The last few years have seen a flurry of excoriating critiques of conscientious objection in the academic press. Many argue that it should no longer be tolerated. (1) As one pundit puts it: 'if people are not prepared to offer legally permitted, efficient, and beneficial care to a patient because it conflicts with their values, they should not be doctors.' (2)

Christians in healthcare should respond to these concerning claims. There is plenty to say about them. But it is also useful to take a step back and consider what conscience is. Then we will understand its role in clinical decision-making and its relationship to conscientious objection. This will help us reflect on the current opposition in this area.

conscience: the instrument of moral reasoning

Some associate 'conscience' with guilt: it is the barb which snags us when we wilfully sin. But we must not confuse the pangs of conscience with conscience itself. There is more to conscience than the consequences of ignoring it.

The apostle Paul addresses conscience in his epistle to the Romans. The Roman Christians were confused about laws concerning the ceremonial cleanness of foods; Paul reminds them that all foods are clean. But he adds a caution: beware of the weaker brother's conscience. 'All food is clean, but it is wrong for a person to eat anything that causes someone else to stumble' (Romans 14:20). What Paul is saying is that although you might be happily (and rightly) convinced that eating bacon is clean, do not practise this legitimate liberty in a way which offends your brother. If he is convinced in his own mind — albeit wrongly — that not all foods are clean, do not lord your good conscience over him.

This doesn't seem like it has much to do with conscientious objection in healthcare. Yet, Paul concludes this teaching with: 'But whoever has doubts is condemned if they eat, because their eating is not from faith; and everything that does not come from faith is sin' (Romans 14:23). The principle underlying this teaching is that if one's conscience, even if it is mistaken, conflicts with one's actions, then one has sinned, even if the thing done is not wrong in itself. For example, though it is not a sin to eat bacon, if your conscience convicts you that it is and you eat it anyway, you have sinned. The thing itself is not a sin, but the intention to act against conscience is. (3)

This raises some questions. What is conscience? If it is merely a gut feeling, why not ignore it? If it is merely an emotional response after the fact, why not suppress it?

Clearly, Paul does not think conscience is trivial. He understands it to be something which is constitutive of morality, and believes that seeking to do the right thing involves the mind, (specifically the conscience) putting principles into practice. It is the God-given instrument of moral reasoning. To violate its demands is to become indifferent to good and evil.

In the language of philosophy, conscience is the act of reason which applies general moral principles to particular situations. (4) Conscience takes a general principle (eg. it is wrong to kill innocent persons) and applies it to a situation (eg. Socrates is a person) to yield a judgment about how one should act or refrain from acting (eg. I should not kill Socrates). (5)

Why does this matter? For one thing it shows that morality is reasonable, not irrational, and neither is conscience: to apply conscience is an act of reason. For another, it shows that every time anyone tries to do the right thing, whether they are aware of it or not, they use conscience. Every decision we make — assuming we are trying to do the right thing — necessitates conscience, including routine clinical decisions.

If a patient complains of feeling nauseated, miserable and of not opening their bowels for five days, my decision to prescribe laxatives is moral. I first realise that my patient is subject to something bad (constipation). Then I must be disposed to do good to them by reversing this condition, which in this case means prescribing laxatives. Absurd as it might sound, prescribing laxatives to a patient is a moral decision of conscience. Conscience takes the general principle about loving one's neighbour and specifies it to the situation presented.

conscientious objection:

opting out for moral (and clinical) reasons

To conscientiously object means refraining from taking part in something one considers to be gravely immoral. It is not merely a refusal to do something one does not like. It means opting out of something because one is morally opposed to it. It is not a whim, or a pretext for laziness or prejudice, and neither is it an opportunity for activism. Conscientious objection arises when the demands of patients or colleagues are so incompatible with the requirements of one's conscience that one must abstain from taking part in them.

Conscientious objection to abortion is an important case in point, in part because of the conscience clause in the Abortion Act (1967). (6) Yet conscientious objection can potentially arise to any proposed act which one considers to be seriously wrong, not just abortion or the other 'big two' (euthanasia and contraception). We tend to think that conscientious objection only applies to a predetermined list of controversial procedures. This is far from reality. It can arise from many a clinical scenario where one is asked to do something morally wrong.

To see this, it is helpful to distinguish between conscientious objection to ends and conscientious objection to means. Conscientious objection to ends occurs when the morality of the given goal is in question, for example abortion, female genital mutilation, euthanasia, or amputation of a healthy limb. The conscientious objector opposes the thing because it is wrong in and of itself. However, the conscientious objector to means does not object to the thing itself but to its appropriateness, for example the prescription of antibiotics to a patient with a viral cold who demands them. Put like this, it becomes clear that conscience and conscientious objection are at work even when they go by another name. And whether it be to means or ends, it is the same process of conscience applying general principles to particular situations.

For example, no intensivist opposes CPR, intubation and ventilation in and of themselves. Yet if a patient demands such escalation of care when it is clearly not appropriate, he may object to it. Moreover, one often hears it said that it would be wrong — cruel even — to attempt to perform CPR on certain patients. This moral language does not imply that CPR is wrong in and of itself, only that there is a time when it is so grossly inappropriate that it becomes wrong. In this situation, one does not object to ends but to means.

This shows that conscientious objection is happening all around us. When a patient asks for an intervention which is inappropriate but not wrong in itself, we make a moral decision based on our intention to do good to say 'no'. A request might be slightly inappropriate, but nevertheless within what can reasonably be considered beneficial. At other times, however, the request might be downright dangerous to the patient or others: a patient in renal failure demanding their normal doses of (renally-cleared) sedatives. Saying 'no' to such a request is usually viewed as the work of clinical judgment — which it is — but it is primarily a moral judgment specified to a clinical setting. There are so many such cases of conscientious objection in clinical practice that we often fail to recognise them as such.

This demonstrates that conscientious objection is merely one by-product of conscience. Conscience is at work whenever we make a clinical decision. Often it only comes to mind when there is a severe conflict between a patient's demand and our understanding of the right thing to do, yet it is at work in the formation of every clinical judgment. We should think of conscientious objection as only the beginning of practical reason. (7)

why is conscience objection under threat?

Opponents of conscientious objection have not reckoned with the fact that conscience is at work in every clinical decision, not just the morally controversial ones, and that conscientious objection under the name of clinical judgment is already part and parcel of good practice. It seems therefore, that restricting conscientious objection when it comes to the 'usual suspects' is arbitrary. More could be said about this, (8) but a theological angle will help us think more clearly.

What does the offensive against conscientious objection teach us about our spiritual condition? For one thing, it shows how much emotivism colours our thoughts. There is an underlying assumption in some quarters that morals are irrational, that morality is just a sophisticated way of expressing likes and dislikes, and so is any appeal to conscience. (9) Therefore, moral claims can be dismissed when it is convenient to do so. If the conscience is fundamentally irrational, then it can be overruled by those for whom it is inconvenient. But man is not a fundamentally irrational creature, but a thinking being, fashioned in the image of the God of reason. God has equipped all human beings with an innate sense of right and wrong, and a conscience to use to seek the former and avoid the latter. Paul, again writing to the Romans, says concerning the Gentiles who are ignorant of the law of God that 'the requirements of the law are written on their hearts, their consciences also bearing witness…' for they 'do by nature things required by the law.' (10) By the grace of God, no human being is completely indifferent to good and evil, which is to say that no human being is without a conscience. Conscience and conscientious objection, therefore, are not only for those of faith, but for all who care about doing the right thing.

Another reason why conscience is marginalised is apathy towards God. Why would anyone care about God's law if one does not recognise him as Creator, Legislator and Redeemer? In an imaginary world where there is no ultimate judge to whom we are accountable, (11) the dictates of conscience are often too inconvenient to obey. Conscience and its application of the law which God has written on the human heart seems much less important.

conclusion

Paul exhorts us to not be conformed to this world's thinking, but rather be transformed in the renewing of our mind. By God's grace, our conscience is being renewed, in order that it aligns more closely with God's good, pleasing and perfect will. (12) As we perceive the requirements of morality more clearly, we might well encounter external demands which come into conflict with these. Our conscience will be at work (as it is every time we try to do the right thing) whether or not objection is necessary. Encouragingly, there is plenty of scholarly ammunition to defend the liberty of conscience in the public square. 13 We can make the case for conscience, not as a special religious exemption, but as a basic function of human reason and clinical practice.

Toni Saad is a clinical medical student in Cardiff

SUMMARY

conscience

• A function of reason which we use every time we try to do the right thing
• Applies general moral principles to specific situations to yield a judgment about how one should act

conscience objection

• Conscientious objection to ends and conscientious objection to means can be distinguished, though both are substantially similar in that they entail the application of general moral principles to particular situations
• Conscientious objection to ends includes objection to abortion, euthanasia, contraception, female genital mutilation, or an amputation of a healthy limb
• Conscientious objection to means (often called clinical judgment) entails objecting to the appropriateness of means, not to the end itself. For example, under some circumstances, CPR and/or invasive and aggressive organ support can be so inappropriate as to become wrong, and a doctor would be morally justified in refusing to perform such things under certain circumstances
• Conscientious objection, in the name of clinical judgment, goes unnoticed in clinical practice