Are Conscientious Objections Always Acts of Conscience?
- Introduction and Hypothesis
- Fields of Study
1. Introduction and Hypothesis
Conscience is essential for moral decision-making. Historically, healthcare has been perceived as a moral endeavour in which healthcare professionals (HCPs) do what they perceive to be professionally ethical and beneficial for their patients (Sgreccia 2012). Moral decisions are an inherent part of the healthcare professions, and HCPs can draw on bioethical approaches to substantiate and guide their conscience to inform their moral decisions. However, more recent, relativistic approaches to morality in healthcare have emerged as the substantive basis for moral decision-making (Savulescu and Schuklenk 2017; Giubilini 2014; Giubilini 2017). As such, moral decisions in healthcare now predominantly revolve around prioritizing patient access to legally permissible services based on patient preferences, rooted in socio-cultural-political justifications as opposed to moral philosophical or theological approaches to morality (Lamb 2021). Specifically, the global movement to accelerate assisted death as a legal option operationalized through healthcare is one example of how ethics in healthcare is becoming construed with issues of legal access. One concern with a legalistic approach is that the healthcare professions do not derive their ethical ethos solely from the law. Rather, HCPs embody an ethos that aims to sustain and support life through ethical research and care approaches to life and end-of-life care contexts, as opposed to engaging with directly ending one’s life (Sgreccia 2012). As a result, moral decision-making in healthcare is becoming synonymous with systematic acculturation of patient choice as the basis for providing legal health services.
Yet, individual HCPs and some health systems that align with the ethics-based approach to healthcare —that objective morality can guide but also transcend the law —as the basis of patient care provision are often at odds with the access-based approach to healthcare. One mechanism for vocalizing their dissent has been through conscientious objection (CO). Conscientious objections are acts of conscience whereby the objector refuses to do something on the basis of conscience. Conscience is the ability to make decisions based on information derived from moral knowledge in order to decide to do something that is ethical, or refrain from doing something unethical (Lamb 2021). While there may be many reasons for making a CO in the context of healthcare, the scholarly literature reveals that COs are being discounted by the access-to-care approach owing to the lack of understanding of what conscience is (Lamb 2021). One example is where advocates for legal access to abortion assert that COs should not be used and instead insist that abortions be provided where they are legally permissible (Savulescu and Schuklenk 2017). Whereas those in favour of CO and conscience for moral reasons -amongst others- may use COs to refrain from providing them (Fleming, Frith, Luyben et al. 2018). Still others assert that conscience should form the basis for compliance in providing abortions (Buchbinder, Lassiter, Mercier et al. 2016).
From a practical perspective these approaches to conscience and CO need to be reconciled in order to facilitate effective care provision. From a moral perspective, these approaches cannot be reconciled since they are —among other things —mutually exclusive views on what constitutes ethical care provision. The question with respect to CO is, which of the views utilize conscience?
In the philosophical and theological ethics literature conscience is perceived as the individual response to objective morality, which transcends culture, community and the individuals themselves (Sgreccia 2012). If this is what conscience is, then is it relevant to call all acts of conscience, i.e. COs in healthcare today, acts of conscience? Do acts of conscience differ from choices that lack moral objectivity? If so, how and why? And, in light of the access-based healthcare model, who in healthcare today is making legitimate COs?
To study these questions in more depth I narrowed my focus to the uninterrupted philosophical-theological understanding of conscience in the moral philosophical-theological Catholic Christian tradition. Specifically, I looked at the philosophical-theological work of Thomas Aquinas’s Summa Theologiae and Pope John Paul II’s encyclical Fides et Ratio to explain what conscience responds to in order for acts of conscience to be legitimate. In light of the Catholic Christian intellectual tradition, the legitimacy of conscientious acts is clear: conscience responds to objective truth and it is up to each person, Catholic or otherwise, to make conscientious decisions that align with objective truth to satisfy the requirements of an informed conscience. Based on my initial research my hypothesis was: Not all choices are acts of conscience and acts of conscience are not only choices. If this is the case, then are HCPs who make COs against issues of moral gravitas (i.e. assisted death) in light of access-based approaches to healthcare making legitimate COs?
2. Fields of Study
2.1 The Theology of Conscience
This puzzle does not address whether all the choices HCPs make are acts of conscience. Choice requires delineating or deciding between two or more options. Making sound decisions require reflection, consideration and deliberation. Certain kinds of decisions require moral reflection, consideration and deliberation. These latter decisions require the work of conscience. This is because the work of conscience requires a specific knowledge base and direction: it necessitates an understanding of and adherence to truth, which is the object of morality. Objective, moral truth is therefore the goal of conscience. This puzzle addresses how we can know whether our conscience is aligned with objective truth to voice a CO. This puzzle therefore explores how making a COs require an understanding of objective truth, moral knowledge and a typology of conscience. In the Catholic Christian approach, the First Vatican Council showed that truth is understood by both faith and reason. The Council further lays out that although faith and reason are distinct, they are not mutually exclusive (Fides et Ratio 1998, I-9). Rather, faith and reason are synergistic.
In Fides et Ratio Pope John Paul II (1998) writes that truth is ultimately revealed in the fullness of the Revelation of God; striving towards this truth provides people with the purpose of their humanity and their identity which ultimately requires both faith and reason to comprehensively grasp the meaning of their existence as one that is meant to be in relationship with God. Truth is both divinely revealed through Revelation and intellectually obtained by way of natural law. Natural law is universal or truth obtained through human reason. Truth obtained through Revelation is not irrational but it requires the gift of faith to believe it, mediated by grace. Faith is believing the knowledge of the divine revealed to humanity by God which the believer can come to know and accept aided by grace. Grace is the supernatural gift from God to free and help one to respond to the invitation to believe in God in order to sanctify, justify and unify us with God (Catechism of the Catholic Church 1995, 1996-2003).
In order to arrive at truth there are various kinds of knowledge. Philosophical or rational knowledge is based on “sense perception…experience and which advances by the light of the intellect alone” (Pope John Paul II 1998, I-9). The knowledge that faith inspires us to draw on the knowledge of the infinite being of God can enhance our natural or rational understanding of the finite world. Theology is this knowledge that can intersect the finite with the infinite: it aims to provide knowledge of God through attending to the ways in which revelation is revealed. Further, theology, and particularly moral theology, can help us delineate ways to rightly consider knowledge of God as the moral inspiration for our moral actions. Moral knowledge is rooted in both faith (theology) and reason (philosophy) as knowledge of things to be done. It requires action or inaction. The mechanism for moral activity is conscience and the outputs of conscience are moral acts.
To understand what conscience is, the Catholic Church consistently draws on the work of Thomas Aquinas for a baseline philosophical-theological theory of conscience. In the Summa Theologiae, Aquinas (1998) lays out his comprehensive theory. A summative account of his work on conscience consists of defining conscience as the application of reason to specific situations; it involves applying universal (objective) natural law standards or principles of morality to particular cases. However, Aquinas notes that particular moral knowledge can be complex; navigating this complexity may require more than a general understanding of universal or natural law. Indeed, conscience qua conscience necessitates a deeper degree of moral knowledge. While moral knowledge might begin with intuitive knowledge of universal principles of natural law (synderesis), acts of conscience primarily consist of a more comprehensive knowledge base of natural law (Aquinas 1998; Ratzinger 2007; Lamb 2021). A deeper understanding of moral knowledge leads us to the ability to make complex decisions on how to act or refrain from acting in a moral way (practical wisdom). It is at this level of complexity that the conscience can also operate. The conscience can therefore be comprehensively understood as the innate ability of finite beings to acquire, understand and utilize moral knowledge to do a moral act or to refrain from doing something unethical. In the latter instance, inaction is the moral act (Aquinas 1998; Lamb 2016; Lamb 2021; Lamb and Pesut 2021).
Because conscientious acts are specific kinds of acts —moral acts —conscience requires knowledge of and the ability to discern and decide between the intention, object, means and circumstances which are the parts of moral acts (Sgreccia 2012). Moral acts are therefore distinguishable from other kinds of acts. Moral acts are not only based on decisions between one or more options; they are based on decisions that will affect our relationship to do the good overall, for ourself, for others involved and ultimately the other as God, who faith and reason informs us is the ultimate good and goal of every moral act (Aquinas 1998). Owing to the goal of conscience —to seek the truth in alliance with natural law and Revelation —the responsibility to form, develop and follow our conscience are what Aquinas (1998) articulates as the duties of conscience. Therefore, acts of conscience are significant; they differ from other choices and decisions since they are not ultimately oriented to what we would prefer to do; rather, they are decisions that orient us to what we ought to do (Wojtyla 1979). Further, these duties of conscience follow on from the responsibility we owe to the significance of being human persons, who have the unique ability to be moral persons. Our moral ontology is ultimately a response to the personal relationship we can all have with God, who is truth. Therefore, all actions of conscience are to align with truth, which is objective: it exists outside of ourselves. In this way, acts of conscience and morality are unique acts because they correspond with truth in such a way that while moral decisions involve us, they are ultimately meant to align us with the other as God. However, this does not mean that our conscience is infallible.
To account for the fact that we are human and can make mistakes, Aquinas lays out a typology of conscience. As I have written elsewhere, this typology categorizes the kinds of conscience we can have, in proportion to the extent to which we acquire, understand and use moral knowledge commensurate with seeking the truth in all moral situations (Aquinas 1998; Lamb 2016; Lamb 2021; Lamb and Pesut 2021). This typology consists of having a formed or correct conscience; an un-informed or incorrect conscience; a conscience ignorant of moral knowledge (not necessarily or fully culpable) and a deliberately ignorant conscience (willfully not developed or apathetic and culpable) (Aquinas, 1998). However, Aquinas cautions us still further in his typology with respect to our duties of conscience. So much so that he points out that we have a responsibility to acquire moral knowledge. For instance, if we could have become knowledgeable about a moral issue but deliberately didn’t, we could be held morally accountable for that (Aquinas 1998; Lamb 2016). Hence, the duty to inform our conscience is paramount. To an extent, natural law safeguards us from ignorance leading to a culpable, erroneous conscience. That is, in theory, minimal effort is needed to start thinking about what morality means and how to be a moral person unless we purposely ignore natural law and our conscience. Yet, the degree of moral knowledge required for conscientious acts is so important that the necessity of responsibly seeking out and developing a strong basis of moral epistemology in relation to our moral ontology and our actions, is essential. This application of theory to practice is the work of applied ethics. Yet, since truth is not only known through natural law, philosophy and experience, other ways of knowing are essential for developing one’s conscience as the truth-seeking mechanism of the human person. One other way of knowing is through the enlightenment of faith. In this way, faith and reason work together towards the same goal: of responding to truth which is the goal of moral acts through our conscience in response to following God who is truth itself.
2.2 Conscience in Health Science
Healthcare professionals typically receive their formative education in the discipline of health science. While ethics and bioethics —the branch of philosophy concerned with right action in relation to the human person and health – play a significant role in contemporary healthcare, more recent iterations of practical and applied ethics are pluralistic. Due to this, the notion of objective or universal truth and the role that conscience plays in the pursuit of objective truth through moral decision-making have been predominantly sidelined in secular or access-based approaches to the purpose and function of the healthcare professions. At the same time, conscience has started to receive more attention in the scholarly literature in healthcare and ethics in relation to CO, although conscience and CO are not necessarily linked across this scholarship. Significantly, conscience has been found in the empirical healthcare literature to be something that some HCPs understand on an intuitive level, while others may understand it conceptually although to varying degrees (Lamb 2017). However, the literature on CO is polarizing. Empirical research reveals that CO is sometimes being used to advance a particular pluralistic perspective without conscience versus investigating how conscience and CO might be utilized by HCPs in an effort to understand truth in the context of moral issues occurring in patient care and clinical practice.
As such, little theory, research and training exists regarding HCPs’ understanding and use of conscience leaving them unequipped to address issues of conscience in healthcare practice (Lamb, Kennedy, Clark et al. 2022). Research that does exist shows that HCPs report conscience as an influential aspect of their ethical practice (Jensen and Liddell 2009; Lamb et al. 2018; Pesut et al. 2020). When able to use their conscience in practice, HCPs have reported decreased stress over practice situations that trouble their conscience; staying true to their personal, professional and patient oriented approaches to care and being able to voice ethical concerns over patient issues that may otherwise go unnoticed (Catlin et al. 2008; Gustafsson, Eriksson, Strandberg et al. 2010; Juthberg, Eriksson, Norberg et al. 2007a; Juthberg, Eriksson, Norberg et al. 2007b; Juthberg, Eriksson, Norberg et al. 2010). HCPs also report making a conscientious objection to maintain their autonomy in keeping with professional standards (Bouthillier and Opatrny 2019).
Conversely, HCPs who are not able to voice their conscientious concerns in practice report a lack of professional support to do so; increased stress of conscience related to issues that trouble their conscience; burnout; being met with silence by colleagues and clinical leaders when raising their ethical concerns, and stigmatization for bringing up controversial ethical issues within clinical practice or that challenge the professional or social status quo (Lamb et al. 2018; Gustafsson, Eriksson, Strandberg et al. 2010; Juthberg, Eriksson, Norberg et al. 2007). Despite this intriguing body of evidence, little progress has been made to support HCPs understanding and use of conscience in secular, mainstream healthcare. The need therefore exists for an inter-disciplinary approach to conscience across research, education and practice in which theology, philosophy and science are triangulated to form a robust theoretical basis of conscience for ethical healthcare practice.
The challenge with COs in contemporary healthcare contexts is that they are sometimes being made in face of opposition (Lamb 2019). These reasons may stem from polarizing perspectives on the nature and purpose of healthcare. However, in light of the philosophical-theological articulation of conscience in the Catholic Christian tradition, the further challenge around HCPs being understood for declaring a CO in light of a formed conscience exists. As I have written elsewhere, this challenge consists in relation to the pluralistic context of healthcare today (Lamb 2021). According to pluralism, truth and objective morality are not the goals of ethics. Subsequently, relativists do not necessarily value what conscience is and may discount COs on, or in relation to, that basis (Giubilini 2017). Or, pluralists might further discount COs because they hold that ethics is grounded in community-based models that they view as a replacement to objective morality (Lamb 2021). For example, the legal system or communities that hold sway over moral decision making by virtue of majority consensus (Savulescu and Schuklenk 2017; Lamb 2021). Yet, if COs are not rooted in conscience, are these CO then mere choices? And, are they choices that lack morality in totality or in part?
The insights from Aquinas are clear: for acts of conscience to occur, they require a degree of moral knowledge which at the very least corresponds with objective morality or universal truth. And this is true for morality, which is a human concern across cultures and not just in the healthcare professions (Haidt 2007; Lamb 2021). Choices, on the other hand, are options that might not lead to decisions that are substantively moral. Whereas conscience does have substantive moral content. Yet, this substantive content hinges on whether we inform and develop our conscience or if we leave it inert and empty and devoid of objective moral content. Echoing Aquinas, if we do not properly acquire moral knowledge to make ethical decisions, we are not fulfilling our responsibility to be moral persons. Not only will we feign our attempts at making authentic conscientious decisions which will be a problem in and of itself, but we may also be morally culpable for making unethical decisions instead.
The challenge of whether or not we make authentic COs rooted in conscience is particularly relevant for HCPs. The relevance lies in the fact that HCPs occupy a space where life and death as well as decisions about one’s well-being across all life’s phases are the substantive content of their professions. As such, HCPs have a higher degree of responsibility to acquire moral knowledge in relation to the decisions they make with their patients, at times for their patients (i.e. for those who lack capacity and consciousness) and in relation to themselves as moral persons as well as their colleagues.
While choice has a place in moral decision-making, not all choices are moral, whereas all acts of conscience are. For example, one may have to choose between life or death in risking their life for another and that is an objective moral choice, requiring deliberation and more personal commitment than a preference. Other instances may involve a parent undergoing high-risk surgery to donate an organ to their child for transplant purposes or an HCP may choose to work in a pandemic to save others by putting their own lives at risk. These latter ‘choices’ require moral deliberation and call on the inner workings of one’s conscience.
Other factors go into a concrete act of conscience, including a consideration of the options that one must decide between, what the respective action taken will bring about (intent, means and object) and the consequences involved across all options. In order for COs to be authentic in healthcare today, they need to be rooted in conscience which must align with objective, moral truth in alliance with Revelation. Therefore the example that HCPs cannot make COs to object to issues of moral gravitas —such as abortion and assisted death —on the rationale that ethical authority of access to legal services trumps the role of conscience is not a substantive argument.
This is due to the fact that legal access or permissibility is the output of legal authority, which can err if is not in line with morality as the transcendent basis for right action in society. Specifically, objective morality supersedes the law, and not vice-versa (Sgreccia 2012). Rather, the duty of the state and the law is to ensure that prevailing moral views do not impose on or restrict the freedom of others (Waldron 2018). As such, conscientious objectors in healthcare today need to be supported to articulate how their COs are objectively good for them to do, for their patients and in alliance with faith and reason, revelation and moral objective truth. To that end, pluralism and relativism are not sufficient for moral knowledge as the substantive content for conscience because these approaches do not seek objective morality in the pursuit of truth (Lamb 2021).
Conscientious objection is becoming an increasingly occurring phenomenon in pluralistic healthcare contexts. At the same time, conscience is receiving little attention with respect to the nature of what conscience is, how it is utilized and to what purpose. In order to ascertain whether or not COs are being made as decisions rooted in a formed conscience, the extent to which moral knowledge is informing COs needs to be explored. Specifically, COs need to align with objective morality which is truth-seeking. To that end, as Aquinas and Pope John Paul II in Fides et Ratio point out, seeking the truth hinges on universal or natural law aided by faith and supported by reason. Further research is needed to explore how HCPs in pluralistic healthcare contexts today are understanding and using moral knowledge to inform and use their conscience. Since philosophy and theology are the disciplines that house the substantive work on conscience, a starting place is to conduct research studies employing empirical scientific methods to investigate how this is happening in healthcare or not (Lamb, Kennedy, Clark et al. 2022). Research in this area is needed not only to support HCPs to make informed and authentic COs, but to enhance and empower HCPs moral decision-making capacities. Providing this support will require inter-disciplinary research that aims to fill the gap in pluralistic healthcare which the prevailing pluralistic approaches to practical ethics fail to provide: that the application of moral philosophical-theological ethics is the necessary, substantive content of conscience rooting COs. Without this substantive content, the notion of conscience has little meaning and practical relevance for COs or moral decision-making in healthcare today.
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Cite this article
Lamb, Christina. 2022. “What Makes a Conscientious Objection an Act of Conscience?” Theological Puzzles (Issue 12). https://www.theo-puzzles.ac.uk/2022/07/25/lamb/.