On September 11, 2008, the President’s Council on Bioethics heard testimony by Anne Lyerly, M.D., chair of the Committee on Ethics of the American College of Obstetrics and Gynecology (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.” That 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. Edmund Pellegrino, chairman of the President’s Council on Bioethics, asked Council member and Princeton professor Robert P. George to respond to the ACOG Ethics Committee’s Opinion. The article below is based on Professor George’s remarks at the Council meeting.
In its recent report on the role of conscience in medicine, the American College of Obstetricians and Gynecologists discussed whether or not physicians should be allowed to follow their consciences in refusing to perform morally contested procedures like abortion. Perhaps most controversially, the report suggested that in some cases physicians should be compelled to perform abortions. Why is this problematic?
The first thing one notices 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.”
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 recommendation offered 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 in the committee’s report—the putative 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, structured, and 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.
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, 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 is only that the report is laced with, and dependent upon at every turn, philosophical judgments. The report, in other words, in its driving assumptions, reasoning, and conclusions does 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 truth is that the physician or the pharmacist who declines to dispense coerces no one. He or she, that physician or pharmacist, simply refuses to participate in the destruction of human life—the life of the child 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 either to get in line or go out of business.
If their advice were followed, if 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, the moral and political convictions of the report’s authors. So, in truth, who in this debate is guilty of intolerance? Who is favoring coercion? Who is imposing their values?
While I am on the pro-life side of the abortion question, one need not share my view to see that it is those responsible for this report who are the ones seeking to impose their views and values on others.
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. 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.
There is one final irony in all of this. 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, the report said that such referrals “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 myself 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.
But then what could possibly justify the exercise of coercion to compel thoughtful, morally sincere physicians who believe that abortion is a homicidal injustice either to perform the procedure or make a referral for it, or else leave the practice of medicine? The report’s “my way or the highway” attitude 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.