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The Dictates of Conscience: Can They Justify Conscientious Refusals in Healthcare Contexts?



In a recent article in this journal, Steve Clarke (2017) identifies two different bases for conscience-based refusals in healthcare: (1) all-things-considered moral judgments, and (2) the dictates of conscience. He argues that these two bases have distinct roles in justifying conscientious objection. However, accepting that there are these two bases, I argue that both are not able to justify conscientious objection. In particular, I argue that the second basis of the dictates of conscience cannot justify conscience-based refusal in a healthcare context. Even if someone objects in a healthcare context on the basis of the dictates of her conscience, and even if we can explain why she objects with reference to the dictates of her conscience, her objection will only be justified if she makes a judgment.



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Acknowledgements: I would like to thank Samantha Vice and Jonathan Mitchell for comments on a previous version of this paper, as well as members of the Department of Philosophy at the University of the Witwatersrand for a number of helpful discussions



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1. Clarke, S. Two concepts of conscience and their implications for conscience-based refusal in healthcare. Cambridge Quarterly of Healthcare Ethics 2017;26:97108.

2. Following Clarke, my focus in this paper is on what role a person’s conscience can play in justifying conscientious objection. I want to home in on the role of conscience itself, leaving open the possibility that other factors may be important for assessing conscientious objection overall. These might include social factors that influence the values a person holds and what she is prepared to act on, but I am not here addressing what these factors and influences might be.

3. For discussion of the South African context, see Van Bogaert, L-J. The limits of conscientious objection to abortion in the developing world. Developing World Bioethics 2002;2:131–43; Harries, J, Cooper, D, Strebel, A, Colvin, CJ. Conscientious objection and its impact on abortion service provision in South Africa: a qualitative study. Reproductive Health 2014;11; Ngwenya, CG. Conscientious objection to abortion and accommodating women’s reproductive health rights: Reflections on a decision of the Constitutional Court of Colombia for an African regional human rights perspective. Journal of African Law 2014;58:183209; Mahlanga, E. Health workers undermining women’s rights. Health-e News 2017, Aug 14; available at (last accessed 17 Aug 2018). Other critiques of unconstrained scope for conscientious objection and how it impacts the rights of healthcare users can be found in Meyers, C, Woods, RD. An obligation to provide abortion services: What happens when physicians refuse? Journal of Medical Ethics 1996;22:115–20, looking at California in the USA, and Minerva, F. Conscientious objection in Italy. Journal of Medical Ethics 2015;41:170–3, looking at Italy. More general critiques focusing on the way unconstrained conscientious objection allows discrimination can be found in Kantymir, L, McLeod, C. Justification for conscience exemptions in healthcare. Bioethics 2014;28:1623 and Ancell, A, Sinnott-Armstrong, W. How to allow conscientious objection in medicine while protecting patient rights. Cambridge Quarterly of Healthcare Ethics 2017;26:120–31.

4. See note 3, Meyers, Woods 1996, and Meyers, C, Woods, RD. Conscientious objection? Yes, but make sure it is genuine. American Journal of Bioethics 2007;7:1920.

5. Card, RF. The inevitability of assessing reasons in debates about conscientious objection in medicine. Cambridge Quarterly of Healthcare Ethics 2017;26:8296.

6. Card, RF. Conscientious objection and emergency contraception. American Journal of Bioethics 2007;7:814; see note 5, Card 2017.

7. See note 3, Kantymir, McLeod 2014.

8. See note 1, Clarke 2017, at 100.

9. See note 1, Clarke 2017, at 101.

10. See note 1, Clarke 2017, at 101.

11. See note 1, Clarke 2017, at 102.

12. See note 1, Clarke 2017, at 101.

13. See note 1, Clarke 2017, at 103.

14. See note 1, Clarke 2017, at 102.

15. Thagard, P, Finn, T. Conscience: What is moral intuition? In: Bagnoli, C, ed. Morality and the Emotions . Oxford: Oxford University Press; 2011:150–69.

16. See note 15, Thagard, Finn 2011, at 150.

17. Different forms of this idea can be found in Scanlon, TM. What We Owe to Each Other. Cambridge, MA: Harvard University Press; 1998; Wallace, RJ. Three conceptions of rational agency. Ethical Theory and Moral Practice 1999;2:217–42; Jones, K. Emotions, weakness of will, and the normative conception of agency. In: Hatzimoysis, A, ed. Philosophy and the Emotions. Cambridge: Cambridge University Press; 2003:181200; Korsgaard, C. The normativity of instrumental reason. In: The Constitution of Agency: Essays on Practical Reason and Moral Psychology . Oxford: Oxford University Press; 2008:2768.

18. For more on arousal, motivation and justification of an action, see Carman, M. How emotions do not provide reasons to act. Philosophia 2018a;46:555574.

19. Charland, LC. The heat of emotion valence and the demarcation problem. Journal of Consciousness Studies 2005;12:82102.

20. Only at first glance, as there are other aspects of Clarke’s account that favor not interpreting him this way. But for the sake of being comprehensive, let us walk through how the affect-valence-as-basis might work.

21. See note 1, Clarke 2017, at 104.

22. See note 1, Clarke 2017, at 105.

23. See note 1, Clarke 2017, at 105.

24. See note 15, Thagard, Finn 2011, at 150. Italics added.

25. See note 19, Charland 2005.

26. Forms of this idea can be found in Goldie, P. The Emotions. Oxford: Oxford University Press; 2000; Johnston, M. The authority of affect. Philosophy and Phenomenological Research 2001;63:181214; Döring, S. Seeing what to do: Affective perception and rational motivation. Dialectica 2007;61:363–94; Helm, BW. Emotions as evaluative feelings. Emotion Review 2009;1:248–55.

27. See note 17, Jones 2003; also Arpaly, N. On acting rationally against one’s best judgment. In: Unprincipled Virtue: An Inquiry Into Moral Agency. Oxford: Oxford University Press; 2002:3365; Döring, S. Why be emotional? In: Goldie, P, ed. The Oxford Handbook of Philosophy of Emotion. Oxford: Oxford Basil Blackwell; 2010: 283301; Carman, M. Emotionally guiding our actions. Canadian Journal of Philosophy 2018b;48:4364.

28. See note 17, Jones 2003. I have elsewhere argued in favor of a version of Jones’ account, and will here just accept it as the most viable option. See note 27, Carman 2018b.

29. That said, Jones is someone who argues for the possibility of rational akratic actions (see note 17, Jones 2003). However, even on her account FC’s and the doctor’s actions are irrational because they do not accept their conscience as generally reliable. For a critique of Jones’ account and an explanation of why akratic action is in fact irrational, see note 27, Carman 2018b.

Acknowledgements: I would like to thank Samantha Vice and Jonathan Mitchell for comments on a previous version of this paper, as well as members of the Department of Philosophy at the University of the Witwatersrand for a number of helpful discussions

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Cambridge Quarterly of Healthcare Ethics
  • ISSN: 0963-1801
  • EISSN: 1469-2147
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