Letters

To the editor: Adrienne Martin breaks fresh ground in “Tales Publicly Allowed: Competence, Capacity, and Religious Belief” (Jan–Feb 2007). Her claim that persons can lack capacity for decision-making yet retain competence to decide is refreshing, for it suggests that more is at stake than autonomy in the debate over decision-making. Religion may include a set of basic moral premises, but it is much more than that. Martin helpfully notes that not all religious claims have the same epistemic status. Some, such as a belief in God, may be beyond evidential backing; others, such as a claim that men and women are of different moral status, may be vulnerable to an evidentiary counterargument. Saying that all religious moral claims are of equal status when medical decisions are at issue ignores this difference.

Taking religion seriously entails more than respect for individual conscience; in particular it involves respect for religious institutions and practices. Martin points out that a focus on the individual conscience is not the only—nor obviously the best—way of understanding religion’s claims within medicine.

Moreover, what constitutes a religion or a religious claim is in no way obvious. Some definitions of religion are psychological: one’s god is whatever is central in one’s life, or what one would die for. Others are more substantive: a specific kind of issue is per se a religious issue. This is the view Ronald Dworkin takes in Life’s Dominion. Martin forces us to ask “just what are we committed to respecting when we respect religious beliefs?”

Finally, the essay is done with rigor and force but with respect as well. No one with any sense could fail to appreciate the perspectives of which Martin is critical or the importance of respect for autonomy. The harder question is the sufficiency of that paradigm. We should move beyond it carefully; the question of how to talk to persons with incapacitating beliefs is but one of many that remains on the table. But this essay represents a necessary step in the right direction.

David H. Smith
Yale University

To the Editor: I would like to add a legal observation to Adrienne M. Martin’s discussion of competence, capacity, and religious belief. The “Establishment Clause” of the Constitution disallows the state from giving more respect to religious beliefs than to secular ones. Thus, if one cannot get a court order to coerce an adult Jehovah’s Witness to accept a blood transfusion, one should also not be allowed a court order to coerce someone to accept a medical intervention that she is refusing due to a factually incorrect secular belief (e.g., that blood transfusions carry a high risk of transmitting HIV). In both cases, it would certainly be appropriate to engage the patient in conversation in an attempt to encourage them to rethink their decisions, but it would be wrong to treat those decisions differently.

Dena S. Davis
Cleveland-Marshall College of Law

To the Editor: Adrienne Martin maintains that decision-making capacity and competence are logically distinct concepts that have been mistakenly conflated in bioethics and the law. This is brought home, she argues, by cases in which patients with unusual religious beliefs are said to be competent by clinicians because their beliefs are religious—even though, in her view, these clinicians think that the religious beliefs at issue are false and assess such patients as decisionally incapacitated. Her argument, however, rests on a misconception about the falsification of religious beliefs, a failure to distinguish between unorthodox and bizarre religious beliefs, and an inaccurate assessment of current legal and social practices regarding respect for religious belief.

Consider Martin’s discussion of the teaching of Jehovah’s Witnesses (that scripture and the early Christian tradition prohibit blood transfusion); many members believe that to accept such a transfusion could prevent them from living eternally in God’s new world. Martin maintains that medical professionals hold that this belief is false, for it prevents Jehovah’s Witnesses from arriving at an accurate assessment of the risks of blood transfusion. Thus, in her view, clinicians maintain that such patients are decisionally incapacitated on account of their...