In my last post (May 18, 2013) I made a passing reference to an article by Julian Savulescu that had been included in our packet of information for the meeting of the Council on Health Care Ethics of the Wisconsin State Medical Society. On the agenda for the meeting was consideration of a resolution encouraging the State Medical Society to promote the protection of the conscience of all physicians. Whether the article by Savulescu was intended as “background information” or as an alternative perspective from which to judge the merits of the conscience resolution was unclear. (Savulescu is the editor of the Journal of Medical Ethics, cited by Jon Holmlund in his recent post of May 23, 2013). This particular article, which set the tenor for the meeting, was published in 2006 in the British Medical Journal (BMJ. 2006 February 4; 332(7536): 294–297) and deserves a response of its own.
For the purposes of this post, I need only address Savulescu’s opening paragraph. Savulescu begins his article antagonistically with a quote, not from a philosopher, ethicist, or theologian, but from a playwright–Shakespeare–one which reflects his attitude and efficiently summarizes his article: “Conscience is but a word cowards use, devised at first to keep the strong in awe” (Richard III V.iv.1.7). He then proceeds to make bold and contentious assertions without adequate argumentation.
Continuing on, he states: “Conscience, indeed, can be an excuse for vice or invoked to avoid doing one’s duty. When the duty is a true duty, conscientious objection is wrong and immoral. When there is a grave duty, it should be illegal.” It is apparent that Savalescu subscribes to a non-traditional, deconstructed understanding of “conscience.” For Savulescu, conscience is neither an inherent sense of moral responsibility before God or a higher authority, nor is it a post-modern construct–an arbitrarily defined set of core values and beliefs–but merely an excuse to avoid one’s duty. While traditional understandings of conscience acknowledge that conscience can be fallible, conscience as the instantiation of one’s sense of moral responsibility and moral selfhood is the primary focus–one ignored by Savulescu. Furthermore, Savulescu fails to define “duty,” “true duty,” or “grave duty,” terms he flippantly banters about. In what does that duty consist? By whom or what is that “duty” required? To whom is that duty owed? To put it more concretely, is the refusal to provide pregnancy termination as an alternative to contraception for one who has failed to exercise their right to reproductive freedom responsibly a violation of a duty, a true duty, or a grave duty? Furthermore, does he truly believe, as he states, that the “primary job” of an obstetrician is “to deal with pregnancy termination”? If he does, and he is probably not alone, he is operating from a divergent concept of medicine, one that is inconsistent with the values of a traditional or neo-Hippocratic understanding of medical care.
“A doctor’s conscience has little place in the delivery of modern medical care which should be determined by law, just distribution of resources, the patient’s good, and informed desires.” According to this statement, it is not only the doctor’s conscience that has little place in medicine: missing is any role for the physician him- or herself; missing is any acknowledgement of the primacy of a relationship; missing is any recognition of the need for clinical judgment; missing is any conceptualization of “care;” missing is the heart and soul of medicine. Also missing from his statement is any concept of the “profession of medicine” as an institution governed by internally-derived values and standards, not externally-imposed rules and regulations. His use of the term “public medicine” implies the same. It appears that rather than attack the profession itself, his strategy is to attack its moral foundation and challenge its moral authority.
The above statement also reflects Salvulescu’s presumption about the nature of conscience which he sees as a whim that can be set aside at will without adverse personal consequence, and not as an integral aspect of one’s personhood. Furthermore, in speaking cavalierly about conscience, entitlements, and the law, Savulescu fails in his obligation to cite those laws that would require a physician to violate their conscience or that make medical care an entitlement (perhaps, because there are none). Quite ironically, he neglects the facts that conscience is, in truth, protected by our constitutional laws, and that entitlement to medical care, in actuality, does not exist.
The apogee of this introductory paragraph culminates in the following brash and unreflective assertion: “If people are not prepared to offer legally permitted, efficient, and beneficial care to a patient because it conflicts with their values, they should not be doctors. Doctors should not offer partial medical services or partially discharge their obligations to care for their patients.” First of all, it is not clear from whence he derives the authority to make such impetuous claims and to presumptuously set the standards for a profession to which he does not belong. Secondly, it is apparent that he has not carefully considered the ramifications to medical care of such a contentious assertion. Practically speaking, if one considers that there are conservatively 15,000 practicing “neo-Hippocratic” physicians who, if faced with the alternative of violating their consciences or walking away from medicine, would potentially choose the latter; and considering that a significant proportion of those individuals practice in rural America, can he–or we–afford to make such an egregious declaration? Is no care for all truly preferable to limited care for some (especially when those limits largely pertain to issues of quality of life and not life threatening conditions)? Given our grave concerns about imminent physician shortages related to implementation of the Affordable Care Act, can we truly afford to lose such a vast number of physicians AND discourage many who might consider entering the profession, but for their conscientiously held beliefs? And just what will medicine become when serviced by physicians without conscience who are beholden to nothing greater than “informed” desires of individuals and the tyranny of the state? Has he–and we–learned nothing from the mistakes of history?
Savulescu’s “argument” is nothing more than an appeal to emotion, not reason, and an expression of his own personal opinion. He makes repeated negative references to paternalism throughout the article (which is not at all pertinent to discussions of conscience) of which he, himself, is ironically guilty, for his ethical argumentation is grounded merely on the “fact” that “it is, because I said so.” The portrait of medicine Savulescu paints pales in comparison to the richly textured one painted by Pelligrino, where medicine is pictured as “the most humane of the sciences, the most empiric of arts, and the most scientific of humanities.” Ultimately, Savulescu’s argumentation aptly exposes his position as the “house of cards built on a foundation of sand” that it is.