Why religious belief should be declared as a competing interest
BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k1456 (Published 12 April 2018) Cite this as: BMJ 2018;361:k1456
All rapid responses
I was interested to read this article by Richard Smith and Jane Blazeby. I think perhaps it reveals a hidden bias on their part, that in some way religious beliefs are more likely to shape a person's outlook, values and ethics than non-religious beliefs. Every person has a world view which shapes their ethics, whether it is a religious faith, atheism, humanism, agnosticism, Darwinism, materialism. Those who believe they are accountable to the God who made them will tend to place a higher value on human life, especially at its beginning and its end, than those who believe that ultimately we are accountable to no one and that it is for the good of the human race if only the strong survive. I know who I would rather be treated by when I am helpless and demented.
Perhaps it would be more pertinent to require that a person should disclose their worldview, rather than their religious belief, to provide full context in public debate.
Competing interests: I am a Christian, and this influences every area of my life including my medical practice, as I walk with Jesus and try to become more like him.
This is indeed a thought provoking and at the same time uneasy topic given the number and variety of sentiments and views expressed [1].
Declaration of conflict of interest or competing interest has by and large been restricted to professional literature in medicine and that too only to financial interests rather than the practice per se. This seems sensible as money can be an extremely strong motive to sway people’s opinions and even beliefs, as can be seen in every conflict situation being played out every day around us today, be it in the family, community, national or the international stage. Statements on conflict of financial interest appear to have come about relatively recently in the long history of medical science when the noble art of medicine shifted gears to the business of medicine. Has religion or personal faith of physicians the world over had any influence on the ethical practice of medicine, its literature or its progress is perhaps an interesting research question.
I am sure most or many of us are aware of the Golden Rule or the Ethics of Reciprocity, which is the principle of treating others as one would wish to be treated, that is accepted as a universal conduct of ethics by almost all peoples, religious or otherwise [2]. Again when we look at the historical origins of medicine itself, its ethical practice and writings, there is arguably religion or religious ethics. Remember the Hippocratic Oath? “I swear by Apollo the Healer, by Asclepius, by Hygieia, by Panacea, and by all the gods and goddesses, ….” Of course we have come a long way from those lofty times. I would say that as far as the art of medicine is concerned: "Primum non nocere: Practice two things in your dealings with disease: either help or do not harm the patient" [3]. Which I am sure holds true for writing for and of medicine.
But as far as the business of medicine is concerned and therefore writing: “History shows that where ethics and economics come in conflict, victory is always with economics. Vested interests have never been known to have willingly divested themselves unless there was sufficient force to compel them.” – Dr. B. R. Ambedkar (1891 – 1956), Indian jurist, economist, politician and social reformer [4].
References:
1. Smith, R., & Blazeby, J. (2018). Why religious belief should be declared as a competing interest. Bmj, 361, k1456.
2. Neusner, J., & Chilton, B. D. (Eds.). (2008). The golden rule: The ethics of reciprocity in world religions. Bloomsbury Publishing.
3. Lloyd, Geoffrey, ed. (1983). Hippocratic Writings (2nd ed.). London: Penguin Books
4. Ambedkar, B. R. (2005). TOWARDS CONVERGENCE. Anti-imperialism & annihilation of castes, 225.
Competing interests: No competing interests
Whilst JB is right to say that "we must recognize that we are all conflicted and declare accordingly”(1). I wonder why he has chosen to single out religion in his article. Surely, religion plays as much a role as culture, ethnicity, country of birth/upbringing, political viewpoint, parental views, the views of close friends etc. Does he honestly expect authors to declare all these as 'conflicts of interest'?
This is very problematic. For instance, should we expect a homosexual writing in favour of gay rights to 'out' himself (before feeling ready to do so) before their views are heard? I don't think so. I'd rather hear their argument and assess it on a rational basis.
The danger of labelling all the aforementioned as 'conflicts of interest' and forcing disclosure is that it would allow arguments to be screened out or disregarded based on the bias/prejudice of editors or readers.
(1) Anonymous. Outside interests. Nature 2018; 554: 6.
Competing interests: No competing interests
In response to our commentary a friend, Seamus O’Mahony (author of The Way We Die Now) sent a teasing email, in which he imagined the competing interest statement he might make when writing on an issue where faith might be relevant:
“Seamus O’Mahony was raised in a devoutly Catholic family, and was educated in a seminary. He is now agnostic and non-practicing, but has great affection for the tradition and ritual of the Church. He is not sure to what extent his views on assisted suicide and abortion are informed by his upbringing and education.”
Seamus raises two issues: that we ultimately don’t know what factors influence our thinking; and where to stop with a declaration?
Some of those responding directly to the BMJ have made similar points, but do they amount to reasons for not declaring your faith or lack of it?
The fact that we don’t ultimately know what exactly influences our thinking could be used as an argument for not declaring any competing interests. Most people with competing financial interests are confident that those interests have not influenced their thinking, and perhaps they may not have done--but it’s precisely because competing interests, like bias, work unconsciously that they should be declared.
Where to stop? It might be useful in some ways to know the full biography of authors in order to appreciate and understand more deeply their arguments, which is why biographies of literary figures and philosophers are numerous and popular. But it’s clearly impractical to attach a full biography to everything published in, for example, the BMJ.
It’s for authors and editors to decide which are the broad competing interests that are best declared, and that includes, we argue, faith or the lack of it when writing on an issue where faith plays a major role.
We return to the first line of our commentary: “If in doubt, declare a competing interest.”
Competing interests: RS has no religious faith but respects those who do. JB has a religious faith and respects those who do not.
Dear Editors
I have been following this thread with some interest but I am now contributing only in response to the change in the content of the discussion and ideas which, in my opinion, only seeks to misdirect and confuse
Just like the fallacy that the term "Christianity" encompass a monolith of ideas and beliefs with no variation in interpretation, to suggest there is a real divide in beliefs between humanists and theists based on religious beliefs and faith (or lack of) only serves to create fear and distrusts through undue emphasis on the differences rather than common or shared values.
Such tactics are often used to generate raw emotion which would cloud judgement and understanding of the real issues; unfortunately these are often very successful in confusing the issues with side shows leading to outcomes like the Brexit and the Trump presidency.
It is curious that those who are more likely to use these methods appear to belong to certain religious groups rather than those who do not follow a faith.
Regardless of religious background (or not), I would remind people that both healthcare professionals and clients are, at the end, individuals who do not often have all their beliefs and values sitting right in the mainstream of the group they identify with.
Even for certain religious sects perceived to have relatively homogenous practitioners of the faith, it is possible to find significant variation in an individual's interpretation of contentious issues, as our experience involving human blood products and medical products with animal-origin has shown.
Hence doctors declaring themselves 'Christian', does not automatically mean shared value with a patient identifying as 'Christian' as well, nor must it mean the clinicians must have opposite views to an agnostic person.
Certainly the good conduct rules for doctors require practitioners to put patients' wellbeing above their own and if what patients request is in direct conflict with doctors' values and religious beliefs, the latter is obliged to direct them to another clinician who can help them.
Hence requiring to declare religious beliefs would not change the obligations of doctors to seek the best care on behalf of the patient
Competing interests: I do not identify myself as a Humanist or Theist
To the Editor:
I share Drs. Smith and Blazeby’s view that religious beliefs pertaining to matters of moral conflict in medicine should be disclosed; however, I contend that they were right for the wrong reasons.
eligious beliefs unarguably exert a powerful influence on one’s moral convictions. Yet this influence takes form not as a competing interest but rather as a background metaphysical and moral foundation for those convictions. As the authors point out, competing interests exert influence apart from moral suasion; they must be disclosed because they may hinder us from doing what is good. Competing interests do not redefine what is good; they function as motivations to act against the good. Religious beliefs therefore cannot be described as competing interests: they are an organized network of foundational beliefs about metaphysics and morality that shape our notion of the good.
In fact, this influence is not limited to “religious” foundational beliefs. Inasmuch as morality is rooted in metaphysics [1], everyone—including non-religious persons—is subject to such influence. Thus, it is only natural that those who believe that humans are purely physical objects who exist as the product of mere accident, whose value derives only from one’s own affirmation and whose destiny is non-existence upon physical death (claims affirmed by most secular humanists [2]) will hold a very different view of euthanasia or abortion from those who are convinced that humans exist by virtue of Divine intention and therefore have intrinsic purpose and transcendent value (as affirmed by most theists).
Competing interests should be set aside; metaphysics and morality must be brought to bear. Given the universal influence of our foundational beliefs on our moral convictions, the real question is not whether one’s particular religious convictions (or secular humanism) should be disclosed as a competing interest; rather, it is what these foundational beliefs entail for medical ethics and whether these foundational beliefs are true. The authors’ proposal for full disclosure of foundational beliefs (which should include secular humanism) is an important first step in opening up truly meaningful debate in matters of moral conflict in medicine.
Ewan C. Goligher MD PhD FRCPC
Disclosures
Ewan Goligher is a Christian.
References
1. Singer, Peter. Rethinking Life and Death: The Collapse of Our Traditional Ethics. St. Martin’s Griffin, 1996.
2. Council for Secular Humanism, What is Secular Humanism? https://secularhumanism.org/index.php/3260. Accessed April 24, 2018.
Competing interests: Ewan Goligher is a Christian
Smith and Blazeby sensibly advocate a declaration of religious belief when 'participating in a debate on an issue affected by religious belief, such as abortion or assisted suicide’.
Personal and cultural bias plays a significant role in the personal beliefs and opinions that many people hold and express. Witness the continued prevalence of specific belief systems and practices organised by geography and family. Hidden bias contributes to the fact that some people claim that they are above such influences and that their professional views and opinions are wholly distinct from their personal or religious beliefs. We are none of us immune to these biases and some can have a profound and disproportionate effect on the debate, particularly when they are deliberately hidden.
The personal, the cultural and the professional are interwoven in all of us to some extent. This web becomes increasingly complicated when the person’s chosen religion takes a strong view on an ethical issue of the day such as abortion, ritual genital cutting or assisted dying. Some people will naturally or wilfully gravitate towards specialties which afford expression of their personal beliefs. This is as much the case for religious as for non-religious people some of whom – in both camps - might actively choose to work in gynaecology because of their conscientious commitment to providing sexual health and abortion services for example.
Whilst it is important to declare a religious bias, if one is active at the highest levels of the medical profession or Government, it is even more important when advocacy for or against a particular cause is being sponsored by religious (or non-religious) organisations. Just as we take a robust stance on declaring financial sponsorship for advocacy, we should be clear when it comes to advocacy on behalf of a faith group, who provide sponsorship and support that is not strictly financial but a significant benefit in kind.
Competing interests: Chair: Secular Medical Forum of the National Secular Society Member: Healthcare professionals for assisted dying Member: International NGO coalition for genital autonomy working to protect children from the forced genital cutting promoted by 2 of the major world religions I have neither religious belief nor affiliation
Man is a social creature. Religion is way of life, that gives you an identity in society. It brings in a class division with it. Agnostic societies are becoming more popular, yet our instinctive behaviour makes us seek out others from the same religion.
Declaring one's religious belief in the conflicts, can help readers feel more comfortable with the opinions of the author. It allays their fears within their subconscious mind that they are not accepting something against their own beliefs.
Competing interests: No competing interests
Smith and Blazeby have written a thought- provoking piece and replied to some of the points that have been raised(1),(2). But the fact remains that their suggestion is unlikely to achieve what they want: full and open discussion on contentious issues. In fact it is likely to silence some contributors. Not everyone is as brave about their religion or lack of it as they are. A requirement to state allegiance is not going to encourage many to declare it. It is more likely to shut them up. They seem not to have thought of this.
In addition their idea “that people’s beliefs may conflict with those of their religion may add strength to their argument, suggesting deep thought rather than passive acceptance” (1) appears not to recognise that a person’s view conflicting with the prevailing orthodoxy of the secular society in which they live may also suggest deep thought rather than passive acceptance.
If “it would be wise to declare your type of faith and perhaps explain the line that strict adherents to the faith would take on the issue” (2) then those who take a multi-faceted approach to their faith, who are occasional attendees at a place of worship and who may have a hazy idea of the line that strict adherents would take (just how strict are we talking anyhow) may not even be sure what to declare. Again they are less likely to contribute.
This move will suppress debate, not encourage it. Surely neither Smith nor Blazeby would want that.
1. Richard Smith, Jane Blazeby. 361:doi 10.1136/bmj.k1456
2. Smith R, Re. Why religious beliefs should be declared as a competing interest.
Competing interests: No competing interests
Re: Why religious belief should be declared as a competing interest
Religious Conflict of Interest
Richard Smith and Jane Blazeby in their article (April 14th BMJ) state that “It thus seems elementary that you should declare a religious competing interest.....”. It seemed far from elementary to me and I shared the article and the accompanying ‘Head to Head’ feature with my neighbour and friend who is the co-author of this letter because he has a background in Philosophy and ethics and is “dressed in purple, perhaps wearing a mitre,” and “would not need to declare [his] religion as a competing interest”.
A key question is what constitutes a ‘religious interest’? Paul Tillich writes that religion is ‘That which any of us takes utterly seriously and without reserve’. “The name of infinite and inexhaustible depth and ground of our being is God. That depth is what the word God means. And if that word has not much meaning for you, translate it, and speak of the depths of your life, of the source of your being, of your ultimate concern, of what you take seriously without any reservation” (The Shaking of the Foundations)
All of us have preconceptions which we bring to ethical debate, related to our deeply held beliefs about the nature of life and the world. In the logic of the article these must be declared, with none, rationalist, agnostic or secularist being privileged over another. If then you attempt to reduce these fundamental convictions to a single word e.g. Christian or Humanist then the definition of that single word may embody principles for one person with which others may disagree. Therefore to insist that only those who follow a ‘recognised’ religion should need to declare it as a competing interest is to be over simplistic if not illogical.
If anything needs to be ‘declared’ it would be the a priori assumptions, the evidence base and our own particular assumptions which each and all bring to the discussion. The authors significantly do not declare their own philosophical assumptions in this article.
We live in a society in which shared moral norms are on the wane, the consequence of which the authors appear not to address. Instead what they appear to proffer is a ‘secularist’ model of a moral community, the basis of which is notably fluid. Within this, though, it becomes increasingly difficult to be certain of the basis of ‘ethics’; is this mainly about the regulation of a ‘supermarket’ of infinite and unlimited choice, within which one or other set of assumptions may or may not be privileged over another, or is it about trying to determine an issue of truth, of what may or may not be, in often complex circumstances, admissible for human well being?
It would seem to us far from ‘elementary’ that a simple ‘religious competing interest’ should be declared. If it were to be taken further this proposal would need more detailed consideration taking into account much more than ‘religion’, a term used too often to sideline or dismiss the views of a substantial minority, thereby allowing an assumption that a secularist viewpoint is the new normal.
Dr John Pilling
12 The Meadows,
Walberton,
Arundel
BN18 0PB
Rt Rev Michael Langrish
39 The Meadows,
Walberton,
Arundel
BN18 0PB
Competing interests: No competing interests