Birchley, G. (2012). A clear case for conscience in healthcare
practice.
Journal of Medical Ethics
,
38
(1), 13-17.
https://doi.org/10.1136/jme.2011.043653
Early version, also known as pre-print
Link to published version (if available):
10.1136/jme.2011.043653
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A clear case for conscience in healthcare practice. Giles Birchley
1
A clear case for conscience in healthcare practice.
Mr Giles Birchley,
Paediatric Intensive Care Unit,
Bristol Royal Hospital for Children,
Bristol
BS2 8BJ. UK.
Tel.: + 44 0117 342 8018
Keywords: Conscience, Consciousness, Clinical Ethics
This is a prepublication draft, with only minor differences to the final published
version. If citing please use the following information to reference the published
version:
Birchley G., A clear case for conscience in healthcare practice. J Med Ethics. 2012
Jan;38(1):13-7. doi: 10.1136/jme.2011.043653.
A clear case for conscience in healthcare practice. Giles Birchley
2
Abstract
The value of conscience in healthcare ethics is widely debated. While some sources
present it as an unquestionably positive attribute, others question both the veracity of its
decisions and the effect of conscientious objection on patient access to healthcare. This
paper argues that the right to conscientiously object should be broadened, subject to
certain previsos, as there are many benefits to healthcare practice in the development of
the consciences of practitioners. While effects such as the preservation of moral integrity
are widely considered to benefit practitioners, this paper draws on the work of Hannah
Arendt to offer several original arguments in defence of conscience that may more
directly benefit patients, namely that a pang of conscience may be useful in in rapidly
unfolding situations where there is no time to satisfactorily reflect upon our activities and
that, given the hierarchical nature of healthcare institutions, a right to defy authority on
the basis of conscience may benefit junior staff who lack the institutional power to
challenge the orders of superiors.
A clear case for conscience in healthcare practice.
As healthcare professionals, how should we consider the judgements of conscience? Its
perceived irrationality, its quasi religious status and its potential for professional abuse
have led to the idea of a professional heeding their conscience being a discreditable abuse
of their position, like a politician who fiddles their expenses. In fact, rights to
conscientious objection are limited; while the law recognises conscience inasmuch as it
provides a right to conscientiously object to participation in termination of pregnancy and
embryo research, in most other situations sustained objections have resulted in the
dismissal of the practitioner concerned,[1, 2] and I suspect practitioners who have
objections consequently tend to utilise other, more surreptitious, means to avoid
participation. Conscience is thus both misconceived and invisible in healthcare but for a
small and controversial area of the law and this bulwarks the impression that
conscientious objection represents a straightforward dichotomy between patient choice or
practitioner rights. While conscience has its defenders within the healthcare ethics
A clear case for conscience in healthcare practice. Giles Birchley
3
discourse, few of these bring us any closer to resolving this dichotomy in a satisfactory
way. While not considering specific controversies, but rather focusing on the value of
conscience per se, in this paper I attempt to improve this defence of conscience in two
ways: By offering an analysis of the properties of conscience that seeks to breaks it down
into its constituent parts, consciousness and voice of conscience, I seek to explore the
workings of conscience and suggest it can be the partner of reason in the reflective
process. Secondly, by drawing on the relatively novel theories of Hannah Arendt, I argue
that there is an intrinsic value in the exercise of conscience by healthcare practitioners
that can improve the quality and probity of practice and therefore have real benefits for
both practitioners and their patients.
Is practitioner conscience desirable?
If, as a junior member of the multi-disciplinary team, my conscience tells me to refuse to
obey an instruction, what should I do? Certainly in current circumstances my position
would be both legally and institutionally untenable, as cases lie on record of nurses being
successfully dismissed due to similar refusals
a
. Yet I cannot be alone in agreeing with
Johnstone’s,[1] observation that the idea of a nursing workforce that operated without
conscience would be troubling, and I suggest this observation applies just as equally to
doctors and physiotherapists. As Arendt observed in her reflections on the totalitarian
systems of the Nazi Germany and Stalinist Russia,[3], the idea of obedience in itself is a
morally questionable activity for creatures of reason such as human beings. For these
reasons I cannot help but feel conscience has an important part to play in the delivery of
healthcare, and this paper is conceived as a defence of this value of conscience per se,
rather than as a defence of conscientious objection in any specific situation. This is
important because an overemphasis on specific instances can hamstring practical
considerations of this value, and, while healthcare literature contains wide ranging views
of conscience
b
, a significant section of the medical ethics discourse downplays the role of
a
See for instance Warthen's case (where a nurse was dismissed for refusing further attempts to dialyse a
terminally ill paient after previous attempts had resulted I severe complications) in Johnstone M, Taking a
stand: conscientious objection, clinical ethics committees and whistleblowing In: Bioethics – a nursing
perspective, 4th ed. London: Churchill-Livingstone, 2005: 325.
b
Although there is a notable difference in the polarity of nursing and medical views.
A clear case for conscience in healthcare practice. Giles Birchley
4
conscience as a moral arbiter, and in particular the issue of conscientious objection to
abortion dominates. This domination is perhaps because UK law
c
only allows overt
expressions of conscience in the rights to object to participation in termination of
pregnancy,[4] and embryo research,[5]. The law does not demand an explanation of the
objection from the practitioner and in the USA similar rights have seriously impacted on
patient access to treatment,[6]. This crisis has led to ethicists such as Savulescu,[7] taking
positions inimical to conscientious objection in healthcare. The problem a right of
conscientious objection creates for patients with a genuine need for services provides a
compelling case for reform, which I shall examine in due course. However, a case for
reform must logically be preceded by an exploration of the value of conscience in the
workplace, as the disvaluing of conscience by Savulescu,[7] and others,[8] has been on
the basis of its disutility. I would like to argue that this disutility is an extrinsic feature of
how we treat conscience rather than an intrinsic feature of conscience itself. In order to
do this I shall introduce the novel theories of Arendt, who reconsidered conscience
through the lens of an era of extremity – the dictatorships of Hitler and Stalin - for I
suggest these theories show that conscience is an intrinsically valuable faculty that
contains much to commend itself to practice in the unusual circumstances of healthcare.
Arendt and the intrinsic value of conscience
Although post-enlightenment philosophers spent much time considering the fallibility of
conscience and its relationship to reason,[9, 10] – a relationship I shall discuss later –
conscience has a more universal property that is independent from notions of its
reliability; that of providing an internalised second opinion over our thoughts and actions
that is less easily persuaded than the faculties of reason, and Hannah Arendt,[11] closely
considered this independent property. In the aftermath of the Second World War, Arendt
was struck that some individuals in Nazi Germany resisted the regime despite the
overwhelming mass of the German population not just consenting, but in many cases
actively abetting, actions that were a complete inversion of previously universal moral
values. She noted these resistors did not stop to think what was reasonable, but instead
c
I only consider UK law in this paper; however, US law is similar in this respect. The detail of the law is
fairly unimportant as my point is that the law unduly influences the view of conscience taken by medical
ethics commentators.