Julian Savulescu's blog

The end of conscientious objection?

A relationship counsellor, Gary McFarlane, 48, in Bristol was sacked in 2008 for refusing to provide sex therapy to a gay couple. He took action against his former employer, Relate Avon, arguing that it had failed to accommodate his Christian beliefs. He lost, appealed and his appeal has just been turned down by the High Court.

Lord Justice Laws said legislation for the protection of views held purely on religious grounds cannot be justified. He said it was irrational and "also divisive, capricious and arbitrary".

This decision is at odds, logically at least, with the protection currently given to conscientious objection in medicine. Doctors are allowed to refuse abortion services and pharmacists sometimes refuse to supply emergency contraception on religious grounds. I have argued that these practises are immoral (see blog and articles), yet they continue to occur. Pregnant women are denied available services to plan their family because of the religious beliefs of the health practitioner. This kind of denial of service is similar to denying couples sex therapy who need it – both are legal, beneficial, desirable services.

What we might conclude from this case is that if the NHS sacked doctors who conscientiously object to provide abortion services, as Relate Avon sacked Mr McFarlane, those doctors would not have legal appeal that their religious views had been insufficiently recognised.

Or are doctors special?

Political Responsibility

The prospect of a hung parliament following the upcoming UK election has raised several interesting ethical issues. One such issue which has been discussed is what are the responsibilities of the party which holds the balance of power? Should members of that party support the party holding the majority of votes or follow their own party policies?

Politicians are public officials whose charge is to act in the public interest. In voting on policy, the overriding principle governing their decisions should be to support that course of action for which there is most reason to support. What we have reason to do and choose is of course a hotly contested philosophical topic. However, some points can illuminate political debate.

Whether a member of party who holds the balance of power should vote for majority policy or party policy turns on which policy there is most reason to support. This will depend on the context and circumstances. It also turns on how likely one’s own party policies are likely to track what is right.

In determining what is right and best, it is important individuals and parties do not follow ideology, but engage in rational deliberation, gathering and weighing evidence, considering appropriate values.

The values which should govern policies must be publicly defensible values. They must not be personal, idiosyncratic or purely ideological. I have written on the role of conscience in the delivery of medical care [Savulescu, J. (2006) “Against medical conscientious objection”  BMJ  332 294-297
doi 10.1136/bmj.332.7536.]. I argued that personal conscience should not constrain the delivery of legal, beneficial desired health care, regardless of one’s personal morality. In a similar way, politicians should set aside their own personal values and moralities and follow a publicly defensible reason when choosing policies. What matters is not what an individual or party care about, but what is defensible to a secular public.

Serving the public interest is not serving a majority party or other party. Parties exist as a means of attempting to find the best policy for the public which they serve. But ultimately it is the public and whole electorate that matter. Individual politicians should choose that policy which best serves them, not themselves, their party or some other party.

In 1996, conservative Catholic MP from Victoria, Kevin Andrews, introduced a private members’ bill which ultimately overturned the Northern Territory’s Rights of the Terminally Ill Act, which permitted euthanasia in the Northern Territory. This Act was produced by a democratic process led by Marshall Perron. Euthanasia at that time had wide support in the Northern Territory, Australia and Andrews’ own electorate. The intervention, on conscience, by Andrews was an act of political irresponsibility. It did not serve the public interest but served his own particular set of moral values. This kind of political action is what must be avoided in the situation of a hung parliament and in parliament in general.

In choosing to be a politician, we should choose set aside our own personal morality and strive to find those reasons which best serve the public interest. All civilised countries will eventually permit assisted dying. The interference of personal values and party politics only serves to increase the suffering of those who are denied assistance in dying by such delays. But this is not merely an issue for euthanasia. In all political debates, we need a reorientation to find the public interest, not merely provide a platform for the expression of individual or party values.

Choose Your Sex: Male, Female or Neither … or Both

In Australia, Norrie is understood to be the world’s first person to have ‘Sex Not Specified’ on their birth certificate. The NSW government has legally recognised that Norrie is neither male nor female.

“Norrie, 48, was born in Scotland and registered as male at birth. At age 23 Norrie commenced sex and gender conversion to female through hormone and construction of a vagina and was then issued with a gender recognition certificate as female in Australia.

“But this did not work out for Norrie as zie (gender-neutral pronoun) did not feel comfortable living solely as a female so zie ceased lifelong hormone treatment and took up a neuter identity which is neither male nor female, resisting any further female or male normalisation.

“In January 2010 doctors declared that they were unable to determine Norrie as either male or female as zie has no gonads, the hormonal system was atypically male or female, and Norrie’s psychological identity was neuter.”

Such legislation is a step forwards for the respect for personal autonomy and for human enhancement. It acknowledges the right of individuals not merely to choose whether to be male or female, but to choose something in between or different. It allows fine tuning of sexual choice. And given people’s different psychology, anatomy and physiology, it is likely to enhance their lives.

I have written elsewhere about the principles which should govern such controversial choices (Savulescu, J. (2007). ‘Autonomy, the Good Life, and Controversial Choices’. In Rhodes, R. Francis, L. P. and Silvers, A. (eds). The Blackwell Guide to Medical Ethics.(Oxford: Blackwell Publishing. Part 1, Chapter 1, pp. 17 – 37). Be the person you want to be. Or rather, be the kind of person you want to be – is one principle behind such legislation. The old binary categories are falling – tall and short, talented and untalented, smart and stupid, male and female. Human life is incredibly diverse. All states and talents affecting humans occur in shades of grey. We should make our choices in recognition of the shades of grey. And it makes sense to make decisions not based on crude categories but fine-grained realities.

Norrie has opted, reportedly, for neither sex. In the future, there may be some who opt for both sexes. And such choices may be right. If enhancement technologies radically progress, people will be able to choose any shade of grey. Your sex would be your choice. You might have the best or worst of both worlds.

How should we address the organ shortage problem?

Israel has come up with a new answer. In Israel, many orthodox Jews will accept an organ but have religious objections to donating one. It has one of the lowest organ donation rates. So there is a move to change this: sign a donor card, and you and your family move up in line for a transplant if one is needed.

Art Caplan described this as “reciprocal altruism”, a euphemism for preventing free-riding. Free-riding goes on all the time in organ transplantation. There is a vast shortage of organs yet many people in Western societies are prepared to accept one without committing to giving one.

In an article written with Dominic Wilkinson which will appear soon in Bioethics, we argue that people who will have treatment withdrawn and die could opt, previously while competent, to elect to have their organs removed before they become unusable by what we call “organ-retrieval euthanasia”.

A more extreme, though equally rational, suggestion would be to restrict organ transplantation to those who commit to donating organs (with the exception of children and other incompetents). If such a proposal were widely distributed and publicised, it would be fair.

The alternative would be to remove everyone’s organs after their death, unless they had rejected this explicitly. Such proposals have been accepted in Spain, France, Belgium, Austria – so called presumed consent or opt-out. Such a proposal still allows free-riders. The fair version of such a proposal would be not to allow those who opt-out for whatever reason, including religious reasons, to receive transplants, unless there no altruists who are suitable for that organ.

We should stop being soft on organs and take a hard line on free-riders. For too long they have enjoyed the benefits of organ transplantation without being prepared to contribute.

Lifesharers is a voluntary organisation which distributes organs amongst its members, who agree to donate, and distributes organs to those outside only if there are no compatible recipients amongst its members. It is a model of rational fairness.

No willingness to contribute an organ? You should be treated as a lowest priority recipient.

Going Green Makes You Mean … and Distracts You

When doing something is worse than doing nothing

According to a study reported in the Guardian, when people feel they have been morally virtuous by saving the planet through their purchases of organic baby food, for example, it leads to the "licensing [of] selfish and morally questionable behaviour", otherwise known as "moral balancing" or "compensatory ethics". The article came under the wonderful heading, “How going green may make you mean.”

How should an ethicist respond to yet another psychological study of human limitations? Some would no doubt argue that personal ethics should global, not local. Living ethically is a way of life, not an individual choice. That ethics should infuse all our choices, etc, etc

That is not my response. The “green movement” has another more significant adverse effect. It is a distraction. Governments and the public lead themselves to believe that they are actually addressing the environmental crisis by turning off lights, recycling and making people feel miserable for taking planes and driving cars. But they are doing little for the environment, while believing that they are saving it. This is a distraction from the real problem. The fate of the environment will now in large part be determined by China and the developing world. Our putting out the recycling will do nothing to change that. But while we feel good about ourselves, we fail to acknowledge the real problems and find solutions. Our ethics makes us feel good about ourselves and (falsely) reassures us that we are addressing the problem.

Toby Ord has identified the failure to give appropriate scale to the problems and solutions in development. He famously said that it matters more where you give, rather than whether you give because some programmes and charities are fabulously more cost-effective in orders of magnitude. The same applies to our efforts to improve the environment. Most of the things which we currently feel are so important will make little or no difference. And the biggest fish swim free.

We should not only identify ethical problems and find a solution. We should find the best solution. Too often doing something makes us feel good when we could and should do something else. In ethics, something is not always better than nothing.

The Great Egg Raffle: Why Everyone’s a Winner If We Price Life and Body Parts

Imagine someone offered you £1 000 000 to cross a busy road. There is a small chance you might lose your life or a limb. But most people would accept the chance. I certainly would. We do that kind of thing every day for trivial reasons, such as to buy a packet of cigarettes or a pint of beer that might also kill us.
 Would you be exploited if you crossed the road for a million pounds? Hardly. You were lucky to get such an offer that you judged made it worth crossing the busy road. After all, you could have stayed put or even crossed the road for nothing.

Why then do so many people have such revulsion to proposals to take risks involving one’s body when it comes to selling eggs for infertility treatment? Such revulsion is behind the opposition to the egg raffle put up by the Bridge Clinic to give away a cycle of IVF in the US using a paid egg donor of your choice (). The risks of donating eggs are no greater than (or not much greater than) crossing a busy road. So what’s the fuss?

One of the arguments is that this exploits the women who donate the eggs. But these risks are reasonable: woman in the UK are allowed to donate for no money or in exchange for cycles of IVF (a payment in kind). If the concern is exploitation, the solution is simple. Raise the price. Someone who crosses the road for a million pounds does so because he or she judges risk to be worth the money, or rather the goods and improvement in life that it could buy.

The solution to concerns about the sale of body parts is pure and simple: set a minimum fair price, just as we set a minimum price for labour and we adjust that price according to the risk of health that the labour entails.

The objection to selling eggs cannot be about the removal of eggs to benefit another person: that can already been done for free or in exchange for goods in kind (IVF treatment). It has to be about doing it in exchange for cash. But the exchange is only wrong if it exploits someone – and that is easily prevented by setting a fair minimum price.

If we can risk our lives and health in our jobs (to make money) or in life in general, we should be able to risk them by at least selling bits of our body that are not necessary for our survival, like eggs and sperm.

It is time to allow the sale of eggs for infertility treatment. The key will be to set a high fair minimum price. After all, people will be prepared to pay a lot to have a child. And that money will benefit the donor. Moreover, it will remove a potential egg recipient from the altruistic pool of eggs and there will be more eggs to go around to those who can’t afford to buy them. Everyone is a winner from pricing life and body parts, if we price them ethically.

When Conscientious Objection Becomes Moral Imperialism

Imagine that I went to the pharmacist to obtain chemotherapy for my chronic leukemia. Jenny, the pharmacist, refuses to dispense it because she believes the packaging is environmentally unfriendly. It is not Green enough.

 

Imagine that I went to the pharmacist with a prescription for morphine tablets for my chronic pain from prostatic cancer. Cyril refuses to dispense them because narcotics are addictive.

 

Imagine that I went to the pharmacist for antibiotics. Wayne refuses to serve me because I am wearing a burka.

 

It is legal to refuse to sell products even if one has them in stock. Yet as health care professionals , Jenny, Cyril and Wayne all fail in any basic duty of care. They should be sacked.

 

These stories are all as fictional as they are outrageous. Yet similar stories are not. Janine Deeley recently took a prescription for an oral contraceptive to her local pharmacy. The pharmacist refused to sell it. The pharmacist, with the support of the code of ethics supplied by the Royal Pharmaceutical Society of Great Britain, had decided not to distribute contraceptives on religious grounds. To get her prescription, (which was in fact to use the pill to control the symptoms of her endometriosis), Janine would have to return another day, when a different pharmacist would be on duty and submit her pain-reducing prescription to another pharmacist’s conscience for scrutiny.

 

It does not lessen the outrage that this woman was taking the pill as a pain reliever. The use of the pill for family planning is widely accepted in this society and with no good ethical objections to it. Indeed, reports today suggest thatwomen who have taken the contraceptive pill are at lower risk of heart disease and cancers. Three million British women are prescribed the pill, which in addition to its contraceptive properties, has been used to treat the symptoms of endometriosis, polycystic ovary syndrome  problematic periods, and acne. It is available free of charge on the NHS as a policy decision.

 

The place of such religious values is in the home or place of worship – not in the workplace to the detriment of others. This kind of religious imperialism, or indeed any kind of moral imperialism, should not be tolerated in a secular liberal society. People should be free to practise their own religion or pursue their values but not at cost to others.

 

There are plenty of careers that don’t involve the provision of the oral contraception.

 

It would be absurd for a vegetarian to take a job in a slaughterhouse and then invoke conscientious objection to performing his or her job.

 

Even more important is that our health care professionals deliver the best quality health care.

What Does a Practical Ethicist Do?

What is practical ethics? How should we do it well?

There are two broad approaches. The first, the Evangelist Model, aims to convert people to be better citizens, to cause people to behaviour more ethically. It is premised on knowledge of ethical truths, of clear insight into what is right and what is wrong. Peter Singer is perhaps the most famous living bioethical Evangelist.

The second broad approach is the Socratic Model. It is not premised on knowledge of truth or directly aiming at transmission of truth or changing behaviour. Its goal is inquiry and reflection, the discovery of ethical truths. The goal of such an approach is to provoke people to think ethically for themselves, to engage in deeper reflection and to arrive an ethical conclusion of what they should do. This book is an example of the Socratic Model.

While much of my own work argues for a particular course of action, like allowing doping in sport, the primary (unstated) goal is not to realise such actions, but to cause people to think, by the use of provocative argument. There are many ways to encourage people to think. But one way is to consider the unthinkable.

Michael Sandel once famously wrote we should be “open to the unbidden”. I believe we should be open to the forbidden. Open in the sense that we can articulate the reasons for why the forbidden is wrong. But ethics is about progress and reform, as well as justifying our intutions. In many cases, rational reflection will cause us to revise our beliefs about what should be forbidden and indeed what we have moral imperative to do.

It is by considering the controversial that we can get people to think, to exercise their ethical muscles. In that way, we discover our own reasons for action.

Our Lethal Moral Ideals: Having a Child to Save Another

In an article in the New York Times, Lisa Belkin relates the story of Laurie Strongin Allen Goldberg who tried to use PGD to create a sibling to provide bone marrow to treat their son, Henry, suffering from Fanconi anemia. Congress, however, shut down the lab that was working on P.G.D., calling it illegal stem-cell research. “That led to an 18-month delay that may well have cost Henry his life. Laurie went through nine in vitro fertilization cycles before and after that pause, and each time the embryos transferred were not only free of the genetic flaw that threatened Henry but were also his bone-marrow match. Nine attempts failed to take, and Henry had to settle for an imperfectly matched unrelated donor. He died in 2002 at the age of 7.”

The story goes on to  end on an upbeat note, partly launching Laurie’s new book “Saving Henry: A Mother’s Journey”. Indeed, another couple read about their story a number of years ago and used PGD successfully to create a saviour sibling who did successfully save the life of his brother who would have died from Fanconi Anaemia. The story ends with the father of the boy who was saved writing,

“The reason for writing this letter is to thank you and especially to thank Henry. You see, if we had never read that New York Times article, we would have never tried P.G.D. Your determination to succeed at P.G.D. gave us inspiration. Henry did not die in vain. Henry is a pioneer who has and is saving lives every day. I can only imagine what it is like to lose a son. Hopefully you can find some comfort in knowing without a doubt you and your son helped save our son’s life.”

I want to be a bit more down-beat.

Economists call it “opportunity costs”. Sometimes it is a decision not to act, to fail to act, to do nothing. In this case, “it” is the avoidable death of an innocent 7 year old child, Henry. American Congress took a decision which arguably foreseeably contributed to, possibly significantly, the death of a child.

Our ethics can have life and death implications. In this case, the moral ideals of Congress arguably contributed to a child’s death. Congress, or its members, should take responsibility for this. Whenever there is a conflict between someone’s life or well-being and some moral ideal, we should be very confident in those ideals when they result in other people’s death or suffering.

So how valid are these ideals and what were the justifications? There are no good moral arguments against creating saviour siblings – see Spriggs M, Savulescu J. (2002) ‘Saviour siblings’. J Med Ethics, Oct; 28(5): 289. Provided that the saviour sibling is loved, cared for and treated as an individual and an end, the choice of these parents only brings about good and no harm.

The moral of the story is to consider the opportunity cost of your choice, and if the result of deciding not to act is the life or well-being of someone, you have to be VERY confident the ideal is worth dying or suffering for.

It is easy to spout high minded ethical ideals when someone else suffers the consequences of those ideals. Tragically, this kind of ethical imperialism is all too common.

Even the hyperconservative UK regulatory body, the HFEA, has reversed its prohibition of the use of PGD to create saviour siblings, bowing to the force of reason. Sadly, many children would have lived if this decision had been taken earlier.

Getting ethics right is an urgent, life and death matter.

Geoengineering: Contender for Biggest Ethical Issue of the Century

The UK Science and Technology Committee and the US Congressional Science and Technology Committee are both starting new inquiries into the regulation of geoengineering.

This may well be one of the biggest ethical issues the world will face this century. We are of course geoengineering the planet on a daily basis now.

Together with colleagues Steve Rayner (Professor of Science and Civilisation, Director of the Institute of Science, Innovation and Society at the Said Business School), Catherine Redgwell (Professor of International Law at University College London), Nick Pidgeon (Professor of Psychology at Cardiff University) and Tim Kruger (Director of the Oxford Geoengineering Institute), I have submitted written evidence to the committee.

The first submission: http://www.publications.parliament.uk/pa/cm200910/cmselect/cmsctech/memo/geoengineer/ucm0702.htm

The second submission (responding to oral evidence to the committee): http://www.publications.parliament.uk/pa/cm200910/cmselect/cmsctech/memo/geoengineer/ucm07a02.htm.

Our response now to the challenges raised by geoengineering will have a massive impact on our future.