Abstract In his work on medical ethics, Lauris Kaldjian identifies conscience with integrity. However, there are competing notions of integrity that may guide the conscience. This paper addresses debates over conscientious refusals by considering Cicero’s account of integrity, a conception previously not discussed in the context of this debate. Cicero offers a framework for understanding integrity and conscience for the physician that is an alternative to Alasdair MacIntyre’s notion of the completely unified life, an idea appropriated by Kaldjian in his argument that there can be no clean distinction between personal, private, practical reasoning and moral decision-making. Cicero’s account rejects the modern-individualist idea of the autonomous self living a wholly compartmentalized life. It agrees with Kaldjian’s stress on flexible decision- making, the internal morality of medicine, the importance of virtues, and the need to accommodate pluralism. However, Ciceronian integrity is better suited than the MacIntyreian account to our present liberal order. It offers a place for the “moral hero” while recognizing that the vast majority of moral agents will be “progressors” who lack the consistency of the moral hero’s fully integrated life. The inclusion of both types of individuals in the medical field may offset the potentially harmful tendencies to which each is prone.
Extract I am responding to a letter by Dr. Eric Brown about semantics in referring for medical assistance in dying (MAiD). . . The intended implication, it seems, is that any conscientious objectors should simply leave the practice of medicine.
Abstract The issue of conscientious refusal by health care practitioners continues to attract attention from academics, and was the subject of a recent UK Supreme Court decision. Activism aimed at changing abortion law and the decision to devolve governance of abortion law to the Scottish Parliament both raise the prospect of altered provision for conscience in domestic law. In this article, building on earlier work, we argue that conscience is fundamentally connected to moral integrity and essential to the proper functioning of moral agency. We examine recent attempts to undermine the view of conscience as a matter of integrity and argue that these have been unsuccessful. With our view of conscience as a prerequisite for moral integrity and agency established and defended, we then take issue with the ‘incompatibility thesis’ (the claim that protection for conscience is incompatible with the professional obligations of health care practitioners). We reject each of the alternative premises on which the incompatibility thesis might rest, and challenge the assumption of a public/private divide which is entailed by all versions of the thesis. Finally, we raise concerns about the apparent blindness of the thesis to issues of power and privilege, and conclude that conscience merits robust protection.
Abstract The dominant approach to conscience in contemporary bioethics presumes that conscience functions to promote personal moral integrity, and therefore presumes that the relevant values are inherently personal. This approach fails to demonstrate when and why claims of conscience should be taken seriously by others. I draw on Hannah Arendt’s deliberative model of conscience and Cheshire Calhoun’s social model of integrity to develop an alternative relational view of conscience – one that demonstrates that the relevant values are social as well as personal. I show how the goal of improving ethical practice over time constrains which conscience claims should be taken seriously by others.
Abstract Conscientious objection in health care is a form of compromise whereby health care practitioners can refuse to take part in safe, legal, and beneficial medical procedures to which they have a moral opposition (for instance abortion). Arguments in defense of conscientious objection in medicine are usually based on the value of respect for the moral integrity of practitioners. I will show that philosophical arguments in defense of conscientious objection based on respect for such moral integrity are extremely weak and, if taken seriously, lead to consequences that we would not (and should not) accept. I then propose that the best philosophical argument that defenders of conscientious objection in medicine can consistently deploy is one that appeals to (some form of) either moral relativism or subjectivism. I suggest that, unless either moral relativism or subjectivism is a valid theory-which is exactly what many defenders of conscientious objection (as well as many others) do not think-the role of moral integrity and conscientious objection in health care should be significantly downplayed and left out of the range of ethically relevant considerations.
Abstract Avoiding complicity in injustice is not limited to engaging in acts of noncompliance on behalf of one’s patients. The injustices from which one’s patients suffer may be rooted in morally suspect norms to which the profession of medicine, or some influential part of it, has lent its support or that it has not opposed and from which it and its practitioners have benefited. There may also be injustices that the profession has condemned but that remain. In general, avoiding complicity in wrongdoing involves, as a base- line, understanding that the norms and practices responsible for it have contributed to making noncompliance an option that at least deserves serious moral consideration, if not endorsement. A physician may then decide to engage in some form of rule breaking in order to act on this understanding and express her refusal to be complicit.. . .Complicity threatens the moral and professional integrity of the physician, and noncompliance may be warranted in part because it is the only way that a physician can meet the threat.
Abstract One of the requirements in the Dutch regulation for euthanasia and assisted suicide is that the doctor must be satisfied ‘that the patient’s suffering is unbearable, and that there is no prospect of improvement.’ In the notorious Chabot case, a psychiatrist assisted a 50 year old woman in suicide, although she did not suffer from any somatic disease, nor strictly speaking from any psychiatric condition. In Seduced by Death, Herbert Hendin concluded that apparently the Dutch regulation now allows physicians to assist anyone in suicide simply because he or she is unhappy. In this paper, I reject Hendin’s conclusion and in particular his description of Mrs Boomsma as someone who was ‘simply unhappy.’ After a detailed narration of her lifestory, I turn to the American philosopher Harry Frankfurt’s account of volitional incapacity and love for a more accurate characterization of her suffering. Having been through what she had, she could only go on living as another person than the one she had been when she was a happy mother. That would have violated her integrity, and that she could not bring herself to do.
Christina Juthberg, Sture Eriksson, Astrid Norberg, Karin Sundin
Abstract Aims. The aim was to study the relationship between conscience and burnout among care-providers in older care, exploring the relationship between stress of conscience and burnout, and between perceptions of conscience and burnout.
Background. Everyday work in healthcare presents situations that influence care-providers’ conscience. How care-providers perceive conscience has been shown to be related to stress of conscience (stress related to troubled conscience), and in county council care, an association between stress of conscience and burnout has been found.
Method. A questionnaire study was conducted in municipal housing for older people. A total of 166 care-providers were approached, of which 146 (50 registered nurses and 96 nurses’ aides/enrolled nurses) completed a questionnaire folder containing the stress of conscience questionnaire, the perceptions of conscience questionnaire and the maslach burnout inventory. Multivariate canonical correlation analysis was used to explore relationships.
Result. The relationship between stress of conscience and burnout indicates that experiences of shortcomings and of being exposed to contradictory demands are strongly related to burnout (primarily to emotional exhaustion). The relationship between perceptions of conscience and burnout indicates that a deadened conscience is strongly related to burnout.
Conclusion. Conscience seems to be of importance in relation to burnout, and suppressing conscience may result in a profound loss of wholeness, integrity and harmony in the self.
Relevance to clinical practice. The results from our study could be used to raise awareness of the importance of conscience in care.
Extract Contrary to what Lawrence and Curlin (2007) suggest, it is not primarily disagreement about the nature of “the conscience” that underlies the controversy about whether and when health professionals should be allowed to refuse to provide services that violate their ethical beliefs. Rather, the primary source of disagreement is over the professional obligations of physicians, pharmacists and other healthcare providers and how to resolve conflicts between those obligations and healthcare professionals’ interest in maintaining their moral integrity.
Extract I think most would agree that to progress the debate over the role of conscience in medicine we must continue the conversation about the means and ends of medicine as suggested by Lawrence and Curlin (2007, 10). This must be done because the tensions that exist between negotiating one’s personal integrity and one’s professional integrity will never go away. These tensions are not exclusive to the profession of medicine, but are enhanced by potential conflicts between physician integrity and patient autonomy. The objective of the conversation should neither be to eliminate these tensions nor to narrowly compartmentalize them as having religious or secular origins. Rather, the objective of the conversation should be to first encourage each physician to engage in moral reflection upon what they believe is right or wrong and the source that informs these values. Only then will physicians be able to appropriately negotiate the tensions that exist between the moral duties of personal and professional integrity and engage in meaningful dialogue rather than disagreement with their peers and their patients.