Catholic Medical Quarterly Volume 68(3) August 2018
Conscience in Medical Ethics:
The Voice of God or The Judgement of
Dr Joseph Shaw
A version of this paper was delivered to the Youth Conference of the Catholic Medical Association 10th March 2018
In the 1650s a female Quaker walked through the streets of Oxford naked. She explained her actions by ‘declaring that those in authority would in like manner be stripped by God of their power.’ 
She was inspired no doubt by Isaiah 20:2ff, in which the prophet is commanded by God to take off his clothes and sandals as a prophetic gesture aimed at Egypt, which some in Israel saw as an ally against the might of Assyria. The Egyptians, Isaiah explained, would be defeated and led captive, stripped and naked, to their shame.
Isaiah, of course, acted as he did on the basis of direct divine commands. It is possible that the 17th century Quakeress thought she had been inspired in a similarly direct way to act as she did. However, it is more likely that she, and the many others of that era who performed what they regarded as prophetic actions, often involving violence towards property or persons, hadn’t had visions: they had simply decided that it was a good idea. Nevertheless, the Quakeress would have claimed, if asked, that she acted according to her conscience, and that the voice of conscience is the voice of God.
My first, and perhaps shocking, contention in this paper is that, while it is possible to understand the claim that conscience is the voice of God in an orthodox way,  it is a deeply unhelpful way of talking. Instead, I recommend St Thomas Aquinas’ definition of conscience: to paraphrase, conscience is a rational judgment about whether a proposed action is right or wrong.  Contrary to the Quakeress, there are three important differences between the conclusions of our own thinking and divine commands.
First, unlike God, our personal conclusions are fallible.
Secondly, God, unlike us, has authority to command us to do things which we don’t fully understand, or which in other circumstances be absurd or even, in some cases, wrong. 
Thirdly, our personal conclusions are based on a process of reasoning open to review and discussion by others. This can be the basis of persuading others, and we may legitimately change our opinions when presented with pertinent arguments or extra information.
None of these points means that we may set our conscience aside, for example if it conflicts with our own desires, the orders of a superior, or the law of the land. What we mean by conscience simply is what we think we ought to do. To agree to act against our conscience just is to act contrary to what we think we ought to do.
This creates the paradox of the ‘erring conscience’. How can it be right to do what is wrong? The classic, and perhaps not very helpful, answer from the Catholic tradition is that what an agent with an erring conscience really ought to do is to think matters through again and straighten his conscience out. Short of that, Aquinas points out that an action contrary to conscience is a sin, because in such an act the agent has chosen sin. 
On the other hand, a person who thinks, conscientiously, that, say, fornication is morally permissible, and carries it out, will over time feel the effects of doing that objectively evil action. You cannot develop the virtues of chastity, justice, and charity through actions objectively opposed to them, even if you are unable to see that they are opposed to them.
This is what the classical Catholic tradition has to say. By contrast, the concept of an erring conscience is difficult to combine with the view, characteristic of Protestantism, that the voice of conscience is the voice of God, or even, as late Scholastic and Counter-Reformation Catholics tended to say, the deliverances of the virtue of Prudence, which are correct by definition.  Cardinal Newman, who also used the language of conscience as the voice of God, was obliged to contrast this variously with a ‘counterfeit conscience’, a ‘mean, ungenerous, selfish, vulgar spirit’, and a ‘false conscience’. The less charitable Protestants of 17th century England dismissed their opponents’ claims of conscience as insincere, or even demonic.
The result of this was that Oxford’s undergraduates, who had to pass a religious test before matriculating, amused themselves in that era by disrupting the worship of Protestant Dissenters ‘jeering and shouting, singing bawdy songs, setting dogs upon the congregation or setting off fireworks’.  Dissenters in their turn interrupted church services of which they disapproved, but some of which they were legally obliged to attend. Catholic Masses were also disrupted, when their location was discovered. During the reign of Queen Mary Tudor, there were cases of Protestants attacking priests with knives during Mass, and violently disrupting religious processions. This was still going on, at least in pockets of Protestant zeal, three centuries later. In the town of Lewes, famous for its bonfire-night burning of effigies of the Pope, a High Anglican funeral complete with religious sisters in habits, organised by the hymnwriter J.M. Neale, so enraged the locals in 1857 that the participants were besieged in a public house and had to be rescued by the police.  This is what happens when people feel they are directly inspired by God, and that everyone who disagrees with them is inspired by Satan.
Cardinal Newman sets great store by the contrast between the religious view of conscience, as the voice of God, and the secular view of conscience, as entirely subjective.  One can see what he means, but from a historical perspective the secular view is simply the religious view in lay clothes. If religious faith weakens in people who have been taught that they have within themselves an infallible moral guide conveyed by their feelings, they will stop calling these feelings the voice of God, but they won’t cease to accord them the ultimate authority over their actions.
The irresolvable religious conflict of the late 16th and 17th centuries set the scene for the development of the concept of religious toleration. As the philosopher John Locke makes clear in his famous Essay on Toleration, it was evident by the time of the English Revolution of 1688 that the Anglican Church was not going to succeed in suppressing Protestant religious dissent. Against the Catholic threat represented by King James II, Locke proposed that Anglicans and Dissenters form a united front and allow each other to worship in peace. It was another century before the need to pacify Ireland led to this toleration being extended to Catholics.
The Oxford Quakeress already mentioned would have rejected appeals to keep her clothes on based on Natural Law, or the authority of a recognised body of tradition, or the authority of an institution like the Church, or to reason. Indeed, she might have borrowed Luther’s line that the last of these, reason, is a whore. If conscience is either God’s will, or a fraud, it places religious and moral convictions in a completely different category from rational opinions. There is, literally, no arguing with them. Some kind of toleration may be possible if you could put a lid on the threat to public peace, but this implies that troublesome religious views be withdrawn from the public, political sphere, into the merely domestic, private sphere.
Many in Locke’s day and since may conclude that this was a pretty good solution to a pressing social and political problem. The difficulty is that Lockean toleration is based on two, related, false claims.
The first is that public policy can be based on a set of political principles which are uncontroversial and don’t favour one set of religious convictions over any other.
The second is that you can take away the political implications of religious world-views without changing those world-views in any important way. Only if this is true can the Lockean system be said to be tolerating a range of authentic religious views.
These problems can be illustrated in the practical difficulties Catholic doctors find themselves today. If a Catholic medic tells his colleagues that he cannot in conscience perform an abortion, for example, one common reaction is to say that the Catholic has set aside his rational, professional judgment (the universal, rational, principles Locke assumed would govern political and professional life) in favour of promptings from a very different source: religion.
If you are lucky, you may be offered what is known in the law as a ‘reasonable accommodation’. This means you might be allowed to opt out of abortions, in the same way that Muslim professionals might be allowed to opt out of shifts incompatible with Friday prayers. Beyond this little bubble of accommodation, it will remain the case that you will be expected, first, to think and act professionally on the basis of official standards which may include attitudes at variance to the Natural Law. By the same token, the version of Catholicism officially permitted, and indeed protected, is a declawed one with no implications for one’s professional life.
These are implications of fundamental principles which are widely, if not universally, accepted. In the real world attitudes and rules of conduct tend to be messier and often confused, sometimes to the advantage of the conscientious Catholic professional. To stay with the fundamental issues, however, the key to dealing with this problem is for us as Catholic professionals to keep insisting that when we talk about conscience, we are not appealing to a right to a private spiritual life: we are talking about the conclusions of our thinking about what we should do.
If this goes against current official protocols, there are precedents. There have been professionals in earlier eras who refused to go along with conventional, but wrongheaded or abusive, medical practices, such as bleeding patients who were suffering from blood-loss, highly speculative brain-surgery on patients with mental disorders, or, more recently, the over-prescription of pyscho-active drugs. Again, there are the more extreme cases of the corruption of the medical profession in Nazi Germany and the Soviet Union. The history of some of these cases illustrates how closed-minded a professional group can become, and what obstacles and even persecution await those who have the knowledge and will to do things better.
When talking about conscience, conscientiousness, and conscientious objection, the cases just listed are in a very different category to, for example, the issue raised by those who want to avoid eating pork for religious reasons. Recall the contrast noted above between the obligations (which may be perfectly real) arising from direct divine commands, and the conclusions of our faculty for practical reasoning. The latter are fallible; they will not involve claims to any special right to do what others should not do; and they are both susceptible to correction by others presenting arguments or new information, and also can form the basis of a public argument designed to persuade others. It should be particularly clear in these kinds of case that attempts to relegate the views of the conscientious dissenters to a ‘private sphere’ make no sense at all.
Should those who opposed lobotomies have avoided performing them themselves, but made sure that colleagues were on hand to do them instead? Should the pioneers of hygiene have kept their private views about patients’best interests to themselves, and not allowed these views to effect their professional judgements, as formed by their training and official guidlines? Should Catholic doctors called upon to apply arbitrary criteria for determining Jewishness during the Nazi Shoah simply have done the job they were paid and ordered to do, and sped the unfortunates up the railway track to death?
No. It was on the basis of their understanding of medicine and of their patients’ interests, which is to say as medical professionals, they knew that what was happening was wrong. The same is true of a Catholic doctor today confronted with a child wishing to be irreversibly sterilised, a frightened mother asking for an abortion, or a depressed old person wishing to be euthanised. It is a medical judgement - admittedly, not a difficult one - that those things are not in the patients’ interests. A trained, professional judgment, is the application of practical reasoning to a specific kinds of cases, making use of a specific body of knowledge and set of analytical skills. Nevertheless, its conclusions can still be moral imperatives. In these cases the men and women involved believed, reasonably and correctly, that it was not the right thing to do as medical professionals to go along with the official view of their day.
To summarise my argument, I have wanted to stress that conscience is not a mysterious black box which produces unchallengable commands, but, as Aquinas taught, simply the conclusion of our reasoning about what to do. On this understanding it ought to be part of the public conversation, not relegated to a private sphere. For a Catholic medic, conscience is the product of a professional judgement, informed as it should always be by a concern for patient welfare, no different from the judgements of earlier generations of pioneers, whistleblowers, and those refusing to allow their medical expertise be twisted into a means of oppression.
We must be innocent as doves and as wily as serpents, and I’m not the one to advise Catholic medics how to navigate the difficulties they face. My concern has been to say that the privatisation of religious commitments, which many in positions of authority try to enforce, is based on a fundamental mistake. Our moral reasoning is not a separate domain from our practical and professional reasoning: it is how we determine what we should do, and how we should live.
Dr Joseph Shaw, MA, DPhil Oxf - Senior Research Fellow, St Benet’s Hall, Oxford University
- The Encyclopædia of Oxford Encyclopaedia ed. Christoper Hibbert and Edward Hibbert (London: Macmillan, 1988) p122
- See Thomas Aquinas Summa Theologica Ia IIae Q19 a.5 ad1: ‘ Although the judgment of an erring reason is not derived from God, yet the erring reason puts forth its judgment as being true, and consequently as being derived from God, from whom is all truth.’
- See Thomas Aquinas Summa Theologica Ia Q79 a.13; Ia IIae Q19 a.5
- Not that God can make any wrong act right by commanding it, but he can give humans permission to do what he has the authority to do, just as a human can, by giving a permission, make actions which would have been wrong, permissible. See Joseph Shaw “The Application of Divine Commands” Religious Studies 35, 1999 pp307-321
- On this topic see M.V. Doughherty: Moral Dilemmas in Medieval Thought: from Gratian to Aquinas (Cambridge: Cambridge University Press, 2011) p156, citing Bonaventure; Dougherty expounads the views of a succession of authors in the following pages.
- Summa Theologica Ia IIae Q19 a.5 c. ‘And since the object of the will is that which is proposed by the reason, as stated above (Article 3), from the very fact that a thing is proposed by the reason as being evil, the will by tending thereto becomes evil.’
- See John Lamont “Conscience, Freedom, Rights: Idols of the Enlightenment Religion” The Thomist 73 (2009): 169-239
- See Letter to the Duke of Norfolk §5: ‘This [Divine] law, as apprehended in the minds of individual men, is called “conscience;” and though it may suffer refraction in passing into the intellectual medium of each, it is not therefore so affected as to lose its character of being the Divine Law, but still has, as such, the prerogative of commanding obedience.’
- The Encyclopædia of Oxford Encyclopaedia p122
- J.M. Neale recounted the incident in a letter to The Times, London, November 23, 1857
- Op. cit.: ‘When men advocate the rights of conscience, they in no sense mean the rights of the Creator, nor the duty to Him, in thought and deed, of the creature; but the right of thinking, speaking, writing, and acting, according to their judgment or their humour, without any thought of God at all.’