As a science and practice transcending metaphysical and ethical disagreements, ‘secular’ medicine should not exist. ‘Secularity’ should be understood in an Augustinian sense, not a secularist one: not as a space that is universally rational because it is religion-free, but as a forum for the negotiation of rival reasonings. Religion deserves a place here, because it is not simply or uniquely irrational. However, in assuming his rightful place, the religious believer commits himself to eschewing sheer appeals to religious authorities, and to adopting reasonable means of persuasion. This can come quite naturally. For example, Christianity (theo)logically obliges liberal manners in negotiating ethical controversies in medicine. It also offers reasoned views of human being and ethics that bear upon medicine and are not universally held—for example, a humanist view of human dignity, the bounding of individual autonomy by social obligation, and a special concern for the weak.
- Religious Ethics
- Cultural Pluralism
- Moral and Religious Aspects
- Philosophical Ethics
- Political Philosophy
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- Religious Ethics
- Cultural Pluralism
- Moral and Religious Aspects
- Philosophical Ethics
- Political Philosophy
Why secular medicine should not exist
Does secular medicine exist? In the sense of empirically based medical science and practice, of course it does. But should it exist? In the sense of a medical body of knowledge and practice that pretends to be rational—and so to command the consent of all reasonable people—by excluding religious belief, no, it should not.
Empirical medical science raises questions that are not susceptible of an empirical answer. It can tell us about the development of the human fetus, for example, but it cannot tell us what a ‘person’ is or at what point the fetus becomes such a thing: those are philosophical or theological questions. Nor can medical science tell us under what conditions it is permissible to kill a person: that is an ethical question. Questions of philosophical or theological anthropology, or questions of ethics, cannot be answered simply by appeal to empirical data and thereby to medical science. That does not mean that their answers are irrational: appeal to hard empirical data is not the only form of reason. So are appeals to moral intuitions about what is good and right, to logic and rational consistency, and even to beauty. However, given the long-standing controversy that attends such issues as the definition of the human person and the conditions for permissible killing, it is clear that applying ‘reason’ to such matters does not produce consensus, and nor is it likely to any time soon. So the ideal of secular medicine as a realm of reason and therefore as untroubled by deep metaphysical and moral disagreements is a fantasy. Even if medicine were religion-free, its peace would still be disturbed by disputes between philosophical schools—Aristotelian, utilitarian and Kantian, to mention only a few.
Why religion is not simply irrational
Religion, therefore, is not uniquely awkward. It is not the only disturber of the peace in the ethics of medical practice. Philosophy can disturb perfectly well on its own. Nevertheless, it is widely supposed that religion should be kept out of ‘secular’ space—whether medical or educational or political—because it is by nature irrational and dogmatic. After all, religion is a matter of faith, not reason, is it not?
Yes and no. For sure, some religious believers can believe some violently irrational things—for example, that God commands them to detonate suicide bombs in Baghdad marketplaces or on the London Underground. Violent irrationality, however, is not the creature of religion as such: the practice of suicide-bombing was pioneered by the secular, political separatist movement, the Tamil Tigers.
It is true that religious believers believe in things that they cannot put under a microscope or demonstrate mathematically—God's existence, for example, or cosmic teleology or the afterlife. But, then, many unbelievers have faith in human dignity and in the unstoppable progress of human history, neither of which can be proven empirically or logically, and both of which attract rational doubts.
So the fact that religion involves faith (in the sense of belief that outruns proof) does not mean that it is bereft of reason. Unbelievers, of course, doubt that religion commands sufficient reason. But believers beg to differ.
Plural secularity instead of antireligious secularism
Secular space—whether in medicine or elsewhere—cannot expect to be free of conflict between rival kinds of reasoning (pace Jürgen Habermas and John Rawls).i In medicine, conflict is an irremovable fact of life at the metaphysical and ethical levels. Secular space, therefore, is not and should not pretend to be neutral, transcending conflict. According to its original meaning, developed by Augustine of Hippo in the early 5th century AD, the word ‘secular’ refers to the time before the complete establishment of divine order in the world. The saeculum is the age of spiritual and moral mixture and ambiguity. In this secular age, peace in political society is the result, not of natural uniformity, but of negotiation and provisional compromise between rival viewpoints.
This Augustinian conception of secularity is more consonant with a genuinely liberal, plural political ideal than the dogmatically antireligious, secularist version. And if we admit that religion is not simply, invariably or uniquely irrational, then it follows that it should be allowed to sit at the table of public negotiation—whether in the legislature or in the governing body of a professional (say, medical) association or institution. To take a seat at the negotiating table, however, implies a readiness to negotiate and so to persuade; and that has implications for what one does at the table, for how one behaves. To persuade, one must become persuasive.
Persuasive religion and the abortion controversy
For religious believers, what does this mean? First of all, it requires the abandonment of all sheer appeal to authority—whether to that of the Bible or of the Pope or of the Qur’an. Such appeals are imprudent and disrespectful. They are imprudent, because they are unlikely to move those who do not recognise them. But they are also disrespectful, because they fail to notice that, in a secular and therefore plural context, the people addressed might not share the believer's assumptions. To appeal to religious authority, therefore, is to refuse to engage with the auditor's difference, pushing past as if it were so stupid or wicked as to be beyond rational consideration. To unbelievers this is bound to seem insensitive and gauche, if not high-handed and insulting.
Positively, if I, a religious believer, am going to succeed in persuading you, an agnostic or atheist or different kind of religious believer, of my moral view, then I will have to show you that your view has weaknesses or problems, that these cannot be adequately repaired in your terms, but that they can be repaired in mine. So, for example, if you are an uncompromising advocate of women's right to choose whether or not to abort a pregnancy, I would point out that there are no very strong reasons why such a right should cease upon the birth of a child. If women have the unqualified right to kill fetuses, there is no very cogent reason why they do not have the right to kill infants. The Romans used to accord this right to the male parent (until Christians had it withdrawn), and some contemporary utilitarian philosophers are now arguing that it should be restored to parents in general.3 Suppose that you, the ‘pro-choice’ advocate, agree with me that giving mothers the right to kill infants would not be a good idea, if we want to have a humane society where weaker persons are not abused by stronger ones. If you agree with me on that, then you are bound, I suggest, to reflect critically on what it is about a child that rightly constrains the mother's liberty to kill it, and then to go on to ask whether that property is ever acquired by the fetus, and, if so, when. In other words, you are bound to take seriously the issue of the status of the fetus, and not just the mother's freedom. Once I have persuaded you onto that territory, you might come to agree with me that the same reasons for according a child the right not to be killed by its mother apply more or less equally to the fetus at a certain point. We can argue, of course, about where that point is; and we might not agree. But wherever you eventually decide to draw the line, you have ceased to be simply ‘pro-choice’ and I have succeeded in persuading you to move towards my moral position.
‘My moral position’, yes; but what's religion got to do with it? Religion has the following to do with it. As a Christian monotheist, I esteem the lives of human individuals very highly: all individuals are equally the creatures of one divine Father, and each has a special vocation in their time and place. As a consequence, even if I believe that it can be morally right for one individual to take another's life, I think that killing is a morally and socially hazardous business and that it should never be done casually and without cogent reason.
What is more, as a religious believer who finds in the life, teaching and death of Jesus crucial clues about the nature of the human good or flourishing, I believe that living well involves meeting obligations as well as claiming rights, and that sometimes meeting an obligation can be seriously costly.
Further, as a believer who regards as authoritative the prophetic tradition of the Bible, I am sensitive to the plight of the ‘poor’—that is, the weak and vulnerable. Historically, of course, this category includes women, and in many parts of the world it continues to include them. But it also includes immature human beings, certainly children and arguably fetuses, at least beyond a certain point in their development.
Further still, as an Augustinian Christian I see history as morally ambiguous and sometimes tragic. In regard to many moral issues, there may well not be a perfectly satisfactory solution. We may have to settle for a somewhat messy compromise. We may have to admit that it is not clear at what point a developing human being becomes a person deserving of the civil right not to be harmed under normal circumstances. We may have to draw a line at a point that commands some reason, but not very strong reason. Nevertheless, it is far better that we admit the uncertainty that attends the status of the fetus than that we pretend that it is not an important consideration at all.
Finally, as an Augustinian Christian I also think that the roots of human wrongdoing reach far deeper than mere ignorance or social malformation. They lie in our loving the wrong things or loving the right things wrongly. They have to do with our worshipping things that are not worthy of our worship, and our being possessed and driven by them. Therefore, the danger that faces a liberal society that emphasises individual freedom, specifies freedom as a freedom to choose, and exposes the individual to the excitation and engineering of material loves or appetites by commercial powers, is that it creates a society whose citizens are psychically incapable of seeing beyond their own inflated stomachs and paying due attention to the rightful needs of others. The danger facing a liberal society that is substantially consumerist is that it grows citizens who are disposed to be careless of others, and especially careless of fetal others, who can barely kick back.
My purpose here is not to offer a conclusive argument in favour of my Christian view of abortion, but rather to point out the religion that lies behind my moral views, and the religious nature of the ground onto which I would like to persuade the uncompromising ‘pro-choice’ advocate. At this point a sceptical reader might be inclined to say, “That's all well and good, but much of the moral position you occupy does not require religious belief. For example, you don't have to be religious to have a high regard for human individuals, or to recognise moral obligations as well as rights, or to be sensitive to the needs of the vulnerable, or to be alert to the morally corrosive influence of consumerist liberalism”.
To this I would reply that I have not yet claimed that my moral view is one that only Christian monotheistic religion can ground. My claim so far is merely that this is a view that such religion does ground, and that it is therefore a religious view, even if not exclusively so. Whether there are equally good or better grounds is a topic about which we have yet to argue. If I succeed in persuading you that, all things considered, my religious ground is more supportive than the alternatives, then the moral view of abortion to which I have persuaded you will seem religious in an even stronger sense.
Religion as a matrix of liberal manners
Religion is, of course, famous for its bad manners. Stereotypically, it is dogmatic, strident, unreasonable and violent. But a stereotype is only a stereotype: it presents as typical what is in fact occasional. For sure, sometimes religion does live down to its stereotype, but not always. And, again, religion does not have a monopoly of dogmatism and stridency: atheism, whether fascist or communist or even just Dawkinsian has been known to stop its ears and turn up the volume.
But if religion is sometimes a source of bad behaviour, it can also be a source of good. So, during one of the periods of European history that gave rise to the secularist stereotype of religion, the so-called Religious Warsii running from the mid-16th to the mid-17th centuries, pleas for tolerance and reason were heard to arise from Christian lips, long before they rose from Enlightenment ones. I think here, for example, of the Anglican Lucius Carey, Lord Falkland, who was eloquent in his appeals for pacific reasonableness in the face of the religious and political polarisation overtaking England in the 1630 s.iii Sometimes religion can be, not at all the sworn enemy of generous, liberal attitudes, but their very mother.
In case this seems unlikely, let me explain how this can be. Christianity is structurally humanist in its credal affirmation of the special dignity of human beings made in the image of God—a dignity intensified by God's assumption of human flesh in the Incarnation. According to this high vision, human beings are not merely the random result of the blind operation of physical forces, nor their activity simply determined by genes or chemistry, nor their asserted significance just so much desperate whistling in the enveloping cosmic dark. Rather, humans are the creatures of a benevolent divine intelligence, which has striven through natural evolution to bring about individuals who flourish in freely understanding the truth about the world's good and investing themselves in it.
In such a vision, there is truth—be it sometimes complex and internally plural—to be understood: as the creation of the one wise God, the world possesses a given rationality that is there for rational beings to grasp. The point of engaging in conversation with other human beings, therefore, is to discover the truth—and not, for example, simply to bend their will to your own.
Further, according to this vision of things, human beings are rational but finite and fallible, and they are made to flourish in society. Therefore their reasoning needs to be social: they need to reason together. Conversation, therefore, is an important social endeavour. It is not properly an occasion for the egotistical display of wit, for the scoring of clever points, for the assertion of superior rhetorical power, or for the domination of the weak by the strong. It is rather about the common searching out of the truth, and common deference to its authority.
Believing as it does in the unity and rationality of things, Christian humanism dignifies human conversation with a serious moral significance. It also has the resources to grace it with generous, liberal virtues: an openness to being taught and corrected, since humans are finite and fallible; a readiness to confess conversational dishonesty, since we are also sinners; respect for others as potential speakers of the truth, since everyone is a potential medium of God's Word; a tolerance of strange and unwelcome views, since finitude and fallibility forbid us to identify the true with the familiar; patience with frustrations in understanding, since truth is as much self-revealing as grasped, and since faith sustains the hope that what is now seen through a glass darkly shall yet be seen face to face; and forgiveness as a reaction to conversational injustices like wilful misrepresentation, provocative contempt and evasive sleights of hand—since all victims are perpetrators too.
Christian monotheism fosters a view of reality, in which attitudes such as these appear as conversational virtues, not vices. And the pacific negotiation of disagreements—especially emotive, ethical disagreements—in secular, plural societies needs virtues such as these. It needs citizens who are so formed as to be capable of restraining themselves, of transcending themselves so as to hear uncomfortable truths, of intellectual and existential courage, of admitting error, of absorbing and forgiving petty injury, of hopeful and resilient patience, and of countenancing compromise without sinking into despair or cynicism. The typical liberal virtues of respect, tolerance and fairness are just not enough to see us through the storms of controversy, especially when the storms persist for years, even decades.
From manner to content (1): Christian support for humanist medicine
One important contribution that the Christian monotheist version of religion can make, therefore, is to foster a set of conversational virtues that will help to make the conduct of public controversy about emotive issues in medical ethics liberal, not just in the sense of free and open, but also in the sense of generous—‘liberal’ as in ‘liberality’. Christianity can help keep the manner of conducting bioethical controversy generous and cooperative. But beyond manner, what about content? What has Christianity got to offer bioethical discussion materially, as well as formally?
First of all, through its humanism it offers support for substantive notions of universal human dignity, basic human equality and natural human rights. For sure, these notions are now widely affirmed outside of the Christian religion, but their affirmation is by no means universal. Moreover, some eminent contemporary philosophers doubt that they have any secure theoretical home outside of a theological framework.iv
Religion, at least in its Christian monotheistic form, offers a worldview in which notions of universal human dignity and equality make sense. It offers theoretical support for humanism. And this support is needed, for not all worldviews do support humanism, and some actually corrode it. For example, the Hobbesian picture of the human world as a no-holds-barred war of each against all, until self- interested prudence guides the instinct of self-preservation to make social contracts, is not at all a flattering one. At natural base, Hobbes’ human beings are brutes, driven by the fear of pain and death; and this is the corrosive anthropological assumption that underlies much modern political philosophy and most attempts to reconstruct ethics on the basis of natural evolution.
Not all worldviews support humanism. Humanism, and the liberal ethos that depends on it, are not the natural, default position. Awareness of this was one of the main motives behind the work of the pre-eminent modern theorist of liberalism, the late John Rawls. Rawls was aware that liberal values and the larger humanist views that support them are not universally held, and that a liberal ethos is therefore contested and vulnerable. There will always be views that would suppress it, and there is no guarantee that these will not prevail,9 as they did in the Weimar Republic.10 Liberal virtues comprise political capital that can depreciate and constantly needs to be renewed.11 Consequently, Rawls was eager to build as broad as possible an alliance of support for a liberal ‘overlapping consensus’ and, in striking contrast to liberal secularists, he sought allies in ‘reasonable’ forms of religion—such as certain kinds of Catholic Christianity and Islam.
So, Christian monotheism supports humanism—but what has that got to with medicine? The relevance of humanism to medicine is that it affirms that the primary purpose of medical practice is the promotion of human well-being. That might seem so obvious a truth as to hardly need stating. In fact, it is not as obvious or as universally accepted as it looks. Humanism affirms that the proper purpose of medicine is the service of the well-being of all human beings—not just the Greeks, but also the barbarians; not just the citizens, but also the slaves; not just the rich, but also the poor; not just the articulate, but also the illiterate; not just those capable of living the kinds of life we hold dear, but also those who cling to kinds of life we reckon worthless; not just those who will reward our sleepless efforts by recovering, but also those who will stubbornly defy them by dying. The equal dignity of all human beings is easy enough to sign up to in principle. In practice, however, it is much harder to recognise in the actual faces of the old, the awkward, the ugly, the demented and the moribund.
What is more, the medical profession, like any other, is about career and status and promotion; and if a medic is of an academic bent, it can also be about the solving of knotty scientific problems. This means that the motives of physicians, nurses and other healthcare professionals are several, not single; and where there are several motives, there is scope for conflict. That, then, poses the question, “Are you being formed into the kind of medical professional, whose loves are so well ordered that you are capable of putting the best interests of your patients first?”
Further still, human beings like having power and medical professionals have a lot of it. There is nothing wrong with power as such, for without it we can achieve nothing. But the possession of power involves temptation. We like feeling powerful, and one way to feel powerful is to dominate and manipulate others. This is a temptation for healthcare professionals. Take, for example, the infamous English case of Dr Harold Shipman, the general practitioner who was convicted in 2000 of murdering 15 patients by lethal injections of diamorphine, but whose victims—mostly elderly and mostly women—are reckoned to number about 250. No one knows why he did it, and no one ever will, since he hanged himself in prison in 2004. In some cases there appears to have been a financial motive, but not in all. I speculate that, in addition to greed, the sheer pleasure of power probably had something to do with it; and in support of my speculation I note that serial killers are commonly supposed to be obsessed with manipulation and control—of which suicide is a further expression.
The humanity of medicine is not something that we can afford to take for granted. We need medical professionals whose particular view of the world—of what is good and right, of what makes moral sense—forms them in the virtues that make them capable of practising medicine humanely. Christian monotheism is one such view.
From manner to content (2): a Christian view of physician-assisted suicide and voluntary euthanasia
So far my discussion of what Christian monotheism can contribute to the content of secular, plural medicine has been general: a conviction about the equal dignity of all human beings (or at least persons), and a sense of primary obligation to serve their well-being. Here I will become more specific, taking as an example the practical issue of the legalisation of physician-assisted suicide (PAS) and voluntary euthanasia. What does Christian monotheism bring to the discussion of the ethics of these as medical practices?
Both sides in the debate about PAS and voluntary euthanasia (henceforth, ‘euthanasia’) are concerned about human welfare. Those who argue in favour of making it legal for doctors to assist patients to commit suicide or to kill them upon request are concerned about the wretchedness of the lives of the patients. Those who argue against legalisation are not unconcerned about the wretchedness of patients who want PAS or euthanasia, but they are also concerned about the practical ramifications of legalisation with regard to other patients. The decisive question, it seems to me, is whether it is possible to permit doctors to perform PAS or euthanasia without weakening a general societal commitment to support human life in adversity, and without exposing vulnerable patients to subtle pressure to choose to die. What does Christian religion contribute to an answer to this question?
One thing is a healthy suspicion of ‘autonomy’. Christian tradition has long recognised a limited sphere of autonomy, where the individual should be free to make up her own mind about what moral obligations and vocations require in a particular case, here and now. This is what is commonly known as ‘conscience’. But the freedom of conscience is a morally responsible freedom. It operates within the bounds set by objective moral obligation and vocation. It does not vault itself above them. Immanuel Kant would not have demurred: for him, the individual's autonomy is exercised under the moral law that is given in and with universal human rationality. With this kind of morally responsible autonomy, Christianity has no quarrel.
Usually, however, the kind of autonomy that is asserted in the debate about PAS and euthanasia is not of this qualified, responsible kind. Rather, it is absolute and libertarian, as in “My life is my property, and I have the right to dispose of it when and how I choose”. To this the Christian should, in my view, respond: “Whether or not you have such a right is not something that you can establish merely by asserting it. It depends on whether or not you are subject to overriding obligations to other people, which constrain your choice of PAS or euthanasia”. Are there in fact such obligations? There would be, if granting a certain class of patient the right to PAS or euthanasia would undermine any societal commitment to support human life in adversity, and if it would expose a much larger number of patients to abusive manipulation. If that were the case, then larger considerations of social good would preclude the granting of a small class of individuals the right to PAS or euthanasia.
“If that were the case”: but is it in fact so? The answer to this is necessarily speculative, but it is not therefore fanciful. It can appeal to reasonable considerations of logic, of experience, and of human nature. Among these, a Christian formed by religious belief and practice to care for the equal dignity of all humans and to be especially sensitive to the plight of those at the bottom of the social heap, would point to the fact that in the USA and the UK the minority of those lobbying for the right to PAS tends to be economically secure, highly educated, articulate, independent and accustomed to control, whereas the majority of patients are far less self-confident, far more dependent on others and therefore far more vulnerable to abuse. In the UK, as Rabbi Julia Neuberger has pointed out in her 2008 book, Not Dead Yet: A Manifesto for Old Age, at any one time about 500 000 elderly people are being abused, mostly by close relatives.12 In such circumstances, it is not wilfully pessimistic to suppose that, if patients were granted a right to PAS, many of them would be persuaded to choose it as a means of ending misery that is socially manufactured. The humanity of a society is to be measured by its care for the most vulnerable: to grant patients the right to PAS, where social circumstances such as I have described obtain, would be to abandon many of the poor to the mercy of unscrupulous relatives.
In this essay I have argued that medicine should be considered ‘secular’, not in the secularist sense of being religion-free, but in the Augustinian sense of being a forum for the negotiation of rival metaphysical and ethical views. I have argued that religion deserves a place at the secular table of negotiation, because it is not simply or invariably or uniquely irrational. Nevertheless, in deciding to take a seat at the table, the religious believer commits himself to being persuasive, and that involves abandoning any sheer appeals to religious authorities, thinking one's way sympathetically into the viewpoint of one's opponent, identifying points of common ground, and then reasoning her—step by step—towards one's own position. So, yes, religion must learn table manners—it must learn to behave in public.
Sometimes, however, religion does not need to be constrained to behave. Sometimes it behaves well naturally, because its own convictions naturally generate the virtues that sustain good behaviour. Sometimes, as John Rawls recognised, religion can be an important matrix and model of generous, liberal conduct. One example of such religion is Christian monotheism.
So monotheism does bring good manners to the negotiating table, and it also brings particular views of human being and ethical issues, which command reasons. It models form and it provides reasoned content. One general instance of such content is a high, humanist view of human dignity, which is not an inevitable part of the cosmic furniture and which we cannot afford to take for granted. Other, more specific instances are the notions that individual autonomy is properly bounded by social obligation and a special sensitivity to the plight of the poorer and weaker.
Competing interests None.
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↵i Habermas and Rawls are two leading political theorists of liberalism, both of whom aspire to a form of public discourse—‘secular reason’ in the case of Habermas, ‘public reason’ in that of Rawls—that transcends deep metaphysical and ethical conflict. For further discussion of this, see references 1 and 2.
↵iii For example: “I confess this opinion of damning so many, and this custome of burning so many, this breeding up those, who knew nothing else in any point of religion, yet to be in a readinesse to cry, to the fire with him, to hell with him … If any man vouchsafe to think, either this, or the author of it, of value enough to confute the one, and informe the other, I shall desire him to do it … with that temper, which is fit to be used by men that are not so passionate, as to have the definition of reasonable creatures in vaine, remembering that truth in likelyhood is, where her author God was, in the still voice, and not the loud wind …”.5
↵iv Thus Jeremy Waldron: “I actually don't think it is clear that we—now—can shape and defend an adequate conception of basic human equality apart from some religious foundation”.6 Thus, too, Raimond Gaita: “The secular philosophical tradition speaks of inalienable rights, inalienable dignity and of persons as ends in themselves. These are, I believe, ways of whistling in the dark, ways of trying to make secure to reason what reason cannot finally underwrite. Religious traditions speak of the sacredness of each human being, but I doubt that sanctity is a concept that has a secure home outside those traditions”.7 And even Habermas has gestured in the same direction, saying in an interview with Le Monde that religious traditions “have the distinction of a superior capacity for articulating our (presumably, liberal humanist) moral sensibility” and that secular society cannot afford to sever itself from these “important resources of meaning”.8
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