First and second things, and the operations of conscience in science

Bruce G. Charlton

Medical Hypotheses

Abstract: Why is modern science less efficient than it used to be, why has revolutionary science declined, and why has science become so dishonest? One plausible explanation behind these observations comes from an essay First and second things published by CS Lewis. First Things are the goals that are given priority as the primary and ultimate aim in life. Second Things are subordinate goals or aims – which are justified in terms of the extent to which they assist in pursuing First Things. The classic First Thing in human society is some kind of religious or philosophical world view. Lewis regarded it as a ‘universal law’ that the pursuit of a Second Thing as if it was a First Thing led inevitably to the loss of that Second Thing: ‘You can’t get second things by putting them first; you can get second things only by putting first things first’. I would argue that the pursuit of science as a primary value will lead to the loss of science, because science is properly a Second Thing. Because when science is conceptualized as a First Thing the bottom-line or operational definition of ‘correct behaviour’ is approval and high status within the scientific community. However, this does nothing whatsoever to prevent science drifting-away from its proper function; and once science has drifted then the prevailing peer consensus will tend to maintain this state of corruption. I am saying that science is a Second Thing, and ought to be subordinate to the First Thing of transcendental truth. Truth impinges on scientific practice in the form of individual conscience (noting that, of course, the strength and validity of conscience varies between scientists). When the senior scientists, whose role is to uphold standards, fail to posses or respond-to informed conscience, science will inevitably go rotten from the head downwards. What, then, motivates a scientist to act upon conscience? I believe it requires a fundamental conviction of the reality and importance of truth as an essential part of the basic purpose and meaning of life. Without some such bedrock moral underpinning, there is little possibility that individual scientific conscience would ever have a chance of holding-out against an insidious drift toward corruption enforced by peer consensus.


Charlton BG. First and second things, and the operations of conscience in science. Med Hypotheses. 2010 Jan;74(1):1-3. Epub 2009 Sep 5.

Islamic Biomedical Ethics: Principles and Application

Islamic Biomedical Ethics: Principles and Application

Sachedina A. Islamic Biomedical Ethics: Principles and Application. Oxford: University Press; 2009. Print ISBN-13: 9780195378504. DOI:10.1093/acprof:oso/9780195378504.001.0001

Abstract:This book undertakes to correlate practical ethical decisions in modern medical practice to principles and rules derived from Islamic juridical praxis and theological doctrines. This study links these rulings to the moral principles extracted from the normative religious texts and historically documented precedents. Western scholars of Islamic law have pointed out the importance of the historical approach in determining the rules and the juristic practices that were applied to the cases under consideration before the judicial opinions were issued within a specific social, economic, and political context. These decisions reflected aspects of intellectual as well as social history of the Muslim community engaged in making everyday life conform to the religious values. Ethical decisions are an important part of interpersonal relations in Islamic law. Practical guidance affecting all facets of individual and collective human life, have been provided under the general rules of “Public good” and “No harm, no harassment.” However, no judicial decision that claims to further public good is regarded authoritative without supporting documentation from the foundational sources, like the Qur‘an and the Sunna (the exemplary tradition of the Prophet). Hence, Muslim jurists, in order to infer fresh rulings about matters that were not covered by the existing precedents in the Qur‘an and the Sunna, undertook to develop rational stratagems to enable them to solve problems faced by the community. This intellectual activity led to the systematic formulation of the principles of Islamic jurisprudence, which has assumed unprecedented importance in connection with the distinct field of medical ethics in the Islamic world that shares the modern medical technology with the West. The book argues that there are distinct Islamic principles that can serve as sources for Muslim biomedical ethics that can engage in dialogue with both secular and other religiously oriented bioethics in the context of universal medical practice and research.


“Abdulaziz Sachedina is the leading Islamic thinker writing in Engish today.  Thus, his Islamic Biomedical Ethics is a welcome addition to the already extensive literature in the field because of his great knowledge of the classical and modern Islamic legal and ethical sources, his authentic religious commitment to the truth of Islam, and his willingness to engage perspectives from other traditions in what is becoming a genuinely multicultural field of moral discourse.”  David Novak, author of Jewish Social Ethics

The prisoner as model organism: malaria research at Stateville Penitentiary

Nathaniel Comfort

The prisoner as model organism: malaria research at Stateville Penitentiary

Abstract

In a military-sponsored research project begun during the Second World War, inmates of the Stateville Penitentiary in Illinois were infected with malaria and treated with experimental drugs that sometimes had vicious side effects. They were made into reservoirs for the disease and they provided a food supply for the mosquito cultures. They acted as secretaries and technicians, recording data on one another, administering malarious mosquito bites and experimental drugs to one another, and helping decide who was admitted to the project and who became eligible for early parole as a result of his participation. Thus, the prisoners were not simply research subjects; they were deeply constitutive of the research project. Because a prisoner’s time on the project was counted as part of his sentence, and because serving on the project could shorten one’s sentence, the project must be seen as simultaneously serving the functions of research and punishment. Michel Foucault wrote about such ‘mixed mechanisms’ in his Discipline and punish. His shining example of such a ‘transparent’ and subtle style of punishment was the panopticon, Jeremy Bentham’s architectural invention of prison cellblocks arrayed around a central guard tower. Stateville prison was designed on Bentham’s model; Foucault featured it in his own discussion. This paper, then, explores the power relations in this highly idiosyncratic experimental system, in which the various roles of model organism, reagent, and technician are all occupied by sentient beings who move among them fluidly. This, I argue, created an environment in the Stateville hospital wing more panoptic than that in the cellblocks. Research and punishment were completely interpenetrating, and mutually reinforcing.


Comfort N. The prisoner as model organism: malaria research at Stateville Penitentiary. Stud Hist Philos Biol Biomed Sci. 2009;40(3):190-203. doi:10.1016/j.shpsc.2009.06.007

Legal protection and limits of conscientious objection: when conscientious objection is unethical

Bernard M. Dickens

Medicine and Law

Abstract: The right to conscientious objection is founded on human rights to act according to individuals’ religious and other conscience. Domestic and international human rights laws recognize such entitlements. Healthcare providers cannot be discriminated against, for instance in employment, on the basis of their beliefs. They are required, however, to be equally respectful of rights to conscience of patients and potential patients. They cannot invoke their human rights to violate the human rights of others. There are legal limits to conscientious objection. Laws in some jurisdictions unethically abuse religious conscience by granting excessive rights to refuse care. In general, healthcare providers owe duties of care to patients that may conflict with their refusal of care on grounds of conscience. The reconciliation of patients’ rights to care and providers’ rights of conscientious objection is in the duty of objectors in good faith to refer their patients to reasonably accessible providers who are known not to object. Conscientious objection is unethical when healthcare practitioners treat patients only as means to their own spiritual ends. Practitioners who would place their own spiritual or other interests above their patients’ healthcare interests have a conflict of interest, which is unethical if not appropriately declared. [Full Text]

Dickens BM. Legal protection and limits of conscientious objection: when conscientious objection is unethical. Med Law. 2009 Mar;28(2):337-47. PubMed PMID: 19705646.

Book Review: Conflicts of Conscience in Health Care: An Institutional Compromise

Sean Murphy*

Conflicts of Conscience in Health Care: An Institutional Compromise

Lynch HF. Conflicts of Conscience in Health Care: An Institutional Compromise. Boston: The MIT Press; 2008. 368 p. ISBN: 9780262123051

Conflicts of Conscience in Health Care was published in 2008 as the 24th volume in the Basic Bioethics series from the Massachusetts Institute of Technology. It is an American book dealing with the American political and legal controversies over freedom of conscience in health care. However, the discussion of the American experience by Holly Fernandez Lynch is relevant elsewhere, since the United States has the most extensive and varied network of protection of conscience legislation in the world.

While acknowledging that freedom of conscience is of concern to all health care workers and institutions, Fernandez Lynch focuses exclusively on physicians. This carefully and deliberately restricted focus is one of the strengths of the book.

After a preface and introduction, discussion and argument occupy about 260 pages, supplemented by 53 pages of end notes, many of which offer expanded comment on the text. A good 12 page index has been included, as well as four pages of cited statutes and cases. The earliest source found in a list of 300 references is from 1951; the rest date from 1972 to 2007.

Goal

The author introduces her subject with a statement from Pope John Paul II:

. . . to refuse to take part in committing an injustice is not only a moral duty, it is also a basic human right. Were this not so, the human person would be forced to perform an action intrinsically incompatible with human dignity, and in this way human freedom itself, the authentic meaning and purpose of which are found in its orientation to the true and the good, would be radically compromised.

Fernandez-Lynch does not argue from a Catholic or even religious perspective. Nonetheless, she describes this as “a powerful statement about the nature of conscience, complicity in morally objectionable actions, and avoidance of injustice.” She adds that it is generally acceptable to religious and nonreligious people alike, regardless of their political views.

This reflects the spirit in which she pursues her project. As the subtitle of the book indicates, she is seeking a compromise that will provide “maximal liberty for all parties.” She believes that freedom of conscience for physicians and the provision of legal medical services are both important social goals, and that they are not incompatible. Thus, she rejects “all-or-nothing” strategies that seek “total victory.” Ultimately, quoting the Protection of Conscience Project, she affirms that all legitimate concerns can be met by “dialogue, prudent planning, and the exercise of tolerance, imagination and political will.”

Context of the discussion

The author recognizes that she writes with the abortion controversy more or less continuously in the background. But she insists – correctly, in the Project’s view – that “limiting the debate to tired abortion rhetoric could be quite dangerous if it prevents meaningful discussion” of broader issues. Referring to a number of other controversial issues and the impact of ongoing technological developments, Fernandez Lynch predicts that these, combined with “increasing diversity of health-care providers” have “the potential to create a perfect storm.”

Overview

The shape of the compromise proposed by Fernandez Lynch can be outlined while describing the book’s structure. It consists of three main parts.

The first reviews American protection of conscience laws and examines four paradigms of medical professionalism. The author selects one of these paradigms – physician as gatekeeper – as most suited to the compromise she seeks.

In Part II, Fernandez Lynch explains what she believes to be the source of the current controversy. Applying the professional model of physician as gatekeeper, she observes that an objecting physician may sometimes be the only available “gatekeeper” who can open the gate to a desired service. Her solution: tell patients about other gates and gatekeepers, redistribute them, and, if necessary, provide more gates and more gatekeepers. Or, to paraphrase anti-euthanasia activists, if access is the problem, eliminate barriers to access, not objecting physicians.

To accomplish this, the author suggests that a designated institution ensure access to services through effective distribution of health care resources and connect patients with willing physicians. Hence, the subtitle of the book: an institutional compromise. Fernandez-Lynch identifies state licensing boards as the institutions best placed to accomplish this. The last two thirds of the book describes how the compromise might be implemented in practice. It includes a model statute and extended discussions about calculating patient demand and meeting it through the supply of willing physicians. . .


Murphy S. Book Review: Conflicts of Conscience in Health Care: An Institutional Compromise. Protection of Conscience Project; 2009 Dec 17.

Conscientious commitment

Bernard M. Dickens

The Lancet

In some regions of the world, hospital policy, negotiated with the health ministry and police, requires that a doctor who finds evidence of an unskilled abortion or abortion attempt should immediately inform police authorities and preserve the evidence. Elsewhere, religious leaders forbid male doctors from examining any part of a female patient’s body other than that being directly complained about. Can a doctor invoke a conscientious commitment to medically appropriate and timely diagnosis or care and refuse to comply with such directives?


Dickens BM. Conscientious commitment. Lancet [Internet]. 2008 Apr 12; 371(9620): 1240 – 1241

Reconciling principles and prescriptions: Do pharmacist refusal clauses strike the appropriate balance between pharmacists’ and patients’ rights?

Sarah Tomkowiak   

University of Illinois Law Review

Conclusion: When a woman and her physician decide that a prescription for contraception is in her best health interests, legal, professional, and ethical obligations should prevent a pharmacist from being able to effectively override that determination. The right of a pharmacist to abide by her moral or religious principles when faced with a prescription that goes against those principles is an important right to protect. However, this right should never be allowed to infringe on a patient’s right to access birth control, an equally important right that has significant implications for the majority of American women’s reproductive health. Pharmacist refusal clauses acknowledge pharmacists’ right to refuse at the expense of women’s right to access contraceptives, inappropriately reconciling these rights. Griswold v. Connecticut may be forty years old, but the issues debated before the Supreme Court then have risen anew today, this time behind the pharmacy counter. Following in the footsteps of the Griswold Court, we must now reaffirm that women have the right to make their own family planning decisions, including the decision to use contraception. Legislatures, pharmacy boards, pharmacies, pharmacists, and patients must work together to put the needs of patients back where they belong—as the first priority of the pharmacy profession.


Tomkowiak S. Reconciling principles and prescriptions: Do pharmacist refusal clauses strike the appropriate balance between pharmacists’ and patients’ rights? U Illinois L Rev 2007(4) 1329-1360

The Ever-Expanding Health Care Conscience Clause: The Quest for Immunity in the Struggle Between Professional Duties and Moral Beliefs

Maxine M. Harrington

Florida State University Law Review

Introduction:  During the past few years, the debate over whether health care professionals should be required to provide services that conflict with their personal beliefs has focused primarily on pharmacists refusing to fill prescriptions.1 According to one media account, during a sixmonth period in 2004 there were approximately 180 reports of pharmacists refusing to dispense routine or emergency oral contraceptives. 2 This controversy, however, extends beyond the pharmacy into every facet of the heath care system. . .


Harrington MM. The Ever-Expanding Health Care Conscience Clause: The Quest for Immunity in the Struggle Between Professional Duties and Moral Beliefs. 34 Fla. St. U. L. Rev. 779, 816 n.237 (2007) 

Conscientious objection in medicine

Julian Savulescu

British Medical Journal

Shakespeare wrote that “Conscience is but a word cowards use, devised at first to keep the strong in awe” (Richard III V.iv.1.7). 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. A doctors’ conscience has little place in the delivery of modern medical care. What should be provided to patients is defined by the law and consideration of the just distribution of finite medical resources, which requires a reasonable conception of the patient’s good and the patient’s informed desires (box). 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. . .


Savulescu J. Conscientious objection in medicine. BMJ. 2006 February 4; 332(7536): 294–297. doi:  10.1136/bmj.332.7536.294

The scope and limits of conscientious objection

Bernard M. Dickens, Rebecca J. Cook

International Journal of Gynecology & Obstetrics

Abstract: Principles of religious freedom protect physicians, nurses and others who refuse participation in medical procedures to which they hold conscientious objections. However, they cannot decline participation in procedures to save life or continuing health. Physicians who refuse to perform procedures on religious grounds must refer their patients to non-objecting practitioners. When physicians refuse to accept applicants as patients for procedures to which they object, governmental healthcare administrators must ensure that non-objecting providers are reasonably accessible. Nurses’ conscientious objections to participate directly in procedures they find religiously offensive should be accommodated, but nurses cannot object to giving patients indirect aid. Medical and nursing students cannot object to be educated about procedures in which they would not participate, but may object to having to perform them under supervision. Hospitals cannot usually claim an institutional conscientious objection, nor discriminate against potential staff applicants who would not object to participation in particular procedures.


Dickens BM, Cook RJ. The scope and limits of conscientious objection. Int J Gynaecol Obstet. 2000 Oct;71(1):71-7.