Cooperation in evil or wrongdoing is a problem for all of us, affecting many areas of our lives. It's certainly a problem for those who work in health care, perhaps especially in the reproductive area. Sometimes it is easy to work out the right thing to do, even if very hard to do it. Other times, however, it may be much more difficult to work out how ‘close' to get to others' wrongdoing, and strike a balance between being too strict and (perhaps more likely) not strict enough. Getting advice and even a second opinion on particular issues can be very helpful – but we should also try to be aware ourselves of the principles that will apply across the board. (2)
So what are these principles? We should start with the difference between ‘formal' (intentional) cooperation in evil/wrongdoing and ‘material' (unintentional) cooperation. Material cooperation is doing what in effect assists or enables wrongdoing and/or gives the impression of condoning it, but without sharing the precise wrong-making intentions of the main wrongdoer. We know that we are helping someone do wrong in effect, but that's not what we intend in what we do. Material cooperation is sometimes right and sometimes wrong – indeed, it can be very wrong due to likely effects on the victim, the main wrongdoer, the one who cooperates, and others who may be badly harmed or confused. Other times, however, material cooperation may be justified, due to its ‘remoteness' and/or the goods at stake, especially if the evil in question is in any case likely to occur. Examples might be when a taxpayer helps to fund abortions, without intending this in any way, or a bus driver stops at all his stops, including those outside abortion clinics or labs where IVF embryos are destroyed. No-one is likely to think that such ‘remote material' assistance means that the taxpayer or bus-driver is thereby intending abortion or embryo research – which are sadly all too likely to continue with or without such ‘help in effect'
In contrast, ‘formal' or intentional co-operation, where we actually share some wrong-making intention of the main wrongdoer, is always itself morally wrong, and must always be avoided. Thus it is wrong not just to do abortions, imagining I'm a doctor, but to arrange deliberately that my colleague do them (or sign the form). If it is wrong to do an abortion myself, it is also wrong to get someone else to do one – perhaps in a futile attempt to keep my own hands clean. In fact, it is worse to get someone else involved, as this compromises both of us, not just one. Neither I nor my colleague is a cog in a machine: we are both moral agents with responsibilities, and I should not use my colleague to ‘do my dirty work for me', so to speak.
Imagine, for example, that I am a GP or obstetrician whose patient has just asked for an abortion. I encourage her sympathetically to think again about having her baby, and tell her candidly that I do not believe abortion is in her clinical best interests. Pregnancy, even when it comes at an extremely difficult time, is not a disease but in fact a sign of health; I am more than happy to support her every step along the way should she wish to change her mind. Nor is abortion without medical risks, whether physical or psychological: risks incurred by thwarting – as opposed to simply exercising – one's own life-giving bodily powers.
As I say these things and more, I might mention to the patient that she is, of course, free to seek a second opinion from a doctor of her choice. That may be something I need to tell the patient to try to cover myself with my employer or regulatory body (see below), so as to go on practising as a doctor, and helping patients as best I can. It may also be something that helps defuse the situation: the patient may be more likely to hear what I have to say about support to have her baby if she does not feel actively obstructed from pursuing what is a common, however seriously harmful, procedure in many parts of the world. (Note that ‘feeling unobstructed' from doing something is not the same as forming or ‘re-forming' an intention to do it: by analogy, if someone is physically restraining me from moving, and then lets go of me, I may calm down immediately and stop trying to move, welcoming the ability to move without as yet reviving my plan to do so.)
In contrast, very different morally is deliberately attracting and ‘re-directing' the patient's abortion-seeking motives, by suggesting she find a doctor who does (or signs for) abortions – or worse, telling her exactly who to go to. Instead, if the patient asks me where to go for an abortion, having heard that I will not do or sign for one myself, I might stress again that she is free to seek a second opinion should she wish from whomever she chooses. It is entirely up to her, I might tell her, whom she consults; what she says is also a matter for her. In any case, I hope she'll understand that I would not feel comfortable helping her find someone else specifically to give her something I as her doctor truly believe will do her harm. That would be hypocritical, I might say: why would I deliberately help her get something I think is not in her best interests?
Depending on how the conversation goes, I might then say that this is obviously an important decision to make: the patient may wish to think about it further, and perhaps discuss it with her family. She is welcome to come back to me at any time, including if she does go ahead with the abortion and has problems afterwards. I might hand her as she leaves, or invite her to pick up for herself, a card for an organisation offering positive pregnancy support (LIFE or Good Counsel Network or whoever is available in my area). Even better, I might make an offer to phone right away and get her a counselling appointment – perhaps even with a pregnancy counselling service linked to my own practice, where individual solutions can be found to whatever is making this pregnancy so difficult. We might think of the initiative described at the 2015 Mater-Care International Conference of Joseph and Cushla Hassan, a New Zealand GP and nurse who set up their own pregnancy counselling service with the support of local churches for women wishing to take time to explore alternatives to abortion. Very encouragingly, the abortion figures seemed to respond to that and other new initiatives in the area, so it's always worth thinking about options for support that we ourselves might introduce.
PREPARING FOR WRONGDOING
I mentioned earlier that it is wrong for the woman (or couple) to plan for her to obtain an abortion via some other doctor, and therefore wrong for me to intend the woman (or couple) form that plan. Planning or preparing to do something wrong is also wrong and the same is true of deliberately helping someone else prepare, intending our own act precisely as inviting or supporting that (wrongful) plan of action. If I decide to be a mugger, it is wrong for me to buy a knife and lie in wait. And it is wrong for others deliberately to help me in my mugging endeavours – say, by selling me the knife for that shared purpose or volunteering thoughts on good mugging areas or possible partners in crime. Similarly, if abortion is in fact wrongful homicide – a wrongful assault, however good the motive, on an innocent human being – then deliberate preparation for abortion will also be morally wrong and should not be invited qua preparation.
‘Acting wrongly' is not, we should remember, the same as ‘being culpable'. My abortion-friendly colleague down the hallway may not be particularly culpable for his choices in this area, depending on his personal background and awareness of what he is really doing. Nonetheless, if I actually intend that he act in a way I at least know is seriously wrong, my own act in sending my patient to him is also seriously wrong and I may be far more culpable than he is.
FERTILITY ADVICE / TREATMENT FOR UNMARRIED COUPLES
What are some other cooperation problems that can arise in reproductive health care? Problems can arise in the course of fertility consultations, where many women or couples seeking advice or treatment will be unmarried or in second or third or otherwise invalid marriages. Again, if I am a doctor or nurse, I may well be tempted to help an unmarried couple to conceive naturally, if only to avoid the couple pursuing IVF, with all that means in terms of dehumanizing the couple, risking the woman's health and discarding embryos. My motive here to help the couple avoid IVF is certainly good, but good motives are not enough: all our intentions must be morally right for our actions to be morally right. So if I deliberately assist the couple to find a good day to conceive when the woman is more likely to be fertile, I am colluding in their wrongful sexual acts, plus their wrongful choice to conceive. (To repeat, ‘wrongful' is not the same as ‘culpable': the couple may be in complete good faith in trying to conceive outside marriage, even if good faith alone cannot justify their choices in this area.)
GMC / OTHER PROFESSIONAL GUIDANCE
So what should I tell the couple, in explaining that I cannot help them with day-to-day conception choices? That may depend what country I live in and what attitude my regulatory body takes. In some countries, it may work for a doctor to cite in a sensitive manner the best interests of the child, pointing out that research shows overwhelmingly that children do better with married parents, not least because unmarried parents so often split up, depriving the child of their joint care. In other countries, however, doctors may need to be especially tactful and discreet in responding to these kinds of request. In particular, the GMC in Britain is not well disposed to what it sees as discrimination on the basis of marital status (for example, doctors may avoid prescribing contraception altogether, according to GMC guidance on Personal Beliefs, but may not prescribe it to married patients only, as, for example, an Evangelical doctor might wish to).
While it is obviously good to be aware of GMC and other professional guidance in contentious areas, it should go without saying that professional guidance and medical ethics will not always and inevitably coincide – and where they do not, the latter should of course prevail. That said, if a doctor sincerely believes that elective abortion or contraception, say, is not in the patient's clinical interests – bearing in mind that fertility and pregnancy are not diseases but healthy states – these ‘treatments' can be refused and discouraged as clinically unhelpful to the patient before the GMC instructions on ‘conscientious objections' (in Personal Beliefs, presented as non-clinically based objections) are even engaged. Personal Beliefs is worth studying closely on this point. In the same way, pharmacists should study the Standards of Conduct, Ethics and Performance of the General Pharmaceutical Council for encouragement to clinical objections to what, in the judgment of the individual pharmacist, is unsafe for patients or for others
PROMOTING FERTILITY VERSUS ACHIEVING IMMEDIATE CONCEPTION
Returning to fertility consultations: it may be wise for the doctor to link him or herself to some other body or network with a Code of Ethics and/or ethical advisors to refer to, and where patients are only accepted onto the fertility programme after a written application process. (Any such application process might include, in the course of getting patient details, information on the patient's past and present marital status to avoid problems down the line.) The doctor might explain that because of conscientious objections, which need to be respected, of people working on the programme, unmarried patients are not in practice accepted onto the waiting list, unless they are planning on getting married. If the couple are indeed planning to marry – or on the point of forming such a plan – they are most welcome to apply, though the doctor cannot obviously promise they will be accepted onto the programme. In any event, day-to-day help to conceive, as opposed to information and investigations and perhaps curative treatment, will begin once the wedding bells have actually rung and conception can be unreservedly pursued.
In any event, the doctor can try to discourage the woman or couple gently from IVF, letting them know that this is a very stressful procedure involving many ethical dilemmas and certainly with no guarantee of success. Potentially, the doctor could offer to investigate(3) and/or treat possible structural causes of infertility such as blocked tubes, including after sterilization. This is rather different from collaborating with day to day acts aimed at immediate conception. Someone who has had her sterilization reversed is more fertile, and thus healthier, whether or not she then goes on to conceive, and a doctor who reverses her sterilization may well be justified, even if there is some unintentional, material cooperation with the patient's aim of conceiving as soon as possible. The doctor's own aim in reversing the sterilisation may be, first, the patient's health or ‘functionality' (tendency towards healthy functioning) and secondly, conception at some later, suitable time – bearing in mind that a permanent reversal of infertility, unlike help to conceive on a day-to-day basis, will still be effective in the future when the patient may be married and justified by any standard in ‘trying for a baby'. This also applies to some extent to teaching natural family planning to a single woman as a ‘skill for life', without oneself intending immediate conception – though if the woman herself intends this, one may give out wrong messages by giving detailed fertility information, which is a very real concern. In any event, it goes without saying that any refusal to help an unmarried person seek immediate conception should be made in a kind and courteous way, always bearing in mind that the person may be in perfectly good faith in seeking conception outside marriage – let alone in an invalid marriage he or she may not realise is anything of the kind.
FETAL TISSUE/CELL LINES
One common but still non-standard form of cooperation in evil that can sometimes raise questions is sometimes described rather as ‘appropriation' of evil or being an ‘accessory after the fact'. An example might be a medical researcher who works with foetal tissue obtained from abortions. Even if the researcher does not intend that abortions take place – as he or she may well do, especially if the abortion will need to be done in a certain way – it will be difficult for the researcher not to give the impression of accepting abortion while working and preparing to work with foetuses obtained at one remove from those who bring about their deaths.
What should we say about the case of a researcher who does not work on aborted foetuses, but does use a cell-line or product of a cell-line originally derived from an aborted foetus? We might think of the controversy surrounding the news that the rubella vaccine was made using a cell-line derived from a foetus aborted in the 1970s. Opponents of abortion were divided on the question whether a boycott of the vaccine was required. Some argued that a boycott was required in order to avoid complicity in abortion and in the original wrongful use of foetal tissue. Others argued that the price of the boycott in terms of pregnant women who might catch rubella, and whose children might be affected and even aborted, was too high to pay.
In trying to establish whether or not material co-operation in such cases is morally justified we need to compare the reasons for co-operating with those for not co-operating. These reasons include the harm done, to ourselves and others, by either course of action. Refusal to co-operate materially may have unfortunate consequences in (for example) putting lives at risk and/or closing off some avenue of research which could serve the common good. It could also affect our families or colleagues who rely on us for support of various kinds. On the other hand, co-operating – even remotely – in an unjust procedure may harm us, to begin with, in that it may make us less sensitive to the wrong involved in that procedure and inclined to cooperate more closely in the future. It may also harm other people, in that it may give them the impression that the wrong concerned is not, after all, so very wrong in our eyes.
The greater the risk of corrupting ourselves, or of giving the impression to others that we have no objection, or no strong objection, to some wrongful procedure, the more serious needs to be the reason for doing what facilitates or seems to condone this procedure. The desire to pursue a promising line of research is not an adequate reason to use foetal tissue obtained from an abortionist – or indeed from a go-between as would normally be the case. The message one would give to the abortionist or go-between, not to mention one's colleagues, is that the objection one has to abortion is either weak or non-existent. Similar objections can be raised to co-operating with those who experiment on embryos by, for example, asking them to share their results. In contrast, making use oneself of results already published in a journal is less likely to give the impression that one has no problem with the destruction of embryonic lives. In the same way, using a cell-line originating decades ago in an aborted foetus is less likely to give the impression that one regards abortion as morally acceptable than was the original use of foetal tissue. Use of the decades-old cell-line, or a vaccine made from it(3) (as opposed to the foetal tissue itself or a cell-line just created) is remote material co-operation in an unjust procedure, of a kind which may well be justified, depending on the circumstances. (This is rather like the difference between buying something direct from a thief or receiver of stolen goods, and buying it in the market when you can see it must have been originally stolen, though it can’t now be returned to the original owner.) Having said that, there can be a place for refusing even remote co-operation with a past evil, particularly where this seems likely to give effective witness against a similar ongoing evil. This might apply where new foetal cell-lines are being created, due partly, no doubt, to lack of protest at the old ones (cell lines are not, it seems, quite as immortal as they are sometimes represented).
Back to the bigger picture: are there ways of health professionals ‘heading off ' some complicity problems they may face? Yes, there are – beginning with job applicants letting prospective colleagues know their position before starting (if not before getting) the job, which is often, if not always, a good idea. Obviously, in applying for jobs, the applicant will want first of all to win the confidence of the panel as a good person to work with, establishing rapport in areas of common interest. It is better not to assume hostility, but rather to invite prospective colleagues to agree – as they may well do – that they would not wish to put us in a difficult situation by asking us to act against our conscience or do what we believe will harm a patient. Applicants could stress that they are aware that many patients take a different view from them on some issues, that they realise that they are, in practice, free to act on that view, and that in any case, they think it important patients be spoken to in a respectful and considerate manner. Such points can also be made by established health professionals who want to make changes in the way they do their work, bearing in mind that colleagues may tolerate such changes in someone they have come to know and respect. Taking a stronger moral line on some issue may not be as difficult as one fears.
COMMUNICATING VERSUS DELEGATING/REFERRING
Conscientious objectors should always bear in mind the distinction between on the one hand, reporting to a supervisor their inability to do something expected of them, and on the other hand, deliberately getting the supervisor or some other colleague to do precisely what is wrong. Telling my boss that I cannot do or arrange abortions (or fill out prescriptions for the morning after pill) is not the same as asking my boss or a colleague to do it in my place. If things go badly, despite one's best efforts, or if one needs advice in advance, help is available from organisations such as the Anscombe Bioethics Centre and other sympathetic bodies. Health professionals may want to stress particularly that they do not regard abortion (or sterility etc) as in the best interests of the patient and therefore simply cannot help the patient get something they think will do no good but only harm. Again, it is important, as far as possible, to be confident and pleasant in our personal interactions, and show by the quality of our work and our flexibility where we can be flexible that we are good and helpful members of the team.
Why does all of this matter so much, we might ask ourselves in these situations? Even at a natural level, it matters more than anything else what kind of people we become. We are, not what we eat (or not only what we eat), but rather, what we choose. While it may be desirable and even a duty to save our jobs and careers if we can, there are certain things we simply cannot choose as they make us genuinely complicit in evil. Failure to remember this harms not only our patients, but our own moral characters; as these are serious matters, our very souls may be at stake. On the other hand, we can be overscrupulous, and this danger too must be avoided, as it will make us less productive and less helpful to others than we should be. After all, there are many shared projects where we may be able to make a contribution to the common good without actual complicity, as opposed to some acceptable level of unintentional material cooperation. Dr Mike Delany(5) makes the point that if we refuse to countenance such acceptable material cooperation, we may sin by omission, in that we are not contributing our God-given talents, or helping to redeem the practice of medicine. The aim is clearly to pursue one's vocation to the best of one's ability while avoiding all wrongful cooperation, whether formal/intentional, or scandalously close material cooperation. Doing this successfully may require, of course, forward planning, as well as courage and commitment. Planned or not – and surprises can happen, even to those who do their best to avoid them – success across the board may require the wisdom of the serpent, as well as the innocence of the dove.
Helen Watt, PhD, is a senior research fellow at the Anscombe Bioethics Centre in Oxford, England.
- Earlier versions of this talk were given in 2015 to a conference in Rome of MaterCare International, and to a meeting of the Birmingham branch of the CMA.
- For more on these issues, including cooperation problems in medical training, primary care, end of life care, and medical research, see H. Watt (ed.), Cooperation, Complicity and Conscience (London: Linacre Centre, 2005).
- Though male fertility tests pose obvious problems even for married couples. I discuss this and other fertility dilemmas in ‘Ethical Reproductive Technologies: Misplaced Hope?’ in H. Watt (ed.), Fertility and Gender (Oxford: Anscombe Bioethics Centre, 2011).
- Dignitas Personae (paragraphs 34-35) makes several distinctions here, including between parents and researchers, and between those in institutions who make the decision to use illicit material and those who have no voice in these decisions.
- ‘General medical practice: the problem of cooperation in evil’, in Cooperation, Complicity and Conscience (this paper is also available on the CMQ website).
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