This piece was written in response to an article in the BMJ by the Oxford philosopher Julian Savulescu. I really didn’t like what he had to say at all. I thought his argument to be poorly constructed, and the position he reached (or perhaps started out from) to be repellent and dangerous. Here is a link to my rapid response to the BMJ, published on the 2nd of February 2006: Conscience is our Safeguard I don’t know why the formatting is so shoddy when you get there. It doesn’t make it any easier to read, so I have pasted it here for ease of reading. If it was due to my error in the original submission, then my apologies to the BMJ:
Strolling through woods, my friend asked me “is that normal?” and seemed astonished when I replied, “Is that question even relevant?” We were talking about thoughts, feelings, experience – I can’t remember, now, exactly which. In any case, I have been asked that question, or variants of it, so often. We seem to be obsessed with normality; strange when in so many areas of life we are busy deconstructing the notion.
So here is my theory. Normality is an idea that stems from the herd. Herd behaviour is primitive, instinct-driven, and designed to ensure the survival of the group at the expense, if necessary, of the outliers. The slowest, or those on the fringes, can be sacrificed to the group cause; picked off by predators or extreme conditions.
Two things follow.
- The individual, when the group is operating at this primitive level, becomes anxious if they find themselves at the back, or off too far to one side. “Am I normal?” becomes a proxy for “am I safe?”
- The group, when under pressure, will expend less energy supporting individuals on the fringes and may even push them further to the edge, since their value to the group lies chiefly in their expendability.
And this is how insecurity leads to Stigma:
- We are generally placid as long as things continue as they always have (and provided our basic needs, at least, are met). But if something out-of-the-ordinary arrives we are challenged, and the degree of challenge depends on the extent to which we feel insecure. If something unfamiliar turns up in my experience or in my group, I may welcome it if I am feeling secure, but if I am feeling insecure I shall be suspicious of it.
- Because, in the latter instance, novelty is unwelcome, I do not want the group to associate me with it. If they do – if I run next to this individual – then the group may sacrifice me also, in the interests of its survival. The unusual person – near the rim of the bell-shaped curve – is at the fringe and expendable; a target for predation or a low priority for succour – so the further I am from them the better.
We have developed an attachment to “normality” and when our attachment behaviours are activated this can contribute to stigma and marginalisation.
- An insecure group will tolerate difference less; will stigmatise it more; will be happier to see it suffer and disappear.
- A secure group – one in the mood for exploration and discovery rather than survival – will be more likely to welcome difference in its midst, as a possible new resource .
- To decrease stigmatisation of minorities, maybe we need not to attack the perpetrator more, but somehow reduce their sense of insecurity.
When we find ourselves asking “is it normal?” we are operating from a primitive and insecure position. The better question might be “is it dangerous?”. At least then we allow ourselves the possibility of a higher-level existence; welcoming and experiencing novelty, and providing succour to individuals rather than marginalising them.
Julian Savulescu’s piece on conscientious objection demands, and will no doubt receive, critical discussion. My initial reaction was to respond ironically, presuming that he wrote the piece tongue-in-cheek. However, I am not practised at irony. Saying one thing and meaning another has always seemed too much like lying, and my conscience (sic) has tended to prevent me from being ironic with the conviction that is needed to bring it off. The other problem, which a colleague raised, was that Savulescu may have been writing with sincerity, and that to respond with irony might be disrespectful. I have therefore decided to respond as though he meant what he said.
He is right that individual values can get in the way of ethical health care. He is catastrophically wrong in jumping to the conclusion that doctors should eliminate their own values from their practice. He might just as well argue that, as there can sometimes be problems with policies, we should ignore them all. It was this startling lack of philosophical and ethical sophistication in his writing that caused me to presume that he was being ironic.
The paper opens with a quote from Shakespeare’s Richard III. Savulescu chooses to cite the values of a king who was known for his ruthless dishonesty (arguably almost devoid of conscience) , who put the Princes in the Tower, and whose subjects were ultimately too ashamed to fight for him at the Battle of Bosworth. In doing so, Savulescu has inadvertently put the case for the importance of conscience as an essential element of respectful and trusting relationships. He attributes the words to Shakespeare rather than his character, thus giving them greater weight. The Bard was probably himself writing ironically. Conscience, for Shakespeare’s Richard III was, after all, mostly guilt in the shape of the ghosts of his past victims. He could not go to war with a good conscience, so he had to ignore it. Finally, Savulescu, in what may be a Freudian slip, directs us in error to Scene iv, in which Richard, the “bloody dog” , gets the gruesome end that he deserves. This is an admonition and warning to those who would eschew the importance of conscience. Savulescu appears to take it as the opposite.
Next we are introduced to the concept of conscience invoked to avoid duty. I would call this idea oxymoronic: One cannot knowingly, by definition, use conscience for an ulterior end, although one could pretend to, in which case avoidance of duty is the value to which one’s conscience is urging adherence. I hope that Savulescu is not suggesting that avoidance of duty is an important value for doctors.
It is impossible to be impressed with the moral or philosophical weight of Savulescu’s argument when he uses absolutes ( “always” appears in two consecutive sentences) and value-laden phrases ( “Their values crept in…”, and “..has been squarely overturned…”) with reckless abandon. He refers to duty without saying to whom the duty is owed, and introduces “true” and “grave” duties without definition. He speaks of action in the public interest without alluding to the inevitable conflict between individual and public interest that pervades any debate about state provision of health services. Even his use of the word “paternalism” implies that it is a negative, when in ethical discourse it is a value of
central importance to be weighed against autonomy – each having their role to play in differing proportions. He reduces complexity to a series of right / wrong dichotomies, and claims that a position that is morally defensible when adopted by a few becomes indefensible when adopted by a larger number. He conflates distinct concepts (for example conscience with values with religious belief with adherence to a school of religious thought). He seems to believe that acting according to one’s conscience is the same as “making moral decisions on behalf of patients”. This is not a good example of reasoned argument!
By his exclusive use of the termination of pregnancy as the medical paradigm, he exposes his starting point, but he doesn’t begin to discuss even this narrow area with balance. I would agree that a doctor who objects to abortion might choose to work in another area of medicine, but he fails to acknowledge that a woman who has a conscientious objection to abortion may have a right to treatment by a gynaecologist who does not perform the operation. He totally ignores other branches of medicine, such as general practice, geriatrics, psychiatry.
Savulescu suggests that doctors should simply carry out instructions and that the full range of a doctor’s duties can be set out at medical school for the student to take or leave. I can only infer that he left clinical medicine at a relatively junior stage. Medicine must, by its nature, be an evolving profession, responding to an evolving world The doctor’s commitment must therefore be constantly renewed.
It seems that, in Savulescu’s utopian vision of the world, medicine is neither an art, nor has it anything to do with a relationship between individuals; our scientific and moral knowledge is comprehensive and incontrovertible; last year’s scientific theories were held in good faith but were wrong, whilst this year’s are correct, and so faith doesn’t come into the equation. He seems to be advocating blind adherence to the current dominant values and he does not consider the risk of institutionalised abuse of medicine. He implies that though this happened in Hitler’s Germany and in the USSR, we have learned that lesson once and for all. He seems to have forgotten that the values of individual clinicians may be the only real safeguard against that horror.
There is a place for the maverick and the iconoclast in ethical discourse and I welcome the provocation of this debate, but Savulescu has given us no clue, other than the outrageous nature of his argument, that he may be acting as “devil’s advocate”. He appears. therefore, to bring the weight of philosophy, Oxford University, and medical ethics with him. What worries me more than Savulescu’s views, therefore, is the fact that the BMJ has published them without qualification, disclaimer, or balancing argument. The danger of publishing this extreme view on its own and provoking uncontrolled debate is that the (hopefully) inevitable howl of protest may be read by some as the squealing of doctors as we are brought further to heel.
I must conclude, therefore, by readily accepting that individual values can result in unethical practice. The risk, though, is best minimised by teamwork, continuous professional development, appraisal, and supervision. Personal integrity underpins the doctor-patient relationship. The values of the individual doctor are our safeguard against the institutionalised abuse of medicine.
cite as BMJ 2006;332:294