The Inescapability of Reasons-Assessment

[I]t is clear that conscience is not in any usual sense a faculty or source of moral knowledge. Of itself it does not tell the agent what is right or wrong, good or evil, either in individual concrete instances or as a matter of principle.

—Peter Fuss

Introduction

In this chapter, by contrasting my view with other positions in the literature I will argue that a conscientious exemption from what would otherwise be a health care provider’s professional duty should be granted only if the practitioner makes the objection and its reasoned basis public and the justification offered for the exemption is subjected to assessment (Card, 2007). I suggest reasonability as the standard for evaluation and will emphasize that the established views on this issue do not attend to the reasonability of the putative objection. There are several dominant positions in the debate regarding providers’ refusals—including (e.g.) simply ensuring that the objector’s belief is genuinely held, requiring a referral to a willing provider, or ruling out such objections altogether because they are incompatible with one’s professional role—but I will argue that these competing positions falter precisely because of their inattention to the grounding reasons offered to support a conscientious exemption. In the next chapter, I develop the reasonability standard by presenting its content and explaining how it is used in practice, but our present question is: why should we care about reasons?

Before we carefully examine the extant philosophical views regarding conscience objections by providers, we should recall that the conscience dilemma arises from ascribing importance to two considerations: maintaining provider integrity and meeting the professional duty to care for the patient. Regarding the former point, while one might argue that providers should completely uncouple their moral values from their activities as practitioners, I will argue at length later that this would be a mistake. It seems understandable that medical providers, deeply ensnared in numerous moral dilemmas regarding life and death and subjected to morally distressing situations on a regular basis, would not want to adopt a default position of satisfying any legal request made of them, no matter how it relates to their values as a person.

Regarding the latter consideration, medical practitioners have a professional obligation to meet the standard of care for their patients. I maintain that this professional duty should be understood as a fiduciary obligation; medical professionals should ascribe primacy to their patients’ interests. I argued in the last chapter that this fiduciary obligation regarding patient well-being is at the center of medical professionalism (Card, 2007); it should be understood not only in terms of seeking to avoid harm, but also as a positive obligation to assist patients. This fiduciary obligation implies that providers possess a prima facie duty to provide legally available, medically appropriate, and safe services, even if they violate their moral beliefs, so long as providing that service promotes the patient’s interests as expressed in a durable manner by that patient. The burden of proof lies on the provider to show that there are reasonable countervailing considerations that defeat this prima facie obligation. With this background in place and the dilemma of conscience clearly in focus, we shall now turn to critically examining the main philosophical positions on how to approach conscientious objections in medicine.