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Group 5. Claud. Eian. Helaine. Jill. Marj. Sheen. MEDICAL ETHICS | 1

Lecture 5: Conscience

July 9, 2010 Medical EthicsDr. E.T. Acevedo, MD, MPH, MPA

STANDARDS OF MORALITY o Just as in human acts, some norms or standards of acting are

followed, the same can be said with regard to the moral behavior

of people. Norms of moral actions are highly necessary if peoplehave to live in peace, order and harmony.

o Two norms or standards of moral or ethical actions recognized

and understood in Bioethics:

1. Natural Law

2. Conscience

CONSCIENCE

o The subjective norm of morality, therefore, maybe erratic and

prone to miscalculations.

o Resides in the human intellect which is imperfect and therefore

prone to errors.

o Nevertheless, as judgment of the intellect, it makes declaration of

truth or untruth, goodness or badness about the actions he wants

to pursue, or about thoughts he wants to believe.o Definitions of Conscience:

(Greek word “suneidesis” - Democritus)

Later translated “conscientia” - Cicero)

Comes from two Latin terms: Con and science - “with knowledge”

1. Conscience is the meeting point of the MORAL LAW,

objectively and universally valid and the INDIVIDUAL

PERSONALITY.

2. A judgment of reason whereby the human person recognizes

the moral quality of a concrete act that he is going to

perform, is in the process of performing, or has already

completed performing.

3. Refers to the inner sense of right and wrong in moral choices,

as well as to the satisfaction that follows action regardedas right and the dissatisfaction and remorse

resulting from conduct that is considered wrong.

4. The CAPACITY TO MAKE PRACTICAL JUDGMENT in matters

involving ETHICAL ISSUES. The capacity cannot be delegated

to anyone else nor to any institution.5. Theological meaning: The process in which the general norms

of the moral law are applied to a concrete action which a

person is about to perform or has performed, telling the

person what his obligation is here and now or judging his

past acts.

6. St. Augustine and the Franciscan School: The place of the

innermost encounter between God and man

, and therefore the

voice of God. The person’s most secret core and sanctuary.

The spark of the soul; the peak of the soul.

7. An ultimate practical judgment on the morality of a concrete

action, commanding to do what is good and to avoid what is

evil.

8. Second Vatican Council: the most secret core and sanctuary of

the human person.

9. Present at the heart of the person, enjoins him at the

appropriate moment to do good and to avoid evil. It alsojudges particular choices, approving those that are good

and denouncing those that are evil. When man listens

to his conscience, the prudent man can hear God

speaking.

o Conscience evaluate the quality of the Human acton whether it is

desirable or undesirable.

Question: Should a man follow his conscience, be it right or

wrong?

1. It is right to practice contraception knowing that another

child will add more burdens to an already impoverished

family.2. It is not right to pay for donated organs, but I need one for

my survival. Thus, I might as well compensate the donor with

high financial reward and not shortchange him.

3. I need to perform surgery on the mother who attempted

abortion to remove the fetus. But, if I help her, she might be

doing it over again and I might be accused of cooperation in

an evil act. I might just as well send her to another hospital

that does it.

FOLLOW ONE’S CONSCIENCE

o St. Thomas Aquinas:

“Every conscience, whether right or erroneous, whether with

regard to acts which are evil in themselves or acts which are

indifferent, is obligatory, so that he who acts against his

conscience does wrong.o How do we follow our Conscience?

1. To follow one’s conscience is to follow the law.

Limitations:

Legality does not always mean morality.

Legalizing abortion

2. To follow one’s conscience is to follow one’s cultural beliefs.

Limitations: When people become more aware of equality rights.

Jehovah’s Witness - against blood transfusion

Muslim women – death punishment for commission of

adultery.

3. To follow one’s conscience is to follow one’s feelings.

Argument: Feelings belong to the domain of emotions or

passions. They are erratic and can change depending on how the

swing of moods presents itself to the person. Hence, judgment

based on feelings is highly unstable and can hardly be relied

upon.

4. To follow one’s conscience is to follow one’s religious beliefs.

The language of God is always love and peace. But the language

of those who kill in the name of God is hatred and violence.

Thus religious beliefs can be distorted by man due to his

concupiscence, greed and pride.

PRINCIPLE OF A WELL-FORMED CONSCIENCE (INFORMEDCONSCIENCE)

o This principle states that:

“To have a good judgment of conscience, one is obliged to form it

diligently in accordance with some reasonable processes so that one

arrives at a right moral decision.”

o Conscience judges a concrete act as good or evil in accord with a norm

of morality given to it. This norm is NATURAL LAW.

o Well-formed Conscience:

To attain the true goals of human life by responsible actions, in every

free decision involving an ethical question, one is morally obliged to

do the following:

1. Inform himself as fully as practically possible about the facts and

the ethical norms. Knowledge of the Ethical principles is

necessary.

2. Form a morally certain judgment of conscience on the basis of

this information3. Act according to this well-formed conscience;

4. Accept responsibility for his actions.o Thus, t o follow one’s conscience properly is to follow one’s well -formed

conscience .o Morality always involves a choice in arriving at a moral decision:

1. There are many alternative means to a goal, some of which are

clearly in-appropriate, but often many are appropriate, each with

its advantages and disadvantages;2. It is possible for people to reconsider their goals and to redefine

or even alter them in view of some higher goal.

Man has the right to act in conscience and in freedom so as

personally to make moral decisions. He must not be forced to act

contrary to his conscience, nor must be prevented from acting

according to his conscience.

EDUCATION OF CONSCIENCE

o

The education of conscience is indispensable for human beings whoare subjected to negative influences and tempted by sin to prefer their

own judgment. The education of conscience is a LIFE-LONG TASK. From

the earliest years, it awakens the child to the knowledge and practice

on the interior law recognized by conscience. Prudent education

teaches virtue; it prevents or cures fear, selfishness, and pride,

resentment arising from guilt, and feelings of complacency, born of

human weakness and faults. The education of conscience guarantees

freedom and engenders peace of heart.

o An informed conscience needs knowledge of the facts and of the law, but

it also requires a disciplined or virtuous affection for what will truly

satisfy our needs in an integral manner. o

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DIVISIONS OF CONSCIENCE

A. LEVELS OF CONSCIENCE:

1. Antecedent - judgment on the morality of an action and the

obligation to perform or omit it is passed before the action is

translated into reality . - Commands, exhorts, permits, or forbids.2. Concomitant - refers to the actual awareness of being morally

responsible for the goodness or the badness of a particular act which

we are carrying out.

3. Consequent - if it evaluates a deed already done or omitted . -

approves, excuses, reproves, or accuses.

B. QUALITIES WHICH REFER TO FREEDOM

1. Free - one is able to assume a personal moral stand with regard to a

particular action in a way that is unhindered, in order to answer

for that particular action or attitude.

2. Unfree - One’s moral at titude or responsibility for a particular action

is hindered by some obstacles such as fear or anger.

C. QUALITIES WHICH REFER TO OBJECTIVE VALUE:

1. Right - agrees with the objective norms of morality. It judges

conscience as morally right or wrong, in accordance with fact, that is, when it judges as good that which is really good and as evil that

which is really evil. What is morally good, however, must not

necessarily be morally right, and vice versa.

2. Erroneous - conscience that is not true. There is lack of conformity

between the objective values and the moral demands that go with

them and one’s subjective moral perceptions, discernment, dictates,

and decisions in the habitual or actual levels of conscience. Either

vincibly or invincibly.

a. Vincibly erroneous - erroneous through the agent’s fault. This is

culpable, because with some good will its error could be

corrected. This cannot be followed as a legitimate rule of action. insufficient grounds, to judge a thing slightly evil, when actually it is gravely evil; to be lawful, while in fact it is unlawful & sinful;

This is considered as vincibly erroneous.

b. Invincibly erroneous - erroneous without the knowledge or fault of the agent. Inculpable, since the person has no awareness of the

possibility of error.

The invincibly erroneous conscience must be followed just

the same as a certain consciencewhich is right.

D. QUALITIES WHICH REFER TO MORAL ATTITUDE:

1. Lax conscience or dulled conscience – is inclined, on

Compensatory conscience - a variety of lax conscience which

attempts to conceal a fundamental lack of generosity in the spiritual

life which is intended to divert attention from the unwillingness to

live up to one’s true vocation.

2. Strict conscience - shows that the conscience tends to judge

obligations too harshly, especially in an excessive legalistic way.

3. Scrupulous conscience - Scrupulosity is the persistent, gnawing,

unreasonable fear that one has offended God or is about to do so.

The scrupulous person is in constant dread of sin where there is

none, or of grave sin where there is only venial sin. St. Francis

de Sales points out that scrupulosity has its source in PRIDE. It must

be avoided as in lax conscience.

4. Pharisaical conscience - akin to the compensatory Conscience which

attaches great importance to small things and makes light of serious

matters. Conscience tends to be self-righteous as far as one’s own

moral evaluation is concerned.

5. Callous conscience - the worst type of conscience because it has nosensitivity to sin, as if the person has no conscience at all.

6. Clear conscience - a conscience which confidently and freely acts

with due regard for perceiving, appreciating and internalizing true

values.

E. QUALITIES WHICH REFER TO DEGREE OF CERTITUDE:

1. Certain conscience - passes judgment without fear or error. An

absolutely certain conscience, however can still be erroneous.

a. A certain conscience must always be obeyed when it commandsor forbids. It is the competent and indispensable guide given to

man to discern his vocation and moral obligation. Therefore to

disobey this faculty is to disobey the moral order, it is to disobey

the will of God, and this is sin.

b. The certainty required for the judgments of conscience generally

need not be a strict moral certainty, but a wide moral certainty is

sufficient.

Examples: Strict moral certainty - people will not kill arbitrarily. Wide moral certainty - physicians will act responsibly & with

competence.

2. Doubtful or Dubious - uncertain concerning the morality of an action.

The agent cannot definitely decide whether the action to be done isgood or evil. The doubt may either concern the existence of a law

and moral principle or the existence of a fact.

Example:

Legal or moral – therapeutic abortion

Factual - presence of a cancerous growth in the uterus of a

pregnant woman.

Guide for action in doubtful conscience:

1) In a practical doubt about the lawfulness of an action one may

not act.

2) The action must be postponed until certainty can be reached.

Practical certainty can be gained directly by solving the doubt

through:

a. reflection on the case in the light of the general principles

b. consultation of experts and pertinent books

c. clarification of the facts, etc.

3) If the doubt cannot be solved directly-but only then-one mayattempt to gain practical certainty indirectly by the application

of the so-called reflex principles.

4) If there is no time or possibility to solve the doubt, one must

opt for the safer alternative, that is, one must favor the

alternative which excludes the danger of sin and injustice most

certainly.o When in doubt about whether a course of action is ethical, give

benefit of the doubt to:

1) existing customs

2) established and well-known laws

3) usual way of acting

4) acceptance of what has already been done:

codes

policies

long experience

5) reflections6) survival

3. Probable conscience - When conscience is doubtful, but grounded

upon solid reasons, the agent is said to have a probable opinion.

4. Perplexed conscience - The agent is confronted with two alternative

precepts and he is afraid of choosing any of the alternatives; a type

of erroneous conscience which, in a conflict of duties, fears sin in

whatever choice it makes. Classified as an erroneous conscience,

because objectively only one of the two conflicting obligations can

be binding. It would contradict justice and the wisdom of God if man

were confronted with two equally binding obligations, of which after

all he can fulfill only one.

Example: A resident physician feels obliged by precept of the Church to

go to Sunday Mass and bound by charity to report for duty in

the hospital because of a critically sick patient, the obligation of

charity should be preferred to the obligation of theecclesiastical precept.

GUIDELINES FOR ACTION

1. Certain conscience must always be obeyed when it commands

or forbids. Certainty needs not be a strict moral certainty but a wide

moral certainty is sufficient.

2. Invincibly erroneous conscience must be followed just the

same as a certain conscience which is right.

3. The vincibly erroneous conscience, lax conscience, the

perplexed conscience and the doubtful conscience cannot be

followed as a legitimate rule of action.

o A Well-formed Conscience is one which may be antecedent,

concommittant, or consequent and one which is free, righteous, or

invincibly erroneous, clear and certain.

THE CONSCIENCE OF THE PHYSICIAN VERSUS THE CONSCIENCE OF

THE PATIENT.o In order for the patient to make a decision with an informed

conscience, the physician has to provide himself with the necessary

information. If the patient, owing to his age or condition, is unable to

judge the situation clearly, the physician has to give adequate

information to those who bear responsibility for him.o When the doctor has done his duty in discussing the prospect of

success of a certain treatment or surgical intervention he will, after

sufficient dialogue, abide by the decision of the patient or of those

persons morally and legally responsible for him.






1. If, for instance, a fully conscious adult patient refuses a blood

transfusion in accordance with the teaching of his religious sect, thedoctor will abide by the patient’s request to let him die. If such a

request is not stated explicitly, the doctor will prescribe the

transfusion in an emergency situation without questioning; he isjustified in assuming that a patient wants to be saved by the use of

such an ordinary procedure especially if such a restriction has not

been unequivocally imposed on the attending physician.

2. Case of a child or a minor:

The doctor normally does not need an explicit permission from

the family, at least for a life-saving transfusion, and can act on the

presupposition mentioned above. If, however, the family has

definitively insisted that no blood transfusion be given, the

physician will have to distinguish the moral from the legal aspect

of the problem. Whereever there is no legislation, the doctor will

also save the life of the child should it be possible. However, when

legislation stipulates that the physician must follow the dictates

of the family, he will not always be empowered to perform the

transfusion.

3. Cases when physician finds himself in disagreement with his patient

on some moral principle or its application: A particular human situation wherein the physician is convinced

that sterilization is necessary to ensure reasonable health or life

for the patient and stability for the family. The patient refuses,

because she considers sterilization absolutely immoral. Even if

there is justification in the procedure, the doctor is bound to

respect the patient’s decision.

4. The physician has the duty to give his patient proper health care

even if morally he disapproves of the life situation in which the

patient contacted the illness

Example: Patient with STD or AIDS.

5. A woman who committed criminal abortion comes to a physician for

professional assistance: Physician is duty-bound to help her. In due

time, he may refer to a matter of conscience in so far as this is part of

the healing process, or he may urge her, at the proper time, to

cooperate in denouncing the criminal so as to avoid harm to otherpersons.

6. A doctor faced with the case of a suicidal neighbor, has, in

conscience, a right or duty to save the life of his neighbor even

against the latter’s will. the high probability is that the person

contemplating suicide is unable at that moment to make a truly

personal decision. However, the help which the doctor or any friend

may offer cannot be restricted to saving the biological life; rather, all

eforts should be directed towards helping the prospective suicide to

find the sense of his life and then arrive at a responsible decision.

7. A number of Catholic theologians have supported the concept of

“freedom of choice of abortion” despite the declarations against

abortion by the Vatican. They have argued:

a. It is not always necessary or helpful to support morality by

law;

b. There is no national consensus on the question;

c. A law against abortion could not be enforced;

d. It might lead to abortion seems to be medically justified.

o What would be the proper process to inform one’s conscience on these

issues?

1. A fully conscioust patient refuses a blood transfusion in accordance

with the teaching of his religious sect.

DECISION

The doctor will abide by the patient’s request to let him die. If

such request is not stated explicitly, the doctor will prescribe the

transfusion in an emergency situation without questioning; he is

justified in assuming that a patient wants to be saved by the use

of such an ordinary procedure especially if such a restriction has

not been unequivocally imposed on the attending physician.

2. Blood transfusion in a child or a minor:

DECISIONS

Doctor normally does not need an explicit permission from the

family (considered as a life-saving procedure) If family has definitely insisted for no blood transfusion, physician

will have to distinguish the moral from the legal aspect of the

problem. Wherever there is no legislation, the doctor will save the

life of the child.

o Just as the doctor has to respect the patient’s conscience, so does the

patient incur the same obligation towards his physician.

o The patient should never request a treatment which he knows to be

against his doctor’s conscience.

o In some cases in which the physician has a well-informed and firm

conviction that a certain treatment or intervention is both immoral andharmful to the patient’s well-being, he should expose the facts clearly,

including of course the medical and ethical aspects.

CERTITUDE IN ETHICAL DECISIONS REQUIRE: o Adequate informationo Clear understanding of values

o When making personal decisions about health care, one must have the

responsibility to follow informed conscience

Example:

1. Obtain as much relevant information as possible about a situation,

both the facts and the objective moral standards (principles)

applicable to the situations:

a. learn the facts about the medical condition,

b. determine in accord with an objective value system the needs and

rights of the people involved;

2. Make and carry out a decision in accordance with this information.

o Knowledge of the factors involved, however, is not enough to make a

rational decision. This must be supported by a free will and a healthy

emotion.

QUIZ

o Ms. July A. Santos is a nurse who travelled to the USA to work in order

to help her family back home. In the hospital where she workds, she

was asked to help in an abortion procedure which was legal in US.

Now, Ms. Santos is a Catholic who does not believe in the procedure.

Her conscience dictates that cooperating in the procedure is

cooperating in the killing of the unborn child. Later, she was given

instruction that since abortion is legal, she may be committing an

illegal act by her uncooperative action and such may cost her job. This

bothered her as she may not be able to help her family back home.

1. Can Ms. Santos object to the hospital based on the dictates of her

conscience? Explain, briefly and direct to the point.

2. What can Ms. Santos conscientiously do to avoid such dilemma?

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