The President's Council on Bioethics
Thursday, September 11, 2008
Session 2: Conscience and the History of Moral Philosophy

---

Discussion

CHAIRMAN PELLEGRINO: Thank you very much, John. Gilbert Meilaender, Dr. Meilaender, will open the discussion. Gil?

PROF. MEILAENDER: Thank you very much for the presentation. I feel myself at a grave disadvantage on several counts here. A man who thinks that eating a few carrot sticks is falling off the wagon doesn't inhabit my world. I had six of those Burger King chocolate chip cookies at the airport yesterday. And a man who deals in these award-winning movies that I have not seen, I can't - if he were to comment on Mamma Mia or, dare I say, House Bunny, I've seen them and we could have sort of engaged each other on that.

Let me just raise a couple of points really to highlight some issues that come out, not to disagree, but just to note some things.

You began by saying that conscience is inner-directed, not other-directed, and, yet, if we think about the whole of your talk, I think that was too simple a formulation to capture what, in fact, you said. You later in talking about the process of discernment talked about the conscience as social, and, clearly, conscience is not in your view entirely inner-directed since one is alone, not with oneself but with God, so that an utterance of conscience is not simply self-assertion; thus, this is the person I am. It's able to be questioned so that in some sense, while there is that enormously important subjective aspect of conscience, there is also in your view an objective aspect in a way.

At least in respect to the relation with God and maybe somewhere else, when you first talked about the things we know about conscience, you said we that we can act on the basis and we know that we can fail, and you later used the word "lapse" - "We will lapse." But then you also asked the question, "Can we be wrong?" and your answer was, yes, so that there is some kind of objective aspect as well. It's not just an assertion itself that's involved. And I think sorting out the relation between those two is what makes for some of the complications in the kinds of questions that we're facing.

When you said - and I don't know. I would defer to your judgment about what St. Thomas says, and I haven't looked lately - but when you said, what's the test for validity of one's conscience - and I think you were talking in the context of discussing Thomas, but I may not remember right - you said a willingness to pay the price for acting in accord with it. Now as I said, I don't know what Thomas said- but validity seemed like a strange word there, the fact that I'm willing to pay the price for it, at least in our normal use, if one grants it, there is an objective aspect of conscience. The fact that I'm willing to pay the price says something about my wholeheartedness but not necessarily about the validity of my conscientious judgment, I think, but I don't know. I'm just puzzling over that relation between the objective and the subjective.

And then, finally, just one more thing. When you came to the issue of cooperation at the end, which is really where we're headed, of course, you distinguished between formal cooperation which is, I think, really sort of embracing the evil as a good, which is always forbidden, and material cooperation in not-so-great evils, which, if the truth were to tell, we're all involved in all the time and you can't, as you said, live in society without that.

It leaves the category of material cooperation in a grave evil, and, of course, the difficulty of reaching agreement on what constitutes a grave evil, and that I wasn't so clear on either what you wanted to say or what any of us ought to want to say about it.

So just by way of a summary, I mean, I think that relation between the objective and the subjective, in various ways you came back to it, and sorting it out is really hard. And I think some kinds of cooperation are pretty easy to decide what we think about. But material cooperation in what one thinks to be a very serious evil is not so easy to work through.

FR. PARIS: Well, you found the difficulty I had in putting this talk together. And in talking with Dr. Pellegrino, he said, "I want you to talk informally. I don't want you to come and give a lecture."

And the relation between when talking about the super-ego and conscience in the early part saying the super-ego is simply other-directed, I was not implying that conscience has no other-directed as part of it, but it's trying to distinguish it from the super-ego which is exclusively other-directed. You simply incorporate the values of your parents and the authority figure and you don't want to lose their affection and, therefore, you do it, not because you believe that it's the right thing to do, but because you fear their disapproval. That's not conscience. Freud is on point on that with psychologists. That's something different because it doesn't have that sense, that innate sense, of "this is who I am and this is why I act the way that I do because these are the values that I have." It's just simply you don't want to incur the wrath of some authority figure. And I moved too quickly into that.

The same on St. Thomas. I moved in and out of St. Thomas several times. But St. Thomas doesn't talk about conscientious objection, that willingness to pay the price was moving over into, for example, the war issue, that you'd be willing to pay the price. You simply can't say, "I object to the war and, therefore, I'm not participating, and I am free." No, no, no, no.

There's a presumption that the laws are to be obeyed. There's a presumption that you are to fulfill your duties in society, and if your conscience says to you, "This is something evil," you simply don't proclaim, "I believe it's evil," and, therefore, don't participate. It's, "I believe it's evil, and I'm willing to bear the price," and the price for More is execution. The price for Luther is excommunication. The price for Ghandi is imprisonment.

And part of the price is, this will then affect the conscience of those who impose it and they'll see the injustice because of my willingness to accept it. This is very much what Ghandi was talking about, saying, "When they see the punishment that we will accept unjustly, then their consciences will be affected. They will be like David. Suddenly, the scales will fall from their eyes, and they will see."

And it may or may not be effective in implementation. But the argument that I was trying to make there was, the invocation of conscience alone doesn't absolve me from responsibility. And the test, the test which had nothing to do with Thomas, the test of the authenticity of my conscience is my willingness to suffer adverse consequences up to and including death for it.

PROF. MEILAENDER: I just note that you switched from validity to authenticity in that formulation. I think that's a better formula, the test of the authenticity would be. I'm not sure it's a test of the validity.

FR. PARIS: Oh, oh, you're right. You're right. You're absolutely right, yes.

And, oh, you didn't miss the point that I did not talk about, what your Council is going to have to discern, the tough and difficult parts. I just give the big picture. That's the role of the casuist. That's the role of the Council, because you are going to be casuists, taking the principles and applying to specific issues and trying to discern the prudent response to that in a community.

CHAIRMAN PELLEGRINO: Gil, had you completed your comment? Dr. Gómez-Lobo?

PROF. GÓMEZ-LOBO: I'm sorry. When I was listening to our speaker and to Gil, it suddenly felt a little bit strange. I said, "We are American public officials enjoying a theological feast at this moment. Should we be doing this or not? Where's the separation of church and state?"

And my little contribution to that question is this: Although our speaker said on several occasions "theologians say this," "theologians say that," and although if I'm well-informed, the bulk of Aquinas ' theory of the conscience is in the Prima Secundae of the Summa Theologica, I would argue that it's not specifically a theological doctrine.

The fact that we're starting from principles known by themselves, perse nota omnibus, to everyone, not just sapientarus, not just to those who are wise nor fidelirus, not to those who have the faith, allow us to say, "Look. This is a theory about, partly about, moral psychology, about human understanding of action, and it's also a normative theory. But the whole of it, the whole of it, can be understood in purely philosophical terms."

That is the reason why this discussion is relevant to what we're going to be doing in the afternoon. In other words, it seems to me that the discussion this afternoon has to be to the effect that here we have an understanding of the particular judgment that a person makes about his or her action, such that society as a whole has to respect that or not respect that if we take the other position. But my inclination is to emphasize that, that the defense of conscience can be - not necessarily that it must be - but it can be defended on purely rational grounds.

FR. PARIS: You're absolutely right. That's how Thomas begins. The reason I use theologians - I mean, we end up quoting councils and popes, but they're reflecting now, not on received revelation. They're reflecting on rational analysis and philosophical discourse. But they were theologians, so I don't want to misconstrue that they were just - you know, they were philosophers independent of that.

But the fact is that within the Catholic Church this sort of discussion and debate has been going on for centuries and that's where the richness of the debate comes. But you're absolutely right. Thomas says everyone is capable of doing this.

CHAIRMAN PELLEGRINO: Dr. Elshtain?

PROF. ELSHTAIN: Well, thank you very much, Fr. Paris, for your interesting presentation. I'd like to get your reflections on a couple of statements that emerge in one of the documents in our briefing book, specifically the limits of conscientious refusal in reproductive medicine is the essay. You needn't have read it to respond.

FR. PARIS: I haven't.

PROF. ELSHTAIN: That's what I'm going to ask you. It's put out by the American College of Obstetricians and Gynecologists, the Women's Health Care Physicians Division. And there are a couple of interesting things here. One is that conscience is defined as private. And I took your argument to be that - and building on what Gil Meilaender has said - that that is not an adequate characterization of conscience, that there is an inevitable subjective dimension, but the reference point is always some notion of an objective moral law, and the presupposition is that human beings can be formed within that moral law and that that in a sense becomes the very substance or content of conscience that then is held, if you will, subjectively. So I'd like to get your comments on that.

And then one of the other claims in this essay we were given to read is that - and I'm sure you would agree with this - claims of conscience are not always genuine; that is, you can have, as you put it, an erroneous conscience. But that creates a terrific problem, does it not, when we're dealing with the kinds of issues that this Council is going to be talking about; namely, who makes a judgment as to whether a claim of conscience is or is not authentic or is or is not sincere? Do we have some body that adjudicates that? Do we make a case or make the argument that any claim of conscience has to be backed up by a set of stipulated reasons on the part of the conscientious objector before we acknowledge that claim of conscience as genuine? Or, again, alternatively to some other group, simply claim - that's in a position of authority - or that can say, "We don't really think that's an authentic claim of conscience." So how does one sort out whether a particular claim of conscience is or is not a genuine one?

FR. PARIS: Well, to the first point on the privacy, I agree completely that that's a vast overstatement and misstatement. Conscience is not simply a subjective wish, whim, will, or desire. It's not that. It never historically has meant that, and I'm afraid that we've gone far, far, too far on this, what I call now, the autonomy run amok, that it's my belief and therefore -

PROF. ELSHTAIN: And that's it?

FR. PARIS: Therefore that's it, yes.

Then you come to the difficult question of, how do we assess, A, the sincerity of the conscience? Now part of that was in my answer to Prof. Meilaender, that historically what we've done - and the classic case was war, a conscientious objection to war - and then the willingness to pay the price, and it became a negotiated price within the society of willingness to be in the medical corps or willingness to - or go to jail or go to exile. But there were prices that were attached to it.

When you get into the medical side of it, a part of the issue becomes, in using the pharmacy bit as the early example, saying, "Well, if you find this offensive and we, as a community, insist upon this, then you may choose not to practice," and there the real test, I think, there becomes a legislative one, certainly not a judicial one. But the enactment of the law saying, if as a society, we believe that this violation forth sincerely held would be so appalling to the conscience of a civilized society or to an organized community, we will write exemptions into the law. You would petition for these, and they would be written, and that's how we organize ourselves in a democratic society.

I think you have to be careful though of there's a difference between a sincere conscience and then the erroneous conscience of saying, "Well, I don't do this because I believe that this is." An example of this - and I'm not going into details because I don't know anything about it - but is this morning-after pill, Plan B. And Dan Sulmasy wrote an article in the Kennedy journal on this saying, "Look. This is not abortifacient. You in conscience will not participate in an action that is abortifacient. But there's no physiological support for the argument that this is. So you have to do your homework better, and when you understand" - now whether Sulmasy's physiology is correct, I haven't a clue. But there's an argument where you can say, "This could be an erroneous conscience. You raise the question. And more work, more investigation, more analysis, more understanding of medicine..." - and it certainly persuaded the bishops of Connecticut and New York. They stopped their opposition on that on the basis of the argument that Sulmasy put forward and said, "Well, if it is true that this is not certain, then we cannot say it's a grave moral error when there's lack of certainty."

Who's right in this debate, I don't know. But that's an example where you could say, "Here's an erroneous conscience based on faulty facts." That's different from a sincere and factual, but non-supportable in the community.

PROF. ELSHTAIN: Can I do just a very quick followup? I was very happy you mentioned conscientious objection because, reading over some of these documents that called for more restriction perhaps on the operation of conscience, a conscience clause could certainly be used to limit conscientious objection in time of war as well. I mean, that would be one of the implications, it seems to me, that was not drawn by the folks writing this. Thank you.

CHAIRMAN PELLEGRINO: Dr. Carson?

DR. CARSON: Well, thank you for that very thoughtful discussion. And I certainly understand why you started out by talking about a theological basis of conscience because it's fairly easy to understand the concept of right and wrong if you have a theological base.

My question is, you said you certainly understood the point also -

FR. PARIS: The point that Alfonso made?

DR. CARSON: - the point that Alfonso made, about it being possible to have a well-developed conscience without a theological base. Now, let's say that man is the result of an evolutionary process that takes advantage of survival of the fittest. At what point in that process does the conscience arise? Should a lion have a conscience? Maybe they're a little lower on that scale when they kill a lamb or they kill the mother of a lamb and leave the lamb without a mother. I mean, where along that continuum, if, in fact, that is how things arose, does conscientiousness arise?

FR. PARIS: It arises with the ability to reason and to reflect upon one's action in a reasoned fashion and to formulate values and articulate those values as important for the assessment and understanding who you are. So it has to do with reason.

DR. CARSON: Well, if, in fact, it has to do with reason, why would it not be legitimate for someone to say, "My conscience tells me that I need to eradicate certain people because they're a scourge upon the earth"?

FR. PARIS: Well, we've certainly seen people who, at least philosophy - I wouldn't even use the word conscience - articulates that, and we, as a world community, hold them guilty of genocide or crimes against humanity.

PROF. ELSHTAIN: And those articulations, if I may just add this, are usually not made in the language of conscience. It's another rhetoric entirely that enters in when you want to exterminate categories of people. Usually a language of the will, a language of fit and unfit, a language that seeks to dehumanize those you aim to destroy, which in its own bizarre way, I suppose, could be a kind of underhanded tribute to conscience that says we don't treat fellow human beings this way, so you make them less-than-human. But I don't recall, for example, Hitler ever saying, "My conscience tells me to do this." It was a very different language.

CHAIRMAN PELLEGRINO: Rebecca?

PROF. DRESSER: Getting back to the analogy of objection to the military service, my memory is that draft boards did make distinctions about people claiming conscientious objections. So I was a little young for this, but I remember during the Vietnam War, some people said, "Well, the Vietnam War is immoral, but I can imagine a just war," and that wasn't being counted, that you had to be a complete pacifist.

I mention this because this has been suggested. I remember reading in an article about access to abortion and how many residents were unwilling to learn the technique and physicians unwilling to do it. And the question was, was this based on sincere conscience or a fear of protestors or the negative things that could come from that? And the suggestion was, well, we could have an examination of their beliefs to see how sincere they really are.

Now my view is, I don't think that would be a good thing to import into medicine, and I don't think it was very good in the military context either. But I wondered if you had any thoughts about that?

FR. PARIS: Well, actually, I wrote a doctoral dissertation on that subject. So you don't want to know all that I think about that.

What you had was a society, in fact, that, if we're going to make these kinds of distinctions and authorize some objection, you've got to have a bright line. You can't have a fuzzy line. And a philosophical objection to war in principle is a clear, bright line. If we're getting in a just war, which is the traditional Catholic argument and analysis, then you've got all sorts of areas in which there can be disputes and distinctions and there's no clarity on the behalf of those who have to judge, namely, the draft board, as to whether you sincerely hold this, whether you really hold this view or not. It's an impossible task, and we'd be right into wholly-subjective, self-serving withdrawal from it. So that won't work as policy.

It's easy to say it's all or nothing, and we understand and we're willing to accept and we're willing to accommodate those who are philosophically opposed to war in principle. But if I'm opposed to war because I think it's too costly on the American economy, that's not going to - how are we ever going to be able to calibrate that?

Over then into your issue with regard to residents declining to participate in this issue, you can say. Now, one of the very interesting phenomena would be if you had a whole class of people called physicians who all declined in this action. That might cause society to reflect and say, "What is it that they see that I'm missing?" And it's relatively easy to say, "Yes. I refuse to learn how to perform an abortion because I'm morally opposed. I believe it's a grave moral evil, and I won't participate in it." Now that might exclude me from ever being a gynecologist, but I'd be happy to be a dermatologist, radiologist, or ophthalmologist - better working hours.

But when you're setting policy, you have to have it in a practical way that you can discern which side of the line these people are on, and you cannot make a purely subjective assessment.

PROF. DRESSER: Yeah. I was just going to say that I think the bright-line rule is one thing, but the sincerity is very difficult because how can we know?

FR. PARIS: It's impossible to test sincerity. Yeah, it's impossible.

PROF. DRESSER: And sometimes people are probably fooling themselves about what they believe. So as a policy matter, I think we can't say, "Well, it will depend on how authentic or sincere it really is."

FR. PARIS: That's too flexible a standard, I suspect, to be able to be judged objectively by an independent observer.

CHAIRMAN PELLEGRINO: Other comments, members of the Council? Dr. Hurlbut?

DR. HURLBUT: I'm only making a comment because nobody else is, okay, because I don't want to waste the - what do we have? Ten minutes left roughly with such a well-informed and thoughtful speaker?

I don't have this very well formulated, but I'd just like you to respond a little bit to the modern critique of moral theory that's emerging, often designated sociobiology or evolutionary psychology, and its erosion or corrosion at the core source of what we call moral conscience. In other words - and I'm sure you're familiar with this. Right? Am I right in that?

FR. PARIS: Some of it, yes.

DR. HURLBUT: So the comment is made that conscience doesn't necessarily have any transcendent referent of truth but is socially constructed. You've said yourself that there's a degree of communal grounding and conscience. Such thoughtful authors as Charles Taylor speak of the dialogical nature of conscience formation. In fact, I believe if you go back etymologically and look at the source of our word conscience and conscientiousness were joined together thinking together in moral matters, our very conscientiousness then itself is formed within social process.

The critics then say, "Well, these flow forward from a kind of functional utility that are to some extent relative to circumstances, to some extent whether relative to one circumstance or not at the foundation of biological adaptive advantage, in this case social engagement."

And what I'm trying to get at here - and I'll stop saying my part and let you say something - is basically the question comes down to in a modern society with so many diverse views of what medicine should be and what constitutes the good of medicine, this controversy obviously is about it's most centrally - in medicine at least, it's most centrally oriented along the axis of the abortion debate. And yet for thousands of years, the moral traditions of medicine, the great weight, was against abortion. And yet people have new views on this and diverse views on this, likewise on many reproductive technologies.

It seems to me that what you're saying you're implying that there is something that overarches and transcends individual's thoughts of this and even social culture's constructions of it and that we must tap into that, when an individual is doing that, his claim to following conscience is legitimate; otherwise, it's not.

I guess what I'm getting at here is something maybe akin to a natural affirmation or something like that. Can you just carry that a little ways?

FR. PARIS: Well, part of it was the discussion I heard briefly this morning about what's the nature of medicine? Is this simply a business? Bud Relman wrote year after year in the New England Journal "At the peril of its soul, medicine will adapt the business model as its goal in its understanding."

And then we hear, "Well, I only treat patients who pay." It used to be that we would have patients and they didn't have the ability to pay, we treated them, there was no concern. Today, it's about contracts and capitated payments and covered lives and consumer-driven health insurance and, if you can't pay, well, too bad. And then you have others saying, "But that's not what I understand by medicine. As a profession, we have duties and obligations to sick people indifferent to their ability to pay."

I mean, the whole debate is how do we - which is how do understand ourselves? How do we understand who we are and, from that follows, how do we understand what we ought to do?

If you understand that we're just social constructs and that this is just simply a contractual relationship and my involvement in medicine is simply that, if you can contract for it and pay for it, I'll provide it, and those who haven't got the ability to pay, that's too bad. But then you say, is that medicine? What's that got to do with the tradition of medicine? What's that got to do with how we understand ourselves as humans - which gets you right back into the question of conscience.

How do we understand who we are and what our obligations are? Are we simply just isolated monads in a world of Leibniz in which our relationships have nothing to do with anybody else? And, if so, I can be purely subjective. Or if, in fact, the impact of my actions have significant involvement with you, then I've got to be careful about what it is that I do so that I don't adversely injure you or hurt you.

It's a basic philosophical assessment as to who we understand ourselves to be as individuals and as a community.

CHAIRMAN PELLEGRINO: Thank you, John. If there are no more questions, we're five minutes before the termination of our session. I see none. Let us adjourn until - I'm sorry, Gil. Were you reaching for the microphone?

DR. HURLBUT: Well, while we're on it, why don't we really get to the crux here? You're basically affirming that there should be common terms of reasoned truth and conscience formation, that there is something that transcends individuals? It's not just opinion? I mean, isn't this the crux of our cultural dilemma here? We have the different competing concepts of the source and significance of world and our place in it?

I mean, is this resolvable? Are we just heading for two diverging theories of two diverging, what you might call, spiritual anthropologies, or do we have a foundation for finding a way to resolve these conflicts? If I understand it right, you're affirming there is the latter.

FR. PARIS: And it's a lifetime task. It's not solved in one conference or solved in one semester. It's a lifetime ongoing task, which I think is probably best seen by parents raising children. You can tell them. You can guide them. You can direct them. You can inform them. You can pray for them. You can work with them. But in the end, you can't force them. And when they err and fall, you don't abandon them. You bring them in and they are still - this is a loving, caring relationship. These are our children. This is what's precious. They've made a mistake, and we go back time and time again to try to do it.

So whatever it is, this discussion is not a philosophical debate that's resolved by analytical clarity. It's a lifetime commitment to trying to be what we were created to be.

CHAIRMAN PELLEGRINO: Thank you. Oh, no. Gil, I'm sorry. Were you going to speak? Forgive me. Did you want to respond?

I think, I mean, I agree with you that we need to have an answer. I think at least I have expatiated far too much in this in the literature, so I'm not going to say anything here at this point. But did you want to say something further?

I'll just end it by saying that there is an act of profession which you referred to when you become a physician, and the answer is, we do have an end and the immediate end is, as it always has been, the care of the suffering, the relief of pain and suffering, cure when possible, care always, and I don't think there's any argument about that.

The question is, how well do we do it? And I happen to agree with John that it is the task of a physician to reflect on who he or she is in relationship to the obligation one has professed oneself to at the very entry into the profession.

Now that's a little, again, a sermon, a sermonette. I'll be glad to talk a lot about it, but I think we're at this point and can maybe pick it up later on when we move to the more concrete questions of what the physician does when the patient wants X and the physician, both from the point of view of professional and moral integrity, thinks it is not to be done.

And I think we thank John for laying out for us some of the fundamental questions about conscience - that was the idea we had - and we'll move into the concrete questions and, therefore, John and Gil, I think we asymptotically at least approach your question.

Have a good lunch. We will reassemble at 2:00 o'clock.

---

Notes

The President's Council on Bioethics was appointed by President George W. Bush and operated from 2001 to 2009.

Source: Archived transcript of the session.