Conscience, reason and action

Reader Bob Hunt comments [reproduced in full]:

Mr. Hamelin,

Then we will have to disagree.

As a function of the intellect, conscience is the capacity to discern how I ought to act in any particular circumstance: if my conscience is certain that an action is good, I can perform that action; if my conscience is certain that an action is evil, I must not perform that action. This demands the use of one's reason.

What it doesn't mean is that my conscience is always correct. One could have an ill-formed conscience for any number of reasons, including wilful ignorance, laziness, being exposed to a pervasive culture of death, etc... An ill-formed conscience often leads to erroneous conclusions, the idea that it is legitimate to kill human life in the womb being just one example. One's conscience can be deformed by insanity, or other mental illness. The person who is convinced that his duty is to murder his mother, for instance. Certainly it is the community's responsibility to stop such a person from acting. Error has rights; evil has none. Given that, it is certainly possible for a person to act according to a certain conscience, even if that conscience has come to an erroneous conclusion. Even entire cultures have been led astray by charismatic leaders committed to a culture of death and moral relativism. Truth is objective, but one's conscience is not infallible. It is, however, inviolable. Again, I'm not philosopher, and I'm sure that there are others who could put it far better than I. That's the best I can do in my limited time.

Applying the above practically on the matter of conscience clauses for health care professionals: if a doctor or nurse possesses a certain conscience that performing a particular procedure is evil, he or she must not perform it, for it would be, for him or her, an evil act -- even if he or she is wrong as a result of an ill-formed conscience. Neither the state nor a patient can ethically require a person to perform an act if that person possesses a certain conscience that that act is evil.

I understand we disagree. We obviously approach the matter from two very different worldviews. As I understand it, then, it is your position that the doctor would be required, ethically, to participate in the act of assisting Mrs. Coumbias in killing herself. Perhaps you would let him off if he gave reasons you found convincing. But what reasons could there possibly be, given your definition of the patient's best interest being defined by his or her own terms? How would you punish the doctor or the nurse for refusing to participate? How would you recommend that the state of Montana punish its doctors for refusing to assist Mr. Baxter in killing himself? And how do you think this might impact health care in Montana?

These aren't rhetorical questions. I would really like to know.

Bob Hunt, RN

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My response

Mr. Hunt asserts that conscience is a function of reason, and that feelings of conscience can be correct or incorrect. These assertions require some sort of an ontological correspondence: a correct feeling of conscience must correspond to some aspect of existence (i.e. reality); an incorrect feeling of conscience must fail in some substantive way to correspond to existence. These assertions also require some sort of epistemic method: there has to be some way to know whether some feeling of conscience is correct or incorrect.

But Mr. Hunt gives us absolutely no ontological or epistemological account to support his assertions. He asserts that "the idea that it is legitimate to kill human life in the womb," is an example of an erroneous conclusion (or feeling) of conscience. But this is precisely the matter of controversy: many people, myself included, hold that killing a non-sentient blastocyst or fetus is not morally relevant and we object strongly to interfering with a pregnant woman's bodily autonomy.

If Mr. Hunt wishes his assertions to stick, if he wishes us to consider his objection to abortion as anything other than a personal subjective preference, he will need to tell us precisely how his particular preference corresponds to reality (and the opposite preference fails to correspond with reality), and furthermore how we can know he's correct and dissenters are incorrect. We must ask: what sort of existence do correct feelings of conscience correspond to? How do we know whether some feeling of conscience is correct or incorrect?

It's also worth mentioning that Mr. Hunt's view is deeply inconsistent with demanding individual exemptions by reason of conscience. Demanding individual exceptions implicitly condones the practice of those who do not want the exemption; Mr. Hunt is thus condoning behavior he believes to be in some sense objectively wrong. But to condone behavior entails that one believes it to be at least permissible: how can it possibly be permissible to do that which is objectively wrong?

It's worth mentioning that meta-ethical subjectivism is based on psychological egoism: the descriptive (non-normative) scientific theory that people do what they most want to do, all things considered. We have competing desires, reality places strictures on the available actions and their outcomes, we have limited knowledge of how reality works, and there are those pesky six billion other people also trying to do what they want, but at the end of the day, each individual does her best to work out all these complicated factors and does what she decides she most wants to do. A corollary to this foundational principle, also descriptive, is we do in fact experience the consequences of our actions.

Under this view, it's perfectly reasonable for an obstetrician to refuse to perform abortions if, all things considered, he cannot do so in good conscience. It's also perfectly reasonable that the obstetrician will experience the socially constructed consequences of refusing to perform an abortion, which may include loss of professional privileges, including the privilege of practicing medicine. In just the same sense, it might be perfectly reasonable for me to break any law I consider unconscionable, but I would therefore expect to experience the consequences of breaking that law, including going to jail. It's sometimes a very tough choice, but life is full of tough choices. C'est la vie.

Dr. Martin Luther King, Jr. broke the law and faced the consequences: he believed that the imposition of consequences would shock the consequences of the nation more than his breaking the law. His belief was indeed accurate, and he made gains in civil rights for black people. If people such as Mr. Hunt truly believe that it is somehow incorrect or even deeply objectionable for anyone to perform abortions, let them show the sort of moral courage as Dr. King, and let the nation judge whether the act or the consequences are more shocking.

Mr. Hunt asserts it is evil to ever demand a person (assuming doctors and nurses are merely exemplars, and not morally privileged as a class) act contrary to his conscience, even if that conscience is somehow "ill-formed."

[I]f a doctor or nurse possesses a certain conscience that performing a particular procedure is evil, he or she must not perform it, for it would be, for him or her, an evil act -- even if he or she is wrong as a result of an ill-formed conscience. Neither the state nor a patient can ethically require a person to perform an act if that person possesses a certain conscience that that act is evil.

This is a very odd view: It would entail that the "state" (presumably including those who set professional medical standards) should not require a physician (or an institution) to provide care to black people or gay people if his conscience forbade him. If a physician believe in good conscience that antibiotics were evil, or that bacteria had moral standing, even if such a position were obviously "ill-formed" (or subjectively reprehensible), the state should not require him to treat infection with antibiotics; Neither may the state subject him to any sanctions whatsoever, including the loss of the privilege to practice medicine, for a failure to do so.

It is difficult to see Mr. Hunt as arguing for anything but pure moral anarchy, the idea that all socially-constructed norms are universally reprehensible. A norm is no norm at all unless dissenters are somehow coerced, and we coerce only those whose consciences — perhaps "ill-formed" — dissent from a norm.

As I understand it, then, it is your position that the doctor would be required, ethically, to participate in the act of assisting Mrs. Coumbias in killing herself. Perhaps you would let him off if he gave reasons you found convincing. But what reasons could there possibly be, given your definition of the patient's best interest being defined by his or her own terms? How would you punish the doctor or the nurse for refusing to participate?

Mr. Hunt is presumably talking about Betty Coumbias, "an elderly [but otherwise healthy] Vancouver resident [who] has indicated she wants to die alongside her husband, George, who suffers from heart disease."

It is unobjectionable and uncontroversial that we must do more than simply query a patient to ascertain her s best interests when we have good reason to suspect serious mental illness. (This qualification is notably absent when discussing abortion.) The desire of an otherwise healthy person to die is scientifically known to be a symptom of a number of serious mental illnesses, including schizophrenia and depression. Since scientific knowledge is presently ambiguous regarding the patient's best interests in this type of case, a physician has a legitimate basis for refusing treatment. If we were to determine as a matter of scientific truth that Ms. Coumbias were sane, and it was thus indeed in her best interest to die, then yes, a physician would have an obligation to assist her.

How would you recommend that the state of Montana punish its doctors for refusing to assist Mr. Baxter in killing himself? And how do you think this might impact health care in Montana?

Mr. Hunt is presumably talking about Baxter v. Montana, where the state of Montana has made it permissible for a physician to assist with the suicide of mentally competent terminally ill patients. Since the science here is well-defined, I do indeed believe that a physician with a relevant domain of practice does indeed have an obligation to assist suicide in these cases. It may take the law and professional medical standards a while to catch up, though.

In general, every mentally competent person — and mental competence, mental illness and sanity are well-defined, or defined well enough for most cases — should have autonomy over his or her own life and body, including the autonomy to end it at will, and it requires medical training and competence to end it with a minimum of suffering. Physicians, therefore, if the best interests of their patients does indeed drive their conduct, and they are not seeking to use their privilege, power and expertise to impose their own beliefs on the consciences and preferences of their patients, do indeed have an obligation to assist suicides as well as perform abortions.

Note that euthanasia is substantively different from abortion on a number of grounds: a person who desires euthanasia is a sapient, sentient being, with self-awareness and the capacity to suffer; a fetus has neither characteristic. Furthermore, live or die a person desiring euthanasia infringes on no one else's interests in a controversial way; a fetus does indeed infringe on the pregnant woman's interests, posing a nontrivial risk of illness and death, and substantially restricting the scope of her ordinarily free conduct. I address Mr. Hunt's questions regarding euthanasia here because they are interesting in their own right and they do indeed shed light on the fundamental ethical question we're considering: the rights, obligations and liberties of physicians in caring for their patients.

There are two fundamental questions here: how much control should we as a society give individual conscience? And second: which is more important when they conflict: an individual's life or her own liberty? Should we restrict a person's liberty to preserve her life?