Bryan Pilkington

In this paper, I consider the role of conscience in medical practice. If the conscientious practice of individual practitioners cannot be defended or is incoherent or unreasonable on its own merits, then there is little reason to support conscience protection and to argue about its place in the current medical landscape. If this is the case, conscience protection should be abandoned. To the contrary, I argue that conscience protection should not be abandoned. My argument takes the form of an analysis of an essential feature of the conscience dissenter’s argument, the role of disagreement within “the medical profession.” Conscience dissenters make certain assumptions within their arguments about the profession, disagreements within the professions, and how such disagreement should be adjudicated. If it is the case that these assumptions are accurate reflections of the current medical landscape, then the advocate of conscience protection has one less leg to stand on. I aim to show that this is not the case and that the assumptions of the conscience dissenter are not only mistaken but are mistakes of significant magnitude, so significant as to raise serious questions about the merit of their position. If the argument in this paper is sound, then, at the very least, the conversation over conscience protection in medicine, in particular, and health care, in general, must continue.

The proper role of conscience in healthcare continues to be a topic of deep interest for bioethicists, healthcare professionals, and health policy experts. This issue of HEC Forum brings together a collection of articles about features of these ongoing discussions of conscience, advancing the conversations about conscience in healthcare from a variety of perspectives and on a variety of fronts. Some articles in this issue take up particularly challenging cases of conscientious objection in practice, such as Fleming, Frith, and Ramsayer’s contextually rich piece on midwives in Scotland or Harter’s professionally grounded analysis; others engage the changing institutional landscapes which impact considerations of conscience, such as Cummins’ work on the role of employers in institutional policies about conscience and Ben Moshe’s discussion of publicity and institutional committees. Pieces by Howard and Pilkington both raise conceptual considerations about how we think about the role of conscience in medicine, questioning the use of “conscientious objection” in these discussions, and Byrnes pushes back on the most influential work in this area by Mark Wicclair. The issue concludes with a piece by Wicclair, which engages each of these distinct offerings, further extending the discussions of conscience in healthcare and helpfully connecting key themes discussed by authors in this issue to his contributions and to the longer tradition of discussions of conscience in medicine. This issue challenges readers to engage different arguments from different perspectives and asks them—in some cases—to be open to revising how they think about the role of conscience and the existence of and justification for conscientious objection in the dynamic, interdisciplinary fields of healthcare.

In this paper, I argue that distinctions between traditional and contemporary accounts of conscience protections, such as the account offered by Aulisio and Arora, fail. These accounts fail because they require an impoverished conception of our moral lives. This failure is due to unnoticed assumptions about the distinction between the traditional and contemporary articulations of conscience protection. My argument proceeds as follows: First, I highlight crucial assumptions in Aulisio and Arora’s argument. Next, I argue that respecting maximal play in values, though a fine goal in our liberal democratic society, raises a key issue in exactly the situations that matter in these cases. Finally, I argue that too much weight is given to a too narrow conception of values. There are differences between appeals to conscience that are appropriately categorized as traditional or contemporary, and a way to make sense of conscience in the contemporary medical landscape is needed. However, the normative implications drawn by Aulisio and Arora do not follow from this distinction without much further argument. I conclude that their paper is a helpful illustration the complexity of this issue and of a common view about conscience, but insofar as their view fails to account for the richness of our moral life, they fail to resolve the issue at hand.

In this article, I argue that there is a moral difference between deactivating an implantable cardioverter defibrillator and turning off a cardiac pacemaker. It is, at least in most cases, morally permissible to deactivate an ICD. It is not, at least in most cases, morally permissible to turn off a pacemaker in a fully or significantly pacemaker-dependent patient. After describing the relevant medical technologies—pacemakers and ICDs—I continue with contrasting perspectives on the issue of deactivation from practitioners involved with these devices: physicians, nurses, and allied professionals. Next, I offer a few possible analyses of the situation, relying on recent work in medical ethics. Considerations of intention, responsibility, and replacement support my distinguishing between ICDs and CPs. I conclude by recommending a change in policy of one of the leading cardiac societies.

Understanding what sorts of things one might be responsible for is an important component of understanding what one should do in situations where the administration of artificial hydration and nutrition are required to sustain the life of a patient. Relying on work done in the philosophy of action and on moral responsibility, I consider the implications of omitting the administration of artificial hydration and nutrition and instances in which the omitting agent would and would not be responsible for the death of the patient. I am primarily interested in arguing against those who wish to seat responsibility for the death of a patient in an underlying pathology, even when the underlying pathology is not the cause of the patient’s death