Conscience in medical practice

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Morality in the secular public square

A1.    All public behaviour - how one treats other people, how one treats animals, how one treats the environment - is determined by what one believes. All beliefs influence public behaviour. Some beliefs are religious, some not, but all are beliefs.41 This applies no less to “secular” ethics than to religious ethics. Secular ethics may be independent of religion,42 but they are not faith-free, nor are they beyond the influence of faith. On the contrary: a secular ethic, like any ethic, is faith-based. That human dignity exists — or that it does not — or that human life is worthy of unconditional reverence — or merely conditional respect — and notions of beneficence, justice and equality are not the product of scientific enquiry, but rest upon faith: upon beliefs about human nature, the meaning and purpose of life, the existence of good and evil.

A2.    That everyone is a believer reflects the fact that the practice of morality is a human enterprise,43 but it is not a scientific enterprise. The classic ethical question, “How ought I to live?” is not a scientific question and cannot be answered by any of the disciplines of natural science, though natural science can provide raw material needed for adequate answers.44

A3.    Answers to the question, “How ought I to live?” reflect two fundamental moral norms; do good, avoid evil. These basics have traditionally been undisputed; the disputes begin with identifying or defining good and evil and what constitutes “doing” and “avoiding.” Such explorations are the province of philosophy, ethics, theology and religion.

A4.    Nonetheless, since the practice of morality is a human enterprise, reflections about morality and the development and transmission of ideas about right and wrong also occurs within culture and society outside the framework of identifiable academic disciplines and religions. In consequence, the secular public square is populated by people with any number of moral viewpoints, some religious, some not: some tied to particular philosophical or ethical systems, some not: but all of them believers.

A5.    Further, since morality is a human enterprise, moral judgement is an essential activity of every human person, moral judgement necessarily involves some kind of individual or personal conviction, and maintaining one's personal moral integrity is the aspiration of anyone who wishes to live rightly. Thus, beliefs are "personal," in the sense that one personally accepts them and is committed to them.

A6.    However, this does not mean that such "personal" beliefs are parochial, insignificant or erroneous. Christian, Jewish and Muslim beliefs, for example, are shared by hundreds of millions of people. They "personally" adhere to their beliefs, just as non-religious believers "personally" adhere to their non-religious beliefs. In neither case does the fact of this "personal" commitment provide grounds to set beliefs aside. Thus, it is important to recognize that pejorative or suspicious references to "personal" beliefs or "personal" values frequently reflect underlying and perhaps unexamined prejudice against them.

A7.    The Supreme Court of Canada has acknowledged that secularists, atheists and agnostics are believers, no less than Christians, Muslims, Jews and persons of other faiths. Neither a secular state nor a secular health care system (tax-paid or not) must be purged of the expression of particular philosophical, moral or religious beliefs.

The problem with this approach is that everyone has ‘belief’ or ‘faith’ in something, be it atheistic, agnostic or religious. To construe the ‘secular’ as the realm of the ‘unbelief’ is therefore erroneous. Given this, why, then, should the religiously informed conscience be placed at a public disadvantage or disqualification? To do so would be to distort liberal principles in an illiberal fashion and would provide only a feeble notion of pluralism. The key is that people will disagree about important issues, and such disagreement, where it does not imperil community living, must be capable of being accommodated at the core of a modern pluralism.45

Medicine: a moral enterprise

A8.    The practice of medicine is an inescapably moral enterprise precisely because physicians are always seeking to do some kind of good and avoid some kind of evil for their patients.46 However, the moral aspect of practice as it relates to the conduct and moral responsibility of a physician is usually implicit, not explicit. It is normally eclipsed by the needs of the patient and exigencies of practice. But it is never absent; every decision concerning treatment is a moral decision, whether or not the physician specifically adverts to that fact. Xavier Symons has recently highlighted this point:

To claim that conscience is relevant to moral decision-making while denying its indispensable role in clinical judgements about controversial treatments is to draw an arbitrary distinction between situations in which conscience matters and situations in which it does not.47

A9.    It is a mistake, argues Symons, to propose “an arbitrary     dichotomy between technical and moral judgements in medicine” because this presupposes a distinction “between matters in medicine that are of a technical nature and on which physicians should be able to exercise their discretionary judgement and matters of a moral nature where physicians should defer to patients.”48 Technical and moral matters are, he observes, “two dimensions of the same clinical reality.”

While some contemporary philosophers might contend that the domains of science and ethics are entirely separate, the lived experience of professionals is such that faccts and values are inextricably linked, and both come into play in clinical decision making. Indeed, even the most banal decisions in medicine are directed at some good, be it health or the relief of suffering or even just human solidarity. As such, these decisions have an ethical dimension.49

A10.    This is frequently overlooked when a physician, for reasons of conscience, declines to participate in or provide a service or procedure that is routinely provided by his colleagues. They may be disturbed because they assume that, in making a moral decision about treatment, he has done something unusual, even improper. Seeing nothing wrong with the procedure, they see no moral judgement involved in providing it. In their view, the objector has brought morality into a situation where it doesn’t belong, and, worse, it is his morality.

A11.    In point of fact, the moral issue was there all along, but they didn’t notice it because they have been unreflectively doing what they were taught to do in medical school and residency, and what society expects them to do. Nonetheless, in deciding to provide the procedure they also implicitly concede its goodness; they would not provide it if they did not think it was a good thing to do. What unsettles them is really not that the objector has taken a moral position on the issue, but that he has made an explicit moral judgement that differs from their implicit one.

A12.    Once medicine is understood to be a moral enterprise, it becomes easier to understand why it is a mistake to think that moral or ethical views are unwelcome intruders upon the physician-patient relationship. 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, and cannot practise medicine 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.”50

A13.    Further, moral judgement being an essential activity of every physician, it necessarily involves individual or personal adherence to moral convictions relevant to medical practice. Hence, the maintenance of personal and professional moral integrity is the aspiration of all physicians who wish to practise medicine in good conscience. Medicine is a moral enterprise, morality is a human enterprise, and physicians, no less than patients, are moral agents.

A14.    Consistent with this account of the practice of medicine understood as a moral enterprise, the CMA Code of Ethics states that a physician first considers the well-being of the patient and always acts to benefit and promote the good of the patient.51

A15.    What benefits the patient? What constitutes the good of the patient? How is that good best promoted? Answers to these questions depend not only upon one’s conception of morality, but upon one’s conception of reality. It is thus important for the CPSA to cultivate a form of rational moral pluralism that enables physicians to discharge their obligations to patients with integrity, notwithstanding deep and persisting differences in comprehensive world views that operationalize concepts of the human person foundational to the practice of medicine.

Notes

41.    Iain T. Benson, “There are no secular ‘unbelievers’” (2000) 4:1 Centrepoints 1-3.

42.    Peter Singer, Practical Ethics 2nd ed (Cambridge: Cambridge University Press, 1993) at 3.

43.    This presumption obviously underlies standard bioethics texts. See, for example, Tom L Beauchamp & James F Childress, Principles of Biomedical Ethics 7th ed (New York: Oxford University Press, 2013).

44.    Sean Murphy, “Science, religion, public funding and force feeding in modern medicine” (8 June, 2015), Protection of Conscience Project (website)(Responding to Tristan Bronca,“A conflict of conscience: What place do physicians’ religious beliefs have in modern medicine?” Canadian Health Care Network, 26 May, 2015).

45.   Chamberlain v. Surrey School District No. 36 [2002] 4 S.C.R. 710 (SCC) at para 137, (Gonthier J dissenting, but the full court concurring on this point).

46.    Maddock 1973, supra note 38.

47.    Xavier Symons, Why Conscience Matters: A Defence of Conscientious Objection in Healthcare (London/New York: Routledge, 2023) at 37.

48.    Ibid, citing Warren Kinghorn, “Conscience as clinical judgement: Medical education and the virtue of prudence” (2013) 15:3 Virtual Mentor 202–205.

49.    Ibid.

50.   Margaret Somerville, "Fundamentalism, religious or secular, gets us nowhere", The Age (1 June, 2007).

51.    CMA Code, supra note 31 at 2, B.