The President's Council on Bioethics
Thursday, September 11, 2008
Session 2: Conscience and the History of Moral Philosophy
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
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
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
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
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. GÃ“MEZ-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
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
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.
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
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
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,
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
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
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
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
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
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
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
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
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
Have a good lunch. We will reassemble at 2:00