Medical Ethics Lecture 5: Conscience
Dr. E.T. Acevedo, MD, MPH, MPA July 9, 2010
 STANDARDS OF MORALITY
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o Just as in human acts, some norms or standards of acting are
followed, the same can be said with regard to the moral behavior
of people. Norms of moral actions are highly necessary if people
have to live in peace, order and harmony.
o Two norms or standards of moral or ethical actions recognized
and understood in Bioethics:
1. Natural Law
2. Conscience
 CONSCIENCE
o The subjective norm of morality, therefore, maybe erratic and
prone to miscalculations.
o Resides in the human intellect which is imperfect and therefore
prone to errors.
o Nevertheless, as judgment of the intellect, it makes declaration of
truth or untruth, goodness or badness about the actions he wants
to pursue, or about thoughts he wants to believe.
o Definitions of Conscience:
 (Greek word “suneidesis” - Democritus)
Later translated “conscientia” - Cicero)
Comes from two Latin terms: Con and science - “with knowledge”
1. Conscience is the meeting point of the MORAL LAW,
objectively and universally valid and the INDIVIDUAL
PERSONALITY.
2. 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 performing.
3. Refers to the inner sense of right and wrong in moral choices,
as well as to the satisfaction that follows action regarded
as right and the dissatisfaction and remorse
resulting from conduct that is considered wrong.
4. The CAPACITY TO MAKE PRACTICAL JUDGMENT in matters
involving ETHICAL ISSUES. The capacity cannot be delegated
to anyone else nor to any institution.
5. Theological meaning: The process in which the general norms
of the moral law are applied to a concrete action which a
person is about to perform or has performed, telling the
person what his obligation is here and now or judging his
past acts.
6. St. Augustine and the Franciscan School: The place of the
innermost encounter between God and man, and therefore the
voice of God. The person’s most secret core and sanctuary.
The spark of the soul; the peak of the soul.
7. An ultimate practical judgment on the morality of a concrete
action, commanding to do what is good and to avoid what is
evil.
8. Second Vatican Council: the most secret core and sanctuary of
the human person.
9. 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. When man listens
to his conscience, the prudent man can hear God
speaking.
o Conscience evaluate the quality of the Human acton whether it is
desirable or undesirable.
 Question: Should a man follow his conscience, be it right or
wrong?
1. It is right to practice contraception knowing that another
child will add more burdens to an already impoverished
family.
2. It is not right to pay for donated organs, but I need one for
my survival. Thus, I might as well compensate the donor with
high financial reward and not shortchange him.
3. I need to perform surgery on the mother who attempted
abortion to remove the fetus. But, if I help her, she might be
doing it over again and I might be accused of cooperation in
an evil act. I might just as well send her to another hospital
that does it.
 FOLLOW ONE’S CONSCIENCE
o St. Thomas Aquinas:
 “Every conscience, whether right or erroneous, whether with
regard to acts which are evil in themselves or acts which are
indifferent, is obligatory, so that he who acts against his
Group 5. Claud. Eian. Helaine. Jill. Marj. Sheen.
conscience does wrong.
o How do we follow our Conscience?
1. To follow one’s conscience is to follow the law.
Limitations:
Legality does not always mean morality.
Legalizing abortion
2. To follow one’s conscience is to follow one’s cultural beliefs.
Limitations: When people become more aware of equality rights.
Jehovah’s Witness - against blood transfusion
Muslim women – death punishment for commission of
adultery.
3. To follow one’s conscience is to follow one’s feelings.
Argument: Feelings belong to the domain of emotions or
passions. They are erratic and can change depending on how the
swing of moods presents itself to the person. Hence, judgment
based on feelings is highly unstable and can hardly be relied
upon.
4. To follow one’s conscience is to follow one’s religious beliefs.
 The language of God is always love and peace. But the language
of those who kill in the name of God is hatred and violence.
Thus religious beliefs can be distorted by man due to his
concupiscence, greed and pride.
 PRINCIPLE OF A WELL-FORMED CONSCIENCE (INFORMED
CONSCIENCE)
o This principle states that:
“To have a good judgment of conscience, one is obliged to form it
diligently in accordance with some reasonable processes so that one
arrives at a right moral decision.”
o Conscience judges a concrete act as good or evil in accord with a norm
of morality given to it. This norm is NATURAL LAW.
o Well-formed Conscience:
To attain the true goals of human life by responsible actions, in every
free decision involving an ethical question, one is morally obliged to
do the following:
1. Inform himself as fully as practically possible about the facts and
the ethical norms. Knowledge of the Ethical principles is
necessary.
2. Form a morally certain judgment of conscience on the basis of
this information
3. Act according to this well-formed conscience;
4. Accept responsibility for his actions.
o Thus, to follow one’s conscience properly is to follow one’s well-formed
conscience.
o Morality always involves a choice in arriving at a moral decision:
1. There are many alternative means to a goal, some of which are
clearly in-appropriate, but often many are appropriate, each with
its advantages and disadvantages;
2. It is possible for people to reconsider their goals and to redefine
or even alter them in view of some higher goal.
 Man has the right to act in conscience and in freedom so as
personally to make moral decisions. He must not be forced to act
contrary to his conscience, nor must be prevented from acting
according to his conscience.
 EDUCATION OF CONSCIENCE
o The education of conscience is indispensable for human beings who
are subjected to negative influences and tempted by sin to prefer their
own judgment. The education of conscience is a LIFE-LONG TASK. From
the earliest years, it awakens the child to the knowledge and practice
on the interior law recognized by conscience. Prudent education
teaches virtue; it prevents or cures fear, selfishness, and pride,
resentment arising from guilt, and feelings of complacency, born of
human weakness and faults. The education of conscience guarantees
freedom and engenders peace of heart.
o An informed conscience needs knowledge of the facts and of the law, but
it also requires a disciplined or virtuous affection for what will truly
satisfy our needs in an integral manner.
o
MEDICAL ETHICS | 1
 Medical Ethics
Dr. E.T. Acevedo, MD, MPH, MPA
 DIVISIONS OF CONSCIENCE
A. LEVELS OF CONSCIENCE:
1. Antecedent - judgment on the morality of an action and the
obligation to perform or omit it is passed before the action is
translated into reality. - Commands, exhorts, permits, or forbids.
2. Concomitant - refers to the actual awareness of being morally
responsible for the goodness or the badness of a particular act which
we are carrying out.
3. Consequent - if it evaluates a deed already done or omitted. -
approves, excuses, reproves, or accuses.
B. QUALITIES WHICH REFER TO FREEDOM
1. Free - one is able to assume a personal moral stand with regard to a
particular action in a way that is unhindered, in order to answer
for that particular action or attitude.
2. Unfree - One’s moral attitude or responsibility for a particular action
is hindered by some obstacles such as fear or anger.
C. QUALITIES WHICH REFER TO OBJECTIVE VALUE:
1. Right - agrees with the objective norms of morality. It judges
conscience as morally right or wrong, in accordance with fact, that
is, when it judges as good that which is really good and as evil that
which is really evil. What is morally good, however, must not
necessarily be morally right, and vice versa.
2. Erroneous - conscience that is not true. There is lack of conformity
between the objective values and the moral demands that go with
them and one’s subjective moral perceptions, discernment, dictates,
and decisions in the habitual or actual levels of conscience. Either
vincibly or invincibly.
a. Vincibly erroneous - erroneous through the agent’s fault. This is
culpable, because with some good will its error could be
corrected. This cannot be followed as a legitimate rule of action.
 insufficient grounds, to judge a thing
 slightly evil, when actually it is gravely evil;
 to be lawful, while in fact it is unlawful & sinful;
 This is considered as vincibly erroneous.
b. Invincibly erroneous - erroneous without the knowledge or fault
of the agent. Inculpable, since the person has no awareness of the
possibility of error.
 The invincibly erroneous conscience must be followed just
the same as a certain consciencewhich is right.
D. QUALITIES WHICH REFER TO MORAL ATTITUDE:
1. Lax conscience or dulled conscience – is inclined, on
Compensatory conscience - a variety of lax conscience which
attempts to conceal a fundamental lack of generosity in the spiritual
life which is intended to divert attention from the unwillingness to
live up to one’s true vocation.
2. Strict conscience - shows that the conscience tends to judge
obligations too harshly, especially in an excessive legalistic way.
3. Scrupulous conscience - Scrupulosity is the persistent, gnawing,
unreasonable fear that one has offended God or is about to do so.
The scrupulous person is in constant dread of sin where there is
none, or of grave sin where there is only venial sin. St. Francis
de Sales points out that scrupulosity has its source in PRIDE. It must
be avoided as in lax conscience.
4. Pharisaical conscience - akin to the compensatory Conscience which
attaches great importance to small things and makes light of serious
matters. Conscience tends to be self-righteous as far as one’s own
moral evaluation is concerned.
5. Callous conscience - the worst type of conscience because it has no
sensitivity to sin, as if the person has no conscience at all.
6. Clear conscience - a conscience which confidently and freely acts
with due regard for perceiving, appreciating and internalizing true
values.
E. QUALITIES WHICH REFER TO DEGREE OF CERTITUDE:
1. Certain conscience - passes judgment without fear or error. An
absolutely certain conscience, however can still be erroneous.
a. A certain conscience must always be obeyed when it commands
or forbids. It is the competent and indispensable guide given to
man to discern his vocation and moral obligation. Therefore to
disobey this faculty is to disobey the moral order, it is to disobey
the will of God, and this is sin.
b. The certainty required for the judgments of conscience generally
need not be a strict moral certainty, but a wide moral certainty is
sufficient.
Group 5. Claud. Eian. Helaine. Jill. Marj. Sheen.
Lecture 5: Conscience
July 9, 2010
Examples:
 Strict moral certainty - people will not kill arbitrarily.
 Wide moral certainty - physicians will act responsibly & with
competence.
2. Doubtful or Dubious - uncertain concerning the morality of an action.
The agent cannot definitely decide whether the action to be done is
good or evil. The doubt may either concern the existence of a law
and moral principle or the existence of a fact.
Example:
 Legal or moral – therapeutic abortion
 Factual - presence of a cancerous growth in the uterus of a
pregnant woman.
Guide for action in doubtful conscience:
1) In a practical doubt about the lawfulness of an action one may
not act.
2) The action must be postponed until certainty can be reached.
Practical certainty can be gained directly by solving the doubt
through:
a. reflection on the case in the light of the general principles
b. consultation of experts and pertinent books
c. clarification of the facts, etc.
3) If the doubt cannot be solved directly-but only then-one may
attempt to gain practical certainty indirectly by the application
of the so-called reflex principles.
4) If there is no time or possibility to solve the doubt, one must
opt for the safer alternative, that is, one must favor the
alternative which excludes the danger of sin and injustice most
certainly.
o When in doubt about whether a course of action is ethical, give
benefit of the doubt to:
1) existing customs
2) established and well-known laws
3) usual way of acting
4) acceptance of what has already been done:
codes
policies
long experience
5) reflections
6) survival
3. Probable conscience - When conscience is doubtful, but grounded
upon solid reasons, the agent is said to have a probable opinion.
4. Perplexed conscience - The agent is confronted with two alternative
precepts and he is afraid of choosing any of the alternatives; a type
of erroneous conscience which, in a conflict of duties, fears sin in
whatever choice it makes. Classified as an erroneous conscience,
because objectively only one of the two conflicting obligations can
be binding. It would contradict justice and the wisdom of God if man
were confronted with two equally binding obligations, of which after
all he can fulfill only one.
Example:
 A resident physician feels obliged by precept of the Church to
go to Sunday Mass and bound by charity to report for duty in
the hospital because of a critically sick patient, the obligation of
charity should be preferred to the obligation of the
ecclesiastical precept.
 GUIDELINES FOR ACTION
1. Certain conscience must always be obeyed when it commands
or forbids. Certainty needs not be a strict moral certainty but a wide
moral certainty is sufficient.
2. Invincibly erroneous conscience must be followed just the
same as a certain conscience which is right.
3. The vincibly erroneous conscience, lax conscience, the
perplexed conscience and the doubtful conscience cannot be
followed as a legitimate rule of action.
o A Well-formed Conscience is one which may be antecedent,
concommittant, or consequent and one which is free, righteous, or
invincibly erroneous, clear and certain.
 THE CONSCIENCE OF THE PHYSICIAN VERSUS THE CONSCIENCE OF
THE PATIENT.
o In order for the patient to make a decision with an informed
conscience, the physician has to provide himself with the necessary
information. If the patient, owing to his age or condition, is unable to
judge the situation clearly, the physician has to give adequate
information to those who bear responsibility for him.
o When the doctor has done his duty in discussing the prospect of
success of a certain treatment or surgical intervention he will, after
sufficient dialogue, abide by the decision of the patient or of those
persons morally and legally responsible for him.
MEDICAL ETHICS | 2
 Medical Ethics Lecture 5: Conscience
Dr. E.T. Acevedo, MD, MPH, MPA July 9, 2010
o In some cases in which the physician has a well-informed and firm
conviction that a certain treatment or intervention is both immoral and
1. If, for instance, a fully conscious adult patient refuses a blood harmful to the patient’s well-being, he should expose the facts clearly,
transfusion in accordance with the teaching of his religious sect, the including of course the medical and ethical aspects.
doctor will abide by the patient’s request to let him die. If such a
request is not stated explicitly, the doctor will prescribe the  CERTITUDE IN ETHICAL DECISIONS REQUIRE:
transfusion in an emergency situation without questioning; he is o Adequate information
justified in assuming that a patient wants to be saved by the use of o Clear understanding of values
such an ordinary procedure especially if such a restriction has not o When making personal decisions about health care, one must have the
been unequivocally imposed on the attending physician. responsibility to follow informed conscience
2. Case of a child or a minor: Example:
 The doctor normally does not need an explicit permission from 1. Obtain as much relevant information as possible about a situation,
the family, at least for a life-saving transfusion, and can act on the both the facts and the objective moral standards (principles)
presupposition mentioned above. If, however, the family has applicable to the situations:
definitively insisted that no blood transfusion be given, the a. learn the facts about the medical condition,
physician will have to distinguish the moral from the legal aspect b. determine in accord with an objective value system the needs and
of the problem. Whereever there is no legislation, the doctor will rights of the people involved;
also save the life of the child should it be possible. However, when 2. Make and carry out a decision in accordance with this information.
legislation stipulates that the physician must follow the dictates
of the family, he will not always be empowered to perform the o Knowledge of the factors involved, however, is not enough to make a
transfusion. rational decision. This must be supported by a free will and a healthy
3. Cases when physician finds himself in disagreement with his patient emotion.
on some moral principle or its application:
 A particular human situation wherein the physician is convinced
that sterilization is necessary to ensure reasonable health or life
for the patient and stability for the family. The patient refuses,
because she considers sterilization absolutely immoral. Even if
there is justification in the procedure, the doctor is bound to
respect the patient’s decision.
4. The physician has the duty to give his patient proper health care
even if morally he disapproves of the life situation in which the
patient contacted the illness
Example:
 Patient with STD or AIDS.
5. A woman who committed criminal abortion comes to a physician for
professional assistance: Physician is duty-bound to help her. In due
time, he may refer to a matter of conscience in so far as this is part of
the healing process, or he may urge her, at the proper time, to
cooperate in denouncing the criminal so as to avoid harm to other
persons.
6. A doctor faced with the case of a suicidal neighbor, has, in
conscience, a right or duty to save the life of his neighbor even
against the latter’s will. the high probability is that the person
contemplating suicide is unable at that moment to make a truly
personal decision. However, the help which the doctor or any friend  QUIZ
may offer cannot be restricted to saving the biological life; rather, all o Ms. July A. Santos is a nurse who travelled to the USA to work in order
eforts should be directed towards helping the prospective suicide to to help her family back home. In the hospital where she workds, she
find the sense of his life and then arrive at a responsible decision. was asked to help in an abortion procedure which was legal in US.
7. A number of Catholic theologians have supported the concept of Now, Ms. Santos is a Catholic who does not believe in the procedure.
“freedom of choice of abortion” despite the declarations against Her conscience dictates that cooperating in the procedure is
abortion by the Vatican. They have argued: cooperating in the killing of the unborn child. Later, she was given
a. It is not always necessary or helpful to support morality by instruction that since abortion is legal, she may be committing an
law; illegal act by her uncooperative action and such may cost her job. This
b. There is no national consensus on the question; bothered her as she may not be able to help her family back home.
c. A law against abortion could not be enforced; 1. Can Ms. Santos object to the hospital based on the dictates of her
d. It might lead to abortion seems to be medically justified. conscience? Explain, briefly and direct to the point.
2. What can Ms. Santos conscientiously do to avoid such dilemma?
o What would be the proper process to inform one’s conscience on these
issues?
1. A fully conscioust patient refuses a blood transfusion in accordance
with the teaching of his religious sect.
DECISION
 The doctor will abide by the patient’s request to let him die. If
such request is not stated explicitly, the doctor will prescribe the
transfusion in an emergency situation without questioning; he is
justified in assuming that a patient wants to be saved by the use
of such an ordinary procedure especially if such a restriction has
not been unequivocally imposed on the attending physician.
2. Blood transfusion in a child or a minor:
DECISIONS
 Doctor normally does not need an explicit permission from the
family (considered as a life-saving procedure)
 If family has definitely insisted for no blood transfusion, physician
will have to distinguish the moral from the legal aspect of the
problem. Wherever there is no legislation, the doctor will save the
life of the child.

o Just as the doctor has to respect the patient’s conscience, so does the
patient incur the same obligation towards his physician.
o The patient should never request a treatment which he knows to be
against his doctor’s conscience.

Group 5. Claud. Eian. Helaine. Jill. Marj. Sheen. MEDICAL ETHICS | 3