The President's Council on Bioethics
Thursday, September 11, 2008
Session 2: Conscience and the History of Moral Philosophy
John Paris, S.J., Ph.D.
WalWalsh Professor of Bioethics, Department of
Theology, Boston College
FR. PARIS:trong> Thank you very much,
Dr. Pellegrino. As he said, I've known him for
years, worked with him at the Kennedy Institute,
worked with him at the Center for Clinical Bioethics
at Georgetown, and have been a great admirer of his
work for many years.
So when he called, he called with a very open
discussion, "I'm going to make you an offer, and you
cannot refuse." Now it wasn't an offer that I would
willingly refuse. "So whatever you're doing, you
have to do this because this is an important issue."
And I said, "Oh, Ed. What is this great issue?"
"Conscience." "Oh, MON DIEU! That's not my
field of expertise." He said, "No, but you're going
to do it."
Conscience is a word we all use, and
it's not very well understood. Despite the fact that
there is an enormously rich, complex history to it
going back into the ancient Hebrews, into the
ancient Greeks, all through the medieval period, the
focus that I'll have - and some of you will wonder
why this is so particularly oriented to Catholic
theology, and that's because that's where the
development has been very sophisticated and very
nuanced in its assessment and evaluation.
But before we begin that, I think it would be
important to see why we need conscience. And the
best way into contemporary culture, I think, is
through film, and two films that we saw in the
Academy Award winners this year, No Country for
Old Men and There Will Be Blood, point
out the issue of the role of conscience.
In the first of these, No Country for Old
Men, you know the psychopath goes around and
kills everybody with his bolt gun. He's seeking some
money. That $2 million was stolen, and he's after
it, and he goes and kills anybody who gets in the
way. And there's no remorse, there's no regret,
there's no reflection, there's nothing. This is the
psychopath who has no concern or consideration for
anything but the goal he wants to achieve.
Equally dark and equally neolithic is There
Will Be Blood, and there you have the
protagonist in Plainview blinded by greed. He wants
money, and he will do anything to obtain money. One
of the workers - he's in a oil field. One of the
worker's sons is killed, and he adopts him, not
because of any empathy for the child, but because he
sees this as the way of getting sympathy and selling
his product better. In fact, when the boy suffers an
injury and is nearly deaf, he sends him off to a
school for the deaf. And later when the young man
comes back to see him, he says, "You have nothing in
me. You are nothing but a bastard in a basket. Get
out." The only thing this man wanted was wealth, and
he would do anything for it - throw out his adopted
son, murder - it didn't matter.
And what you see in these two is the absence of
what we call conscience. There was no
reflection. There was no sense of right and wrong.
There was no sense of regret. There were no moral
values other than self-interest.
Conscience is that process by which we reflect
upon life and ask, "What is it that I should do, not
because somebody else wants me to do it" - and
here's one of the counter-distinctions about
conscience, not to be confused with the super-ego,
that psychological theory of guilt. The super-ego is
imposed on us by the ego of others, parents or
families in saying "don't do this," "don't do that."
We do it to children to protect them from injury.
But it's always other-directed. Conscience is an
inner-directed sense of growth.
Where does it come from? How does it form? What's
its basis? Well, part of it is that we understand
ourselves as moral entities. We understand ourselves
as entities who have freedom, who can make choices,
and these choices are not arbitrary. We determine
them for some purpose, and the purpose is that they
would achieve some good, that they would avoid doing
These are internalized values. They're acquired
values. And the way in which we acquire them and
achieve them is varied. And there are whole world
views, there are religious views, philosophical
views as to understanding this. And the way I'm
going to approach it is from the Catholic
perspective because that's the one in which I am
most familiar and it's the one in which I said I
find the greatest richness in the history of it.
And the baseline theological reason as to why we
argue that we have freedom and that we have
conscience is because we are creatures of God and we
are in the image of God. And of all places, we find
this in the Inaugural Address of George Bush, in his
second Inaugural Address, and he said the following.
He said, "From the days of our founding, we've
proclaimed that every man and every woman on this
earth has rights and dignity, and this is because
they bear the image of the Maker of heaven and
So here you have a broad consensus at least that
we have dignity, and if there's one thing that this
commission has done, it's to write books on the
dignity of the human being. And while there may be
disputes as to what the source of this is, at least
theologically it is because we are creatures of God.
We are in the image of God, and God is at work in
Theology understands two things: One, we are to
act on the basis of our conscience. We are to act on
the basis of values. We are to act on the basis of
what we perceive or understand to be right and to
refrain from acting on what we understand to be
And theologians also understand that we can fail,
that failure and error are part of the human
condition. We can fall short of what it is that we
want to do as the right thing. This is put best, I
think, by St. Paul in Romans when he says, "The good
that I would do, I do not, and the evil that I would
avoid, I do." Why? Why do I not do what I resolve to
do when I say, "This is the right thing to do"? And
it's as easy as and as frequent as getting on that
scale yesterday and discovering 160 pounds, which
some people would think was great, but I think is
terrible and say, "I'm not going to snack anymore
between these meals," and on the way down to this
talk, three carrot sticks and four dips later, what
happened to the resolve?
Now, I don't think it's, as Paul would put it,
sin, and I don't think it's really sloth or
gluttony. But you say, there are things where we
fall short. We don't do what it is that we want. But
we do have values, and we identify ourselves by our
And I think we've seen that certainly in the
story of John McCain when he's talking about his
days in the prisoner-of-war camp, and he said, "Why
did I do what I did? Because that is who I am." And
he said, "I sat there thinking of my father and my
grandfather and the values that I had and who it is.
It would have been easy. It would have been in my
self-interest to sign up to leave early. But that's
not who I am."
Conscience has to do with character. And even a
clear expression of that was seen in Tim Russert's
book on his father called Big Russ. His
father was the superintendent of sanitation in
Buffalo, and he was offered a big promotion if he
would - offered a big bribe, rather - if he would
allow somebody else to get the promotion on the list
by taking himself off, and he said no. And when he
was explaining it to Tim, he said, "Because that's
not who I am. I define myself by my values and my
Conscience is an old notion. It goes back to the
Hebrew notion of the heart, that the heart was the
seat of reason, that the heart is the seat of our
feeling. The heart is the seat of our
decision-making. And the call of the prophets was to
put on a new heart so that you would be faithful to
St. Paul in Romans talks as well about the Greek
and Hebrew notion of this fundamental awareness
that's implanted in the heart of each of us, that's
in our nature, that's ingrained, that all of us have
somehow ingrained in our very being this sense of
what is right and what is wrong, and that becomes
the guide to our decision-making.
I think that the best single articulation of that
in the modern world is one of the conciliar
documents of Vatican II called The Church in the
Modern World in which the Council fathers said
the following, following along the same lines as the
Hebrews, "Man has in his heart a law written by God.
To obey is the very dignity of man for there he is
alone with God whose voice echoes in his depths."
And here they make the distinction between you find
yourself alone in the depths of your very own soul -
the words they would use using the Latin, solo
cum solo, that is alone with another alone,
alone with God, not as they put it, solo cum se
ipsa, alone with oneself. That is, that God is
implanted in our hearts, in our nature, in our being
as a part of the dignity of being in his image, this
sense, this capacity, for understanding good.
There are, I propose to you, three parts to this
conscience. The first is the capacity for it, this
natural capacity we have; then a process by which we
discern; and then a judgment by which we make a
decision to act.
Except for the brain-damaged, infants, and the
psychopaths, it seems to me that everybody has an
innate sense of right and wrong. They know what
right is, and they know what wrong is. Thomas
Aquinas called this that first kernel, that kernel
of first principles that we all understand. And
Thomas writes later, "Most people don't have the
time, the capacity, or the inclination to do vast
philosophical analysis." But we have, all of us, got
this capacity to reason about what's right and
what's wrong, about what the good thing to do and
Now it's important to understand that this
foundation that we have is not the same as - and we
don't have equal clarity or certainty - with
applying this conscience to concrete situations in
the human world. That's the role of the second
factor of process.
Now that we have this sense, this innate sense,
how do we begin to work at it? And it's through
experience, through critical investigation, through
looking to sources of moral wisdom. We know that
don't ourselves have all this capacity, so we look
to others, to family, and you certainly saw it in
the political conventions. Every single one of the
candidates began his or her biography with, "Here's
my family. There's my 91-year-old mother. There's my
96-year-old mother. There was my father. I learned
at my grandmother's knee." They went to their
families. Then they went to their tradition, and
then they went to the sense of their community. So
you get this wisdom, not simply from your own
self-reflection, but you get it from the wisdom of
We get it in the broader perspective from the
prophets, from scripture, from the tradition, from
the Founding Fathers. We find this richness of the
wisdom, and we go there.
And then, finally, you have a judgment. What is
it that I ought to do in these particular
circumstances, given my understanding of right and
wrong, given the sort of history of where this all
fits in? One of the ways in which this works - and
I've talked to Dr. Pellegrino just two weeks ago
wholly independent of this - we begin to apply this.
There was in the August 14th issue of the New
England Journal of Medicine a very
controversial article about infant heart
And the proposal of the Denver transplant team
was that we should, when removing a ventilator from
a brain-damaged child, wait for death to occur, or
wait for the cessation of cardiac activity, and then
wait 75 more seconds to declare them dead and
harvest the heart.
The commentary and the prospective in that same
issue of the journal by a physician at Dartmouth
says, "Wait a minute. What do you mean, 75 seconds?
What about the dead-donor rule? What about
auto-resuscitation? What about? What about? What
about?" He said, "We have to look at the tradition
of cardiology. It's not simply a matter of saying,
'We like hearts, and, therefore, 75 seconds is
enough. Let's look to the tradition of medicine.'"
One of the judges, late judges, of our Supreme
Court in Massachusetts, Paul Liacos in the Saikewicz
case case [Superintendent of Belcherton State
School v. Saikewicz, 370 N.E. 2d. 417 (1977)]
raised the same sort of issue when the question
came, could we remove or could we withhold
chemotherapy from a patient, an elderly,
mentally-incompetent patient with leukemia? And this
was a case of first impression. The question had
never been raised in the law before, and Justice
Liacos says, "The law frequently lags behind
technology." The technology has advanced. Now we
have to have our moral reflection on it. And the law
simply doesn't bring it out of thin air. As Justice
Liacos puts it, "We look to philosophy and to
theology and the tradition of medicine. We look to
the wisdom of the society in order to determine what
it is we believe the right thing to do is, law not
being conscience, but law saying, 'This becomes the
reflection of the conscience of the society on how
we behave in this particular activity.'"
That is, the formation of conscience is social in
nature. It's not simply solipsistic. It's not
simply, "I believe, and, therefore, it is." It's
formed with experience and with knowledge and aware
that we can have lapses. We look to families, to
friends, to colleagues, and to experts in the field.
We also look to stories, and to laws, to images, to
traditions, to rituals, to norms. We look to all of
these for insight and for understanding as to what
constitutes the right thing.
Another factor is that conscience goes to
character. It's not simply, "What should I do," but
"What sort of a person ought I be?" John McCain put
that so forcefully when he said, "This is who I am."
This is how we act because this is who we are.
We also have to understand very clearly, of
course, that conscience can err. Kerry Kennedy put
this best, I think, in her new book [Being
Catholic Now: Prominent Americans Talk About Change
in the Church and the Quest for Meaning (Largo,
Maryland: Crown Books, 2008)] - I haven't seen
the book yet, but I heard it on NPR the other day -
talking about how the nuns were talking to the
various students in school and looked at one boy and
says to him, "You have a superabundance of original
sin." Now, I'd never heard that put that way before.
I thought we all had it and all had it in abundance.
But it's the only empirically verifiable theological
concept we have, but it's there.
Knowing we can err, what then about conscience?
Well, in the investigation, we might be mistaken. We
might distort. We might have the wrong facts. We
might be driven by passion. There is Plainville in
There Will Be Blood driven by greed. It
blinds him to all other aspects of life.
What about the erroneous conscience? What about
the conscience that's mistaken either out of passion
or out of ignorance or out of failure to do the
homework? It can be what the theologians call,
either vincible or invincible; that is, it can be
conquered, or it's just intransigent. You cannot
And Thomas puts it this way: "If by more diligent
study you could have learned the facts, you have
responsibility for changing." A simple example would
be HIV/AIDS. When this first occurred, physicians
didn't have an idea as to what this was and had lots
of misdiagnoses. I recall a person whom I know now
died of HIV, but this was before we understood what
it was. And he went everywhere from Dana Farber to
Stanford in search of a diagnosis. They said, "We
can't figure out what's gone wrong." Were those
doctors in error? Yes. Was it a moral judgment, a
moral lapse? No.
Alternatively, if today a patient came to your
hospital and had HIV and you said, "It sounds like
the flu to me," this would be an error, but it would
be a moral lapse as well. It would be the failure to
exercise your knowledge.
Knowledge is going to include the ability to
reason and to analyze. It also requires experience
and reflection, not just information. It involves
freedom, but not just to self-chosen goals. It's not
a license to do whatever we want.
Another aspect is going to be the emotions. The
emotions are a very important part of this, and that
was what's missing in the psychopath. He has no
empathy whatsoever. Those of you who have seen the
film know that along the course of his way when he's
going out killing everybody, he comes across the man
in the store, and he says to him, "Flip a quarter."
And the guy says, "What do you mean, 'Flip a
quarter'?" He said, "Well, if it's heads, you live.
If it's tails, you die" - no empathy about the human
condition, no concern about anything, no regret, no
remorse, just wanton killing.
Conscience is what the moral theologians call the
proximate norm of personal morality. Now that will
put you to sleep - if nothing else will today. What
does it mean? It says it sets the boundaries for
acting with integrity and for acting with a sincere
What's the test of the validity of one's
conscience? You say, "Oh, my conscience wouldn't
allow me to do that." What's the test? The test
historically has been the willingness to pay the
price of an adverse outcome for standing for what
you believe in.
The best example historically, I think, is Antigone. You'll recall in Sophocles ' play
King Creon decrees that no one shall bury the bodies
of those who are in revolt, and Antigone says, "My
brother is my brother, and duty requires me to bury
him." And she's advised, "Don't do this. You'll be
killed." And she says, "I have a duty that
transcends the law." That is the willingness to pay
the price. In Martin Luther's, "Here I stand. I can
do no other," the price was being excommunicated
from the Church.
Thomas More in the Oath of Supremacy, his friend,
the Duke of Norfolk, comes and says, "Oh, just come
along and do it." And More looks at him, as you
recall, and particularly in A Man for All
Seasons, and says, "Oh, that's fine for you.
Your conscience allows you to do that. And when you
die, you go to heaven. And as for me, I go to hell."
And Norfolk says, "Well, do it for friendship's
sake." And he says, "When I go to hell, Norfolk,
will you come with me for friendship's sake" - the
test of your conscience, the test of your
willingness to bear the price.
And in the long history of conscience, there've
been disputes even against the Church. And amazingly
enough, Thomas Aquinas in his commentary on the
sentence of Peter Lombard says, "If your conscience
tells you that this is wrong," Lombard says, "Your
conscience can never go against the Church." And
Aquinas says, "If your conscience - and you've
diligently applied yourself to it - tells you that
this is wrong, you should be willing to die
excommunicated rather than violate your conscience,"
whereas Cardinal Newman said in a somewhat jocular
vein one time, "If we were to toast a pope, I would
toast first conscience and the pope afterwards
because ultimately I am not going to be judged by
the pope. I'm going to ultimately be judged by
What do we do with the erroneous conscience? How
do we deal with the erroneous conscience? If someone
came to you and said - you go home tonight and you
meet your spouse and he says to you, "Oh, dear. Some
terrible news, but I want you to know he did it out
of conscience," would you find those comforting or
warning words? The fact that someone does it out of
conscience doesn't necessarily mean it's right. The
fact that someone did it out of conscience means, if
it's a sincere conscience, that he or she believed
it was right and was willing to do it, contrary to
the norms of the standards of society, even contrary
to the law, and willing to pay the price.
Aquinas picks up this question and he asks about
the sincere conscience. He said, "There must be
sincerity. There must be integrity in the individual
in believing this, and the individual must also be
striving to ascertain why it is that others are
holding a different position. You owe it as an
obligation to attempt to understand what the
objections to your actions are, if there are them."
If the person sincerely believes it and even if he's
wrong, Thomas says, "Ah, this person is excused."
He's not saying what he is doing is good, but he's
excused from any moral impropriety.
Today, we'll find people very lightly using the
theme, "It's my conscience." "My conscience wouldn't
let me do that." And then you press further and you
get, "My conscience wouldn't let me do that." And
you press further, and you get the same answer.
Well, what is there in your conscience that won't
let you do it? It's not as Joseph Ratzinger called
it, "It's simply the apotheosis of subjectivity.
It's not simply, 'This the way I see it and that's
the end of the story.'" He said, "In order to have
your conscience be properly formed, you must know
what the general rules are, the circumstances, the
contingencies, to anticipate the consequences, and
to anticipate what the response of the consequences
is going to be."
An easy way into this is storytelling. Abstract
theory, at least in my experience - and I suspect
it's yours - when you stand there and give them
abstract theory, they fall asleep. They want cases.
And there's a big problem in medical ethics. They
only want cases - no theory.
But let's look at two cases of conscience and see
how conscience was formed. Did this individual know
what was right and know what was wrong? Did he
violate that without any impact on his conscience?
The first case I'd like to examine is David and
Bathsheba. We know the story. David looks over and
see the beautiful Bathsheba, lusts for her, does his
thing. She announces she's pregnant, and there's a
problem. She's got a husband who is a soldier in the
army. So what does David do? He calls him back to
see him, suggests he go visit his wife for the night
so that he will have sex with her and think he's
father. He said, "Oh, David, while my soldiers are
in the field, I could not sleep in my own bed. I
will camp on your doorstep." So the next day, David,
continuing his cunning ways, invites him in for a
big banquet and gets him drunk thinking this will
dull his will - the same thing. Now David has got a
problem. What does he do? He calls his generals in
and said, "Bring this general out, put him in front
of the army, withdraw your troops, and he will be
killed," and he was.
David thinks he solved his problems. David has no
remorse, no regret. He's got Bathsheba. Where's his
conscience? Does he have one? Is he a psychopath not
knowing good and evil? The test is very shortly
thereafter. The prophet comes to him and says, "Let
me tell you the story of the man with one little new
lamb and the rich man. The rich man takes the poor
man's new lamb for his feast." And David looks and
says, "As long as I am king and judge of Israel,
that man deserves to die." He knew right from wrong.
And the prophet looks and says, "Thou art the man,"
and David knew.
A more contemporary example of this is Chuck
Colson. If you go back to the Committee to Re-Elect
[the President] and you'll recall Chuck Colson 's
argument, "I would walk over my grandmother to
achieve the reelection of Richard Nixon." It reminds
me of [Thomas] More, but for Wales. Now he's in jail
post-Watergate and reflects on it, and his comment
was, "I lost my moral compass," much the same as
Solzhenitsyn did in the Gulag Archipelago
when he writes, "Here I was in prison, and I had
these blue stripes on my tunic. That set me apart,
and I did awful things." Now in prison - and not in
prison for that, but in prison - he realizes how he
had behaved, and he said, "I forgot the lessons I
learned from my grandmother when kneeling at her
side when she sat underneath the icon."
Colson, Solzhenitsyn, they had consciences. They
had erred. They had failed. But they had not lost
their capacity to reflect and needed simply the
occasion, as did David, to reflect on the moral
action and to be able to pronounce a judgment on it.
Conscience is not simply Jack Abramoff as he was
last week saying, "Have mercy on me. I'm now the
butt of jokes." That's not conscience. Conscience is
what the theologians call that antecedent
conscience. It's not the regret that you got caught.
Conscience is before the action understanding and
assessing its moral character and determining
whether one should or should not do it because it is
good or because it is evil.
Now the question - the question that Dr.
Pellegrino and the question this group, this
Council, is going to confront is - What about
cooperating in what you understand to be wrong? Your
conscience says it's wrong. When, if ever, may you
cooperate, in what you perceive to be evil - what
theologians call cooperatio in male? Must
you refrain from all action that your conscience
tells you is morally improper?
There are those who try to do that: H. Richard
Niebuhr in Christ and Culture writes about
Christ against culture. Culture is evil, rescind
from it, withdraw from the evil world and keep
yourself pure. The best articulation of that, I
think, is J.D. Salinger 's The Catcher in the
Rye. Do you remember when Holden Caulfield is
there with his little sister, Phoebe, and they go to
that awful place called New York City and they see
the terrible graffiti on the walls and Holden is
going to erase the graffiti. But what does he learn?
You can't erase all the evil in the world. You can't
protect individuals from all evil, that in this
world you're going to have to adjust somehow so that
your conscience doesn't result in pure moral purity
of the eschaton here.
Let me give you two cases broaching, bridging
into where you're going to go, two legal cases. The
law is not the definitive analysis of morality, but
it gives you an insight into at least how we
approach it. These are two recent cases of
addressing exactly the issue: One, Storman
versus Selecky, the 9th Circuit, 2000 [Stormans
Incorporated, et al. v. Selecky, et al.: U. S.
District Court for Western District of Washington
No. 07-cv-05374-RBL: "Order Granting Preliminary
Injunction," November 8, 2007], was the
pharmacy case, and you're all familiar with this.
Some states have laws insisting pharmacists do not
have to violate their conscience. Some states say
pharmacists must [fill all legally valid
prescriptions]. We haven't sorted out that problem
But the 9th Circuit looked at it and said, "If
the pharmacist is being ordered to provide a
contraceptive that he believes is killing the life
of a newborn or of a newly-created life, he has no
obligation to do it." The pharmacists wanted a
refuse-and-refer, and the state wouldn't allow it.
And the court said, "This is a Hobson's choice for
this pharmacist. Either he violates his conscience
or he loses his job," at least in the state of
Washington, where this occurred.
A different case was one that occurred in
California involving Catholic Charities, and it was
the issue of insurance. If you have an insurance
plan, the argument or the statute read, you must
provide prescription contraceptives to all the
insured. Catholic Charities protested and said,
"This violates our institutional conscience. We
don't believe that this is a moral action and,
therefore, we won't." And the California court said,
"It may well offend your conscience, but these
people have a right to it," and the argument is very
narrow. You would not have to provide it if you were
an institution designed simply to inculcate
religious values, if the majority of your employees
and participants were members of this faith, and you
were what the IRS calls a church; that is, a convent
or a religious order.
A convent of Carmelite nuns might have a
legitimate argument as to why they would not provide
insurance benefits involving contraceptive
prescriptions, but does that apply to Georgetown
University and Medical Center? Is this an
institution designed to inculcate religious values?
Are the majority of their people going to be of one
religious faith? And is it specifically restricted
to those? We'll recognize conscience in the narrow
sense. But in the broader, it's not.
Those are just two ways in which the approach
came, and it gets you into sort of one of the final
descriptions of how it is: namely, what's the degree
and intensity of the involvement of the individuals
with conscience in the practice?
There's the question of - and we have it from
1973 from Senator Church 's amendment on abortion.
You need not - no physician or health care provider
need directly be involved in the procuring of - I
wouldn't even use procuring - in the performance of an abortion.
How far up does that extend? Does that extend to
when Ed Pellegrino was a kid working in the pharmacy
stocking the pharmacy with contraceptives?
The philosophers make the distinction between
direct formal participation, which is a very high
value, and then indirect and material.
Does the porter in the hospital who is pushing
the patient down the hall to the operating room?
Does the clerk in the insurance company who's
processing the insurance claims have a right to say,
"I believe this procedure is immoral. It violates my
conscience, and I won't process the claim nor will I
report the non-processing of the claim because
others would be now involved in it."
Where along the line do you begin to draw the
difference between direct formal participation in a
grave evil and indirect material participation in an
evil that the society doesn't quite find as
egregious an act? And I think that MacIntyre put it
best when he said, "If we're going to have a stable,
social society, we must have some consensus as to
what constitutes acceptable behavior or tolerable
behavior, or otherwise we're in chaos." We simply
have individuals saying, "My conscience is the only
value and I am not willing to compromise in any way
for any purpose," and then you have, not a society
or a community. There you have chaos, and we'd be
right back with Hobbes. And do we want to have a
short, brief, vicious, and bitter community at each
other's throats, or is there a possibility of saying
there are some things that are so important, and so
imperative, and of such value to an individual that
as a society we would be willing to recognize that
individual's right to rescind from direct form of
participation in that form of behavior? But we've
got to make distinctions as to where along the
continuum that line falls. Thank you very much.
[Applause] [. . .Discussion]
President's Council on Bioethics
was appointed by President George W. Bush and operated from 2001 to 2009.
Archived transcript of the session.