The Health Care Professional as Person:
The Place of Conscience
Canadian Catholic Bioethics Institute (March, 2016)
Reproduced with permission
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
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.
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
1. For a fuller discussion of these ethical principles, see any edition
of Tom L. Beauchamp and James F. Childress, Principles of
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.
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"
7. The Splendor of Truth, sec. 64.