Wednesday, June 26, 2019

On Conscientious Objection in Medicine

Nir Ben-Moshe has a summary of his paper, "The Truth Behind Conscientious Objection in Medicine" at the blog for the Journal of Medical Ethics. It's an interesting and worthwhile paper, but in both the summary and the paper itself, Ben-Moshe makes an all-too-common error in formulating the problem. As he puts it in the summary:

Conscientious objection in medicine has become a topic of heated debate in recent years, but answers to the question of what justifies such objections in medicine have proven to be elusive. According to the two primary justifications found in the literature, conscientious objection in medicine is justified either out of respect for the moral integrity of the objector or because we should tolerate different moral points of view.

These are indeed common reasons given for why one should respect conscientious objection, but there is a more fundamental question in the wings, which is why it requires any justification at all beyond the reasons for the objection itself.

Consider it at the abstract level. Someone refuses to do X because they believe X is in some way evil, either directly or indirectly, either in itself or by what goes with it. This is an entirely adequate reason for them to conscientiously object. So they don't need a further justification. But usually when people talk about conscientious objection in medicine they are talking about justifying the allowance of it. So the real question is what anyone would need beyond this to justify allowing someone not to do something they regard as evil. And the obvious answer is, nothing. Nothing more is required to justify allowing someone not to do what they think is evil, beyond the fact that they think it is evil. Put it another way, from the other side. Someone comes along and asks you, "What is the justification for you not forcing people to do what they regard as evil?" Such a person doesn't understand how ethical justification works; not forcing people to do things they think are evil is not something you have to justify to begin with. If you have to justify anything, it's forcing people to do things that they think are evil.

There is a great deal of food for thought here, particularly when we ask why the major discussions of medical ethics so often fail to recognize this when we get to conscientious objection. Part of the reason, I think, is the growing, and very disturbing, tendency to treat medical personnel as nothing but tools for getting results in 'health care' -- as mere means rather than as ends in themselves. If you have a tool that is not doing something you want done, it's perfectly legitimate to ask, why should I have tools that don't do what I want? And if I assume that the tool is for a certain purpose and it does not fulfill that purpose, then that's a reason I would have for taking the tool to be a failure. If I want to keep the tool that fails me, it makes sense to ask what justifies that. But doctors, nurses, pharmacists, medical technicians, are not tools, not slaves; they are persons, moral agents in their own right. Medicine is not a matter of picking up a doctor and using him, or plugging yourself into a vending machine constructed of medical personnel to get the service you desire; it is a matter of you and the medical personnel cooperating in a joint venture for your health and well-being. And while medical personnel have deferential responsibilities to patients, as part of that joint venture, it is nonetheless a cooperative enterprise and one in which they have not, and could not have, abdicated their position as moral agents. We tend to focus on patient autonomy, for obvious reasons, but medical personnel have to be regarded as having some autonomy as well.

Another part, I think, is a general failing to regard them as significant members of society in their own right, and their medical activity as part of their own personal contribution to society. I've noted before the bizarre fact that discussions of conscientious objection in cases of military draft attribute far more freedom to objectors than discussions of conscientious objection in medical matters, despite the fact that the latter are not generally drafted for national purposes but are simply people who have signed up to try to help people. It makes no sense for draftees in a war to have more freedom of objection than your average doctor or nurse. But the reason is that the former usually begins with a presumption that the former are objecting as members of society; so if we say, "Society says that you must shoot someone," it's legitimate to respond, "This part doesn't, and thinks the rest of society is making a mistake." Their contribution as members of society is considered relevant to their duties to society, even if people come to the conclusion that the latter somehow override the former. But this is regularly passed over in the case of medical personnel; people talk about the ethics of medicine as if it were detached from the ethics of medical professionals, something to which they had but to comply.

So the notion that we need to justify allowing people to avoid evil, to their best judgment, is absurd, and seems to be based on unsustainable assumptions. What you would need to justify is forcing them to do what they think is evil. And thus the real question comes down to this: What is it in this specific activity that makes it so necessary to common good that the common good authorizes forcing their compliance? It's a question that is rarely asked, but it is the only question that is relevant. (One suspects that the reason it is rarely asked is that if you ask it, it immediately becomes obvious that most discussions of conscientious objection in medical ethics consist of people trying to rig the discussion so that it reaches a pre-set conclusion.) Conscientious objection is not an intrusion on medicine from the outside, but an integral part of medical practice, essential to it as a conscientious activity and as a humanitarian tradition. Nothing can really justify trying to prohibit or overrule it except what's necessary for everyone's good.

Ben-Moshe's discussion, however, is actually quite valuable because the essential idea of the argument survives the re-framing, from the bad framing of assuming that you need a justification for not demanding that people do what they think is evil to the correct framing of looking at the justification for such a demand. A Smith-style postulation of an impartial spectator is one way you could go about looking at the question of whether specific activities are (at least apparently) inconsistent with the genuinely common good.

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