Degrees, thresholds, and the continuum of harm

In my introductory chapter, I conjured up a story about a doctor who abandons a patient in order to move her illegally parked car. My claim then was that, although her reason for refusing to treat the patient was a genuine moral belief which others might well share (‘I ought not to park my car illegally’), it seems clear that it doesn’t warrant the kind of moral weight that justifies abandoning a patient. To put it briefly, I suggested that the harm that the doctor would suffer if she ignored that belief in this case is unlikely to be significant enough to want to accord her belief moral weight. And indeed, throughout this chapter, I’ve been referring to ‘significance’ as a kind of threshold: if violating a belief would cause someone ‘significant’ harm, then that belief deserves ‘significant’ moral weight; otherwise, it doesn’t.

In other words, there seems to be a threshold of harm. It seems that we can draw a line on the ‘harm continuum’ somewhere, and say that all harms that lie beyond this line deserve to be accorded significant moral weight, while the rest don’t.

But I now want to make the claim that there’s actually no need to draw the line at all, at least at this stage. Why? Well, where there are degrees of harm, from the trivial to the severe, there are also corresponding degrees of moral weight, from the trifling to the weighty. So (I propose) we don’t need to legislate for a ‘significance’ threshold of harm, saying that only harms that surpass this threshold are worthy of moral weight. Instead, we should simply say that all potential harms have moral weight — and the degree of weight we grant to each one simply corresponds to the degree of harm that would be caused if it was violated. We should assign a large moral weight to an objection based on a belief that, if violated, would cause someone (a doctor, in this case) great emotional agony, and a small moral weight to one that would cause a moment or two of discomfort.

By the way, my view that all harms matter puts me at odds with Mark Wicclair again. Wicclair argues that considerations offered are sometimes not just outweighed but actually

completely cancelled by opposing considerations. He thinks, for instance, that a moral belief

has zero moral weight as a reason for respecting an objection if that belief lacks “consonance with the values of medicine” (Wicclair, 2000, pp.216-217; I considered this in detail in the previous chapter). He also thinks that tolerance has zero moral weight as a reason for respecting an objection when it clashes with considerations such as patient autonomy or

informed consent (something I will discuss in the next chapter). Now, I can see why Wicclair would have to make these claims if it were true that a reason for respecting an objection were completely cancelled by opposing considerations. But I have just argued that we need not accept that cancellation claim. Rather, it’s perfectly coherent to say that the fact of a doctor’s objection always carries some moral weight. The exact weight it carries will depend, of course, on the strength of the objection, the risk and gravity of harm to the doctor if it’s violated, and (if what I say in my next chapter is right) the extent to which that objection represents a position that ought properly to be tolerated. But — and this is the important point — its weight will not be zero, because all else being equal we may as well respect it. As I said in chapter 3, and as even the most stolid opponents of conscientious objection concede, surely some moral objections can be accommodated when this would result in no harm, or perhaps incredibly trivial harms, elsewhere.

The advantage of my position over Wicclair’s is that we don’t have to make an ad-hoc list of opposing features that, when present, are supposed to cancel the moral weight of the doctor’s objection. We can simply say that the objection always has moral weight in itself, and the question then becomes: in any given situation, is that moral weight outweighed by the opposing considerations?

Yes, this will mean that we are bound to assign some moral weight even to trivial harms, such as the suffering of my hypothetical doctor who feels bad about her parking violation. But, in my view, this is appropriate. We should not shy away from assigning non-zero but relatively low degrees of moral weight to minor harms. As long as the degree of moral weight we assign to each harm is proportionate to its severity — that is, as long as trivial harms have correspondingly trivial moral weights — all will be well. And we don’t lose anything this way. Remember that we are anyway going to weigh these harms against the harms that would be caused to others (e.g. patients) if we allowed the doctors in question to act on their beliefs, and we will use the outcome of this weighing process to determine whether we should actually let that happen. And that process, if we do it well, will ensure that the most trivial harms are easily outweighed even once acknowledged, while more serious ones are given due consideration and might win through if we judge them to be weightier than rival considerations. If we want to, we will still be able to say, for instance, that the opposing moral weight of acting in the interests of the patient will always (or almost always, or often) be greater than that of respecting the doctor’s objection — not because the

moral weight of the doctor’s objection is reduced to zero, but simply because patients’ interests are always (or almost always, or often) morally more important.

This brings me back to a point I made at the end of my introductory chapter about my approach so far. When I say that some objections have moral weight, I’m simply saying that they have features which count in favour of making allowances for them. This is not an entirely trivial claim (it stands in opposition to the claim that doctors’ moral objections are not even relevant) but it is not as significant as all that. I’m saying that some objections have ‘pro tanto’ moral significance, but not necessarily that they will be decisive in the final analysis.

And this is why, for all I’ve said in this chapter, I don’t think I have actually addressed a real-life fault line between proponents and opponents of conscientious objection by doctors. Even the most stalwart defender of doctors’ rights will concede that there are some more or less trivial objections which ought not to be granted in the final analysis because they are outweighed by the needs of patients, professional duties, or the justifiable expectations of society (I showed this with my car parking example). And equally, even the most stalwart opponent of allowing doctors’ personal moral beliefs to affect the care they offer will grant that some moral objections can be accommodated when this would result in no ill effects, or perhaps incredibly trivial ill effects, elsewhere; this was Savulescu’s point in the quote I offered in my introductory chapter (p.47 of this thesis).

Harm is harm, and the fact that it has moral weight ought not to surprise anyone. If

requiring a doctor to violate her belief would cause her harm, then this fact has some degree of moral weight, be it large or small. The important question is: should we, at the end of the day, insist that the doctor does as she’s told, or allow her to demur because of her personal beliefs? To answer this question for any particular situation, we need to weigh the harm inflicted by forcing her to act against her beliefs against other morally relevant

considerations, such as patients’ rights. The disagreement between, say, Wicclair and Savulescu is not about whether some particular doctors’ beliefs are of a particular kind that rises to the threshold level of significant moral weight; the disagreement is about the relative moral weights to be assigned, which will determine the outcome in each individual case. I will confront this disagreement later in my thesis. But before I do, there’s another factor I want to introduce: that of tolerance.

Chapter 4: