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What does the character of medicine as a social practice imply for professional conscientious objection?

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Abstract

The dispute over professional conscientious objection presumes a picture of medicine as a practice governed by rules. This rule-based conception of medical practice is identifiable with John Rawls’s conception of social practices. This conception does not capture the character of medical practice as experienced by practitioners, for whom it is a sensibility or “form of life” rather than rules. Moreover, the sensibility of medical practice as experienced by physicians is at best neutral, and at worst hostile, to the demands of those who would override physician conscientious objection to the provision of currently contested services. That being so, calls for overriding physician conscientious objection are much more demanding of the medical profession than they appear in light of Rawls’s view. As such overriding may entail the forcible transformation of medicine’s form of life, the author contends that it would be more prudent to provide contested services by circumventing the medical profession than by compelling it.

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Notes

  1. Robert Card and Mark Wicclair respectively rely on tests of reason and conformity to core professional obligations as criteria for evaluating conscientious objections. See [5] and [6, ch. 3].

  2. The following discussion, as will be evident, is deeply indebted to Michael Thompson’s explication of Rawls in [14, ch. 10].

  3. As has been pointed out by, among others, H. Tristram Engelhardt, Jr. in [17, pp. 320–325].

  4. Practical holism is the view that while understanding “involves explicit beliefs and hypotheses, these can only be meaningful in specific contexts and against a background of shared practices.” Stern [18, p. 188] quoting Hubert Dreyfus.

  5. Wittgenstein [12, pp. 185–219]. The central rule following passages in [12] are pp. 185–242. See also [13, p. 3].

  6. See Thompson [14, ch. 11] for a defense of the suggestion that the unity of practices is analogous to that of a life form.

  7. As per William Osler: “To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all” in [23, p. 220].

  8. For contemporary defenses of the distinctiveness of knowing how from knowing that and of the indispensability of knowing how for practical action, see P.M.S. Hacker [24, ch. 4] and David Wiggins [25].

  9. See [26]; the ensuing discussion is indebted to my more extensive treatment of these issues in [27].

  10. That is, in the case of the two most controversial services, abortion and physician-assisted death.

  11. In 2005, 80% of US abortions were performed by the 22% of abortion providers who did 1000 or more abortions that year [34, p. 12, Table 4].

  12. Jonathan Imber documented this phenomenon in his important study [36].

  13. Surveys up to the year 2000 summarized by Emanuel suggested that while two-thirds of the American public supported PAS, surveys of physicians rarely revealed support as high as 50% and willingness to participate was much lower. Oncologists were less willing to participate than were other physicians [37]. Recent Medscape surveys put physician support for the availability of PAS at 54% [38]. Support of PAS by medical students has been higher in some surveys, e.g., [39]. A 2003 survey of members of Britain’s Association for Palliative Medicine revealed 92.6% of members to be opposed to legalization of PAS [40].

  14. For reasons of space and focus, the constraint against killing patients professed by American medical organizations and the majority of American physicians, which I contend is often experienced as a deontological constraint, an aspect of the sensibility of medical practice, cannot be defended here. It is enough for my purposes to note that its validity is an open question.

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  1. Division of General Internal Medicine, UAB School of Medicine and the Birmingham VA Medical Center, University of Alabama at Birmingham, FOT 744, 1530 3rd avenue South, Birmingham, AL, 35294, USA

    Thomas S. Huddle

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Huddle, T.S. What does the character of medicine as a social practice imply for professional conscientious objection?. Theor Med Bioeth 38, 429–445 (2017). https://doi.org/10.1007/s11017-017-9426-8

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