The publication before you marks a transition for Dignitas in several ways. Not only does it usher in yet another year, but it will also be the last of the combined issues; the 2023 publication year will return to our regular quarterly publication cycle. In addition, Dignitas is shifting to themed editions. As a Center, we want to address bioethical topics on the forefront of societal change with core truths of the Christian faith. Thus, the themes chosen for this upcoming year represent either a rising concern within the domain of bioethics or an exploration of ideas necessary for groundwork as these issues continue to evolve. Because we see it as important to continue publishing sound scholarly work that may not fit one of these themes, space will be given in each publication for articles outside of the topic, and the final issue of the year will remain open. Thus, the themes for 2023 will be as follows:
This issue of Dignitas deals with matters of healthcare and conscience, and it includes a primer piece for our 30th annual conference on The Christian Stake in Bioethics Revisited: Crucial Issues of Yesterday, Today, and Tomorrow (June 22–24, 2023). In addition, Bryan Just has eloquently summarized key ideas from our 2022 annual conference. Heather Zeiger provides the last of the Covid Timelines for Dignitas as the 2023 publication will shift to matters of global health.
Joseph Dunne explores the question of why it is wrong to violate one’s conscience, suggesting that many of the arguments typically used are based on subjective assertions that can just as easily be used to support superfluous or nefarious conscience-based decisions. He thus critiques arguments that support acting in accordance with one’s conscience based on the notion that it is (a) identity conferring, (b) integrity maintaining, or (c) to act against it would pose a volitional impossibility. Opining instead that any argument we use to support obeying one’s conscience must be able to override reasons not to obey it, he asserts that we must find an all-things-considered reason to obey.
Utilizing Richard Sorabji’s work, Dunne defines conscience as the source of our beliefs regarding those actions and attitudes that may be wrong or not wrong, using our individual concept of morality to apply value beliefs to everyday decision making. This means that conscience is value neutral in that it is able to hold all beliefs pertaining to an individual’s moral perception, making it void of a universal morality and also fallible.
With this definition in hand, he tackles the first of what he considers to be subjective reasons for adhering to one’s own conscience. Some would argue that to act in a way that betrays what characterizes one’s individuality would be morally problematic. Under such a conception, one’s own personal morality plays an important part in setting him or her apart in society and therefore confers identity. However, Dunne suggests that the identity-conference argument is not able to override reasons to disobey conscience. Second, he tackles the position that listening to one’s conscience is essential due to the need to remain internally consistent and integrous. Third, and finally, Dunne critiques the admission that adherence to one’s conscience is necessary due to the psychologically catastrophic nature of working in opposition to one’s determined aversions, a volitional impossibility with embodied consequences.
Dunne concludes his essay by demonstrating that even the combination of these three subjective reasons for obeying conscience could be employed both in support of a physician who is conscientiously opposed to performing an abortion and a physician who is conscientiously compelled to do so. Thus, one must employ some type of objective, all-things-considered reason to obey one’s conscience in order to determine that one of the physicians has greater moral responsibility to obey her conscience than the other.
Andrew Kubick similarly explores conscience, specifically as it pertains to positive claims of conscience—the ability to commit an act one deems to be good—that conflict with the institutional identity of a governing healthcare organization. Natural law is central to Kubick’s understanding of conscience. Through natural law, all of humanity has been given an impulse to do good, seek truth, and preserve human life, along with passing on these values to the next generation.
Building off of this, Kubick states that there are two distinct intellectual activities involved in responding to natural law: synderesis and conscience. Synderesis is the act of habitually listening to that moral voice, conscience its application to a specific moral dilemma. Citing St. Thomas Aquinas, he states that while synderesis cannot err, one can erroneously apply that moral voice—conscience can be wrong. This occurs not only because of corruption in values, but also merely through ignorance. Delineating three kinds of ignorance, each with carrying levels of moral culpability, he ultimately concludes that ignorance cannot be an excuse to disobey natural law.
Shifting specifically to positive claims of conscience, Kubick asserts that while a man is constrained to avoid evil, circumstances may reasonably keep him from committing an act he thinks to be good. Thus, while there should be much space given for people to act in accordance with what their conscience determines to be good, it is reasonable for a healthcare organization to reject some positive claims of conscience. This he evidences specifically within the Catholic healthcare system, showing how certain ethical commitments are what form institutional identity. As healthcare providers commit to work in that specific hospital system, they bind themselves to the guidelines which form such an identity. Thus, individual positive claims of conscience must be examined in light of larger institutional commitments.
The final piece in this issue is a re-publication from the early days of Dignitas. The late Edmund Pellegrino, writing nearly 20 years ago, highlights a shift in medicine from healing to enhancement. Defining enhancement as those procedures that seek “to increase, intensify, raise up, exalt, heighten, or magnify,” he calls this movement “the end of medicine.” Advances in biotechnology have caused this societal shift; however, Pellegrino does not relegate all biotechnologies to the realm of societal evils. He states that, as physicians navigate this new biotechnological world, they will need to discern between those procedures that (a) treat diseases, (b) meet the desire of patients to perfect some bodily or mental trait, and (c) redesign humanity both now and in the future. The author unequivocally affirms the use of these technologies in treating disease, stating that it honors the doctor’s unchanging purpose to heal. Still, ethical questions remain. For instance, even for therapeutic purposes, he rejects those procedures that require the destruction or distortion of human life.
Pellegrino further clarifies his position, recognizing that even some therapies can be seen as enhancing human life in the sense that a disease has been cured and a person’s life has inevitably become better. Yet these do not go beyond the natural ends of medicine. He contrasts this kind of enhancement with that of a woman who has no sickness, disease, or injury; she merely is discontented with her social lot in life based on whatever physical or mental “defect” she deems to be unsatisfactory. She therefore desires a procedure to help her fit or even surpass what she perceives to be societal standards.
Pellegrino points to greater moral ambiguity when it comes to things like ensuring healthy and bright children, yet still questions the means that are used to bring about such a result. Noting the existence within this shift of those who seek to define “patient” as anyone unhappy, he warns of grave consequences, not only for the world of medicine but for society as a whole. Yet an affirming contingent is growing, and the rejection of enhancement will inevitably meet great resistance as the seemingly insatiable need to satisfy all desires deepens in society. He suggests it may even lead to physicians being forced to perform enhancement procedures, seeing it within the responsibilities of the doctor to meet such “needs.” Other physicians may themselves become convinced that it is the best good to perform such procedures.
This transition also poses new conflicts of interest. Where there is demand, there will inevitably be transactions, and Pellegrino worries that the thirst for advancement may cause the less integrous physician to perform unethical or dubious procedures merely for the monetary benefits. In conclusion, Pellegrino opines that a rush towards enhancement may distort our understanding of what it means to be human and shift societal focus from ethical interrogation to regulation and efficiency, with patient autonomy becoming the greatest good in medicine.
Undoubtedly, many with modern eyes will read Pellegrino’s warning 20 years ago and see the fulfillment of some of his predictions. Indeed, the thirst for happiness only intensifies, patient autonomy has become primary, and physicians are increasingly pressured to give in to patient demands. His admonitions for the future display the necessity for core truths that can help gauge the ethicality of recent moves. This is the reason behind our asking questions like, “What does it mean to be human?” and “What is distinctively Christian bioethics?” Furthermore, it displays the purpose for choosing a conference theme of The Christian Stake in Bioethics Revisited: Crucial issues of Yesterday, Today and Tomorrow. With so much having changed within the world of bioethics, even within the realm of medicine as a whole, it is important that we continuously reevaluate what the Christian stake in bioethics is and that we remain committed to ethical interrogation, heeding Pellegrino’s reprimand of slipping too far down the road of mere regulation and practicality.
Anna Vollema and Matthew Eppinette, “Editorial (Fall-Winter 2022),” Dignitas 29, no. 3–4 (2022): 1–2, www.cbhd.org/dignitas-articles/editorial-fall-winter-2022.
