Religious pluralism and the ethics of healthcare

Abstract

Democratic societies that separate church and state face major challenges in accommodating religious convictions. This applies especially to determining healthcare policies. Building on our prior work on the demands and limits of religious accommodation in democratic societies, we propose a set of ethical standards that can guide societies in meeting this challenge. In applying and defending these standards, we explore three topics: vaccine resistance, abortion, and concerns about rights to healthcare. We clarify these and other issues of religious accommodation and propose ethical standards for approaching these and other problems.

1 ∣. INTRODUCTION

The contemporary world exhibits wide religious pluralism, especially in democratic societies. Principles are needed to resolve the conflicts such pluralism tends to generate. One reason is that religious commitments sometimes place moral and legal requirements on healthcare providers and patients. These demands introduce questions about parentalistic interventions by governments and protection of rights and interests of other citizens as well as higher-order questions about how to address disagreement within and between societies on these issues.

Even a book-length treatment would not fully cover this topic, but here we will consider representative examples from each, building on prior work that outlined and defended a broadly intuitionist, pluralistic framework for democratically accommodating religious convictions in determining healthcare policies in democratic societies.¹ After introducing our framework (Section 2), we consider questions about parentalism and protection of third parties arising from vaccine resistance (Section 3). We then take up civic discourse in relation to abortion policy (Section 4). Finally, we turn to the notion of a right to healthcare to illustrate how liberal societies must protect individuals against infringement that may arise from religious beliefs both within their borders and abroad (Section 5).

Our goal here is not to address any of these specific issues fully, but rather to extend the overall case for our framework by showing that it coheres with intuitively compelling, but independently justified, points about each case, and brings explanatory insight into these cases. The extension of this framework to cover as many relevant cases as possible is critical. Any arguments applying some set of principles to some issue are only as strong as the support provided by the underlying principles. And any set of principles is only as strong as their ability to apply across a range of cases. Hence, any complete defense of underlying principles requires achieving a reflective equilibrium covering the myriad relevant cases, just as any full defense of some position on the relevant cases requires showing that principles invoked apply across a range of cases.

2 ∣. THE CORE FRAMEWORK

We conceive democracy broadly, as a form of government that is “of, by and for the people,” where the “of” is taken to indicate that those governed include both citizens and others, such as long-term residents, who may be considered among “the people.”² If government is by the people, then political power is determined by adequately frequent, free elections with one-person one vote, no one above the law, and freedom of political expression. We take the “for” to be normative, entailing (at least) that democratic governments should be guided by standards for the “good of the people,” broadly understood.³

We must explicate the notion of religion because citizens request accommodation for beliefs that are not always obviously religious in nature.⁴ It is not clear that the notion of religion admits of analysis, but we can offer a criterial characterization of religion, drawing on elements conceptually important for the notion yet not individually necessary or sufficient conditions:

1. appropriately internalized belief in one or more supernatural beings (gods) (internalization applies differently to individuals and institutions);

2. observance of a distinction between sacred and profane objects (as arises, in discussions of commodification of, for example, Buddhist religious objects given increasing secular interest from the West);⁵

3. ritual acts focused on those objects (e.g., Hindu yajna focused on sacred fire);

4. a moral code considered sanctioned by the god(s) (e.g., Buddhist ethics based in the five precepts and the Hebrew—Christian love commandments);

5. religious feelings (awe, mystery, etc.) that tend to be aroused by the sacred objects and during rituals (e.g., singing hymns);

6. prayer and other ritualistic or communicative forms concerning the god(s);

7. a worldview representing individuals as having a significant place in the universe;

8. a more or less comprehensive organization of life based on the worldview (say, as expressed in Catholic social teaching);

9. reverential attitudes appropriately connected with at least one of the above (e.g., toward natural or sacred objects, including houses of worship); and

10. a social organization built around a subset of (1)–(9), as is characteristic of well-established churches.⁶

This characterization accommodates nontheistic religions but allows giving most weight to the supernaturalistic element in determining whether a person or institution is religious and special emphasis on ethical elements bearing on religion and healthcare. There is no nonarbitrary way to eliminate borderline cases, as where someone claims a religious exemption from a nontheistic stance that satisfies only (5) and (7)–(9). A further consideration is that the appropriate use of the term “religious” may partly depend on whether those with particular beliefs and social structures self-identify as religious, spiritual, or something else entirely. Regardless of that, if people sufficiently satisfy the criteria, this yields at least a prima facie case for considering them religious.

Against this background, we propose several prima facie principles⁷ for governmental treatment of citizens:

The liberty principle: Government should protect religious liberty to the highest degree possible within a reasonable interpretation of the harm principle—i.e. (in rough terms), the principle that restrictions of liberty are justifiable only on adequate evidence that they are required to prevent significant harm.

The equality principle: Government should accord equal treatment to different religions within its jurisdiction.

The neutrality principle: Government should accord equal treatment to the religious and the non-religious.

We also propose a principle that is important for participation in self-government and also bears on the application and interconnections of these and other democratic standards:

The sociopolitical equality principle: Government should protect, and in some cases promote, equal sociopolitical relations among citizens, at least insofar as such promotion is needed to assure equal status before the law.

Here, we note just two points. First, the neutrality principle supplements the liberty and equality principles because governments not adhering to the liberty principle could favor religious institutions and individuals in ways that threaten both liberty and basic political equality. Consider some implications in healthcare. Some patients would resent a crucifix visible in their room or compulsory visits by even a nondenominational chaplain. If they cannot be treated in a secular hospital, should the law require religiously affiliated hospitals to respect these preferences? Are secular patients entitled to referrals for surgeries or procedures that are legal but not supplied by a hospital they have been sent to or forced to choose for reasons of finance or availability?

Second, while the first three principles focus on, mainly, the balance of liberty and harm (and equal treatment in striking this balance), the fourth is important in distinctively contributing to the problems arising because government must confront serious infringements on equality—and in particular political equality, implicitly including equality before the law—that mere protection of equal liberty may fail to prevent. This is evidenced by, for instance, the widening gaps in income in various societies, and their resultant effects on political power.⁸

In addition to the appropriate governmental treatment of citizens, there are questions regarding the ethics of citizenship—roughly of how citizens ought to treat each other and their governmental institutions. Among these is how citizens should reason together in governing each other through democratic institutions, laws, and policies which they can all accept. Here, we suggest

The principle of natural reason (PNR): Citizens in a democracy have a prima facie obligation not to advocate or support any law or public policy that restricts human conduct, unless they have, and are willing to offer, adequate natural (thus secular) reason for this advocacy or support (e.g., for a vote).⁹

Two points are needed here to prevent misinterpretation.

First, abiding by the PNR does not require considering religious reasons less important than natural ones. One can abide by the PNR while being more strongly motivated by religious reasons, while regarding nonreligious reasons as evidentially dependent on religious ones,¹⁰ and while appealing to religious justifications for public policies.¹¹

Second, the prima facie obligation does not preclude a moral right to act inconsistently with the principle in certain cases. The PNR expresses an element in civic virtue; violations of it (like some violations of obligations of beneficence) are protected by liberty rights. Liberties that democracies must protect are not thereby placed beyond criticism; but their exercise, in healthcare as elsewhere, may still contravene the civic virtues that support democracy.

Finally, we propose a principle of civic discourse that may guide institutions and individuals in disputes.

The principle of interpretive charity (applicable particularly in political or policy discussions): Citizens in a democracy have a prima facie obligation to seek mutual understanding through careful listening and reading, civil discourse, and attention to democratic principles.

This suggests ways in which individuals and organizations can noncoercively improve public discourse. We consider abortion (addressed in Section 4) an instructive example—although there are certainly others, such as euthanasia and organ transplantation. Such cases illustrate the importance of a kind of obligation that is broadly social and coheres with an ideal of civic community, particularly for citizens whose lives overlap geographically, politically, or institutionally.

3 ∣. GOVERNMENT'S ACCOMMODATION OF RELIGION-BASED VACCINE RESISTANCE

Historically, vaccination ethics has largely focused on questions of childhood vaccination; here, as in medicine generally, parents’ moral powers to authorize on behalf of their children are narrower than for themselves.¹² But the COVID-19 pandemic has drawn fresh attention to the ethics of vaccine resistance among adults, including questions about vaccine passports¹³ and vaccine mandates.

Religious objections to vaccination are common. But scholars have questioned whether many purportedly religious objections are, in fact, religiously based.¹⁴ Notably, explicit appeal to principles theologically codified by an authoritative text has played a minor role in vaccine resistance.¹⁵ Core texts of the world religions with the largest followings rarely prohibit vaccination per se, and many religions provide reasons that might support vaccination.¹⁶ Nevertheless, religious individuals may think vaccine refusal is supported by religious principles, for example that accepting vaccines expresses lack of faith in God's providence.¹⁷

The general implications of our framework for vaccine ethics might seem straightforward. The liberty principle requires accommodating religious considerations—but only when balanced with the harm principle,¹⁸ which might be thought to favor strong pressures to promote vaccination, such as mandates. But several complexities arise.

First, the neutrality principle favors accommodating non-religious objections based in comparably important nonreligious values.¹⁹ While many focus on the importance of religious liberty in vaccination ethics, the importance of the neutrality principle should not be overlooked. Moreover, these values are sometimes difficult to distinguish from religious values. One important value here is a reverential concern with animals, plants, or the environment more broadly. For example, some might object to vaccines or other kinds of healthcare as purportedly depending on exploitation of animals. Likewise, many place significant ethical value on “natural” or an eco-ethical lifestyle, whether for ecological reasons or for reasons of reverence to the environment and, in turn, object to being asked to use “unnatural” (roughly, synthetically designed) chemicals.²⁰ These cases might be easy to overlook, for example, because such values may not be as prominent as religious ones.

Second, accommodation for medical needs must be distinguished from religious (and related) accommodations. The liberty principle does not accomodate medical needs, such as exemptions for those with allergies to the vaccination. But the appeal to harm prevention is less weighty in such cases because the risks and benefits, medically speaking, are unlike those for the general population. Likely, for that reason, such accommodations are frequently taken as uncontroversial.²¹

Finally, balancing the concern for harm prevention against the protection of liberty while ensuring sociopolitical equality, requires policy-makers to use practical wisdom since the weight of these considerations in vaccine ethics is remarkably complex. For example, religious values may be insincerely invoked.²² There is a tradeoff between efficiency in vaccine policy and accuracy in judging religious sincerity. Vaccine policy is not adequately efficient if it must test for sincerity—as opposed to deterring insincerity through, for example, requiring documentation to provide good evidence for the relevant religious convictions. Our principles are meant to be applied with appropriate, feasible cautions against insincerity, but there is no cost-free or infallible way to test for insincerity or to determine appropriate sanctions when it is detected.

Vaccine passports and mandates also illustrate the challenges in balancing harm prevention and accommodation. Both types of policy can be achieved in accordance with our principles. But eligibility criteria that are too strong unduly restrict liberty; those that are too weak, for example, overly accommodating, endanger the population. A detailed discussion of such challenges would be a paper in itself and would require careful attention to pairwise comparison of similar cases. Here we seek to make five important points about possible types of restrictions,²³ supporting our claim to the flexibility of weighing considerations of harm, accommodation, and political stability—each of which will vary with different political contexts and likely with different empirical features of different vaccines.

First, various coercive interventions might be ineffective or even counter-productive, and their justification depends on their effectiveness. Estimations of efficacy can be empirically complicated, and often data is indecisive for these. The ethics of such interventions will thereby be challenging as well.

Second, as the sociopolitical equality principle brings out, governments have reason to ensure that those with lower socioeconomic status have equal access to vaccinations. But governments have further reason to ensure that certain groups (such as the poor) are treated equally before the law because some penalties (e.g., financial penalties) are particularly burdensome to them and practically inconsequential to the rich. This disparity creates potential tensions with the harm and liberty principles, since some non-financial means of ensuring vaccination can be greater restrictions on liberty. These include forcible vaccination, restricting public liberties or access to public goods, and non-financial sanctions for not being vaccinated (or for transmitting disease to another when not vaccinated).²⁴

Third, all else equal, the degree of harm avoided by vaccination should be greater than the harm of the coercive force applied—for example, in overriding autonomous refusal. The weight of the harm prevented by vaccination is a function of, among other things, the probability that vaccination mandate can enable a society to achieve herd immunity as well as the severity of the illness that might be avoided through vaccination. For instance, in the United States the reasons to mandate the Measles Mumps and Rubella vaccine may be growing given the increasing frequency of measles outbreaks and the harms measles can cause.

Fourth, restriction of access to public resources, which is a historically common way of incentivizing vaccination, is frequently less imposing than (at least some) other options, and can often be enforced with reasonably equal treatment of citizens. Historically, such restrictions have been common perhaps only because restricting access to school is a relatively easy means of targeting a broad portion of the child and adolescent population, where most vaccine policy has focused. But during the COVID-19 pandemic, restricting access to private organizations also received attention in discussion of vaccine passports. Intuitively, restricting access is significantly less coercive than forcible vaccination—though it may be more or less coercive than, say, financial penalty depending on (among other things) the magnitude of the penalty. This lesser coerciveness relative to government-enforced mandates is reason to prefer that the state encourage organizations and individuals to require vaccinations for certain activities. Another reason is that, in many countries, private organizations have broader prerogatives in their treatment of customers, employees, and the like than governmental ones do in their treatment of citizens. Finally, privatizing incentives to vaccinate may diminish the destabilizing effects of political backlash, which can arise when some vaccine policies are seen as defending and others oppressing freedom of religion.

However, arguably, the evolution of the COVID-19 pandemic illustrates that, in some cases, the need to avoid harm may override other considerations. Unfortunately, governments must act with great uncertainty regarding the people's responses to various pressures. If a legal sanction is sometimes required to save lives, our principles are compatible with quite rigorous governmental mandates, provided the harms the mandate prevents are sufficiently great relative to those it creates. This is further complicated when pathogens evolve and, in turn, vaccination efficacy changes—as the COVID-19 pandemic has illustrated with new variants proving less susceptible to some vaccinations.²⁵ Arguably, empirically speaking, some societies, such as the United States, have proved sufficiently resistant to COVID-19 vaccines to make the effects of a vaccination mandate sufficiently positive, and the harms of lack of vaccination sufficiently serious, to have warranted government-enforced vaccine mandates at some points during the pandemic. With decreasing virulence of recent variants and decreasing likelihood of achieving herd immunity, this time may have passed. But future pandemics are likely, raising the possibility that mandates may again become necessary.

Finally, for vaccine refusal as for the other challenges that we will discuss, religious institutions often play a role over and above that of religious individuals. Religious institutions help to generate and sustain in their members both religious and other beliefs—including political beliefs.²⁶ Sometimes, however, religious (and other) institutions have such effects through spreading disinformation or through otherwise epistemically vicious mechanisms, as can happen in communities with pediatric vaccine resistance.²⁷ In the medical domain, preventing such disinformation is especially important—particularly to reduce the risk of harm or violation of human rights, or both. To illustrate, it has been widely reported in major news media that former U.S. President Donald Trump (as well as other populist and nationalist leaders) have encouraged skepticism about coronavirus and public health measures to combat it, including vaccines.²⁸ With Trump, the supporting political associations include religious institutions. Several papers make a case that partisanship and religiosity increase belief in misinformation about COVID. Some of the authors take this to provide evidence both of effects of the Administration's misinformation and of religious influences. Moreover, some studies have demonstrated behavioral change suggesting acceptance of misinformation in response to misinformation from President Trump. They also suggest that Trump's later positive messaging on vaccination influenced his supporters more than evidence from scientific experts.²⁹ Given this literature, it may be unsurprising that Evangelicals and Republicans were more vaccine hesitant during the pandemic.³⁰ A question for both democracy and public health here is how a society can achieve better public understanding of healthcare issues (among others) and of the difference between scientific evidence and summary statements by political leaders.

Here we note that, as composed of individuals and, in many cases, political officeholders, churches are governed by the PNR and the principle of interpretative charity, and so have reason not to engage with and instead to counteract such disinformation. Likewise, they are subject to the same constraints that citizens are regarding liberty, harm, neutrality, and sociopolitical equality, and so are appropriate targets of governmental policy interventions, including coercive ones.³¹ But it is similarly notable that governments might coordinate or incentivize harm-reducing and equality-promoting beliefs and practices of religious institutions. For instance, with COVID-19, counter-disinformation campaigns might have been particularly effective if they employed sources respected by communities with distrust of scientific expertise.³² Religious communities, in addition to others (e.g., local medical providers, community leaders, and celebrities), can contribute to this effort. But there is uncertainty about the speed and effectiveness of such campaigns. Would the pandemic have been stayed faster, more fully, or more lastingly by these tactics, by coercive measures, or by utilizing private organizations, such as businesses, as noted above? We cannot settle the question here, but we believe that our principles support coercive measures to guarantee vaccination only within the proportionality restrictions built into the application of the harm principle.

4 ∣. THE ETHICS OF CITIZENSHIP AND THE HEATED DISCUSSIONS OF ABORTION

Debates about the permissibility of abortion are wide-ranging, and both pro-life and pro-choice positions have been advanced on both religious and non-religious grounds. Nevertheless, public dialog about abortion often invokes religious positions, and in that regard the principles of our framework are especially important. Indeed, we believe that failures to abide by principles such as those we propose contribute to heated discourse that tends to be detrimental to democracy.

Consider the influence of the idea that (most kinds of) abortions are murder.³³ This is an inflammatory term. A charge of murder is very serious, and it should not be unjustifiedly made. Two points are important here. First, the truth conditions for charges of murder are distinct from those of other notions that opponents of abortion might employ, such as wrongful killing. In calling abortion murder, many likely do not consider using the notion of wrongful killing instead. But wrongful killing, even of persons, is very serious yet also possible where there is mitigation or even excuse. A speeding driver who kills a child that heedlessly runs in front of the car may wrongfully kill but is not guilty of murder. Murder goes beyond wrongful killing; it requires intentionality, typically intending (or at least hoping) to kill a person—as recognized by the distinction between murder and manslaughter, as where a hunter incautiously fires at a deer, not realizing that a hiker might be killed by the exiting bullet. Intention to kill a person entails conceiving the target or victim as a person, which is not how most defenders of abortion rights conceive the conceptus or developing fetus.³⁴

Second, we contend that the claim that most abortions in fact are murders is not entailed by even very stringent views about when the rights of personhood (or of human beings, for those who prefer to avoid the notion of persons) arise. For illustration, consider the influential ensoulment-at-conception view, on which (1) the rights of personhood (or rights of a human being conceived as a person)—and particularly the right to life possessed by persons—arise at the time of ensoulment (i.e., when a living thing acquires a soul rather than merely being, say, biological matter) and (2) ensoulment occurs at conception. For the sake of argument, suppose this ensoulment view is correct. That entails nothing about the mental states of agents engaging in abortion. Those who accept this view can consistently acknowledge that others deny it and see that those who do lack some conceptions or beliefs needed to imply intention or mens rea in performing or requesting an abortion. Those holding the ensoulment view may even consider some who disagree rational and, though mistaken, morally conscientious. They may respect—even if they cannot accept—the view that there is more to being a person than, for instance, being a fertilized egg having the genetic make-up that enables development into a person and (as a secular person may think) that ensoulment is not what is missing. These points, taken together with the interpretive charity principle, imply that those who, on a religious basis, consider practitioners who perform abortions murderers are, in at least many cases, wronging them—much in the way that the state would wrong citizens if it illegalized Muslim calls to prayer on the basis of Christian, theological reasons. Neither the state nor we as citizens should determine others’ intentions on the basis of a religious construal of the facts, biological or other.

These points generalize well beyond application to the ensoulment-at-conception view. They apply similarly to views on which secular reasons, such as those based on biological data, purport to show that personhood begins—that is, is first instantiated in the human species—at conception. They also apply to arguments that eschew concerns about whether personhood begins at that time, but ground the relevant rights in potentialities of a conceptus. A corollary of these points is that, on many typical, philosophical, pro-life arguments, there is no basis for deeming the belief that the conceptus is not a person to be irrational and not conscientious or demanding use of the term “murderer” in reference to those requesting or performing abortions. Whether or not one takes abortion to entail killing a person, to substitute “wrongful killing” for “murder”—especially where that is done by policy and accompanied by an explanation—is a significant contribution to lowering the temperature of the abortion issue.

The principle of interpretive charity may further imply that Christian religious institutions that advocate legal enforcement of pro-life positions have a prima facie obligation to discuss the variety and complexity of positions on abortion with some who disagree or, where this is unfeasible, to read literature that treats the issue from a conflicting perspective.³⁵ In both political and non-policy-oriented discourse, these obligations are not commonly recognized by the parties. The counterpart obligation holds for those who find most abortions permissible. Such discussion, civilly conducted, tends to encourage a respectful and potentially shared understanding of citizens with divergent views. This applies to citizens in different religions—who may or may not share similar political views—and should acknowledge that even among those with many shared religious beliefs there are varieties of views about ethical positions on abortion, as on other issues.³⁶

Here the history of the Catholic Church is instructive. Many Catholics likely believe that the ensoulment-at-conception is (nearly) universally accepted in their faith tradition, but the tradition prominently includes Aquinas, who held that ensoulment occurs much later than conception. This is widely discussed in the scholarly literature and has been noted by the Catholic Church itself, including the Congregation for the Doctrine of the Faith.³⁷ This history does not appear widely known among either people opposing at least early abortions or those supporting their legality even in the third trimester. Noting this historically important diversity should widen the civility with which opponents treat each other in both public discourse and private conversation.

We have emphasized the importance of discourse appropriate to decisions about healthcare and other matters of medical treatment and public policy. Three final points are notable regarding the abortion discourse. First, although our principles do not exhaust the demands of democratic civility, they strongly support it. To illustrate, the principle of interpretive charity implies, on the negative side, avoiding condescension in voicing and vocabulary and, on the positive side, open-minded listening. It also coheres with the view that, when possible, we should seek positions that capture important elements one can accept from opposing views.

Second, the PNR has notable implications for discourse and communication. First, it supports the principle of interpretative charity in stressing the need, in arguing for a view, law, or policy, to seek common ground. Here natural reasons, often considerations of pain and pleasure and of equal and respectful treatment, are prominent examples. Less obvious is the importance of finding converging paths, even apart from wider common ground. A theological view that takes the dignity of persons³⁸ to survive their capacity for consciousness may provide a path to restricting involuntary euthanasia just as would a secular view that focuses on protection of the vulnerable.

Third, the PNR has some indirect substantive implications that we cannot fully address here. Nothing we have said implies that the conceptus is not morally important. But PNR asks citizens to avoid advocating views on abortion unless they can support them with natural reasons. Some would argue that no standard of personhood can be defended on such grounds if it counts all human organisms in development, beginning with the fertilized, implanted egg, as persons; others will disagree—or contend that even potential persons have rights sufficient to sustain some legal sanctions on killing them.³⁹

5 ∣. THE RIGHT TO HEALTHCARE IN THE GLOBAL NORTH AND THE GLOBAL SOUTH

Before considering the conflicts between a right to healthcare and religious claims, four preliminary points are critical to support the existence of and illustrate the implications of this right. First, we take a right to something to be roughly a justified claim to it. Content of rights always at least indirectly concerns action or potential action by others (“addressees”), but the actions in question vary greatly depending on the right in question. Generally, rights are to be allowed to x, where x represents an action, or to be guaranteed x, where x represents a state of affairs, or to (acquire, consume, sell, etc.) an object. Here an action might be to choose one's physician; a state of affairs might be to receive information about one's health; and an object might be medicine. Rights are best specified by noting at least (1) possessor, (2) addressees (those responsible at least in part for according the right), (3) content (action, state of affairs, or object), and (4) domain (e.g., moral or legal). Behavioral specifications of content are clearest, say “to receive life support” or “not to be killed,” as opposed to substantial specifications, for example, “to life,” which can be ambiguous between the former two.⁴⁰

Second, we take rights to be (at least typically) prima facie rather than absolute. They can interact with, conflict with, or override other rights.⁴¹ For example, limited resources impose choices between healthcare and early childhood education.⁴² But fulfilling either may be a means of fulfilling the right to education (since, often, healthcare may be necessary to receive education without significant consequences—such as foregoing education to pursue a job to pay for healthcare). Such conflicts are particularly important in considering the place of religion in healthcare, when, for example, a patient's legal right to treatment conflicts with a physician's right not to give it even where no other physician is available. One notable example is that of a patient's right to abortion conflicting with a provider's rights of conscience.⁴³

Third, since some rights are politically grounded, the absence of a natural right to healthcare would not imply that anyone lacks a right to it, and we remain neutral on whether healthcare rights are natural or political. Indeed, if we assume that international human rights law has normative force, then perhaps some general legal right to healthcare is universal.⁴⁴ Given this point and the “competition” among rights in conditions of scarcity, the theory of rights by itself is not a sufficient basis—even among those who agree that there is a right to healthcare—for determining ethically adequate healthcare policies.

Fourth, one way to clarify the overall implications of healthcare rights is to focus on the policies those rights call for. If no degree of healthcare is specified (in terms of both content and addressee), the right is vague and so is the claim to it (or rejection of it).⁴⁵ While we cannot offer a full theory of such specification, we believe that a broadly intuitionist approach, employing reflective equilibrium as a constraint on proposed solutions and incorporating judgments about cases in refining and specifying the principles in question, will be critical to such a theory.

Given these and other points we have made, the fact that legitimate democratic governments must be “for” the good of the people, strongly supports the view that democratic nations must, so far as resources permit it, provide a national healthcare system that guarantees at least minimal care of citizens. Moreover, given that healthcare contributes to realization of many human rights (as illustrated by education above), basic principles of human rights (as well as the sociopolitical equality principle) support minimal provision—at least (as in much of the Global North), where resource scarcity does not preclude minimal healthcare. This leaves open both how to determine the minimal level and what mix of governmental and privately controlled delivery systems best fulfills the appropriate standards. While a full treatment of such details is beyond our scope, we close by considering several prominent cases of conflict of the right to healthcare with religious claims and thereby illustrating several points regarding specification of rights to healthcare, where religious claims sometimes conflict.

First, providing a right to basic healthcare does not entail illegalizing private healthcare for those who can afford it,⁴⁶ and private healthcare institutions can sometimes conform to the religious views of their patients and employees in ways that state institutions cannot.⁴⁷ Illegalizing private health care is a pro tanto violation of liberty rights, although there can be reason at least to limit it—particularly where private healthcare “siphons” resources from public healthcare that result in failures to fulfill healthcare rights or duties of equal treatment before the law. This might happen where political partisans and the financially well-off seek to undermine the public healthcare system. Those with sufficient resources have an economic incentive to form healthcare pools that preferentially treat them and may minimize meeting others’ needs. Similarly, private healthcare institutions facing market pressure to cater to wealthy individuals are willing to pay for certain amenities (e.g., private chefs in hospitals, special floors, concierge doctors, and the like). If, in order to attend to such amenities, these institutions use resources required to contribute their fair share in supporting healthcare needs of the wider public, then citizens' healthcare rights can be undermined.⁴⁸

Second, even in areas with scarce resources, healthcare rights are often not in conflict with, but supported by, education, good workplace standards, and equitable financial outlays. Fulfilling rights in these areas conduces to health and well-being in the society.⁴⁹ Relatedly, health appears instrumental to realizing numerous other goods, including those critical to several social and political rights.⁵⁰ Religion can be particularly important in impacting health in societies where medical resources are either scarce or distributed unevenly. In Nepal, for example, rights violations arise from a Hindu tradition inspired by beliefs concerning impurity, which has led to use of menstrual huts that separate women from their household and usual shelter, with insufficient hygiene sometimes causing death.⁵¹ Such confinements not only violate rights to healthcare but also basic rights to shelter. Moreover, political rights violations sustain the practice through lack of enforcement of laws against this and other practices that violate women's rights.⁵² Similarly, Saudi Arabia's Islamic political system restricts women's rights against repression and accords no legal right against marital rape—policies that have negative health effects.⁵³

Third, religiously motivated policies often conflict with healthcare rights in the international context. Some nations may impose aid restrictions on health protections that rich countries should provide to other nations and that realize human rights.⁵⁴ Some policies motivated by religious convictions have disadvantaged other countries owing to restrictions imposed by the Global North (e.g., the United States) on the Global South. One is declining to provide healthcare, as supported by faith-based communities influencing the Bush Administration's President's Emergency Plan for AIDS Relief (PEPFAR) program: the result was limiting the influence of scientific policy calling for condom usage and encouraging abstinence and monogamy.⁵⁵

The PNR applies in such cases and expresses a moral standard relevant to internationally significant policies. Moreover, the laws and policies it concerns within a broadly liberal democracy, even when produced by citizens in a democracy, may affect coercive laws and policies outside that society. Civic virtue is not subordinate to nationalism. It has a cosmopolitan element, at least insofar as there is an international community. Withholding appropriate aid for contraception or abortion can not only reduce, in the nations in question, the exercise of liberties protected under the extant laws but also encourage policies that narrow the scope of legal freedom. Making aid conditional on illegalizing abortion, for example, can result in either tightening extant legal restrictions or enhancing their enforcement.

6 ∣. CONCLUSION

We have seen a number of ways in which accommodating religious pluralism in healthcare is a challenge for contemporary democratic societies. Religious pluralism is particularly challenging if accommodation includes secular and anti-religious citizens. Many citizens are concerned with freedom for religion, but many others in contemporary societies are concerned with freedom from it. Given this challenge to democracy, we have proposed two kinds of principle: institutional principles applying especially to governmental actions and principles expressing standards for citizens acting as individuals.

We have applied these principles to issues of parentalistic intervention, protection of the rights and interests of citizens, and higher-order questions about how to address disagreement within and between societies on these issues as illustrated by the cases of vaccine resistance, abortion rhetoric, and rights to healthcare. In exploring these issues, we have sought to contribute to understanding the proper scope of religious accommodation in democracies, the range of responsibilities of governments in providing healthcare, and the quality of civic discourse. We have stressed that in arguing for their views religious and nonreligious citizens can and should fulfill duties of mutual respect. We have sought neither to downplay the importance of religion in human life nor to undermine its free exercise. But standards grounded in a religion, however well they guide its followers, should not restrict the liberty of those outside it, nor dominate the discourse through which the liberty of all citizens should be determined by standards all can see as reasonable. These are standards that, like the importance of preventing disease, are respected by virtually all religions but do not depend on religion. In addressing all these matters governments must, within certain limits, accommodate religious pluralism. Those limits are not easily specified, but our framework should guide reflection on their place in making decisions in and beyond the realm of healthcare.

Biographies

Robert Audi writes in ethics—theoretical and applied—epistemology, philosophy of action, and philosophy of religion. His books include The architecture of reason (2001), The good in the right (2004), Rationality and religious commitment (2011), and Means, ends, and persons (2016). He is a past president of the American Philosophical Association and currently John A. O'Brien Professor of Philosophy at Notre Dame.

William R. Smith, MD, PhD, is a post-doctoral fellow in the University of Pennsylvania's Department of Psychiatry. His research focuses on ethics, policy, and implementation science in healthcare—particularly in psychiatry. His work has recently appeared in JAMA, Psychiatric Services, The Journal of Medical Ethics, Bioethics, and Neuropharmacology.