Progressive British Muslims: the religious voice in bioethics
Prof. Søren Holm
Professorial fellow in bioethics, Cardiff Law School & Professor of Medical Ethics II, University of Oslo
Introduction
Religion plays a significant role in the life of many people in the UK and many health care professionals have chosen their profession because they believe that their religion calls them to serve the needy and the sick. In previous times society was much more overtly religious and most of our health care institutions have religious roots. Because of the historial importance of religion the traditional ethics of the health care professions has also been significantly influenced by religious ideas as exemplified in the writings of the early medieval physician-philosophers Ibn Sina and Maimonides.
This influence of religious thinking on bioethics stretches all the way up to the beginning of modern bioethics in the late 1960s in Western countries where many of the leading thinkers were Christian theologians.
However, in recent years there has been a move to exclude religious voices and arguments from the public debates about bioethics or to claim that such arguments are irrelevant in modern secular, multicultural societies like the UK . The Liberal Democrat MP Dr Evan Harris has for instance been quoted for the following observation in relation to euthanasia legislation:
"Doctors are split and at the moment the religious lobby is winning the tactical battle, but society should not allow religious views on the sanctity of life to trump the right to autonomy of a patient who does not share those views."
This essay will first consider the arguments against giving a public role to religious bioethics and will argue that all of the arguments are flawed. It will argue that religious voices have a legitimate role to play in public debates about ethical issues and that religious leaders may have standing both as authentic representatives and as experts (in so far as anyone can claim expertise in ethics). The second part of the essay will then discuss the role of religion in the clinical setting and in the decision making of patients and families.
But before moving to the analysis it is important from the beginning to note that there is one area where everybody ought to agree that listening carefully to the religious voice is required. That is when the religious voice is the voice of the patient who has to decide on diagnostic procedures and treatments. Every one of us makes decisions based on our own values and when these decisions are about our own lives as patients health care professionals ought to listen very carefully and elicit those values, whether the values are religious or not. We need not to agree with, for instance a member of Jehovah's Witnesses claiming that the soul is in the blood to be able to understand that giving a person who sincerely believes this a blood transfusion against their will is a violation of their values and their dignity.
The argument against religious bioethics
There are a number of different arguments against allowing religious voices any say in public debates.
One set of arguments are aimed at the claim that religious views should be given special weight or prominence in the debate and another more radical set claims that there are reasons to exclude religious views all together
One problem that both sets of arguments share is that it is not always obvious whether an argument or a position is a religious position or not. And it is therefore not obvious what kind of arguments we are supposed to exclude from the public debate.
A first set of problems in distinguishing religious arguments is that religion and culture are often intertwined and it may be difficult to decide whether a view expressed by for instance a Somali Muslim should be taken as a religious or a cultural expression.
A second problem is that the mere fact that an argument is uttered by a recognised religious leader does not necessarily make it a religious view, some religious leaders have a rather unfortunate tendency to express views on all manner of non-religious issues. So we might try to focus on the content of the argument, on its elements or premises and say that any argument that contains explicitly religious premises is thereby religious. If someone for instance says that euthanasia is wrong because God has said that human life has infinite value then that is a religious argument. But in many circumstances the same person may have other arguments leading to exactly the same conclusion, for instance in this case arguments from human dignity or universal human rights.
Philosophers are rightly sceptical about what is called “argument from authority” i.e. arguments of the type “X who is an authority said Y and therefore Y is true” but this scepticism is directed at all such arguments, not just the religious ones. We could decide never to allow arguments from authority in public debate, but in that case we would also have to exclude arguments from philosophical authority completely. But this would be silly. We do not need to exclude references to the “patron saint” of liberalism John Stuart Mill from ethical debates. We just need to remember that the sentence “Mill established that X is the case” must always be taken as a claim, not as a true assertion.
But let us look more closely at the arguments for excluding religious views completely from the public debate. A very extreme version of the position that there are narrow limits to what ethical propositions that can be defended in a secular world is held by the American bioethicist H. Tristram Engelhardt. In the preface to the second edition of his influential “The Foundations of Bioethics” he writes:
“If one wants more than secular reason can disclose – and one should want more – then one should join a religion and be careful to choose the right one. Canonical moral content will not be found outside of a particular moral narrative, a view from somewhere. Here the reader deserves to know that I indeed experience and acknowledge the immense cleft between what secular philosophical reasoning can provide and what I know in the fullness of my own narrative to be true. I indeed affirm the canonical, concrete moral narrative, but realize it cannot be given by reason, only by grace. I am, after all, a born-again Texan Orthodox Catholic, a convert by choice and conviction, through grace and in repentance for sins innumerable (including a first edition upon which much improvement was needed). My moral perspective does not lack content. I am of the firm conviction that, save for God's mercy, those who wilfully engage in much that a peaceable fully secular state will permit (e.g., euthanasia and direct abortion on demand) stand in danger of hell's eternal fires. As a Texan, I puzzle whether these are kindled with mesquite, live oak, or trash cedar. Being schooled in theology, I know that this is a question to be answered only on the Last Day by the Almighty. Though I acknowledge that there is no secular moral authority that can be justified in general secular terms to forbid the sale of heroin, the availability of direct abortion, the marketing of for-profit euthanatization services, or the provision of commercial surrogacy, I firmly hold none of the endeavours to be good. These are great moral evils. But their evil cannot be grasped in purely secular terms. To be pro-choice in general secular terms is to understand God's tragic relationship to Eden . To be free is to be free to choose very wrongly.” (Engelhardt 1996, p. xi)
On Engelhardt's fairly pessimistic analysis of the situation the religious person who wants to speak to the world must therefore either divorce his or her religious and secular sides, or must adopt a purely prophetic role exhorting the world to repentance. For Engelhardt this follows because he thinks that there are no compelling non-religious arguments establishing most important ethical truths.
But this is, of course quite the opposite position of the position that is held by most religious traditions. Most religious traditions think that there are good non-religious arguments concerning how one should live and that these are broadly congruent with what the religion in question commands.
Others argue that only arguments that have premises that are in principle understandable by all have a legitimate place in public debates, and that this rules out religious arguments. Quite how a requirement of understandability is supposed to rule out religious views is difficult to grasp. Most atheist presumably have no problem with understanding the sentence “There is one and only one omnipotent God”, they just deny that it is true.
At a more general level it is important to note that all ethical arguments must stop somewhere at some basic sets of values and ideas that are accepted but not argued for. All participants in ethical debates hold some basic worldview that is the foundation of their arguments and there is no good reason to hold that a well thought through religious worldview is less worthy or important than any other worldview.
This is not the same as saying that religion should be able to veto democratically decided policies, but just that religious people have exactly the same right and duty to influence public policy as anyone else.
The weaker version of the “religious views should be excluded” idea holds that there are no reasons for giving special weight to religion, religious arguments or religious representatives in public debate or political decision making. This weaker version is, in my view correct as far as it goes. There is no reason for giving the views of the Archbishop of Canterbury special weight just because he is the Archbishop of Canterbury and a religious figure and therefore no reason why he and many other Anglican bishops should hold automatic seats in the House of Lords. But there is reason to give special weight to his views in so far as he speaks as the representative of the many members of the Church of England and as a voice for their ethical values and concerns. Considerations of values and of how persons should lead their lives are core in most religious traditions and religious leaders are therefore often in a position to truly speak on behalf of their members. Religious traditions have not suddenly discovered bioethical issues, matters of life and death have always been a core concern and there is therefore a rich and authoritative shared tradition to draw upon.
Another reason to listen attentively to some religious leaders is that they are intelligent and well read people who have reflected deeply on the issues. We listen to bioethicists because they have spent a long time learning about the issues and analysing the arguments; and if the sustained and reflective engagement of bioethicists with ethical issues is a good reason for listening to them it must also be a good reason for listening to those religious leaders who have reflectively engaged with the same issues. This listening may not lead to agreement, but it might lead to a more nuanced understanding.
Religion in the clinical setting
In the clinical setting where health care professionals treat patients within the context of a health care system (in the UK the National Health Service (NHS)) considerations of religion and its ethical precepts play a role for patients, for health care provides and for the health care organisations.
In the case of the health care professional who is religious this may influence the kind of procedures they are willing to provide or participate in and the advice they give to patients.
Legally recognised conscientious objection is the clearest example of this influence. In many jurisdictions health care professionals can legally refuse to participate in induced abortions if they have a conscientious objection to this procedure. Such objections can be based in non-religious values but will most often be religiously based.
But there are limits to the scope of conscientious objection where a health care professional works within a large organisation. The interests of patients will often outweigh the interests of the professional.
In the more general situation of interaction with a religious patient the health care professional will often need to understand something about the patient's religion and culture in order to 1) provide appropriate care and advice and 2) not behave inappropriately towards the patient. Without such knowledge the interaction with the patient may become unsuccessful or in some cases directly harmful. Health care professionals cannot have an obligation to know everything of relevance about all religions, because that would be impossible, but they can be reasonably expected to know something about those religious groups that are prevalent in the locality where they work and reasonably expected to be sensitive towards religious views. This information will often have to be fairly specific, e.g. not just knowledge about health care relevant beliefs in Judaism in general but knowledge about the beliefs of the Lubavitcher branch of Hasidic Judaism.
Understanding the patient's religious views becomes especially important in relation to decisions about incompetent patients. It is generally accepted that such decisions should be made in the best interest of the patient and that the scope of best interest is broader than just “medical best interest”. In the leading UK case Re S (Adult Patient: Sterilisation) this wider conception of best interest was expressed in the following way:
“…that, once satisfied that the proposed treatment options were within the range of acceptable opinion among competent and responsible practitioners, the court should move on to the wider and paramount consideration of which of them was in the patient's best interests;…”
This entails that a patient's deeply held religious views may influence or determine what is in that patient's best interest.
In cases where there is conflict between what the health care professional believes to be the clinically indicated course of action and the patient's religiously influenced decision the conflict may sometimes be resolved by involving a religious leader whom the patient trusts. The patient may have misunderstood what the religion actually requires, or the degree to which the requirements can be suspended in cases of illness. Most branches of Islam will, for instance suspend the Ramadan fasting requirements for people who are ill and allow the use of products containing materials from pigs as part of necessary medical treatment, but not all Muslims know this.
Religion is important for health care organisations because:
1) the organisation has to act appropriately in relation to the religious views of its patients and staff, and,
2) the organisation may itself be committed to a particular religious view and have a religious identity.
Any health care organisation needs to make conscious decisions about how it is going to accommodate the religious views of patients and staff. This becomes more urgent but also more complicated for health care organisations that are situated in multi-cultural and multi-religious environments. Making room for religious views and practices becomes especially important when there is a link between care and treatment outcomes for patients and the degree to which specific aspects of their religion is catered for. Hospitals should, for instance as a general policy be able to meet the dietary requirements of the population that they serve because of the link between nutrition and treatment outcome. And they should also have systems for facilitating care for the religious needs of patients.
The degree to which an organisation's religious identity can determine its delivery of health care is a more contentious issue. In a free market where patients could choose freely between a large number of health care providers there would probably be few restrictions to the degree to which an organisation could legitimately let its religious identity influence its health care delivery. Patients who did not want to go to, for instance a Catholic hospital could just choose the Muslim or the Atheist alternative. But the NHS restrict patient choice to a considerable extent and this also limits the extent to which a health care organisation can let its religious identity influence its actions. If the patient has no choice then that patient will in general have a strong, legitimate presumption of being able to access a complete package of treatment options whatever institution he or she is admitted to.
About the author
Søren Holm is a medical doctor and philosopher. He is Professorial Fellow in Bioethics at Cardiff Law School and Professor of Medical Ethics (part-time) at the Section for Medical Ethics, University of Oslo , Norway . He is a practising Christian and has been thinking and writing about issues in bioethics since the mid 1980s.
References
BBC News 29 June 2006 . Doctors change euthanasia stance. http://news.bbc.co.uk/1/hi/health/5123974.stm
Engelhardt HT. The Foundations of Bioethics (2. Ed.). Oxford : Oxford University Press, 1996.
Re s (Adult Patient: Sterilisation) [2001] Fam 15