What Role does Conscience play in Medical Ethics?

Presentation to the Association of Catholic Doctors
Dublin, 27 September, 2008

Reproduced with permission

D. Vincent Twomey, SVD*

In preparation for this talk, I took a look at Dr Deirdre Madden's book, Medicine, Ethics, and the Law, which seems to me to be a valuable resource. It is, however, a resource that needs be read with a critical eye, since the author has a tendency to fudge the issues, which in this area is extremely dangerous. For example, I noted with approval her account of the Principle of Double Effect (in the context of her treatment of euthanasia) and how it was used in civil law in the UK in particular.[2] However, on further reading I was somewhat surprised to note that Madden on the other hand seemed to approve the way this principle had been misinterpreted by the UK judge in the famous Bland case. The learned judge considered the distinction between the withdrawal of life-sustaining treatment and taking steps to kill a patient to be illogical (cf. p.532). Of course, there are times when these two distinct acts practically amount to the same thing, but there are times when the former quite simply doesn't. Madden fails to note that important distinction, which is precisely one of the situations where the principle of double effect can help in making a prudential decision.

I noticed that a similar blurring of distinctions apparently gave rise to the inclusion of article 24.6 in the Medical Council's Guide to Ethical Conduct and Behaviour (Sixth Edition 2004) entitled "The Child in Utero":

The Council recognises that termination of pregnancy can occur when there is real and substantial risk to the life of the mother and subscribes to the view expressed in Part 2 of the written submission of the Institute of Obstetricians and Gynaecologists to the All-Party Oireachtas Committee on the Constitution as contained in its Fifth Progress Report, Appendix IV, page A407. 

The Medical' Council's Guide claims to subscribe to the views expressed in Part 2 of the written submission of the Institute of Obstetricians and Gynaecologists to the All-Party Oireachtas Committee on the Constitution as contained in its Fifth Progress Report, Appendix IV, page A407. The text is given in Appendix C:

In current obstetrical practice rare complications can arise where therapeutic intervention is required at a stage in pregnancy when there will be little or no prospect for the survival of the baby, due to extreme immaturity. In these exceptional situations failure to intervene may result in the death of both mother and baby. We consider that there is a fundamental difference between abortion carried out with the intention of taking the life of a baby, for example for social reasons, and the unavoidable death of the baby resulting from essential treatment to protect the life of the mother.

This precise, clear text is, it seems to me, to be based on the principle of double effect. But what is disturbing is that the Medical Council's Guide clearly permits the same principle to be given a broader interpretation. What are the implications of this broader interpretation?

We can approach the issues involved by first raising a few practical questions.

Does the new, broader, interpretation mean that in future the training of obstetricians and gynaecologists must include training in abortion, in limited circumstances of course?[3]

Will a training centre that refuses to undertake such training be refused recognition by the Medical Council, since one of their functions is to oversee professional training of health care officials?

Will a doctor who refuses to offer such treatment be disciplined for one of the rather vague reasons given in the Medical Practitioners Act 2007,#57, such as (a) professional misconduct, or (b) "poor professional performance, or (d) "a failure to comply with a relevant condition"? 

- Will such a doctor be able to claim the right of conscientious objection, if he or she is truly conscientious, and refuses to refer the patient to another doctor who will perform it?

A similar question must be raised with regard to Artificial Insemination by donor and I.V.F., both of which are intrinsically wrong and which must cause a grave crisis of conscience for responsible medical personnel - not just those who are Catholic.

The key question for us at the present is raised by the Medical Council's Ethical Guide #2.6, which states:  "If a doctor has a conscientious objection to a course of action this should be explained and the names of other doctors made available to the patient".

I am informed on good authority that this "obligation of referral", as I would like to call it, was already in operation in the UK in 1967. Generally speaking, advocates of the obligation to refer patients to other doctors who will perform the morally repugnant action claim that such referral is "universal practice", thereby putting pressure on the local objectors. Is that the truth?

In response to an attack by pro-abortion groups in America on (what at the time purported to be) a leaked draft of a proposed federal regulation on conscience rights of health care providers, the Chairman of the American Bishops' Committee for Pro-Life Activities, Cardinal Justin Rigali, writing to Members of Congress[4] made the point:

[I]n November 2007 the Ethics Committee of the American College of Obstetricians and Gynaecologists [ACOG] issued an opinion stating that pro-life physicians must do abortion referrals – and ACOG had to be  reminded by the Secretary of Health and Human Services that such coerced referrals are among the abuses that federal conscience laws have long been directed against.

He added:

It seems the statutory policy is clear and needed, and at the same time is relatively unknown, misunderstood and unenforced.

Even more pertinent in our context is the recent row involving the Catholic Pregnancy counselling agency CURA and the Government Crisis Pregnancy Agency since it hinged on precisely the same issue.

Catholic moral theology[5] rejects such referral because it would be a kind of material cooperation that facilitated, albeit indirectly, the act that is objectively wrong in itself. Thus it would seem that the same type of political pressure ("political" is to be understood in the broad sense of social and cultural) is being used to force Irish medical personnel to act against their conscience.

This pressure, as can be expected, might well sway the majority of lay members of the Preliminary Proceedings Committee or the Fitness to Practice Committee should they have to judge a related case, in particular if they happen to have pro-choice ideological bias. That possibility cannot be excluded in the near future, since, according to the Medical Practitioners Act 2007, #17 subsection 1, sub-subsection (n) ii, the Minister can appoint five persons who "have such qualifications, expertise, interests, or experiences, as in the opinion of the Minister, would enable them to make a contribution to the performance of the Council's functions [my emphasis]." Apart from the broad scope of such qualifications, there is no way of questioning the "opinion of the Minister" with regard to the standards the Minister might use to determine who is qualified to sit on the board.[6] Appointments are entirely at her or his discretion.

What I find most upsetting in the Act as a whole is something that Dr Kevin Doran in his excellent article in The Medical News also pointed out recently, namely the vast extent of the discretionary and statutory power given to the Minister in the 2007 Act. Is this but another incidence of the totalitarian tendency of modern so-called democratic governments (not only in Ireland) and the attendant mushrooming of anonymous bureaucracy responsible only to those over them? As civil servants they must do as they are told by those in charge – or else they lose their job or are denied rightful promotion. That is considerable pressure.

***

These question are posed by way of introduction to the core issue I want to address, namely the nature of conscience. Seen in its most positive light, it is arguable that, behind the above understanding of conscientious objection that has now been enshrined in the Medical Council's Guide to Ethical Conduct and Behaviour, is an honest failure to understand what conscience actually is.

Put simply, conscience is assumed to be a purely subjective thing, a personal preference that is fundamentally irrational and so cannot be "imposed" on others. Behind that rather common assumption is that post-Enlightenment philosophical tradition that finally spawned moral relativism, a discourse on which I am going to spare you today. I would just like to stress the need for those who reject this false notion of conscience to appreciate that those who subscribe to a subjective notion of conscience, and so to relativism in moral matters, are not acting in bad faith.

"Pro-choice" itself, as it were on its own terms, is based on this subjective notion of conscience and its attendant moral relativism, which could be summed up rather coarsely as: "I choose my own moral principles and no one dare impose their values or principle on me". That is its seductive power. This generally accepted assumption of modern culture -- together with highly emotional hard cases introduced by the advocates of moral change to move people's hearts-- has wrought nothing less than havoc to society in so-called developed countries.

The sincerity of those who hold a subjective view of conscience is not in doubt. But is it enough? More importantly, what is wrong about that all-pervasive contemporary understanding of conscience? For the rest of this paper, I will concentrate on such a misunderstanding in the hope of clarifying what conscience in fact is. Related to this topic there is a question of no small significance for Catholics: what is the nature and extent of the binding force of the Church's authoritative teaching on our conscience? If Catholic doctors are to appeal to their conscience as Catholics, then they must have some appreciation of the relationship between conscience and Church authority – but they also be ready for the consequences, often of a negative nature, that comes from being true to your conscience.

****

May I begin with the sombre reminder of the general tendency of sinful human nature:

In his lapidary Sickness Unto Death, Kierkegaard observed that most people "work gradually at eclipsing their ethical and ethical-religious comprehension." He believed that moral knowledge is universally distributed, in the form of conscience. However, as he saw it, conscience has an uphill battle because we all know in our bones that its directives will clash with what seems to be our immediate self-interest.

So what do we do when our moral principles push us toward losing our jobs or our friends, or just having to put up with people's irritation with us? He answers, "We allow a little time to elapse, an interim called: 'We shall look at it tomorrow'." And during that interval our moral knowledge becomes more and more obscured, until finally we come to our senses and convince ourselves that the convenient course is the righteous course.[7]

This rather bleak picture of human nature is not without a grain of truth. It reminds us of two undeniable facts: (1) that conscience usually makes demands on us that will upset us, make us suffer perhaps, or even cost us our lives. (2) Many people choose to close the ears of their heart, preferring present comfort to probable pains should they dare to follow their conscience. Conscience costs something, perhaps even one's life. St Thomas More is one of the many martyrs whose obedience to conscience did in fact cost them their lives. More  recently, and on a much lower level, but still significant, Steven Spielberg resigned as artistic consultant to the Beijing Olympic Games "saying his conscience will not let him choreograph an event for a country that has done little to use its influence to ease the  slaughter in Darfur" (The Guardian, 16.02.08). His decision shook the Chinese government. The voice of conscience strikes terror into the powers that be, especially those of a totalitarian bent. Conscience has a real existential primacy in the political world as well as in civil life (business, professional life, etc.) – but also in the life of the Church. What roused Spielberg's conscience? It seems that it was an article by Mia Farrow (in the New York Times). Conscience generally needs to be roused by an external voice uttering the truth.

But there is more to it than that.[8] As the German philosopher, Robert Spaemann, once put it, conscience is not an oracle, rather it is an organ, a spiritual capacity that, like our innate capacity for language needs to be activated from without. Just as we learn to speak through interaction with the communities into which we are born, so too conscience has to be formed by the moral communities we inhabit, above all the religious community, which for Catholics is the Church, where the Bishop of Rome as Successor of St Peter enjoys a primacy with regard to her teaching authority. Blessed John Henry Newman succinctly captures the intrinsic relationship between conscience and the divinely guided authority of the Church when teaching faith and morals. In his famous letter to the Duke of Norfolk replying to Gladstone's attack on the dogma of Papal Infallibility that had been proclaimed by Vatican I, Newman wrote: "Certainly, if I am obliged to bring religion into after-dinner toasts, (which indeed does not seem quite the thing), I shall drink –  to the Pope, if you please, - still, to Conscience first, and to the Pope afterwards."[9]

Newman was most of his later life a firm opponent of the spirit of liberalism and of Christian subjectivism, as found in the Evangelical movement he once embraced. Evidently he was not suggesting a clash between conscience and the Papal teaching authority. According to Ratzinger: "Newman embraced an interpretation of the papacy, which is only then correctly perceived when it is viewed together with the primacy of conscience – a primacy not put in opposition to the primacy of conscience but based on it and guaranteeing it." Ratzinger adds: "Modern man, who presupposes the opposition of authority to subjectivity, has difficulty in understanding this."[10] That, of course, is a understatement. Not only do we moderns have difficulty in understanding this, we have produced a number of false ideas of conscience, each based on the denial of objective truth.

One false notion is the tendency to reduce conscience to what Ratzinger called an "excuse mechanism", a kind of rationalization to justify one's actions which, in fact, are wrong in themselves (and deep down one knows that, even if one is in denial).[11] This can lead to the situation where conscience is effectively silenced; we can refuse to let it cause us disquiet or let it give rise to guilt feelings, which, of course, is precisely its divinely given task. This is spiritually and psychologically dangerous. Albert Görres, a German psychologist, once pointed out once that, like bodily pains which alert us to illness, feelings of guilt alert us to the fact that something is wrong. Not to experience any sense of moral guilt – as in the case of many perpetrators of grave crime[12] – is to be morally moribund – quite literally a sickness unto death. It "shows that the feeling of guilt, the capacity to recognize guilt, belongs essentially to the spiritual make-up of man. This feeling of guilt disturbs the false calm of conscience and could be called conscience's complaint against my self-satisfied existence."[13]

Another contemporary misunderstanding is to reduce conscience to a basically irrational personal preference: what I feel, that is right. And what others feel, is right for them, provided they do no (obvious) harm to someone else. Behind this widespread assumption is the modern philosophical denial of any objectivity in moral issues. It recognizes only one moral imperative: not to be "judgemental" of others, even in such issues as abortion.

Another, closely related, misunderstanding is put into the mouth of St Thomas More in Robert Bolt's play, A Man for All Seasons. To quote Anthony Kenny, "for the More in Bolt's play, what matters is not whether the Pope's supremacy is true, but the fact that More has committed his inmost self to it. As he says to Norfolk, 'What matters to me is not whether it's true or not, but that I believe it to be true, or rather not that I believe it but that I believe it'."[14]

Now, of course, that is precisely what More would never have said, not only because it has distinct echoes of Luther's Hier stehe ich, ich kann nicht anders, but because it is a thoroughly modern concept of conscience. It is alien to all that More stood, and fell, for, namely conscience as the sensorium of transcendence (Eric Voegelin) and so of truth.[15]

Conscience, properly understood, is that which, if we allow ourselves to be prompted by its deepest dictates, drives us to search for objective truth (both theoretical and practical). And it enables us to recognize the truth as truth when we find it – or, if we are truly open, when the truth presents itself to us in the course of our search for it. And the truth More died for was the truth about the universal Primacy of the Bishop of Rome in matters of faith and morals.

More died a witness to objective truth[16] (that is the definition of a martyr), and not simply for his personal subjective conviction. Though our grasp of truth is personal (and so, in a sense, subjective), truth itself is objective: it is something we discover or, more precisely, we re-cognize; we ourselves do not devise it. Further, it is not individualistic. Though intensely personal and particular in its recognition and expression, truth is by nature universal and communal. This means not only that truth can be recognized by all (and so is universally binding) but it creates community, not least through its moral expression in just laws that are therefore binding in conscience not simply because of external pressure (as in a police state). In sum, one could say that moral truth here is that rare thing called common sense -- what to an unprejudiced mind is reasonable, fair and just. Such is the source of the commonweal, or common welfare, of a society.

Since conscience needs to be awakened from outside, as it were, God instituted an ultimate, universal authority – the conscience of a particular person exercising his responsibility as the Successor of St Peter – to be the guarantor of the revealed truth He intended for the salvation of all humanity. In More's own words, after he had studied the question of "Papal Supremacy" (to use the now easily misunderstood term), "…it holdeth up all".[17] There is, therefore, an intrinsic, and not just an accidental, relationship between More's conscience and the authority of the Bishop of Rome, as he himself seems to have indicated when, after his judgement, it was "prudent" for him to break his silence.[18] In sum, conscience and the Church's teaching authority should not be seen as in opposition but as interrelated. The question is: how? 

It is quite revealing that the quotation from Bolt's play actually features in some modern moral theology handbooks, such as that of Richard Gula,[19] as an example of the primacy of (subjective) conscience – now understood as the final arbiter as to how we should act.[20] Indeed some theologians go so far as to claim that an adult should be capable of choosing what moral principles he or  she might adopt, even if one or other is in opposition to those taught by the Church's apostolic authority.[21] The term used for this is "dissent", sometimes even "loyal dissent", a term from the realm of politics, first given to those courageous men and women in the Soviet Union and its satellites, such as Osip and Nadezhda Mandelstam, Andrei Sakharov, and Vaclav Havel, who dared to oppose the totalitarianism of the State.

To summarize, we can say that subjectivity today poses as true conscience – it claims the authority of conscience – though it is the very antithesis of what conscience truly is. This truth was captured by Steven Wright in two aphorisms:

 "A conscience is what hurts when all your other parts feel so good."

"A clear conscience is usually the sign of a bad memory."

***

What then is the role of conscience in medical ethics? Conscience is fundamental to all ethical behaviour (i.e. the actions of free agents) and thus to the sub-discipline of medical ethics. Conscience is, in the final analysis, about our humanity in all its depth and dignity. It is thus the last bulwark against the inhumanity of those negative forces in the world which threaten our true wellbeing both personal and communal. Those negative forces come in many guises, internal (our own frailty) and external. The external forces (political pressure as defined above) range from more or less subtle pressures to conform to "what everyone else is doing" to the economic and political forces that aim to dominate the world ostensibly for the good of humanity. The misleading term used by the Medical Council to put pressure on "conscientious objectors" is "universal practice". The term alludes to what is known as "best practice", namely a medical practice which, having been subject to rigid tests, has stood test of time.[22]

"Universal practice" is a fuzzy concept. For example, one might ask: what if the universal practice (in a country, continent, or even the world community, when it relentlessly promoted by its rich and powerful advocates) is morally reprehensible, as is the case with abortion? In promoting such "universal practice", anti-life forces usually conceal their aims behind some appealing mask, such as human rights (in particular women's rights), equality, or even alleviation of poverty. The latter are noble causes, but often used for less noble ends, in particular when they are woven into a rigid ideology and ultimately frozen in legislation. Whatever the form the mask takes, it generally betrays one common feature. It poses as the means necessary to prevent or ameliorate suffering. In addition, each mask appeals to the most fundamental assumption of modern culture: the absolute nature of man's freedom to choose. As "pro-choice", it both advocates (and appeals to) a freedom without limits. This, of course, is a claim to become like God, i.e. unlimited. It is the original seduction of man.

***

Morality is essentially about those limits which define our common humanity. Conscience is our innate sense of right and wrong, which can be either developed or deformed by one's upbringing and immediate environment, namely the polis (the political, cultural and economic community in which we live). But even when deformed, conscience can never be obliterated entirely, and so remains the pre-condition for repentance and so for recovery of our full humanity. The development of one's conscience depends on many conditions, but two are essential: help from outside in the form of knowledge about right and wrong (such as communal values and legal prescriptions) and help from Above (even when one may be agnostic about God's existence). Most people are docile to help both from outside and from Above (even when they seem not to acknowledge God) and so their sense of right and wrong matures – at least to the extent that they remain alert to what they observer or hear, are critical of common assumptions, and, above all, are self-critical. Conscience of its nature is restless to know the truth.  Humility is its hallmark. Another is moral courage – the readiness to stand up and be counted, irrespective of the consequences for oneself.

The role of the Church's teaching authority is to witness to the truth about our human condition in the light of reason (the wisdom of humanity common to all authentic Religions) and God's self-revelation in Jesus Christ. Her role is, in a word, to awaken consciences. Her teaching on ethics in general and medical ethics in particular is thus of universal significance – and so can be recognized as such by those men and women of good will in other Religions or even without any religion. Her sacraments are there to enable those to follow their conscience and so are struggling to abide by what they know is the truth, what they know they ought to do but find it difficult, if not at times almost impossible to do so. This applies today in particular when health care professions have to deal human life at its most vulnerable. Here the purpose of medical ethics is to indicate the limits to the kind of behaviour required to ensure that, in treating patients, no serious harm is done. For example, the Principle of Double Effect – or more precisely, the principle of foreseen side-effects – helps medical practitioners at all levels to distinguish between a necessary medical intervention needed to save the life of the patient despite the foreseen side-effect that might do irreparable harm to another person - even death.

 "Conscientious objection" is the term used in the Medical Council's Guide to replace "conscience". In the context of the Guide, the term "conscientious objection" assumes that conscience is something subjective, merely a personal preference, i.e. one not binding on anyone but oneself. Further, "conscientious objection" is a negative term with a very restricted application. It has its origin in the context of war. Pacificists who object to war on conscientious grounds cannot and do not prevent others going to war, though they may publicly protest. By way of contrast, the Guide insists on what they call "the obligation of referral."  In effect it instructs practitioners who object to certain practices on conscientious grounds to refer the patient to other medical personal who they know will provide the same (morally objectionable) "services."

Such guidelines offend against the common moral perception articulated in another ethical principle, the principle of co-operation. Put simply, this means that one cannot co-operate in doing serious harm to another person which you can foresee will undoubtedly happen. Medical ethics, which is a highly sophisticated discipline, fine-tunes that moral intuition. The conscience of a man or woman of integrity urges that person, when facing a moral dilemma in medical practice, to seek whatever help medical ethics based on objective (i.e. reasonable) morality can offer. It takes real courage both to seek that truth and to live it.

+ + +

Since 2008, when I first gave the above talk, the Medical Council Guidelines were revised and the 7th Edition published in 2009. The section (#10) on "Conscientious Objection" as been refined,  simplified, and radicalized. It reads:

10.1 As a doctor, you must not allow your personal moral standards to influence your treatment of patients.

10.2 If you have a conscientious objection to a course of action, you should explain this to the patient and make the names of other doctors available to them.

10.3 Conscientious objection does not absolve you from responsibility to a patient in emergency circumstances.

This revised guideline was adopted by Justice Ryan's Expert Report and found its way into the Heads of  Bill for the proposed legislation on abortion. The following is an excerpt from my submission to the Oireachtas Committee:

According to the Notes, Head 12 ("Conscientious Objection") is to be understood in terms of the Medical Council's Guide # 10.2 and #10.3. This, in fact, is exactly what the Expert Report suggested. It is interesting that the Expert Report (and following it, Head 12) omitted the introductory statement (#10.1), which in fact is the key to understanding what the Medical Council now understands by the term "conscientious objection". The introductory #10.1 states: "As a doctor, you must not allow your personal moral standards to influence your treatment of patients."

This extraordinary statement seems not to have raised an eyebrow when the President of the Medical Council quoted it in his statement to the Oireachtas Committee. In effect, it affirms that doctors should ignore their own sense of right and wrong. It would signal the relegation of morality to the sphere of feelings and the irrational; in a word, it would amount to the abolition of morality.

Consequently, the term "right to conscientious objection" used by the Medical Guide (#10.1), the Expert Report (6.9) and now Head 12 of the Bill implies that conscience is something entirely subjective, merely a personal preference, and therefore not binding on anyone but oneself. Both the Medical Guide and the Expert Report thus logically insist on the obligation of referral. And so the proposed Bill now proposes to write this into the law of the land.

I rest my case.

© D. Vincent Twomey svd

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Notes:

[2] In an article "Double effect principle must not be dismissed" (Rite and Reason, The Irish Times 27 June 2000; revised and reprinted as "The Principle of Double Effect and Civil Law" Irish Theological Quarterly, vol. 67, p.32 & p. 54) this writer took issue with a distinguished Senior Councillor at the time (now Supreme Court Judge), who had published an article rubbishing the moral principle that, he claimed, originated in Catholic moral theology (St Thomas Aquinas) and, on the ground of being "Catholic", denied its applicability to civil law.

[3] Since they generally offend common moral instinct (often dismissed as traditional), radical changes in medical practice are often justified by way of "exceptional circumstances" when first introduced by means of Guidelines or new ("progressive") legislation. But then, slowly but surely, the exception become the norm, since, in a sense, most  medical interventions are exceptional, being particular to each case. It should be noted that there is a school of modern Catholic theology (known as "proportionalism") which has adopted as one of its fundamental principles the principle of justifying certain actions, otherwise regarded as illicit, because of  "exceptional circumstances". Blessed Pope John Paul II's encyclical Veritatis Splendor (1993) shows this kind of theology is seriously mistaken.

[4] The letter is dated 18 July 2008.

[5] It should be added that here, as elsewhere, Catholic moral theology, when true to the Church's teaching, simply articulates a common moral instinct, i.e. an instinct which is common to our humanity and found in all religious traditions. I own the phrase "common moral instinct" to Fr Seamus Murphy SJ: it is the source of what is known technically as "natural law".

[6] Since I gave this paper, the present Minister for Health (Mr O'Reilly) appointed a prominent member of the Irish Planned Parenthood as head of the HSE.

[7] Gordon Marino, 'Before Teaching Ethics, Stop Kidding Yourself' in The Chronicle Review 50/24 (20 February 2004) B5.

[8] What follows is indebted to Joseph Cardinal Ratzinger, On Conscience (Philadelphia/San Francisco: The National Catholic Bioethics Center/Ignatius Press, 2007); see also D. Vincent Twomey SVD, Pope Benedict XVI, The Conscience of Our Age (San Francisco, Ignatius Press, 2007), in particular pp.121-134.

[9] It has to be acknowledged that, in modern Catholic theology, this quote of Newman has been used to support a subjective notion of conscience. A reading of the whole "letter" [in fact a book]  – and not just this intentionally provocative quote taken out of context –  makes it clear to the reader that such an interpretation simply misses the mark.

[10] Joseph Cardinal Ratzinger, On Conscience (San Francisco, Ignatius Press, 2007), 23.

[11] This all-too-human tendency is exacerbated by the theoretical denial of any acts that are wrong in themselves, a position held by too many modern Catholic moral theologians

[12] See Peter Charleton's classic, Lies in a Mirror An Essay on Evil and Deceit (Blackrock Co Dublin: Blackhall Publishing, 2006).

[13] Ratzinger, On Conscience, op.cit., p.18.

[14]Anthony Kenny, Thomas More [Past Masters Series] (Oxford, 1983), p 95.  This would seem to be the way some contemporary moral theologians also interpret conscience and, as we will see, even appeal to Bolt's play in support.

[15] See: 'A Discourse on St Thomas More's Great Matter: Conscience' in Amelia Fleming (ed.),Contemporary Irish Moral Discourse. Festschrift for Patrick Hannon (Dublin: Columba Press, 2006), pp.155-79; reprinted in Enda McDonagh and Vincent McNamara, An Irish Reader in Moral Theology: The Legacy of the Last Fifty Years, Volume I: Foundations (Dublin: Columba Press, 2009), 335-53

[16] More died for both theoretical (or dogmatic) and moral truth - i.e. both Papal Supremacy (dogmatic truth) and the wrongness of divorce (moral truth).

[17] R.W. Chambers, Thomas More, London 1935 [1948 reprint], p. 196.

[18] Cf. ibid., p. 340

[19] Richard M. Gulla, S.S., Reason Informed by Faith: Foundations of a Catholic Morality (New York/Mahwah: Paulist Press, 1989), pp. 123-134, here pp.133-5. Gula rightly distinguishes between psychology's superego and conscience. However the distinction is nullified by the fact that he sees the distinction not one of kind but only of degree (p.129): the superego is seen as "a primitive but necessary stage on the way to genuine conscience" (p.128). Gula quotes Vatican II's Gaudium et Spes #16 in support of his understanding of conscience without recognizing the deficiencies of that text: see Joseph Ratzinger's critique of G&S #16 in his commentary on the text in Commentary on the Documents of Vatican II, vol 5, Pastoral Constitution on the Church in the Modern World, edited by Herbert Vorgrimler (London/New York, 1969), pp. 115-63; here pp.134-6. According to Ratzinger, the treatment of conscience in Gaudium et Spes is naive.

[20] "I must always do what I believe is right and avoid what I believe is wrong" (Gula, p.133). This, of course, applies to an erroneous conscience in good faith - but Gula, like many other moral theologians, ignores the distinction between genuine conscience (what is objectively true) and a subjective conscience that is in error. That erroneous conscience may be due to negligence (by failing to search for the objective truth or for what the Church's apostolic authority teaches.

[21] The technical term for the Church's teaching authority is the Magisterium, a Latin term which, when used in any modern language, especially English, has, unfortunately, a somewhat authoritarian ring about it.

[22] I am grateful to Dr Mary McCaughey for this helpful distinction.