DIFFICULT QUESTIONS the place of conscience in medicine & public life

‘I ‘m sorry, I can’t sign those’. So began a discussion of conscientious objection to abortion when I (Laurence) was an obstetric SHO. Often, we were presented with sets of notes where we were expected to provide a second signature on the legal form needed to authorise an abortion, and then prescribe relevant medication. My nursing colleagues were civil enough (after all I wasn’t the first doctor who had refused this), but I sensed some frustration, as several others I worked with took the same position, and considerable work would be needed to find a signatory on some days. These dilemmas still occur around abortion, and may arise in other areas too. How are we to think about conscience as Christian medical students, and how should we try to protect conscientious objection when it is under threat?

Rick Thomas helps us to think through this:

‘Conscience’ comes to us from the Latin ‘conscrire‘, a conjunction of the prefix ‘con‘ meaning ‘with’ and the verb ‘scrire‘ meaning ‘to know.’ It carries the sense of ‘having knowledge’. In psychoanalytic terms, this knowledge inhabits a realm beyond the conscious self but can communicate with, and comment upon the choices made by the conscious mind, classically by conveying a sense of shame. This separation of conscience from conscious self is illustrated in expressions like ‘you can make that choice if you will — that’s between you and your conscience.’ In this model, the ‘knowledge’ that informs the conscience and constructs its ethical boundaries accumulates through environmental influences, particularly during early years. In effect, conscience becomes ‘the voice of others inside you.’ [1]But what if God informs the ‘voice’ inside us, the voice of conscience? It seems Paul suggests this, or at least something like it, in Romans 2:12-16. In context, Paul is talking about God’s future judgment of sin and how it will fall on Jew and Gentile alike. Paul declares that God shows no favouritism in his judgment — he is impartial. But how could it be just for God to judge Jews, who have received God’s law and know its requirements, by the same standard as Gentiles who do not have his written law? Paul makes it clear that God has not left Gentiles in the dark but has in some way written his law in their hearts, brought to light by the operation of conscience. The Gentile, though without the written law, nonetheless has the witness of his conscience acting as a kind of moral alarm signal, disapproving of, or commending his actions. So, Paul argues, God will be just when he judges everyone’s secret life. In biblical thinking, therefore, the conscience is a fundamental aspect of our created humanity and present in all, not just in believers.

Paul clearly values the role of conscience highly. He frequently describes himself as living with a clear conscience. [2] He urges his young disciple Timothy to live in the same way [3] and lists integrity of conscience as a qualification for leadership in the church. [4] He warns the Christians in Corinth against violating the consciences of others who have scruples over certain matters that they don’t share. Not all consciences are calibrated the same, it would seem, and Paul argues that those who feel less constrained by conscience than their brothers and sisters should be careful to respect their scruples (‘weaker’ consciences) and voluntarily limit their own freedom rather than risk causing offence. [5]

Laurence:

It is quite clear that ‘conscience’ in itself is important. And when the conscience of a Christian is likely to conflict with the current desires of society, that will cause difficulties. How might this concept affect how we interact with society?

Rick responds:

Firstly, it will shape the language of our appeal. We live in a post-Christian, secular society. The words and ways of God are no longer common knowledge. But conscience — an intuitive commentary on our plans and actions, that inner sense of what is good or bad, right or wrong — is universal. It is also remarkably consistent across peoples from widely different cultures. For example, stealing, lying, murder, incest, and adultery are almost universally held to be unlawful, even in those less ‘developed’ societies where no moral code has been written down. No doubt, upbringing and environment help shape (or sometimes misshape) the contours of conscience over time but, if we have interpreted Paul correctly, it is God who originally plants that knowledge of ‘how things truly are’ in the human conscience. That being so, then appeals that reflect God’s will and ways will frequently find a resonance, if only as a faint echo, in the hearts of those who may not share an overtly Christian worldview. Connect with these deep moral intuitions, and the conversation becomes a very different one. In many people, the intuitive knowledge of conscience is not deeply buried and may be helped to surface by an approach that is invitational rather than adversarial.Secondly, it will strengthen our commitment to the notion of conscientious objection (CO). The biblical record clearly affirms the legitimacy of CO. To force someone to act against their conscience is wrong, and Christians will resist attempts to minimise freedom of conscience.

However, here we must pause to reflect. Conscience appeals to an objective set of moral norms outside oneself, generally to the tenets of religion. But with the ‘fading’ of religion in our culture, might the trend in the law be to accept as claims of conscience any beliefs personally and consistently held?

In a secular society, non-religious beliefs strongly enough held could eventually command the same right to CO as a recognised religion. In times past, the law took its bearings from the understanding of God as Creator and Lawgiver, with the Scriptures providing an objective reference point against which claims of conscience could be measured. Now the law must decide just what such claims mean when they are divorced from that body of truth. To draw a ridiculous illustration, if I claim a strong personal belief that it is wrong to pay taxes, it is (sadly) unlikely the Inland Revenue will see that as a legitimate claim to CO! To guard against the ‘every conscience a law unto itself’ scenario, it is likely that the law will become more restrictive. The privilege of CO on ‘religious’ grounds will come under increasing threat and could be lost altogether.

So, should Christians press for freedom of conscience for all, no matter how frivolous a claim may be, in the name of equality? Or should they restrict their appeal to apply only in support of conscience claims based on historic credal beliefs and be accused of bias and narrow self-interest?

We suggest, with Magelssen, [6] that CO should be acceptable when the objection has ‘a plausible moral or religious rationale’ such that providing healthcare would ‘seriously damage the health professional’s moral integrity by constituting a serious violation of a deeply held conviction’.

when the lawmakers get it wrong

The Bible teaches that God institutes human authorities and expects us to obey them: ‘Let everyone be subject to the governing authorities, for there is no authority except that which God has established. The authorities that exist have been established by God. Consequently, whoever rebels against the authority is rebelling against what God has instituted, and those who do so will bring judgment on themselves.’ (Romans 13:1-2) But Scripture is equally clear that if laws that discriminate against Christians are passed, and obeying such laws involves disobeying God, then there is a place for civil disobedience. In fact, when we are forced to do something wrong, it is a Christian duty to disobey. When the king of Egypt ordered the Hebrew midwives to kill all male Hebrew children, they refused to do so and God commended and rewarded them. [7] When Peter and John were commanded by the Jewish authorities not to preach the gospel, they replied, ‘We must obey God rather than men,’ and continued to do it. [8]So, whilst recognising that we have an obligation to obey the governing authorities that God has instituted, nonetheless, our obedience to God himself takes precedence if the law of the land requires us to disobey him.Of course, we should do our best to oppose the passing of laws that seek to criminalise normal Christian behaviour. And if their passing looks inevitable, we should seek for ‘reasonable accommodation’ to be made. The Abortion Act and Human Fertilisation and Embryology Act, for example, both contain conscience clauses. These provide some protection from being forced to participate for those with a moral objection to the activities they legalise. Even when there is not such provision in legislation, ‘reasonable accommodation’ should usually be possible with an employer. But we may not be successful in seeking a reasonable accommodation. In such a circumstance, we must be willing to count the cost and to pay the price for being faithful to God in the face of threats. The long list of heroes of faith in Hebrews 11 contains not only those who were delivered from the legal consequences of civil disobedience but also those who paid the price. And paying the price may be what God requires us to do in similar circumstances — through loss of reputation, job, registration, money (facing a fine), freedom (imprisonment), and even, perhaps, life. In all this, we have the confidence that we follow in the footsteps of a Saviour who, in facing everything the religious and political authorities could throw at him, willingly carried the cross and emerged ultimately victorious.

Laurence considers how this works for today’s student:

We are rarely the final decision maker at this stage. But will we observe procedures to which we might object? Or get involved in tasks that are themselves morally neutral (such as siting a cannula), but may facilitate a procedure we object to (such as an abortion)?In most circumstances I think it helpful to observe procedures even when uncomfortable. I feel better informed having done that as a student with regard to abortion. Sometimes this approach might bring opportunities to discuss concerns and reason with those teaching you.

But it is wise to avoid contributing to procedures that you are uncomfortable with. I remember using the phrase ‘I am uncomfortable with this so would prefer not to assist in any way’, and on that occasion it did open some conversation, without (I hope) appearing too dogmatic.

If something arouses feelings such that you don’t think you will be able to discuss it rationally, it is better to stay away. At least for abortion, the conscience clause in the 1967 Abortion Act has always been clearly held to protect medical students who do not wish to observe or participate in abortion.

Eventually, many of us will be the main decision maker — in fact sooner than you think. It is much easier to work in line with your conscience if you are clear, knowing what you cannot in good conscience do. Dilemmas are rarely all that clear cut in ‘real life’, and if not thought through first, the line of least resistance is often the easiest course. So, take time now to read around the common issues. Currently, that means beginning and end of life issues, and resource allocation. But be aware that the challenges may change during your career. Puberty blockers in children with gender dysphoria are a big question currently; I don’t remember a single mention of this as a student or junior doctor.

Occasional curveballs will still arrive. We can still prepare through a good underlying knowledge of God’s Word, and living for him so that our minds are renewed, and we discern his will (Romans 12:1-2). The more deeply ingrained the principles of God’s kingdom, the better we’ll be able to decide how these principles apply in an unforeseen and complex situation.

Laurence Crutchlow is CMF Associate Head of Student Ministries and a GP in London
Rick Thomas is CMF Public Policy Researcher