Abstract
The proper role of conscience in healthcare continues to be a topic of deep interest for bioethicists, healthcare professionals, and health policy experts. This issue of HEC Forum brings together a collection of articles about features of these ongoing discussions of conscience, advancing the conversations about conscience in healthcare from a variety of perspectives and on a variety of fronts. Some articles in this issue take up particularly challenging cases of conscientious objection in practice, such as Fleming, Frith, and Ramsayer’s contextually rich piece on midwives in Scotland or Harter’s professionally grounded analysis; others engage the changing institutional landscapes which impact considerations of conscience, such as Cummins’ work on the role of employers in institutional policies about conscience and Ben Moshe’s discussion of publicity and institutional committees. Pieces by Howard and Pilkington both raise conceptual considerations about how we think about the role of conscience in medicine, questioning the use of “conscientious objection” in these discussions, and Byrnes pushes back on the most influential work in this area by Mark Wicclair. The issue concludes with a piece by Wicclair, which engages each of these distinct offerings, further extending the discussions of conscience in healthcare and helpfully connecting key themes discussed by authors in this issue to his contributions and to the longer tradition of discussions of conscience in medicine. This issue challenges readers to engage different arguments from different perspectives and asks them—in some cases—to be open to revising how they think about the role of conscience and the existence of and justification for conscientious objection in the dynamic, interdisciplinary fields of healthcare.
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Notes
Most often those who appeal to best judgement in this context intend something like best moral judgement, where moral and clinical judgements are distinguished. However, where to draw sharp lines between moral judgements and clinical judgments is not always obvious, especially in light of arguments offered in this issue about disagreement (Pilkington, 2021), about the very notion of conscience (Howard, 2021), and to whom it relates (Cummins, 2021).
Some may disagree with the relevance of this reference to Paul Starr’s famous sociological work on the emergence of the medical profession in the United States. This might be for at least two reasons: First, the special status that physicians, as a profession, were able to carve out for themselves, including the special privileges and power that come with this status may not be as greatly felt as it once was. Second, some may worry that the suggestion behind this reference begs the question against the those who do not believe that conscience protections should be extended to physicians, in particular, and healthcare practitioners, in general. I flag these concerns here so that a thoughtful reader might not be swayed by my reference. In response to the first concern, I merely aim to draw the reader’s attention to the history of the medical profession, at least in the United States, and I leave to the side normative judgements about the profession’s status. In response to the second concern, I appreciate that an argument is needed to further this discussion and I point the reader to the piece by Pilkington in this issue, in particular the section entitled “Conscience Dissenters Bear the Burden of Proof”.
However, it is worth noting that in many contexts, bricklayers and plumbers can refuse work; whereas one of the live issues in the debates over conscience in healthcare is whether healthcare professionals have that option.
These are not the only arguments that focus on professions. Parsi and Elster (2020) in a discussion of the use of film to teach medical students about the role of oaths, argue, “The oath is used in this scene to reflect the conscience of the medical profession. This scene also illustrates how oaths impact the public’s perception and sets the public’s expectation of the profession”(p. 182).
It should be noted that there are separate critiques of legal and social norms focused positions; for example, Koch (2019) argues, “the integrity of medical conscience and its vocational values is now under attack from those who insist physicians accept the dictates of legal and social agendas irrespective of conscientious (and clinical) objections”(p. 227). Others have attempted to clarify the legal landscape, such as Sawicki (2018).
While issues of conscience are often seen in terms of the abortion and medical aid in dying or assisted suicide debates debates, it shows up at least implicitly in many other contexts, including decisions regarding the determination of death (Shewmon, 2021), the deactivation of cardiac devices (Pilkington, 2020), and expanding access to investigational drugs (Buckley and O'Neil, 2020). For exploration of the role of religion in medicine and bioethics (see Camosy, 2021; Blackford and Schuklenk, 2021; Goss and Bishop, 2021; Parks, 2021; Smith and Audi, 2021; Stempsey, 2021).
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Acknowledgements
I am grateful for helpful conversations around some of the issues presented in this paper with Thomas Cavanaugh and his ethics students at the University of San Francisco; with Richard Kim, Jennifer Parks, and the Loyola University Chicago Ethics and Values Symposium participants; and also with Jeffery Bishop, Mark Cherry, and Jason Eberl. I am also grateful for instructive comments from anonymous reviewers.
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Pilkington, B. Considerations of Conscience. HEC Forum 33, 165–174 (2021). https://doi.org/10.1007/s10730-021-09457-5
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DOI: https://doi.org/10.1007/s10730-021-09457-5