After two years of virtual conferences, those of us at The Center for Bioethics & Human Dignity were thrilled to return to gathering in person for Integrity and Conscience: Bioethics and the Professions! Meeting on the campus of Trinity International University from June 23–25, CBHD’s 29th annual conference was a wonderful time of reconnecting with those we had only seen online.
Ekaterina Lomperis opened the conference by addressing “Conscience as a Theological Concept.”[1] As she demonstrated, our ideas of religious freedom and rights of conscience are relatively modern developments. Early Christians often faced persecution, but they did not understand their loyalty to their faith as a matter of conscience or religious freedom. Rather, they understood standing for their faith as a core portion of their identity—to deny Christ was to deny being themselves. Even well into the Middle Ages there was no real “right to conscience;” those with different beliefs were excommunicated if not executed.
By the High Middle Ages there began a push for separating civil and religious authority, but unlike today, where the focus is on ensuring that the state does not exert undue influence on the church, the concern then was that the church (especially the papacy) was exerting undue influence on the state. It was not until the 16th century Protestant Reformation that modern conceptions of conscience rights and religious freedom began to take shape: “The record growth and spread of Protestantism throughout early modern Europe brought to the forefront practical questions of the political possibilities and limits of religious tolerance.”
A second major way that the Protestant Reformation influenced the development of conscience was through the formulation of Protestant doctrine around good works. While Catholics believed that salvation came through grace and good works together, Protestants believed in salvation by grace alone through faith alone. This led Catholics to accuse the Protestants of “abandoning virtue.” Martin Luther strove to counter this critique by developing a distinction between the inner and outer person, with the conscience as part of the inner person. Luther would subsequently develop his theology of the two kingdoms in which he would make “the first theological argument for the separation of the church from the state and the freedoms of religious conscience, conceptualized by Luther through his theology of the inner vis a vis outer person.”
In the midst of our often contentious debates about conscience today, Lomperis reminded us that “for Luther, free Christian conscience is simply one expression of a larger Christian spiritual liberty. . . . It is impossible to truly take this freedom away, as it is impossible to take away the Gospel, which establishes and sustains Christian freedom of conscience.”
While Lomperis focused on the historical foundations for the freedom of conscience, Jeff Barrows looked at modern examples of coercion of conscience in his address “Conscience on the Front Lines.”[2] Preferring to use the language of “conscience freedoms” over the commonly used “conscience rights,” Barrows considered how we got to the point of needing to defend freedom of conscience, and he pointed to several fundamental shifts in the history of medicine. When the foundational goal of medicine was to heal disease, doctors were seen as professionals. In recent times, however, the foundational goal has shifted to relieving suffering. With this shift, physicians lost their status as professionals and became seen as mere providers. Other transitions include the rise of autonomy as the guiding principle of medicine and the shift from viewing life as sacred to viewing it as merely worthy of respect.
With these changes in medicine have come new procedures and assumptions that weaken conscience freedoms. For example, a document on “The Limits of Conscientious Refusal in Reproductive Medicine” was deliberately written to prioritize refusal over rights. It asserts that conscience freedoms should be limited if they impose religious or moral beliefs, negatively affect a patient’s health, are based on misinformation, or exacerbate social or racial inequalities. These criteria are extremely broad and can justify virtually any limit on conscience. The document also asserts that conscientious refusal cannot do anything to jeopardize the patient’s wellbeing. By focusing on the patient’s generic “wellbeing” rather than on health, disease, or healing, this physicians-as-providers model makes their purpose simply meeting patient desires, whatever they may be. Unfortunately, this document, which clearly exemplifies the shifts to which Barrows refers, reflects a growing belief that since physicians freely entered the field of medicine, they lack any conscience freedoms and must entirely abide by their patients’ wishes.
Barrows concluded his presentation by overviewing several of the current threats to conscience freedoms, such as the 2016 addition to Rule 1557 of the Affordable Care Act that changed the definition of sex discrimination to include gender identity and pregnancy. This definitional change made physicians liable to accusations of sex discrimination if they do not provide or refer for services for gender transition or abortion. Another national-level threat to conscience freedoms comes from the federal government’s changes to the HHS conscience rule. This rule came into being in 2008 and was meant to strengthen previously passed laws. Unfortunately, the rule has seldom been enforced, and while it was strengthened during the Trump administration, the Biden administration is preparing to either revise the rule or rescind it entirely.
There are also threats to conscience freedoms at the state and local level, such as physician-assisted suicide laws in California. Unfortunately, many cities and states are adopting definitions of sex discrimination similar to Rule 1557. There are those who are fighting to protect conscience freedoms, but in many cases, this is a losing battle. Barrows warned that many healthcare professionals will leave medicine if forced to practice against their conscience. He shared several ways that his own organization, The Christian Medical and Dental Associations (CMDA), is fighting to protect conscience freedoms, and he encouraged the audience to assist CMDA in their own states.
Saturday morning began with a lecture by Bart Cusveller focused on recent research he and his colleagues conducted regarding “Professional Integrity in Caring Professions.”[3] Commonly, people think of two “slogans” when they think about professional integrity: “doing the right thing when no one is watching” and “integrity is like pregnancy; you either have it or you don’t.” While these might have some utility in other fields, Cusveller argued that they are inadequate for healthcare professionals.
Through numerous interviews with healthcare professionals, Cusveller and his colleagues found several traits that go together to make up professional integrity, which he described as “a quality of professional conduct such that the healthcare worker is personally involved in her professional position oriented toward the patient’s interest.” They found several key themes or “gravitational forces” that held the traits of integrity together: (1) agreement between what you think, say, and do; (2) boundaries between persons, roles, and relationships; (3) openness for evaluation of one’s conduct by others; (4) responsible use of means, position, and information; and (5) fostering the wellbeing of the other. In each of these dimensions, transparency is key, hence the problem with doing the right thing when no one is watching; part of integrity is to have people watching and offering feedback and evaluation. Integrity thus takes on a social quality.
Why is integrity important? A major reason is trust—“a precondition for making oneself dependent or even vulnerable to the professional’s expertise and ability to help depends on the professional’s dependability.” Integrity thus becomes a necessary condition for a caring relationship. This also helps us see why saying you either have integrity or you don’t is incorrect. We can have differing degrees of trust, and that difference is based on the perceived integrity of the one we are trusting. We also recognize that there are degrees of failure of integrity as well: making an error in treatment or accidently sharing confidential information is a breach of integrity but is of a different degree than stealing from or sexually abusing a patient.
Cusveller and his colleagues found a number of attributes, attitudes, and actions that corresponded with the maintenance of integrity. Specifically, they found three main dimensions around which integrity is oriented: (1) the use of self (including such things as navigating personal/professional boundaries and resisting institutional pressures); (2) the use of position (including practices such as talking to, not about, others and making proper use of facilities and information); and (3) the orientation of service (including things such as trying to see things from the patient’s perspective). Cusveller closed by reminding listeners that professional ethics does not exist on its own; it must be situated within “a comprehensive, normative worldview,” one that stems from an encounter with the living God.
The Friday of the conference, June 24, 2023, proved to be a historic day in the U.S., as the Supreme Court announced their decision in the Dobbs case, which overturned Roe v. Wade. This announcement was met with great enthusiasm by the conference attendees, and before the next session Paige Cunningham graciously agreed to give a brief presentation on the decision, how it was argued, and its implications for U.S. law.
Following this, Ana Iltis spoke on “Conscience and Integrity in Research: Moving Beyond the Don’ts.”[4] She lamented that very little has been written about conscience in research, and what has been written about integrity is often limited to a few specific areas: trust in methodology and findings, and avoiding falsification, fabrication, and plagiarism. While more has been done on specific topics like embryonic, stem cell, and animal research, even this is usually framed negatively—what should be avoided? In contrast, Iltis asserted that there is much more to integrity and conscience in research than just “avoiding wrongdoing.”
After defining conscience and integrity, Iltis provided several examples of how these concepts both constrain and compel research. Two examples come from the COVID-19 pandemic. The first involved the need for all of us, whether researchers or not, to be informed about how research works. As the COVID vaccines were rolled out, many people objected that they had been developed or tested with fetal cells sourced from abortions, and some refused to receive them because of their beliefs. While not weighing in on whether someone should take the vaccine, Iltis pointed out how many people’s positions were inconsistent or based on misinformation. Many who opposed the vaccine on moral grounds had no idea how many other products, medical or otherwise, that they used had been developed or tested with cell lines replicated from other cells that were originated from fetal tissues from abortions. Others opposed the vaccine because they believed that ongoing abortions were necessary for their production or that certain vaccines contained fetal cells when this was not the case. All of these people were moved by their conscience, and many wanted to act in a way that demonstrated personal integrity, but their efforts were hindered by their lack of knowledge.
Another example concerns how many doctors (as well as the public) are suspicious of randomized controlled trials. People’s reaction to these is often “how could you refuse an experimental treatment to someone who needs it?” However, sometimes this urge to provide whatever treatment we are able to offer gets in the way of doing what is truly best for the patient. During COVID, hydroxychloroquine was thought to be a promising treatment in the early stages of the pandemic, and many people clamored for it. Some physicians even went so far as to say that it had become the standard of care and used implicit appeals for conscience to say that this was something they absolutely needed to provide to their patients. The problem was, the “studies” that had been done proving hydroxychloroquine’s effectiveness were all rushed, usually still preprints, and eventually shown to be faulty; hydroxychloroquine did not actually have an effect. By not doing research properly and awaiting final, peer-reviewed results, many rushed to judgments and provided a treatment that was not actually beneficial, and even had the potential to cause harm.
People’s moral commitments can determine what kinds of research they will or will not pursue. We are familiar with certain common conscience claims (such as avoiding research that could promote abortion or makes use of embryonic cells or tissue), but there are other areas, such as research that could produce bioweapons, that investigators might avoid for conscience reasons. However, integrity and conscience can also propel research; some researchers make it their life’s work to solve a particular problem or work with a particular population. Conscience and integrity not only influence what research people pursue, but how they go about it.
In many publications, appeals to conscience take place implicitly rather than explicitly, and Iltis provided the example of a study dealing with newborn genetic testing. The researchers were initially only going to report results to families when a mutation could result in a disease that could arise or be treated in childhood. However, one newborn had a hereditary mutation that would not affect them until adulthood, but it meant that one of their parents was at a greater risk for certain cancers. The researchers received permission to amend their study protocol and inform the parents of this finding. While the language of conscience was not explicitly used, this was clearly the impetus for changing the protocol, and Iltis recounted the anecdotal evidence of researchers telling her that it felt wrong for them to know information about someone and not tell them.
Outside of these examples, Iltis included numerous questions that researchers working with human subjects can ask about their own work, as well as some internal and external barriers to ethical research. Her goal with these, as with her other examples, was to show how conscience and integrity in research affects far more than just researchers. As she concluded, conscience and integrity are “not fringe concepts! They are mainstream sources of guidance; they are worthy of protection and promotion. They’re not dirty words—conscience and integrity are meaning giving and obligation generating for all of us.”
For the final session on Friday, Richard Zimmerman spoke on “COVID-19 Vaccination and Policy Making.”[5] A former member of the CDC’s Advisory Committee on Immunization Practices, Zimmerman was able to provide a first-hand account of how the organization weighs evidence and makes recommendations for vaccinations. He then went on to discuss some of the biblical and theological principles that apply to decisions about vaccination. From the Old Testament, he showed how God at times commands his people to engage in preventative measures for others’ protection—for example, building a wall around the roof of their house so that someone cannot fall off (Deut 22:8). From the New Testament, he focused on the commands to love one another and promote justice.
Zimmerman then considered how these ethical principles applies to COVID-19 vaccinations specifically. After considering the data on COVID, he put together a syllogism:
Against the objection that we do not need a vaccine because God is sovereign, Zimmerman countered that when you start with “God is sovereign,” you can justify all manner of things. If God is sovereign, why put gas in your car, when he can ensure you get where you need to be anyway? Rather than being a sign of faith and trust, this excuse is an abdication of our responsibility and demonstrates a worldview of determinism that “leav[es] humans to dance on the strings of God as a grand puppet-master in the sky.”
Zimmerman then considered COVID-19 vaccinations in relation to issues of conscience. How do we determine whether someone’s objection is truly a matter of conscience or simply a case of “herd thinking”? Regarding the use of fetal cells in COVID-19 vaccinations, he posited that we can use Robert Orr’s criteria for determining moral complicity (timing, proximity, certitude, knowledge, and intent) to weigh whether someone has a legitimate claim to conscience. After considering all of these areas, he determined that for Christians there is no ground for conscientious objection to the COVID-19 vaccines available in the U.S. on the basis of their use of cell lines derived from abortions.
Finally, Zimmerman considered the principle of the least restrictive alternative and how that should be applied to vaccine mandates. He noted that in the case of the Center for Medicaid Services, a vaccine mandate was justified and fit the criteria of being the least restrictive means for obtaining their intended goals. Conversely, the OSHA attempt to mandate vaccines did not meet these criteria, and it demonstrated an overreach on the part of that organization. While he believes that the vaccine is a good idea for everyone, he argued that the pros outweighed the cons for a mandate for healthcare workers, but not for the rest of society.
Saturday morning opened with a talk from Kathy Schoonover-Schoffner on “Integrity, Conscience, and Current Ethical Burdens through the Lens of Nursing Ethics.”[6] From events like the COVID-19 pandemic to the Russian war in Ukraine, nurses are consistently on the front lines of providing care. Schoonover-Schoffner provided several definitions of nursing, which encompasses “promoting health, the restoration of health, and advocacy.” She then went on to summarize the history of nursing and the centrality of ethics to the development of the field.
Until the 19th century, nursing was not a desirable profession. However, much changed with the Civil War and the great need for skilled nurses it created. Dorothea Dix developed codes for nurses that transformed the perception of the field, and in 1873 the first schools of nursing were opened, where ethics and etiquette were a large part of a nurse’s training. The American Journal of Nursing began in 1900, and much of the writing in that publication was about ethics. Between 1900–1964, over 100 textbooks and books on nursing ethics were published. From all of this, Nursing developed a “heritage ethics” that was based in virtue, relationship, and vocation.
This began to shift in the 1970s. Nursing education moved from hospital schools into the university, and in the process, much of nursing’s heritage literature on ethics was lost, as it was not considered “scholarly” enough. In 1979, Beauchamp and Childress’ Principles of Biomedical Ethics was published, launching principlism as the dominant paradigm of medicine and furthering the transition from nursing ethics to bioethics.
Despite this paradigm shift, nursing ethics still has an important and unique place in the contemporary world. Nursing ethics are not problem oriented, but “virtue-based, relationally-based, and vocation/calling oriented.” It is a “preventative ethics,” not fixated just on the problem at hand but on forming a relationship. Today, nursing ethics focuses on five main relationships: between the nurse and (1) the patient/family, (2) other health professionals, (3) the self, (4) the profession, and (5) society. Though the Code of Ethics for Nurses that lays out these relational principles is a bit of an anomaly in today’s bioethics-dominated world, the heritage ethics of nursing still have much to teach us. When followed, its principles help nurses to advocate for patients, see them as whole persons, and build relationships with them—all tasks central to the vocation of nursing.
Saturday afternoon, Allen Roberts spoke on “Medical Error: Conscience and Integrity.” [7] He began by talking about the nature of conscience and how it brings with it moral duties and obligations, then overviewed four cases of medical errors that he was either involved in or had made national news.
He then moved on to a history of medical error. Hippocrates is widely considered the father of medicine and made several comments on error. While the physician could not be held responsible for misfortune or the patient’s illness itself, they were responsible for things they did wrong or inappropriately, as there are correct and incorrect ways of doing things. Moving to William Osler, the founder of modern medicine, he advocated for medicine as a high calling, and encouraged medical students and doctors to always take responsibility for what they did. Thus, the early 19th and 20th centuries were a time of “paternalistic integrity,” and doctors were open about both successes and failures.
Due to several cases of failures making their way into tabloids, this era gave way to a period of “concealment, blame, and shame.” Errors were hidden or denied whenever possible, and if one did come to light, blame was always shifted elsewhere. By the 1950s there were some quiet publications that discussed the harm this culture of silence caused. In the 1990s, surveys showed that 98% of patients wanted to be informed of errors, and that they were less likely to sue after being informed. The VA system eventually adopted policies of disclosure and risk reduction, and this was a major turning point. In 1999, the Institute of Medicine (IOM) issued a report titled “To Err Is Human: Building a Safer Health System.” This led to enhanced knowledge on safety, structures of mandatory reporting, higher safety standards, and safety systems within healthcare organizations.
This IOM report was hugely influential and has shaped how health systems respond to medical error throughout the 21st century. There is far greater transparency and communication with patients and family about errors, reporting and investigation when errors occur, equitable and fair resolutions to preventable errors, including an apology, and continued improvements to keep errors from occurring again. All of these changes have been very good things and help to reduce medical errors. They have also led to acknowledgement of the “second victim” of medical errors—the one who actually made the error—and methods to care for them as well. However, with these changes has come a shift in responsibility from the individual to the organization or system. Greater understanding of medical errors has also highlighted many of the disparities in health care, as ethnic minorities, women, and members of the LGBTQ community are more likely to be the victim of a medical error.
Roberts concluded with some thoughts on the current approach to medical error, called “just culture.” Patient safety has become a primary goal, but there is an acknowledgement that human error cannot be entirely eradicated. The focus is instead on creating systems that minimize and mitigate those human errors and that fairly assign accountability, as well as systems of restorative justice for both the patient harmed as well as the medical provider.
For the final session of the conference, Lauris Kaldjian spoke on “The Challenging & Joyful Task of Christian Integrity in Healthcare.”[8] He began has talk by considering several definitions of conscience from a Christian perspective, noting the paradox that conscience is both supremely binding on the individual and must be followed, but at the same time is fallible and subject to error and corruption. Thus, our consciences must be both well “formed and informed,” and we must have humility regarding the conclusions of our consciences. From a purely philosophical perspective, conscience encompasses our “intellect, will, desires, and our ultimate goals,” and includes the dimensions of “moral reasoning, morally directed emotion, and moral motivation.”
Kaldjian went on to discuss the relation between conscience and integrity, the two of which he sees as being mostly interchangeable. He defined integrity as “a moral virtue that maintains the harmony and constancy of individual moral character and identity by ordering and integrating moral beliefs, virtues, principles, words, and actions across time and place, thereby motivating moral action and empowering moral agency.” In thinking about integrity and conscience together, he concluded that “a claim of conscience communicates a moral concern that is (1) deep enough to involve our integrity (moral identity); (2) serious enough to require respect (conscience rights); and (3) serious enough to warrant examination (giving of reasons).”
From here, Kaldjian discussed five key domains of foundational belief and how conscience and integrity interact with them: (1) respect for life, (2) the concept of health, (3) duty to care as an act of love, (4) respect for freedom, and (5) respect for conscience. This brought him to the challenge of Christian integrity. Christians believe that we live in a fallen world, but also that God is active and present in our world and in our hearts. In the midst of our fallen world, it can be difficult to be salt and light in medical practice, and to give reasons for our moral beliefs. And yet, there is great value to us doing so. As Paul reminds us in 2 Corinthians 4:2, “by setting forth the truth plainly we commend ourselves to every man’s conscience in the sight of God.” We are to be witnesses (or martyrs) to our Christian beliefs in all aspects of our lives.
While being Christian witnesses may be difficult, we must remember the second part of the story—that God is active and in control, and whatever we do we do for him. When we speak up in matters of conscience, we remember that God is with us. Without understating how difficult conflicts of conscience can be, Kaldjian pointed to the joy that comes from integrity and following a well-formed conscience. When encountering a situation that could cause moral distress, keeping silent can lead to moral injury, compartmentalization, and burnout. However, if we instead use the situation to engage in moral communication, it can help us to clarify our own thoughts, open a way forward, and engage in conscientious practice. When we do what is right, we live in harmony with God, our soul is revived, and our heart rejoices. Even if we are persecuted and suffer for the sake of our conscience, we rejoice knowing that we are inheritors of the kingdom of heaven.
We at CBHD are deeply grateful to those who helped make our conference a success! Preparations are already underway for our 30th anniversary conference: The Christian Stake in Bioethics Revisited: Crucial Issues of Yesterday, Today, and Tomorrow. We have an excellent lineup of speakers, including Christina Bieber-Lake, PhD; F. Matthew Eppinette, MBA, PhD; Peter Jaggard, MD; Bryan Just, MA; Adam Omelianchuk, PhD, MA; and Scott Rae, PhD. We look forward to seeing you in Deerfield, June 22–24, 2023!
[1] Ekaterina N. Lomperis, “Conscience as a Theological Concept” (plenary address, The Center for Bioethics & Human Dignity’s 29th Annual Conference, Integrity and Conscience: Bioethics and the Professions, Deerfield, IL, June 23, 2022).
[2] Jeff Barrows, “Conscience on the Front Lines” (plenary address, Integrity and Conscience, June 23, 2022).
[3] Bart Cusveller, “” (plenary address, Integrity and Conscience, June 24, 2022).
[4] Ana S. Iltis, “Conscience & Integrity in Research: Moving Beyond the Don’ts” (plenary address, Integrity and Conscience, June 24, 2022).
[5] Richard Zimmerman, “COVID-19 Vaccination and Policy Making” (plenary address, Integrity and Conscience, June 24, 2022).
[6] Kathy Schoonover-Schoffner, “Integrity, Conscience, and Current Ethical Burdens through the Lens of Nursing Ethics” (plenary address, Integrity and Conscience, June 25, 2022).
[7] Allen Roberts, “Medical Error: Conscience and Integrity” (plenary address, Integrity and Conscience, June 25, 2022).
[8] Lauris Kaldjian, “The Challenging & Joyful Task of Christian Integrity in Healthcare” (plenary address, Integrity and Conscience, June 25, 2022).
Bryan A. Just, “Integrity & Conscience: 2022 Conference Recap,” Dignitas 29, no. 3–4 (2022): 18–22, www.cbhd.org/dignitas-articles/integrity-conscience-2022-conference-recap.
