Religious Liberty and Human Dignity

A December 30th AP article relates the results of a poll that asked respondents about their views of religious liberty. The lead paragraph reads, “Americans place a higher priority on preserving the religious freedom of Christians than for other faith groups, ranking Muslims as the least deserving of the protections, according to a new survey.” The article goes on to detail the percentages of people who thought it was important to protect Christians’ religious liberty vs. the percentages who thought it important to protect Muslims’ religious liberty, etc.

Of course, the results of all such surveys are suspect, because the way the questions are worded determines the outcomes. Given that caveat, the questions this survey asks are fundamentally self-contradictory. To speak of religious liberty for one religion but not another is an absurdity. If “religious liberty” does not apply to all religions, then it is not religious liberty, but religious hegemony. On this understanding “Religious liberty” is a Hobson’s choice: “You have the liberty to practice your religion, as long as it is the one I approve.”

Christians should be particularly keen on this issue, for at least three reasons. First, since we desire the freedom to practice our faith according to our consciences, to disallow the same freedom to those of other faiths is flagrantly hypocritical (and whom did Jesus castigate more harshly than the hypocrites?). Second, Christians have often been (and still are in many parts of the world) subject to religious persecution; if we do not defend the religious liberty rights of others, we have no reason to expect our religious liberties to be defended when someone decides it is the practitioners of our faith who should be persecuted. Finally, religious liberty is closely intertwined with human dignity; denying religious liberty to a certain group entails the denial of their human dignity, and as Nigel Cameron once said, “Human dignity is indivisible; any assault on anyone’s dignity around the world is an assault upon mine.”

 

(Also see Steve Phillips’ post from December 9th.)

(Incidentally, the Cameron quote is from a Frontline interview from about sixteen years ago on assisted reproduction; the whole interview makes fascinating reading, considering all that has transpired since then.)

 

(I could not find the actual questions asked in the survey; this post is based on the reporting of the survey results.)

A Not-So-Open Discussion

Courtney Thiele posted on March 3oth about an article in the Washington Post describing “a new push to de-stigmatize the nation’s most controversial medical procedure by talking about it openly and unapologetically.” A clinic in Maryland called “Carafem” dispenses abortion pills, and “promises a ‘spa-like’ experience for women with an open and unabashed approach to pregnancy termination.” (quotations from the Washington Post’s article)

This clinic is no doubt trying to move the experience of abortion as far away from Gosnellian horrors as possible. But despite the claims of the owners (and the Washington Post), their own terms reveal that it is not openness they seek, but a façade to hide the truth.

Whenever we hear the term “stigma,” we know that we’re getting lectured about judgmental people who are imposing their bad thoughts, and seeking to infringe upon someone’s freedom. The term in medical use describes a “mark” due to some condition, and therefore a natural consequence and characteristic identifier. In non-medical parlance, it has come to represent an externally imposed non-physical mark, unfairly applied.

For those wishing to deflect criticism, this is a useful word. It serves to convey the impression that if we feel anything negative about an entity or act, it is the fault of external forces, usually having malevolent intent. “Stigma” becomes a surrogate—a strawman—for “guilt” and “shame.” The founders of this clinic, of course, are trying to sell abortion, and trying to blame the guilt that participants may feel on judgmental others.

Most revealing is the clinic staff’s use of a term describing the abortion itself. They dodge the truth when they state how the abortion pill will “pass the pregnancy.” Pregnancy, as we know, is a state of being, not something to pass out of one’s body. It occurs because something is in the body, namely an embryo or fetus. By misusing the term, the clinic staff belies their understanding that the issue is about the human being of the embryo. But, if they acknowledge its being then moral questions must arise, and their goal of casual and stress-free abortion fails. Better to not acknowledge it. Simply talk around it, by substituting a misleading term, and we can pretend there isn’t really a person there.

I’ve seen enough about the coarsening of our culture to have a general sense of pessimism about the ability for many to see through this verbal obfuscation. Still, the sense that a pregnancy is a human is not going to go away, and unlikely to be something the modern public is oblivious to, especially with technological advances in ultrasonography. I doubt that there will be a time when those who take part in abortion are completely free from the burden of guilt, knowing that what they have passed was not simply their condition, but someone on our common path toward birth.

The importance of religious freedom

Like Jerry Risser who recently wrote about the hysteria surrounding the passage and signing of the Religious Freedom Restoration Act in Indiana, I am a Hoosier, having lived almost all of my life in Indiana. I agree with his concern about the unexpected hysteria involved in the passage of this legislation and I agree that we who follow Jesus Christ need to be calm and caring in our communication with everyone.

However, I do think that religious liberty is an issue that we should take a stand on. Back when Charles Colson, Robert George and Timothy George drafted the Manhattan Declaration in 2009 they chose religious liberty along with the sanctity of life and the integrity of marriage as one of he three most pressing moral issues that Christians need to take a stand on, they were questioned about why they chose to include religious liberty. Timothy George has presented reasons for this choice in an article in First Things, titled “Let Religious Freedom Ring”.

We live in a world in which religious freedom is not a given. It is something that we need to stand up for. When radical Islamists terrorize and kill Jews, Christians and those in other Islamic groups who will not renounce what they believe we need to stand up to them. When a church in Ukraine is burned we need to do something. Even in the US where religious freedom is one of the founding principles of our government, there is a move toward limiting religious freedom. In bioethics we see it in OB-GYN physicians being required to refer for abortions against their beliefs, pharmacists being required to fill prescriptions for types of contraception the believe are wrong, and private businesses and church related organizations being required by law to provide insurance coverage for things they believe to be wrong. The underlying principle in all of these cases is the same. People should be free to live according to their faith without being coerced to do things that violate their deeply held moral convictions.

Hysteria surrounding the recently passed Indiana law centers on the fact that, even thought the law is similar to the federal law and the laws of 19 other states, it was passed after the advocates of same sex marriage had used the courts in other states to attempt to coerce individuals who did business as florists and photographers to participate in same sex wedding ceremonies that they had declined to participate in because of their religious convictions. As Jerry noted the people of Indiana tend not to be the first to do anything. After the federal RFRA was passed no need was seen to pass a similar state law, but as the number of situations increased in which people were being coerced by law or by the courts to do things against their religious convictions the need for such a state law was seen and the law was passed. Those who wish to convert negative rights into positive rights and to have the ability to coerce others to do what they want them to do in spite of their religious objections have reacted vehemently. I hope that people will be able to see that upholding the fundamental principle of religious freedom is something that still should be important in our nation.

Conscience of the Profession: Against Savulescu

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.

 

 

 

 

 

 

The Irony of “Rational” Secularism

This past week I attended the meeting of the Council on Health Care Ethics for our state medical society. In the packet of information for the meeting was a resolution on “right of conscience” along with 2 “supporting” documents, one by Julian Savulescu and the other by Alta Charo, both addressing the issue of abortion and both filled with “entitlement” rhetoric (the article by Salvulescu even stated that those who are unwilling to provide services to which people were “entitled” should not be physicians, as if abortion is the vital core of healthcare). Based on the “supporting” documents, the tenor of the meeting seemed less than balanced.

To my great surprise, the author of the resolution was a first-year medical student. The resolution had been brought to the state convention, where it encountered considerable opposition and was sent to our committee for further discussion (presumably out of deference to her status as a young student). The resolution in its current state was greatly truncated, seeking merely to  preserve “collegiality” among physicians  through support of the right of conscience of all physicians by the state medical society.

When the resolution was read by the author to our committee, there was silence in the room. To break the uncomfortable tension I applauded the resolution and spoke of the importance in a pluralistic society of protecting the right of conscience of all practitioners, noting that much of our disagreement centers on differing definitions of conscience (self-chosen values vs. moral obligation to a Higher authority).  Taking advantage of the opportunity, I then addressed the fallacies of the “supporting” articles by Savulescu and Charo, pointing out that both ignored (or implicitly denied) a crucial fact: that abortion is a negative right which entails no corresponding obligation–a fact ignored by most supporters of abortion “rights.”

There. It was out in the open: that “a” word. I watched with curious amusement as the other members danced around that word for the remainder of the brief discussion. Brief? Yes, brief, because one member quickly responded by slinging out the term “moral fascists.” Moral fascists? Really? (I seem to say that a great deal lately.) Really? The comment was profoundly ironic: those trying to establish protection from the moral encroachments of others are labeled “moral fascists”; and secularists who label religious sensibilities “irrational”–who claim no higher power than reason–are unable to mount a rational argument in defense of their position.

The discussion detoured briefly before dead-ending in the issue of “referral for abortion” which has curiously become the central contention in the debate–another curiosity. For 25 years I have practiced obstetrics and gynecology–now just gynecology–in rural communities with no abortion services, located in both eastern and mid-western states. In those 25 years I have never had a patient come to me 1) seeking an abortion,  2) asking where to go to obtain an abortion, or 3) requesting a referral for abortion. Two patients (two!) have made appointments with me to discuss their decision and/or to receive assurance that they could return to me for care after the procedure. In both cases those women already had appointments scheduled for the procedure. Patients “know” where to go, whether through family or friends or general “street knowledge”–not to mention that it is first listing in the yellow pages after “abortion alternative.”  Nor are referrals required by the provider or insurer. In cases involving congenital fetal anomalies or life-threatening maternal health conditions, the patient is sent to a tertiary center for evaluation, counselling, and treatment–not specifically for abortion. Quite frankly, the issue seems like a red herring…

Right of conscience extends far beyond the issue of abortion into many other aspects of care, a horizon that will no doubt expand even farther in the coming years as our technological innovations continue to outstrip our moral sensibilities, yet the same principles apply. A decade ago, Nigel Cameron suggested that given our ideological disparities, medicine might best be served by the establishment of two separate factions of  healthcare providers: Hippocratic and non-Hippocratic. Perhaps it is an idea whose time has come. Just as all businesses have “mission statements” today (another irony–or oxymoron…), hospitals, clinics, and individual providers could have their mission or value statements posted on-line or at the facilities, allowing individuals to choose  primary providers and facilities whose values were most consistent with their own. It would also fulfill the idea of informed consent, enabling individuals to make informed choices about the providers of their care. It is an option that would eliminate “moral fascism” and promote freedom in a pluralistic society–the essence of “liberty and justice for all” in healthcare.

 

 

Conscience or convictions?–that is the question!

Conscience is a term bandied about quite frequently in contemporary ethical discussions, yet despite the frequency of its usage, it is an enigmatic term defying definition—or inviting post-modern reconstruction. Such is the case in an article which appeared in the “Perspective” section of the New England Journal of Medicine in September by Lisa H. Harris, M.D., Ph.D., a recognized name in the area of women’s reproductive rights. The article was entitled “Recognizing Conscience in Abortion Provision” (NEJM 367;11: 981-983). Harris’ position, which had a peculiarly defensive tone, was that neither conscience nor rights of conscience is the sole prerogative of those opposed to abortion, but that abortion providers are likewise driven in their work by moral convictions—hence, conscience—and ought to have their rights of conscience protected as well. While there are many aspects of her argument that could be challenged, there are two that demand attention: the definition of conscience and the distinction between forcing and prohibiting an action.
Harris’ first move is to argue that the actions of abortion providers are “conscientious,” and then to equate that with “conscience,” which she defines as “a special subset of an agent’s ethical or religious beliefs—one’s core moral beliefs.” She cites the provision of safe, compassionate abortion care before its legalization by those compelled to do so, care that was undertaken at great risk to the provider, and done for “reasons of conscience.” Those reasons include but are not limited to: women’s reproductive autonomy, women’s prerogative to make the best childbearing decisions, and the valuation of the health of the woman over the potential life of a fetus. Harris does acknowledge that abortion opponents label such motivations “political beliefs,” a label with which she disagrees but for which she offers no defense.
But what is conscience? And how does it differ from one’s convictions? Historically, the concept of conscience has been understood to be a faculty of moral reasoning and the seat of responsible personhood. In possessing both antecedent and consequent functions, conscience governs our responsible relationship to God and others through the application of timeless moral principles (not merely political convictions). It is that “sacred” place where one listens to God, reflects on her responsibility to God, self, and others, and determines to act. It is the seat of the moral “ought”—and is incomprehensible apart from a source of moral authority.
Conversely, moral convictions are strongly held beliefs or opinions, beliefs about which one is convinced or persuaded. While such convictions have antecedent functions which guide moral decision-making and behavior, they lack any consequent function; and absent is any necessary reference to authority other than the self. Lacking any transcendent moral authority, violation of one’s moral convictions, therefore, provokes no sense of guilt or shame, only anger. To equate conscience with moral convictions is hence a category mistake.
Conscience is inseparable from responsibility to both mankind and to God as transcendent authority. But for Harris, the concept of conscience has been deconstructed from a relational concept grounded in community and oriented to God to an individual prerogative to independently determine the good and to act accordingly. In so doing, conscience has been stripped of both its relational interconnectedness and its transcendent telos—of its entire substance; only an insubstantial, unrecognizable skeletal form remains.
This is, however, an ominous omen for rights of conscience in the political sphere. The fluidity of definition and meaning in the post-modern perspective, a perspective that predominates among intellectuals, academics and those in authority, means that the concept of conscience, and its attendant rights, can simply be defined away—or alternatively, defined so broadly as to negate its uniqueness. In broadening the scope of the concept while eliminating any source of transcendent authority, there remains nothing in the concept before which the State needs to bow its knees, no transcendent authority to which it must defer. It can pay its “respects” to individual opinion, while still enforcing its laws; for in the State’s reality, conscience is now nothing more than a personal moral conviction—and despite one’s personal convictions to the contrary, they are still subject to the law.
The second point must await a future post…