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Matters of conscience arise with some frequency in bioethics. A health professional may cite considerations of conscience in declining to perform or participate in a certain procedure. A patient may refuse a particular treatment on grounds of conscience. And new or unanticipated circumstances may create conflicts of conscience for patients and health professionals alike. What do we mean by "conscience" in these and related contexts? Is conscience an internal moral sense sufficient for distinguishing right from wrong? Is the "voice" of conscience simply the echo of parental and social prohibitions? Or does conscience differ in important ways from either of these? How much weight should be given in ethical reflection to claims of conscience? To what extent and for what reasons should health professionals compromise personal convenience, institutional efficiency, or medical effectiveness in order to respect individual conscience, their own or their patients'?

Three Conceptions of Conscience

The idea of conscience has a long and complex history (D'Arcy, 1961; Mount). The word "conscience" derives from the Latin conscientia, introduced by Christian Scholastics. Most generally, it refers to conscious awareness of the moral quality of some past or contemplated action and the disposition to be so aware (conscientiousness). In what follows we consider three main conceptions: (1) conscience as an inner sense that distinguishes right acts from wrong; (2) conscience as the internalization of parental and social norms; and (3) conscience as the exercise and expression of a reflective sense of integrity.

MORAL SENSE. Conscience is sometimes conceived as an internal moral sense sufficient for distinguishing right from wrong. The reliability of this inner sense is usually attributed to its divine origin, its reflection of our true nature, or some combination of the two. There are, however, difficulties with this conception.

Consider, first, a variation of an argument developed by Plato in his Euthyphro. Is what makes an act right the fact that it is endorsed by one's conscience? Or does conscience recommend a certain course of conduct because it is right? If the former, the promptings of conscience appear to be arbitrary. Whatever is urged by a person's conscience would, in this view, be right. There would be no way to assess the deliverances of conscience or to compare the consciences of, say, Hitler and Mother Teresa. If, on the other hand, conscience directs us to perform certain acts because they are right, it cannot be the principal source of moral knowledge. We must, in this event, have prior, independent criteria of rightness and wrongness that allow us to distinguish those acts that should be recommended by conscience from those that should not—in which case conscience is not sufficient to guide conduct.

A related difficulty is the prevalence of conflicts of conscience, both within persons and between them. Such conflicts are especially pronounced in bioethics, where advances in knowledge and technology confront us with unprecedented, consequential choices ranging well beyond our ethical traditions. The limitations of conscience, if it is conceived as a sufficient guide to moral decision making, may not be so noticeable in static, homogenous, insular cultures and subcultures. But where new circumstances require members of pluralistic societies to come to some agreement on bioethical questions, appeals to an internal, self-validating sense of right and wrong are apt to generate more heat than light.

INTERNALIZED SOCIAL NORMS. The most plausible explanation for the limitations of conscience in resolving ethical conflicts is that the "voice" of conscience is simply the echo of social and parental admonitions impressed upon the developing psyches of young children (i.e., the Freudian superego). Whatever its psychological and developmental significance, conscience so conceived has little normative import. That we have certain moral compunctions as a result of our socialization does little to establish their validity. We are bound by the voice of conscience only if we can provide independent justification of its dictates. It is the adequacy of the justification, not the persistence of the voice, that carries moral authority. Conceived as internalized social norms, then, conscience plays no direct role in ethical deliberation.

SENSE OF INTEGRITY. "I couldn't live with myself if I were [or were not] to perform the abortion in these circumstances." "I can no longer participate in this treatment plan in good conscience." "How could I continue to think of myself as a Jehovah's Witness if I were to consent to the blood transfusion?" Each of these sentences expresses an appeal to conscience that is neither a deliverance of an internal moral sense nor an internalization of an external social norm. What is expressed in each case is the culmination of conscientious reflection about the relationship between a certain course of action and a particular conception of the self. So understood, appeals to conscience are closely connected to reflective concern with one's integrity. The focus is not so much on the objective or universal rightness or wrongness of a particular act as on the consequences for the self of one's performing it.

There is something absurd, Gilbert Ryle has observed, in saying "My conscience says that you ought to do this or ought not to have done that" (Ryle, p. 31). I may be troubled by your wrongdoing, but unless I have advised or assisted you, or culpably failed to prevent you from performing the act in question, my conscience will be clear. The same is not true, however, about those of my acts that I have determined, for one reason or another, were or would be morally wrong. Having judged a certain act to be wrong, an appeal to conscience stresses the added wrongness of my performing it. Appeals to conscience therefore presuppose a prior determination of the rightness or wrongness of an act (Childress, 1979). Moreover, one may or may not extend the standards one employs in making this assessment to others in similar situations. If, for example, the standards are universalizable principles of respect for persons, justice, or beneficence, one will maintain that anyone would do wrong in performing the act in question. But if one's standards are grounded in religious convictions, personal ideals, or a particular worldview and way of life, one may not hold everyone else to them. What is at stake in all such appeals is one's wholeness or integrity as a person.

Integrity

"It would be better for me," Socrates says in the Gorgias, "that my lyre or a chorus I directed should be out of tune and loud with discord, and that multitudes of men should disagree with me rather than that I, being one, should be out of harmony with myself and contradict me" (Arendt, 1971, p. 439). One cannot lead a good and meaningful life, Socrates suggests, unless the self is reasonably unified or integrated—unless, that is, one's words and deeds cohere with one's basic, identity-conferring, moral, religious, and philosophical convictions. Hence the importance of critical reflection on one's life as a whole. The words, deeds, and convictions of an unexamined life are unlikely to be sufficiently integrated to constitute a singular life—let alone one worth living.

Conscience should not, therefore, be conceived as a faculty or component of the self. It is, rather, the voice of one's self as a whole, understood temporally—as having a beginning, a middle, and an end—as well as at a particular moment. Operating retrospectively, what Christian tradition calls "judicial" conscience makes judgments about past conduct. Operating prospectively, what the same tradition calls "legislative" conscience anticipates whether a prospective utterance or course of action is likely to be at odds with one's most basic ethical convictions (D'Arcy, 1961). In each case, the signal that something is wrong—that one's integrity has been, is currently, or would be compromised—is an actual or anticipatory feeling of guilt, shame, or remorse.

Consider, in this connection, the words of Aleksandr N. Chikunov, a veteran of the 1968 Soviet invasion of Czechoslovakia, as he explains sharing his experience with young soldiers called to Moscow to suppress democratic reforms during the abortive coup ofAugust 1991: "I entered Prague in 1968 and I still have an ill conscience about it. I was a soldier then, like these guys. We were also sent like they are now, to defend the achievements of socialism. Twenty-three years have passed, and I still have an ill conscience" (New York Times, August 20, 1991, p. A13). Here Chikunov draws upon the lessons of his "ill" judicial conscience to inform and alert the legislative consciences of the young soldiers. His motivation, it seems, is not only to spare them the pangs of an ill conscience but also to help heal his own (and thus to heal himself).

The authority and sanctions of conscience are, Mr. Chikunov suggests, self-imposed. No external source can create or directly relieve a troubled conscience. Nor may we easily rationalize or evade its judgments. "Other judges," as D'Arcy points out, "may be venal or partial or fallible; not so the verdict of conscience" (D'Arcy, 1961, p. 8). The oppressiveness of a guilty conscience is due in part to its identity with the self.

Conscience in Bioethics

Three factors contribute to the prevalence of appeals to conscience in bioethics: (1) bioethical decision making often involves our deepest identity-conferring convictions about the nature and meaning of creating, sustaining, and ending life; (2) healthcare professionals and patients and their families will occasionally have radically differing beliefs about such matters; and (3) the complexity of modern healthcare often requires agreement and cooperation on a single course of action.

CONFLICTS OF CONSCIENCE. Conflicts of conscience arise not only between individuals but also within them. Consider a physician whose patient, suffering greatly from the ravages of the last stages of a terminal illness, is also a longtime friend. The patient requests the physician to provide both the substance and the instruction for taking his own life. The physician finds herself torn. On the one hand, her conception of medicine and professional identity is incompatible with what appears to be physician-assisted suicide. On the other hand, the bonds of friendship and her natural sympathies strongly incline her to accede to her patient's request. The situation has, as a result, precipitated a crisis of conscience, and the physician must engage in what Charles Taylor has called "strong evaluation"—reflection about the self by the self in ways that engage and attempt to restructure one's deepest and most fundamental convictions (Taylor). Such reflection manifests an admirable concern for wholeness or integrity.

CONSCIENTIOUS REFUSAL. From Socrates to Sir Thomas More to Henry David Thoreau, individuals have appealed to conscience in refusing to comply with a wide range of legal or socially mandated directives. In some cases such noncompliance may be covert and evasive—for example, a physician's providing contraceptive information to married couples in Connecticut before that state's anticontraceptive law was declared unconstitutional (Childress, 1985). In most cases, however, health professionals and patients give reasons of conscience in openly seeking personal exemption from certain standard practices.

Physicians may appeal to conscience in refusing to do procedures that are both legal and performed by their colleagues. Consider an obstetrician's refusal to perform a legal abortion or a pediatrician's refusal to prescribe human growth hormone for short, but normal, children at the behest of their anxious parents. In each case the physician's decision may be based on moral convictions or personal ideals. The obstetrician need not believe that abortion ought to be illegal or that women who request, or physicians who perform, abortions are deeply immoral. The pediatrician may neither urge the legal prohibition of administering human growth hormone to short, but normal, children nor regard parents who request this treatment, or other pediatricians who administer it, as unethical. Both agree, however, that it would be a violation of conscience—a betrayal of their deepest personal convictions about life or the nature of medicine—if they were to perform the act in question.

Similarly, nurses appeal to conscience in seeking exemption from procedures or care plans that threaten their sense of integrity. For example, a nurse may conscientiously refuse to follow a physician's directive to remove medically administered hydration and nutrition from a patient in a persistent vegetative state. Regardless of the act's legality, the family's concurrence, and the physician's directive, given her deepest identity-conferring convictions about the nature and value of life, the nurse may be unable to carry out the action. Her reasoning, she might add, is not strong enough to condemn others who believe differently; but as for herself, she must refrain.

Patients, too, may appeal to conscience in refusing forms of medical treatment. When informed, mentally competent Jehovah's Witnesses refuse blood transfusions on religious grounds, they do not at the same time urge that blood transfusions be legally prohibited, nor do they condemn those who gratefully accept blood transfusions. What they want is not so much respect for the content of their particular convictions as much as respect for their consciences. The same is true of other patients who refuse or request certain forms of treatment on the basis of fundamental moral and religious convictions.

Respect for Conscience

Respect for conscience is a corollary of the principle of respect for persons. To respect another as a person is, insofar as possible, to respect the expression and exercise, if not the content, of a person's most fundamental convictions. A society's respect for individual conscience may extend not only to religious toleration but also, for example, to exempting conscripted pacifists from direct participation in war.

In the biomedical context, respect for conscience may be inconvenient, inefficient, or detrimental to medical outcomes. Still, it must always be taken seriously and often should prevail. In some cases, respect for conscience may be balanced with biomedical goals. At a certain level of abstraction, the purpose of healthcare is strikingly similar to that of protecting individual conscience. Although healthcare is usually focused on the body, emphasis on informed consent implies that the principal function of medicine is the health or wholeness of the patient as a person. Yet a person's sense of health or wholeness may also be threatened by what the former Soviet soldier, Aleksandr Chikunov, revealingly called an "ill" conscience. The values underlying appeals to conscience within the healthcare system are not, therefore, radically at odds with the values underlying medical and nursing care. In each case the aim is to preserve or restore personal wholeness. Insofar, then, as appeals to conscience and the healthcare system share a fundamental commitment to preserving and restoring personal wholeness or integrity, we ought in cases of conflict to seek some sort of balance or accommodation between them.

Health professionals who refuse, withdraw, or dissociate themselves from certain practices or procedures on grounds of conscience may well be among the more thoughtful and effective members of a healthcare team. Thus a healthcare institution intent on retaining such nurses and physicians has prudential as well as ethical grounds for accommodating their claims of conscience even at the cost of some inconvenience or expense. Respect for conscience requires going to greater lengths for patients, however, than it does for healthcare professionals. This is in part because an individual's role as a healthcare professional is voluntary in a way that being a patient is not. It is one thing, for example, to respect a Jehovah's Witness patient's conscientious refusal of a blood transfusion; it is quite another to respect the conscientious refusal of a physician who is a Jehovah's Witness to administer blood transfusions. An individual whose moral or religious convictions are incompatible with a common, essential type of healthcare has no business seeking a position in which such care is a routine expectation.

Problems and Limits

At least two important questions remain. First, how do we distinguish genuine claims of conscience from claims serving as smoke screens for laziness, cowardice, distaste for certain procedures, or dislike or prejudice toward certain patients? Second, given that a genuine act of conscience may be morally wrong, should individuals always (or always be permitted to) follow their conscience?

GENUINENESS. Understanding the nature and justification of conscientious refusal allows us to distinguish genuine from spurious or self-deceived appeals to conscience. In assessing the authenticity of such appeals we may, for example, inquire into (1) the underlying values and the extent to which they constitute a core component of the individual's identity; (2) the depth of the individual's reflective consideration of the issue; and (3) the likelihood that he or she will experience guilt, shame, or a loss of self-respect by performing the act in question. Such criteria have been employed with reasonable success by the U.S. Selective

Service System in identifying those whose deep and longstanding moral convictions forbid direct participation in war. They can be used with similar success in identifying genuine appeals to conscience in the healthcare setting (Benjamin and Curtis).

CONSCIENTIOUS BUT WRONG. Conscience is not an infallible guide to conduct. Even those who attend carefully to matters of integrity and who critically examine their basic convictions may, at a later date, judge some of their conscientious acts as wrong. Should one, then, always follow one's conscience? If by "conscience" we mean the exercise and expression of good-faith efforts to integrate conduct with reflective ethical conviction, the answer is "yes." Following conscience is obligatory, even if one's act turns out to be wrong, because one is doing what one reflectively believes to be right. Conversely, deliberately acting contrary to conscience is blameworthy, even if one's act turns out to be right, because one is doing what one reflectively believes to be wrong.

We must therefore distinguish the character of an agent from the rightness of a particular act. That an act is required by conscience entails neither that it is right nor that others must endorse the agent's convictions or permit the act to occur. It is difficult, for example, to question the character of Jehovah's Witness parents when they conscientiously refuse to consent to a life-saving blood transfusion for a young child. Yet if we have good reasons for believing that withholding the transfusion would be seriously wrong, we may try to persuade the parents to consent and, if necessary, seek a court order mandating treatment. Distinguishing the conscientiousness of the parents from our judgment of the act, though not eliminating the difficult question of whether, and if so, how, to intervene, enables us to attend more adequately to its complexity.

MARTIN BENJAMIN (1 995)

SEE ALSO: Autonomy; Conscience, Rights of; Emotions; Ethics, Religion and Morality; Freedom and Free Will; Human Dignity; Human Nature; Principlism; Profession and Professional Ethics

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