons for striking
down legal restrictions on abortion was that, through the law, the state was
'taking sides' on what is essentially a moral question that should be left
to private judgement. She rejected the idea that the state should endorse
and enforce "one conscientiously-held view at the expense of another," for
that is "to deny freedom of conscience to some, to treat them as means to an
end, to deprive them . . .of their 'essential humanity'."9
Crusaders in high places, joined now by handmaidens on Facebook, are
demanding that physicians, as a matter of principle and even as a matter of
law, can be compelled to do what they believe to be wrong, and that they can
be punished if they do not. It is the position of the Project that this is a
blasphemy against the human spirit. Applying to such demands the words of
Alexander Solzhenitsyn, "To this putrefaction of soul, this spiritual
enslavement, human beings who wish to be human cannot consent."10
This section of the paper draws from an extended discussion of the subject in Murphy S, Genuis S.J.
Freedom of Conscience in Health Care: Distinctions and Limits. J Bioeth
Inq. 2013 Oct; 10(3): 347-54
This
does not, of course, dispose of the practical question of how freedom of
conscience can be rationally and adequately accommodated in a society
characterized by a plurality of moral and political viewpoints and
conflicting demands. Ultimately, like the difficult compromise achieved by
the Canadian Medical Association, this is a work in progress. Nonetheless,
it is possible to propose some foundational principles that provide some
guidance.
Perfective Freedom of Conscience
A traditional view holds that one who freely chooses a moral good - say,
helping someone in need - perfects himself/herself to the extent that what
is chosen is truly good and not just apparently so. A moral pluralist might
say that the free choice of a desired good actualizes personal autonomy and
thus contributes to an ultimate end described as self-fulfillment. The
decision to pursue an apparent good in either case can be called an exercise
of perfective freedom of conscience because it is potentially perfective of
the human person.
Preservative Freedom of Conscience
On the other hand, one who refuses to participate in wrongdoing -
refusing an invitation or pressure to steal, for example - preserves his own
integrity, even though he does not achieve the kind of personal growth that
might be possible by doing some positive good. A moral pluralist might hold
that such a refusal preserves rather than develops personal autonomy. Thus,
a decision to avoid an apparent evil can be described as an exercise of
preservative freedom of conscience.
The problem of limits
It is generally agreed that the state may limit the exercise of freedom
of conscience if it is objectively harmful, or if the limitation serves the
common good. While there is disagreement about how to apply these
principles, they are seen at work when the law refuses to countenance human
sacrifice in religious worship or when it limits the practice of medicine to
qualified professionals rather than faith healers.
Such limitations may interfere with some of the aspirations of citizens
or their pursuit of moral perfection but are not necessarily inconsistent
with democratic freedom or human dignity. Certainly, restrictions may go too
far; they might fail to demonstrate sufficient understanding and respect for
human freedom and dignity, even if they do not subvert them entirely. But no
polity could long exist without restrictions of some sort on human acts, so
some limitation of perfective freedom of conscience is not unexpected.
If the state can legitimately limit perfective freedom of conscience by
preventing people from doing what they believe to be good, it does not
follow that it is equally free to suppress preservative freedom of
conscience by forcing them to do what they believe to be wrong. There is a
significant difference between preventing someone from doing the good that
he/she wishes to do and forcing him/her to do the evil that he/she abhors.
Protecting fundamental goods
By its nature, perfective freedom of conscience demands much more of
society than preservative freedom of conscience. Limiting perfective freedom
of conscience may prevent people from perfecting themselves, fulfilling
their personal aspirations, or achieving some social goals. This may do them
some wrong; that is why democratic regimes have been increasingly inclined
to err on the side of freedom, demanding that restrictions on freedom of
conscience must be demonstrably necessary, narrowly framed, and strictly
construed. But if it does them some wrong, it does not necessarily do them
an injury.
In contrast, to force people to do something they believe to be wrong is
always an assault on their personal dignity and essential humanity, even if
they are objectively in error; it is always harmful to the individual, and
it always has negative implications for society. It is a policy
fundamentally opposed to civic friendship, which grounds and sustains
political community and provides the strongest motive for justice. It is
inconsistent with the best traditions and aspirations of liberal democracy,
since it instills attitudes more suited to totalitarian regimes than to the
demands of responsible freedom.
This does not mean that no limit can ever be placed on preservative
freedom of conscience. It does mean, however, that even the strict approach
taken to limiting other fundamental rights and freedoms is not sufficiently
refined to be safely applied to limit freedom of conscience in its
preservative form. The stakes are far too high. Like the use of potentially
deadly force, if the restriction of preservative freedom of conscience can
be justified at all, it will only be as a last resort and only in the most
exceptional circumstances.
Notes
1. One must distinguish 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
we are not, in the present context, concerned with law. The subject here is
the relationship between science and philosophy.
2. 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. 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 deliberations.
3. Somerville M.
"Why are they throwing brickbats at God?" MercatorNet (1
June, 2007) (Accessed 2007-07-05)
4. As, for example suggested by John Rawls' "veil
of ignorance". Rawls J. A Theory of Justice. Cambridge, Mass.:
Harvard University Press, 1971
5. "We have multiple ways of human knowing in
addition to reason, all of which are essential to ethics. They include
history (human memory) — this is beautifully encapsulated in aboriginal
people's practice in making ethical decisions of looking back seven
generations. Imagination and creativity — looking forward seven
generations to try to assess the ethical acceptability of the impact of
what we plan to do on future generations. Intuition — especially moral
intuition. Common sense. Experiential knowledge — including what we can
know, as the gym teachers tell us, by listening to our bodies. And
"examined" emotions, to name just some." Somerville M.
"Why are they throwing brickbats at God?" MercatorNet (1
June, 2007) (Accessed 2007-07-05).
6. Which is not to say that questions of fact and
distinctions between knowledge and belief are irrelevant in such
disputes.
7. Somerville M.
"Why are they throwing brickbats at God?" MercatorNet (1
June, 2007) (Accessed 2007-07-05).
8.
R. v. Morgentaler (1988)1 S.C.R 30 (Supreme Court of Canada)
(Accessed 2014-02-24)
9.
R. v. Morgentaler (1988)1 S.C.R 178-179 (Supreme Court of
Canada) (Accessed 2014-02-24)
10.
Solzhenitsyn, Alexander, "As Breathing and Consciousness Return." In
From Under the Rubble. Bantam Books (USA & Canada) 1976, p. 23