The Practitioner’s Paradox: Conscientious but …Without Conscience

Main Article Content

Tom Koch


Over the last decade a group of moral philosophers concerned with medicine have argued, some stridently, that conscience has no place in the conscientious practice of medicine. And yet, it is hard to separate conscience from conscientiousness. This paper reviews and critiques the argument against conscience and the assumptions underlying it. It argues that it is often difficult to separate conscience, a moral perspective on appropriate practice, from the clinical knowledge and experience that practitioners possess and patients do not. The result is not paternalistic although it challenges the assumption that the patient in distress often knows best. The focus in this paper shifts from simple autonomy as a reflexive rule to the social and broadly clinical context in which decisions about procedures like abortion and medically assisted death are made.

Keywords: ethics, conscience, medicine, moral philosophy, practitioner

Article Details

How to Cite
KOCH, Tom. The Practitioner’s Paradox: Conscientious but …Without Conscience. Medical Research Archives, [S.l.], v. 11, n. 1, jan. 2023. ISSN 2375-1924. Available at: <>. Date accessed: 19 july 2024.
Research Articles


1. AMA Code of Medical Ethics (2016). Chicago: American Medical Association.
2. Azar A. II. Coats Amendment. (1996, March 19). Protecting Statutory Conscience Rights in Health Care; Delegations of Authority. Office for Civil Rights; Office of the Secretary: 45 CFR Part 88 RIN 0945‐AA10.
3. Balanced Budget Down Payment Act. Amendment No. 3508. Congressional Record 142 (38).
4. Brody H, Miller FG. (1998). The internal morality of medicine: Explication and application to managed care. Journal of Medicine and Philosophy 23 (4): 384–410. Doi: 10.1076/jmep.23.4.384.2572.
5. Carter v Canada. (2015). 1 SCR 331.
6. Conscience. Merriam Webster Dictionary Online. Accessed July 31, 2011.
7. Conscientious. Encyclopedia.Com, Oxford University Press. Accessed July 31, 2022.
8. Conscientious. Merriam Webster Dictionary Online.
9. Liu I. (2022). Personal Interview. Vancouver, BC. Aug. 26.
10. Koch T. (2000). Life quality versus the ‘quality of life’” assumptions underlying prospective quality of life instruments in health care planning. Social Science & Medicine 51:3, 419-428.
11. Koch T. (2001). Future States: Testing the axioms underlying prospective, future-oriented, health planning instruments. Social Science & Medicine 52:3, 453-466
12. Koch T. (2006). Weaponising Medicine: "Tutti fratelli," no more J. Med. Ethics 32: 252-255. Doi:10.1136/jme.2006.016485.
13. O’Neill O. (2004). Autonomy, plurality and public reason. In, New Essays on the history of autonomy: A Collection Honoring J.B. Schneewind. Eds. N. Brender and L. Krashnoff. Cambridge: Cambridge University Press, 181-194.
14. R. v Morgentaler, [1988]. 1 SCR 30.
15. Savulescu J. (2006). Conscientious objection in medicine. British Medical Journal 332 294–297. Doi: 10.1136/bmj.332.7536.294.
16. Schücklenk U., Smalling R. (2017). Why medical professionals have no moral claim to conscientious objection accommodation in liberal democracies. Journal of Medical Ethics 43, (4): 234-240. URL:
17. Schneewind J. B. (1998). The Invention of Autonomy: A History of Modern Philosophy. Cambridge, Cambridge University Press.
18. Savulesqu J. (2006). Conscientious objection in medicine. BMJ (4 Feb.): 332 (294): 294-297. Doi:
19. Weldon Amendment, Consolidated Appropriations Act, 2009, Pub. L. No. 111-117, 123 Stat 3034.
20. Fikremariam D, Serafini M. Multidisciplinary approach to pain management. In: Vadivelu N, Urman RD, Hines RL, eds. Essentials of Pain Management. Springer; 2011:17-28. doi:10.1007/978-0-387-87579-8