Some difficulties involved in locating the truth behind conscientious objection in medicine

Inspired by Smith, Ben-Moshe suggests that we should only accommodate conscientious objections (COs) in medicine based on moral beliefs that are true, or which closely approximate to the truth. He suggests that we can identify moral truths by consulting our consciences when our consciences adopt the standpoint of an impartial spectator. He also suggests some (surprisingly modest) changes to our current practices in regard to the management of CO in medicine that would be needed were his proposal to be adopted. Here, I argue that both Smith and Ben-Moshe underestimate the difficulties involved in adopting the standpoint of an impartial spectator. In particular, both authors fail to recognise the extent to which cognitive bias and ideological commitments prevent many of us from identifying the standpoint of an impartial spectator and also prevent us from realising that we are failing to be impartial. I also consider some different changes to current practices that would be needed if we were to take on Ben-Moshe's approach to CO in medicine while also recognising the difficulties involved in adopting the standpoint of an impartial spectator.

Legitimacy in bioethics: challenging the orthodoxy

Several prominent writers including Norman Daniels, James Sabin, Amy Gutmann, Dennis Thompson and Leonard Fleck advance a view of legitimacy according to which, roughly, policies are legitimate if and only if they result from democratic deliberation, which employs only public reasons that are publicised to stakeholders. Yet, the process described by this view contrasts with the actual processes involved in creating the Affordable Care Act (ACA) and in attempting to pass the Health Securities Act (HSA). Since the ACA seems to be legitimate, as the HSA would have been had it passed, there seem to be counterexamples to this view. In this essay, I clarify the concept of legitimacy as employed in bioethics discourse. I then use that clarification to develop these examples into a criticism of the orthodox view-that it implies that legitimacy requires counterintuitively large sacrifices of justice in cases where important advancement of healthcare rights depends on violations of publicity. Finally, I reply to three responses to this challenge: (1) that some revision to the orthodox view salvages its core commitments, (2) that its views of publicity and substantive considerations do not have the implications that I claim and (3) that arguments for it are strong enough to support even counterintuitive results. My arguments suggest a greater role for substantive considerations than the orthodox view allows.

A libertarian case for mandatory vaccination

This paper argues that mandatory, government-enforced vaccination can be justified even within a libertarian political framework. If so, this implies that the case for mandatory vaccination is very strong indeed as it can be justified even within a framework that, at first glance, loads the philosophical dice against that conclusion. I argue that people who refuse vaccinations violate the 'clean hands principle', a (in this case, enforceable) moral principle that prohibits people from participating in the collective imposition of unjust harm or risk of harm. In a libertarian framework, individuals may be forced to accept certain vaccines not because they have an enforceable duty to serve the common, and not because cost-benefit analysis recommends it, but because anti-vaxxers are wrongfully imposing undue harm upon others.

Distributive justice and the harm to medical professionals fighting epidemics

The exposure of doctors, nurses and other medical professionals to risks in the context of epidemics is significant. While traditional medical ethics offers the thought that these dangers may limit the extent to which a duty to care is applicable in such situations, it has less to say about what we might owe to medical professionals who are disadvantaged in these contexts. Luck egalitarianism, a responsibility-sensitive theory of distributive justice, appears to fare particularly badly in that regard. If we want to maintain that medical professionals are responsible for their decisions to help, cure and care for the vulnerable, luck egalitarianism seems to imply that their claim of justice to medical attention in case of infection is weak or non-existent. The article demonstrates how a recent interpretation of luck egalitarianism offers a solution to this problem. Redefining luck egalitarianism as concerned with responsibility for creating disadvantages, rather than for incurring disadvantage as such, makes it possible to maintain that medical professionals are responsible for their choices and that those infected because of their choice to help fight epidemics have a full claim of justice to medical attention.

The case against libertarian arguments for compulsory vaccination

In a recent paper in this journal, Jason Brennan correctly notes that libertarians struggle to justify a policy of compulsory vaccination. The most straightforward argument that justifies compulsory vaccination is that such a policy promotes welfare. But libertarians cannot make this argument because they claim that the state is justified only in protecting negative rights, not in promoting welfare. I consider two representative libertarian attempts to justify compulsory vaccination, and I argue that such arguments are unsuccessful. They either fail to show that the state is justified in implementing the policy or overgeneralise. I suggest that Brennan's solution is especially well motivated insofar as it addresses the shortcomings of these arguments. Brennan argues that we violate the rights of others by participating in an activity that imposes an unacceptable collective risk of harm. Going unvaccinated is an activity that imposes an unacceptable collective risk of harm, and thus amounts to a rights violation. So, the state can implement a policy of compulsory vaccination I object, however, that Brennan's delineation of acceptable and unacceptable risk implicitly rests on classical liberal rather than libertarian principles; he justifies compulsory vaccination on the grounds that it promotes welfare. I also object that Brennan's argument would entail significant departures from libertarian institutional arrangements. This leaves libertarians with a choice: they can develop new arguments to demonstrate that their position is compatible with compulsory vaccination, or they can accept that their view entails the impermissibility of compulsory vaccination, and argue that this is not an unpalatable implication of their view.

What is wrong with the emergency justification of compulsory medical service?

Michael Blake holds that liberal states are precluded from introducing compulsory medical service to improve access to health care under conditions of critical health worker shortage. "Emergency circumstances" are the only exception when the suspension of liberty may be justified. I argue that there are three problems with Blake's emergency justification of compulsory service. First, his concept of emergency is vague. Second, his account does not really rely on emergency as much as liberty. Third, his conception of permissible restrictions of liberty is too narrow. I argue that liberties may be limited to some degree, temporarily, for the sake of attaining the capacities necessary for the exercise of liberties and for safeguarding the social conditions of the right to health. I conclude that in poor societies, temporarily delaying emigration through a highly qualified compulsory medical service can sometimes be justified.

On emergencies and emigration: how (not) to justify compulsory medical service

I have argued that the best way to understand the supposed right to restrict emigration is with reference to the concept of an emergency; restrictions on emigration are permitted, if at all, only as responses to an emergency situation, and must be judged with reference to the ethics of responding to such an emergency. Eszter Kollar argues, against this, that the concept of 'emergency' fails to describe the actual situation in low/middle-income countries, in which shortages of medical personnel are long-standing problems; she also argues that there is no need to invoke the concept of an emergency, when we might simply discuss these restrictions with reference to the relative importance of the human goods and interests involved. I argue, against Kollar, that we have no reason to think that an emergency must involve novelty; if the moral stakes are significant enough, we have reason to think of a situation as an emergency, regardless of when that situation began. I argue, too, that we have reason to differentiate between restrictions of liberties undertaken as part of the process of specifying liberal freedoms and emergency restrictions of those liberties defended by liberalism itself. The latter, I suggest, ought to be recognised and defended as a distinct moral category, if only to recognise the continuing moral remainder when a liberal right is temporarily suspended under emergency circumstances. I conclude that a permission to restrict emigration is, if at all, only justifiable as an emergency response to unfavourable circumstances, and ought not to be analysed in the more conventional liberal terms Kollar deploys.

Relevant evidence, reasonable policy and the right to emigrate

In this article I respond to commentaries by Javier Hidalgo and Phillip Cole. Javier Hidalgo believes that we would be justified in restricting the liberties of health personnel if we had compelling evidence that this would bring about beneficial consequences. He is sceptical that this evidence exists or would ever be forthcoming. Hidalgo therefore supports my position, at least in theory, that where there is good evidence concerning relevant beneficial consequences for remedying important losses associated with high skill migration, we may permissibly restrict health personnel's freedom to migrate through introduction of carefully crafted compulsory service and taxation programmes. So one important issue is whether such evidence is or could ever become available in a form useful to members of government. By contrast, Phillip Cole expresses significant reservations about the policies I argue are permissible under certain conditions. He believes that health workers should never be required to comply with the sorts of taxation and compulsory services programmes I recommend. I show that the programmes for which I argue are not as onerous as Cole imagines and therefore that they can be justified. I also show that relevant evidence exists to address Hidalgo's concerns.

Income-based equity weights in healthcare planning and policy

Recent research indicates that there is a gap in life expectancy between the rich and the poor. This raises the question: should we on egalitarian grounds use income-based equity weights when we assess benefits of alternative benevolent interventions, so that health benefits to the poor count for more? This article provides three egalitarian arguments for using income-based equity weights under certain circumstances. If income inequality correlates with inequality in health, we have reason to use income-based equity weights on the ground that health inequality is bad. If income inequality correlates with inequality in opportunity for health, we have reason to use such weights on the ground that inequality in opportunity for health is bad. If income inequality correlates with inequality in well-being, income-based equity weights should be used to mitigate inequality in well-being. Three different ways in which to construe income-based equity weights are introduced and discussed. They can be based on relative income inequality, on income rankings and on capped absolute income. The article does not defend any of these types of weighting schemes, but argues that in order to settle which of these types of weighting scheme to choose, more empirical research is needed.

On Engster's care-justification of the specialness thesis about healthcare

To say health is 'special' is to say that it has a moral significance that differentiates it from other goods (cars, say or radios) and, as a matter of justice, warrants distributing it separately. In this essay, I critique a new justification for the specialness thesis about healthcare (STHC) recently put forth by Engster. I argue that, regrettably, Engster's justification of STHC ultimately fails and fails on much the same grounds as have previous justifications of STHC. However, I also argue that Engster's argument still adds something valuable to the debate around STHC insofar as it reminds us that the moral significance of healthcare may be wider than simply its effect on the incidence of disability and disease: one further reason we may think healthcare is morally significant is because it concerns the treatment and care of those who are already unwell.

Two conceptions of conscience and the problem of conscientious objection

Schuklenk and Smalling argue that it is practically impossible for civic institutions to meet the conditions necessary to ensure that conscientious objection does not conflict with the core principles of liberal democracies. In this response, I propose an alternative definition of conscience to that offered by Schuklenk and Smalling. I discuss what I call the 'traditional' notion of conscience, and contrast this with the existentialist conception of conscience (which I take to be a close cousin of the view targeted by Schuklenk and Smalling). I argue that the traditional notion, grounded in an objective moral order, avoids the criticisms advanced by Schuklenk and Smalling; the existentialist conception, in contrast, does not. I conclude by discussing the benefits and risks of a 'restricted view' of respect for conscience.

Reasons, reasonability and establishing conscientious objector status in medicine

This paper builds upon previous work in which I argue that we should assess a provider's reasons for his or her objection before granting a conscientious exemption. For instance, if the medical professional's reasoned basis involves an empirical mistake, an accommodation is not warranted. This article poses and begins to address several deep questions about the workings of what I call a reason-giving view: What standard should we use to assess reasons? What policy should we adopt in order to evaluate the reasons offered by medical practitioners in support of their objections? I argue for a reasonability standard to perform the essential function of assessing reasons, and I offer considerations in support of a policy establishing conscientious objector status in medicine.

Selling conscience short: a response to Schuklenk and Smalling on conscientious objections by medical professionals

In a thought-provoking paper, Schuklenk and Smalling argue that no right to conscientious objection should be granted to medical professionals. First, they hold that it is impossible to assess either the truth of conscience-based claims or the sincerity of the objectors. Second, even a fettered right to conscientious refusal inevitably has adverse effects on the rights of patients. We argue that the main problem with their position is that it is not derived from a broader reflection on the meaning and implications of freedom of conscience and reasonable accommodation. We point out that they collapse two related but distinct questions, that is, the subjective conception of freedom of conscience and the sincerity test. We note that they do not successfully show that the standard norm according to which exemption claims should not impose undue hardship on others is unworkable. We suggest that the main reason why arguments such as no one is forced to be a medical professional are flawed is that public norms should not constrain citizens to choose between two of their basic rights unless it is necessary. In fine, Schuklenk and Smalling, who see conscience claims as arbitrary dislikes, sell freedom of conscience short and forego any attempts at balancing the competing rights involved. We maintain the authors neglect that most of legal reasoning is contextual and that the blanket restriction of healthcare professionals' freedom of conscience is disproportionate.

Civic republican medical ethics

This article develops a civic republican approach to medical ethics. It outlines civic republican concerns about the domination that arises from subjection to an arbitrary power of interference, while suggesting republican remedies to such domination in healthcare. These include proposals for greater review, challenge and pre-authorisation of medical power. It extends this analysis by providing a civic republican account of assistive arbitrary power, showing how it can create similar problems within both formal and informal relationships of care, and offering strategies for tackling it. Two important objections to civic republican medical ethics-that it overvalues independence and political participation in healthcare-are also considered and rebutted.

A framework for assessing the ethics of doctors' strikes

The first aim of this article is to offer a framework for constructive and rigorous discussions of the ethics of doctors' strikes, beginning with an in-principle distinction between the questions of how one should conduct oneself while working as a doctor and when and how one can suspend that work. The second is to explore how that framework applies to the contemporary British case of strikes by English junior doctors, with my suggestion being that those strikes do meet all of the criteria proposed. In closing, I gesture towards a further ethical dimension to strikes which is too often overlooked: namely, the responsibilities of employers and others not to misrepresent or demonise those doctors who are engaged in or considering taking industrial action.

An evaluative conservative case for biomedical enhancement

It is widely believed that a conservative moral outlook is opposed to biomedical forms of human enhancement. In this paper, I argue that this widespread belief is incorrect. Using Cohen's evaluative conservatism as my starting point, I argue that there are strong conservative reasons to prioritise the development of biomedical enhancements. In particular, I suggest that biomedical enhancement may be essential if we are to maintain our current evaluative equilibrium (ie, the set of values that undergird and permeate our current political, economic and personal lives) against the threats to that equilibrium posed by external, non-biomedical forms of enhancement. I defend this view against modest conservatives who insist that biomedical enhancements pose a greater risk to our current evaluative equilibrium, and against those who see no principled distinction between the forms of human enhancement.

Direct to consumer genetic testing and the libertarian right to test

I sketch a libertarian argument for the right to test in the context of 'direct to consumer' (DTC) genetic testing. A libertarian right to genetic tests, as defined here, relies on the idea of a moral right to self-ownership. I show how a libertarian right to test can be inferred from this general libertarian premise, at least as a prima facie right, shifting the burden of justification on regulators. I distinguish this distinctively libertarian position from some arguments based on considerations of utility or autonomy, which are sometimes labelled 'libertarian' because they oppose a tight regulation of the direct to consumer genetic testing sector. If one takes the libertarian right to test as a starting point, the whole discussion concerning autonomy and personal utility may be sidestepped. Finally, I briefly consider some considerations that justify the regulation of the DTC genetic testing market, compatible with the recognition of a prima facie right to test.

Clarifying the best interests standard: the elaborative and enumerative strategies in public policy-making

One recurring criticism of the best interests standard concerns its vagueness, and thus the inadequate guidance it offers to care providers. The lack of an agreed definition of 'best interests', together with the fact that several suggested considerations adopted in legislation or professional guidelines for doctors do not obviously apply across different groups of persons, result in decisions being made in murky waters. In response, bioethicists have attempted to specify the best interests standard, to reduce the indeterminacy surrounding medical decisions. In this paper, we discuss the bioethicists' response in relation to the state's possible role in clarifying the best interests standard. We identify and characterise two clarificatory strategies employed by bioethicists -elaborative and enumerative-and argue that the state should adopt the latter. Beyond the practical difficulties of the former strategy, a state adoption of it would inevitably be prejudicial in a pluralistic society. Given the gravity of best interests decisions, and the delicate task of respecting citizens with different understandings of best interests, only the enumerative strategy is viable. We argue that this does not commit the state to silence in providing guidance to and supporting healthcare providers, nor does it facilitate the abuse of the vulnerable. Finally, we address two methodological worries about adopting this approach at the state level. The adoption of the enumerative strategy is not defeatist in attitude, nor does it eventually collapse into (a form of) the elaborative strategy.

The ethics and politics of mindfulness-based interventions

Recently, there has been a lot of enthusiasm for mindfulness practice and its use in healthcare, businesses and schools. An increasing number of studies give us ground for cautious optimism about the potential of mindfulness-based interventions (MBIs) to improve people's lives across a number of dimensions. This paper identifies and addresses some of the main ethical and political questions for larger-scale MBIs. First, how far are MBIs compatible with liberal neutrality given the great diversity of lifestyles and conceptions of the good characteristic of modern societies? It will be argued that the potential benefits of contemporary secular mindfulness practice are indeed of a sufficiently primary or all-purpose nature to qualify as suitable goals of liberal public policy. Second, what challenges are brought up if mindfulness is used in contexts and applications-such as military settings-whose goals seem incompatible with the ethical and soteriological views of traditional mindfulness practice? It will be argued that, given concerns regarding liberal neutrality and reasonable disagreement about ethics, MBIs should avoid strong ethical commitments. Therefore, it should, in principle, be applicable in contexts of controversial moral value. Finally, drawing on recent discussions within the mindfulness community, it is argued that we should not overstate the case for mindfulness and not crowd out discussion of organisational and social determinants of stress, lowered well-being, and mental illness and the collective measures necessary to address them.

The limited impact of indeterminacy for healthcare rationing: how indeterminacy problems show the need for a hybrid theory, but nothing more

A notorious debate in the ethics of healthcare rationing concerns whether to address rationing decisions with substantial principles or with a procedural approach. One major argument in favour of procedural approaches is that substantial principles are indeterminate so that we can reasonably disagree about how to apply them. To deal with indeterminacy, we need a just decision process. In this paper I argue that it is a mistake to abandon substantial principles just because they are indeterminate. It is true that reasonable substantial principles designed to deal with healthcare rationing can be expected to be indeterminate. Yet, the indeterminacy is only partial. In some situations we can fully determine what to do in light of the principles, in some situations we cannot. The conclusion to draw from this fact is not that we need to develop procedural approaches to healthcare rationing, but rather that we need a more complex theory in which both substantial principles and procedural approaches are needed.

Obesity, paternalism and fairness

Many liberal theories are committed to the promotion of population health, and the principle of non-interference in individual life plans. Public health interventions often bring out a tension between these two values. In this paper, I examine this tension by assessing the justifiability of liberty-restricting policies in the field of obesity prevention. As I want to show, a 'soft' form of paternalism, which interferes with people's choices to safeguard their true interests, goes some way in justifying such policies, but it leaves unaddressed the problem of limiting the liberty of those whose true interest is in pursuing an unhealthy lifestyle. I argue that in this latter case, the key to reconcile the promotion of population health with the respect for individual liberty is distributive justice: when we cannot help those who care about their health without doing the same for those who do not, fairness will often require us to do so.

On the univocity of rationality: a response to Nigel Biggar's 'Why religion deserves a place in secular medicine'

Nigel Biggar (2015) argues that religion deserves a place in secular medicine. Biggar suggests we abandon the standard rationalistic conception of the secular realm and see it rather as "a forum for the negotiation of rival reasonings". Religious reasoning is one among a number of ways of thinking that must vie for acceptance. Medical ethics, says Biggar, is characterised by "spiritual and moral mixture and ambiguity". We acknowledge this uncertainty by recognising rival viewpoints and agreeing to provisional compromises.In this response, I object to Biggar's characterisation of medical ethics as "morally ambiguous" and "provisional". I argue that Biggar has failed to provide adequate support for his conception of ethics as a "forum for negotiation and compromise". I criticise Biggar's attempt to 'pluralise' rationality, and assert that if religion is to play a role in secular medicine, it must be ready to defend itself against a universal standard of reason. In the second section of my response, I argue that 'theistic natural law' gives us the resources to defend using reason alone ostensibly faith-based positions in healthcare ethics. In doing so, we retain a univocal conception of rationality, while at the same time leaving space for 'theism' in healthcare ethics.

Phase-dependent justification: the role of personal responsibility in fair healthcare

The main aim of this paper is to examine the fairness of different ways of holding people responsible for healthcare-related choices. Our focus is on conceptualisations of responsibility that involve blame and sanctions, and our analytical approach is to provide a systematic discussion based on interrelated and successive health-related, lifestyle choices of an individual. We assess the already established risk-sharing, backward-looking and forward-looking views on responsibility according to a variety of standard objections. In conclusion, all of the proposed views on holding people responsible for their lifestyle choices are subjected to reasonable critiques, although the risk-sharing view fare considerably better than the others overall considered. With our analytical approach, we are able to identify how basic conditions for responsibility ascription alter along a time axis. Repeated relapses with respect to healthcare associated with persistent, unhealthy lifestyle choices, call for distinct attention. In such situations, contextualised reasoning and transparent policy-making, rather than opaque clinical judgements, are required as steps towards fair allocation of healthcare resources.

Should nutritional supplements and sports drinks companies sponsor sport? A short review of the ethical concerns

This paper proposes that the sponsorship of sport by nutritional supplements and sport drinks companies should be re-examined in the light of ethical concerns about the closeness of this relationship. A short overview is provided of the sponsorship of sport, arguing that ethical concerns about its appropriateness remain despite the imposition of severe restrictions on tobacco sponsorship. Further, the paper examines the main concerns about supplement use and sports drinks with respect to efficacy, health and the risks of doping. Particular consideration is given to the health implications of these concerns. It is suggested that they, of themselves, do not warrant the restriction of sponsorship by companies producing supplements and sports drinks. Nevertheless, it is argued that sports sponsorship does warrant further ethical examination--above and beyond that afforded to other sponsors of sport--as sport sponsorship is integral to the perceived need for such products. In conclusion, it is argued that sport may have found itself lending unwarranted credibility to products which would otherwise not necessarily be seen as beneficial for participation in sports and exercise or as inherently healthy products.

Why religion deserves a place in secular medicine

As a science and practice transcending metaphysical and ethical disagreements, 'secular' medicine should not exist. 'Secularity' should be understood in an Augustinian sense, not a secularist one: not as a space that is universally rational because it is religion-free, but as a forum for the negotiation of rival reasonings. Religion deserves a place here, because it is not simply or uniquely irrational. However, in assuming his rightful place, the religious believer commits himself to eschewing sheer appeals to religious authorities, and to adopting reasonable means of persuasion. This can come quite naturally. For example, Christianity (theo)logically obliges liberal manners in negotiating ethical controversies in medicine. It also offers reasoned views of human being and ethics that bear upon medicine and are not universally held-for example, a humanist view of human dignity, the bounding of individual autonomy by social obligation, and a special concern for the weak.

A framework for luck egalitarianism in health and healthcare

Several attempts have been made to apply the choice-sensitive theory of distributive justice, luck egalitarianism, in the context of health and healthcare. This article presents a framework for this discussion by highlighting different normative decisions to be made in such an application, some of the objections to which luck egalitarians must provide answers and some of the practical implications associated with applying such an approach in the real world. It is argued that luck egalitarians should address distributions of health rather than healthcare, endorse an integrationist theory that combines health concerns with general distributive concerns and be pluralist in their approach. It further suggests that choice-sensitive policies need not be the result of applying luck egalitarianism in this context.

Good medical ethics, justice and provincial globalism

The summer 2014 Ebola virus outbreak in Western Africa illustrates global health's striking inequalities. Globalisation has also increased pandemics, and disparate health system conditions mean that where one falls ill or is injured in the world can mean the difference between quality care, substandard care or no care at all, between full recovery, permanent ill effects and death. Yet attention to the normative underpinnings of global health justice and distribution remains, despite some important exceptions, inadequate in medical ethics, bioethics and political philosophy. We need a theoretical foundation on which to build a more just world. Provincial globalism (PG), grounded in capability theory, offers a foundation; it provides the components of a global health justice framework that can guide implementation. Under PG, all persons possess certain health entitlements. Global health justice requires progressively securing this health capabilities threshold for every person.

Wait times and national health policy

Many arguments against US healthcare reform appeal to facts about wait times, and wait times are also discussed in debates about national health policy in other industrialised countries. This paper points out that there are several different ways to measure wait times. We currently measure them in one way, and this paper describes an alternative. The most reasonable assessments of US and international health reforms need to rely on the alternative method, and so when critics of health reform rely on the standard method, their arguments are unsound.

Voluntary moral enhancement and the survival-at-any-cost bias

I discuss the argument of Persson and Savulescu that moral enhancement ought to accompany cognitive enhancement, as well as briefly addressing critiques of this argument, notably by John Harris. I argue that Harris, who believes that cognitive enhancement is largely sufficient for making us behave more morally, might be disposing too easily of the great quandary of our moral existence: the gap between what we do and what we believe is morally right to do. In that regard, Persson and Savulescu's position has the potential to offer more. However, I question Persson and Savulescu's proposal of compulsory moral enhancement (a conception they used to promote), proposing the alternative of voluntary moral enhancement.

Religious circumcision, invasive rites, neutrality and equality: bearing the burdens and consequences of belief

The decision of the German regional court in Cologne on 26 June 2012 to prohibit the circumcision of minors is important insofar as it recognises the qualitative similarities between the practice and other prohibited invasive rites, such as female genital cutting. However, recognition of similarity poses serious questions with regard to liberal public policy, specifically with regard to the exceptionalist treatment demanded by certain circumcising groups. In this paper, I seek to advance egalitarian means of dealing with invasive rites which take seriously cultural diversity, minimise harm and place responsibility for the burdens and consequences of beliefs upon those who promote practices.