Research

Conscience references our ability and ultimately, our attentiveness, to being moral persons. Morality is universal: it is something that everyone can discover, commit to, and enact. This is especially true for those in specific kinds of communities who are committed to safeguarding and enacting morality, e.g., in courts of law, civic life, bioethics and healthcare. Since morality is relevant for people across communities and cultures (Haidt, 2013), conscience is also universally relevant.

Aletheia is the Greek word for truth or unveiling. This program of research was named the Aletheia Conscience Project (ACP) to align with the goal of conscience: to seek truth by way of understanding and enacting morality in a general sense, as well as in the focused context of bioethics and healthcare.

However, to fully appreciate how people generally -and healthcare professionals specifically- understand, intentionally commit to, and enact morality in their lives by way of their conscience necessitates inter-disciplinary considerations.

The PI and collaborators for the ACP therefore engage with research in science and bioethics with philosophy, theology and religious studies to comprehensively consider not only how to use conscience in healthcare, but to first consider what conscience is and why it is important in healthcare.

The research questions guiding the ACP are:

What is conscience?
How do healthcare professionals understand and use their conscience?
What supports exist to assist healthcare professionals to understand and use their conscience, as voiced by healthcare professionals?
How can healthcare professions benefit from conscientious practitioners?
How do patients benefit from interpersonal relationships with conscientious practitioners?

The research detailed below shows how the studies in the ACP are unfolding in response to these research questions to date.

Initial study

Exploring the lived experience of conscientious objection for Registered Nurses in Ontario.

Initial research

What are conscience and conscientious objection and what do they mean for nurses in Canada?

Conscience is recognized as a right within the United Nations Declaration of Human Rights and Freedoms (1948). This freedom is essential because it recognizes and safeguards each person’s right to freely choose to pursue and enact morality in their lives. It also exists to protect morality within and across communities. In the Canadian context, conscience is recognized as a fundamental freedom in the Charter of Rights and Freedoms (1982).

While meta, normative, and subsequently applied perspectives of morality differ in the pluralistic country that is Canada, the fundamental freedom to conscience ought to provide a baseline assurance that conscience is an inherent feature of being human, and, importantly, being moral persons. In the context of Canadian healthcare, moral agency is a requirement for being an ethical healthcare professional in Canada (Code of Ethics, Canadian Nurses Association [CNA], 2017). In Canada, the right to freedom of conscience is explicated to varying degrees in the Codes of Ethics for various healthcare professions (Code of Ethics, CNA, 2017; Canadian Medical Association, 2018).

In Canada, nurses are expected by their regulatory bodies to enact morality and committed to fostering moral communities (CNA, Code of Ethics, 2017). They do so with their conscience and are supported to make conscientious objections in practice if necessary (CNA, Code of Ethics, 2017). Conscientious objections are objections based on conscience to not do something if it morally conflicts with a person’s conscience.

However, as research in the scholarly literature reveals and the initial research in this project uncovered, conscience is not something that is fully or conceptually understood by all Canadian nurses. The challenge with this knowledge disparity prompts the question: how do nurses understand conscience to use it in practice? Moreover, making a conscientious objection is a fundamental freedom and a provision of being a nurse in this country. If nurses are not informed or equipped to understand, use, and enact morality conscientiously in practice, what kind of professional development is necessary to ensure this happens?

These and other questions prompted the PI to study how some nurses in Canada make meaning of their experiences of conscience by way of conscientious objection. To start to answer these questions, the initial empirical research in the Aletheia Conscience Project was an interpretive phenomenological study exploring how Registered Nurses in Ontario made meaning of their lived experiences of making conscientious objections.

Research Question

What is the lived experience of making a conscientious objection for registered nurses practicing in Ontario?

Sub questions of the study included:

What does conscience mean for nurses?
What meaning do these nurses make of the ethical encounters that prompt their conscientious objections?
How do these situations come to be and how do nurses respond to them?

Significant findings of the study:

There is a gap from the Code of Ethics to practice for some Canadian nurses. Specifically, there are some Canadian nurses who do not have formal knowledge of what conscience and/or conscientious objections are. All nurses in this study have degrees of intuitive or experiential knowledge.
Nurses in this study had an inherent sense of morality.
Nurses in this study wanted to act or refrain from acting in relation to ethical issues. I.e., action is an essential part of their understanding of conscience / conscientious objections.
Some Canadian nurses are not professionally supported to use their Chartered freedom of conscience and their regulatory responsibility to follow their conscience /make conscientious objections in care practice.
Nursing leaders in Canada need to support their colleagues to use their conscience /make conscientious objections especially to ethically controversial practices, i.e., assisted death. I.e., the federal legislative framework on Medical Assistance in Dying (MAiD) in Canada expressly notes that nothing in that framework “compels an individual to provide or assist in providing” assisted death: Criminal Code, s. 241.2(9).

The following recommendations were made in this study:

Adopt morally inclusive approaches in Canadian nursing to support and develop to support, nurse leaders and front-line nurses alike to ensure that nurses can voice their ethical concerns in their workplace.
Provide information sessions that outline how nurses can be supported to ethically refrain from participating in practices such as assisted death/MAiD.
Support the creation of conscience protection policies in workplaces settings, rooted in the provisions already laid out by nursing regulatory bodies in this jurisdiction.
Disseminate findings via public-facing forums to professional as well as public-facing bodies in Canada.
Disseminate findings to political bodies to show how nurses have experienced making conscientious objections to assisted death/MAiD.

Outputs for this empirical research study:

PI’s Doctoral Dissertation:

Lamb, C. (2019). Exploring the lived experience of conscientious objection for registered nurses in Ontario. (Doctoral Dissertation). Western University, London, ON. Canada.

Results of study-CO:

Lamb, C. Babenko-Mould, Y., Evans, M., Wong, C.A. & Kirkwood, K. (2018). Conscientious objection and nurses: Results of an interpretive phenomenological study. Nursing Ethics, 1-13 (E-pub ahead of print). doi:10.1177/0969733018763996.

Results of study-Conscience:

Lamb, C. Evans, M., Babenko-Mould, Y., Wong, C.A. & Kirkwood, K. (2018). Nurses’ use of conscientious objection and the implications for conscience. Journal of Advanced Nursing, (E-pub ahead of print: 16 October, 2018). doi: 10.1111/jan.13869.

Theoretical research and review papers:

Lamb, C. Evans, M., Babenko-Mould, Y., Wong, C.A. & Kirkwood, K. (2019). Conscience, conscientious objection and nursing: A concept analysis. Nursing Ethics, 26(1)37-49. doi: 10.1177/0969733017700236. Epub 2017 Apr 12.

Lamb, C. (2016). Conscientious objection: Understanding the right of conscience in health and health care practice. The New Bioethics, 22(1), 33-44. doi: 10.1080/20502877.2016.1151252

Funding:

Funding for research and outputs in relation to this study were awarded from an Ontario Graduate Award and an Establishment Grant from the Faculty of Nursing, University of Alberta, Canada.

Engaging with Conscience and Other Disciplines

Conscience and related issues in bioethics, healthcare, law and civil life.

Research across this category in the Aletheia Conscience Project include investigating conscience as it relates to healthcare, bioethics, the law, and civic life. Papers to date include scholarly outputs as well as opinion editorials that show how conscience is meaningful as a fundamental freedom in Canada and as an essential part of being human.

At times, conscientious care providers need to involve themselves with civic engagement and the judicial system to advocate for freedom of conscience in relation to upholding the fundamental freedom to conscience as citizens of a country and as members of ethical professions.

Works cited in this section focus on recent issues of conscience in Canadian healthcare that intersect with nursing, medicine, law, and government. Pieces refer to conscience and nursing, assisted death, the provincial attempts in Alberta, Canada, to enact conscience legislation (2019) and in response to a medical regulatory body’s provisions on obligatory referral in Ontario, Canada (2019).

Collaborative Outputs:

Lamb, C., Pesut, B. (2021). Conscience and conscientious objection in nursing: A Personalist bioethics approach. Nursing Ethics 28(7/8): 1319-1328. doi: 10.1177/0969733021996037.

Bird, B. & Lamb, C. (2021). A lack of reconciliation: Assisted death and conscience. The National Post. February 11, 2021.

Lamb C., (2019). Unpacking freedom of conscience in light of obligatory referrals in Canadian healthcare. Journal of Medical Ethics. December 4th, 2019.

Engaging with Conscience and Science-engaged Philosophy and Theology

Research in this section refers to a series of studies in ACP housed under the following project entitled: Conscience in healthcare: Creating a science-engaged theological education intervention for healthcare professionals.

Project overview:

Conscience is essential for moral decision making in theology, philosophy, bioethics, and the health sciences. However, much of the scholarly work on conscience is housed in philosophy and theology. In fact, little research and conceptual work on what conscience is has been conducted in the science-based literature. To date, little research and training exists in the health sciences regarding HCPs’ understanding and use of conscience leaving them unequipped to address issues of conscience in healthcare practice.

To address this knowledge gap, the purpose of this project under ACP is to engage with science as empirical research to answer inter-disciplinary (philosophical and theological) research questions around what moral philosophy and theology can lend to the meaning of conscience for bioethics and the health sciences/ healthcare professions. Work to date on this project includes philosophical papers that explore what conscience means considering recent philosophers and / or theologians who have generated new, inter-disciplinary insights into what conscience is.

Empirical work in this project currently consists of using systematic review methods to examine the state of the international, interdisciplinary literature on what interventions exist to support healthcare professionals’ understanding and use of conscience.

Outputs:

Lamb C, Kennedy, M, Clark A, et al. (2022). Effectiveness of interventions on healthcare professionals’ understanding and use of conscience: A systematic review protocol. BMJ Open. 12:e053880. doi: 10.1136/bmjopen-2021-053880.

Lamb, C. (2021). Conscience: An Investigation in Stenian philosophy in relation to bioethics.Religions. Religions 12, 1-13. doi: 10.3390/rel12080566.

The PI initiated this project under Aletheia as a Fellow in New Visions in Theological Anthropology with the School of Divinity in the University of St. Andrews, Scotland (2020-22). Funding for this project was received by the PI from the John Templeton Foundation as part of Follow-on-Funding awarded during this fellowship.

Collaborators in health science, philosophy, theology and bioethics have been involved in this project (as cited in the works listed). Where not listed, the PI acknowledges Dr. Renée Köhler-Ryan, Dean, School of Philosophy and Theology, University of Notre Dame, Australia and Dr. Antonio Calcagno, Professor of Philosophy, King’s College, Western University, Canada, for their helpful reviews and feedback on aspects of this research in their capacities as theologian-philosopher and Stenian scholar, respectively. The PI thanks all her research assistants involved in the work to date on this project.

Forthcoming:

Empirical research: Systematic Review Study: In progress.

Philosophy and theology research paper:

Lamb, C. (2023). Newman’s personalism and the experience of conscience: Moral meaning in relation to bioethics.Religions. Status: In progress.