Conscience and conscientiousness within surrogate decision making: Philosophical considerations on the ethical relevance of conscientiousness

Abstract

Decisions at the end of life often result in conflicting opinions between medical and nursing professionals and the people concerned themselves. Especially when different beliefs and values clash, it can be difficult to understand each other's situation. Appropriate communication, with the necessary respect for the opinions and interests of other individuals, seems to be crucial here. However, if the person concerned is no longer able to express their own views on further treatment or possible withdrawal, support is often needed in the form of a surrogate decision maker, which poses specific challenges. This article deals with the ethically relevant difference between conscience and conscientiousness in the context of surrogate decision making. In the first step, due to the multitude of different views, it is shown what can be understood by conscience. By differentiating between building conscience, formation of conscience, and conscience conformity, a distinction is made between conscience and conscientiousness. In the second step, representatives are placed in relation to the concept established so far, and ethical implications are pointed out. The final step attempts not only to bring together the previous considerations and present suggestions for action but also to clarify common misunderstandings regarding the two terms. The ethical relevance of conscientiousness and the willingness of representatives to be open to other views on the one hand and to remain true to their own values on the other appear to be essential.

Keywords

Conscientiousness conscience surrogate decision making ethics moral attitude

Introduction

In the medical context, difficult tasks arise for people involved, particularly at the end of life and in emergency situations, for example when decisions must be made about further medication or the withdrawal of treatment measures. Such challenges become even more urgent and ethically relevant if the person concerned is no longer able to communicate their own wishes and goals. In these cases, family members, close relatives, or even trusted persons often see it as their duty to make a crucial decision that they can justify to the person concerned and to themselves.¹ However, the first strategy is usually to act as the person concerned would have done, which may conflict with the surrogates’ conscience. Even though many authors^2–7 have dealt with ethical aspects of surrogate decision making, the link to conscientiousness, i.e., the willingness to be critical and to allow other views, has not been sufficiently considered in the philosophical debate. This article is concerned with an ethical examination of the concept of conscientiousness in the context of surrogate decision making, i.e., the decision-making situation of authorized representatives for patients who are unable—or unwilling—to express themselves. The tension between one's own conscience and the obligation in surrogate decision making is examined and an attempt is made to resolve it with reference to conscientiousness. First, it is examined how conscientiousness can be understood, what ethical implications are associated with it, and what distinguishes it from conscience. The second step shifts attention to the individuals who are authorized to make decisions and at the same time attempts to establish a relationship with the preceding idea of conscientiousness. This is followed in a third step by the presentation of ethical aspects that emphasize the importance of this attitude on the one hand and draw attention to potential limitations on the other.

Conscience in medicine

The exact nature of a person's conscience is the subject of diverse and sometimes divergent perspectives. It is not only philosophy that has been dealing with this topic for some time, but also psychology, religious studies, and neuroscience. Lenk raises the question of whether conscience is a voice or a medium.⁸ It could be a control instance for specific (professional) guidelines⁹ and, according to Rothhaar, decisions can thus be ethically reviewed.¹⁰ It may also simply be a form of self-reflection.¹¹ According to Giubilini in the “conscience” entry of the Stanford Encyclopedia, it “[…] is always knowledge of ourselves, or awareness of moral principles we have committed to, or assessment of ourselves, or motivation to act that comes from within us […].”¹² From a psychological perspective, conscience is often used to describe a personality trait whereby people act in a purposeful, planned manner and in accordance with given norms.^13–15 Symons, for example, says: “[…] conscience provides agents with a personal sense of moral obligation.”¹⁶ Regarding conscience, a distinction can be made between prospective and retrospective, for example in the sense of “I could not reconcile that with my conscience” or “I have a guilty conscience,” which Sulmasy describes accordingly as legislative and judicial conscience.¹⁷ While conscience and its function are seen as an essential part of the human being, there seem to be many, sometimes contradictory and often unclear descriptions of what is meant by this.¹² In addition, the processes that are important for conscience are usually hidden and cannot be objectively proven.¹ However, what can be derived from numerous authors and their views is presented below in order to make the concept of conscience easier to understand and to show a distinction from conscientiousness, which is essential in this article. In addition, special attention is paid to the ethical dimension of conscientiousness, which has so far received insufficient attention in the scientific literature. In the following, three stages (building, formation, conformity) regarding conscience will be discussed, which are particularly based on the reflections of Thomas Aquinas, but also integrate contemporary perspectives. In contrast to some authors, however, no reference is made to conscience that can only be justified with reference to (a) God.

Building conscience

For the first component of conscience, it is assumed that human^a beings have an innate ability to recognize certain basic principles. These include avoiding evil and doing good.²³ In this context, one could speak of practical reason, or of moral and possibly ethical sensitivity.²⁴ A plausible view is that such basic principles are not only rationally applicable but can also motivate emotionally. One example would be something like a precursor to the Golden Rule, according to which one should not do to others what one would not want to experience oneself.²⁵ The particularly clear distinction made by Thomas Aquinas²⁶ between synderesis and conscientia is useful in this regard.²⁷ Synderesis is associated with general knowledge of principles, for example, and conscientia corresponds to specific decisions of conscience. The basic principles mentioned are accessible to everyone in general and precede, so to speak, synderesis and conscientia. On the basis of such basic principles, however, further development is then needed, namely of one's own conscience. In agreement with Herzberg, one may speak of an evolving habitus.²⁸ Let us take an example of a basic principle that is rationally understandable: “it is wiser not to harm other people in order to avoid harm in the future.” However, such principles can also be emotionally motivated because one values and respects others, or has a good feeling when one avoids harm.²⁹ From a normative point of view, the rational and emotional dimensions then also lead to a self-perceived obligation to fulfill these claims. By perceiving and then appreciating, for example, moral values or specific situations in which certain aspects appear as morally right, valuable, and worthy of following, one forms the basic prerequisite for the formation of conscience.^30,31 According to neuroscientific research,^18,32,33 moral intuitions already take shape in early childhood and, like the principles described, form part of conscience. These (secular) moral intuitions are comparable, for example, to divine precepts or general principles from a theological viewpoint.^34–37 That being said, such moral cues are specifically recognized through social life, whereby one can agree with Childress that “[…] moral values, principles, and rules […] are determinative for […] conscience.”³⁸ From an ontological point of view, it is quite plausible to claim that conscience is a component of the human being that makes us who we are—which, however, does not mean that we cannot change. Since a conscience combines both cognitive and emotional dimensions, the physiological constitution of the human being serves as a basis, but its formation is initiated by experience.

Formation of conscience

Following the considerations regarding basic principles, interpersonal life appears to be crucial for the formation of conscience, since moral cues are recognized through socialization, exchanges with loved ones, education by significant others, training, or professional life. Subjective experiences of what is morally good, what is desirable, or what is considered morally valuable often lead to their internalization. This refers to a personal conviction that, due to its importance, understands such aspects as desirable points of reference for personal actions and decisions, and consequently wants to integrate them into one's own personality.³¹ In accordance with Thomas Aquinas, reference can be made here to (A) knowledge of principles, (B) fundamental convictions, and (C) specialized knowledge, which corresponds to synderesis.²⁶ The (A) principles addressed here differ from the basic principles described above primarily in that they are learned and then internalized over the course of a lifetime. Emundts speaks of moral receptivity,³⁹ according to which personal attitudes or even the will are decisive for following subjective convictions (reasons) and using these perceived aspects to form a conscience⁴⁰—what can be reconciled with (B) fundamental convictions. Specialized knowledge (C) enables, for example, a physician to assess the risks of an operation or a representative to understand the wishes of the person concerned. Such knowledge is acquired throughout life and influences moral decisions, but it is not absolute. The second component regarding conscience thus describes the internalization of moral concerns based on learned and acquired knowledge. Lenk describes conscience as a psychological reaction or processing of a model-like developed interpretation and self-evaluation which develops in interaction with formative influences of the social and especially the family environment.⁸ An identity can be formed during this process, that is oriented toward these moral aspects.⁴¹ For Wester, these can be secular or religious elements.⁴² From these considerations, it becomes clear that knowledge of principles, fundamental convictions, and specialized knowledge are also specific to an individual's conscience. Even if the moral reference points described are essential and have a motivational character, this does not imply any objective or generally valid claim—of a subject-related conscience. According to Ernst, we internalize ethical norms and values, basic convictions and evaluations that we adopt from others in the course of our upbringing, but also later in life.²³ This can also be seen as a personally perceived obligation or commitment^30,43—“[…] to be moral”¹⁷—which cannot be made understandable by externally imposed constraints but represents the convictions—the core ethical values⁴⁴ that are considered important—of the respective subject as guidelines for moral and ethical action.

Conscience conformity: Conscientiousness

After considering innate basic principles (building conscience) and moral reference points (formation of conscience), the focus is on the executive character of conscience—conscientiousness. Even after becoming aware of and internalizing moral aspects, conscientiousness still requires actively exercising these points of orientation. This also reveals the executive character of conscientiousness in comparison to conscience. Luhmann supports this view insofar as conscience does not stand or fall by the fact that it appears in action.⁴⁵ While conscience in principle remains a fundamental part of the human being, even without concrete application in a specific setting,⁴⁶ this does not appear to be the case regarding conscientious decisions. The third component of conscience thus refers to a connection between knowledge and action in the sense of conformity to conscience. This is comparable^b to the previously mentioned conscientia,²⁶ insofar as it refers to an act.²⁸ While conscientia could describe the following of conscience, conscientiousness is not yet associated with moral rightness or even ethical justification.^27,28 A person may have built up a kind of moral compass—the conscience—over the course of their life, which would approve or prohibit certain courses of action in situation X or Y.³⁰ By actively applying personal convictions and using them for the respective decision, one can speak of acting according to one's conscience.¹⁶ Conscientiousness, however, requires not only (subjective) agreement with one's conscience, which is sufficient for conscientious objection. An objective aspect is crucial, which Curran describes in a similar way.³⁴ This means that both^c internal (conscience) and external aspects (e.g. non-internalized moral norms) are used for the evaluation of a specific decision. Thomas Aquinas also emphasized that there can be an erroneous conscience. While the basic principles seem to be free of error because they make the distinction between good and evil possible in the first place, (A) knowledge of principles, (B) fundamental convictions and (C) specialized knowledge are susceptible.²³ This susceptibility is reflected in the fact that we can also internalize ethically unjustifiable convictions or lack certain knowledge. Openness to critical evaluation is therefore important regarding conscientiousness because certain actions are definitely morally wrong (or right), even if they are not (yet) embedded in one's own conscience.^38,47 However, conscientiousness should not be understood as an explicit call to action, because it can also be reflected in an omission, but equally represents the executive character. This idea is comparable to the statements by Lamb and Pesut when they speak of an “[…] application of moral knowledge to situations that require moral decisions […].”³⁰ Lenk relates this call to action to the concept of responsibility, insofar as the convictions stored in the conscience should also lead to decisions in specific situations.⁸ However, such responsibility also reveals a tension between legitimately following one's own conscience and its ethically significant questioning. It becomes clear that conscientious decision-making involves rational and emotional aspects, which results in a normative claim. However, a certain degree of openness seems necessary regarding this claim.

“Conscientious objection”^{9,34,42,48–50} is a frequently discussed topic in this context, meaning that people are unable to carry out an action for reasons of conscience. In most cases, reference is made to medical, pharmaceutical or nursing professionals. These people then refuse, for example, to undergo what they consider to be a hopeless therapy that leads to suffering or refuse to participate in practices such as assisted suicide or abortions because this is not compatible with their conscience. However, this article focuses on conscientiousness regarding lay people. While conscientious objection means to refuse certain actions based on one's conscience, and thus to declare an action that is seemingly morally wrong or does not conform to general norms to be acceptable, conscientiousness is understood differently here. Conscientious objection is a logical consequence of (subjective) conscience. However, in addition to the reference to one's own conscience, conscientiousness needs an (objective) ethical dimension in this context. If a nurse is required to perform an abortion, she can refuse to do so on the grounds of conscientious objection. She is acting in accordance with her own conscience, but that does not automatically render her conscientious. To be conscientious, she needs to evaluate her own and others’ values in order to weigh up the options available and to give reasons for her actions. This does not mean, however, that there is no connection to one's own conscience.

The difference between conscience and conscientiousness

Based on these three components of conscience, which are frequently discussed in the literature, but usually in a different way, it is easier to understand the meaning that one's own persecution can have for the corresponding individual. In medically relevant contexts, the possibility of not only trusting the instructions of a medical professional, for example, but also following one's own ideas of morally adequate interaction enables people to contribute their own identity.²³ A representative who must make a crucial decision for an affected individual is at best guided by the patient's previously expressed wishes, but this does not render their own convictions obsolete. The respect reflects these internalized and identity-forming convictions, so to speak. For Ernst, too, conscience represents a standard that we want to meet when we follow what we ourselves have recognized as ethically good and right.²³ Let us imagine a situation in which an unresponsive patient has a brain tumor, and the decision now has to be made by a relative. After consulting with the surgeon in charge, it becomes clear that the healthcare professional advises the surrogate against surgery, as it would be too risky and unlikely to be successful. Even if this recommendation is against the surgical procedure, it is quite conceivable that the person authorized to make the decision would request the operation based on their experience and close relationship with the patient. This conceivable conviction is in line with Sulmasy, who sees in the judgments of conscience the obligation „[…] to unite one's powers of reason, emotion, and will into an integrated moral whole based upon one's most fundamental moral principles […].”¹⁷ This decision could express the patients previously expressed wishes and goals (C—knowledge) to take advantage of available options even in seemingly hopeless situations. The value of human life (A—principles) and respect for the interests of the person (B—convictions) who is increasingly unable to consent are thus available as points of reference. This knowledge of one's own and other people's priorities and their significance thus forms the basis for decisions based on the first two components. A conscientious approach can be said to exist if the representative decides contrary to an external suggestion, provided that personal considerations are followed and not merely acting contrary to medical authority. Rather, what is crucial are reasons relevant to the decision—which includes rational and emotional aspects—, that reflect subjective convictions and indirectly refer to the person's identity and conscience.⁴²

In this context, it is important to emphasize the plurality of moral convictions, which increases awareness of the fact that different people have different ideas of what is morally good.²³ This means that a decision by person A or B may be in accordance with their conscience, but the question of conscientiousness still remains unanswered. In the scenario described, this individual orientation should not be understood as undermining the possible integration of other opinions, conscience, and conscientious decision-making. The second component of conscience formation proves to be open to potential adaptation and possible revision.^46,51 This does not imply the constant change of already internalized moral points of view, but rather the necessary willingness to question oneself and the associated convictions. According to Luhmann, it is about making the identity of one's own personality the point of reference for reflection.⁴⁵ Childress argues similarly, because conscience “[…] is a person's consciousness of and reflection on his own acts in relation to his standards of judgment.”³⁸ That being said, conscientiousness still requires the external dimension described. If the surgeon points out the futility of an operation on the one hand and the potential consequences associated with it—such as the quite realistic death of the patient—on the other, a change in subjective value orientations can take place. For example, the fundamental demand to preserve life under all circumstances could lose meaning in favor of minimizing suffering and care. This makes it clear to what extent conscience-based learning and adaptation are not only to be seen as a threat to moral identity, but can also be realized even more strongly through the willingness to accept other opinions and being critical.^16,42 Apart from the purely positive-functional meaning—of conscience—it also becomes clear that shared norms are important when it comes to different values, which prevent a completely arbitrary definition of what is morally relevant. Consequently, appeals to conscience with ethically questionable or even reprehensible moral concepts seem absurd and unjustifiable. It is quite conceivable that a person is unaware of certain principles (A), does not consider specific knowledge (C) to be important, or has convictions (B) that are difficult to justify objectively. Even if pluralistic views of morality can be explained on this basis, this does not mean that all decisions of conscience are ethically justifiable. Sulmasy and his call for tolerance offer a plausible point of reference for this. Tolerance toward other ideas of conscience may only go as far as they themselves are tolerant, there is no serious danger (illness, injury, death) for people of other faiths and beyond that there is a need for justification.¹⁷ Wicclair emphasizes comparably that values are to be accepted as long as they do not deviate too far from what is generally considered ethically acceptable.⁴⁴

According to the previous considerations, conscientiousness is distinguishable above all by its executive nature, from the notion of conscience. In ethical terms, the practical relevance of conscience, i.e. the pursuit of the values constitutive of human identity, can also be described as an attitude.⁴⁵ If individuals listen to their conscience in most cases but never put these demands into practice and possibly follow the advice of other people, not only are conscientious decisions impossible, but the values, principles and ideas of a good life that are apparently considered important lose their meaning. Lamb and Pesut see it similarly: “To determine what is moral and then to act on it is the work of conscience.”³⁰ The emphasis on the relevance of certain values and their internalization in the conscience, with simultaneous disregard or non-compliance in practical decision-making situations, not only corresponds to a logical contradiction. Rather, the points of orientation that are decisive for human coexistence are not considered at all. If health, truth, freedom or, for example, life are morally significant, they offer sufficient persuasive power for their realization in conscientious decisions. A corresponding attitude will not always be easy to implement and requires time, a suitable environment, and the subjective will, but it appears to be advocated. In a similar vein, Sulmasy speaks of virtues in terms of conscientious judgments¹⁷ and Beauchamp and Childress’ account goes in a comparable direction when conscientiousness is associated with a morally good character.¹¹ In this article, however, conscientiousness primarily refers to the willingness to permit other opinions, to consider new values, and to take a critical attitude towards one's own conscience. This approach seems particularly plausible for the surrogate decision makers addressed in this article, who often have to make a vital decision for another person.

The preceding passages may raise the question of whether all decisions based on one's own conscience are not morally correct. What is the difference between moral conscience and an ethically justified and praiseworthy attitude of conscientiousness? The tolerance mentioned by Sulmasy¹⁷ serves as a point of reference here, but requires further analysis. Based on the three components presented, conscientious decisions seem to follow logically from the building and formation of conscience. These components correspond to (1) an innate human ability, (2) learned and internalized moral knowledge, and (3) an active action. The important ethical considerations involved have already been emphasized and are now explicated. Sulmasy takes a similar view because conscience is associated with “[…] an obligation to form one's conscience correctly […].”¹⁷ It is understandable to claim that a doctor, for example, does not give any particular thought to the needs of his patients, ignores them and usually acts in a paternalistic manner. If these personal values are accepted as such and represent the doctor's own view of life, he can certainly be said to act in accordance with his conscience. However, if he fails to take into account the autonomy of the person concerned due to benevolent coercion,^11,52 conscientious actions appear hardly plausible.

One would hardly agree to speak of a conscientious healthcare professional if that person completely neglects ethical considerations. It is precisely for this reason that it is essential to consider the interests of others and not just the pursuit of selfish objectives.^30,53,54 Consequently, ethical reflections, associated values, and the examination of one's own point of view are to be regarded as conditions for making conscientious decisions. If conscientiousness integrates ethical aspects—as the previous descriptions suggest—then conscience is also subject to ethical evaluation, provided that conscientious decisions follow from conscience. Otherwise, the case described with the physician would result in the conclusion that conscientiousness cannot withstand an ethical analysis, since his actions are disqualified as conscientious. Such ethical assessments are by no means disconnected from one's own conscience, but the convictions found therein are both the subject and a basis for critical reflection. A conscientious decision by person X can therefore not be understood without X's conscience. Nevertheless, the evaluation requires taking a point of view⁵⁴ that goes beyond the ideas of morality expressed exclusively by one's own conscience and subjecting them to critical reflection. If these lines of thought are comprehensible, it seems justified to claim that a conscience can be shaped in one way or another in moral terms,²⁸ but that its usability for the question of conscientiousness must withstand the processes of an ethical assessment. In conscience, the ego discovers itself in possession of its full possibilities: as a potential enemy of its already formed self,⁴⁵ which refers to the ability of critical self-examination respectively internalized values.

The case of Christopher Duntsch,^d whose surgical and human achievements can also be seen in the first season of the television series Dr Death,^56,57 is a media-impressive and at the same time shocking prime example of the assumptions made above. Not only is this doctor completely unscrupulous in his treatment of his patients, and the negative consequences of his actions do not seem to bother him at all, but what is essential for this article is the fact that his actions are entirely compatible with his conscience. Nevertheless, few people would make the claim that the logical deduction of conscientiousness (conscience conformity) from the two components (building and formation) of conscience must lead to that person being conscientious. In this case, it seems reasonable to assume that the physician has some convictions (B) that do not take into account other people and their interests. It is possible that he does not care about certain principles (A), such as nonmaleficence or respect for autonomy, or that he lacks the necessary knowledge (C) in the surgical context. Furthermore, it can at least be questioned whether the recognition of basic principles is even disturbed. However, the lack of an ethical dimension, in the sense of a critical self-assessment and evaluation of conscience, his humility and arrogance-based ignorance of the (caused) suffering of the people concerned, suggests that there may well be morally bad people^e with an associated immoral conscience. Such beliefs and values, however, also make any questions regarding conscientiousness obsolete. Ernst and Emundts take a similar view when it is necessary for a judgment of conscience to carefully seek a comprehensible justification.^23,39 Dr Death would most likely be able to provide such a justification, but with rather inadequate reasons in ethical terms.⁵⁴ What now arises for further consideration of conscientiousness that may be attributed to representatives is, firstly, the essential distinction between (moral) conscience and (ethical) conscientiousness, and, secondly, the need for an intersubjectively comprehensible justification for the respective decision.

Conscientiousness and surrogate decision making

Having distinguished between conscience and conscientiousness, the focus is on surrogates. Surrogate decision making, which is often described in the context of medical ethics, concerns precisely those people who have to make decisions on behalf of a person who is no longer capable^f of making decisions.⁵⁹ These individuals can be specified in written documents or are requested when a certain situation arises. The spouse, children, siblings, grandchildren or friends of the person concerned can take responsibility, for example. If no such individuals are available, a court-appointed representative can also be assigned.⁶⁰ In most cases, the decision will not take place in a closed room, without the support of medical or nursing staff—or other individuals—but this does not in any way diminish its significance and urgency. In most cases, there are “[…] interdisciplinary care teams forming the basis of care […],”⁴⁹ even if doctors take on a special role. At least in theory, those people are available to clarify vital decisions.

The procedures and points of reference for people authorized to make decisions described by Beauchamp and Childress are useful in this context. These include the substituted judgment standard, the pure autonomy standard and the best interest standard.¹¹ According to the order listed, the judgment of a substitute will (1) refer to previously expressed wishes and needs, (2) use the written autonomy as a reference point or (3) act according to what would be in the best interests of the person concerned.^11,61 Aside from these seemingly structural approaches, it is important to consider the burden that is assumed by surrogates because they not only have to make a choice for this other person, but also have to answer to medical and nursing professionals, family members and, last but not least, their own conscience.⁶² In addition, the survey by Su et al. shows that “[…] most surrogates lacked preparation,”⁶¹ which means that conscientiousness probably has an even greater meaning.

The present analysis pays particular attention to those constellations in which the pure autonomy standard is not applicable because, for example, advance directives^g (living will or DPA) are missing. This appears to make sense because it means that a conscientious choice and the weighing up of different reasons, scenarios and problems are even more significant than simply having to decide between accepting and rejecting^h written wishes—moreover, advance directives cannot cover all potential scenarios.^59,61 Although this makes the decision-making challenge for surrogates even greater, it also highlights the importance of conscientiousness. Frey et al. draw attention to the associated burden: “Decision-making autonomy often comes with substantial psychological distress.”⁶⁷ The results of Su et al. reveal something similar, because “[…] surrogates […] often struggled to make decisions, seeking more information and reassurance.”⁶¹ For these reasons, in the context of such an important decision, it would be perfectly understandable not to shift responsibility to just one individual, but to push for a joint solution.

Such an approach is also evident from the survey⁶⁷ by Frey et al. and the opinions of patients—what kind of decision making they would like to see from decision-makers—and surrogates. According to the results, a form of shared decision making⁶⁸ seems to be particularly preferred—as is the personal choice of the surrogate⁶¹—whereas delegation to healthcare professionals is not widely supported. This shows the importance of personal closeness to and understanding of the needs of the person concerned, which can also be understood ethically in terms of the principle of respect for autonomy¹¹ or specific care.⁶⁹ Even if, in such cases, patients are no longer able to make an autonomous choice, it appears to be relevant that the person authorized to act represents the beliefs, wishes and ideas of a dignified end of life—of the person concerned—in the best possible way. The considerations of substituted judgment and the best interest standard are also compatible with this, if on the one hand the patient's specific concerns (C) are considered and on the other hand principles (A) and values (B) that are generally considered important remain in focus.

The differentiation between conscience and conscientiousness examined in detail so far also suggests that these people subject their own thoughts and internalized ideas to critical reflection.⁴² A very realistic scenario arises, for example, when a patient (P1) is placed in an artificial coma after a serious accident and this condition has now lasted for several months. The attending physicians regularly talk to all parties involved and, after a discussion, conclude that long-term effects on P1 cannot be ruled out, but that waking up is a distinct possibility. This is a delicate situation for the surrogate (S1) because there are no written wishes in the sense of an advance directive. Nevertheless, S1 is certain that it would not be in P1's best interests to maintain such a condition indefinitely because P1 did not want to be connected to tubes if there was no guarantee that her condition would improve. The responsible physician (M1) advocates a wait-and-see approach, but this is not compatible with the wishes anticipated by S1 with regard to P1. A conscientious decision now requires consideration, but at the same time can take into account S1's internalized beliefs.

While the substituted judgment standard would tend to favor the termination of life-sustaining measures (without reference to S1's conscience), the best interest standard seems to take both M1's and S1's arguments into account.¹¹ However, both standards are extended by the perception of S1 and their moral convictions, insofar as these considerations do not usually play an explicit role. But what is the point? If S1 can follow their own conscience and subsequently make a conscientious decision, then this also involves a certain degree of impartiality and universalizability.⁵⁴ Such impartiality arises if there is a willingness to critically examine one's own and others’ ideas of morality, as described above—in contrast to considering only one's own conscience. Little sums this up comparatively, because in general “[…] the consciences of others ought to be respected,”³⁶ although the tolerance mentioned before should be kept in mind. This means that reference can be made not only to P1's previously (supposedly) expressed preferences but also to M1's considerations and S1's current assessment. In many cases, family members with such a task not only have an impression of the ideas of a good life and death of the person concerned but also personal moral concepts. These can make a valuable contribution precisely when, as in this scenario, M1 presents contrary ideas that should be taken into account. It is not possible to give a clear answer as to how to proceed here, but it is clear that there is an additional option when considering the conscientious decisions of surrogates. Wishes and fears can change, medical professionals can make mistakes, and moral ideas are not automatically ethically justifiable.

This additional option could also be used to counter intra-family conflicts. In the previous scenario, a surrogate (S2) could be urged by other family members to maintain the life-sustaining measures, which, according to what has been said so far, corresponds neither to the implicit ideas of the person concerned (P2) nor to the considerations of S2. Even if the medical professional (M2) tends to take a similar approach to the family members mentioned here, this is still not enough to resolve the possible conflict (in the sense of a majority decision). As in the example described above, this requires joint and respectful^29,61 communication, especially between the family members (F2), M2 and S2. Due to S2's moral and legal responsibility, the final decision will have to be made alone, but it still leaves room for this discussion, in which the positions of F2 and M2 on the one hand and S2's perspective on the other are to be brought to light. The example given would become more complicated and demanding for S2 if P2 was never competent. According to Capron, the best interest standard should be applied in such cases.⁷⁰ However, many surrogates would probably find it difficult to assess the best possible strategy without ever having known the preferences of P2, for example.

In the course of this communicative discussion, it is conceivable that S2 can convince everyone else of their impressions of P2 and also present their personal moral concepts in a comprehensible way. The opposite is also extremely plausible.²³ The relevance of considering the beliefs of representatives lies in the closeness to the person concerned, the possibility of an additional perspective, and the distance from the medical profession that usually exists. While medical professionals usually have the human body (predominantly) in mind, representatives are (at least it is assumed) concerned with the person. However, this mediating position of S1 and S2 should not be confused with completely arbitrary and uncritical permission for these people to do what they want or what their conscience tells them. The ethical dimension of conscientiousness already mentioned limits complete arbitrariness in this context. In contrast to conscientious objection, conscientiousness requires a certain degree of openness to consider other opinions. In addition, a significant difference is that conscientious objection usually only applies to oneself, whereas surrogates explicitly decide for another person. May describes this important consideration of other consciences, based on a tendency of humans to effect a future harmony with themselves and others.⁷¹ However, this also implicitly addresses ethically significant aspects, such as respect, tolerance, and justice—not least regarding the affected patient, who is represented by a surrogate.

While the previous considerations on moral convictions and conscientiousness, which are connected to conscience welcome the associated decision, numerous studies illustrate the challenges for surrogates. These include uncertainty about and struggles with the decision, post-traumatic stress,⁶² the sometimes desperate search for support, depression, anxiety, and generally the negative effects of this commitment.^14,61,68 In contrast, other studies draw attention to the extent to which adequate communication, knowledge of the wishes of the person concerned,^67,72 and family support can counter these challenges.^61,73 This means that not only the ability to reflect and a critical attitude towards one's own values are crucial, but also the consideration of other opinions. Conscientiousness can also manifest itself in the fact that help is sought from medical professionals or family advice is a decisive factor in one's own judgment. The statement of a person authorized to make decisions illustrates this: “I wasn’t afraid to ask questions. I had my questions written down.”⁶² Nevertheless, it should be kept in mind that diverse opinions can also lead to new or other problems.⁵⁸

This highlights the importance of communication between all parties involved that is appropriate to the situation by at least supporting and facilitating the final decision by authorized representatives.⁷⁴ Medical and nursing professionals or their institutional guidelines play an essential role here, insofar as “[…] healthcare providers could improve confidence in decision-making by providing quality family communication.”⁶¹ As a result, conscientious decisions, which are in principle to be supported, can be implemented more easily. Communicating personal ideas about a good life and death with others not only opens up an opportunity to consider other perspectives but also to integrate the associated convictions into one's own conscience.^68,75,76 This corresponds to a learning process that strengthens the ethically important aspect of intersubjectivity in particular and is described in a comparable way by a surrogate decision maker: “[…] I had to make a lot of phone calls to family and friends and let them know what was going on […].”⁶² Even if proxies take over this last choice, such an orientation appears to relieve the burden on the individual in question, to promote an ethically important exchange⁷⁴ and thus also to give the best possible consideration to the interests of the person—whose life is affected.

Surrogates have a conscience that develops over the course of their lives and represents a form of ethically relevant verifiability of moral concerns.^23,77 Although they do not have the medical training and the associated convictions, knowledge of and adherence to professional guidelines, they can rely on medical professionals in this sense. The reference to the three components of conscience presented here is useful in order to clarify the relevance of intersubjective exchange possibilities. As representatives, these individuals have built up an idea of moral aspects from the very beginning (building conscience), which have solidified into a moral identity in the course of personal development (formation of conscience).^27,45,78 Nevertheless, the medical-professional standards and scientific knowledge can be integrated into one's own conscience, provided that a doctor is available—or the person familiarizes themselves with them independently. Apart from this, it is plausible to claim that this personal closeness to the patient also opens up a special insight into the patient's world of experience and specific values. For this reason, Rothhaar can be agreed with when the delegation of the decision to the individual who is best qualified to assess the situation in factual and normative terms is virtually imperative.¹⁰ A conscientious decision is ultimately based on personal convictions (conscience conformity), which are, however, open to reflectionⁱ and revision and can also rely on the influence of the environment.^42,72 In this sense, it is therefore about preserving human identity based on conscience, while at the same time being open to moral pluralism and the associated learning and maturation processes, which should be supported based on ethical considerations.

Final considerations

What can be concluded from the previous descriptions is not only the function of conscience as a moral point of reference, which is so important for us humans and forms our personal identity but also the dimension of conscientiousness, which is substantially different. This is also accompanied by an ethically relevant requirement, namely to actually apply the convictions (B), guidelines (C), and moral concepts (A) embedded in conscience in concrete cases.³⁰ Surrogates are usually in a situation characterized by pressure, personal uncertainty, and conceivable influences from other people. In such constellations, it is a great challenge not only to listen to one's own conscience but also to recognize these demands as effective.⁷⁶ Su et al. agree with this: “Healthcare providers should encourage surrogates to share the decision-making process with family members […].”⁶¹ Their perspective can initiate new considerations and lead to a more conscious examination of one's own conscience. Nevertheless, it can be argued that these individuals with decision-making power should incorporate their thoughts into the decision-making process and not just hope for external guidance. “The preferences of the surrogates and the patient/older adults should be respected.”⁶¹

Another noteworthy point that has not yet received due attention is the role of reflection or the “[…] form of self-reflection […]”¹¹ assumed by Beauchamp and Childress. According to the considerations so far, neither conscience nor conscientiousness seems to be identical with the concept of reflection, nor sufficiently describable. Conscience in the understanding presented so far can in principle be formed and shaped without a form of reflection. The unquestioned acceptance of moral cues appears at least conceivable and does not necessarily involve reflective action. Ernst writes that although our judgment of conscience is also determined by internalized commandments and prohibitions, there is an obligation not to leave it that way.²³ This not only reveals an ethically required ought regarding conscientiousness, but also the potential formation of conscience without the ability to reflect and make use of it. Admittedly, it is precisely these reflective processes of weighing up,⁷⁵ critical consideration¹⁰ and subsequent revision of one's own ideas of the morally good that make sense and are an essential aspect of making conscientious decisions possible³⁰—but they are not part of conscience itself. It always requires something to which specific reflections refer and this something could, in the formulation of self-reflection chosen by Beauchamp and Childress, refer to the self or conscience.¹¹ Nevertheless, conscientiousness cannot be understood exclusively as a capacity for reflection, because the executive character is lost and consequently the application of the ideas expressed by conscience loses its relevance. It seems reasonable to conclude that neither human conscience nor conscientiousness can be reduced to a capacity for reflection, but that it is an essential aspect of both. This means that personal reflections refer to the conscience, the self-described, and associated moral convictions.

Conscience appears to be the best possible expression of moral identity, for which brain-physiological foundations are necessary, but these are not only to be perceived in a physical-biological sense, but rather as belonging to the human being.¹⁸ The distinction made between moral conscience and ethical conscientiousness allows a connection to the moral identity often mentioned in this context. Insofar as people act according to their conscience, they express certain values and assumptions, which can also be described as moral integrity and at the same time reveals the moral identity of the corresponding subject.^11,16,53 In the words of Lamb and Pesut: “[…] acting according to our conscience […] we can fully know who we are as moral persons […].”³⁰ Conscientiousness, on the other hand, requires an ethical standpoint, which enables the individual to distance themselves to a certain extent from subjective convictions and to give priority to moral concepts that are subjectively considered important, but which in turn can satisfy a claim to universal applicability. Consequently, a person endowed with moral integrity—such as Dr Death—still appears to have a conscience corresponding to this idea, even if ethical reflections play a marginal to non-existent role.

This view differs from Sulmasy, for example, insofar as moral integrity is apparently always to be understood as something positive: “Conscience is a fundamental moral commitment on the part of a moral agent to moral integrity, involving a commitment to uphold fundamental moral precepts and moral identity and […] to make use of reason, emotion, and will […].”¹⁷ His considerations seem to imply that there is such a thing as morality, which applies as an orientation for all people and therefore, by agreeing or disagreeing with certain guidelines, grants a person moral integrity or not. According to Wicclair,^44,48 however, the opposite is conceivable if, for example, false values are internalized. Moral integrity means that a person has core ethical values that define them as an individual and that disregarding them comes close to self-deception.⁴⁴ The previous considerations have drawn attention to moral plurality and the associated development and life phases, which also lead to different moral concepts in different individuals. Empirical studies^14,41,68,74 confirm these interpersonal differences in conscience. Nevertheless, the ethical impossibility of a corresponding (moral) arbitrariness was emphasized. The considerations of Tuck and Glenn, in the context of potential medical interventions to improve moral behavior, are helpful for this perspective: “[…] someone gaining moral conscience following treatment would also be viewed as exhibiting significant identity change.”¹⁸ This makes it at least implicitly clear that people with poor or non-existent moral concepts also have a moral identity. A conceivable coercion¹¹ to follow external guidelines, or generally accepted values, could potentially cause ethically justified attitudes, but undermines this concept of moral identity. Apart from this, only the consideration of morally relevant aspects,^23,48,78 such as beneficence, nonmaleficence or others’ interests in general, permits an ethical justification, which appears to be constitutive to describe a person or action as conscientious. Terrorists may also be said to act according to their own conscience, are thus morally upright and thus visualize their moral identity for other people—which, however, cannot be used or plausibly justified for conscientious decisions.

Finally, after the foregoing considerations, conscientiousness seems to become understandable as an attitude and not in the sense of a virtue. While the attitude of conscientiousness not only brings the acting subject and the associated moral identity more strongly to the fore but also allows the consideration of other living beings as an ethical point of orientation, there is a decisive advantage. As a virtuous behavior or basic orientation, conscientiousness would probably only be attributable to a human elite and beyond that would be dismissed as a praiseworthy, valuable, and welcome attitude¹¹—which, however, eludes any normative claims. Especially if a virtue is understood in this sense, which can also be questioned.⁶⁹ Kukla's idea can be followed here because “[…] conscientiousness is inherently a virtue displayed over time […],”⁵¹ which means that conscientiousness is demanding but not impossible. In this article, such a claim was pursued in the sense of a moral ought, according to which the attitude of conscientiousness can stand up to ethical justification, takes into account the respective person and their convictions, and furthermore represents a plausible normative point of orientation—in a certain sense, the attitude becomes a virtue. Moral concerns appear too important and too little attention would be paid to them if only approaches that go beyond the normal level were to demonstrate conscientiousness. For surrogate decision makers, the advocated exchange can be valuable but should not make personal convictions and their active contribution impossible.

Footnotes

Author contributions

The author has accepted responsibility for the entire content of this manuscript and approved its submission.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Code availability

Not applicable.

Declaration of conflicting interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics approval

Not applicable.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Mario Kropf

Data availability

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

Notes

References

Klemperer

. “Wem dient die Medizin wirklich?": Interessen, Zielkonflikte und Patientenwohl in der Klinik. In: Frewer

Bergemann

Jäger

(eds) Interessen und Gewissen: Moralische Zielkonflikte in der Medizin. Würzburg: Königshausen & Neumann, 2016, pp.27–50.

Buchanan

Brock

. Deciding for others: the ethics of surrogate decision making. 1. publ. Cambridge: Cambridge University Press, 1989.

Cohen

. Deciding for others: the ethics of surrogate decision making. Hastings Cent Rep 1991; 21: 41–44.

Berger

DeRenzo

Schwartz

. Surrogate decision making: reconciling ethical theory and clinical practice. Ann Intern Med 2008; 149: 48–53.

Shea

. The ethics of choosing a surrogate decision maker when equal-priority surrogates disagree. Narrat Inq Bioeth 2021; 11: 121–131.

Torke

Alexander

Lantos

. Substituted judgment: the limitations of autonomy in surrogate decision making. J Gen Intern Med 2008; 23: 1514–1517.

Sulmasy

Snyder

. Substituted interests and best judgments: an integrated model of surrogate decision making. JAMA 2010; 304: 1946–1947.

Lenk

. Gewissen und Verantwortung als Zuschreibungen. Z Philos Forsch 1987; 41: 571–591.

Symons

. Conscientious objection in health care: why the professional duty argument is unconvincing. J Med Philos 2022; 47: 549–557.

10.

Rothhaar

. Das Gewissen in ethischen Fragen des Lebensendes: Überlegungen aus moralphilosophischer Perspektive. In: Frewer

Bergemann

Jäger

(eds) Interessen und Gewissen: Moralische Zielkonflikte in der Medizin. Würzburg: Königshausen & Neumann, 2016, pp.263–278.

11.

Beauchamp

Childress

. Principles of biomedical ethics. 8th ed. New York, Oxford: Oxford University Press, 2019.

12.

Giubilini

. Conscience. In: Zalta

Nodelman

(eds) The Stanford encyclopedia of philosophy (Winter 2024 Edition). Winter 2016. Stanford, USA: Metaphysics Research Lab, Stanford University, 2016, pp.1–17.

13.

Bogg

Roberts

. The case for conscientiousness: evidence and implications for a personality trait marker of health and longevity. Ann Behav Med 2013; 45: 278–288.

14.

van Scoy

Bliton

Smith

, et al. Intrinsic traits such as personality and decision-making style are predictive of stress in surrogate decision-makers. Am J Hosp Palliat Care 2023; 40: 694–703.

15.

Verkade

Karsten

Koenraadt

, et al. Conscience as a regulatory function: an integrative theory put to the test. Int J Offender Ther Comp Criminol 2020; 64: 375–395.

16.

Symons

. Why conscience matters: a theory of conscience and its relevance to conscientious objection in medicine. Res Publica 2023; 29: 1–21.

17.

Sulmasy

. What is conscience and why is respect for it so important? Theor Med Bioeth 2008; 29: 135–149.

18.

Tuck

Glenn

. Cultivating conscience: moral neurohabilitation of adolescents and young adults with conduct and/or antisocial personality disorders. Bioethics 2021; 35: 337–347.

19.

Larsen

Jalava

Griffiths

. Are psychopathy checklist (PCL) psychopaths dangerous, untreatable, and without conscience? A systematic review of the empirical evidence. Psychol Public Policy Law 2020; 26: 297–311.

20.

López-Romero

Cutrín

Maneiro

, et al. Psychopathic traits in childhood: insights from parental warmth and fearless temperament via conscience development. Brain Sci 2021; 11: 1–15.

21.

Vujošević

. Conscience as the rational deficit of psychopaths. Philos Psychol 2015; 28: 1219–1240.

22.

Greenacre

. Conscience in the psychopath. Am J Orthopsychiatry 1945; 15: 495–509.

23.

Ernst

. Grundfragen theologischer Ethik: Eine Einführung. München: Kösel, 2009.

24.

Hübsch

. Philosophie und Gewissen: Beiträge zur Rehabilitierung des philosophischen Gewissensbegriffs. 1. Aufl. Göttingen: Vandenhoeck & Ruprecht, 1995.

25.

Höffe

. Wirtschaftsbürger, Staatsbürger, Weltbürger: Politische Ethik im Zeitalter der Globalisierung. München: Beck, 2004.

26.

von Aquin

. Summa theologica: Die deutsche Thomas-Ausgabe (Summa theologica). Übersetzt von Dominikanern und Benediktinern Deutschlands und Österreichs. Vollständige, ungekürzte dt.-lat. Ausgabe. Graz; Wien; Köln; Heidelberg; Salzburg: Pustet / Kerle / Styria, 1933.

27.

Forschner

. Die Stoa als Quelle des philosophischen Gewissensbegriffs. In: Bormann

F-J

Wetzstein

(eds) Gewissen: Dimensionen eines Grundbegriffs medizinischer Ethik. Eberhard Schockenhoff zum 60. Geburtstag. Berlin: De Gruyter, 2014, pp.156–167.

28.

Herzberg

. Die thomanische Deutung des Gewissens. In: Bormann

F-J

Wetzstein

(eds) Gewissen: Dimensionen eines Grundbegriffs medizinischer Ethik. Eberhard Schockenhoff zum 60. Geburtstag. Berlin: De Gruyter, 2014, pp.189–208.

29.

Kropf

. Spirituality and family caregivers: ethical considerations on the role as a spiritual guide. J Study Spiritual 2024; 14: 156–168.

30.

Lamb

Pesut

. Conscience and conscientious objection in nursing: a personalist bioethics approach. Nurs Ethics 2021; 28: 1319–1328.

31.

Pfeifer

. Didaktik des Ethikunterrichts: Bausteine einer integrativen Wertevermittlung. 3. Aufl. s.l.: Kohlhammer Verlag, 2013.

32.

Karpman

. Conscience in the psychopath; another version. Am J Orthopsychiatry 1948; 18: 455–491.

33.

Hamlin

Wynn

Bloom

. Social evaluation by preverbal infants. Nature 2007; 450: 557–559.

34.

Curran

. Conscience in the light of the catholic moral tradition. In: Curran

(eds) Conscience. New York: Paulist Press, 2004, pp.3–24.

35.

Sepper

. Taking conscience seriously. Va Law Rev 2012; 98: 1501–1576.

36.

Little

. Conscience, theology, and the first amendment. Soundings: Interdiscip J 1989; 72: 357–378.

37.

Keenan

. Redeeming conscience. Theol Stud 2015; 76: 129–147.

38.

Childress

. Appeals to conscience. Ethics 1979; 89: 315–335.

39.

Emundts

. Über Gewissen und Gewissheit. Dtsch Z Philos 2016; 64: 495–521.

40.

Deutscher

Ethikrat

. Mensch und Maschine - Herausforderungen durch künstliche Intelligenz: Stellungnahme. Berlin: Dt. Ethikrat, 2023.

41.

Nunner-Winkler

. Entwicklungspsychologischer Blick auf reife Urteilsfähigkeit und Gewissensentscheidungen. In: Bormann

F-J

Wetzstein

(eds) Gewissen: Dimensionen eines Grundbegriffs medizinischer Ethik. Eberhard Schockenhoff zum 60. Geburtstag. Berlin: De Gruyter, 2014, pp.101–114.

42.

Wester

. Conscientious objection by health care professionals. Philos Compass 2015; 10: 427–437.

43.

Buchbinder

Lassiter

Mercier

, et al. Reframing conscientious care: providing abortion care when law and conscience collide. Hastings Cent Rep 2016; 46: 22–30.

44.

Wicclair

. Conscientious objection in medicine. Bioethics 2000; 14: 205–227.

45.

Luhmann

. Die Gewissensfreiheit und das Gewissen. Archiv des öffentlichen Rechts 1965; 90: 257–286.

46.

Kirchschläger

. Gewissen aus moraltheologischer Sicht. Z Kath Theol 2017; 139: 152–177.

47.

Fuss

. Conscience. Ethics 1964; 74: 111–120.

48.

Wicclair

. Conscientious objection in health care. Cambridge, UK: Cambridge University Press, 2012.

49.

Shanawani

. The challenges of conscientious objection in health care. J Relig Health 2016; 55: 384–393.

50.

McGuire

. On conscience. J Philos 1963; 60: 253–263.

51.

Kukla

. Conscientious autonomy: displacing decisions in health care. Hastings Cent Rep 2005; 35: 34–44.

52.

Beauchamp

. Informed consent. In: Veatch

(eds) Medical ethics. Boston: Jones and Bartlett, 1989, pp.173–200.

53.

Bergemann

Jäger

Frewer

. Conflicting interests, rights and conscientious objection: why professionalism and vulnerability matter. In: Frewer

Bergemann

Jäger

(eds) Interessen und Gewissen: Moralische Zielkonflikte in der Medizin. Würzburg: Königshausen & Neumann, 2016, pp.311–317.

54.

Singer

. Practical ethics. 2nd ed., 24. print. Cambridge: Cambridge University Press, 1993.

55.

Gajanan

. Peacock’s Dr. Death is based on a chilling true crime podcast about a murderous surgeon. Here’s what to know, https://time.com/6080714/dr-death-true-story/ (2021, accessed 14 November 2024).

56.

Goodman

. Dr. Death. Plano surgeon Christopher Duntsch left a trail of bodies. The shocking story of a madman with a scalpel, https://www.dmagazine.com/publications/d-magazine/2016/november/christopher-duntsch-dr-death/ (2016, accessed 23 January 2024).

57.

Beil

. A surgeon so bad it was criminal, https://www.propublica.org/article/dr-death-christopher-duntsch-a-surgeon-so-bad-it-was-criminal (2018, accessed 23 January 2024).

58.

Peterson

Karlawish

Largent

. Supported decision making with people at the margins of autonomy. Am J Bioeth 2021; 21: 4–18.

59.

Schöne-Seifert

. Grundlagen der Medizinethik. Stuttgart: Alfred Kröner Verlag, 2007.

60.

MSD Manual. Default surrogate decision making, https://www.msdmanuals.com/home/fundamentals/legal-and-ethical-issues/default-surrogate-decision-making (2023, accessed 21 January 2024).

61.

Yuki

Hirayama

. The experiences and perspectives of family surrogate decision-makers: a systematic review of qualitative studies. Patient Educ Couns 2020; 103: 1070–1081.

62.

Greenleaf

Foy

van Scoy

. Relationships between personality traits and perceived stress in surrogate decision-makers of intensive care unit patients. Am J Hosp Palliat Care 2023; 41: 664–672.

63.

Seifart

Heubel

Schmidhuber

, et al. Professionalität der Gesprächsbegleitenden und Freiwilligkeit der Teilnehmenden als ethische Herausforderungen von Advance Care Planning. Ethik Med 2024; 36: 55–70.

64.

O'Rourke

Brodeur

. Medical ethics: common ground for understanding. St. Louis: Catholic Health Association of the United States, 1989.

65.

In der Schmitten

Rixen

Marckmann

. Advance care planning: ein Konzept zur Stärkung der Autonomie pflegebedürftiger Menschen (nicht nur) am Lebensende. In: Jacobs

Kuhlmey

Greß

, et al. (eds) Pflege-report 2022. Berlin, Heidelberg: Springer, 2022, pp.83–102.

66.

Morrison

Meier

Arnold

. What's wrong with advance care planning? JAMA 2021; 326: 1575–1576.

67.

Frey

Hertwig

Herzog

. Surrogate decision making: do we have to trade off accuracy and procedural satisfaction? Med Decis Making 2014; 34: 258–269.

68.

Butler

Hirshberg

Hopkins

, et al. Preliminary identification of coping profiles relevant to surrogate decision making in the ICU. PLoS One 2016; 11: 1–16.

69.

Biller-Andorno

. Gerechtigkeit und Fürsorge: Zur Möglichkeit einer integrativen Medizinethik. Zugl.: Hagen, Fernuniv., Diss., 2000. Frankfurt am Main: Campus-Verl., 2001.

70.

Capron

. Human experimentation. In: Veatch

(ed) Medical ethics. Boston: Jones and Bartlett, 1989, pp.125–172.

71.

May

. On conscience. Am Philos Q 1983; 20: 57–67.

72.

Geddis-Regan

Errington

Abley

, et al. Enhancing shared and surrogate decision making for people living with dementia: a systematic review of the effectiveness of interventions. Health Expect 2021; 24: 19–32.

73.

Spoljar

Curkovic

Gastmans

, et al. Ethical content of expert recommendations for end-of-life decision-making in intensive care units: a systematic review. J Crit Care 2020; 58: 10–19.

74.

Hakim

Santoso

Takwin

, et al. Group decision quality, conscientiousness and competition. Cogent Psychol 2021; 8: 1–17.

75.

Juthberg

Eriksson

Norberg

, et al. Perceptions of conscience in relation to stress of conscience. Nurs Ethics 2007; 14: 329–343.

76.

Shinkunas

Klipowicz

Carlisle

. Shared decision making in surgery: a scoping review of patient and surgeon preferences. BMC Med Inform Decis Mak 2020; 20: 1–14.

77.

Torke

Fitchett

Maiko

, et al. The association of surrogate decision makers’ religious and spiritual beliefs with end-of-life decisions. J Pain Symptom Manage 2020; 59: 261–269.

78.

Kropf

Schmidhuber

. Family caregivers and the ethical relevance of moral identity. Nurs Inq 2024; 31: 1–9.