Monday, November 26, 2007

Catholicism and Acupuncture

Fr Timothy Finnigan, Parish Priest of Blackfen and blogger, wrote on acupuncture and Catholicism in his regular column in the Catholic Herald, 16/11/07, concluding:

A Catholic ought to be sure that their therapist is not committed, in their therapy and advice, to promoting a world view that is incompatible with Christianity. If there is any doubt about this at all, it would be better to steer clear of acupuncture.

I wrote a reply which was published in full in the 23/11/07 edition, as follows:


Fr Finigan is quite correct to point out that acupuncture is based on a medical 'model' related to Taoism, a philosophy incompatible with Catholic teaching. It should also be remembered that conventional Western medicine is based on a medical model which takes the philosophy of materialism for granted. This philosophical outlook is held by the great majority of researchers and practitioners, and has many implications for medical practice. Like Taoism, it is incompatible with Catholic teaching.

As well as being impractical, it would seem unnecessary for ordinary Catholic patients to worry about the metaphysical commitments of their doctors. All medical models are imperfect; treatments based on imperfect models can still have good results; prudence directs us to the doctors best at curing disease, not the ones best at philosophy or theology. The focus of moral attention, on the other hand, should be on whether a doctor is giving concrete advice lacking in the moral dimension, as when materialist doctors propose to treat the unborn or the dying without the respect due to human persons. It is far from clear that medical traditions based on Eastern philosophies such as Taoism are worse off, in this respect, than traditions based on home-grown absurdities such as materialism.

Indeed, not even a medical tradition rooted in Catholicism, such as the 'humours' theory used in Medieval and Early Modern Europe, is immune to manipulation by immoral doctors. Ben Johnson and Nicolo Macchiavelli both wrote plays lampooning doctors who recommended sex (if necessary, outside marriage) as an aid to health. The compatibility of the medical model with Church teaching at a metaphysical level does not guarantee the compatibility of a practioner's advice with the Church's teaching on a practical, moral, level.


Joseph Shaw

Friday, November 23, 2007

Genetic Enhancements: reply to Savalescu

My talk at the inaugaral meeting of the Wolfson Applied Philosophy Society, chaired by Dr Francine Baker. My paper responds in general terms to an article by Professor Julian Savalescu of the Oxford Uehiro Centre for Practical Ethics which can be read here (pdf).

Gene Therapy and Genetic Enhancement

Part I

I am not a specialist in medical ethics, and I can only hope that I will bring some freshness to a specialist debate, and give the specialists present today something to talk about. I am a specialist in theoretical, normative, ethics, and I approach this question with an eye to seeing what general principles of theoretical ethics might be applicable.

Professor Savalescu, of course, does this in his paper, saying that gene therapy is no different from ordinary medical treatment, and is therefore morally unproblematic. I shall adopt the same starting point. If we ask what moral principles govern medical treatment, we find most famously the principle that medical treatment is for the restoration of health, and perhaps also for the prevention of disease. When this definition is violated, treatment becomes morally problematic.

For example, it is morally problematic when governments propose to sterilise or castrate or lobotomise mentally retarded or mentally ill or simply morally bad persons for social reasons. It is problematic when governments regard political dissidents as mentally ill, and confine them to insane asylums. It is problematic when a person suffering from ‘Body Integrity Disorder’ asks a surgeon to amputate his healthy limb. It is problematic in all these cases because medical treatment is being given to people other than with a view to their restoration to health, or to the prevention of disease.

To take the first of these examples, when governments sterilise the mentally disabled, this is usually condemned for two reasons. First, the patient is not in a position to consent. Second, the procedure is not in the medical interests of the patient—it is not aiming at their restoration to health. On the contrary, an aspect of the patient which is functioning normally, healthily, is subjected to a procedure designed to prevent it functioning healthily. Even if consent could make this kind of thing permissible, in this case consent is lacking.

It should be noted that the fact that patient is not in a position to consent makes it all the more important to make sure medical treatment is medically required. This principle is clearly going to be applicable to embryos and young children subjected to genetic enhancement.

In certain cases consent can make a non-therapeutic procure permissible. Giving blood would be an example. But where a serious and permanent harm is done to the health of a patient, other than to restore the patient to health (as when a gangrenous limb is amputated), consent does not seem to be sufficient to make it permissible. This is the case with Body Integrity Disorder. Those who want limbs amputated just because they suffer from an unfortunate desire, are refused treatment by conscientious doctors, because the treatment would do nothing to restore them to health.

The patient believes that the treatment would make him happier. The medical establishment replies that this belief is itself part of a mental illness. The patient may insist that he is mentally fine, and the doctor should get on with it. We have a disagreement here, and it is important to note that both sides are obliged to appeal, not simply to the importance of satisfying preferences, but to an objective notion of health. Such disputes have raged about homosexuality: is it a medical condition, or, as the jargon has it, a way of being normal? A view has to be taken if we are to decide what treatment is appropriate or permissible.

What was wrong about the Soviet practice of confining dissidents to looney bins is that the dissidents were not truly mentally ill. The claim that they were, according to some strange Marxist-Leninist psychological theory, was simply implausible. Such claims have to be examined and debated, if they are to be used to justify medical treatment. Professor Savalescu apparently believes that we can talk about medical practice without talking about the concept of health, but he is wrong.

Savalescu draws on a series of examples which appear to make unclear the point I have tried to make clear. Food supplements to improve mental abilities, for example, and plastic surgery, do not seem to be attempts to restore health, but surely, he seems to be saying, they are not impermissible. In response, one may ask whether food supplements fall under the concept of medical treatment at all; there may be borderline cases here, of course. But insofar as we regard them as medical treatment, we can regard their function as properly medical, that is, as giving the patient a better state of health, of healthy functioning. There is no question at all, in such cases, of impairing function, of mutilation, which is the opposite of restoring health.

In the case of plastic surgery, what we have is a medical intervention which frequently does not seem to have the normal justification, of restoring health, unless having a large nose, or small breasts, is regarded as a disability, and not just a way of being normal. It may be that this is indeed how it is regarded by the patients, at least in conjunction with their own attitudes to their bodies. They may be wrong; they may be suffering from something parallel to Body Integrity Disorder. It may be better for the medical profession to offer counselling, rather than surgery, to perfectly healthy people seeking plastic surgery, as opposed to car crash or burns victims. On the other hand, it is clearly not such a serious matter as the examples I gave earlier, since there is normally no loss of function where plastic surgery is concerned. My aim here is not to settle the matter, but to point out that argument here is possible.

So, let us apply the principles I have been developing to the case of gene therapy. Gene therapy is a medical intervention; since it has permanent effects, which may be irreversible, it is a serious matter and demands serious justification. The justification it needs, like all medical intervention, is a medical justification, which is to say that it restores or preserves health. Thus, if a person had a genetic disorder which impaired life expectancy or function, and if this could be cured by gene therapy, whether this involved addition or subtraction or modification of genes, then it would seem, in principle, the therapy is justified. If a person had a gene for homosexuality—to use one of Savalescu’s examples—then intervention to remove that gene would be justified if, and only if, homosexuality is regarded as a disability, and not as a way of being normal. And so on with the other cases.

So it seems that gene therapy would not be justified in order to enhance intelligence or vital statistics, unless one were able to argue, and argue successfully, that without the therapy the person would be suffering from poor health, limited functioning, disability. Evidently such arguments would be successful in certain cases. Equally evidently, the demand for medical justification would prevent the kind of genetically enhanced utopia Savalescu seems to have in mind.

Part II

Let me now present in a different way the argument I have set out. It would be possible to imagine a medical profession that saw itself in an entirely technical light. Doctors would exist solely to do what patients asked them to do. They know how to bring about various effects on the human body, for good or ill, and they would do those things on request. Sometimes this would involve restoring health, and sometimes destroying it. Sometimes saving a diseased limb, sometimes cutting off a healthy one. This kind of medical profession would be the one ready to do Savalescu’s bidding. Perhaps the practice of plastic surgery has been leading the medical profession in this direction, but cases like Body Integrity Disorder show that we are not there yet.

What cases like Body Integrity Disorder show is that medicine is not merely a body of technical knowledge, like plumbing, but a value-laden enterprise. It is necessarily connected with the concept of health, which is a normative concept. Part of the understanding which doctors have to acquire is an understanding of what health is, which is part of an understanding of what is good for people, what is in their interests. Patients certainly have autonomy, notably the right to refuse treatment, but they rely on doctors not only for technical information, but for an evaluation of their options. If the medical profession became a purely technical matter, doctors would become mere technicians. That is not our image of doctors, nor theirs of themselves. It would be a degrading change. As things stand, doctors are answerable to their own professional evaluations; this means they must have the right to refuse to carry out inappropriate treatment.

Here’s a parallel we in this room should understand. People engaged in academic study are not merely gaining a body of useful technical knowledge; that would not be academic study. We are engaged in an essentially value-laden enterprise, connected with truth and professional judgement. Academic conclusions should have academic justification, which is to say justification in terms of reasoned argument; they cannot be justified by their convenience or money-value. There is something appalling about the idea of an academic who deliberately falsifies his own conclusions, regardless of the reason. Normally we can rely on academics’ sense of their own dignity to prevent this. Academia would be pointless if we did all our studies but didn’t undertake a proper evaluation of the results. We are answerable to our own professional evaluation of the material we are working with. For a serious academic to argue for whatever conclusions those paying him preferred would be a kind of prostitution, and he would immediately cease to be viewed by others as a serious academic. For the whole of academia to go down that road would be the complete degradation of the profession. This is not a Utilitarian argument, but it is nevertheless a consideration Professor Savalescu, as an academic, would ignore at his peril.

Just as the work of academics is essentially value-laden, the central value being truth, or, if you prefer, the exercise of academic judgement, so the work of doctors is essentially value-laden, where the central value is health, or the medical good of the patient. The idea that this might be reducible to the patient’s own preferences would be news to the whole branch of medicine, psychology, whose stock in trade is the changing of patients’ preferences. I have not articulated what the concept of health amounts to; it is enough to point out that there is such a concept, and that it has this role.

Given that there is such a concept, and that doctors make use of it in their evaluations of what treatment is appropriate, it should be clear that it will never be permissible to make serious medical interventions to healthy people. It may be possible to make the strong stronger or the clever cleverer, but that is not what medicine is for. The fact that this would satisfy the preferences, or assumed preferences, of the patient is an insufficient justification; that does nothing to provide the medical justification which is needed for a medical intervention.

Part III

This conclusion may seem mysterious. Medicine is governed by certain values internal to itself which prevents it from being as useful to others as it might be. The same is true of academia: academics worthy of the name do not manipulate their conclusions to further even worthy goals of social policy. But this seems less mysterious. For an academic who honestly thought one thing, and said another in public, would be lying, and it is a familiar enough idea that there is a moral constraint against lying. What is the moral constraint at the basis of a doctor’s refusal to make medical interventions other than with a view to restoring health?

I would propose that the answer is that there is a moral constraint here, most familiarly known as a constraint against mutilation. I put it in this cautious way because the cases we have may not look at first glance like cases of mutilation; what I am suggesting is that, properly understood, the constraint behind the limits of medical practice, which is very clear in classic cases of mutilation, is sufficiently broad to cover the cases we are focusing on here. Accordingly I propose to use the word ‘mutiliation’ in a broad sense.

One easy way to express what is wrong with sterilising the mentally disabled is that it is a case of mutilation. The way I have been expressing it is that the medical intervention has no medical justification, which would be justification in terms of restoring the patient to health. My suggestion is that the two ways of putting it are equivalent; they are interdefinable. Medical interventions without medical justifications are mutilations. We may raise the scalpel against, or give potions and drugs to, our fellow human beings only with a view to the cure or prevention of disease of the patient. To do so otherwise is wrong; it is akin to assault, battery, and mutilation. I think the moral intuition here is clear enough; stipulatively, for convenience, I will call the forbidden action mutilation. So the next question will be: is it plausible to characterise genetic enhancement, when lacking a medical justification, as mutilation in my broad sense?

First of all, let me clarify the meaning of mutilation. Normally, mutilation leaves the victim worse off, but this need not be so. Cutting off a healthy limb for no good reason is obviously mutilation. Would it cease to be mutilation if victim was fulfilling the condition necessary to gain a vast sum of money, leaving him overall better off? Of course it would; we would then ask whether the mutilation was worth it, or was morally justified by it. Like the ugly sisters in the un-Disnified version of the Cinderalla story, who cut of parts of their feet in order to get them into the magic slipper, we can see that there is a moral problem with this. This is not the way we should treat our bodies.

Now consider prosthetic limbs. These have been getting better and better. It will not be long before a prosthetic leg will actually be better than the usual healthy natural leg; perhaps this is so already. Let us suppose it is indeed so. Would it be right for a person to allow either or both of his healthy natural legs to be removed, in order to be fitted with souped up prosthetic legs, as we might say, bionic legs? Again, our moral intuitions are against this. By all means, let the unfortunate souls who lose their legs on land mines or in any other way get the best prosthetic limbs money can buy; but it would not be right to cut off a healthy limb to enjoy the benefits of an artificial one.

Our genes are part of our bodies. This is perhaps something we have to learn; it is not obvious, just by looking at us, but it must be so. Given the moral constraint on mutilation, it follows that it would be wrong to remove parts of our DNA to replace them with others, artificial or borrowed, supposed to be preferable, without medical justification. The moral constraint against mutilation is the protection morality gives to our physical integrity; it is the moral implication of the value, the moral importance, of the human body. Too often ethics limits itself to the moral implications of the value of life, or pleasure, but few if any philosophers defend the view that these are the only things of moral importance. So just as the value of life has the implication that we may not kill, without certain limited kinds of justification, so the value of the body has the implication that we cannot invade or disarrange it, without certain limited kinds of justification. The violation of the constraints protecting life is murder; the violation of the constraints protecting the body is mutilation.

Wednesday, August 08, 2007

'Personal Beliefs and Medical Practice'

The consultation is about a draft ‘guidance’ document, ‘Personal Beliefs and Medical Practice’ (‘PBMP’), from the General Medical Council. Using examples, the Guidelines aim to set out principles which should govern cases where patients ask for a type of treatment a doctor does not wish to give.

PBMP is, unfortunately, seriously confused. The first problem is its reference to two red herrings: first, the principle that doctors should not ‘discriminate’ on the basis of their own or their patients beliefs (or lifestyle, race, etc.), and second, the distinction between ‘personal beliefs’ and ‘clinical knowledge and judgment’.

On the first, although discrimination is not defined in the document, it would be reasonable to understand it, in the medical context, as treating different patients differently on the basis of non-relevant criteria. Thus, a racist doctor who consistently gave cheaper and less effective medicine to patients who were members of a particular racial group, would clearly be guilty of (wrongful) discrimination.

PBMP’s three examples are the circumcision of boys for religious reasons; abortion; and the refusal of Jehovah’s witnesses to use blood products. In each case, what the patient (or the patient’s parents) is asking for may not be what the doctor thinks is right. However, in none of these cases is discrimination an issue. A doctor who refuses to go along with the patient’s wishes would be applying to the patient in front of him the same judgements he would apply to everyone. The way the PBMP keeps returning to the principle of non-discrimination suggests that such a doctor might be guilty of discrimination, but this claim is never explained or justified.

The second red herring is the distinction between a doctor’s ‘personal beliefs’ and ‘clinical knowledge and judgment’ (para 16). Taking each side of the alleged distinction separately, PBMP acknowledges that doctors must be free to exercise their judgment as to what is clinically, medically, appropriate to a patient. On the other hand, by contrasting this with something ‘personal’, it suggests that clinical judgment is somehow ‘public’, or common to the profession. This is a mere slight of hand: clinical judgement is personal, and good doctors sometimes disagree. It would be better to talk about a doctor’s ‘personal, clinical judgement’. Again, the term ‘knowledge’ is misleading, as contrasted with ‘belief’, since the bases of clinical judgements will include opinions which couldn’t count as ‘knowledge’, including the doctor’s personal medical experience. So along with ‘personal, clinical judgement’ we must talk of the doctor’s ‘clinical views’, not limited to ‘knowledge’.

When we contrast a doctor’s ‘clinical views and personal, clinical judgement’ with his ‘personal beliefs’, there does not appear to be any contrast at all. However, what PBMP clearly intends to include under ‘personal beliefs’ are moral beliefs and values. It is mere rhetoric to assume these must be beliefs rather than knowledge (don’t we all know that paradigmatic cases of murder are wrong?). So the contrast PBMP is trying to make would turn out to be that between the doctor’s medical views, and his moral views.

There is, unfortunately, a serious problem with this distinction, arising from the fact that medical views and judgements are necessarily value-laden. Medicine is about giving appropriate treatment to patients, and thus depends on the concepts of health, well-being, and benefit, and their contraries. These are all clearly evaluative terms. When a doctor says that a certain treatment will return a patient to good health, or that the benefits of a certain operation will not outweigh the pain and inconvenience, he is making a value judgement.

If the GMC wishes to avoid this, they might insist that clinical judgments are purely instrumental: they are simply about how to get a patient from one physical (or mental) state to another. If a patient wishes to get rid of a back pain, or to walk without a limp, the doctor will advise on the best ways of doing this. If a patient wants to end up in what a doctor might, as the maker of value-judgments, regard as a worse state, the doctor will nevertheless, as a clinical technician, advise the patient how to achieve that. But the GMC cannot take this view, because it is committed, as the NHS and whole medical establishment is committed, to resisting the pointless demands of obsessive or deluded patients.

One example of such demands is that of a person suffering from a mental affliction known as ‘body integrity disorder’. Sufferers want healthy limbs amputated. It would be natural to say: such an amputation would not be medically or clinically justified. That claim, of course, makes use of the fact that medical/clinical judgements include judgements of value: the amputation won’t make the patient better off. However it is expressed, it is the doctor’s grasp of values, the value of health, and the purpose of medicine to advance human well-being, which enables him to resist requests to amputate healthy limbs.

The clinical/moral distinction, accordingly, collapses. PBMP tries to buttress the distinction by reinforcing it with a distinction between what is non-personal, and what is personal, and again between knowledge and mere belief. But none of these distinctions works in the way PBMP needs it to work.

However the distinction is understood it turns out to be irrelevant to the GMC's argument, as will emerge below.

The crucial part of the guidelines is paras 18-21, which tell doctors what they must do if a patient asks for a treatment the doctor does not judge appropriate (based on the doctor’s ‘personal beliefs’).

Para 19 tells us that doctors are not required to refer the patient to another doctor. On the other hand, ‘you must ensure’ the patient is capable of seeking another opinion; if the patient is not capable, para 20 tells us that the conscientious doctor must arrange for another doctor to take over the case, ‘without delay’. Finally, para 21 tells us that doctors opposed to certain procedures should inform their employers, so their employers can find a way to make sure the procedures remain available through other doctors.

I have shown that the clinical/moral distinction will not work. Doctors may and indeed must make all-things-considered judgements about what will benefit patients, as a basis for refusing to accede to patient demands, where those demands are misguided. The GMC might retort, all the same, that in such a case a patient has the right to a second opinion, and the doctor has the duty to facilitate the patient in seeking a second opinion. If another doctor may come to a different judgment, so be it.

Thus, if Doctor A regards a possible operation as so risky, and of such limited benefit to the patient, that it would not be right to perform it, and if the patient persuades Doctor B to perform it, then Doctor A can simply wash his hands of the matter. Presumably, Doctor B has made a different assessment of the risks and potential benefits, and thinks the operation justified.

It is this kind of case which PBMP seems to have in mind, to supply the principles to deal with conscientious objections: the principle that the patient’s right to a second opinion is paramount. However, this principle is only operative within a certain range of cases. Doctor A knows he has made a prudential judgment which other doctors whose judgment he respects may agree or disagree with. It is a different matter where a patient has asked for a procedure which is ruled out, not by a prudential judgment, but by a fundamental medical moral principle. If a patient asks for an unnecessary amputation, a doctor who refused might be sufficiently confident in his colleague's judgement that allowing the patient to seek a second opinion would do no harm. If he lacked that confidence, however, taking steps to assist the patient get a second opinion would be wrong, because it would be taking steps to violate the fundamental value of the medical profession, that medicine seeks the patient’s welfare. This patient is mentally ill, and seeking something which, if he recovers mentally, he will bitterly regret, which will cause him pain and loss of function, with no good effects at all, apart from the satisfaction of a disordered desire. This is not something a doctor should be assisting, even by referring the patient to another doctor.

Again, if a patient asks for a supply of psycho-active drugs for recreational use, a doctor who refuses should not refer the patient to another doctor for a second opinion, unless the first doctor had complete confidence in his colleagues’ probity. This would be so even if the law allowed doctors to supply such drugs for such purposes. As things stand, the law recognises that the patient’s good is more important than the patient’s wishes, and forbids doctors to cooperate with the giving of drugs for recreational purposes.

The problem, in the case of abortion, is that the wrongness of abortion, the fact that it is never in the interests of the patient, is no longer recognised by law, or by the medical profession as a whole. The fact remains, however, that from a conscientious doctor’s point of view, it is a case like that of the unnecessary amputation or the recreational drug use, and not like the risky operation. It should be contrary to the evaluative, medical judgment of a doctor to assist in or recommend or in any way to cooperate in an abortion. This problem is in part recognised by the ‘conscience clause’ of the Abortion Act itself, and by PMBP itself, where it wishes to force a conscientious doctor to refer a patient to another doctor only where, in the GMC’s view, this is absolutely necessary.

Clearly, however, PBMP still seeks to force doctors to cooperate with abortion, by assisting patients’ getting a second opinion. As I have argued, this would make sense if the doctors who refused to perform the operation did so from a prudential calculation which another doctor might re-evaluate in good faith. It is wrong to ask a doctor to act against his judgement when this judgement is based on a fundamental principle: that abortion can never be in the interests of a patient, all things considered.

Friday, May 25, 2007

What makes a Catholic institution?

Catholic charities of all kinds are ceasing to be so. In some cases they like to parade their Catholic 'heritage' when asking for Catholic money. It would be useful to have proper criteria for Catholic organisations, which we could use to weed out the fakes.

First: on claims to a Catholic 'ethos' or 'values'.

A charity can obviously claim to have a Catholic 'ethos', or say that it is founded and informed by Catholic values or a Catholic perspective. This will effect who wants to be a donor, a trustee, or a beneficiary. So although one might think that the mere claim to a Catholic ethos or Catholic values is a rather feeble effort for a 'Catholic' institution, actually it is of great significance, because the claim - on websites and so on - itself tends to create such an ethos. And it is amazing how many formerly Catholic charities decline to make such a claim.

Second: on cooperation with evil.

We need to go beyond this, of course, and say what effect Catholic values have on the running of the institution. So it would be reasonable to say, as a result of the ethos and values, there are certain things the charity will not do: obviously formal cooperation in intrinsically evil actions, but also proximate material cooperation in intrinsically evil (or gravely evil) actions. Catholic teaching gives us a list of intrinsically evil actions to use. So a Catholic institution wouldn't employ a person to expedite abortions (formal cooperation) or have a condom machine (proximate material cooperation). It might allow employees to misuse their freedom of speech to speak against the Church or the moral law, since this is a more distant material cooperation, but it would seek to minimise this and counteract the evil effects of it.

Third: on Catholic aims.

The second point is merely negative. So, the next step is to say that a Catholic charity is one which has Catholic aims. These would be of the form: 'To give glory to God by doing X.' X could be anything, but many formerly Catholic institutions would find it deeply embarrassing to put it like that in their self description, and I think that should rule them out. We can take it a step further and say: a Catholic institution is never concerned merely with the bodily or financial welfare of its beneficiaries (or staff), but also with their spiritual welfare. And then we can ask: what do you do to promote this spiritual welfare? The answer should include, I would suggest: by performing our tasks in the spirit of the service of Christ in the persons of our beneficiaries; by prayer in common; by marking the Church's seasons and feasts; by having Mass said in or specifically for the institution at least several times a year.

None of this will get anyone into trouble with the non-discrimination or harassment laws. But it would make for a genuinely Catholic institution.

Tuesday, May 15, 2007

Referrals and the Sexual-Orientation Regulations

In the recent debate concerning the Sexual-Orientation Regulations and adoption agencies the Roman-Catholic Church asserted that its adoption agencies would have to close if the Regulations were adopted on the grounds that it would be impermissible to place children for adoption with two gay parents even though that is what the Regulations would demand. The curious thing is that agencies such as the Catholic Childrens' Society were already, even though not forced so to do by law, referring gay couples wishing to adopt to other agencies. But if it is wrong to place children for adoption with gay couples surely it is wrong to refer gay couples to agencies that will place children with them?

Referrals Again

On an 80s comedy programme On the hour a comedian rang up Conservative Central Office pretending to have a story about Neil Kinnock behaving badly. Central Office said that they were not prepared (presumably for moral reasons) to handle the story, but suggested he take the story to The Daily Mail. But if it is morally unacceptable to handle a story surely it is morally unacceptable to suggest that the peddler take it to another place?

Monday, May 14, 2007

Referrals for Abortions

Dr Ian Sapsford, a Torquay GP, has written letters to several Christian periodicals, asserting that 'The National Health Services Act imposes on Christian doctors an obligation to sin against God while at work'. He explains:
We breach this law if we fail to provide a pregnant woman with an abortifacient pill, or refuse to refer her for an abortion (or to another doctor whom [sic] we know will do so).
The National Health Service Act 1977 Section 29 says:
(1) It is every Area Health Authority's duty, in accordance with regulations, to arrange as respects their area with medical practitioners to provide personal medical services for all persons in the area who wish to take advantage of the arrangements.
(2) Regulations may provide for the definition of the personal medical services to be provided and for securing that the arrangements will be such that all persons availing themselves of those services will receive adequate personal care and attendance, and the regulations shall include provision
(a) for the preparation and publication of lists of medical practitioners who undertake to provide general medical services;
(b) for conferring a right on any person to choose, in accordance with the prescribed procedure, the medical practitioner by whom he is to be attended, subject to the consent of the practitioner so chosen

There does not seem to be anything contrary to this in the National Health Service Reform and Health Care Professions Act 2002 or the National Health Service Act 2006. It seems that Dr Sapsford is wrong in thinking that this is the law.

In fact, there is an explicit exception for those with conscientious objections in the Abortion Act 1967

§ 4 Conscientious objection to participation in treatment

(1) Subject to subsection (2) of this section, no person shall be under any duty, whether by contract or by any statutory or other legal requirement, to participate in any treatment authorised by this Act to which he has a conscientious objection:

Provided that in any legal proceedings the burden of proof of conscientious objection shall rest on the person claiming to rely on it.

(2) Nothing in subsection (1) of this section shall affect any duty to participate in treatment which is necessary to save the life or to prevent grave permanent injury to the physical or mental health of a pregnant woman.

Nevertheless, the GMC adds (and this may be what is worrying Dr Sapsford):

  1. If carrying out a particular procedure or giving advice about it conflicts with your religious or moral beliefs, and this conflict might affect the treatment or advice you provide, you must explain this to the patient and tell them they have the right to see another doctor. You must be satisfied that the patient has sufficient information to enable them to exercise that right. If it is not practical for a patient to arrange to see another doctor, you must ensure that arrangements are made for another suitably qualified colleague to take over your role.

This is what the BMA says:

Doctors with a conscientious objection to abortion should make their views known to the patient and enable the patient to see another doctor without delay if that is the patient's wish.

A spokesman for the Department of Health quoted in The Daily Mail for 3rd May 2007 said: "If GPs feel their beliefs might affect the treatment, this must be explained to the patient who should be told of their right to see another doctor."

What does 'ensure that arrangements are made' mean? And what does 'enable' mean? Is it permissible to ensure that arrangements are made for a patient seeking an abortion to be seen by a doctor that will grant her what she seeks? If it is immoral to sell guns to drunks would it be permissible to ensure that arrangements are made for the drunks to see a gunsmith without scruples? Would it be permissible merely to inform the drunk of the whereabouts of a gunsmith without scruples? Would it be permissible merely to inform the drunk that he could go elsewhere? I guess as follows: no, no, no, yes.

I was interested to read about the case of Janaway v Salford Health Authority in 1988 when a doctor's secretary (Janaway, a Roman Catholic) was sacked for refusing to type a letter of referral. The courts held that ‘the task asked of Janaway did not constitute participation in the actual abortion procedure’. (I can see that the case is referred to in a 1988 edition of Law and Justice: The Christian Law Review by one David Poole, but that is all I know about it.) Is typing a letter of referral permissible? I'm inclined to think not; one is co-operating in evil, albeit without intending that the evil be done. Those Germans that typed letters about the movement of Jews in WWII may not have committed a legal offence, but surely they are morally guilty of aiding and abetting a terrible crime?

One final point: I think that it is impermissible to perform an abortion even to save the mother's life. Is it then morally permissible to be a doctor? I regretfully think not: in becoming a doctor (at least of a certain sort: obs and gyny, and perhaps even a GP) one would be accepting a duty that one couldn't morally discharge. Of course, it is (thankfully) very rare that such a duty would arise, but surely it is immoral to accept a duty knowing one could not discharge it?

Tuesday, February 27, 2007

'Morphine cases'

'Morphine cases' are an established part of the philosophical debate on double effect. It is worth reminding ourselves that medical practice has moved on from the kind of case philosophers have in mind, which in described by the Rev Billings in the radio talk described below. Hat-tip to 'Care not Killing'.

The use of Morphine

"We remain deeply concerned that some media reports are giving the misleading impression that doctors are administering morphine to dying patients in the knowledge that it will kill them.

The latest of these came on Radio Four's 'Thought for Today' on 23 February, when the Rev Dr Alan Billings, Director of the Centre for Ethics and Religion at Lancaster University, addressed the case of Kelly Taylor, a 30 year old woman, who is currently seeking legal permission to be heavily sedated with morphine and then dehydrated until she dies.

In the broadcast, Rev Billings referred to the so-called 'double effect' of high doses of morphine – a misconception that has become pivotal in Kelly's case. He said, 'Every day we allow doctors to end the lives of some people by making a distinction between intention and outcome. A doctor increases the morphine of a terminally ill person in great pain to the point where they die. The morphine kills. That's the outcome, but the doctor is not thought culpable because his intention is the relief of pain, not the death of the patient.'

Rev Billings here was expressing two popular misconceptions about morphine: that it frequently ends the lives of terminally ill people, and that it causes sedation when given in doses necessary to relieve pain. We strongly refute the statement that doctors are ending lives by giving their patients large doses of morphine to control pain.

Morphine, if deliberately given in very high doses to people who are not in pain, does cause respiratory depression and death. It was indeed the drug used by Dr Shipman to kill his victims, and this has undoubtedly heightened public anxiety about its use. However, when correctly used to relieve pain in a patient who is terminally ill, morphine should never cause death. By contrast it usually lengthens life and improves its quality. This is because the therapeutic dose of morphine, which relieves pain, is virtually always well below the toxic dose which ends life and because the relief from pain which it brings removes stress factors in the patient's condition. In addition, toxic doses risk causing increased agitation in some patients- hardly what is intended by those advocating this approach. In modern medicine, and especially in palliative medicine, doctors can kill the pain without killing the patient.

So-called 'terminal sedation' is very rarely necessary; and when it is, it is used to control severe agitation, rather than physical pain, in patients whose conscious level is diminished by their illness. Even when used for the management of agitation, it is very seldom necessary to sedate any patient continuously until they die, but usually only for periods of 12 or 24 hours at a time. Whatever the circumstances, morphine is not the drug of choice used for this sedation since sedation wears off rapidly, which is good for patients taking it for pain relief, but it makes it a poor sedative."

The same mismatch between philosophical examples and medical practice applies to the 'craniotomy case': the procedure at issue (crushing the head of a baby during childbirth in order to remove it quickly from the birth canal) is simply no longer used. The really 'hard' cases often turn out to extremely rare. It is unclear, for example, whether a 'therapeutic' abortion would ever be needed to save the life of a mother.

Philosophers usually aren't medically qualified, and for us an imaginary situation is as good as a real one, for the purposes of testing intuitions and proposed policies. But perhaps we should be more careful about allowing pro-abortion medical myths publicity.

Sunday, February 04, 2007

Marriage, anulments and liturgy

(The following has been published by CFNews, here. For a report on the Pope's speech, see here.)

This week's Catholic Herald carries a front-page story on a recent speech by the Pope condemning over-easy annulments. In part:

In a speech to the Roman Rota, the Church’s highest court of appeal for annulments, the Pontiff pointed to a “crisis” in the way marriage was understood.
He said that Catholics and even tribunal judges were affected by the secular idea of marriage as merely the “formalisation of emotional bonds”.
In “some ecclesiastical realms” this idea has caused annulments to be granted for the sake of the couple’s well-being rather than because the marriage was invalid.
“The crisis over the meaning of marriage has affected the way many faithful think,” the Pope told judges and officials of the Roman Rota last Saturday. “The indissoluble conjugal bond is denied because it’s treated as an ideal that cannot be made ‘obligatory’ for ‘normal Christians’.

The Pope has correctly identified a specific misunderstanding of marriage as a cause of the decline in the ability of marriage tribunals' capacity to apply the correct principles to determining the validity of marriages. The misunderstanding is the replacement of the notion of the 'indissoluble marriage bond', as the central concept of marriage, with the notion of a 'formalisation of emotional bonds'. It seems clear that the same false understanding of marriage is behind the decline of marriage itself: in fewer people being willing to make the commitment of marriage, and ever more people who have married, getting divorced.

Where might we find such a view expressed? Well, here is the opening prayer of the revised marriage ceremony, promulgated in 1969:

"Dear friends, you have come together in this church so that the Lord may seal and strengthen your love in the presence of the Church's minister and this community. Christ abundantly blesses this love. He has already consecrated you in baptism and now he enriches and strengthens you by a special sacrament so that you may assume the duties of marriage in mutual and lasting fidelity. And so, in the presence of the Church, I ask you to state your intentions."

Now look at the Latin:

Dilectíssimi nobis, in domum ecclésiæ convenístis, ut volúntas vestra Matrimónium contrahéndi coram Ecclésiæ minístro, et communitáte sacro sigíllo a Dómino muniátur. Amórem vestrum coniugálem Christus abúnde benedícit et ad mútuam perpetuámque fidelitátem et ad cétera Matrimónii offícia assuménda eos peculiári ditat et róborat Sacraménto, quos ipse sancto iam Baptísmate consecrávit. Quare vos coram Ecclésia de mente vestra intérrogo. (For the full texts, see here.)

There are many problems with the translation, but let's just look at the key phrases:

you have come together in this church so that the Lord may seal and strengthen your love in the presence of the Church's minister and this community.

in domum ecclésiæ convenístis, ut volúntas vestra Matrimónium contrahéndi coram Ecclésiæ minístro, et communitáte sacro sigíllo a Dómino muniátur.

The highlighted Latin phrase means literally '[you've come together so that] the Lord my establish the sacred bond [of matrimony]'. The official translation has removed the notion of matrimony as a sacred bond, established by the Lord, and replaced with the notion of the couple's love merely being strengthened by the Lord. In other words, the correct view of marriage, as an indissoluble bond, is expressed in the Latin, but in the English this view has been replaced by the false view, that marriage is the formalisation of an emotional bond.

So what is His Holiness saying? That the view of matrimony put forward in the scandalously inacurate official English translation of the new order of matrimony is responsible for a misunderstanding of marriage among even the higher echelons of the Church, which has dangerously undermined the institution of marriage itself.

Posted by Joseph Shaw

Wednesday, January 10, 2007

Christ King of Poland?

Daniel writes: What do you think? Would you consider this part of the ideal state? (A small group of Protestants, the Reformed Presbyterians, refused to go along with the British Revolutionary Settlement in 1688 because it made no reference to Jesus as King, interestingly. They are still active today, though I think they are now allowed to vote etc.)
> ** Polish MPs bid to make Jesus king **
> A group of Polish MPs submit a bill seeking to proclaim Jesus Christ king of their country - a move criticised by clerics.
> <>

Respondeo: Yes, I saw that. Also that the Polish bishops aren't keen. It's a nice idea, and it can be done in a number of ways. There was a huge fight before the Revolution in France about consecrating France to the Sacred Heart. The King finally did it, by Royal Decree, at a very late stage. A similar fight is going on about consecrating Russia to the Immaculate Heart of Mary. The people opposed to all these moves want to keep religion out of the public domain. Including the Polish bishops, unfortunately.

Declaring Christ King seems particularly appropriate, and it's suprising that it's not been done before. However I think that it was taken for granted in the Christian monarchies: the king receiving his crown from God etc., as depicted in ceremonial and art. God was always the King of Israel, as I understand it, and the human king a kind of deputy, just as the Pope is Christ's deputy as Head of the Church.

(When Henry VIII made himself Head of the Church of England, he wasn't just usurping the role of the Pope, but of Christ. As Elizabeth seemed to realise; at least she rejected that title.)

It's very interesting about the Presbyterians.

Oral contraceptives as abortifacients

Daniel Hill writes: "I have been discussing with a friend the possibility that the oral contraceptive pill functions as an abortifacient. See, e.g.,: The Growing Debate About the Abortifacient Effect of the Birth Control Pill and the Principle of Double Effect by Waltet Larimore, MD <> Ethics and Medicine (January, 2000;16(1):23-30)

A condensation of the booklet Does the Birth Control Pill Cause Abortions? <>

Since I don't rule out contraception in general, but do rule out abortion, this is of great interest and concern to me. It may be of less interest to you, but this friend also argued that it was impermissible for somebody using NFP to drink coffee, since coffee can (he said) kill a newly fertilized egg (and, indeed, a foetus). Further, since, he went on, coffee affects the ovum, whether fertilized or not, he argued that it was impermissible for a woman ever to drink coffee (pre-menopause) since she would run the risk of damaging her ova in such a way that when fertilized they would not implant, and, hence, that one would be indirectly (though of course unintentionally) bringing about the death of a fertilized egg, should one later become sexually active.

Have you come across these arguments before? How should one respond to them?"

Respondeo: First, I take it that it is uncontroversial that the conventional 'pill' can act as an abortifacient. A similar thing is true of the 'Morning After Pill': that it can prevent fertilisation, but it also works by preventing implantation. If you take the thing after sex has occurred, the chance of it working (if it works) contraceptively, rather than by causing an abortion, is reduced, and continues to fall as time goes on.

I don't see what NFP has got to do with it.

But the coffee issue is less complicated that it looks. It is conceivable (though highly unlikely) that a woman is drinking coffee in order to cause an abortion, or to mutilate herself with a view to reducing her fertility. That would violate the prohibitions on intending those things.

But if not, then it is simply the familiar question: how much care must a (potentially) pregnant woman take over her health? And the answer is: be reasonable! If drinking coffee increases the chance of miscarriage only by some tiny per cent, and a woman regards giving up as a serious inconvenience, then she's under no obligation to give up. If the danger is significant and the inconvenience small, then she should give up. The same is true of crossing the road.

As it happens I've not heard that about coffee. But every other thing is supposed to be bad for pregnant women, and it's becoming absurd. What is really the worst thing for them, IMHO, is to turn them into neurotic invalids, but that's another story...

What is tricky is whether women taking chemicals advertised as 'contraceptives' ('emergency' or not) are guilty in any sense of abortion. Anyone who cares about it will find out quickly enough that taking those things act as abortifacients, but that doesn't settle the question of whether they intend them to act as such. They may, of course, but if they don't then there's still the wrongdoing of recklessness with an innocent life which the agent in question has a particular duty to protect.

Hope that helps.

Saturday, January 06, 2007

Absolute prohibitions

Daniel Hill draws my attention to a Jewish moralist's summary of moral absolutes - things one can never do under any circumstances at all - as a very short list: murder, apostasy, and one or two other things (I think). Can the Catholic tradition produce a similar, neat list?

It looks as though it should be able to. There is a healthy debate on whether lying is forbidden absolutely, or only in certain circumstances. Killing the innocent is clearly prohibited absolutely, as is apostasy. So where's the list?

The problem (if it is a problem) is that Catholic moralists seem to want every prohibition, or at least as many as possible, to be absolute. So, faced with a situation in which a certain class of actions is permissible in some circumstances, and not in others, the tendency is to define a sub-set as being forbidden in all circumstances. So, with lying, for example, we have the taxonomy of officious, jocose and malicious; the last is absolutely forbidden; the jocose lie is not forbidden at all (or at least not on pain of mortal sin), and we can go on arguing about the officious one, but it's probably absolutely forbidden too.

Similarly, to argue that in some cases (the 'starving man and the rich man's surplus') theft is permissible, turns into an argument in favour of a narrower definition of theft, with the starving man case excluded from it, which is absolutely forbidden.

Is this a good or a bad methodological tendency? Although it seems confusing, I think it is the inevitable consequence of two good things. First, it derives from an attempt to cover every case in a clear way. Jewish casuistry is equally interested in hard cases as Catholic casuistry, but is less interested (as far as I can see) in reducing the casuistical analysis to a statement of principles. (Ie to say: now we've got a set of cases where the act is wrong and a set where it is right, what exactly is the principle dividing them?) With the ultimate focus on specific morally relevant principles, rather than more general principles with a set of exceptions, you end up with more moral absolutes.

Second, the role of intention (as usual!) has a role here. The concept of intention makes it possible to produce these plausible and specific moral principles, since the intention of each kind of harm to another is something which can be absolutely forbidden. The exceptions to rules such as 'do not kill' mostly turn out to be cases in which the killing is not intended.

In dealing with non-intended harms there is, instead of an absolute prohibition, the principle of proportionality.

In conclusion, one could say (although the manualists don't talk like this) that there is just one absolute prohibition in Catholic ethics: do not intend harm. And one non-absolute restriction: do not cause foreseen and disproportionate harm. (Plus there are positive duties, such as the duty of worship and obedience to God, and the duty of aid to our neighbour.) Since the question of what is 'harm' in the necessary sense is a controversial one, it is more usual to specify the absolute restrictions as: do not intend deaths, losses of property, etc., each of which has a sister-principle limiting non-intended harms of that kind by the principle of proportionality.

Secularism and state neutrality

Christianity and the ‘non-confessional state’. (This was published by CFNews: see here.)

Philip Trower, in his 2004 article for Catholic World Report included in the 4th Jan CFNews bulletin, argues that the rise of militant secularism – evidenced by the rigorous exclusion of religious language and symbolism from public life, for example – derives from the collapse of the ‘non-confessional state’, a state which does not prefer one religion to another, into a ‘secularist state’, a state in which a set of avowedly non-religious values, centering around humanism and hedonism, are given official status. This is a kind of confessional state, in which what the state confesses is a secularism which has become a substitute religion.

Trower’s diagnosis is certainly correct. What I cannot, however, agree with is the prognosis: the implication of his article that what is needed is a return to a non-confessional state, and that the process by which non-confessional states have become secularist states is based on a ‘misunderstanding’. If only, he implies, politicians and others understood the distinction properly, then we would not have the problem of militant secularism being imposed on us by the state. State schools could go on having nativity plays, etc. etc..

The problem is that there is a deep confusion in the very notion of a non-confessional state. Such a state is supposed to be neutral on controversial, value-laden issues, notably about which religion is correct. So how, in such a state, should human biology, or the history of the Reformation, be taught? What textbooks should be used? The problem is not that these are difficult questions, but that if the state has no controversial or religious values of its own, it will have no basis upon which to make the decisions.

Again: which religions and churches should be accorded charitable status, and for what faith groups should military chaplains be provided? The Taliban? Scientologists? Satanists? How is the state to determine that question, if it has no theological values?

The answer given by political theorists friendly to the idea of a ‘neutral state’, is that without reference to controversial, value-laden religious claims, the state can conduct its affairs by reference to what all reasonable people agree about: basic rationality. Everyone wants food on the table and a roof over their heads, and so on. This quickly reveals itself to be a form of reasoning that does not simply leave to one side the question of which religion is true, but assumes that they are all false. For if the only thing the state takes into account is our material needs, then it is acting as if we had no other needs at all: it has de facto adopted materialism as a substitute religion. The form of ‘rationality’ here, of course, is far from uncontroversial, and carries with it the potential to turn a non-confessional state into a secularist one. This problem has been explored at length by Alastair MacIntyre’s appropriately named book: ‘Whose Justice? Which Rationality?’

The same thing has been forseen in a different way by Edward Norman, in his book ‘Secularization’, where he points out that the non-confessional state is not the stable end-point of a political development, but is simply a transitional phase, when the dominant religion has lost the power or the will to impose itself on the state, but is still too strong to be ignored completely. The rising set of values which will soon be, and in many ways already is, the official creed of the state, is secularism.

The fact is that the state cannot do without values. Political judgments, judgments about the relative merits of educational philosophies or medical treatments, can only be made with the help of values. A non-confessional state inevitably gravitates towards a set of humanistic, hedonistic and secular values, because any move in any other direction will be attacked as giving one religion priority over another.

Catholics and members of other religions have to be clear about this. The goal of their political engagement is not to push the state back into the untenable position of making decisions neither on the basis of Anglicanism nor on the basis of any other coherent set of values or world view. That would be an absurd and Quixotic project. No: our aim is to get the state to make decisions on the basis of what we believe to be the correct values and world view. Sterlising the disabled makes sense if traditional, religiously inspired moral values are set aside in favour of hedonism and materialism. In opposing something like this, we are trying to get politicians and the general public to see that hedonism and materialism are inadequate, and that our own values are superior. We are pushing them, however feebly, towards a confession of the Truth, the only basis upon which correct judgments about how to promote the Common Good will be made.

Joseph Shaw