Religious pluralism in healthcare

The current approach to the accommodation of religious values and practices in public healthcare systems around the world is ad hoc, potentially discriminatory, and can be harmful to patients and families. Many countries are becoming more religiously diverse, and so a systematic approach to such accommodation is needed. Religious pluralism in healthcare raises many important ethical questions. What conceptual and practical conditions are needed to identify and address discrimination, disadvantages, and disparities related to the plurality of religious values and practices in healthcare? How should democratic societies accommodate religious convictions in determining healthcare policies in a political framework professedly secular in orientation? Is there something morally problematic in a modern democracy about giving exclusively or predominantly religious reasons for critical healthcare decisions? What moral theories best justify giving weight to religious preferences in healthcare? To what extent is the doctrine of the sanctity of life conceptually distinct from other forms of the sacred or from other values that may be regarded as sacred? Do doctors have a professional duty to ensure that their patients' religious interests (if any) are addressed, and what would be the scope of this professional duty? In this special issue of Bioethics, we present 13 contributions that examine these and other key issues raised by religious pluralism in healthcare. A notable feature of this special issue is the inclusion of commentaries on six of the seven articles presented here. Earlier versions of these six articles, and the commentaries on them, were discussed at an online workshop on ‘Religious pluralism in healthcare’, hosted by Monash Bioethics Centre, Monash University, in conjunction with the Oxford Uehiro Centre for Practical Ethics, Oxford University, the University of Melbourne, and the Charles Sturt University Practical and Public Ethics Research (PAPER) Group. This workshop helped to crystallise the key points at issue in discussions of these questions, facilitated the cross-fertilisation of ideas and approaches, and provided valuable critical engagement between the speakers and also with the workshop audience. This special issue begins with an article by Roger Crisp, who takes a step back from the often emotive and intractable debates about specific ethical issues involving religion and healthcare, by developing and defending a ‘demoralized welfarist’ approach to ethics, which he then applies in this context. Crisp argues that this approach focuses on what fundamentally matters in conflicts arising from the religious preferences of patients and healthcare workers, and he proposes that it can offer a more promising way of resolving ethical disagreements in such circumstances. In his commentary on this article, Julian Savulescu elaborates on Crisp's arguments. While Savulescu agrees with Crisp that a primary consideration of healthcare is well-being (including the well-being of patients, doctors, and others), he argues that autonomy should also be a primary consideration, and that the well-being and autonomy of patients should be prioritised over those of healthcare providers. Joshua Hordern argues that prevalent conceptions of ‘accommodating’ religious beliefs and practices in healthcare create an unreasonable burden of proof for religious patients and healthcare professionals. He claims that these prevalent conceptions problematically suggest that religious beliefs and practices are somehow anomalous and so religious patients and healthcare professionals must make a case for their views and preferences to be recognised and respected in this context. Hordern argues that a richer and more plausible notion of accommodation can be developed by drawing on a form of agonism in political philosophy, which facilitates and creates the conditions for charitable and patient but also robust discussions about how the religious and other key beliefs and values of healthcare workers and patients could be acknowledged and respected in clinical decisions. In his commentary, Dominic Wilkinson clarifies what agonism means and might be plausibly thought to amount to in the context of allocating scarce healthcare resources, and he questions whether agonism can provide much useful guidance here. Bioethical debates about accommodating religious values and beliefs in healthcare sometimes propose defensible compromises between, for example, religious doctors and secular patients (as seen in discussions of conscientious objection in healthcare). However, Steve Clarke explains how the notion of the sanctity of human life is usually understood in religious terms as supporting uncompromising prohibitions on practices such as abortion and euthanasia. Clarke argues that a more plausible conception of the sanctity of human life can be developed by drawing on recent scientific research on values regarded as sacred in ways that need not be religious, and that this can offer better prospects of reaching compromises through reframing what conduct would and would not constitute violations of such sanctity. In his commentary, Roger Crisp takes such an approach as helpfully clarifying the concept of the sanctity of life, and although he is pessimistic about the prospects for convergence on the issues where this concept is invoked, he nevertheless expresses hope that sensible forms of theism and atheism could support an ethics of toleration and reasonable compromise. The proper place of religion in the public square and the role of religious and secular reasons in justifications of decisions in political contexts remain topics of vigorous debate. Robert Audi and William R. Smith contribute to these debates by elaborating a pluralistic framework of ethical principles, which they argue can justifiably guide democracies in accommodating religious convictions in the development of healthcare policies. Audi and Smith argue that the merits of this framework can be demonstrated by considering how it provides plausible approaches to religious reasons for vaccine resistance, to abortion policy, and to the right to healthcare. In his commentary on this article, Tony Coady raises a number of concerns about a central principle in Audi and Smith's framework, and he offers a caveat about another key principle in this framework. The next two articles address more practical questions about religious pluralism in healthcare. Mehrunisha Suleman presents findings from an empirical study of Muslim attitudes and approaches to death, dying, and end-of-life decision-making. Suleman identifies key values, virtues, and practices that demonstrate Islamic conceptions of ‘a good death’. She explains how Muslim patients and families commonly regard death and dying as an overarching spiritual process and emphasise the importance of approaching death and dying with the virtues of both hope and acceptance. Suleman also describes how non-Muslim practitioners often find it difficult to understand how these virtues of hope and acceptance can plausibly co-exist in dying patients, and sometimes regard patients' hope in this context as an indication that they are in denial about their impending demise. In his commentary, Justin Oakley argues that hope and acceptance seem to have different objects in such contexts, and he raises some questions about professional integrity in cases where doctors recommend that a patient be kept alive where this is not in a patient's overall best interests. In their article, Lauren Notini and Justin Oakley address the question of justifiable moral boundaries on religious discussions between doctors and religious patients. Notini and Oakley argue that doctors can justifiably inquire about the patient's values (including any religious values that the patient may hold), and can permissibly refer patients to a chaplain or religious figure for further discussion. However, Notini and Oakley present two key arguments that they regard as doing separate work—the impracticality argument and the professional role argument—for their claim that it is not morally permissible for doctors to engage in substantive religious discussions with their patients. In his commentary, Joshua Hordern rejects both of these arguments, and he suggests that they are inextricably linked—if one fails, both fail. Hordern claims that the impracticality argument is problematic because it seems to imply that doctors should not substantively engage with any type of belief (religious or secular) if this is not part of ‘strictly medical’ work, and that the professional role argument relies on a notion of medicine that is too restrictive. In our final article for this special issue, David Kirchhoffer presents an argument for a presumption in favour of respecting religious beliefs in healthcare. Kirchhoffer argues that religious convictions are plausibly understood as judgements of conscience, and he suggests that respect for conscience is central to what respecting human dignity amounts to. Kirchhoffer develops an account of religious beliefs in terms of the notion of conscience, where such beliefs are subjective judgements about objective truth. He also considers what justifiable limits there might be on respecting a person's religious beliefs in the context of healthcare. The contributions in this special issue to ongoing discussions about religious pluralism in healthcare present thoughtful perspectives on how healthcare systems can justifiably accommodate a diversity of religious and nonreligious practices and values in systematic and nondiscriminatory ways. The set of reflections provided here will hopefully stimulate further debate on these topics. We also hope that the views and arguments discussed here will help patients, healthcare workers, and policymakers to engage more fully and constructively with these complex and challenging issues. The Religious Pluralism in Healthcare online workshop (16–18 July 2021) and guest editing work for this special issue of Bioethics were supported by Australian Research Council Discovery Project grant DP190101597, ‘Religion, pluralism, and healthcare practice: A philosophical assessment’. We wish to thank Managing Editor Clancy Pegg for her invaluable assistance with the preparation of this special issue

Bioethics · Democracy · Duty · Environmental ethics · Epistemology · Health care · Law and economics · Political science · Politics · Public relations · Reasonable accommodation · Religious organization · Religious pluralism · Sociology · American Constitutional Law and Politics · Law · Religion, Society, and Development · Religion, Spirituality, and Psychology

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