Conscience
When an individual makes a conscientious refusal to perform a certain action, she does so because she believes that to perform that action would be to contradict her core moral beliefs (Wicclair 2011: 4–5) or her religious faith and would go against what her conscience is “telling” her to do. When an individual listens to her con- science, she is responding to a moral judgement and/or feeling that urges her to act or discourages her from acting. Most people are familiar with this feeling, though it is hard to pinpoint exactly what the conscience is and how exactly it relates to whether an action is (or would be) right or wrong. Hill describes the conscience as a “capacity, commonly attributed to most human beings, to sense or immediately discern that what he or she has done, is doing, or is about to do (or not do) is wrong, bad and worthy of disapproval” (Hill 1998: 14). It is most common for the con- science to be referred to in the context of wrong action, as Jenkins explains: “We hear a great deal about a ‘bad’ or ‘guilty’ or ‘nagging’ conscience, and about ‘pangs’
with which conscience afflicts us when it is ‘hurt’ or ‘outraged’. We hear very little about a ‘good’ conscience. This indicates that conscience is peculiarly alert to human malfunctioning” (Jenkins 1955: 261–2). When the good conscience is referred to, it is as a wholesome entity or is described as having an absence of nega- tive properties. As Childress puts it, “often the good conscience is described by nouns such as ‘peace’, ‘wholeness’ and ‘integrity’ or as adjectives such as ‘quiet’,
‘clear’, ‘clean’ and ‘easy’” (Childress 1979: 318).
Despite the sometimes powerful “gut feeling” that an (in)action would be wrong (or right), the conscience is not generally considered by philosophers to be a reliable and definitive indication of what is in fact right and wrong (see Childress 1979;
Hunter 1963; Sulmasy 2008). Indeed, one’s conscience can be desensitised over time by consistent wrongdoing, which implies it is a poor evaluator of whether an action is right or wrong.
The moral judgements of the conscience are not solely based on feelings or intu- itions; a conscientious refusal is often the result of careful, rationalised thought.
This intellectual aspect of moral judgement may make it easier to understand, chal- lenge, persuade or dissuade someone from the position she holds, but it does not
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necessarily make her conscience a more reliable indicator of what is in fact right or wrong. Individuals with equally strong conscientious positions can hold opposing views, again implying the conscience is not a reliable epistemic tool.
Even though the conscience gives an unreliable indication of whether an action would be morally permissible, a person’s appeal to her conscience remains morally valuable because the conscience represents an individual’s commitment to doing what is right. This is captured in Sulmasy’s definition of conscience, which is per- haps the clearest and most fitting among the various definitions in the literature, and will be adopted for the remainder of this chapter:
(1) a commitment to morality itself; to acting and choosing morally according to the best of one’s ability, and (2) the activity of judging that an act one has done or about which one is deliberating would violate that commitment. (Sulmasy 2008: 135)
Importantly, it is this commitment that matters when a conscientious refusal is hon- oured. In this way, the conscience clause has little to do with the particular proce- dure to which the individual is objecting; rather, it is in place partly to respect the individual’s integrity. Take the example of pharmacists supplying EHC. In several countries, including the USA, the pharmacy profession as a whole supports the view that supplying EHC in certain circumstances is morally permissible but allows con- scientious refusals. The fact that an individual pharmacist’s conscience tells her that it is not morally permissible does not in itself persuade the profession that the prac- tice is wrong. Rather, the conscientious refusal is honoured in part because the pro- fession respects the pharmacist’s commitment to morality. The profession accepts that for some individuals, the act of supplying EHC would be a breach of this com- mitment and would violate their integrity.
Integrity
There are several accounts of integrity in the philosophical literature.1 One of the significant differences between them is the implication for the relationship between integrity and morality. There are two reasons why this relationship is important when defending conscientious objections. First, if integrity is linked to doing the right thing, then protecting it would be instrumentally valuable for the profession.
Second, if acting with integrity is morally worthy in and of itself, then, all things being equal, it would be wrong to prevent an individual from exercising her integrity.
Cox et al. (2003) make a convincing case for integrity as a virtue that keeps in check the balance of other virtues, describing integrity as a cluster concept, made up of other virtues. This view is not without its faults, specifically that it does not pro- vide an explicit definition of integrity. Even so, it goes some way towards capturing
1 For further explanation, see Cox et al. 2013, Palanski and Yammarino 2007, and Scherkoske 2013.
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intuitions about integrity and how it is applied to individuals where other accounts seem to miss the nuances of what it means to be a person with integrity. By this account, a person with integrity is reflective and responsive. She takes seriously her commitment to morality, which includes continual assessment and adjustment of her values, particularly by considering the perspectives of others. Under this view, a person with integrity can make mistakes and do wrong, but in the main she will do good because the qualities underlying integrity (e.g. self-awareness, sincerity, reflection) usually contribute to good character. I would add to this, more explicitly, that integrity includes the virtue of a commitment to morality. It is worth briefly visiting three other accounts of integrity (“self-integrated integrity”, “integrity as identity” and “objective integrity”) to explain why integrity is best understood as a virtue.
Under the self-integration account, integrity is a kind of wholeness of the self. It is achieved by a person when her various desires, principles and commitments are in harmony without inner conflict. “The integrated-self picture…emphasizes the fact that people of integrity know who they are, and what they stand for. They have settled reasons for taking the stand they do, and those reasons are their own reasons”
(Mendus 2009: 16). In this view, it makes no difference whether a person is harmo- niously evil or harmoniously good; it is through wholeness, not goodness, that a person achieves integrity. A major criticism of this view is that to exempt integrity from moral evaluation would be to miss an important aspect of integrity, which is about a commitment to the good. Another criticism, made by Cox et al., is that the proponent of this account is mistaken in the claim that conflicts of commitments, values and desires threaten integrity. This is because integrity necessarily involves a capacity to change and involves a “continual re-making of the self” (Cox et al. 2003:
41). “[T]he view that the person of integrity is a whole integrated self, that the suc- cessful integration of self is both necessary and sufficient for integrity, is oversim- plified and mistaken. …[B]eing such a ‘whole integrated self’ is antithetical to integrity since it suggests an end to, or elimination of, the kinds of conflict that integrity is rooted in and thrives upon” (Cox et al. 2003: 18–19). In other words, we should not resist conflict of our own values or regard it as a weakness or sign of a lack of integrity. Instead, it should be accepted that a person with integrity is likely to experience conflict and will possess the necessary virtues (which together consti- tute integrity) to reflect on and make adjustments as appropriate.
This responsive and adaptable element is also missing from Williams’ notion of
“integrity as identity”, which is to hold steadfastly to one’s principles and values as part of one’s identity. For Williams (1981), integrity is a matter of honouring one’s commitments which, if abandoned, would corrupt the very person one is. A person might compromise on minor matters but will show unwavering commitment to the values with which she most closely identifies. Unlike integrity as a virtue, integrity as identity does not necessarily motivate one to act morally, only to act in which a way that is in keeping with one’s character. Thus integrity by identity is descriptive (of consistency with one’s character) and nonnormative. This means that a person can have integrity even if she consistently commits heinous acts. One might respond to this by pointing out that this account sets out a duty to be true to one’s character
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(even if that character is otherwise morally flawed) and that it therefore does have a normative element to it. Pitted against the person who is inconsistent, unreflective and with little integrity of any kind, the evil person who is true to her character might attract a degree of admiration for her consistency that is separate from judge- ments of the acts she commits. However, this single trait of consistency with one’s character is insufficient as an account of integrity. A person who met a commitment to maintaining her poor character would be more likely to be described as constant, stubborn, predictable or unchanging than as having integrity. Integrity is a richer, more complex term. It is used to comment on a person’s moral character, not a sin- gle trait. According to Cox et al., integrity would be more appropriately attributed to a person who overcame her bad character and was not true to her previous self (2003: 31). Again, the integrity as identity account seems to miss important aspects of integrity as being aligned with what is morally right. It is only by understanding integrity as a virtue can we explain that a person may be guided by her integrity to do the right thing.
Doing the right thing is essential under the “objective” account of integrity, which requires “that we abide by our moral commitments and that these commit- ments stem from the moral obligations we actually have” (Ashford 2000: 425). Cox et al. (2013) claim it would therefore be impossible for someone to act with integrity and be morally mistaken. This is far more demanding than the “integrity as virtue”
account, in which a person strives to do good and usually succeeds but is sometimes mistaken in her judgement.
In terms of the correlation between integrity and doing the right thing, the “virtue”
account sits somewhere between the “identity” and “objective” versions. As Cox et al. describe it, “A person of moral integrity cannot be a moral monster . . . because attributions of integrity, being attributions of an important virtue, presuppose a cer- tain moral success; the qualities that make for a character of integrity only constitute integrity when they succeed in making a person, with some degree of latitude, a good person” (Cox et al. 2003: 69). This means the evil tyrant cannot have integrity, even though he stands steadfastly to his principles. It also means that a person can have integrity despite sometimes faltering in her judgement. Instead, what matters is that a person takes seriously her moral commitments and usually displays praiseworthy virtue. A person with the virtue of integrity holds an honest adherence to her values, ready to adjust these values in response to new knowledge, experiences or realisa- tions. Honesty is a virtue in its own right but also forms part of the cluster of virtues that makes up integrity. This honesty demands that the individual is open to adjusting her values as appropriate by considering the perspectives of others and keeping open- minded about the possibility that she has been mistaken or naive. “The appearance of certainty throughout a person’s moral and volitional life may be, and often is, less a sign of integrity than an indication of its lack. Thus, we learn early to beware of the self-righteous and sanctimonious” (Cox et al. 2003: 3).
On the whole, a person with integrity will judge correctly. Importantly, though, integrity is not sufficient for moral action as it may lead to wrong action, and it is not necessary for a morally desirable outcome. This can be seen in the following examples. Sally is a pharmacist who believes that using animals in research is
Conscientious Refusals in Pharmacy Practice
morally abhorrent. Even so, she continues to supply medicines that have been tested on animals because she believes that to refuse to supply them would put her current position of employment in jeopardy. For the sake of argument, assume Sally is mis- taken in her beliefs about using animals in research.2 In this example, Sally is acting against her integrity to do something that is otherwise morally acceptable. In a simi- lar example, George also believes that using animals in research is morally abhor- rent, and he refuses to make the supply. In this case, George acts with integrity to refuse to supply medication tested on animals, but, for similar reasons to Sally, he is mistaken in his reasons for the refusal. Sally’s actions have resulted in a morally desirable outcome despite her lack of integrity, and George’s actions have resulted in a morally undesirable outcome despite his integrity. As someone with integrity, George’s misjudgement is likely to be exceptional; usually, his thoughtfulness, sin- cerity and commitment to morality lead him to make careful, sensitive and well- justified decisions.
So far, it has been shown that neither conscience nor integrity is a reliable indica- tion that the moral judgement a person makes is correct, though integrity as a virtue is generally conducive to doing the right thing. Integrity is thought to be valuable in its own right, such that to force a person to act against her integrity would be to com- mit a great wrong against her. When conscientious refusals are granted, it is because it is thought to be wrong to force a person to act against her integrity to perform an otherwise good act even in cases in which acting with integrity may lead to wrong- doing or an undesirable outcome (Benn 2007: 348). This implies there is something valuable about integrity over and above it being instrumental for morally worthy acts. Importantly, it might also mean that it would sometimes be wrong to force someone to act against her integrity to prevent her from acting in a morally undesir- able way. In other words, it might sometimes be wrong to deny a conscientious objection, even when that conscientious objection amounts to a morally undesirable action. As I have explained elsewhere, “if pressurizing someone to act against her integrity is wrong, then potentially…there are two wrong actions from which to choose the lesser of two evils: pressurizing someone to act against her conscience, or letting her do the wrong thing” (Deans 2013: 51). Take an example of Mike, a pharmacist who is working as a locum in a community pharmacy practice that usu- ally runs a needle exchange service for users of recreational intravenous drugs.
Mike has a moral objection to the needle exchange service because he believes that participating in the scheme would be assisting individuals to harm themselves through drug use and that this would be worse than providing clean needles to reduce the risk of infection through sharing. In one version of events, Mike is allowed to refuse to supply clean needles and therefore denies the patient access to safe instruments, increasing the risk of the patient acquiring or transmitting an infection, but his integrity is respected. In another version of events, Mike is pressured to act against his conscience to supply clean needles, thus reducing risk of infection for the patient and others.
2 Suppose that, despite her efforts to engage with the subject, Sally has not heard all sides of the arguments in the debate and they are arguments that would persuade her to change her mind.
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This example is, of course, oversimplified, but it is intended to illustrate that, whether it would be right or wrong to supply the clean needles, there is an additional moral consideration about whether it would be right to pressure someone to act against her conscience. In this example, if Mike is allowed to refuse to supply the clean needles when the profession supports needle exchange programmes, then this is because the profession considers it worse to pressure someone to act against his integrity than for a morally undesirable outcome to occur (i.e. for the needles to not be supplied).
One reason against pressuring someone to act against her conscience is that it could make her feel uncomfortable. This discomfort has been described as “dis- tressing“ (Benn 2007: 348) and “excruciating moral anguish”(Cohen 1968: 269), but, as Benn points out, there are other distressing aspects of professional life (e.g.
delivering bad news to a patient) that are unavoidable (Benn 2007: 348). The com- parison is imperfect, since it conflates distress arising from fundamentally unpleas- ant situations with distress caused by doing what one believes to be wrong; arguably, healthcare professionals should be prepared to overcome distress caused by unfor- tunate circumstances but should be spared the particular torment of being pressured into wrongdoing. Whatever status is given to the kind of distress brought about by wrongdoing, granting conscientious refusals in order to save the objector from moral anguish will frustrate the conscientious objector. She would like her objection to be upheld out of respect for her integrity and moral position, not merely in order to prevent her from suffering distress (Deans 2013: 50). Professionals who use the conscience clause to avoid a procedure because it is unpleasant rather than because to perform the procedure would be to contravene their moral principles are met with criticism for misuse of the privilege (Millward 2010: 425).
What, then, might the defence be for respecting integrity, especially in cases in which respecting it comes at the cost of allowing a morally undesirable outcome to occur? Contrary to Giubilini’s claim that integrity is an “anaemic” concept that has been assigned too much importance in moral decision-making in healthcare (Giubilini 2014: 162), integrity has weighty intrinsic and instrumental value. First, the agent’s moral engagement brings value to a decision. This is to claim that it is not just the consequences of an action that have moral weight but also the intentions and motivations behind the act. It is to recognise that a person who acts with integ- rity is acting through a self-aware, reflective commitment to doing the right thing.
This involves attempting to make well-considered decisions that take into account the possible outcomes of her actions, while also ensuring she is moral in other ways (e.g. by acting with honesty, kindness, fairness and compassion and by considering carefully her responsibilities). This was exemplified by Sally and George: Sally’s actions resulted in the most desirable consequences (supply of medicine), but it was George who displayed good moral character. Although ultimately mistaken, George showed a commitment to doing what is right.
Second, to act with integrity is to take seriously one’s moral responsibilities.
Restricting individuals in making independent judgements according to their integrity may discourage them from engaging with the world around them. Very basically, the healthcare professions, including pharmacy, are driven by moral
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