The Health Care Professional as Person:
The Place of Conscience

Bioethics Matters
Canadian Catholic Bioethics Institute (March, 2016)
Reproduced with permission 

Full Text

Recently I was asked to present "the Catholic position" on physician-assisted death as part of a panel discussion held at a downtown Toronto hospital. The purpose of the event was not to debate the issue but to educate participants about various points of view. I ran into some difficulty when I was discussing the Catholic Church's interest in protecting the consciences of health care staff. One panelist immediately redirected our attention to the needs of the patient seeking physician-assisted death and the conversation left the health care professionals behind. In this short article, I would like to bring the focus back to the doctors, nurses, social workers, chaplains, therapists, in short, to the health care staff involved in patient care and who may have objections to performing or assisting in physician-assisted death.

Health Care Ethics (Briefly)

While ethics has always been a part of health care (the Hippocratic Oath, for instance, is a statement about the qualities of a "good" doctor), bioethics or health care ethics emerged as a discipline in the 1960s and 1970s, a time in North America when there was a general interest in redressing social injustices and recognizing and protecting the rights of individuals. In health care, this meant moving from the traditional paternalistic model of health care which placed much of the power of the doctor-patient relationship in the hands of the physician, to a patient-centred model that gave the power of decision-making to the patient. In bioethical terms, the principles of nonmaleficence ("do no harm") and beneficence (act for the wellbeing of the patient) gave way to the principle of respect for patient autonomy which recognized the right of the patient to be a self-governing agent.1 This principle is expressed through such practices as informed consent and confidentiality, as well as in the development of advance directives, all of which are part of the current health care landscape. In fact it can be startling in 2016 to realize just how provocative Paul Ramsey's idea was back in 1970 - that the patient was a person.2 This is something we simply take for granted today. But where are health care professionals in this?

The Health Care Professional as Person

Years ago when I was working in hospitals, I was a member of Research Ethics Boards. The purpose of an REB is to review research proposals involving human subjects. Members of the REB want to ensure that the studies going forward in a hospital are sound and worthwhile, treat the human subjects with respect, and do not expose them to undue risk or harm. Normally researchers come to hospitals to enrol patients in their studies; in one particular case, a group had come to enlist physicians. Our chairperson, likely hoping to expedite things, said that although he knew that studies involving patients had to be put through a rigorous ethical review, he wondered if this particular protocol had to be subjected to the same strict process. Were physicians persons in the same way that patients were?

Although I laughed at the time, it is a question that has stayed with me. The answer of course is that health care professionals (even physicians) are very much persons - indeed, as much as patients are. Unfortunately it can be very easy to lose sight of this. Mirroring the ethos of North American society, health care is often portrayed as a consumer-driven activity, with the patient assuming the role of customer and the health care professional being regarded as a service provider. If we assume that the customer is always right and is also willing to shop around, then the health care professional may not be given much of a voice in this fleeting relationship. With the model of health care as industry, there is the danger of the health care professional being little more than a technician, a cog in an impersonal system, ultimately accountable not to the patient or to her own profession, but to the metrics demanded by a particular understanding of quality assurance. In these circumstances, the health care professional as person can be a very elusive idea.

But the reality is this: whether it takes place at the bedside or in the examining room or an office, in x-ray or rehab, and despite whatever else may be going on around them, the encounter between a patient and health care professional is an encounter of persons. It is an intersection of lives; in many cases it is a meeting of strangers at profound and challenging personal junctures. Specific medical interventions may be called for - a prescription, surgery, therapy, assistance - but what elevates the therapeutic encounter is this meeting of persons as persons. To miss this, or belittle it, is to overlook the potential for healing that lies in the therapeutic encounter itself. It is a potential that rests on the ability of health care professionals and patients to be present to each other fully as persons, which means bringing one's conscience to the encounter, whether one is a patient or a health care professional.

Conscience and Persons

The term "conscience" can evoke a variety of images. There is the picture of an angel on one shoulder and the devil on the other competing to direct the uncertain agent; Jiminy Cricket counsels Pinocchio to "let conscience" be his guide. There is the appeal to conscience as a way of justifying unconventional moral choices which may also appear to open the door to moral relativism; there is the insistence on having a properly formed conscience that closes the door again. In all of these images is a common theme: somehow conscience is connected to making moral decisions. But conscience is more than this. It is, according to Pope Saint John Paul II, "‘the sacred place where God speaks to man.'"3

Traditionally Catholic moral theology has distinguished between two aspects of conscience. The first, synderesis, is the basic moral drive to know and do the good. It is a sensibility that is very much a part of being human, so much so that when we come across someone who seems to lack this basic sense - who seems to be amoral - we question their humanity. Conscience, according to this understanding, is like a spark glowing within us. It is a light, as John Mahoney points out, that was not completely extinguished by original sin.4

The second aspect of conscience is syneidesis, that is, conscience in action. It is our search for the good - the seeking, researching, consulting, praying; it is the deliberation and finally the judgement about what the good is. It is here that formation of conscience is so essential, as is being in the company of good companions.5

But judgement is not sufficient; it is not enough to know what the good is. Once we have judged what the good requires in this concrete instance, we must act on it. Morality is not some endless, abstract discussion about insufficient lifeboat space or scenarios involving Nazis. Rather, morality is about how we live and shape our lives. It is about the people we become through the lives we live. It is about how we be good people by performing good acts. This is a holy endeavour.

When we strive to know what the good action is in a particular situation; when we try to understand what right decisions might be; when we try to be "good"  - our search for the good, the right, and the truth is nothing less than a search for God. And it is in our consciences that we have the possibility of understanding what is required morally, of glimpsing the Good, of meeting God. Pope Francis writes that conscience is "the interior place for listening to the truth, to goodness, for listening to God; it is the inner place of my relationship with him, the One who speaks to my heart and helps me to discern, to understand the way I must take and, once the decision is made, to go forward, to stay faithful."6 In the sanctuary of conscience we have the possibility of understanding in an ongoing and unfolding way who we are as persons, what we are called to be, and how to achieve this through our decisions and actions.

Judgements of conscience, then, are not about single, isolated, and unconnected moral questions and issues; rather they are the threads of our personal moral tapestries. What emerges is a picture (for good or bad) of who we are as persons. This is why respecting the right to conscientious objections is so important - and not only for health care professionals, but for everyone. To deny this right is to violate at the deepest, most profound level possible our ongoing becoming as persons. It is to intrude on and attempt to dismiss our personal and intimate communion with God who is all Good. This is the truth that the Catholic Church recognizes when it acknowledges the ultimate inviolability of conscience.

Conclusion

Health care professionals are called constantly to reflect on the meaning of their vocations and what good patient care requires. In this, they turn to their consciences, to the "Voice" who considers with them and guides them to meaning and purpose, to what is required to be "good" at what they do, and how to be most fully persons in their encounters with patients. This is an ongoing dialogue. As Pope Saint John Paul II writes, conscience must be "the object of continuous conversion to what is true and to what is good."7

For health care professionals the refusal to participate in physician-assisted death carries no judgement about the patient who requests it; the refusal speaks only to the health care professional's convictions about what good patient care requires, what the goals of health care are, and what it means to be good in one's profession. It is a refusal based on convictions that may or may not have religious connections; to violate such judgements of conscience is to strike at our notions of the respect and protection that all persons deserve.

Respect for conscience is essential to human freedom. As Pope Francis writes, "Jesus wants us to be free. And where is this freedom created? It is created in dialogue with God in the person's own conscience. If a Christian is unable to speak with God, if he cannot hear God in his own conscience, he is not free, he is not free."8

Notes:

1. For a fuller discussion of these ethical principles, see any edition of Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics.

2. See Paul Ramsey's very influential work, The Patient as Person: Explorations in Medical Ethics (The Lyman Beecher Lectures at Yale University) (New Haven: Yale University Press, 1970).

3. John Paul II, The Splendor of Truth (Sherbrooke, QC: Éditions Pauline, 1993), sect. 58.

4. John Mahoney, The Making of Moral Theology: The Martin D'Arcy Memorial Lectures 1981-2 (Oxford: Clarendon Press, 1987), p. 187.

5. For the traditional understanding of synderesis and syneidesis, see David Bohr, "In Christ a New Creation: Catholic Moral Tradition," revised (Huntington, Ind.: Our Sunday Visitor Publishing Division, 1999), pp. 172-175.

6. Pope Francis, "Angelus, St. Peter's Square, Sunday , 30 June 2013"  (Accessed 2016-03-12)

7. The Splendor of Truth, sec. 64.

8. "Angelus"