| This interpretive phenomenological study explores how physicians experience dilemmas of conscience in their day-to-day practice. Eighteen physicians of various ages and professional backgrounds agreed to participate. The study recognizes that conscience is as a meta-moral commitment to morality that allows tolerance and requires knowledge and experiences. Conscience is a complex phenomenon that cannot be reducible to any one facet of the emotional, cognitive or motivational aspects of a person. It follows, that the participants' stories do not make sense if one tries to understand dilemmas of conscience as focal phenomenon, where abstract rules of conduct are applied to specific cases. Interpretive phenomenology lent itself well for revealing the practical concerns, know-hows and meaningful patterns of the participants' stories. Findings revealed how salient moral features of the clinical context are not only experienced differently by participants but also diversified within the stages of becoming an experienced physician. For young physicians in training, experiences of high emotional strains, informal tests to prove their interests, hidden expectations, confrontations with dismissive authority figures, and struggles with informed consent are prevalent. Whereas, more experienced physicians encounter departmental disagreements in regards to specialized knowledge and exclusion tactics, barriers to care from insurance companies and hospital protocols, system failures like a culture of hopelessness, "we all know it is wrong but" and fears of lawsuits. Findings also suggest that certain orientations to care isolate rather than engage participants or make participants adopt simple maxims rather than keep them open to the clinical encounter. How individual participants cope with their experienced dilemmas of conscience is an adaptive process that involves skillful learning, a process that requires time and rehearsals. Furthermore, the complexity of the healthcare environment requires a shift from thinking of dilemmas of conscience as polarized individual problems, to viewing them as not dissociable from the climate, culture and conscience of the whole institution. To promote the conditions for an ethical climate where all remain engaged in care, it is essential to encourage professionals to speak up, support dialogue and cooperation, ameliorate information exchange, and map how individuals and groups assign or deflect their responsibilities. |
