Every day situations arising in health care contain ethical issues influencing care providers' conscience. How and to what extent conscience is influenced may differ according to how conscience is perceived. This study aimed to explore the relationship between perceptions of conscience and stress of conscience among care providers working in municipal housing for elderly people. A total of 166 care providers were approached, of which 146 (50 registered nurses and 96 nurses' aides/enrolled nurses) completed a questionnaire containing the Perceptions of (...) Conscience Questionnaire and the Stress of Conscience Questionnaire. A multivariate canonical correlation analysis was conducted. The first two functions emerging from the analysis themselves explained a noteworthy amount of the shared variance (25.6% and 17.8%). These two dimensions of the relationship were interpreted either as having to deaden one's conscience relating to external demands in order to be able to collaborate with coworkers, or as having to deaden one's conscience relating to internal demands in order to uphold one's identity as a `good' health care professional. (shrink)

The conception of conscience that dominates discussions in bioethics focuses narrowly on private regulation of behaviour resulting from explicit attitudes. It neglects to mention implicit attitudes and the role of social feedback in becoming aware of one's implicit attitudes. But if conscience is a way of ensuring that a person's behaviour is in line with her moral values, it must be responsive to all aspects of the mind that influence behaviour. There is a wealth of recent psychological work demonstrating the (...) influence of implicit attitudes on behaviour. A necessary part of having a well-functioning conscience must thus be awareness and regulation of one's implicit attitudes in addition to one's explicit attitudes; this cannot be done by an individual in isolation. On my revised conception of conscience, heeding social feedback, being emotionally self-aware and engaging in self-monitoring are important for the possession of a well-functioning conscience. Health professionals may need specific training to help them develop and maintain a well-functioning conscience, which should involve cultivation of awareness of implicit attitudes, emphasis on social feedback and techniques to enable better control over them. (shrink)

In this paper I uncover and critically analyze a methodological assumption in the literature on conscientious refusals in health care. The assumption is what I call the “Priority of Conscience Principle,” which says the following: to determine the moral status of any act of conscientious refusal, it is first necessary to determine the nature and value of conscience. I argue that it is not always necessary to discuss conscience in the debate on conscientious refusals, and that discussing conscience is even (...) problematic, since it can lead authors to beg the question. (shrink)

The ultimate goal of research into computational intelligence is the construction of a fully embodied and fully autonomous artificial agent. This ultimate artificial agent must not only be able to act, but it must be able to act morally. In order to realize this goal, a number of challenges must be met, and a number of questions must be answered, the upshot being that, in doing so, the form of agency to which we must aim in developing artificial agents comes (...) into focus. This chapter explores these issues, and from its results details a novel approach to meeting the given conditions in a simple architecture of information processing. (shrink)

The aim of this article is twofold. Against the traditional interpretation of ‘the conscience of Huckleberry Finn’ (for which Jonathan Bennett's article with this title is the locus classicus) as a conflict between conscience and sympathy, I propose a new interpretation of Huck's inner conflict, in terms of Huck's mastery of (the) moral language and its integration with his moral feelings. The second aim is to show how this interpretation can provide insight into a particular aspect of moral education: learning (...) a moral language. A moral education that has a proper regard for the flexibility of moral language and the importance of the integration of moral language and (pre-)moral feelings should prevent such conflicts as Huck experienced from arising. (shrink)

This article considers the difficult question of whether there are any reasons for theocratic religious devotees to affirm liberalism and liberal institutions. Swaine argues not only that there are reasons for theocrats to affirm liberalism, but that theocrats are committed rationally to three normative principles of liberty of conscience, as well. Swaine subsequently discusses three institutional and strategic implications of his arguments. First, he outlines an option of semisovereignty for theocratic communities in liberal democracies, and explains why an appropriate valuation (...) of liberty of conscience may justify a standard of that kind. Second, he addresses the question of permissible government aid for religion and symbolic endorsement of religious groups. Third, Swaine considers innovations and new approaches that could be employed internationally to better display liberal government's affirmation of religiosity, to promote liberty of conscience, and to help improve relations between liberal and theocratic parties around the globe. (shrink)

A dogma accepted in many ethical, religious, and legal frameworks is that the reasons behind conscientious objection (CO) in healthcare cannot be evaluated or judged by any institution because conscience is individual and autonomous. This paper shows that this background view is mistaken: the requirement to reveal and explain the reasons for conscientious objection in healthcare is ethically justified and legally desirable. Referring to real healthcare cases and legal regulations, this paper argues that these reasons should be evaluated either ex (...) ante or ex post and defends novel conceptual claims that have not been analyzed in the debates on CO. First, a moral threshold requirement: CO is only justified if the reasons behind a refusal are of a moral nature and meet a certain threshold of moral importance. Second, this paper considers the rarely discussed conceptual similarities between CO in healthcare and the legal regulations concerning military refusals that place the burden of proof on conscientious objectors. This paper concludes that conscientious objection in healthcare can be accommodated only in some cases of destroying or killing human organisms. (shrink)

This article attempts to motivate a reorientation of ethical analysis of conscientious objection by physicians. First, it presents an illustrative case from a hospital emergency department for context. Then, it criticizes the standard pro- and anti-CO arguments. It proposes that the fault in standard approaches is to focus on the ethics of the physician’s behavior, and a better way forward on this issue is to ask how the party against whom the physician exercises the CO ought to respond. It connects (...) this question with recent trends in physician employment models, which suggest that CO may become a potential source of conflict in the future. The article then develops a relational account of CO that extends James Childress’ insights about the nature of CO in “Appeals to Conscience”. This relational account characterizes CO as a two-place relation between conscientious objector and expectant party, in which the conscientious objector makes a request of the expectant party, which has implications that will be welcome and unwelcome for both the pro- and anti-CO camps. Finally, the paper applies this relational account of CO to the case when the physician is an employee. This application demonstrates that it is highly context dependent whether or not an employer should accede to the CO requests of physician–employees. (shrink)

This article attempts to motivate a reorientation of ethical analysis of conscientious objection by physicians. First, it presents an illustrative case from a hospital emergency department for context. Then, it criticizes the standard pro- and anti-CO arguments. It proposes that the fault in standard approaches is to focus on the ethics of the physician’s behavior, and a better way forward on this issue is to ask how the party against whom the physician exercises the CO ought to respond. It connects (...) this question with recent trends in physician employment models, which suggest that CO may become a potential source of conflict in the future. The article then develops a relational account of CO that extends James Childress’ insights about the nature of CO in “Appeals to Conscience”. This relational account characterizes CO as a two-place relation between conscientious objector and expectant party, in which the conscientious objector makes a request of the expectant party, which has implications that will be welcome and unwelcome for both the pro- and anti-CO camps. Finally, the paper applies this relational account of CO to the case when the physician is an employee. This application demonstrates that it is highly context dependent whether or not an employer should accede to the CO requests of physician–employees. (shrink)

This article attempts to motivate a reorientation of ethical analysis of conscientious objection by physicians. First, it presents an illustrative case from a hospital emergency department for context. Then, it criticizes the standard pro- and anti-CO arguments. It proposes that the fault in standard approaches is to focus on the ethics of the physician’s behavior, and a better way forward on this issue is to ask how the party against whom the physician exercises the CO ought to respond. It connects (...) this question with recent trends in physician employment models, which suggest that CO may become a potential source of conflict in the future. The article then develops a relational account of CO that extends James Childress’ insights about the nature of CO in “Appeals to Conscience”. This relational account characterizes CO as a two-place relation between conscientious objector and expectant party, in which the conscientious objector makes a request of the expectant party, which has implications that will be welcome and unwelcome for both the pro- and anti-CO camps. Finally, the paper applies this relational account of CO to the case when the physician is an employee. This application demonstrates that it is highly context dependent whether or not an employer should accede to the CO requests of physician–employees. (shrink)

*Runner-up for the 2021 Royal Institute for Philosophy Essay Prize*: What should we think about ‘acts of conscience’, viz., cases where our personal judgments and public authority come into conflict such that principled resistance to the latter seems necessary? Philosophers mainly debate two issues: the Accommodation Question, i.e., ‘When, if ever, should public authority accommodate claims of conscience?’ and the Justification Question, i.e., ‘When, if ever, are we justified in engaging in acts of conscience – and why?’. By contrast, a (...) third important topic – the Conduct Question, i.e., ‘How should we act, morally speaking, when engaging in acts of conscience?’ – has been mostly neglected. This paper aims to offer concrete guidance for persons wishing to engage in acts of conscience in morally virtuous ways. I argue that such agents are subject to two basic prima facie duties: duties to oneself related to demands of integrity and duties to others related to demands of civility. I explain both duties in detail, arguing with regard to, that in light of what I call ‘the paradox of conscience’, we need to rethink our views about both ‘conscience’ and ‘integrity’; and with regard to, that, building upon Rawls’ ‘duty of civility’, we should embrace at least seven general principles for undertaking acts of conscience in a morally conscientious manner. (shrink)

. John Cottingham suggests that “only a traditional theistic framework may be adequate for doing justice to the role of conscience in our lives.” Two main reasons for endorsing this proposition are assessed: the religious origins of conscience, and the need to explain its normative authority. I argue that Graeco-Roman conceptions of conscience cast doubt on this first historical claim, and that secular moral realisms can account for the obligatoriness of conscience. Nevertheless, the recognition of the need for an objective (...) foundation for conscience which emerges from these debates should be embraced by both secular and religious ethicists alike. (shrink)

This study develops conceptual means in philosophy of agency to better and more systematically address intentional omissions of agents, including those that are about resisting the action not done. I argue that even though philosophy of agency has largely concentrated on the actions of agents, when applying philosophy of action to the social sciences, a full-blown theoretical account of what agents do not do and a non-normative conceptual language of the phenomena in question is needed. Chapter 2 aims to find (...) out what kind of things intentional omissions are. I argue that although intentional omissions are part of our intentional behavior, they are not actions in the sense that the standard account of action assumes. Instead, because intentional omissions are homogenous, continuous, unbounded, indefinite and directly uncountable, they should be thought of as activities instead of performances. This view links the ontology of intentional omissions to the ontology of processes instead of to that of events, and I argue that this kind of ontology accounts for the fluid nature of the agency of alive agents not only instigating but controlling and sustaining their intentional omissions as well. Chapter 3 aims to find out on what conditions is an omission intentional. The aim is to find a naturalized explanation of them that would make it possible to combine psychological perspectives with philosophical ones so that intentional omissions could be treated as something that exist in the world, not just in our philosophical intuitions. I argue that intentional omissions necessarily require the agent’s procedural metacognition concerning the action not done. Based on this metacognition view, a non-normative conceptual typology of not doings is presented. Chapter 4 aims to find out on what conditions is an intentional omissions resistance toward something. The necessary elements of resistance are clarified and I argue that resistant intentional omissions in which the agent does not perform an action out of resistance toward something are a normal part of our everyday agency. The implications of the findings are considered for theories of action, especially when it comes to the belief-desire model that may not be able to fully account for resistant intentional omissions. Chapter 5 aims to find out what conceptual means do we have for talking about not doing something as a form of resistance. I argue that in the social sciences, bioethics and military ethics to not do something out of resistance is taken as something that exists, and as something that has causes and effects. However, concepts such as civil disobedience, conscientious refusing, exit and everyday resistance do not account for the ordinariness of this kind of not doings. Thus, I argue that such concepts are not able to fully cover resistant inaction and philosophy of intentional omissions can be of use not just in the social sciences. Finally, Chapter 6 considers the implications of these findings. The main implication of this study is that our view of social and ethical agency would need to better include intentional not doings, not just the sum of the intentional actions of agents. Another major implication is that agents themselves should be heard when analyzing their intentional omissions in society, because intentional omissions are phenomena that can easily be mixed with the passivities of agents from the perspective of an outside observer. (shrink)

Answers to the questions of what justifies conscientious objection in medicine in general and which specific objections should be respected have proven to be elusive. In this paper, I develop a new framework for conscientious objection in medicine that is based on the idea that conscience can express true moral claims. I draw on one of the historical roots, found in Adam Smith’s impartial spectator account, of the idea that an agent’s conscience can determine the correct moral norms, even if (...) the agent’s society has endorsed different norms. In particular, I argue that when a medical professional is reasoning from the standpoint of an impartial spectator, his or her claims of conscience are true, or at least approximate moral truth to the greatest degree possible for creatures like us, and should thus be respected. In addition to providing a justification for conscientious objection in medicine by appealing to the potential truth of the objection, the account advances the debate regarding the integrity and toleration justifications for conscientious objection, since the standard of the impartial spectator specifies the boundaries of legitimate appeals to moral integrity and toleration. The impartial spectator also provides a standpoint of shared deliberation and public reasons, from which a conscientious objector can make their case in terms that other people who adopt this standpoint can and should accept, thus offering a standard fitting to liberal democracies. (shrink)

This article challenges the individualism and neutrality of modern moral conscience. It looks to the history of the concept to excavate an older tradition that takes conscience to be social and morally responsive, while arguing that dominant contemporary justifications of conscience in terms of integrity are inadequate without reintroducing these social and moral traits. This prompts a rethinking of the nature and value of conscience: first, by demonstrating that a morally-responsive conscience is neither a contradiction in terms nor a political (...) absurdity; second, by suggesting how a morally-responsive conscience can be informed by the social world without being a mere proxy for social power or moribund tradition. (shrink)

I will argue that physicians have an ethical obligation to justify their conscientious objection and the most reliable interpretation of the Polish legal framework claims that conscientious objection is permissible only when the justification shows the genuineness of the judgment of conscience that is not based on false beliefs and arises from a moral norm that has a high rank. I will demonstrate that the dogma accepted in the Polish doctrine that the reasons that lie behind conscientious objection in medicine (...) cannot be evaluated or controlled by anyone is based either on a mistaken interpretation of the Constitution or on the unreliable concept of conscience. I will refer to the legal regulations concerning military refusals that require from objectors to reveal and justify their views. Finally, I will demonstrate why conscientious objection under uncertainty does not deserve acceptance, because it is based on a specific version of the precautionary principle. (shrink)

“It's almost like putting salt in a wound, for this person who's already made a very difficult decision,” suggested Meghan Patterson, a licensed obstetrician-gynecologist whom we interviewed in our qualitative study of the experiences of North Carolina abortion providers practicing under the state's Woman's Right to Know Act. The act requires that women receive counseling with state-mandated information at least twenty-four hours prior to obtaining an abortion. After the law was passed, Patterson worked with clinic administrators, in consultation with a (...) lawyer, to write a script to be used in the state-mandated counseling procedure. She and her colleagues took particular steps to mitigate the effects of what she described as HB 854's “forced language”—such as referring to the “father of the child.” While HB 854 stipulated that patients must be informed of the medical risks associated with the particular abortion procedure as well as those of carrying the child to term, Patterson's script made explicit the magnitude of comparative risks, emphasizing that the risks of carrying a pregnancy to term are substantially greater than the risks of an early-term abortion. She felt that these contextualization strategies helped to facilitate trust and rapport in a clinical care situation that proved relationally and morally challenging. In this article, we take up and expand on this point by elucidating an empirically grounded approach to ethically justified care when health care providers face legal or institutional policy mandates that raise possible moral conflicts. Our approach builds on recent bioethics discourse addressing conscience in the practice of medicine. While the concept of conscience has broad philosophical underpinnings relating to moral judgment, agency, and discernments of right and wrong, debates in bioethics have tended to engage the concept primarily vis-à-vis rights of conscientious objection or refusal. Here, we suggest a broader frame for thinking about claims of conscience in health care. Our approach draws on the feminist bioethics and the ethics of care literatures to highlight how providers may be motivated by matters of conscience, including relational concerns, in the active provision of certain forms of care. What emerges are two possibilities: not only conscientious refusal to comply with a policy mandate but also conscientious compliance—working conscientiously within a mandate's confines. (shrink)

This paper addresses the likely impact on women of being denied emergency contraception (EC) by pharmacists who conscientiously refuse to provide it. A common view—defended by Elizabeth Fenton and Loren Lomasky, among others—is that these refusals inconvenience rather than harm women so long as the women can easily get EC somewhere else nearby. I argue from a feminist perspective that the refusals harm women even when they can easily get EC somewhere else nearby.

Health care often involves ethically difficult situations that may disquiet the conscience. The purpose of this study was to develop a questionnaire for identifying various perceptions of conscience within a framework based on the literature and on explorative interviews about perceptions of conscience (Perceptions of Conscience Questionnaire). The questionnaire was tested on a sample of 444 registered nurses, enrolled nurses, nurses’ assistants and physicians. The data were analysed using principal component analysis to explore possible dimensions of perceptions of conscience. The (...) results showed six dimensions, found also in theory and empirical health care studies. Conscience was perceived as authority, a warning signal, demanding sensitivity, an asset, a burden and depending on culture. We conclude that the Perceptions of Conscience Questionnaire is valid for assessing some perceptions of conscience relevant to health care providers. (shrink)

Since the U.S. Supreme Court's decision in Dobbs vs. Jackson Women's Health Organization, a growing web of state laws restricts access to abortion. Here we consider how, ethically, doctors should respond when terminating a pregnancy is clinically indicated but state law imposes restrictions on doing so. We offer a typology of cases in which the dilemma emerges and a brief sketch of the current state of legal prohibitions against providing such care. We examine the issue from the standpoints of conscience, (...) professional ethics, and civil disobedience and conclude that it is almost always morally permissible and praiseworthy to break the law and that, in a subset of cases, it is morally obligatory to do so. We further argue that health care institutions that employ or credential physicians to provide reproductive health care have an ethical duty to provide a basic suite of practical supports for them as they work to ethically resolve the dilemmas before them. (shrink)

Conscience is an idea that has significant currency in liberal democratic societies. Yet contemporary moral philosophical scholarship on conscience is surprisingly sparse. This paper seeks to offer a rigorous philosophical account of the role of conscience in moral life with a view to informing debates about the ethics of conscientious objection in medicine. I argue that conscience is concerned with a commitment to moral integrity and that restrictions on freedom of conscience prevent agents from living a moral life. In section (...) one I argue that conscience is a principle of moral awareness in rational agents, and that it yields an awareness of the personal nature of moral obligation. Conscience also monitors the coherence between an agent’s identity-conferring beliefs and intentions and their practical actions. In section two I consider how human beings are harmed when they are forced to violate their conscience. Restrictions on the exercise of conscience prevent people from living in accord with their own considered understanding of the requirements of morality and undermine one’s capacity for moral agency. This article concludes with a consideration of how a robust theory of conscience can inform our understanding of conscientious objection in medicine. I argue that it is in the interest of individual practitioners and the medical profession generally to foster moral agency among doctors. This provides a prima facie justification for permitting at least some kinds of conscientious objection. (shrink)

This paper comes out of a panel honoring the work of Anne Donchin (1940-2014), which took place at the 2016 Congress of the International Network on Feminist Approaches to Bioethics (FAB) in Edinburgh. My general aim is to highlight the contributions Anne made to feminist bioethics, and to feminist reproductive ethics in particular. My more specific aim, however, is to have a kind of conversation with Anne, through her work, about whether reproductive justice could demand insurance coverage for in vitro (...) fertilization. I quote liberally from Anne’s work for this purpose, but also to shower the reader with her words, reminding those of us who knew her well what a wonderful colleague she was. (shrink)

Background: Troubled conscience among nurses and other healthcare workers represents a significant contributor to healthcare worker moral distress, burnout and attrition. While research in this area has examined critical care in hospitals, less knowledge has been obtained from long-term care contexts such as nursing homes, despite widely recognised challenges with regard to vulnerable patients, increasing workload and maintaining workforce sustainability among nurses. Objective: The aim of this study was to illuminate and interpret the meaning of the lived experience of troubled (...) conscience among registered nurses (RNs) working in nursing homes. Research design: This qualitative research employed narrative interviews with eight nurses to obtain essential meanings of their lived experiences of troubled conscience. The interview texts were analysed using a phenomenological hermeneutic approach. Ethical considerations: Participation was voluntary, informed and was conducted with written consent. The Norwegian Centre for Research Data approved the data processing of personal data. Findings: The analysis uncovered two themes: (1) troubled conscience means abandoning ideals, with the subthemes: failing dependent patients; being disloyal to colleagues; being inadequate in the performance of work tasks and (2) troubled conscience means facing realities, with the subthemes: accepting being part of the system; responding to barriers. Discussion: Troubled conscience meant experiencing continuous and simmering tension between one’s ideals and realities and feeling a drive to preserve accountability and one’s moral integrity. Endangered ideals were often under cross-pressure and included humanistic values, professional values, working life values and the values of the organisation. Conclusion: Nurses’ troubled conscience refers to a struggle, but also a force that plays out at various levels and arenas in long-term care. Openness and dialogue about how professional values and the welfare state’s intentions can be realised within the given framework are important for individual nurses’ occupational health as well as the quality of care provided to patients. (shrink)

The dominant approach to conscience in contemporary bioethics presumes that conscience functions to promote personal moral integrity, and therefore presumes that the relevant values are inherently personal. This approach fails to demonstrate when and why claims of conscience should be taken seriously by others. I draw on Hannah Arendt’s deliberative model of conscience and Cheshire Calhoun’s social model of integrity to develop an alternative relational view of conscience—one that demonstrates that the relevant values are social as well as personal. I (...) show how the goal of improving ethical practice over time constrains which conscience claims should be taken seriously by others. (shrink)

Despite the increasing amount of literature on the legal and political questions triggered by a commitment to liberty of conscience, an explanation of the normative significance of conscience remains elusive. We argue that the few attempts to address this fail to capture the reasons people have to respect the consciences of others. We offer an alternative account that utilizes the resources of the contractualist tradition in moral philosophy to explain why conscience matters.

On the mainstream view, consciences are valuable because they promote moral unity. However, conscience, so defined, will systematically prevent moral growth that threatens unity, even when unity has formed around oppressive moral values. This motivates Carolyn McLeod's alternative ‘Dynamic View’ whereby consciences are valuable to the extent that they are dynamic. Consciences are dynamic when they interact with our best moral judgements to shape or ‘retool’ the moral values underpinning conscience, sometimes at an initial cost to unity. We modify and (...) extend McLeod's account in two ways: (1) We object to her claim that conscience encourages its own retooling. We argue that the opposite is true – conscience creates a motivational barrier to change that moral judgement must overcome to successfully retool conscience. The task of ensuring dynamism, therefore, falls to moral judgement. (2) However, this motivational barrier enables conscience to play a valuable role that McLeod overlooks – compensating for the limitations of moral judgement. On our Balanced View, the value of conscience depends on it being sufficiently open to being shaped by our best moral judgements but inert enough to compensate for distorted moral judgements and to guide action when under cognitive load. (shrink)

Background: Providing nursing care for patients with end-stage renal disease entails dealing with existential issues which may sometimes lead not only to ethical problems but also conflicts within the team. A previous study shows that physicians felt irresolute, torn and unconfirmed when ethical dilemmas arose. Research question: This study, conducted in the same dialysis care unit, aimed to illuminate registered nurses’ experiences of being in ethically difficult situations that give rise to a troubled conscience. Research design: This study has a (...) phenomenological hermeneutic approach. Participants: Narrative interviews were carried out with 10 registered nurses working in dialysis care. Ethical considerations: The study was approved by the Ethics Committee of the Faculty of Medicine, Umeå University. Results: One theme, ‘Calling for a deliberative dialogue’, and six sub-themes emerged: ‘Dealing with patients’ ambiguity’, ‘Responding to patients’ reluctance’, ‘Acting against patients’ will’, ‘Acting against one’s moral convictions’, ‘Lacking involvement with patients and relatives’ and ‘Being trapped in feelings of guilt’. Discussion: In ethically difficult situations, the registered nurses tried, but failed, to open up a dialogue with the physicians about ethical concerns and their uncertainty. They felt alone, uncertain and sometimes had to act against their conscience. Conclusion: In ethical dilemmas, personal and professional integrity is at stake. Mistrusting their own moral integrity may turn professionals from moral actors into victims of circumstances. To counteract such a risk, professionals and patients need to continuously deliberate on their feelings, views and experiences, in an atmosphere of togetherness and trust. (shrink)

In the spirit of this group of articles commemorating the fiftieth anniversary of the Journal of Religious Ethics, dealing with tradition-based reasoning, this article takes up a passage from Deuteronomy 20 that allows the “fearful and faint-hearted” person not to participate in battle, as well as the rabbinic and medieval appropriations of this passage in the Jewish tradition. It argues that this verse gives primacy to affect in a way that complicates standard interpretations of the Jewish tradition on just war (...) and allows us to see the pliability of tradition. Finally, the article argues that scholars assessing the justice of conflicts need to attend to the circulation of affects in a reasoning community, as is currently happening on scholarship on moral injury. (shrink)

BackgroundThis study is part of a major study about difficulties in communicating ethical problems within and among professional groups working in hemodialysis care. Describing experiences of ethically difficult situations that induce a troubled conscience may raise consciousness about ethical problems and thereby open the way to further reflection.The aim of this study was to illuminate the meanings of being in ethically difficult situations that led to the burden of a troubled conscience, as narrated by physicians working in dialysis care.MethodA phenomenological (...) hermeneutic method was used to analyze the transcribed narrative interviews with five physicians who had varying lengths of experience in nephrology.ResultsThe analysis shows that physicians working in hemodialysis care suffered from a troubled conscience when they felt torn by conflicting demands and trapped in irresolution. They faced ethical dilemmas where they were forced to make crucial decisions about life or death, or to prioritize when squeezed between time restraints and professional and personal demands. In these ethical dilemmas the physicians avoided arousing conflicts, were afraid of using their authority, were burdened by moral responsibility and felt devalued and questioned about their way of handling the situation. The findings point to another way of encountering ethical dilemmas, being guided by their conscience. This mean sharing the agony of deciding how to act, being brave enough to bring up the crucial problem, feeling certain that better ways of acting have not been overlooked, being respected and confirmed regarding decisions made.ConclusionThe meanings of being in ethically difficult situations that led to the burden of a troubled conscience in those working in hemodialysis care, indicate the importance of increasing the level of communication within and among various professional groups - to transform being burdened by a troubled conscience into using conscience as a guide - in situations where no way of solving the problem seems to be good. (shrink)

This article suggests that there is a relationship between successfully maintaining integrity in nursing and the practical provision of opportunities for shared reflection offered by good clinical supervision. In order to establish this case, I will first give some definitions and then proceed to consider how these ideas relate conceptually. The article makes no attempt to offer empirical research as confirmation, but provides a conceptual and moral argument making use of anecdotes for puposes of clarification and illumination. It is the (...) author’s belief that, if it is understood and implemented properly, clinical supervision offers a radical challenge to nursing’s existing culture. If nurses are interested in the survival of the profession, it is perhaps a challenge that has to be addressed. (shrink)