In Good Conscience
On Committing, Considering, Conversing, Choosing
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Here’s a confession.
Much of my schooling happened because I was told I had to do it. Even once I got to medical school, I studied because I had to, so I would do well on the exams. I had a vague idea of wanting to help people, but I couldn’t appreciate early in my training what that really meant for a physician. I was buoyed along the turbulent waters of medical school by doing what I was told.
This continued into my internship. Finally, physician-hood! It was time to dispense with the naive worship of test scores. I could order things like Tylenol and potassium for goodness sake. So, sure, I cared that my patients got better and stayed healthy, but this ideal skulked about in the shadow of my attending’s approval. That became the new “right answer.”
In that shadow, patients became MacGuffins. They provided the occasion upon which I would succeed or fail as an intern. Reading this, you might exclaim, “That’s no way to practice medicine, and don’t you come near me if I’m sick.” And in response to your exclamation, I can only offer my suspicion that this affliction is born by more clinicians than we care to imagine. Efficiency, like Wormtongue, whispers in many a young clinician’s ear and ever directs their work. Caring for people, for one reason or another, always falls into second (or third, or fourth…) place.
Somewhere along the way, I changed. I could claim, if I were being dishonest, that the demands of medical training kept an always-latent compassion squashed within me. Once the day-to-day skills were honed into habit, my more caring, humanistic impulses mustered forth.
I don’t think that’s what happened.
Repeated exposure to human suffering, along with the birth of my children and the steadfast attention of my wife and church, jostled me out of the unsustainable, meritocratic way of life I’ve described. It didn’t start with any kind of insight. It started with a feeling, like I was wearing the wrong size shoes but didn’t realize it at first. After a while, though, you sit down and start thinking about why you have so much trouble walking. Every day invites me to be a real person for these people, and many days I fail to some extent. But there’s a cache of something waiting that short-circuits all my designs: grace.
I guess that’s life. No one is perfect, me especially. I use “perfect” in the classical sense, referring to wholeness. None of us are entirely whole. And I say “me especially” not because I’m less whole than you - though perhaps I am - but because I’m acquainted with my needs in ways I’m not acquainted with yours. Anyway, you notice something, you learn something, you grow. Or not. It’s possible I could have just performed as a physician, performed as a father, performed as a husband. But then the insight comes: I don’t want to act out my life. I want to live my life.
And to live one needs a conscience.
What’s a Conscience?
Drummond and I stared at one another. In any given session during my training in psychiatry, words built walls. These walls go by various names - a holding environment, a therapeutic container, a boundary. A patient and I are meant to labor together in building them so we’ll both find ourselves inside this house of healing. But sometimes I would discover we’re on opposite sides of a wall I had built alone.
“I want to help you, and I’m not going to set you up to fail. We’ll figure out something else.”
Conversations about benzodiazepine prescribing sometimes end this way. Other clinicians had started them, and Drummond’s anxiety and substance use disorders hadn’t improved, so I offered to taper them over the coming months. Drummond grumbled and left.
The leap from scientific evidence to medical decision requires something ineffable called “clinical judgment.” This nebulous faculty weighs not just the relevant science, but also a clinician’s past experiences, the unique physiology of their patient, their patient’s goals and values, and other relevant factors (e.g., social circumstances).
How does this thing actually work? How does a clinician decide whether they should offer something, and among the offerings what they’ll recommend? How does a clinician make or rule-out a diagnosis when the likelihood is usually neither 100% nor 0%? How does a clinician know when to ask questions, when to make statements, when to shoot the breeze, and when to remain silent? How does a clinician know when to ask about a patient’s sick spouse and when to hurry a patient along their third story about the grandchildren?
Well, I don’t know. But I want to become better acquainted with something that helps us chart a course through the waters of the clinical encounter in fair weather and foul. What others call clinical judgment I call conscience.
Does that remind you of Jiminy Cricket? Or maybe it smacks of intuition, the likes of which we should continue to shave out of the clinical encounter? Many other folks will be familiar with “conscientious objection.” But it seems to me conscience is neither an insect, a gut feeling, nor a line in the sand. It’s a faculty of reasoning. It is the thing that helps us render clinical judgment.
If we can appreciate what the conscience is, we might have more reasonable conversations about what we’re supposed to do with it. Consider Shannon Vallor’s description of a seven-sided perspective on moral formation. Conscience might be the thing that guides someone through these, helping them to reinforce each other and sustain continuity in the whole project. Conscience would then provide a thread of agency throughout the whole endeavor of the moral life:
Moral habituation
Relational understanding
Reflective self-examination
Intentional self-direction of moral development
Perceptual attention to moral salience
Prudential judgment
Appropriate extension of moral concern
Just like body parts are morally neutral, so, too, is conscience. But just like body parts, the conscience can be under-developed. Weak legs might mean I struggle to climb a mountain. A weak conscience might mean I struggle to see (let alone climb) the metaphorical mountain representing the relationships, identities, histories, and contexts upon which I’m cast. I might pick up a penny’s worth of wisdom here and there, but I’ll be wealthier if I have a better developed conscience to guide me.
But the conscience isn’t just all cognition. Someone might be a conscientious fool. I’ve felt this way sometimes, as you may have gathered from my confession. I was very conscientious, but my priorities were upside-down. Having a sensitive conscience is no fail-safe against making the wrong decision, against ignorance, or against falling prey to vice (but suffering the burden of guilt all the while).1
The conscience is the faculty through which I attend to the moral landscape around me, but it needs accurate information about that world to make sound judgments. Knowing what one can do is a prerequisite to knowing what one should do. Toni Saad makes this observation:
“The moral and technical are distinguishable but inseparable because every clinical judgement is one moral act. … A clinical judgement assumes that good should be done to the patient; any technical considerations serve this ethical goal and are secondary to it. Hence, a clinical judgement cannot be purely technical. We may speak of purely technical considerations when we are discussing, say, the efficacy of a drug in a clinical trial, but as soon as we wish to make a clinical decision about prescribing the drug to a given patient, we are in the realm of morality.”
This is how confused I was early in my training. It may be the case that medical training is a test of one’s abilities, and all the various postures of being a student are relevant (lamenting and celebrating one’s grades chief among them). But part of medical training also involves prioritizing it in service to a greater purpose than accolades or knowledge itself. That greater purpose is to care for other people. I had it backwards, wishing instead that the care of patients would serve my good evaluation at the end of a rotation. My conscience was finely tuned to the classroom, but needed orientation on the high seas of the hospital and clinic.
I Object!
Most people are probably familiar with the idea of conscience by way of this thing called conscientious objection. In its simplest form, it’s a mechanism by which a profession respects someone’s choice to not do something - e.g., participate in abortion, assisted suicide/euthanasia, etc. There’s plenty of storm and stress about this, but I want to double click on just two ideas.
First, groups don’t have consciences. Nevertheless, individuals with their own consciences can shape the deliberations and actions of the group. The history of medicine and science is riven with abuse, even abuse condoned by the highest authorities and institutions, and the fields need some way to humbly acknowledge that objecting individuals might steer things in a better direction. Xavier Symons writes:
“Conscience, it could be said, acts as a check on professional consensus and the law, as the latter sometimes does not provide sound guide for ethical conduct. In America in the late nineteenth and early twentieth centuries, for example, there were a small number of clinicians who, in addition to religious leaders and politicians, spoke out about eugenic practices such as forced sterilization and other forms of birth control. This resistance - in addition to other factors such as the horrors of WWII Nazi eugenics - contributed to the American Medical Associations’ gradual change of position on eugenic policies and practices.”
Kim et al. make a similar observation and then argue that, because of this, we should permit conscientious objection when the nature of medicine is at stake:
“…the medical profession must be designed in such a way that moral self-correction remains possible. For the profession to be correcting, it must acknowledge that its current norms are defeasible. For the profession to be self-correcting, it must accommodate [nature of medicine conscientious objections]. To be the product of self-correction, medicine’s moral reform must arise intra-professionally: doctors qua doctors must be able to express and implement their shareable vision of what any doctor qua doctor ought to do or ought not to do. … Forced compliance with de facto norms and the ejection of those who are unwilling to so comply interfere with moral self-correction of the profession by its members. Clamping down eliminates the possibility of reform.”
By honoring a place for clinicians to object to certain interventions, the profession acknowledges the conscience is critical to the practice of medicine.
So what about conscientious provision?
The term only has relevance when the service in question is outlawed. For example, some American states have outlawed abortion in certain circumstances, but some clinicians there feel conscience-bound to continue providing the service. Conscience is important here too, but how we think about it is different based on practical implications.
Conscientious objection isn’t explicitly illegal, whereas by its very nature conscientious provision is. Most jurisdictions allow for conscientious objection, but just think about it: how would law work if it allowed people to opt out based on conscience? Someone might believe a law is unjust, but until it changes, the law is (officially, if not really) the manifested will of society. Regarding conscientious objection, Udo Schuklenk and Ricardo Smalling argue:
“What we are denying is that professionals are entitled to subvert the objectives of the professions they voluntarily joined by prioritising their private beliefs over the professional delivery of services to the public, especially when they are monopoly purveyors of these services. … Anyone joining a profession knows, or should know, that it is ultimately up to society to determine the scope of professional practice.”
If it is indeed the case that society determines the scope of professional practice (in this case, by law), then conscientious provision would be out of bounds along with conscientious objection. Clinicians in states where abortion is illegal should follow the law. But if there’s something more to this conscience thing, then we need to be a bit more careful about how we think about this.
I disagree with Schuklenk and Smelling on a number of points, but most directly in that I don’t think society has the capacity to act with any degree of nuance in dictating the scope of a profession’s practice without risking harm to the mission of that profession. This is why professions often self-regulate. Nevertheless, law sets up some general boundaries and those who wish to provide an illegal service do so at their own peril.
This is the hard work of the profession to negotiate among the traditions it has inherited, the innovations it now wields, the many beliefs of its members, and broader society with its opinions and laws. There is no “system so perfect no one will need to be good,” as T.S. Eliot poetically warned. We’re left facing people with whom we disagree, each of us with our words, actions, and consciences.
This brings me to the second idea I want to emphasize. It must be the case that one can only object to the practice of certain interventions, not the care of certain patients. For those who object to caring for certain types of people, the problem isn’t with what you’ll do, but who you’ll do it for. The profession, as understood by itself and by society, makes no allowance for that prejudice. Jack’s conscience might affirm his racist beliefs, but the profession won’t support him.
Squashing Crickets
The hope, springing eternal, to scrub the clinical encounter of human fingerprints and replace clinicians with the calculations of a machine suggests we can eventually dispense with the idiosyncratic conscience. But for as long we’ll have human clinicians, we want to preserve and foster human consciences. It might be an over-statement, but not by much, that without conscience, you can’t have human community. Without conscience, you have no agency.
This would satisfy the whims of bureaucracy. As I’ve written about before, the bureaucracy of medicine, with all its techniques bent toward efficiency, would very much prefer to look on the clinical encounter as one primarily, or only, of technical considerations. Farr Curlin and Jacob Blythe observe:
“Technological production calls for a scientific organization of knowledge and assumes a hierarchy of experts. Its style of work is mechanistic, reproducible, measurable, and dependent upon a sequence of production in a large organization.
…
They do not see the practitioner as a particular moral agent working to discern the ethical way forward in complex and particular circumstances. Rather, they dissolve the clinician into the means to various desired medical ends.”
What need is there for conscience in such a world? Dispense with it, because it’s worse than useless. It hinders the aspirations of technology. It blemishes their hopes. Machine medicine, lacking conscience, pleases almost everyone because we want to reduce the distance between desire and its realization. A conscientious clinician (or scientist) may stand in the way of that, if they’re going to question the goodness of an innovation, or ask us to slow down and think.
I’m not sure we really want this machine medicine though. Of course I care about accurate diagnoses, effective therapeutics, and helpful prognoses. Technologies can be useful tools in service to each of these clinical tasks. But we also want, as Anatole Broyard opined, something more:
“I see no reason or need for my doctor to love me - nor would I expect him to suffer with me. I wouldn’t demand alot of my doctor’s time: I just wish he would brood on my situation for perhaps five minutes, that he would give me his whole mind just once, be bonded with me for a brief space, survey my soul as well as my flesh, to get at my illness, for each man is ill in his own way.”
The blinking cursor, the black mirror of a monitor, even the artificial warmth of a simulated voice cannot replace the brooding, concerned, conscientious attention of another person.
So why can’t we have both? I hope we can. Consciences aren’t themselves little machines though. A conscience suitable for the clinical encounter is formed by more than lectures, flashcards, and multiple choice tests. What are ways of tending to the consciences of clinicians - whether in training or beyond? It might start with at least setting aside the space and time to allow for reflection on one’s work, with a thoughtful person to guide those reflections. I could have used more of that during training.
Could we dedicate at least as much time to this as we do to learning about sodium homeostasis?
Kichijiro, from Silence by Shūsaku Endō, is a tragic example of this latter case. He frequently repents of his betrayals only to commit them again and again.