Therefore, whoever says he acts in such and such a way from conscience, speaks the truth, for his conscience is the self that knows and wills. […] Conscience, then, in the majesty of its elevation above specific law and every content of duty, puts whatever content it pleases into its knowing and willing. It is the moral genius which knows the inner voice of what it immediately knows to be a divine voice; and since, in knowing this, it has an equally immediate knowledge of existence, it is the divine creative power which in its Notion possesses the spontaneity of life. Equally, it is in its own self divine worship, for its action is the contemplation of its own divinity.
(Hegel, The Phenomenology of Spirit, 654-655)
Abstract
Mark Wicclair’s defense of conscientious objection is grounded in an effort to respect the core moral beliefs of health care providers. While such a theoretical schema has merit, this paper argues that core moral beliefs should not serve as the basis of conscientious objection in health care because we, as a community, lack reliable access to a person’s core moral beliefs and because individuals are prone to be confused about the scope and extent of their core moral beliefs. Furthermore, a person’s confusion over their core moral beliefs is likely to be exacerbated when they lack time to investigate those beliefs and are under heightened external pressure to do so—both conditions frequently encountered by health care providers. Finally, the paper considers whether grounding conscientious objection in core moral beliefs might have the unintended consequence of further entrenching the practical problems that the move is aiming to solve.
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Notes
I would like to thank Andrew Spear, Hope Sample, David Vessey, Patrick Anderson, José Amorós and Alycia LaGuardia-LoBianco for their comments on drafts of this paper.
Each part of this sentence requires some qualification. First, I am limiting my current discussion to the more familiar cases of conscience-based refusal, but Wicclair himself has presented out some very interesting cases where claims of conscience might be positive (cf. Wicclair 2009, 2013). Second, hypothetical instances of conscientious objection are often accompanied by various qualifications, such as “medically indicated”, “professionally appropriate”, or “otherwise legal”. The implication here is that if a procedure is medically dubious, professionally frowned upon, or illegal, then the refusal of such a procedure cannot be conscience-based because it would be founded on medical, professional, or legal grounds. This distinction reflects the very practical concern of much of the literature in attempting to address the hardest clinical cases; for refusals based in one of those three areas are much more likely to be broadly accepted, or at least addressed in a different domain, than refusals grounded on conscience. Yet, insofar as some conceptual groundwork is needed, I suggest that it cannot be assumed that conscience-based refusals can only occur after it is determined that a given treatment is within the bounds of medicine, professionalism, and the law—particularly the last of these. If one of the reasons why it is important to take the issue of conscientious objection seriously is the provider’s status as a moral agent (as opposed to a health care dispensing machine), then that agential status holds and should be treated with respect independently of the nuanced and changing world of scientific medical practice, understanding of professional conduct, and legal boundaries. Clearly, there is an institutional motivation for health care systems to file the refusal of a patient request under a clear heading of “medically inappropriate”, “not considered professional best practice”, “not legally permitted”, or “provider conscientious objection”, and for the first three categories to trump the last because they are perceived as more publicly defensible. Yet, if we consider a case from point of view of the agents then no such categorical reduction occurs. Thus, respecting the provider’s agency would mean not reducing matters of conscience to another category when there is considerable overlap. While Wicclair himself often uses the “otherwise legal” restriction for conscientious objection, he suggests that there are questions around this qualification (cf. Wicclair 2011, p. xii). There is considerable work to be done exploring the ways in which the standards of conscience, medicine, professionalism, and law overlap, undergird, or undermine each other.
On one hand, the paternalistic medicine of the 19th and early twentieth century can be seen as a failure of medical practice to recognize and adopt the concept of autonomy as it emerged in the Enlightenment. On the other, instances of psychological experiments on mental patients over the same historical period, provided some of the early concepts of psychology, but the neglect of the practical consequences to the patient seems deeply problematic in retrospect.
“Conscience approves description in objects of Benevolence; condemns falsehood, violence and injustice, as such, apart from their consequences… Moral government consists in rendering men happy or unhappy according as they follow their conscience or not” (Butler 1914, p. 70).
Consider, for instance, Mill’s discussion of the “tyranny of the majority” from the introductory chapter of On Liberty: “Society can and does execute its own mandates: and if it issues wrong mandates instead of right, or any mandates at all in things with which it ought not to meddle, it practices a social tyranny more formidable than many kinds of political oppression, since, though not usually upheld by such extreme penalties, it leaves fewer means of escape, penetrating much more deeply into the details of life, and enslaving the soul itself. Protection, therefore, against the tyranny of the magistrate is not enough: there needs protection also against the tyranny of the prevailing opinion and feeling; against the tendency of society to impose, by other means than civil penalties, its own ideas and practices as rules of conduct on those who dissent from them; to fetter the development, and, if possible, prevent the formation, of any individuality not in harmony with its ways, and compels all characters to fashion themselves upon the model of its own. There is a limit to the legitimate interference of collective opinion with individual independence: and to find that limit, and maintain it against encroachment, is as indispensable to a good condition of human affairs, as protection against political despotism” (Mill 2008).
“Authentic” will have to serve as a placeholder here for self-knowledge of a certain degree and quality. The point is that, for Wicclair’s account to work, the health care providers involved need to have a certain degree self-knowledge, and the relevant degree is not merely a matter of the quantity of self-knowledge that the person has. Certainly it is not a matter of the quantity of beliefs one has formulated about one’s self. It is not even merely a matter of the quantity of true beliefs that one has formulated about one’s self. At the very least, for Wicclair’s account to work, it would require health care providers to have something like a ranking of true beliefs about one’s self such that one could readily identify some beliefs a “core” and others a peripheral. Furthermore, this collection of beliefs would have to include permutations and applications beyond what a person has directly experienced, and any gaps in that knowledge—whether of commission or omission—could wreak havoc on the arrangement of beliefs. In other words, what Wicclair’s view requires is a considerable amount of high-quality self-knowledge, which I will call “authentic self-knowledge”. While it is beyond the scope of this paper, there are a number of reasons to think that such authentic self-knowledge is uncommon or even impossible. Freud’s view The Unconscious (2005) is a famous account of structural obstacles to self-knowledge, while Nietzsche speculates that many of us simply have not done the necessary work, saying, “We are unknown to ourselves…and with good reason. We have never sought ourselves…” (Nietzsche 2010).
Contrast this presumption of reflexive authority with literary cases. Consider how often Shakespeare’s dramas derive their compelling force from the characters’ posing to themselves the question, “what is it that I am committed to?” and the way in which the consequences of this question fall upon all the characters. Cordelia gets her commitments right. Lear gets his wrong. Othello gets his commitments wrong. For better or worse, Richard gets his commitments right. Whether or not Hamlet gets his right is the open question of the play.
My concern here is distinct from the worry that agents might be dishonest about their core moral beliefs. Rather, there is simply a question about the extent a well-educated, focused, professional could be expected to know their core moral beliefs out of hand, as it were. The extent to which agents know their deep commitments is partly an empirical question. Perhaps, social science can provide some insights into the accuracy of an agent’s account of her own deepest moral commitments. Still, such social science would need to be grounded in a philosophical account what a “moral commitment” is, what makes one “deeper” than another, etc.
Perhaps the consequences of King Midas’s underestimation of his core moral commitments—reducing all commitment to his single commitment to having more gold—is a notable exception.
Such examples are not entirely fictitious.
See, for example, Wicclair (2011, pp. 93–95).
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Byrnes, J. The Problem of “Core Moral Beliefs” as the Ground of Conscientious Objection. HEC Forum 33, 291–305 (2021). https://doi.org/10.1007/s10730-020-09425-5
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DOI: https://doi.org/10.1007/s10730-020-09425-5