The President's Council on Bioethics
Thursday, September 11, 2008
Session 3: Conscience in the Practice of the Health Professions

Full Text

CHAIRMAN PELLEGRINO: I think we'll move ahead. Robby, would you introduce the discussion?

My comment will focus mainly on the ACOG Committee Opinion No. 385 of November 2007 on "The Limits of Conscientious Refusal in Reproductive Medicine."

PROF. GEORGE: Thank you very much, Dr. Pellegrino , and thanks very much for the opportunity to offer an opening comment and lead the discussion. My comment will focus mainly on the ACOG Committee Opinion No. 385 of November 2007 on "The Limits of Conscientious Refusal in Reproductive Medicine."

The critical things - and I'm very critical of this opinion -but I have to say were reinforced in my saying them by Dr. Lyerly 's presentation this morning. And so I do hope that Dr. Lyerly will be given an opportunity as the other panelists will be to challenge what I have to say because it is highly critical.

DR. ROWLEY: Well, she's not here to hear them, so I think that you have to wait until she comes.

PROF. GEORGE: Absolutely fine with me.

CHAIRMAN PELLEGRINO: She's here. Dr. Lyerly is here. She's just been in the wings.

PROF. GEORGE: Dr. Lyerly, while you were out I said that my comments are going to be focused on the ACOG report of November 2007, "The Limits of Conscientious Refusal in Reproductive Medicine," and my comments are going to be highly critical. So I expressed a hope that you'd be given an opportunity to respond to them and to challenge me if you'd like. The same for, of course, the other panelists.

The first thing to notice about the ACOG Committee report is that it is an exercise in moral philosophy.

The first thing to notice about the ACOG Committee report is that it is an exercise in moral philosophy. It proposes a definition of conscience, something that cannot be supplied by science or medicine. It 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 health care."

Again, knowledge of these limits and values, as well as knowledge of what should count as the ethical provision of health care, are not and cannot possibly be the product of scientific inquiry for medicine as such. The proposed instruction offered here by those responsible for the ACOG Committee report represents a philosophical and ethical opinion - their philosophical and ethical opinion.

The report goes on to, "outline options for public policy," and 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 health care that all women deserve."

Yet again notice that every concept in play here - the punitive balancing, the judgment as to what constitutes an imposition of personal beliefs on others, the view of what constitutes health care or reproductive health care, the judgment about what is deserved is philosophical, not scientific or, strictly speaking, medical.

To the extent that they are medical judgments even loosely speaking they reflect a concept of medicine informed and structured, shaped by philosophical and ethical judgments. Those responsible for the report purport to be speaking as physicians and medical professionals.

The special authority the report is supposed to have 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.

The special authority the report is supposed to have 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.

At every key point in the report their judgments are contestable and contested. Indeed they are contested by the very people on who consciences they seek to impose, the people whom they would, if their report were adopted and made binding, force into line with their philosophical and ethical judgments or drive out of their fields of medical practice. And they are contested, of course, by many others. And 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.

Lay aside for the moment the question of whose philosophical judgments are right and whose are wrong. My point so far has only been that the report is laced and dependent upon at every turn philosophical judgments. I've not offered a critique of those judgments, although anyone who cares to can find plenty of criticisms in my work of those judgments. But lay that aside for now.

The key thing to see is that the issues in dispute are philosophical and can only be resolved by philosophical reflection and debate. They cannot be resolved by science or methods of scientific inquiry. The committee report reflects and promotes a particular moral view and vision and understandings of health and medicine shaped in every contested dimension and in every dimension relevant to the report's subject matter, namely the limits of conscientious refusal, by that moral view and vision.

The report, in other words, in its driving assumptions, reasoning, and conclusions is not morally neutral. Its analysis and recommendations for action do not proceed from a basis of moral neutrality. It represents a partisan position among the family of possible positions debated or adopted by people of reason and goodwill in the medical profession and beyond. Indeed, for me, the partisanship of the report is its most striking feature.

The report, in other words, in its driving assumptions, reasoning, and conclusions is not morally neutral. Its analysis and recommendations for action do not proceed from a basis of moral neutrality. It represents a partisan position among the family of possible positions debated or adopted by people of reason and goodwill in the medical profession and beyond. Indeed, for me, the partisanship of the report is its most striking feature.

Its greatest irony is the report's concern for 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 and certainly to refer for these procedures. The assumption here, of course, is the philosophical one that deliberate feticide is morally acceptable and even a woman's right.

But lay that aside for now. Of course, the physician or the pharmacist who declines to dispense coerces no one, though I think that Prof. Brody and I would have a debate about that. He or she, that physician or pharmacist, simply refuses to participate in the destruction of human life or human life in utero.

By contrast, those responsible for the report and its recommendations evidently would use coercion to force physicians and pharmacists who have the temerity to dissent from their philosophical and ethical views to either get in line or go out of business.

If their advice were followed, they had their way, their fields of medical practice would be cleansed of pro-life physicians whose convictions required them to refrain from performing or referring for abortions. The entire field would be composed of people who could be relied on either to agree with or at a minimum go along with their convictions, those of the report's authors, on this most profound of moral questions upon which reasonable people of goodwill disagree, yet must somehow find a way to live together in peace and discuss their differences with civility and mutual respect.

And, of course, abortion here is simply the most profound of the examples. I do agree with Dr. Lyerly that there are many other issues that are at stake besides abortion, though less profound in most cases than that issue.

Now, I'm on the pro-life side of the question, but one need not share my view to see that the report proposes to impose its morality, the morality of those responsible for the report, on others if these were accepted as binding norms of ethics in the field.

It won't do, in my opinion, to say that what is being imposed for imposition on dissenters here is not a morality, but merely good medical practice for it is not science or medicine itself that is shaping the report's understanding of what is to count as good medical practice. It is philosophical and ethical judgments, judgments brought to medicine, not judgments derived from it.

It won't do, in my opinion, to say that what is being imposed for imposition on dissenters here is not a morality, but merely good medical practice for it is not science or medicine itself that is shaping the report's understanding of what is to count as good medical practice. It is philosophical and ethical judgments, judgments brought to medicine, not judgments derived from it.

Whether an elective abortion or an in vitro procedure or what have you counts as health care as opposed to a decision about what one desires or what lifestyle choices one wishes to make cannot be established or 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 - either way.

So the report's constant use of the language of health and reproductive health in describing or referring to the key issues giving rise to conflicts of conscience is at best - at best - question begging.

Let me close these remarks with yet another irony as I see it. The report in defending its proposal to compel physicians in the relevant fields to at least refer for procedures that physicians may believe are immoral, unjust, and even homicidal said that such referrals - and I quote - "need not be conceptualized as a repudiation or compromise of one's own values, but instead can be seen as an acknowledgement of both the widespread and thoughtful disagreement among physicians and society at large and the moral sincerity of others with whom one disagrees."

So suddenly it's the case that the underlying issues at stake, such as abortion, are matters of widespread and thoughtful disagreement, and I 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 seems to me that it follows from these counsels that thoughtful and sincere people need not agree that abortion, for example, is morally innocent or acceptable or that there is a right to abortion or that the provisions of abortion is part of good health care or is health care at all, at least in the case of elective abortions.

. . . what justification could there possibly be for the exercise of coercion to require thoughtful, morally sincere physicians who believe that abortion is a homicidal injustice that they either make a referral for it, a procedure that they reasonably regard as the killing of a child in utero, or leave the practice of medicine as the other alternative?

But then what could possibly justify - what justification could there possibly be for the exercise of coercion to require thoughtful, morally sincere physicians who believe that abortion is a homicidal injustice that they either make a referral for it, a procedure that they reasonably regard as the killing of a child in utero, or leave the practice of medicine as the other alternative?

The report's "my way or the highway" view of the thing is anything but an acknowledgement of the widespread and 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.

Thank you. [. . . Discussion]

Notes

The President's Council on Bioethics was appointed by President George W. Bush and operated from 2001 to 2009. 

Source: Archived transcript of the session.