must we always respect religious belief?

1
HASTINGS CENTER REPORT 3 January-February 2007 I n her interesting and suggestive article, “Tales Publicly Al- lowed: Competence, Capacity, and Religious Belief,” Adrienne Martin begins with a case that Tom Beauchamp and I discuss in Principles of Biomedical Ethics. The case in- volves a person she calls “Ray,” who generally acts normally but who has been “involuntarily committed to a mental in- stitution as the result of bizarre self-destructive behavior (pulling out an eye and cutting off a hand) [because of ] his unusual religious beliefs.” Martin argues toward two conclu- sions: “that capacity and competence come apart, and that there may in some circumstances be reasons to allow an inca- pacitated person to make her own treatment decisions,” in- cluding, but not limited to, religiously based decisions. Martin raises important questions about capacity and competence and how to view and treat religiously based be- liefs and practices in health care. Her arguments merit close attention; ultimately, though, I find them unconvincing. Her second conclusion involves an argument that some re- ligiously based decisions are “incapacitated,” but that our so- ciocultural respect for religious beliefs and practices leads many bioethicists to view decision-makers as both capacitat- ed and competent to make their own decisions. Martin’s oth- erwise valuable contribution to this important topic is marred by unnecessary and unwise conceptual gymnastics and by se- rious misinterpretations both of Principles of Biomedical Ethics and of the broader bioethical discussion. Martin insists on a sharp distinction between capacity and competence, the former having to do with rational capabilities and the latter with moral status as a decision-maker. She writes that “Beauchamp and Childress exemplify the com- mon view that capacity is both necessary and sufficient for having the status of a competent decision-maker.” While ca- pacity and competence are closely intertwined in our analysis, we do not hold that capacity is necessary and sufficient for competence in her sense of the term. There may be reasons for allowing a person of diminished capacity to make deci- sions in some cases and for not allowing a person with full ca- pacity to make decisions in other cases. If a person has the specific capacity to make a decision, then according to our conception, that person is competent to make that decision. However, such a person does not have an absolute right to make that decision, and others do not have an absolute duty to respect that decision. Such a right or a duty is, at most, only prima facie. For instance, a person’s right to decide may be legitimately overridden in order to prevent some, but not all, harms, costs, and burdens to others. Martin also misstates the way Beauchamp and I approach religious beliefs and practices in the context of health care. Martin claims that Beauchamp and I, like many others, fall into a “trap”: We want to respect religious beliefs and prac- tices, particularly by nonintervention or noninterference, and in order to do so, we hold that religiously based decisions must be “capacitated” (her term). That is a trap, but we don’t fall into it. In my judgment— and I do not claim to speak for Tom Beauchamp on this point—even though a policy that automatically treats persons with unorthodox or bizarre religious beliefs as less than com- petent is indefensible, some people with those beliefs are in- deed incompetent in certain cases, and Ray may be one. If so, then weak paternalistic interventions (based on Ray’s limited capacity and his risk of harm) would be warranted. But even if we reach a different conclusion about his capacity, we should not rule out the possibility of a strong paternalistic justification for intervention. (Indeed, later in Principles of Biomedical Ethics, we discuss a very similar case and indicate that a strong paternalistic intervention can be justified in that case, even though it violates a substantial autonomy interest because it conflicts with the religious views “central to the pa- tient’s life plan.”) Furthermore, when a person is seriously maiming himself, as in this case, forcible intervention is war- ranted because of the heavy burden and costs such injuries impose on others. The central point is just this: if a policy implies that those who have unorthodox or bizarre religious beliefs are less than competent, even if they reason clearly in light of their beliefs, then it “is morally perilous and fails as a policy (without spe- cific and careful qualification).” 1 This point certainly cries out for elaboration, but it is sound. 1. T. Beauchamp and J.F. Childress, Principles of Biomedical Ethics, 5th ed. (New York: Oxford University Press, 2001), 187. James F. Childress is the John Allen Hollingsworth Professor of Ethics at the University of Virginia. Must We Always Respect Religious Belief? By JAMES F. CHILDRESS another voice

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H A S T I N G S C E N T E R R E P O R T 3January-February 2007

In her interesting and suggestive article, “Tales Publicly Al-lowed: Competence, Capacity, and Religious Belief,”Adrienne Martin begins with a case that Tom Beauchamp

and I discuss in Principles of Biomedical Ethics. The case in-volves a person she calls “Ray,” who generally acts normallybut who has been “involuntarily committed to a mental in-stitution as the result of bizarre self-destructive behavior(pulling out an eye and cutting off a hand) [because of ] hisunusual religious beliefs.” Martin argues toward two conclu-sions: “that capacity and competence come apart, and thatthere may in some circumstances be reasons to allow an inca-pacitated person to make her own treatment decisions,” in-cluding, but not limited to, religiously based decisions.

Martin raises important questions about capacity andcompetence and how to view and treat religiously based be-liefs and practices in health care. Her arguments merit closeattention; ultimately, though, I find them unconvincing.

Her second conclusion involves an argument that some re-ligiously based decisions are “incapacitated,” but that our so-ciocultural respect for religious beliefs and practices leadsmany bioethicists to view decision-makers as both capacitat-ed and competent to make their own decisions. Martin’s oth-erwise valuable contribution to this important topic is marredby unnecessary and unwise conceptual gymnastics and by se-rious misinterpretations both of Principles of Biomedical Ethicsand of the broader bioethical discussion.

Martin insists on a sharp distinction between capacity andcompetence, the former having to do with rational capabilitiesand the latter with moral status as a decision-maker. Shewrites that “Beauchamp and Childress exemplify the com-mon view that capacity is both necessary and sufficient forhaving the status of a competent decision-maker.” While ca-pacity and competence are closely intertwined in our analysis,we do not hold that capacity is necessary and sufficient forcompetence in her sense of the term. There may be reasonsfor allowing a person of diminished capacity to make deci-sions in some cases and for not allowing a person with full ca-pacity to make decisions in other cases. If a person has thespecific capacity to make a decision, then according to ourconception, that person is competent to make that decision.

However, such a person does not have an absolute right tomake that decision, and others do not have an absolute dutyto respect that decision. Such a right or a duty is, at most,only prima facie. For instance, a person’s right to decide maybe legitimately overridden in order to prevent some, but notall, harms, costs, and burdens to others.

Martin also misstates the way Beauchamp and I approachreligious beliefs and practices in the context of health care.Martin claims that Beauchamp and I, like many others, fallinto a “trap”: We want to respect religious beliefs and prac-tices, particularly by nonintervention or noninterference, andin order to do so, we hold that religiously based decisionsmust be “capacitated” (her term).

That is a trap, but we don’t fall into it. In my judgment—and I do not claim to speak for Tom Beauchamp on thispoint—even though a policy that automatically treats personswith unorthodox or bizarre religious beliefs as less than com-petent is indefensible, some people with those beliefs are in-deed incompetent in certain cases, and Ray may be one. If so,then weak paternalistic interventions (based on Ray’s limitedcapacity and his risk of harm) would be warranted. But evenif we reach a different conclusion about his capacity, weshould not rule out the possibility of a strong paternalisticjustification for intervention. (Indeed, later in Principles ofBiomedical Ethics, we discuss a very similar case and indicatethat a strong paternalistic intervention can be justified in thatcase, even though it violates a substantial autonomy interestbecause it conflicts with the religious views “central to the pa-tient’s life plan.”) Furthermore, when a person is seriouslymaiming himself, as in this case, forcible intervention is war-ranted because of the heavy burden and costs such injuriesimpose on others.

The central point is just this: if a policy implies that thosewho have unorthodox or bizarre religious beliefs are less thancompetent, even if they reason clearly in light of their beliefs,then it “is morally perilous and fails as a policy (without spe-cific and careful qualification).”1 This point certainly cries outfor elaboration, but it is sound.

1. T. Beauchamp and J.F. Childress, Principles of Biomedical Ethics,5th ed. (New York: Oxford University Press, 2001), 187.

James F. Childress is the John Allen Hollingsworth Professor of Ethics atthe University of Virginia.

Must We Always Respect Religious Belief?

B y J A M E S F. C H I L D R E S S

another voice