From the famous frontispiece of the original edition of Leviathan, by Thomas Hobbes
Canada is soon to have legislation permitting euthanasia and assisted suicide, as decreed by its Supreme Court last year. One question, however, over which some uncertainty hovers is how much wriggle room should be left for doctors who have ethical objections to the new regime.
For one of the country’s most influential bioethicists, Udo Schuklenk, the answer is straightforward: none.
In an article published last weekend, he wrote that “conscientious objection has no place in the practice of medicine”. If doctors feel that they cannot practice euthanasia or refer patients to another doctor for euthanasia, they should find another job.
Dr Schuklenk is worth listening to. He is the co-editor of Bioethics, one of the world’s leading journals in the field, and a professor of philosophy at Queen’s University, in Ontario, Canada. He was one of the authors of an influential white paper commissioned by the Royal Society of Canada for the debate which eventually led to legalisation.
His stand on conscientious objection is not new, but the timing is significant. Bill C-14 was introduced into the Canadian parliament last week implementing the Supreme Court ruling.
Only doctors will be allowed to perform euthanasia, but it is still not clear whether they will have the option of conscientious objection. Dr Schuklenk’s essay in the Journal of Medical Ethics (written with a colleague, Ricardo Smalling, also from Queen’s University), is sure to influence the debate in the weeks before the Supreme Court’s June 6 deadline for passing legislation.
Some Canadian doctors already fear that they will be forced to perform the procedures or refer patients to more compliant doctors. Writing in the Canadian Family Physician, one general practitioner, Dr Nancy Naylor, declared that she was throwing in the towel:
“I refuse to let anyone or any organization dictate my moral code. For this reason I am not renewing my licence to practice medicine. I have practiced full scope family medicine, including palliative care for the past 37 years and solely palliative care for the past 3 years. I have no wish to stop. But I will not be told that I must go against my moral conscience to provide standard of care.”
Such words will not move Schuklenk and Smalling. In a nutshell, they contend that medical professionals have made a contract with society. In return for a lucrative monopoly on the provision of an essential service, patients have a right to demand that they provide them with legal and socially acceptable services. “Forcing patients to live by the conscientious objectors’ values constitutes an unacceptable infringement on the rights of patients.”
By withholding their services, doctors are also are exploiting the power differential between them and patients. They cite approvingly American bioethicist R. Alta Charo, who has said:
“claiming an unfettered right to personal autonomy while holding monopolistic control over a public good constitutes an abuse of the public trust—all the worse if it is not in fact a personal act of conscience but, rather, an attempt at cultural conquest”.
And finally, they believe that conscientious objection, based as it is on indemonstrable premises, is arbitrary and fickle. “Today it might be abortion and assisted dying, tomorrow it might be the use of the tools of personalised medicine or something else altogether.”
Now here’s the interesting part: the writers cite Leviathan, a pioneering political tract by the 17th century philosopher Thomas Hobbes, in support of their attack on the rights of conscience. It’s a tell-tale reference, for Hobbes is generally regarded as intellectual patron of the modern totalitarian state.
Hobbes was writing in a time of bitter religious conflict. A civil war in the middle of the 17th century divided England between royalist Cavaliers, mostly Anglican, and parliamentarian Roundheads, mostly Puritans and Presbyterians. For a decade armies crisscrossed Britain and Ireland. A hundred thousand people or more died in England; in Ireland, 40 percent of the population may have perished.
Hobbes had a gutful of pointless disputes by the king’s subjects over religion. Disagreement led to slaughter and anarchy; peace depended on obedience to the sovereign, or the government, which was, in his words, “that mortal god to which we owe, under the immortal God, our peace and defence”. Unanimity is the hallmark of Hobbes’s state: “seeing a Commonwealth is but one person, it ought also to exhibit to God but one worship”. In these words are the seeds of both the Nazi Leviathan and the Communist Leviathan.
With this in mind, it is astonishing that Schuklenk and Smalling open their argument by citing Hobbes on the question of freedom of conscience. They point out that the subject of Hobbes’s sovereign has no need of an individual conscience, for “the law is the public conscience by which he hath already undertaken to be guided”. Doctors and other healthcare workers in Canada ought to heed this ominous allusion. The euthanasia Leviathan will brook no opposition. And they admit quite candidly their admiration for Hobbes:
“Of course, Hobbes is not quite our archetypical defender of liberal democracies, but the point he is making here is valid, it applies to the case of conscientious objectors in liberal democracies, too.”
Yes, there will be problems in trying to accommodate conscientious objectors to euthanasia, but the answer is not a new totalitarianism.
The problem with an ethical framework in which conscience has no rights is that it works too well – not just in Canada, but in, say, Saudi Arabia. If a doctor there refused to amputate the hand of a thief, would Professor Schuklenk argue that he should to get another job? If he shrank from female genital mutilation, would Professor Schuklenk write a white paper suggesting that refusniks be fired?
When William and Mary came to the throne in 1688, England faced much the same problem as Canada does today. Britain was a patchwork of antipathetic religions: Anglicans, Presbyterians, Catholics, Puritans, and a bewildering variety of non-conformists such as Quakers, Baptists, Socinians, Muggletonians, Ranters, Philadelphians, Levellers and Diggers. England’s great achievement was to repudiate the idea of the all-powerful sovereign and accommodate these opposing beliefs without too much friction.
In their call for the abolition of conscientious objection Schuklenk and Smalling are effectively turning the clock back to 1651, the year Hobbes published Leviathan. If Canadian MPs listen to them, 300 years of liberal democracy are at risk.
Michael Cook is editor of MercatorNet.