Religion’s priority in the realm of conscience
The term “conscience” has for ages belonged to the realm of religion. For almost two thousand years it has had a definition and connotation identifying it with a close relationship to a Divine Being, to God (Rom. 2:15), to Christ (Heb. 9:14), to the Holy Spirit (Rom. 9:1), and closely related to a sense of guilt (Heb. 10:2). a faculty for checking right from wrong (Rom. 2:15), a tremendous spiritual, moral, and psychological booster if we heed the righteous demands of God (I John 3:19–21), and a condemning faculty when we transgress against him.
The traumatic assaults of the world, the flesh and the devil, which are made daily on the psyche of every man and woman since the fall in Eden, are taken account of (not disregarded) in the Scriptures. There are also the wholesome impacts for good on the conscience, resulting in a “good” conscience, a “cleansed” conscience, one not unrealistically troubled and burdened with a sense of guilt (Heb. 10:2). The former traumatic assaults produced a conscience “defiled” by vicious habits, hardened, “branded with a hot iron” (I Tim. 4:2). The prior right of religion to define what conscience is, and what it does, stands as firm as the rock of Gibraltar. Sigmund Freud knew this, yet set out to overthrow religion by the super-ego.
A crude comparison of the conscience to a computer may help us to understand how Freud manipulated the conscience into the super-ego, taking the divine heart out of the “conscience-computer,” leaving only the psychic “material” each person feeds daily into his computer. That residue Freud called the “super-ego.” This daily mass of material, man’s psychical interactions to the wholesome impacts and the damaging assaults of life, as they make impact on the developing brain and psyche of each child and adult, was considered as the only valid material which brought about the origin of a censoring, judgmental “organ.” God had no part in it. These traumatic events and impacts, which occur in every personality that has been born into the world, are often too harshly condemnatory, and it is this Freud called the super-ego. The result was a moral censor, somehow arising out of the “ego,” which in turn had originated from the slime of the swamp of “id” (which was devoid of all morals). A censoring organ resulted, bearing very little relationship to the old fashioned “conscience,” formerly regarded as relating to God. In fact, Freud predicted that the “conscience,” in as far as it was related to religion, would cease, be out-dated, become obsolete with the appearance of psychoanalysis and The Future Of An Illusion. It has truly become so, in essence, in the major part of the psychological and psychiatric world. Yet this crucial part of Freud’s philosophy was based on unproven assumptions.
Abraham Lincoln once put a hypothetical question to an opponent, who was making up his own definitions of terms, and then proceeding on these assumptions and presumptions to use those terms as proven facts. Lincoln asked :
“If I call the tail of a horse a leg, how many legs does the horse have?” “Five,” replied his opponent. “Wrong.” replied Abe. “Calling a tail a leg does not make it a leg. The horse still has four legs.”
Now in the case of our disagreement as Christians with Freud and his true believers today (those who refuse to allow God or absolutes to have a place in their philosophical scheme and psychotherapy), it is the same Lincolnian question, but in reverse, the intellectual (or omniscient) head-end being chosen for transposition.
“Let us suppose that I wish-away the guiding, intelligent head and neck from the horse; what kind of a beast would that be?”
“It would be a headless horse, devoid of supervision and direction from the highest nerve centers.”
“Wrong! It would still be a horse with a head, because you may desire to wish-away any essential aspect of a thing, but wishing it away or writing it away, or preaching it away does not alter the reality. It is you, yourself, who get out of contact with reality. Even if you wish to substitute a torso with human head and human brains on that supposedly headless horse. the answer is still “four legs, horse’s head—it’s a horse,” by the will of God. You haven’t even been able, by your assumptions, and supposings, and wishful thinking, to create that mythological creature called a “centaur.” He never existed, and never will. He was a figment of the human mind, yet a host of folks believed he existed. You have made a new myth. God is still alive.
Freud considered religion to be the result of a compulsion neurosis in man. Man, being so dependent on his father, created by wishful thinking a father in heaven, omnipotent, who would never fail him in his needs. Man thus continued the cycle of neurosis because of his need to have a God, made in his own image. Religion was thus an illusion, would pass away.
However, on the same psychological basis of reasoning, Freud’s compulsion to have “no-God,” “no religion,” was also a neurotic manifestation, a neurosis, wishful thinking, an illusion, and one might write also of “The (Dim) Future Of The Psycho-analytic Illusion.”
Actually man’s conscience (and man’s will, and Freud’s super-ego, for that matter), do not exist as a separate entity or tidy nest of cells in the brain. These concepts include a concept of billions of neurones, nerve cells and nerve fibers in interaction. Freud did not discover a certain discrete anatomical island in the brain. It is a way of explaining things, his philosophical printed works doing in the realm of the mind and psyche what Charles Darwin’s Origin of Species and his Descent of Man did in the realm of the origin of man’s physical side, and of all living things. Freud modified an old concept, deliberately leaving God out.
The super-ego concept, minus God, is vital to psychoanalysis, and is incorporated -whole and unquestioned into the minds of the vast majority of Freudian-oriented psychologists today, and often by others who fail to realize its ethical implications. It is not a mere question of semantics. The term “super-ego” should not be used when we really mean “conscience” as Christian ethical psycho-therapists. God is still central in our psychotherapy.
There was no vacuum requiring the term “superego” when Freud coined the term. The age-long, old-fashioned “conscience” included what Freud appropriated in his “super-ego,” for “conscience” took into account man’s developing psychical reactions as that infantile conscience continued to grow and develop through the years, with God there behind the scenes, the Master Architect who created that stuff from which the amazing computer-like faculty called “the conscience” was to continue its development. But exactly there was the rub! That God in the background! Freud even asks of his friend, Dr. Pfister:12 (page 63) “Incidentally, why was it, none of all the pious ever discovered psycho-analysis? Why did it have to wait for a completely godless Jew?” Exactly! The answer is clear. The pious were pious.
Now this is no mere matter of semantics. This is a matter of absolutes. This is a matter of ethics and guilt. When we are guilt laden, to whom do we give account? To ourselves and man? Or, back of it all, to God?
Guilt has usually been related to conscience in a manner that makes conscience a dreadful thing, a handicap to man rather than in any way a blesSing. Guilt, and its affect (feelings associated with guilt ), the sense of guilt, are usually regarded collectively as a minus, a debit, a negative quantity, something “to be gotten rid of” in the opinions of secular psychiatrists. But spiritually regarded, unless the guilt is completely unrealistic or founded on no past misdeeds, the normal sense of guilt is an asset; uncomfortable, but a character builder, impelling one on to confession of sin, repentance, forgiveness, pardon. The writer of the hymn, “Amazing Grace, How Sweet The Sound,” writes: “Twas grace that taught my heart to fear, and grace my fears relieved.” The conscience thus serves a healthful psychological and spiritual function.
Elton Trueblood even writes of “The Cultivation of the Uneasy Conscience”13 using the sixth commandment as presenting the guilt-producing negative principle in the condemnation of murder (and including war, the use of the atomic bomb at Hiroshima, etc.). It leaves us all with almost unrelievable guilt feelings, since we all share in awful, vast evil deeds committed beyond our wills and controls. Yet these deeds (atom bomb, defensive wars, war on disease, animal experimentation to combat human disease, etc.) also bring us blessings.
Such guilt and sense of guilt is reconstructive, impels to avoidance of repeating the offense. We become tender and sensitive. The suppressing (a conscious act) or the repressing (unconscious) of the guilt feelings (covering them, as it were, with tons of earth that they emerge no more to trouble us), defeats the very purpose of the guilt feelings and the conscience. It produces a condition approaching, or akin to, that of the conscienceless psychopath.
Trueblood says: “The cultivation of the uneasy conscience is a major plank in the platform of reconstruction….The good conscience is an invention of tile Devil.”13(Italics are Trueblood’s). “Good” here refers to the smug, easily stilled conscience which, like the “good” child, gives the parent little trouble. It leaves one in false peace, comfortable. We were not placed in this world to be, first of all, “comfortable.” We are here to develop Christian character and to deal ethically.
Psychotherapy and the Psychotherapist’s conscience
Now what relationship does this have to our psychotherapy and the impact we make on the decisions our patient will make through observing our attitudes, our words, our silences, our direct or indirect counseling with him? Even the most indirect Rogerian psychotherapist, who maintains he is giving no direct advice whatsoever, is none the less giving advice and is producing thought and conduct changes, for the better or the worse, in his patients. Ethics has to do with our hourly and daily decision making, for right or wrong. We are responsible for the decisions we make and which we help our patients to make. This is true not only in our special field of psychiatry during psychotherapy sessions, but also as M.D’s, as doctors of medicine in general. There is scarcely a decision which is required of the usual M.D., be he a surgeon, obstetrician, internist, pediatrician, gerontologist, gynecologist, that is not also required of us. Daily we stand in the sight of God as we make our decisions and help others make theirs.
Some psychiatrists may say: “You relate conscience directly with responsibility to God. I do not believe in God. I do not believe in a God-related conscience. I relate all to the super-ego of man.” I would answer: “You are none the less relating to a god, for you become your own god, your own supreme being with whom you consult. You still have at least your ‘ego ideal’ to match up to as a standard. You must still make decisions as every person truly human must do.”
Now what are some of the items that call for decision? Joseph Fletcher in his book Morals and Medicine2 lists some of these controversial items under the heading of what he believes are our rights, and takes the positive side in these rights he lists, among which human rights are, he says, our right to know our status as to our life, our health, and approaching death; to know the truth; to control our parenthood; to overcome childlessness by various means which involve certain ethical processes; to foreclose parenthood if we wish; and also euthanasia, our right to die if we so choose or to help others to die more quickly.
If our ethics is theo-centrically oriented, with awareness of our responsibility to God, our decisions on these issues and others relating to the physical and mental and spiritual welfare of our patients will have a stable, lofty basis of reference, being based on God. It does not mean that all “God fearing” therapists·will come to exactly the same ethical decisions. Many theo-centric therapists, including Jews, Roman Catholics, and Protestant Christians, will differ as to certain aspects of their decisions, but all should have a world-and-life view that makes them ask: “What would God have me do?” Their patient is one to whom God has given his life; he is one who is made in the image of God; his patient is one who is responsible to God even as the therapist himself is, and the therapist may not lead him astray. The Christian therapist has laid down for him a code of ethics in the Holy Scriptures. He has the law of God written in his heart, he has a conscience which is sensitive to God’s will.
Illustrations of ethical issues which may confront the Christian Psychiatrist
In my treatment of the ethical issues that may confront a psychotherapist I shall try to refrain from forcing any ethical position of my own upon the reader. The subject is so vast and broad that scarcely more than an enumeration of the many ethical issues will be possible. I can take no better starting point than to begin with the various rights of man which Joseph Fletcher, professor of Pastoral Theology and Christian Ethics at the Episcopal Theological School in Cambridge, Massachusetts, defends in his book Morals and Medicine. The first is man’s right to know the truth about himself, about his illness, its diagnosis, and his prognosis. Should the psychiatrist tell his patient all the truth? Should he tell him, for example, that the diagnosis is schizophrenia; and if, in the physical examination which is done in every psychiatric hospital, an inoperable cancer has been found, should he tell him this fact or hide it from him? Can the patient tolerate the truth? Would the truth be the last straw which breaks him and which may lead to a suicidal attempt? I am not giving the answers here. You supply the answers. I’ll raise the questions.
The patient in his interviews with the psychiatrist has perhaps mentioned various matters which are a “privileged communication” between the psychotherapist and the patient. Let us suppose that among these communications the therapist has become aware of the fact that this patient intends soon to marry a girl who to this time is entirely unaware of the serious mental illness of this patient, and he has refused to tell her. Dare the psychotherapist in any way divulge this to the party to whom it has such tremendous concern? Supposing the physical examination has also revealed a venereal disease. Must the therapist permit this young girl to go into this marriage unaware of the perils that face her? Here is a conflict of tremendously great conflicting loyalties.
The psychiatrist has become aware of a woman patient’s dread of further pregnancies and a need for birth control to be practiced between these two people, husband and wife, How shall he treat the matter of control of conception or prevention of conception? Contraceptives? Rhythm method? Or perhaps she is at the time in early pregnancy and the continuance of this pregnancy, in the psychiatrist’s opinion, is very likely to result in his patient going into a retrogression which will be the beginning of a long mental hospitalization. Should he recommend therapeutic abortion? Should he recommend sterilization, if the pregnancy must go to term, but then advise sterilization in order that there be no further pregnancy? Should he simply advise continence and abstinence of sexual relations, even though he knows that it will contribute to emotional imbalance and constant marital frustration between the two parties concerned?
Has the medical man the right to simply foreclose parenthood by means of sterilization of either the woman or the man? Should the law permit unfit parents to conceive and to populate the earth? Has one ever the right to advise the destruction of the fetus to save the mother’s life?
Mental illness at times can be the most excrutiating suffering that the human body and mind can be subject to. Does man have the right to choose not only to live, if he desires, but also to choose to die if he wishes? Has euthanasia any place in the practice of medicine? Did not Job request that his life might end and the day perish wherein he was born? Is one required endlessly to prolong a life which has lost its mental faculties? Is one required endlessly to give intravenous fluids, blood transfusions, antibiotics, until finally the financial resources of the comatose patient are exhausted and nothing is left for the surviving widow and her children?
In the year 1961 a colloquium on medical ethics was held in St. Louis, Missouri, by the Lutheran Academy For Scholarship. This colloquium raised such ethical questions as the following: Is abortion ever permissible? When does the soul enter the body of the developing fetus? What should be the answer of the Christian therapist in the case of the childless couple who desire a child by the method of artificial insemination? Does such practice constitute adultery? Is such practice always wrong?
Even in such generally accepted practices as autopsy certain groups of Christians raise forceful objection. Should not the psychiatrist urge that this practice be accepted in the hope that study of that nervous system may bring forth some knowledge that will help others who become mentally ill in the future?
Among the symptoms presented by one patient was a sense of hostility on the part of his relatives, with subsequent frustration and guilt, because the patient had willed his eyes to the eye bank in order to restore the sight of some other person; other family members of his were contesting this and saying they would seek to prevent such mutilation after the patient’s death. Which of the two parties should the psychiatrist uphold?
A Christian family is deeply grieved because it has in its midst one of its members who is a homosexual. Should the therapist explain this as being the result of sickness or of sin? How can he help this family and still remain ethically sound? Another family has in its midst the memory of a relative who had taken his own life. Should the therapist soften the blow by ascribing all suicidal action to sickness and irresponsibility before God? We must tell the truth, but “tell the truth in love,” as Scripture enjoins us, May his love for these grieving brothers and sisters permit him to tell a “white lie?”
Or, take as example the blasted marriage hopes and life of one spouse married to a spouse who has been spending the last five or six or more years in Pine Rest or in a State Hospital as a mentally ill patient, whose condition seems hopeless for cure. Dare we advise the spouse to seek a divorce and marry again, as laws of many states allow?
These are but a few of the many examples of ethical issues which present themselves to the Christian psychiatrist for his evaluation and decision. The writer can state that in his own years of medical and psychiatric practice many of these issues have either directly or indirectly come into the picture. The answer given will depend on the life and world view of the therapist and on his conscience.
Far more common, however, than these issues mentioned above is the almost daily confrontation of the psychotherapist with the patient struggling with guilt and remorse from past actions either real or fancied. In his sick state, mentally ill as the patient is, guilt is often magnified to an extreme degree, so that the slightest indiscretions of his teenage or early manhood or early marriage are magnified entirely out of proportion to their true importance, In this critical area of psychotherapy with a Christian, the foundations of the psychiatrist’s own ethics and morality are of great significance. If his own view of his own conscience is such that he has almost disconnected his conscience from any relationship to God, his answer to his patient will be very different than that of another therapist who upholds that only by confession, penitence, forgiveness by God, restitution for wrong done (if possible), can the guilt be eradicated and the mind and the soul of the patient put at rest. At Pine Rest Christian Hospital our psychotherapists do take God into their therapy. They do ask: “What wilt Thou have me do and say?” For we often deal with guilt-laden, restless, troubled people, wrestling with their conscience. In this great field of the conscience and of guilt, the words of St. Augustine are especially pertinent: “Man is restless, and he can find no rest, until he rests in Thee.”
BIBLIOGRAPHY
1. Ethics in a Christian Context, by Paul Lehmann. Harper & Row, publishers, 1963. Address: 49 E. 33rd Street, New York 16, New York.
2. Morals and Medicine, by Joseph Fletcher, Professor of Pastoral Theology and Christian Ethics, Episcopal Theological School in Cambridge, Mass. The Princeton University Press, publishers, 1954. Address: Princeton, New Jersey.
3. A General Introduction to Psychoanalysis, by Sigmund Freud, page 344.
4. A Commentary of the Old and New Testament, by Jamieson, Faussett and Brown, Vol. VI, page 234 under verse 23, regarding “different” law.
5. Calvin’s Institutes, Book III, Chapter XIX, paragraph XV.
6. Proceedings 0f the Colloquium on Medical Ethics, The Lutheran Academy for Scholarship, 801 De Mun Avenue, St. Louis 5, Missouri.
7. The Ethical Basis of Medical Practice, by Willard L. Sperry. Paul B. Hoeher, Inc., c/o Harper & Brothers, 49 E. 33rd St., New York 16, N. Y.
8. Principles of Medical Ethics. The American Medical Association, 535 North Dearborn St., Chicago, Illinois 60010.
9. Christianity Today, Volume X, Number I, pp. 19–23, October 8, 1965. Article “Have Psychiatry and Religion Reached a Truce?” by Orville S. Walters, psychiatrist, Ph.D., M.D.
10. Christianity Today, July 2, 1965, page (1015 )3–(1018 )6 – “Psychotherapy and Spiritual Values,” panel discussion.
11. Cruden’s Concordance, Alexander Cruden, M.S. See under “Conscience.”
12. Quotations from Psychoanalyis and Faith, The Letters of Sigmund Freud and Oskar Pfister, translated by Eric Mosbacher, Basic Books, Inc., Publishers, New York, 1963. pp. 109–110; 112–113; p. 63.
13. Foundations for Reconstruction., by Elton Trueblood. Chapter Xl, pp. 66–69 (Revised Edition) 1961. Harper & Brothers, Publishers, New York.
Because of the religious and moral issues involved in dealing with those who need psychiatric help, the Christian facing such a situation can be adequately served only by a committed Christian psychotherapist. This position is developed and defended in this second article by Dr. Stuart Bergsma, Superintendent and Clinical Director of Pine Rest Christian Hospital. The first article appeared in the January issue of this magazine.