Conscience For Me But Not For Thee: The Case for Pro-Life Docs and Pharmacists

August 22, 2008

In two recent threads over at Pharyngula, one about a poll and the other about some recent comments from HHS Secretary Mike Leavitt, I’ve gotten myself caught up in some pretty heated exchanges over the issue of pro-life doctors, and their impact on reproductive choice and access to health care.

This controversy has been building for some time, as legislatures and now licensing boards are increasingly confronting the question of whether, and to what degree, the consciences of anti-abortion doctors should be protected. More and more women are startled to find local doctors and pharmacists refusing what they had assumed were basic and perfectly legal prescriptions.

Now, as far as the original issues go, most of the things that anti-abortion docs, pharmacists, and their advocates are currently pushing for are indeed overboard. The idea that a doctor can refuse to refer a patient to another doctor, or refuse to even give them information, is unjustifiable. And if a CVS pharmacy wants to offer the pill to its customers, then it has all the cause in the world to only hire and retain staff that are willing to dispense it. It’s simply not unjust discrimination to fire someone if their conscience prevents them from doing what the employer needs done, and no reasonable (reasonable on the employer’s terms) accommodation can be found.

Unfortunately, many of my pro-choice compatriots have, I think the wrong idea themselves, asserting principles of their own that go far beyond the right of employers to set the conditions of employment. When it comes down to it, it seems that many people believe that doctors who refuse on ethical and/or religious grounds to prescribe birth control pills, pharmacists that refuse to fill such orders, or even, it seems ob/gyns that resist performing elective abortions should either ignore their consciences or essentially leave their chosen professions. But the justifications given for this harsh ultimatum are, I think fatally flawed.

Two principles in particular are, I think twisted or misapplied to this situation: the idea that pro-life doctors are forcing things on their patients, and the idea that pro-life doctors and pharmacists aren’t doing “their job.”

Doctors Have No Right To Force Their Choices on People

As general principle, this idea Is central to most cannons of medical ethics and medical license boards. And justly so. It’s based, first and foremost, on the idea that people of sound mind have an absolute right to accept or refuse medical care, and to pick the treatment plans they are comfortable with under the advice of the physician. It’s based on a laudable ethic of not forcing something on someone without their consent.

The problem is that this ethic seems to fall by the wayside whenever people start considering the views of people they don’t like. Or it gets implausibly twisted, so that the “forcees” are claiming to be the victims. It takes a true mangling of language to assert that someone not doing something for you constitutes forcing you to do anything. But that appears to be precisely what it going on here.

Consider the common assertion that doctors who refuse to prescribe birth control, especially when they practice in far-flung areas and stats that offer little choice in doctors to begin with, are “forcing” their own preachy choices on the patient. But are they?

When a family doctor sets up a shingle in a small town, people’s access to health care improves in real terms. But now suppose that the doctor refuses to prescribe birth control or perform elective abortions. Has the doctor actually “forced” anything on anyone? His or her values? His or her services?

In virtually all routine situations, no. The people in the town are certainly no worse off than they were before the doctor arrived. The doctor’s existence provides some benefits, but perhaps not all the benefits they’d want. Demand that the doctor violate his or her conscience or else find another profession, and you might well end up with no nearby doctor at all. The same goes for a hypothetical “pro-life” pharmacy.

Yes, people in that situation lack access to things they want and need, and are protected by law. But that’s the exact same situation they were in before the anti-abortion/anti-pill doctor set up shop.

So what’s the solution? Well, if we really care about access to birth control, if that’s really something we consider to be a moral value or even an assured, positive right, who has the responsibility to supply it? Does that responsibility fall almost entirely on the doctor who thinks it’s immoral, just because he happens to be the most local? Or does it fall on all the people who think it’s a basic right? If you answered the former, I have to admit that I’m simply flabbergasted.

The situation here is a little like the often confused outrage at “scalpers” who, during a disaster, offer things like water bottles for sale at ridiculously inflated prices. These people are routinely condemned as greedy, and they certainly are. But somehow it never occurs to all these outraged moralists that, if people in a disaster have some sort of positive right to receive water (free or cheaply), that this right cannot possibly be a burden and a responsibility that falls on some people more than others. At least the scalpers are offering water for sale at all. Rarely have any of the outraged people rushed over to offer even a drop of their own water, at any price. If the scalpers are as greedy as their inflated prices, then the moralists shaking their heads are themselves infinitely greedier.

Blaming the scalpers for a lack of available water, or blaming pro-life doctors for lack of available abortion services and birth control, is, in the end, nothing more than crude scapegoating. It takes the focus, rather conveniently I might add, off of the collective failure for which the moralists themselves are implicated.

And the further irony is that the moralists’ proposed solutions often wouldn’t really help anyone overall. Scalping only works when there is an extremely limited water supply: i.e. there’s too little water to go around in the first place. If scalpers simply gave away all their supplies for free, there would still be too little water: in fact, in the end, there would be exactly the same number of people with and without water. All that would be different is the method by which these people would be chosen (and the usual alternative, first come=first serve, is arguably no more “fair” than rationing the supply by price, which at least has some built in mechanism for assessing people’s relative need for the water).

Likewise, if anti-abortion/anti-pill physicians and pharmacies left the business, as their foes seem to suggest they should, there would still be the same shortage of medical care and lack of access to birth control that we started with.

From where I sit, that makes this issue look a heck of a lot more like an act of partisan revenge than a sound policy or pro-patient principle.

If They Don’t Want to Do What (I Say) the Job Entails, They Should Find Another Job!

This second principle, uttered as if it were an obvious truism, is in fact an utterly bizarre essentialism. Obviously, if we are talking about an employer defining what “the job entails” and finding someone wanting, there’s no problem. But this isn’t the sense in which some people mean “the job.” They mean it in a more cosmic sense: turning mere convention into Platonic form.

Who says that the role of being an ob/gyn, a family doc, or a pharmacist must involve prescribing or dispensing contraceptives? What defines that role such that it’s supposedly essential to this or that specialty? Is this some sort of immutable law of the universe? No. To the extent that they are set and regulated at all, the required roles of various professions (and the permitted variations) are set by committee or political process, not fate. And those debates have to deal with the very political and ethical questions we’re already considering.

Thus, asserting that elective birth control must be part of the role of certain doctors is little more than a begged question. If you regard a fetus or even a fertilized embryo to be a being with moral rights, then harming it without dire need would not legitimately be part of the role of any physician. Reject that idea, and it’s a legitimate part of reproductive health and choice. I certainly have my opinions, but I also have a respect for the importance of social pluralism. And we cannot simply presume anyone’s opinion from the get go when determining what medical ethics demand or deny.

A more reasonable question is: can anti-abortion doctors be reasonably accommodated into our medical system with their existence causing serious additional harm to anyone? I think the answer is yes.

My opponents disagree. They imagine Jehovah’s Witnesses as ER docs who then refuse to transfuse blood to car accident victims. But these examples are absurd. No one would hire such a doctor to such a position in the first place, and if one did, it’s unlikely it could be licensed to accept emergency patients (who are often in a very different situation than a person seeking a physician or going to a pharmacy). On the other hand, plenty of people in the United States not only would have no problem with seeing an anti-abortion ob/gyn, but would favor going to one. Is denying the possibility of this choice even in keeping with the respect for autonomy that underlies pro-choice politics in the first place? I think not.

The early pioneers of reproductive choice knew that making it a reality meant actually physically and financially getting doctors and products out to women everywhere. If choice is a positive right and not just a negative one (i.e. not merely something that the government cannot ban, but something that must actively be ensured, presumably by society itself) then it’s going to take a tall order of money, time, and resources to supply it. Butting heads with anti-abortion doctors and pharmacists, or demanding they conform or go out of business, isn’t even remotely the same thing.


Obama Against “Mental” Exceptions to Late-Term Abortion Bans

July 4, 2008

Obama’s stance on abortion is pretty much in the mainstream of the Democratic Party, but with one critical difference when it comes to late-term abortions (i.e. abortions post fetal viability). And, luckily, for him, it’s precisely the exception I would make. Obama doesn’t think that “mental distress” should qualify as an exception to bans on late term abortions. This position puts him at odds with pro-abortion rights groups and members of his own party.

Still, I think it’s the right one. Anti-abortion groups have a legitimate fear that sufficiently vague “mental” health exceptions could undermine the point of the ban entirely: any person can develop “tremendous emotional toll” even from a normal pregnancy. But that really doesn’t fall under the same situation as health exceptions in general, and in practice, this exception can basically serve as an end-run around the ban. Groups like NARAL, of course, paint things differently:

The official position of NARAL Pro-Choice America, the abortion rights group that endorsed Obama in May, states: “A health exception must also account for the mental health problems that may occur in pregnancy. Severe fetal anomalies, for example, can exact a tremendous emotional toll on a pregnant woman and her family.”

This is yet another situation in which I wish people on both sides of the abortion divide would just express what they actually mean: what specific conditions is NARAL talking about? Conditions like anencephaly, where the brain essentially has not formed properly, and the baby has no higher brain function and no chance of survival beyond a few weeks? (I’m in favor of allowing abortion in such cases) Or does it mean Down’s Syndrome, a missing arm, or a partially malformed gut? All of the latter could be called “severe anomalies,” but such babies are essentially normal in terms of their capacity to feel and suffer. (I’m against abortion in such cases) The details matter.

In any case, while he’s sure to take fire from liberals on this, Obama has about as much chance of getting any honest credit for his stance as the New York Mets do of winning the Superbowl. Anti-abortion groups are, of course, having none of it:

David N. O’Steen, the executive director of National Right to Life, said Obama’s remarks to the magazine “are either quite disingenuous or they reflect that Obama does not know what he is talking about.”

“You cannot believe that abortion should not be allowed for mental health reasons and support Roe v Wade,” O’Steen said.

O’Steen is technically right here: a companion case to Roe was Doe v. Bolton, which defined “health” exceptions very broadly, including considerations of “emotional, psychological, familial” factors. But O’Steen is still essentially dissembling: the definition, while broad, is also vague enough that someone like Obama could reasonably believe that those other factors could almost never, on their own, justify an exception.

O’Steen, of course, has no reason to be charitable and honest in how he portrays Obama. Even if Obama really is closer to his own stance on this issue (which he already has a decent reason to doubt), Obama’s party taking power in the White House is far far more important to his chosen issue (outlawing abortion) than giving him credit for a minor agreement and risking rank-n-file anti-abortion voters potentially seeing Obama more favorably.

New Study: “Abstinence Only” Education Fails Again? Or Not.

June 8, 2008

Ed Brayton is making the case that a new study of high school students provides even more evidence that abstinence-only education has failed in its primary purpose: the reduction or delay in teen sex and disease transmission. The study, which looks to be quite good in terms of dataset and design, basically shows that the steady decline in teen sexual activity and the steady increase in condom use have both leveled off, and both changes came during the time in which abstinence-only education came into its heyday (the early and mid 2000s).

I’m no fan of abstinence-only policies, which are essentially a “pro-ignorance” approach to education. But I’m not so sure we really can take any clear policy conclusions away from this data.

The main reason is that, in the social sciences, we’d expect just about ANY trend to level off naturally whether there were other policy effects or not. Whatever the cause for the decline in teen sex since 1991, there’s only so much you can reduce teenage sexual activity in the first place before diminishing returns set in. The more you reduce teenage sexual experimentation, the harder and harder further decreases become.

This especially makes sense in terms of teens and sex. If we imagine that there is a sort of standard cohort of teens with a natural range of character traits and attitudes towards sex in each generation, then any external effect (like the AIDS scare) which reduces sexual activity is going to be more effective on some students, less effective on others. As this effect increases its influence on each cohort of kids, you’ll effect all the low hanging fruit first (the kids most scared of disease and ambivalent about sex to begin with), and the trend will be fairly large. But as you proceed, you’ve already dropped the sexual activity of many of the prudes down to 0 (and can’t go any further with them), and now what you have left to work on are the kids that are amongst the hardest to convince not to have sex in the first place. Even if the original effect increases dramatically (i.e. AIDS gets more and more scary), it still might not be enough to effect enough of the horniest kids fast enough to keep up the overall trend, year after year.

For all we know, this could be what’s going on here: major social changes in the early 1990s (AIDS, widespread contraception knowledge and availability) spent a decade spreading through the population, and now they’ve pretty much done as much as they can do. Buried underneath these larger trends, abstinence education could have had a positive effect, negative effect, or no effect at all.

All we really can say for certain, from this data, is that abstinence-only education hasn’t sparked any sort of dramatic or obvious revolution in teen prudishness. Other studies, which more directly compare the effects of abstinence-only education to other programs or no program at all, are far more relevant to the debate than this one.

Unintentionally Hilarious Republican Political Attack Ad

May 25, 2008

Over at the Agitator, when he isn’t worrying about the tiny matter of the President now having the power to send the military into a US suburb, abduct a U.S. citizen, and detain him without charges or legal rights for the rest of his life, Randy Balko is a pretty funny guy. In this case, he’s identified one of the silliest political attack ads I’ve seen in a long time.

(New Video Found)

Quips Balko:

I’m trying to figure out how the three dancers are supposed to represent “San Francisco values.” Maybe the black guy in the cowboy hat is gay? But then why is he dancing with two women? Maybe it’s because one of the women is white. But then, the white woman also has a lesbian haircut. Maybe it’s the dancing itself? Or they’re all illegal immigrants? Or they’re planning a visit to the abortion clinic after happy hour?

They should really be clearer about whom were supposed to be hating, here, and why.

Update: Someone didn’t like being made fun of: the original video seems to be gone., so I’ve tracked down another source. And this response ad has a clip of the dancing, though without the “San Fransisco Values!” voiceovers.

More on the Pinker/”Dignity” Bioethics Debate, A Reponse to Patrick Lee and Robert George

May 19, 2008

That Steven Pinker article “The Stupidity of Dignity” is now out in published form, and continues to be a source of controversy. For those who detest Pinker’s tone, Russell Blackford has his own, similar, take to the concept of dignity that he penned a few years ago in response to Francis Fukuyama.

A recent commenter suggested I give my own thoughts on one of the Bioethics Council’s “dignity” essays, and I figured I’d expand my comment into a fuller review. The essay/chapter in question is Patrick Lee and Robert P. George’s “The Nature and Basis of Human Dignity.” And they start off with a definition of dignity that I find problematic right off the bat:

Read the rest of this entry »

Fail? Critics Respond to Pinker’s Essay on “Dignity” as Ethically Worthless

May 17, 2008

In response to Stephen Pinker’s essay bemoaning the vacuity of “dignity” as a concept in bioethics, let’s highlight some critical responses from other thinkers: Yuval Levin, Ross Douthat, and Alan Jacobs.

Let’s accept every single one of their criticisms about Pinker’s tone, his paranoia, and his obviously less than impartial personal opinions about people like Leon Kass. Nevertheless, Pinker does very clearly and very directly raise a lot of serious, and possibly fundamental, problems with the concept of “dignity” in bioethics. And none of these writers seem interested in responding to that particular challenge. Which is too bad, because that’s really the only interesting part of the whole debate in the first place.

As one commenter said:

I’m not convinced Pinker has all the answers, but he seems to be taking the dignity argument more seriously than Jacobs, Douthat, or Levin. I tend to expect better of all three of those names. If Pinker was only 20% substance, that’s a higher percentage than any of the rest of us have achieved today.

Just to be a little provocative myself, let me say that I suspect the high regard that conservative scholars have for “dignity” lies in the fact that it, unlike the concepts of liberty and personal autonomy mediated by due process which have served us quite well so far, “dignity” is malleable enough that it allows the otherwise absurd idea that a random citizen sitting on their front porch is violating their own dignity by behaving in a way those scholars find distasteful (like licking an ice cream cone, or holding the hand of their gay lover). This also alleviates the often distressing inability to directly justify their dislikes as being immoral or harmful in any sensible, non-theological fashion.

“Dignity” also has the amazing power to declare morally important actions and objects that have no “personal” capacity in and of themselves: such as nerveless, intention-less cells that happen to have certain proteins active (i.e. fertilized eggs), but lack any objective capacity that anyone can tie to an ethical interest. If you can’t explain why breaking apart an embryo is morally wrong in any sensibly direct fashion, well then you can always argue that doing so is a sort of bitter voodoo-doll assault on humanity’s dignity, by proxy!

As is often the case, I’m being a little glib here myself. But I don’t think I’m entirely without merit either. It’s true that personal autonomy has it’s own gray areas and problems, but it at least makes sense on some concrete level, especially as a principle value in a diverse and contentious society, and that provides a far more promising foundation than a concept that seems to mean everything and nothing. Furthermore, many of its problems can be redressed far more easily than the critics I referenced above allow. Even under a personal autonomy framework, we can, for instance, still understand why respecting the wishes of someone when they are not actively awake or unconscious would be important.

In that spirit, here’s a much more intriguing and substantive response to the Pinker article, from another writer at the American Scene, Noah Millman.

Human Dignity: An Ethically Useless Concept

May 12, 2008

Last year Steven Pinker wrote a fantastic article on bioethics that somehow had escaped my notice until a commenter recently brought it to my attention: The Stupidity of Dignity.

The point of his essay is not, as one might fear, that human beings lack an inherent dignity or moral importance. It’s that the term “dignity” has been so constantly abused that it has become almost worthless in moral debates. It’s incoherently defined, capable of having nearly any property, even contradictory ones. And it’s all too often used simply as a proxy for the philosopher’s or theologian’s subjective dislike of some behavior or idea.

Here’s the key point of the article:

The problem is that “dignity” is a squishy, subjective notion, hardly up to the heavyweight moral demands assigned to it. The bioethicist Ruth Macklin, who had been fed up with loose talk about dignity intended to squelch research and therapy, threw down the gauntlet in a 2003 editorial, “Dignity Is a Useless Concept.” Macklin argued that bioethics has done just fine with the principle of personal autonomy–the idea that, because all humans have the same minimum capacity to suffer, prosper, reason, and choose, no human has the right to impinge on the life, body, or freedom of another. This is why informed consent serves as the bedrock of ethical research and practice, and it clearly rules out the kinds of abuses that led to the birth of bioethics in the first place, such as Mengele’s sadistic pseudoexperiments in Nazi Germany and the withholding of treatment to indigent black patients in the infamous Tuskegee syphilis study. Once you recognize the principle of autonomy, Macklin argued, “dignity” adds nothing.

The rest of Pinker’s article basically argues that despite an entire volume full of responses to Macklin’s challenge, the mostly conservative and religious Presidential Council on Bioethics have failed to answer it. In some cases, as with the notorious Leon Kass, they did worse than fail, exposing bizarre theocratic preoccupations that celebrate death and bemoan liberty in life.

A tour de force. Anyone know of any good responses to, or critiques of, this piece from conservative critics?