ACOG's Definition of Conscience and Good Medical Practice

We have been examining the definition of conscience forwarded by the American College of Obstetricians and Gynecologists' (ACOG) Ethics Committee and the consequences of taking this definition to its logical conclusion. If one may forgive a medical ethics committee for not being moral theologians, the consequences their statement has on medical practice is perhaps less forgivable. Even the committee’s view of the medical profession is a dangerous paradigm shift rooted in an anemic materialistic philosophy. Not only does this philosophy endanger individual rights of conscience it also endangers the quality of health care for all of us.

Traditionally, professionals were highly educated, specifically trained and highly paid to be experts in their field. Their expertise gave them authority and was the foundation for the trust that we placed in them. Trust was strengthened through demonstrated competence and rapport built through a personal but professional relationship. Think back to the days of the private family practice, when the entire family went to the same doctor who knew every member, remembered their past conditions, and sometimes even came up with their own medicinal concoctions for specific ailments.

ACOG promotes a different view of the professional in support of its reformulation of the moral conscience. A professional is a merchant in a capitalist system whose purpose is to provide to the client (no longer called a patient) products and services in the health market. ACOG says, “A second important consideration in evaluating conscientious refusal is the impact such a refusal might have on well-being as the patient perceives it – in particular, the potential for harm” (3) (emphasis added).

This materialistic definition of the professional has a very important but subtle effect on the principle of patient autonomy. Under the traditional understanding of the medical professional, patient autonomy meant that the patient had the power to make final decisions about whether or not to accept extraordinary means of treatment (treatment with little chance of success or with burdens that outweighed their benefits). Such decisions were always to be made after full consultation with medical professionals so the patient could be fully informed of the choices available. However, patient autonomy did not extend to the refusal of ordinary means of treatment, and certainly did not mean that the patient could request any treatment he or she wanted. However, ACOG’s understanding of the professional changes its understanding of patient autonomy. “One of the guiding principles in the practice of medicine is respect for patient autonomy, a principle that holds that persons should be free to choose and act without controlling constraints imposed by others” (3). Theoretically, a client could walk into a doctor’s office and request an amputation – and the doctor would be obligated to perform the operation as long as the patient was convinced it was necessary. I’m sure that no member of ACOG would extend their principle to this ridiculous extent. However, the very fact that they cannot follow the principle to its logical conclusion shows the error of the principle. ACOG’s redefinition of the professional and of patient autonomy strips the professional of his expertise. The doctor has little more authority than the store clerk.

According to ACOG, a patient requesting contraception or even sterilization has the right to receive the desired treatment just because she wants it. The doctor’s role is only to provide the desired service. If contraception and sterilization are against a doctor’s conscience, the doctor must ignore his or her conscience. Many doctors who oppose contraception and sterilization do so because they judge these “treatments” to be medically bad for patients in addition to being morally evil. However, these doctors do not have the right to deny these treatments even on medical grounds. Why? Because social values, the patient’s opinion, and “accepted medical practice” (which is often directed by political and social tides rather than by science) all outweigh professional judgment. Medical judgments are being made by everyone except those who are most qualified (and best paid) to make apply medical knowledge to specific conditions of the patient.

ACOG’s redefinitions of conscience and of the medical professional are dangerous. They give the power to define medical care to capricious social and political influences rather than to the trained professionals. They thus redefine even the ethical standards that traditionally guided the use of the power that medical professionals have over our bodies. “By virtue of entering the profession of medicine, physicians accept a set of moral values – and duties – that are central to medical practice” (3). Traditionally, these “moral values” and duties were expressed through the Hippocratic Oath, derived from a reasoned understanding of the human person and the nature of the healing arts. The Hippocratic Oath bound doctors to protect all human life and dignity, to not take advantage of the intimacy or authority of the patient-doctor relationship, and to do no harm. This oath is rarely taken in medical schools anymore. Today, these “moral values” and duties are defined by ambiguous and shifting social and political influences. Thus, proper medical care includes contraception, sterilization and abortion because these things are socially and politically favored, even though these treatments violate the basic principle of totality and integrity – the principle that states that the goal of medicine is to make sure the body is kept whole and that it is treated as part of the whole person rather than as a machine or an object. Forcing a woman to accept an “unplanned pregnancy” by refusing contraception, sterilization or abortion is now considered doing harm to the patient. Killing a child in the womb is not considered doing harm because “the moral status of the fetus and the obligations that status confers differs widely.” So, if the moral status of blacks or of women were to differed widely in public opinion, the doctor would be morally justified or even obligated to kill blacks or women? Taken to its logical conclusion, ACOG’s logic would say yes.

If it becomes the norm, ACOG’s reasoning will do serious harm to the medical profession and to the care we receive. Making medical care into a commodity market, removing prudential decision making power from trained professionals, allowing patients and society to decide what is or is not acceptable treatment are sure ways to erode our standard of care. Destroying the solid ethical principles that provide checks and balances to the incredible power that doctors hold over life and death and the intimate nature of the patient-doctor relationship is a sure road to abuse. What was ACOG thinking?

Examining the Consequences of ACOG's Definition of Conscience

In the last blog post we examined the definition of conscience promoted by the Committee of Ethics of the American College of Obstetricians and Gynecologists. When we compare their description to the definition taught by the Catholic Church, we notice that they have many similar points, but one major difference. The definition of conscience proposed by ACOG does not even mention an objective moral law as a norm for conscience. The next logical (and common) question is, so what? This blog article will examine the consequences of understanding conscience according to ACOG’s definition, using the very opinion statement published by that committee. We’ll first explore the committee’s examination of what makes a judgment of conscience valid. We’ll then look at the importance of their implication that the judgment of conscience is not inviolable. Finally we’ll see that their definition of conscience opens the door for tyranny.

Click here to read the first blog article in this series

Click here to read about the Catholic Church's teaching on conscience at the Abbey

According to ACOG’s definition of conscience, a judgment of conscience is only valid to the extent that

1. the underlying values “constitute a core component of” one’s identity


2. the a person has deeply reflected on the issue at hand


3. the person is likely to feel guilt, shame or loss of self-respect by performing the act in question (2).

Notice once again that all of these conditions for an authentic judgment of conscience are subjective. None of them appeal to an objective norm of right and wrong. The committee on ethics goes on to say that a claim to conscience is not genuine if it is a mask for personal distastes, based on discriminatory attitudes, based on self-interested motives, and influenced by social pressures.

On one hand, these statements seem reasonable. We need to deeply reflect on matters of conscience, make sure our decisions are not being unreasonably influenced by social pressures, biases or distaste and be careful that we are not being selfish. However, the list of qualifications offered by ACOG begs the question, “on what is an authentic judgment of conscience based?” ACOG does not satisfactorily answer this question. They seem to offer these possibilities:

1. Social considerations


2. Patient desire


3. “Professional standards”


4. Scientific integrity (at least this one appeals to something objective)

Their first basis for a legitimate judgment of conscience seems to contradict their own qualification that an authentic judgment of conscience should not be influenced by social pressure: “In some circumstances respect for conscience must be weighted against respect for particular social values.” The second basis seems to contradict good medical practice – if the moral conscience of the practitioner cannot contradict the wishes of the patient why is thre need for a medical consultant? Medical care simply becomes another consumer-provider market relationship. We’ll talk about the other conditions in a future blog article. However, the first condition is a major concern for this article.

What is the consequence of ACOG's qualifications for an authentic judgment of conscience? For ACOG, the judgment of one's conscience is not inviolable. If the moral conscience is not inviolable, neither is our right to form our own character and moral destiny. By ACOG’s own logic, personal integrity must sometimes be sacrificed for social standards. In fact, if conscience is a personal feeling and if a medical professional's conscience opposes social "moral norms," "professional standards" or a patient's desire, it would actually be selfish for a medical professional to follow her conscience! Specificallly, ACOG’s statement says, “Although respect for conscience is a value, it is only a prima facie value, which means it can and should be overridden in the interest of other moral obligations that outweigh it in a given circumstance” (2). In one statement, ACOG has relegated judgments of conscience to just one value among many, and must be subverted by moral norms imposed - not by objective truth but by social and "professional" norms created by those in power!

The imposition of a moral choice on an individual conscience (not to be confused with the attempt to rationally convince someone of the rightness of a moral decision) is called tyranny. If ACOG's definition is widely accepted, the individual right to form is own character and determine his own destiny will be usurped by those in social and political power. If conscience must be weighed against social values, then society controls the individual. ACOG itself proposes certain moral assumptions that they claim must be accepted (based on what?). The most egregious include their assumption that because the life of an unborn baby is "debated," it can not be a professional consideration and that the life of the mother must always be placed above the life of the fetus (as if one life should be valued over another).

Our experience of the last century has revealed the fickleness of social standards. Society bases its standards on political majority, media propaganda, and immediate self-interest. For this reason, philosophers from Plato to Saint Thomas Aquinas to John Locke to Thomas Jefferson have stressed the need for guidance of objective standards that transcend the whims of the people (Jefferson did not believe these standards should be enforced by the federal government, but he did believe they needed to be in place). According to ACOG's arguemnt, the personal conscience of the abolitionist should have been sacrificed to the social standard that accepted slavery. The German dissenter during Hitler's reign should have been silenced in the face of the social standard that accepted the values of the Third Reich.

By defining conscience only as a personal judgment without any reference to an objective moral law, ACOG robs the moral conscience of its importance and purpose. ACOG then subverts moral conscience even further by subordinating it to the whims of society and those in power who set medical professional standards.

An Examination of ACOG's Definition of Conscience

In November, 2007, the American College of Obstetricians and Gynecologists (ACOG) Committee on Ethics wrote Committee Opinion Number 385, "The Limits of Conscientious Refusal in Reproductive Medicine." In this opinion, the Committee on Ethics undertook to define conscience, and then to place limitations based on this definition on when a health care provider can refuse to provide "treatment" based on conscientious objection.

Their definition of conscience runs like this: Conscience has been defined as the private, constant, ethically attuned part of the human character. It operates as an internal sanction that comes into play through critical reflection about a certain action or inaction. The committee also says, "Ethical decision making in medicine often touches on individual's deepest identity-conferring beliefs about the nature and meaning of creating and sustaining life." They stress the relationship between conscience and personal integrity: "According to this definition, not to act in accordance with one's conscience is to betray oneself - to risk personal wholeness or identity."

There are some good points of this definition.

• The Committee on Ethics seems to respect the conscience and to give it appropriate weight of importance, especially in its acknowledgement that following one's conscience is a key part of "personal wholeness or identity."
• Conscience is a key part of the human character. The choices that we make define our character, and our conscience helps us make those decisions and is also formed by those decisions as part of our character.
• The Catechism of the Catholic Church says about conscience, "Moral conscience, present at the heart of the person, enjoins him at the appropriate moment to do good and to avoid evil. It also judges particular choices, approving those that are good and denouncing those that are evil" (CCC 1777). That sounds pretty close to the "intenral sanction" in the ACOG definition.
• The Catechism also says, "Conscience is a judgment of reason whereby the human person recognizes the moral quality of a concrete act that he is going to perform, is in the process of performing, or has already completed" (CCC 1778). That sounds close to ". . . that comes into play through critical reflection about a certain action or inaction." In fact, this is part of the definition of conscience that many Catholics ignore today. Conscience is a critical reflection - an exercise of reason. It is not just a "little voice" that tells us what is right and wrong, although the Holy Spirit certainly speaks to our conscience, and part of our conscience is made up of synderesis, the natural moral law that is an inherent part of human nature and is therefore obvious to every human being. However, the primary function of conscience is moral reasoning.
• Finally, the CCC says, "His conscience is man's most secret core and his sanctuary" (1776). This aspect of conscience will actually compose the central argument of the ACOG statement on the limitations of conscience. It is true that the conscience is an intensely personal aspect of the human character. It resides in the heart, the center of our being, where it pulls together all of our human faculties and where our personality meets the Holy Spirit.

The ACOG Committee gets part of the definition of conscience correct, and that gives their statement a certain weight of authenticity. However, their definition omits a crucial aspect of conscience. One cannot speak of conscience as a process of moral reasoning without acknowledging objective truth. What is there to reason about if objective truth does not exist? The Catechism of the Catholic Church repeatedly stresses the relationship between moral conscience and the objective moral law:

• "Deep within his conscience man discovers a law which he has not laid upon himself but which he must obey. Its voice, ever calling him to love and to do what is good and to avoid evil, sounds in his heart at the right moment. . . . For man has in his heart a law inscribed by God" (CCC 1776)
• "It bears witness to the authority of truth in reference to the supreme Good to which the human person is drawn, and it welcomes the commandments" (CCC 1777).
• "It is by the judgment of his conscience that man perceives and recognizes the prescriptions of the divine law" (CCC 1778).
• "Conscience is a law of the mind; yet [Christians] would not grant that it is nothing more" (CCC 1778).

The ACOG Committee on Ethics completely ignores the objective moral law in their definition of conscience. To them, the personal nature of conscience naturally means that conscience is private and subjective.

The consequences of this mistaken definition of conscience are striking, even in the conclusions the Committee on Ethics draws in this opinion.

The authenticity of conscience can be assessed through inquiry into 1) the extent to which the underlyling values asserted constitute a core component of a provider's identity, 2) the depth of the provider's reflection on the issue at hand, and 3) the likelihood that the provider will experience guilt, shame or loss of self-respect by performing the act in question. It is the genuine claim of conscience that is considered next, in the context of the values that guide ethical health care.

Notice that all three of these earmarks of "authentic claims to conscience" are completely subjective. By relegating the claims of conscience to personal and subjective decisions, the Committee on Ethics can summarily dismiss these claims - which is exactly what they do in the rest of the opinion, as we shall see in the next post.