Academic journal article Forum on Public Policy: A Journal of the Oxford Round Table

Nurses and Conundrums of Conscience

Academic journal article Forum on Public Policy: A Journal of the Oxford Round Table

Nurses and Conundrums of Conscience

Article excerpt

Nurses and Conundrums of Conscience

Conscience: The faculty or principle which pronounces upon the moral quality of one's actions or motives, approving the right and condemning the wrong (Oxford English Dictionary 2008).

There is much confusion and controversy in health care today concerning conscience, conscientious objection, and conscience clauses as they relate to health care professionals and some of the activities that they may be asked to perform. (1) Nurses, in particular, have said that they are expected to set aside their beliefs and values and do what others tell them to do even if this would mean acting contrary to their conscience (Laabs 2009). Some nurses have said that they must "deaden" their conscience in order to work in health care (Juthberg et al. 2007). These statements are puzzling. The right of conscience has long been recognized as a fundamental human right. Consider, for example, that freedom of belief and the right of conscience have been codified in the Universal Declaration of Human Rights over sixty years ago and remains so today (Universal Declaration of Human Rights 1948). (2) Still, these statements by nurses indicate that, as nurses, they believe they are expected to suppress their conscience and, thus, may not avail themselves of this right.

This apparent belief raises a number of questions. Why would a particular segment of society be expected to relinquish a human right shared by all? What is even more baffling is why some nurses seem to accept this apparent expectation. To freely enter into a profession knowing that you will be stripped of one of your fundamental rights as a result of being in that profession is perplexing. Perhaps nurses are not aware of this "expectation" until after they have become nurses, or, perhaps this is not an expectation at all but, rather, an unfortunate misunderstanding. Whether expectation or misunderstanding, the setting aside or deadening of conscience can have serious implications for nurses, patients who are cared for by nurses, and the health care system that employs nurses.

The expectation that nurses must set aside their conscience in order to work in health care may explain a problem that has plagued nursing and has been recognized recently in the literature as moral distress. (3) Although the literature may not use the word "conscience," per se, studies imply that violations of conscience are related to moral distress and to compromised moral integrity among nurses (Hardingham 2004; Kelly 1998; Laabs 2007), as well as other health care professionals, such as psychologists (Austin et al. 2005) and pharmacists (Sporrong, Hoglund, and Arentz 2006). Some propose that moral distress is unavoidable in health care (Sporrong et al.) and, thus, represents an occupational hazard for all health care professionals. Among nurses, moral distress and compromised moral integrity have been associated with nurses losing their capacity for caring, avoiding patient contact, failing to give good physical care to patients (Coney 1995; Davies et al. 1996; Kelly; Redman and Fry 2000), burning out, and leaving the nursing profession (Corney; Fowler 1989; Fry et al. 2002; Kelly). Given the chronic shortage of nurses, which is predicted to worsen and so far has defied a full explanation (Black, Spetz, and Harrington 2008; Rosenfeld and Adams 2008), the conundrums of conscience that confound nurses are in need of attention.

In this essay I offer some reflections on various understandings of conscience as they relate to nurses and the work they do. I then suggest that when conscience is conceptualized in terms of relativism and subjectivism, setting aside one's conscience may seem possible and perhaps even an understandable demand in a society with a wide range of moral points of view. However, such conceptions of conscience are not helpful to nurses who are often faced with decisions having serious moral implications, may contribute to nurses' moral distress, and may confound efforts by society to formulate a coherent and morally defensible policy on conscientious objection by health care professionals. …

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