[Thoughts on conscience].
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Ethics, Medical↗
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The "incompatible idea" revisited: the oft-invisible ego-ideal and shame dynamics.
The observation that incompatibility with conscience initiates deployment of defense goes back to Freud's conceptualization of the "incompatible idea" put forward in Studies on Hysteria. In this view, consciousness itself, insofar as it gives rise to painful affect resulting from conflict with the conscience, is the cornerstone for dynamic thinking, first as regards repression of traumatic memory and later for dynamic thinking generally. Subsequent discoveries about the conscience tended to give rise to pars pro toto thinking in which the new discovery replaced rather than added to the basic notion of conscience. Such pars pro toto imbalance exists in full force in psychoanalytic thinking today: Modern conflict theory privileges the postoedipal retaliative aspect of the conscience, as Kleinian thinking does for the preoedipal projective aspects of retaliation. Neither conceptualizes shame adequately. Kohut appreciated the role of shame, but discarded the notion of incompatibility with the ego-ideal. The incompatible idea model still provides an all-inclusive model for conceptualizing the conscience in the context of intrapsychic conflict.
Consciousness↗
The meaning of being in ethically difficult care situations in paediatric care as narrated by female Registered Nurses.
Studies among physicians and nurses in paediatric care reveal experiences of loneliness and lack of open dialogue. The aim of this study was to illuminate the meaning of female Registered Nurses' lived experience of being in ethically difficult care situations in paediatric care. Twenty female Registered Nurses who had experienced being in ethically difficult care situations in paediatric care were interviewed as part of a comprehensive investigation into the narratives of male and female nurses and physicians about being in such situations. The transcribed interview texts were subjected to phenomenological-hermeneutic interpretation. The results showed that nurses appreciated social confirmation from their colleagues, patients and parents very much. This was a conditioned confirmation that was given when they performed the tasks expected from them. The nurses, however, felt that something was missing. They missed self-confirmation from their conscience. This gave them an identity problem. They were regarded as good care providers but at the same time, their conscience reminded them of not taking care of all the 'uninteresting' patients. This may be understood as ethics of memory where their conscience 'set them a test'. The emotional pain nurses felt was about remembering the children they overlooked, about bad conscience and lack of self-confirmation. Nurses felt lonely because of the lack of open dialogue about ethically difficulties, for example, between colleagues and about their feeling that the wrong things were prioritized in the clinics. In this study, problems arose when nurses complied with the unspoken rules and routines without discussing the ethical challenges in their caring culture. The rules and the routines of the caring culture represented structural barriers for creating open dialogue and an ethically justifiable practice, called inauthentic existence, blindness related to our own inauthentic understanding, which focuses on the routines, rules, theories and systems.
Adaptation, Psychological↗
Conscientious objection in medicine.
Recognition of conscientious objection seems reasonable in relation to controversial and contentious issues, such as physician assisted suicide and abortion. However, physicians also advance conscience-based objections to actions and practices that are sanctioned by established norms of medical ethics, and an account of their moral force can be more elusive in such contexts. Several possible ethical justifications for recognizing appeals to conscience in medicine are examined, and it is argued that the most promising one is respect for moral integrity. It is also argued that an appeal to conscience has significant moral weight only if the core ethical values on which it is based correspond to one or more core values in medicine. Finally, several guidelines pertaining to appeals to conscience and their ethical evaluation are presented.
Conscience↗
Practical virtue ethics: healthcare whistleblowing and portable digital technology.
Medical school curricula and postgraduate education programmes expend considerable resources teaching medical ethics. Simultaneously, whistleblowers' agitation continues, at great personal cost, to prompt major intrainstitutional and public inquiries that reveal problems with the application of medical ethics at particular clinical "coalfaces". Virtue ethics, emphasising techniques promoting an agent's character and instructing their conscience, has become a significant mode of discourse in modern medical ethics. Healthcare whistleblowers, whose complaints are reasonable, made in good faith, in the public interest, and not vexatious, we argue, are practising those obligations of professional conscience foundational to virtue based medical ethics. Yet, little extant virtue ethics scholarship seriously considers the theoretical foundations of healthcare whistleblowing. The authors examine whether healthcare whistleblowing should be considered central to any medical ethics emphasising professional virtues and conscience. They consider possible causes for the paucity of professional or academic interest in this area and examine the counterinfluence of a continuing historical tradition of guild mentality professionalism that routinely places relationships with colleagues ahead of patient safety.Finally, it is proposed that a virtue based ethos of medical professionalism, exhibiting transparency and sincerity with regard to achieving uniform quality and safety of health care, may be facilitated by introducing a technological imperative using portable computing devices. Their use by trainees, focused on ethical competence, provides the practical face of virtue ethics in medical education and practice. Indeed, it assists in transforming the professional conscience of whistleblowing into a practical, virtue based culture of self reporting and personal development.
Attitude of Health Personnel↗
Pharmacies, pharmacists, and conscientious objection.
This paper examines the obligations of pharmacy licensees and pharmacists in the context of conscience-based objections to filling lawful prescriptions for certain types of medications--e.g., standard and emergency contraceptives. Claims of conscience are analyzed as means to preserve or maintain an individual's moral integrity. It is argued that pharmacy licensees have an obligation to dispense prescription medications that satisfy the health needs of the populations they serve, and this obligation can override claims of conscience. Although efforts should be made to respect the moral integrity of pharmacists and accommodate their claims of conscience, it is argued that the health needs of patients and the professional obligations of pharmacists limit the extent to which pharmacists may refuse to assist patients who have lawful prescriptions for medically indicated drugs.
Codes of Ethics↗
Gene therapy, human nature and the churches.
Moral analysis must begin with respect for the empirical features, the "facts of the case". Major advances in genetic knowledge and technology -- as in other sciences -- inevitably change mental attitudes. But they could not change human nature, a product of the distinctively human cerebral cortex. Human capacities like compassion and justice are our own and for us to guard. To ask (as some do) about a "right" to inherit a non-manipulated genome is to ask an unanswerable question: the language of rights is inappropriate in this context. Parents have a duty to safeguard and to serve the interests of their potential child. The medical duty is to help in that task in ways which they have limited freedom to choose. The role of churches is to be faithful to their deposit of faith and their theological principles, including that of freedom of conscience. Churches are too easily led in practice to over-rule conscience on grounds of authority, ecclesiastical or biblical, not sustained by convincing reason. This is most evident in some declarations concerning human reproduction. Better were it for them to help their faithful in moral reasoning, the ethics of choice; to keep consciences tender.
Altruism↗
Moral and religious objections by hospitals to withholding and withdrawing life-sustaining treatment.
A patient's right to decide about life-sustaining treatment may conflict with the policies of health care facilities that refuse on the basis or religious or moral convictions to honor certain decisions to forgo treatment. The New York State Task Force on Life and the Law examined the prevalence and nature of facility conscience objections to the refusal of life-sustaining treatment by conducting a survey of New York hospitals. Written questionnaires were distributed to hospitals in New York State. Fifty-eight percent of the New York State hospitals responded. Twenty-nine percent of the respondents indicated that their hospital would object on grounds of conscience either to withholding or to withdrawing life-sustaining treatment in at least one of the twelve hypothetical cases presented. Hospitals were more likely to have "no policy" for withdrawing than for withholding treatment. Only 10% of the hospitals that would object to decisions to forgo treatment on religious or moral grounds had stated the objections in writing. The patient's medical condition and the type of life-sustaining treatment to be withdrawn or withheld are important factors in determining whether a hospital will object on grounds of conscience. The imminence of death appeared more decisive than the degree of debilitation or disability as a factor in the willingness to accept decisions to forgo life-sustaining treatment. Hospitals should establish clear, written policies about their objections to forgoing treatment so that patients and their families can evaluate whether the facility meets their needs.
Advisory Committees↗
Emergency contraception provision: a survey of emergency department practitioners.
OBJECTIVES: To determine emergency department (ED) practitioner willingness to offer emergency contraception (EC) following sexual assault and consensual sex, and to compare responses of practitioners from states whose laws permit the refusal, discussion, counseling, and referral of patients for abortions (often called "opt-out" or "abortion-related conscience clauses") with those of practitioners from states without these laws. METHODS: Using a structured questionnaire, a convenience sample of ED practitioners attending a national emergency medicine meeting was surveyed. RESULTS: The 600 respondents were: 71% male, 29% female; 34% academic, 26% community, and 33% resident physicians; and 7% nurse practitioners and physician assistants. Many respondents (88%) were inclined to offer EC to those sexually assaulted by unknown assailants. More practitioners said they were willing to offer EC if the assailant was known to be HIV-infected rather than if the assailant had low HIV risk factors (90% vs. 79%, p < 0.01). More respondents would prescribe EC after sexual assault than consensual sex (88% vs. 73%, p < 0.01). The rates of willingness to offer EC were the same for practitioners in states with "abortion-related conscience clauses" and those from other states. CONCLUSIONS: Most ED practitioners said they were willing to offer EC. Although the risk of pregnancy exists after consensual sex, practitioners were less willing to prescribe EC after those exposures than for sexual assault. "Abortion-related conscience clauses" did not seem to influence willingness to offer EC.
Adolescent↗
[Revolution is a sensitive undertaking].
A psychological condition of exhaustion, accompanied by panic, triggered by a conversion symptom understood as the "emergency braking" of a drive towards a greater enjoyment of life because of a conflict of conscience arose which was held at bay. The symptom fades away, the drive is not given up in its entirety but is projected onto the loved one. The patient allows her conscience to take over once more in that she takes on the role of the conscience for her loved one. The price is possible satisfaction.
Adaptation, Psychological↗
Internal-external locus of control and guilt.
This study examined the relationship between internal-external locus of control and guilt. Ss were 65 male and 137 college undergraduates who completed the Rotter I-E scale and the Mosher Hostility and Morality-Conscience Guilt Scales. Results demonstrated that internals reported a higher degree of hostility guilt than externals. Also, females expressed greater hostility and morality-conscience guilt than males.
Conscience↗
Parental discipline and externalizing behavior problems in early childhood: the roles of moral regulation and child gender.
We tested whether individual differences in a component of early conscience mediated relations between parental discipline and externalizing behavior problems in 238 3.5-year-olds. Parents contributed assessments of discipline practices and child moral regulation. Observations of children's behavioral restraint supplemented parental reports. Parents and teachers reported on child externalizing symptoms. Parental induction, warm responsiveness, and less frequent use of physical punishment generally were associated with higher levels of moral regulation and fewer externalizing problems. Moreover, moral regulation partially mediated relationships between discipline and externalizing symptoms, with the clearest case of mediation involving induction. However, relationships were found for boys only. Results support a mediation model wherein inductive and physical discipline may influence the expression of boys' externalizing behavior through effects on conscience. Finally, results suggest that different developmental processes may be associated with early externalizing problems in boys and girls, and confirm that fathers' reports contribute to our understanding of the origins of child externalizing problems.
Child↗
Conscientious objection and abortifacient drugs.
The legal right to assert a conscientious objection is reviewed, using as an example the dispensing of abortifacient drugs by pharmacists. The three areas of law that most significantly concern the right to assert a conscientious refusal are employment law, conscience clauses, and religious discrimination law. Each of these is reviewed, with descriptions of recent cases. It is concluded that employment law protects refusals that are consistent with public policy, but does not permit an employee's personal policy to determine how a business will be run; that conscience clauses appear to provide protection for pharmacists who object to dispensing abortifacients, but that the precise meanings of critical words and phrases in some clauses need to be defined; and that even though laws of religious discrimination require that employers accommodate religious beliefs, they may not protect a pharmacist who objects to dispensing abortifacients if the accommodation becomes unreasonably burdensome.
Abortifacient Agents↗
[The Six Factor Test--a personality questionnaire for clinical practice and research].
BACKGROUND: The Six factor Test (SFT) is a personality questionnaire for assessment of the "big five" (neuroticism, extraversion, conscience, aggressivity, openness to experiences) and piety in patients with mental disorders and healthy subjects. METHODS: In a study of 360 probands (125 depressive and bipolar patients, 150 first-degree relatives of these patients, and 85 controls), the reliability and validity of the SFT was examined. Thirty-five controls and 79 relatives were reinvestigated after around 6.5 years. RESULTS: The factorial structure could be replicated, and the concurrent validity was moderate to high. Acceptable internal consistency was observed, with the exceptions of "openness" and "agreeableness". The retest reliability was high, with the exception of "openness". Patients differed from controls in neuroticism and "openness". These factors were also predictive for the first onset of psychiatric disorders in controls and relatives, respectively. CONCLUSION: The SFT is a short und simple instrument for the assessment of personality in clinical samples and controls. Reliability and validity of the three main scales (neuroticism, extraversion, and conscience) were acceptable. The corresponding coefficients of the three shorter scales, in particular of openness, were partly much lower.
Adult↗
Ethical analyses of vaccines grown in human cell strains derived from abortion: arguments and Internet search.
The fact that certain vaccines are grown in cell strains derived decades ago from an aborted fetus is a concern for some. To understand such concerns, a standardized search identified internet sites discussing vaccines and abortion. Ethical concerns raised include autonomy, conscience, coherence, and immoral material complicity. Two strategies to analyse moral complicity show that vaccination is ethical: the abortions were past events separated in time, agency, and purpose from vaccine production. Rubella disease during pregnancy results in many miscarriages and malformations. Altruism, the burden of rubella disease, and protection by herd immunity argue for widespread vaccination although autonomous decisions and personal conscience should be respected.
Abortion, Induced↗
The socialization of aggression in five-year-old boys.
Studies of the relationship between child-rearing and moral development have been represented as supporting cognitive theories of the moral development process. These data have been misinterpreted, since cognitive developmental theory assumes the objective status of moral properties. The significance of the child-rearing studies is re-examined (Ss were 70 mothers and their five-year-old sons) through the application of a new conceptualization of "reasoning" to a study of the relationship between child-rearing and aggression-anxiety in five-year-old boys. In contrast to the notion that different types of moral view have different logical structures, empirical support is offered for the thesis that the difference between the "liberal" conscience and the "authoritarian" conscience reflects a difference in defense against hostile impulses.
Aggression↗
Effortful control as a personality characteristic of young children: antecedents, correlates, and consequences.
Effortful control, the ability to suppress a dominant response to perform a subdominant response, was assessed in 106 children during early childhood (at 22, 33, and 45 months) using multitask behavioral batteries. By 45 months, effortful control was highly longitudinally stable and coherent across tasks and thus appeared to be a traitlike characteristic of children's personality. Children who had been less intense in terms of proneness to anger and joy, and those who had been more inhibited to the unfamiliar in the second year developed higher effortful control. Children with higher effortful control at 22-45 months developed stronger consciences at 56 months and displayed fewer externalizing problems at 73 months. Effortful control mediated the oft-reported relations between maternal power assertion and impaired conscience development in children, even when child management difficulty was controlled.
Child Behavior↗
How physicians face ethical difficulties: a qualitative analysis.
BACKGROUND: Physicians face ethical difficulties daily, yet they seek ethics consultation infrequently. To date, no systematic data have been collected on the strategies they use to resolve such difficulties when they do so without the help of ethics consultation. Thus, our understanding of ethical decision making in day to day medical practice is poor. We report findings from the qualitative analysis of 310 ethically difficult situations described to us by physicians who encountered them in their practice. When facing such situations, the physicians sought to avoid conflict, obtain assistance, and protect the integrity of their conscience and reputation, as well as the integrity of the group of people who participated in the decisions. These goals could conflict with each other, or with ethical goals, in problematic ways. Being aware of these potentially conflicting goals may help physicians to resolve ethical difficulties more effectively. This awareness should also contribute to informing the practice of ethics consultation. OBJECTIVE: To identify strategies used by physicians in dealing with ethical difficulties in their practice. DESIGN, SETTING, AND PARTICIPANTS: National survey of internists, oncologists, and intensive care specialists by computer assisted telephone interviews (n = 344, response rate = 64%). As part of this survey, we asked physicians to tell us about a recent ethical dilemma they had encountered in their medical practice. Transcripts of their open-ended responses were analysed using coding and analytical elements of the grounded theory approach. MAIN MEASUREMENTS: Strategies and approaches reported by respondents as part of their account of a recent ethical difficulty they had encountered in their practice. RESULTS: When faced with ethical difficulties, the physicians avoided conflict and looked for assistance, which contributed to protecting, or attempting to protect, the integrity of their conscience and reputation, as well as the integrity of the group of people who participated in the decisions. These efforts sometimes reinforced ethical goals, such as following patients' wishes or their best interests, but they sometimes competed with them. The goals of avoiding conflict, obtaining assistance, and protecting the respondent's integrity and that of the group of decision makers could also compete with each other. CONCLUSION: In resolving ethical difficulties in medical practice, internists entertained competing goals that they did not always successfully achieve. Additionally, the means employed were not always the most likely to achieve those aims. Understanding these aspects of ethical decision making in medical practice is important both for physicians themselves as they struggle with ethical difficulties and for the ethics consultants who wish to help them in this process.
Adult↗