Polarized society is asking if clinicians should still get conscience protection, says bioethicist

December 1, 2023

Until recently there had been general agreement in the U.S. that clinicians could follow their conscience when it came to whether they provided certain health care services to patients, Catholic bioethicist John Hardt says. However, he sees a shift in public opinion happening, with more people believing services should be provided regardless of whether doing so violates clinicians' consciences.


Speaking in October during a CHA webinar, "Thinking About Conscience in a Divisive Time: Catholic Health Care, The Ends of Medicine, Moral Integrity and the Common Good," Hardt said this opinion trend could have a growing impact on clinicians' ability to act on their moral convictions and the ministry's ability to practice in line with Catholic teaching.

Hardt said "there is a tribal environment now" in which some people cannot tolerate those they disagree with — they see people with beliefs that differ from their own as bad. Such thinking causes many people to oppose the use of certain conscience protections by clinicians, he said.

Hardt is associate professor of bioethics and vice dean of professional formation for Stritch School of Medicine at Loyola University Chicago.

Acting morally
Hardt began the webinar by explaining that conscience has to do with the belief that people should act morally and that people can and should judge whether and how certain actions will affect their integrity. Hardt said conscience "unifies us as moral persons," since all people are striving to act in harmony with their own understanding and beliefs. He noted that Catholic tradition holds that Catholics have an obligation to form their consciences properly, including by drawing upon the moral teachings and traditions of the church.

Since a person's conscience and moral judgments can be based on missing or misunderstood information, Hardt said those beliefs can be wrong. Therefore, he said, a proper understanding and application of conscience requires a moral humility, or acknowledgment that one's beliefs could be incorrect.

He noted that institutions may have a conscience — they may profess a set of moral commitments, they may make moral judgments and they will be critiqued by others accordingly. He explained that the Catholic health ministry makes moral commitments including in the form of the Ethical and Religious Directives for Catholic Health Care Services.

Tolerating disagreement
Hardt said that since conscience is imperfect and individually developed, disagreements will arise when different people or different groups are applying their moral beliefs to a topic.

Tolerance is necessary to accommodate these competing viewpoints, he said. But he contended that tolerance is diminishing in the U.S. today.

He said that in the current cultural moment, issues like abortion and health care services for people in the LGBTQ+ community are hotly contested and there are some people who come to hate those they disagree with. He said it's important to recognize "we can disagree and still love one another."

Compelling action
Hardt said the key question that arises around such contested topics, when it comes to the medical field, concerns whether clinicians are obligated to provide health care services that are legally sanctioned but that they oppose on moral grounds.

He said in his view society should exhaust all other avenues before it resorts to compelling clinicians and health care facilities to provide services they oppose. He said that is because medicine is a complex system requiring complex knowledge and expertise, and there must be space in such a system for providers to use their discretion and to make values-based judgments.

Hardt said that to evaluate the validity of conscience protections, one must come to an understanding of what medicine should be: Is it merely a service industry that must fulfill patient wishes, whatever they may be? Or is it based on the application of clinician knowledge and judgment to determine the best approach for the patient's well-being?

He said many moral questions surround the concept of medicine as a service industry including when it comes to the prescription of growth hormone for normally statured children, the use of the stimulant Ritalin to improve kids' performance on tests in school, the use of hormonal therapy for youth who are questioning their gender identity, the use of abortion for sex selection, the use of euthanasia for the dying and the use of elective surgery for solely cosmetic purposes.

Providing alternatives
He noted that many considerations are at play as society draws the boundaries of conscience protection. For instance, when clinicians invoke conscience protection, are they doing so in a selective and discriminatory way? Are they doing so to avoid being complicit in behavior they deem to be morally wrong? What is the level of harm if they do not provide the service? To what degree does the clinician's refusal to provide a service amount to total service denial, due to a patient's geographic or financial limitations?

Hardt said it is important for society to ask what other alternatives could be used, to avoid compelling clinicians to provide services that go against their convictions. He said it is incumbent upon government agencies to ensure there are other ways for individuals to get the health care services they need — outside of forcing physicians to violate their consciences.

He said that these areas of contention are becoming increasingly challenging for society to navigate. "There is no easy way forward, and especially if we are not willing to engage in dialogue," Hardt said. "We have to agree to disagree while figuring out how to meet the needs."


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