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A defense of conscience in healthcare
Revue des Maladies Respiratoires Actualités (2019) 11, 16—20
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PRACTICES AND CONCEPTS
A defense of conscience in healthcare Une défense de la conscience en soin de santé R.P. George (McCormick professor of jurisprudence, Director James Madison program) The program in Law and Public Affairs, Princeton University, 313, Wallace Hall, Princeton, NJ, USA Received 10 August 2019; accepted 28 October 2019 Available online 2 December 2019
KEYWORDS Conscience; Duty; Healthcare; Physicians; Pro-life practitioners
MOTS CLÉS Conscience ; Devoir ; Soins de santé ; Médecins ; Praticiens pro-vie
Summary Robert P. George is McCormick Professor of Jurisprudence and Director of the James Madison Program in American Ideals and Institutions at Princeton University. In ‘‘A Defense of Conscience in Healthcare’’, Dr. George reacts to Ethics Committee Opinion #385 of the American College of Obstetricians and Gynecologists (ACOG). Among other things, the opinion proposes that physicians in the field of women’s health be required as a matter of ethical duty to refer patients for abortions and sometimes even to perform abortions themselves. Dr. George first responds to this imperative by challenging the nature of elective abortion itself as normal healthcare, based on the implicit judgment that pregnancy, when unwanted, is in effect a disease. In fact, the issues in dispute are philosophical; they cannot be resolved by science or methods of scientific inquiry. If this is the case, there is therefore no justification to compel morally sincere physicians who disagree with this judgment to violate their conscience or else leave the practice of medicine entirely. The ACOG statement fails to acknowledge the widespread debate about abortion in our society and the moral sincerity of pro-life practitioners. © 2019 Published by Elsevier Masson SAS.
Résumé Robert P. George est professeur de jurisprudence à McCormick et directeur du James Madison Program in American Ideals and Institutions à l’université de Princeton. Dans « A Defense of Conscience in Healthcare », le Dr George réagit à l’avis du comité d’éthique #385 de l’American College of Obstetricians and Gynecologists (ACOG). Entre autres choses, l’avis propose que les médecins dans le domaine de la santé des femmes soient tenus, en tant que question de devoir éthique, d’orienter les patientes vers des avortements et parfois même
E-mail address: [email protected] https://doi.org/10.1016/j.jemep.2019.100418 2352-5525/© 2019 Published by Elsevier Masson SAS.
A defense of conscience in healthcare
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d’avorter eux-mêmes. Le Dr George répond d’abord à cet impératif en remettant en question la nature de l’avortement électif lui-même en tant que soin de santé normal, en se fondant sur le jugement implicite selon lequel la grossesse, lorsqu’elle n’est pas désirée, est en fait une maladie. En fait, les questions en litige sont philosophiques ; elles ne peuvent être résolues par la science ou les méthodes de recherche scientifique. Si tel est le cas, il n’y a donc aucune justification pour contraindre les médecins moralement sincères qui ne sont pas d’accord avec ce jugement à violer leur conscience ou bien à quitter complètement la pratique de la médecine. La déclaration de l’ACOG ne reconnaît pas le vaste débat sur l’avortement dans notre société et la sincérité morale des praticiens pro-vie. © 2019 Publi´ e par Elsevier Masson SAS.
A bit more than a decade ago, when I was serving on the President’s Council on Bioethics, the Council heard testimony by Anne Lyerly, M.D., chair of the Committee on Ethics of the American College of Obstetricians and Gynecologists (ACOG). Dr. Lyerly appeared in connection with the council’s review of her committee’s opinion (No. 385) entitled ‘‘Limits of Conscientious Refusal in Reproductive Medicine [1].’’. That opinion proposed that physicians in the field of women’s health be required as a matter of ethical duty to refer patients for abortions and sometimes even to perform abortions themselves. I found the ACOG Ethics Committee’s opinion shocking and, indeed, frightening. One problem was its lack of regard — bordering on contempt, really — for the sincere claims of conscience of Catholic, Evangelical Protestant, Orthodox Jewish, Muslim, and other physicians and healthcare workers who regard the taking of unborn human life in elective abortions to be morally monstrous. But beyond that, it treated feticide — the deliberate destruction of a child in the womb — as if it were a matter of healthcare, rather than what it typically is: namely, a decision based on nonmedical considerations (such as whether a woman or her husband or boyfriend happens to want a child). On the understanding of medicine implicit in the report, the ends of medicine are fundamentally not about the preservation and restoration of health considered as an objective reality and human good. These ends, rather, relate to the satisfying of the felt needs, personal preferences, and/or lifestyle desires of people who come to physicians requesting surgeries or other services, irrespective of whether these services are in any meaningful sense medically indicated. The view of ‘‘healthcare’’ represented by Dr. Lyerly and embodied in her committee’s report is vividly portrayed in the way of an unintentional reductio ad absurdum by a recent photograph promoted by abortion advocates of the pop singer Miley Cyrus with her tongue lewdly extended licking the icing on a cake decorated with the slogan ‘‘Abortion Is Healthcare [2].’’. But the claim is easily shown to be false. Let’s say that a woman conceives a child and is unhappy about it. Is she sick? Does she need an abortion for the sake of her health? Not on any reasonable understanding or definition of health, even if we mean mental health. Pregnancy is not a disease. It is
a natural process. In the normal case, a pregnant woman is not sick. Nor in the overwhelming majority of cases does pregnancy pose a threat to a woman’s health. This is clear enough, but to make it still clearer let’s imagine that a woman who is initially unhappy to be pregnant changes her mind. On reflection, she’s content to be pregnant and happy to have a baby on the way. Did she suddenly shift from being sick and in need of ‘‘healthcare’’ in the form of an abortion to being well? What cured her? Now, let’s consider that a couple of months later, she changes her mind again. It turns out that the baby is a girl, and she really wants a boy. So she is once again unhappy about the pregnancy and she reverts to wanting an abortion. Did knowledge of the baby’s sex transform her from being a healthy pregnant woman to being sick? The question answers itself. Now let us consider the ACOG committee’s report. What jumped off the page at me when I first read it is that it is an exercise in moral philosophy — bad moral philosophy, but lay that aside for now — not medicine. It proposes a definition of conscience, something that cannot be supplied by science or medicine, then proposes to instruct its readers on ‘‘the limits of conscientious refusals, describing how claims of conscience should be weighed in the context of other values critical to the ethical provision of healthcare [1, p. 2].’’. Again, knowledge of these limits and values, or of what should count as the ethical provision of healthcare, is not and cannot possibly be the product of scientific inquiry for medicine as such. The proposed instruction offered by those responsible for the ACOG committee report represents a philosophical and ethical opinion — their philosophical and ethical opinion. They are, of course, entitled to their opinion; but it should bear no special weight or standing, for the simple reason that on the ethical question as such they have no special expertise or authority. If they’ve got an argument, let them make it and let it stand or fall on its merits — its philosophical merits. What is unacceptable, and what needs to be called out and exposed, is the sleight of hand by which they invoke their medical expertise and authority to give a false impression of weight to moral judgments which are not, and cannot be, the fruit of scientific inquiry or medical judgment. To be sure, medicine cannot avoid, and should not try to avoid, ethical questions, and it must
18 be governed by sound ethical norms; but what is going on here is that a particular moral view — frankly, an ideology (the ideology of secular progressivism and expressive individualism) — is being dressed up in a white coat and falsely depicted as medical science in order to brand physicians and other healthcare workers who refuse to go along with that ideology as unfit to serve because they refuse to deliver healthcare to patients who need it. It’s a con game. The ACOG report, which I am going to stick with because it so perfectly illustrates the mentality and strategy of the secular progressive movement when it comes to medicine and health, goes on to ‘‘outline options for public policy’’ and to propose ‘‘recommendations that maximize accommodation of the individual’s religious and moral beliefs while avoiding imposition of these beliefs on others or interfering with the safe, timely, and financially feasible access to reproductive healthcare that all women deserve [1, p. 2].’’. Yet again notice that every concept in play here — the putative balancing, the judgment as to what constitutes an ‘‘imposition’’ of personal beliefs on others, the view of what constitutes healthcare or reproductive healthcare, the judgment about what is deserved — is philosophical, not scientific or, strictly speaking, medical. It’s all a con. To the extent that they are ‘‘medical’’ judgments even loosely speaking, they reflect a concept of medicine informed, structured, and shaped by philosophical and ethical judgments — bad ones, by the way, such as the implicit judgment that pregnancy, when unwanted, is in effect a disease. Although the transgender issue was not on the table in 2008 and was not addressed in the report, it’s easy to see how the same ideological tendencies and strategies are at play now when it comes to that issue. In the ideology of expressive individualism, a biological male can be a female — and not a male — depending on how he feels about himself and how he chooses to ‘‘identify.’’. If he ‘‘feels’’ he is a girl or woman, even though he is a boy or man, and he chooses to identify as such, and he wishes to undergo hormone treatments, genital amputation, breast construction and other procedures, then for him these procedures must be counted as ‘‘healthcare.’’. Doctors and other professionals in relevant fields must be forced, if necessary, to provide such treatments on pain of being banished from medicine or, at least, their particular areas of medical practice. Again, the so-called ‘‘medical’’. judgments reflect a concept of medicine structured and shaped by philosophical and ethical judgments masquerading as the products of scientific and medical expertise. Those responsible for the ACOG report purport to be speaking as physicians and medical professionals. The report’s supposed authority derives from their standing and expertise as physicians and medical professionals, yet at every point that matters, the judgments offered reflect their philosophical, ethical, and political judgments, not any expertise they have by virtue of their training and experience in science and medicine. And we see the same thing today with transgenderism. There is nothing — absolutely nothing — that can reasonably be counted as scientific evidence, much less conclusive scientific evidence, that someone is actually a woman trapped inside a man’s body (or vice versa — a man trapped inside a woman’s body). This is not to say that there are not people who experience gender dysphoria, who ‘‘feel’’ that they are actually not their
R.P. George sex but are rather the opposite sex. Dysphorias, and not just gender dysphoria, are real and present real issues for care. But the question of whether human beings are (male or female) psyches or spirits inhabiting physical bodies — ghosts in machines — is a philosophical question, not a scientific one. That doesn’t mean there aren’t objectively right and wrong answers to it. Indeed, I believe there are objectively right and wrong answers. And, for what it’s worth, I’m confident that the right answer is that human persons are not psyches inhabiting bodies or ghosts in machines. On the contrary, we are our bodies — whatever else we are. Our bodies are not sub-personal instruments of the ‘‘true self’’, considered as the psyche, but are part of the personal reality of the human being. But my point here is not to argue for that view and thus against the contrary presuppositions of transgender ideology (something I’ve done elsewhere) but to note that the question is philosophical, not scientific or medical; for someone or some organization or association to pretend to have reached a judgment on the question that is purely ‘‘scientific’’ and not, ultimately, reliant on philosophical judgments is to engage in what can only be described as a misrepresentation. At the meeting of the President’s Council at which Dr. Lyerly presented her committee’s report, the Council’s chairman, Dr. Edmund Pellegrino, asked me to offer a formal comment on her presentation and the report. I was respectful towards Dr. Lyerly, who certainly seemed like a decent and sincere person, but I sharply criticized her and her committee colleagues for attempting to use their special authority as physicians to force fellow physicians to practice medicine in accord with the their contestable — and contested — philosophical, ethical, and political judgments. And make no mistake about it: at every key point in the report, their judgments are contestable and contested. Indeed, they are contested by the very people on whose consciences they seek to impose — the people whom they would force to fall into line with their philosophical and ethical judgments or drive out of their fields of medical practice. Many others contest the committee’s judgments, too. In each of these contests a resolution one way or the other cannot be determined by scientific methods; rather, the debate is philosophical, ethical, or political. That is the key thing to see: the issues in dispute are philosophical and thus can be resolved only by philosophical reflection and debate; they cannot be resolved by science or methods of scientific inquiry. Lay aside for the moment the question of whose philosophical and political judgments are right and whose are wrong. The point is that the committee’s report reflects and promotes a particular moral view and vision, and particular understandings of health and medicine shaped by that moral view and vision. The report, in other words, in its driving assumptions, reasoning, and conclusions, is not morally neutral. It represents an ideologically partisan position among the possible positions debated by people of good will in the medical profession and in society generally. For me, the ideologically partisan nature of the report is its most striking feature. It represents a sheer power play on behalf of people who believe in the moral goodness (or at least permissibility and desirability) of abortion who happen to have acquired power in their professional association. This is not about medicine. It is about ideology. It is about politics and political power.
A defense of conscience in healthcare The greatest irony of the report is its stated worry about physicians allegedly imposing their beliefs on patients by, for example, declining to perform or refer for abortions — or at least declining to perform abortions or provide other services in emergency situations. The assumption here is the philosophical one that abortion, even elective abortion, is ‘‘healthcare’’, and that deliberately killing babies in their mother’s wombs is morally acceptable and even a woman’s right. The truth is that the physician who refuses to perform abortions or the pharmacist who declines to dispense abortifacient drugs coerces no one. He or she simply refuses to participate in the destruction of human life — the life of the child in utero. Such a physician is not ‘‘imposing’’ anything on anyone, just as a sports shop owner who refuses to stock hollow-point ‘‘cop killer’’ bullets, even if he or she may legally sell them, is not imposing anything on anyone. By contrast, those responsible for the report evidently would use coercion against physicians and pharmacists who have the temerity to dissent from the philosophical and ethical views of those who happen to have acquired power in ACOG — by forcing them either to get in line or to go out of business. And, of course, by the logic of the report, and by the logic of many people in contemporary medicine and in positions of authority in contemporary medicine, the same fate awaits physicians and other healthcare workers who refuse to participate in assisted suicide, as that ghoulish practice spreads. You already see this happening in Canada and some European countries. And that is because partisans of expressive individualist ideology regard suicide and assisted suicide as ‘‘healthcare’’ in the same way that they regard abortion and transgender surgeries and other procedures as ‘‘healthcare.’’. But again, it is the ideology — philosophical and political judgments — driving the train; not science. We should not let those who are pushing this ideology get away with peddling it to the public in the name of science. If these people get their way, the medical field will be cleansed of physicians and other healthcare workers whose convictions require them to refrain from performing or referring for abortions, assisting in suicide, participating in transgender surgeries and other procedures, and the like. Faithful Catholics, Evangelicals and other Protestants, and many observant Jews and Muslims would be excluded from or forced out of obstetrics and gynecology and other fields, probably including pediatrics. Entire fields would be composed of people who agree with, or at a minimum are willing to go along with, the moral and political convictions and ideological predilections of secular progressives. They would have a monopoly — which is, I have no doubt — what many actually want. Religious folk and dissenters of any type — at least those who refused to knuckle under — would be cleansed from the field. So, in truth, who in this debate is guilty of intolerance? Who is trampling on freedom? Who is imposing values on others? These questions, too, answer themselves. It won’t do to say that what these people seek to impose on dissenters is not a morality but merely good medical practice, for it is not science or medicine that is shaping their understanding of what counts as good medical practice. It is, rather, philosophical judgments and moral opinions doing the shaping. The opinion that abortion or assisted suicide or
19 euthanasia is good medicine is a philosophical, ethical, and political opinion; it is a judgment brought to medicine, not a judgment derived from it. It reflects a view that abortion, for example, is morally legitimate and is no violation of the rights of the child who is killed. It also reflects the view that medicine is rightly concerned with facilitating people’s felt needs, desires, and lifestyle choices even when they are neither sick nor in danger of being injured, and even when the ‘‘medical’’ procedure involves the taking of innocent human life. Whether an elective abortion — or a suicide, or a genital or breast amputation for so-called ‘‘gender affirmation’’, or an in vitro fertilization procedure, or what have you — counts as healthcare, as opposed to a patient’s desired outcome, cannot be resolved by the methods of science or by any morally or ethically neutral form of inquiry or reasoning. One’s view of the matter will reflect one’s moral and ethical convictions either way — it will reflect what the late Harvard moral and political philosopher John Rawls called one’s ‘‘comprehensive doctrine’’, be it religious or secular [3]. So to use of the language of ‘‘health’’ (‘‘reproductive health’’, for example) in describing or referring to the key issues giving rise to conflicts of conscience is at best question begging. No, that’s too kind. This language amounts to a form of rhetorical manipulation. The question at issue in abortion is not ‘‘reproductive health’’ or health of any kind, precisely because direct abortions are not procedures designed to make sick people healthy or to protect them against disease or injury. Again, pregnancy is not a disease. The goal of direct abortions is to cause the death of a child because a woman believes that her life will be better without the child’s existing than it would be with the child’s existing. In itself, a direct (or elective) abortion — deliberately bringing about the death of a child in utero — does nothing to advance maternal health (though sometimes the death of the child is an unavoidable side effect of a procedure, such as the removal of a cancerous womb, that is designed to combat a grave threat to the mother’s health). That’s why it is wrong to depict elective abortion as healthcare. There is yet another irony worth noting. Let’s go back to the ACOG report. In defending its proposal to compel physicians at least to refer for procedures that many physicians believe are immoral, unjust, and even homicidal, states that such referrals ‘‘need not be conceptualized as a repudiation or compromise of one’s own values, but instead can be seen as an acknowledgment of both the widespread and thoughtful disagreement among physicians and society at large and the moral sincerity of others with whom one disagrees [1, p. 2].’’. Well, that’s interesting. Suddenly it’s the case that the underlying issues at stake, such as abortion, are matters of widespread and thoughtful disagreement. And I am perfectly happy to agree with that. And it becomes clear from the report that we should show respect for the moral sincerity of those with whom we disagree. But it follows from these counsels that thoughtful and sincere people need not agree that abortion is morally innocent or acceptable, or that there is a ‘‘right’’ to abortion, or that the provision of abortion is part of good healthcare or is healthcare at all, at least in the case of elective abortions.
20 But then what could possibly justify compelling thoughtful, morally sincere physicians who believe that abortion is a homicidal injustice to perform or refer for the procedure, or else leave the practice of medicine or cease to practice in a particular specialty? The report’s ‘‘my way or the highway’’ view is anything but an acknowledgement of the widespread, thoughtful disagreement among physicians and society at large and the moral sincerity of those with whom one disagrees. Indeed, it is a repudiation of it. Towards the end of the George W. Bush administration, conscience-protection rules for medical professionals were put into place. Unfortunately, they were abrogated almost immediately by the Obama administration. The Bush rules had strengthened conscience-protections for pro-life medical professionals and medical students in a variety of ways. For example, they very clearly prohibited any form of discrimination against practitioners and medical students who refused to undergo training for abortions, or to perform abortions, or to refer for abortions. Moreover, they proscribed discrimination in credentialing or licensing on grounds related to the refusal to be involved in the practice of abortion. Clearly the Obama administration’s goal in abrogating conscience-protection regulations was to establish a policy very much in line with the ACOG Ethics Committee’s proposed ‘‘ethics’’ rules on conscientious refusal in ‘‘reproductive’’ medicine. Now the Trump administration has reversed the Obama course and has even established within the Department of Health and Human Services (HHS) a ‘‘Conscience and Religious Freedom Division’’ in the HHS Office of Civil Rights [4]. That office will have chief responsibility in enforcing prohibitions of regulations that would punish physicians, nurses, pharmacists, medical, nursing, and pharmacy teachers and students, and others for their conscientious objection to participating in abortions, assisting in suicides, and the like. Predictably, critics are claiming that these protections license ‘‘bigotry’’ and ‘‘discrimination’’ against ‘‘marginalized people’’ who will be denied ‘‘healthcare’’ under the alleged pretext of claims of conscience and religious freedom. You see, under this form of secular progressive ideology, to reject their beliefs is not to have a philosophical disagreement so much as it is to be a bigot who is out to harm people one doesn’t like by denying them not only affirmation but care they need. Secular progressivism has become adept at using this tactic in policy battles of virtually every type. Instead of debating a subject — take
R.P. George marriage, for example — on the merits, letting each side state the reasons in favor of its position, critics of the secular progressive view are smeared as bigots and haters or, at a minimum, religious fundamentalists who could not possibly have any rational basis for their beliefs. How should those of us who do reject secular progressive ideology and expressive individualism — whether we are Christians, observant Jews, devout Muslims, or whatever — respond? Well, it’s not pleasant being called horrible names like ‘‘bigot’’ or being accused of ‘‘hating’’ people and trying to ‘‘harm’’ them. But as believers in the sanctity of human life and the profound, inherent, and equal dignity of all, we must not permit ourselves to be intimidated or bullied by these rhetorical strategies. We must resist the imposition of secular progressive ideology in medicine and do so not only for the sake of defending victims and potential victims — unborn children, frail elderly persons, persons suffering from dementia, those afflicted with depression, children experiencing gender dysphoria — but also in defense of what James Madison called ‘‘the sacred rights of conscience [5].’’. We, who are the defenders of life and dignity, must also be defenders of conscience and its rights. For many of us, standing up for conscience means defending the principles of our faith. For all of us, standing up for conscience means defending principles of civil liberty on which our nation was founded.
Disclosure of interest The author declares that he has no competing interest.
References [1] American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 385 November 2007: the limits of conscientious refusal in reproductive medicine. Obstet Gynecol 2007;110:1203. [2] Cyrus M. 2019 [Available from: http://www.instagram.com/ p/ByStizPJcO6/]. [3] Wenar L, Rawls J. Stanford encyclopedia of philosophy; 2017. [4] Conscience and religious freedom; 2019 [Available from: www.hhs.gov/conscience/index.html]. [5] Dreisbach DL, Hall MD. The sacred rights of conscience: selected readings on religious liberty and church-state relations in the American founding, xxxiv. Indianapolis: Liberty Fund; 2009. p. 672.
Available online at
ScienceDirect www.sciencedirect.com
PRACTICES AND CONCEPTS
A defense of conscience in healthcare Une défense de la conscience en soin de santé R.P. George (McCormick professor of jurisprudence, Director James Madison program) The program in Law and Public Affairs, Princeton University, 313, Wallace Hall, Princeton, NJ, USA Received 10 August 2019; accepted 28 October 2019 Available online 2 December 2019
KEYWORDS Conscience; Duty; Healthcare; Physicians; Pro-life practitioners
MOTS CLÉS Conscience ; Devoir ; Soins de santé ; Médecins ; Praticiens pro-vie
Summary Robert P. George is McCormick Professor of Jurisprudence and Director of the James Madison Program in American Ideals and Institutions at Princeton University. In ‘‘A Defense of Conscience in Healthcare’’, Dr. George reacts to Ethics Committee Opinion #385 of the American College of Obstetricians and Gynecologists (ACOG). Among other things, the opinion proposes that physicians in the field of women’s health be required as a matter of ethical duty to refer patients for abortions and sometimes even to perform abortions themselves. Dr. George first responds to this imperative by challenging the nature of elective abortion itself as normal healthcare, based on the implicit judgment that pregnancy, when unwanted, is in effect a disease. In fact, the issues in dispute are philosophical; they cannot be resolved by science or methods of scientific inquiry. If this is the case, there is therefore no justification to compel morally sincere physicians who disagree with this judgment to violate their conscience or else leave the practice of medicine entirely. The ACOG statement fails to acknowledge the widespread debate about abortion in our society and the moral sincerity of pro-life practitioners. © 2019 Published by Elsevier Masson SAS.
Résumé Robert P. George est professeur de jurisprudence à McCormick et directeur du James Madison Program in American Ideals and Institutions à l’université de Princeton. Dans « A Defense of Conscience in Healthcare », le Dr George réagit à l’avis du comité d’éthique #385 de l’American College of Obstetricians and Gynecologists (ACOG). Entre autres choses, l’avis propose que les médecins dans le domaine de la santé des femmes soient tenus, en tant que question de devoir éthique, d’orienter les patientes vers des avortements et parfois même
E-mail address: [email protected] https://doi.org/10.1016/j.jemep.2019.100418 2352-5525/© 2019 Published by Elsevier Masson SAS.
A defense of conscience in healthcare
17
d’avorter eux-mêmes. Le Dr George répond d’abord à cet impératif en remettant en question la nature de l’avortement électif lui-même en tant que soin de santé normal, en se fondant sur le jugement implicite selon lequel la grossesse, lorsqu’elle n’est pas désirée, est en fait une maladie. En fait, les questions en litige sont philosophiques ; elles ne peuvent être résolues par la science ou les méthodes de recherche scientifique. Si tel est le cas, il n’y a donc aucune justification pour contraindre les médecins moralement sincères qui ne sont pas d’accord avec ce jugement à violer leur conscience ou bien à quitter complètement la pratique de la médecine. La déclaration de l’ACOG ne reconnaît pas le vaste débat sur l’avortement dans notre société et la sincérité morale des praticiens pro-vie. © 2019 Publi´ e par Elsevier Masson SAS.
A bit more than a decade ago, when I was serving on the President’s Council on Bioethics, the Council heard testimony by Anne Lyerly, M.D., chair of the Committee on Ethics of the American College of Obstetricians and Gynecologists (ACOG). Dr. Lyerly appeared in connection with the council’s review of her committee’s opinion (No. 385) entitled ‘‘Limits of Conscientious Refusal in Reproductive Medicine [1].’’. That opinion proposed that physicians in the field of women’s health be required as a matter of ethical duty to refer patients for abortions and sometimes even to perform abortions themselves. I found the ACOG Ethics Committee’s opinion shocking and, indeed, frightening. One problem was its lack of regard — bordering on contempt, really — for the sincere claims of conscience of Catholic, Evangelical Protestant, Orthodox Jewish, Muslim, and other physicians and healthcare workers who regard the taking of unborn human life in elective abortions to be morally monstrous. But beyond that, it treated feticide — the deliberate destruction of a child in the womb — as if it were a matter of healthcare, rather than what it typically is: namely, a decision based on nonmedical considerations (such as whether a woman or her husband or boyfriend happens to want a child). On the understanding of medicine implicit in the report, the ends of medicine are fundamentally not about the preservation and restoration of health considered as an objective reality and human good. These ends, rather, relate to the satisfying of the felt needs, personal preferences, and/or lifestyle desires of people who come to physicians requesting surgeries or other services, irrespective of whether these services are in any meaningful sense medically indicated. The view of ‘‘healthcare’’ represented by Dr. Lyerly and embodied in her committee’s report is vividly portrayed in the way of an unintentional reductio ad absurdum by a recent photograph promoted by abortion advocates of the pop singer Miley Cyrus with her tongue lewdly extended licking the icing on a cake decorated with the slogan ‘‘Abortion Is Healthcare [2].’’. But the claim is easily shown to be false. Let’s say that a woman conceives a child and is unhappy about it. Is she sick? Does she need an abortion for the sake of her health? Not on any reasonable understanding or definition of health, even if we mean mental health. Pregnancy is not a disease. It is
a natural process. In the normal case, a pregnant woman is not sick. Nor in the overwhelming majority of cases does pregnancy pose a threat to a woman’s health. This is clear enough, but to make it still clearer let’s imagine that a woman who is initially unhappy to be pregnant changes her mind. On reflection, she’s content to be pregnant and happy to have a baby on the way. Did she suddenly shift from being sick and in need of ‘‘healthcare’’ in the form of an abortion to being well? What cured her? Now, let’s consider that a couple of months later, she changes her mind again. It turns out that the baby is a girl, and she really wants a boy. So she is once again unhappy about the pregnancy and she reverts to wanting an abortion. Did knowledge of the baby’s sex transform her from being a healthy pregnant woman to being sick? The question answers itself. Now let us consider the ACOG committee’s report. What jumped off the page at me when I first read it is that it is an exercise in moral philosophy — bad moral philosophy, but lay that aside for now — not medicine. It proposes a definition of conscience, something that cannot be supplied by science or medicine, then proposes to instruct its readers on ‘‘the limits of conscientious refusals, describing how claims of conscience should be weighed in the context of other values critical to the ethical provision of healthcare [1, p. 2].’’. Again, knowledge of these limits and values, or of what should count as the ethical provision of healthcare, is not and cannot possibly be the product of scientific inquiry for medicine as such. The proposed instruction offered by those responsible for the ACOG committee report represents a philosophical and ethical opinion — their philosophical and ethical opinion. They are, of course, entitled to their opinion; but it should bear no special weight or standing, for the simple reason that on the ethical question as such they have no special expertise or authority. If they’ve got an argument, let them make it and let it stand or fall on its merits — its philosophical merits. What is unacceptable, and what needs to be called out and exposed, is the sleight of hand by which they invoke their medical expertise and authority to give a false impression of weight to moral judgments which are not, and cannot be, the fruit of scientific inquiry or medical judgment. To be sure, medicine cannot avoid, and should not try to avoid, ethical questions, and it must
18 be governed by sound ethical norms; but what is going on here is that a particular moral view — frankly, an ideology (the ideology of secular progressivism and expressive individualism) — is being dressed up in a white coat and falsely depicted as medical science in order to brand physicians and other healthcare workers who refuse to go along with that ideology as unfit to serve because they refuse to deliver healthcare to patients who need it. It’s a con game. The ACOG report, which I am going to stick with because it so perfectly illustrates the mentality and strategy of the secular progressive movement when it comes to medicine and health, goes on to ‘‘outline options for public policy’’ and to propose ‘‘recommendations that maximize accommodation of the individual’s religious and moral beliefs while avoiding imposition of these beliefs on others or interfering with the safe, timely, and financially feasible access to reproductive healthcare that all women deserve [1, p. 2].’’. Yet again notice that every concept in play here — the putative balancing, the judgment as to what constitutes an ‘‘imposition’’ of personal beliefs on others, the view of what constitutes healthcare or reproductive healthcare, the judgment about what is deserved — is philosophical, not scientific or, strictly speaking, medical. It’s all a con. To the extent that they are ‘‘medical’’ judgments even loosely speaking, they reflect a concept of medicine informed, structured, and shaped by philosophical and ethical judgments — bad ones, by the way, such as the implicit judgment that pregnancy, when unwanted, is in effect a disease. Although the transgender issue was not on the table in 2008 and was not addressed in the report, it’s easy to see how the same ideological tendencies and strategies are at play now when it comes to that issue. In the ideology of expressive individualism, a biological male can be a female — and not a male — depending on how he feels about himself and how he chooses to ‘‘identify.’’. If he ‘‘feels’’ he is a girl or woman, even though he is a boy or man, and he chooses to identify as such, and he wishes to undergo hormone treatments, genital amputation, breast construction and other procedures, then for him these procedures must be counted as ‘‘healthcare.’’. Doctors and other professionals in relevant fields must be forced, if necessary, to provide such treatments on pain of being banished from medicine or, at least, their particular areas of medical practice. Again, the so-called ‘‘medical’’. judgments reflect a concept of medicine structured and shaped by philosophical and ethical judgments masquerading as the products of scientific and medical expertise. Those responsible for the ACOG report purport to be speaking as physicians and medical professionals. The report’s supposed authority derives from their standing and expertise as physicians and medical professionals, yet at every point that matters, the judgments offered reflect their philosophical, ethical, and political judgments, not any expertise they have by virtue of their training and experience in science and medicine. And we see the same thing today with transgenderism. There is nothing — absolutely nothing — that can reasonably be counted as scientific evidence, much less conclusive scientific evidence, that someone is actually a woman trapped inside a man’s body (or vice versa — a man trapped inside a woman’s body). This is not to say that there are not people who experience gender dysphoria, who ‘‘feel’’ that they are actually not their
R.P. George sex but are rather the opposite sex. Dysphorias, and not just gender dysphoria, are real and present real issues for care. But the question of whether human beings are (male or female) psyches or spirits inhabiting physical bodies — ghosts in machines — is a philosophical question, not a scientific one. That doesn’t mean there aren’t objectively right and wrong answers to it. Indeed, I believe there are objectively right and wrong answers. And, for what it’s worth, I’m confident that the right answer is that human persons are not psyches inhabiting bodies or ghosts in machines. On the contrary, we are our bodies — whatever else we are. Our bodies are not sub-personal instruments of the ‘‘true self’’, considered as the psyche, but are part of the personal reality of the human being. But my point here is not to argue for that view and thus against the contrary presuppositions of transgender ideology (something I’ve done elsewhere) but to note that the question is philosophical, not scientific or medical; for someone or some organization or association to pretend to have reached a judgment on the question that is purely ‘‘scientific’’ and not, ultimately, reliant on philosophical judgments is to engage in what can only be described as a misrepresentation. At the meeting of the President’s Council at which Dr. Lyerly presented her committee’s report, the Council’s chairman, Dr. Edmund Pellegrino, asked me to offer a formal comment on her presentation and the report. I was respectful towards Dr. Lyerly, who certainly seemed like a decent and sincere person, but I sharply criticized her and her committee colleagues for attempting to use their special authority as physicians to force fellow physicians to practice medicine in accord with the their contestable — and contested — philosophical, ethical, and political judgments. And make no mistake about it: at every key point in the report, their judgments are contestable and contested. Indeed, they are contested by the very people on whose consciences they seek to impose — the people whom they would force to fall into line with their philosophical and ethical judgments or drive out of their fields of medical practice. Many others contest the committee’s judgments, too. In each of these contests a resolution one way or the other cannot be determined by scientific methods; rather, the debate is philosophical, ethical, or political. That is the key thing to see: the issues in dispute are philosophical and thus can be resolved only by philosophical reflection and debate; they cannot be resolved by science or methods of scientific inquiry. Lay aside for the moment the question of whose philosophical and political judgments are right and whose are wrong. The point is that the committee’s report reflects and promotes a particular moral view and vision, and particular understandings of health and medicine shaped by that moral view and vision. The report, in other words, in its driving assumptions, reasoning, and conclusions, is not morally neutral. It represents an ideologically partisan position among the possible positions debated by people of good will in the medical profession and in society generally. For me, the ideologically partisan nature of the report is its most striking feature. It represents a sheer power play on behalf of people who believe in the moral goodness (or at least permissibility and desirability) of abortion who happen to have acquired power in their professional association. This is not about medicine. It is about ideology. It is about politics and political power.
A defense of conscience in healthcare The greatest irony of the report is its stated worry about physicians allegedly imposing their beliefs on patients by, for example, declining to perform or refer for abortions — or at least declining to perform abortions or provide other services in emergency situations. The assumption here is the philosophical one that abortion, even elective abortion, is ‘‘healthcare’’, and that deliberately killing babies in their mother’s wombs is morally acceptable and even a woman’s right. The truth is that the physician who refuses to perform abortions or the pharmacist who declines to dispense abortifacient drugs coerces no one. He or she simply refuses to participate in the destruction of human life — the life of the child in utero. Such a physician is not ‘‘imposing’’ anything on anyone, just as a sports shop owner who refuses to stock hollow-point ‘‘cop killer’’ bullets, even if he or she may legally sell them, is not imposing anything on anyone. By contrast, those responsible for the report evidently would use coercion against physicians and pharmacists who have the temerity to dissent from the philosophical and ethical views of those who happen to have acquired power in ACOG — by forcing them either to get in line or to go out of business. And, of course, by the logic of the report, and by the logic of many people in contemporary medicine and in positions of authority in contemporary medicine, the same fate awaits physicians and other healthcare workers who refuse to participate in assisted suicide, as that ghoulish practice spreads. You already see this happening in Canada and some European countries. And that is because partisans of expressive individualist ideology regard suicide and assisted suicide as ‘‘healthcare’’ in the same way that they regard abortion and transgender surgeries and other procedures as ‘‘healthcare.’’. But again, it is the ideology — philosophical and political judgments — driving the train; not science. We should not let those who are pushing this ideology get away with peddling it to the public in the name of science. If these people get their way, the medical field will be cleansed of physicians and other healthcare workers whose convictions require them to refrain from performing or referring for abortions, assisting in suicide, participating in transgender surgeries and other procedures, and the like. Faithful Catholics, Evangelicals and other Protestants, and many observant Jews and Muslims would be excluded from or forced out of obstetrics and gynecology and other fields, probably including pediatrics. Entire fields would be composed of people who agree with, or at a minimum are willing to go along with, the moral and political convictions and ideological predilections of secular progressives. They would have a monopoly — which is, I have no doubt — what many actually want. Religious folk and dissenters of any type — at least those who refused to knuckle under — would be cleansed from the field. So, in truth, who in this debate is guilty of intolerance? Who is trampling on freedom? Who is imposing values on others? These questions, too, answer themselves. It won’t do to say that what these people seek to impose on dissenters is not a morality but merely good medical practice, for it is not science or medicine that is shaping their understanding of what counts as good medical practice. It is, rather, philosophical judgments and moral opinions doing the shaping. The opinion that abortion or assisted suicide or
19 euthanasia is good medicine is a philosophical, ethical, and political opinion; it is a judgment brought to medicine, not a judgment derived from it. It reflects a view that abortion, for example, is morally legitimate and is no violation of the rights of the child who is killed. It also reflects the view that medicine is rightly concerned with facilitating people’s felt needs, desires, and lifestyle choices even when they are neither sick nor in danger of being injured, and even when the ‘‘medical’’ procedure involves the taking of innocent human life. Whether an elective abortion — or a suicide, or a genital or breast amputation for so-called ‘‘gender affirmation’’, or an in vitro fertilization procedure, or what have you — counts as healthcare, as opposed to a patient’s desired outcome, cannot be resolved by the methods of science or by any morally or ethically neutral form of inquiry or reasoning. One’s view of the matter will reflect one’s moral and ethical convictions either way — it will reflect what the late Harvard moral and political philosopher John Rawls called one’s ‘‘comprehensive doctrine’’, be it religious or secular [3]. So to use of the language of ‘‘health’’ (‘‘reproductive health’’, for example) in describing or referring to the key issues giving rise to conflicts of conscience is at best question begging. No, that’s too kind. This language amounts to a form of rhetorical manipulation. The question at issue in abortion is not ‘‘reproductive health’’ or health of any kind, precisely because direct abortions are not procedures designed to make sick people healthy or to protect them against disease or injury. Again, pregnancy is not a disease. The goal of direct abortions is to cause the death of a child because a woman believes that her life will be better without the child’s existing than it would be with the child’s existing. In itself, a direct (or elective) abortion — deliberately bringing about the death of a child in utero — does nothing to advance maternal health (though sometimes the death of the child is an unavoidable side effect of a procedure, such as the removal of a cancerous womb, that is designed to combat a grave threat to the mother’s health). That’s why it is wrong to depict elective abortion as healthcare. There is yet another irony worth noting. Let’s go back to the ACOG report. In defending its proposal to compel physicians at least to refer for procedures that many physicians believe are immoral, unjust, and even homicidal, states that such referrals ‘‘need not be conceptualized as a repudiation or compromise of one’s own values, but instead can be seen as an acknowledgment of both the widespread and thoughtful disagreement among physicians and society at large and the moral sincerity of others with whom one disagrees [1, p. 2].’’. Well, that’s interesting. Suddenly it’s the case that the underlying issues at stake, such as abortion, are matters of widespread and thoughtful disagreement. And I am perfectly happy to agree with that. And it becomes clear from the report that we should show respect for the moral sincerity of those with whom we disagree. But it follows from these counsels that thoughtful and sincere people need not agree that abortion is morally innocent or acceptable, or that there is a ‘‘right’’ to abortion, or that the provision of abortion is part of good healthcare or is healthcare at all, at least in the case of elective abortions.
20 But then what could possibly justify compelling thoughtful, morally sincere physicians who believe that abortion is a homicidal injustice to perform or refer for the procedure, or else leave the practice of medicine or cease to practice in a particular specialty? The report’s ‘‘my way or the highway’’ view is anything but an acknowledgement of the widespread, thoughtful disagreement among physicians and society at large and the moral sincerity of those with whom one disagrees. Indeed, it is a repudiation of it. Towards the end of the George W. Bush administration, conscience-protection rules for medical professionals were put into place. Unfortunately, they were abrogated almost immediately by the Obama administration. The Bush rules had strengthened conscience-protections for pro-life medical professionals and medical students in a variety of ways. For example, they very clearly prohibited any form of discrimination against practitioners and medical students who refused to undergo training for abortions, or to perform abortions, or to refer for abortions. Moreover, they proscribed discrimination in credentialing or licensing on grounds related to the refusal to be involved in the practice of abortion. Clearly the Obama administration’s goal in abrogating conscience-protection regulations was to establish a policy very much in line with the ACOG Ethics Committee’s proposed ‘‘ethics’’ rules on conscientious refusal in ‘‘reproductive’’ medicine. Now the Trump administration has reversed the Obama course and has even established within the Department of Health and Human Services (HHS) a ‘‘Conscience and Religious Freedom Division’’ in the HHS Office of Civil Rights [4]. That office will have chief responsibility in enforcing prohibitions of regulations that would punish physicians, nurses, pharmacists, medical, nursing, and pharmacy teachers and students, and others for their conscientious objection to participating in abortions, assisting in suicides, and the like. Predictably, critics are claiming that these protections license ‘‘bigotry’’ and ‘‘discrimination’’ against ‘‘marginalized people’’ who will be denied ‘‘healthcare’’ under the alleged pretext of claims of conscience and religious freedom. You see, under this form of secular progressive ideology, to reject their beliefs is not to have a philosophical disagreement so much as it is to be a bigot who is out to harm people one doesn’t like by denying them not only affirmation but care they need. Secular progressivism has become adept at using this tactic in policy battles of virtually every type. Instead of debating a subject — take
R.P. George marriage, for example — on the merits, letting each side state the reasons in favor of its position, critics of the secular progressive view are smeared as bigots and haters or, at a minimum, religious fundamentalists who could not possibly have any rational basis for their beliefs. How should those of us who do reject secular progressive ideology and expressive individualism — whether we are Christians, observant Jews, devout Muslims, or whatever — respond? Well, it’s not pleasant being called horrible names like ‘‘bigot’’ or being accused of ‘‘hating’’ people and trying to ‘‘harm’’ them. But as believers in the sanctity of human life and the profound, inherent, and equal dignity of all, we must not permit ourselves to be intimidated or bullied by these rhetorical strategies. We must resist the imposition of secular progressive ideology in medicine and do so not only for the sake of defending victims and potential victims — unborn children, frail elderly persons, persons suffering from dementia, those afflicted with depression, children experiencing gender dysphoria — but also in defense of what James Madison called ‘‘the sacred rights of conscience [5].’’. We, who are the defenders of life and dignity, must also be defenders of conscience and its rights. For many of us, standing up for conscience means defending the principles of our faith. For all of us, standing up for conscience means defending principles of civil liberty on which our nation was founded.
Disclosure of interest The author declares that he has no competing interest.
References [1] American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 385 November 2007: the limits of conscientious refusal in reproductive medicine. Obstet Gynecol 2007;110:1203. [2] Cyrus M. 2019 [Available from: http://www.instagram.com/ p/ByStizPJcO6/]. [3] Wenar L, Rawls J. Stanford encyclopedia of philosophy; 2017. [4] Conscience and religious freedom; 2019 [Available from: www.hhs.gov/conscience/index.html]. [5] Dreisbach DL, Hall MD. The sacred rights of conscience: selected readings on religious liberty and church-state relations in the American founding, xxxiv. Indianapolis: Liberty Fund; 2009. p. 672.