Colgrove N. J Med Ethics November 2019 Vol 45 No 11 Responding (appropriately) to religious patients: a response to Greenblum and Hubbard's 'Public Reason' argument Nick Colgrove ABSTRACT Jake Greenblum and Ryan K Hubbard argue that physicians, nurses, clinical ethicists and ethics committee members should not cite religious considerations when helping patients (or their proxies) make medical decisions.i They provide two arguments for this position: The Public Reason Argument and the Fiduciary Argument. In this essay, I show that the Public Reason Argument fails. Greenblum and Hubbard may provide good reason to think that physicians should not invoke their own religious commitments as reasons for a particular medical decision. But they fail to show that it is wrong for physicians to cite the patient's own religious commitments as reasons for a particular decision. As such, if Greenblum and Hubbard's thesis is to survive, the Fiduciary Argument (or some unmentioned argument) will have to do the bulk of the work. INTRODUCTION Jake Greenblum and Ryan K Hubbard argue that physicians, nurses, clinical ethicists and ethics committee members should not cite religious considerations when helping patients (or proxies) make medical decisions.1i Even if a patient claims that a religious tenet is relevant to her decision-making process, physicians should not 'engage'. That is, physicians should not cite the tenet as relevant to the decision-making process, debate with the patient over the meaning (or application) of the tenet, nor cite alternative religious tenets that may affect the patient's decisions. Patients who insist on discussing religious considerations should be referred to an appropriate expert (eg, a chaplain).ii Greenblum and Hubbard give two 'logically distinct' arguments for their position: The Public Reason Argument and the Fiduciary Argument. In this essay, I argue that the Public Reason Argument fails.iii First, I identify the target of the argument-the 'dominant view'-before discussing (and responding to) the Public Reason Argument itself. I conclude that if physicians have 'no business' discussing religious considerations when helping patients make decisions, it is not because of the Public Reason Argument. The 'dominant view' Greenblum and Hubbard reject the 'dominant view' that, 'physicians should engage with patients on the patient's or physician's own substantive religious grounds if the patient cites religious considerations during the process of deliberation'.1 The dominant view, therefore, is a disjunction of two statements: A. Physicians should engage with patients on the patient's own substantive religious grounds if the patient cites religious considerations during the process of deliberation. B. Physicians should engage with patients on the physician's own substantive religious grounds if the patient cites religious considerations during the process of deliberation. To succeed as a standalone argument, the Public Reason Argument must show that both A and B are false. After all, refuting a disjunction requires showing that both of its disjuncts are false. So, if the argument undermines A but not B (or vice versa) it fails to undermine the dominant view. The Public Reason Argument The Public Reason Argument proceeds as follows: 1. Public employees (eg, lawmakers) should 'cite only public reasons in their capacity as professionals'. 2. Physicians are 'relevantly akin to public employees'. 3. Hence, physicians should cite only public reasons in their capacity as professionals. Public reasons are 'non-sectarian reasons' or 'considerations that any reasonable person could recognise as counting in favour of something', regardless of differences in 'ethical outlooks'.1 A public reason for reducing carbon emissions, for example, is that 'clean air is necessary for the public's health'.1 Lastly, public reasons are said to be 'grounded in brute normative intuitions or shared social values'.1 Whether or not there are public reasons is controversial (not to mention claims that these reasons are grounded in 'brute intuitions or shared social values' and are accessible to any 'reasonable' person).iv I will ignore those concerns, however. The Public Reason Argument still fails because Premise 2 is false. Akin, but not relevantly There may be ways in which physicians are akin to public employees, but not in relevant ways. Lawmakers-the paradigmatic example of public employees for Greenblum and Hubbard-advance policies that apply to morally pluralistic groups of people. When making decisions for a diverse population, it makes sense to restrict deliberations to public reason (ie, reasons that can be acknowledged by all to whom the relevant decisions apply). A patient is not a morally pluralistic group of people. A patient is a singular person. When helping a patient make a decision, physicians are not instituting policies for a plurality of persons. So, they need not rely on reasons that would appeal to a diverse population. When citing reasons for a decision, physicians need only cite reasons that the patient finds acceptable (or, at least, understandable). These reasons may even include religious considerations (at least when a patient herself cites them as relevant). Whether or not the cited reasons are acceptable (or understandable) to other patients is irrelevant. The decision being made is not binding for other patients. Thus, physicians and lawmakers are not relevantly alike. Jarring Assertions and Social Norms Greenblum and Hubbard provide two other cases in defence of the Public Reason Argument. First, a patient described as 'a devout Hindu', complains of chest pain. After inferring that the patient may have lung cancer, the physician, Dr. Chatterjee, Commentary Philosophy, Baylor University, Waco, Texas, USA Correspondence to Dr Nick Colgrove, Philosophy, Baylor University, Waco, TX 76798-7151, USA; nick_ colgrove@ baylor. edu i Following Greenblum and Hubbard, I will use 'physician' to refer to all of these professionals. ii Thus, religious considerations are not banned from the decision-making process. Greenblum and Hubbard simply advocate a 'division of labour' between experts.1 iii For the sake of space, I cannot respond to the Fiduciary Argument here. iv See works by Engelhardt, MacIntyre, Enoch and Mang for a small sample of objections.2–7 Quong provides an overview of the debate regarding public reason as well.8 C enter Blvd. Protected by copyright. on M ay 24, 2020 at Bow m an G ray School O f M edicine M edical http://jm e.bm j.com / J M ed Ethics: first published as 10.1136/m edethics-2019-105678 on 1 August 2019. D ow nloaded from 717Colgrove N. J Med Ethics November 2019 Vol 45 No 11 Commentary v See Grice's work for a well-known account of conversational norms.9 tells the patient 'that there is a new and medically promising lung cancer treatment available...and then adds that since Lord Shiva urges us to purify our bodies' the patient 'should take advantage of the treatment'.1 Dr. Chatterjee's assertion is jarring, Greenblum and Hubbard argue, because 'it is not her place to offer religious considerations in the doctor's office'.1 Yet, Greenblum and Hubbard fail to frame the case properly. The dominant view states that 'physicians should engage with patients on ... substantive religious grounds if the patient cites religious considerations during the process of deliberation'.1 It does not mention cases in which patients do not cite religious considerations. Dr. Chatterjee's patient makes no mention of his faith. Thus, it is jarring when Dr. Chatterjee suddenly starts talking about religious tenets. Dr. Chatterjee's assertion would be far less jarring had it been made after the patient himself mentioned the relevance of his faith to his decision-making process. Imagine a revised case: After the patient describes his faith as providing him with a reason to promote bodily health, Dr. Chatterjee responds by describing available treatment for lung cancer and adds, "Since you see your faith as pushing you towards treatment, you have all the more reason to do it." If Greenblum and Hubbard are correct, then this assertion should be just as jarring as the original case. On their view, whether the patient has mentioned religious considerations or not, it is not the physician's 'place' to cite religious considerations. But I expect the revised case is not as jarring to the reader. If that is right, then we need an explanation for why the original case is jarring, but the revised case is not. Possibilities abound. Perhaps Dr. Chatterjee violates some conversational norms in the original case (but not the revised case) by introducing unprompted or extraneous information into the conversation.v Or maybe she violates some social norms (matters of etiquette, not morality) in the original case, by assuming the patient's religion is relevant to his decision-making process without his having said it is. Plausibly, this is a kind of assumption that nobody (physician or otherwise) should make when speaking with a stranger. Whatever the case, Greenblum and Hubbard's explanation faces two problems. First, there are many competing explanations for why readers will find Dr. Chatterjee's assertion to be jarring. On alternative explanations, some violation of conversational (or social) norms occurs and that violation is sufficient to explain why the assertion is jarring. Thus, we need not grant that the assertion is jarring because the physician is 'overstepping' her place.1 Second, an implication of Greenblum and Hubbard's view is that the revised case will be just as jarring as the original case. That seems false. If so, then alternative explanations-which explain why Dr. Chatterjee's assertion is jarring in the original case but not in the revised case-fit the data better than Greenblum and Hubbard's explanation. The instructor analogy: an incomplete response The second case that Greenblum and Hubbard use to defend the Public Reason Argument compares physicians to instructors at public universities. Specifically, a student seeks academic advice from an instructor. Since 'the site of the exchange is public...it would be inappropriate for the instructor to give the student academic advice based on the instructor's religion'.1 Analogously, if patients seek medical advice, it would be wrong for physicians to make recommendations based on the physician's own religion. This challenges Statement B, but not Statement A. To challenge A, the case must be rewritten. The revised case should specify that the student cites her own religious perspective as relevant to her decision. Greenblum and Hubbard would then have to show that the instructor would be wrong to cite that perspective as relevant. Since they fail to do so, however, the instructor analogy undermines Statement B (at most), leaving Statement A-and, therefore, the dominant view-intact. CONCLUSION The Public Reason Argument fails as a response to the dominant view. As such, the Fiduciary Argument (or some unmentioned argument) must bear the weight of supporting Greenblum and Hubbard's thesis. Whether or not the Fiduciary Argument is up to the task is a question I leave for another time. Acknowledgements I am grateful for comments from Derek McAllister on this project. Contributors NC is the sole author of this essay. Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Competing interests None declared. Patient consent for publication Not required. Provenance and peer review Not commissioned; internally peer reviewed. © Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ. To cite Colgrove N. J Med Ethics 2019;45:716–717. Received 3 July 2019 Accepted 12 July 2019 Published Online First 1 August 2019 ► http:// dx. doi. org/ 10. 1136/ medethics2019105452 ► http:// dx. doi. org/ 10. 1136/ medethics2019105790 J Med Ethics 2019;45:716–717. doi:10.1136/medethics-2019-105678 ORCID iD Nick Colgrove http:// orcid. org/ 000000030506353X REFERENCES 1 Greenblum J, Hubbard RK. Responding to religious patients: why physicians have no business doing theology. J Med Ethics 2019:medethics-2019-105452. 2 Engelhardt HT Jr. The foundations of bioethics. 2nd Edition. New York: Oxford University Press, 1996. 3 Engelhardt HT Jr. Global Bioethics: an introduction to the collapse of consensus. Engelhardt HT, ed. Global bioethics: the collapse of consensus. Salem, MA: M&M Scrivener Press, 2006. 4 MacIntyre A. Whose justice? which rationality? Notre Dame, IN: University of Notre Dame Press, 1988. 5 Enoch D. The disorder of public reason. Ethics 2013;123:147–76. 6 Enoch D. Against public reason. 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