A Sartrean Analysis of Conscience-based Refusals in Healthcare: Workplace Decisions in Light of Group Praxis

Abstract

This paper provides an analysis of conscience-based refusals in healthcare from a Sartrean view, with an emphasis on the tension between individual responsibility and professional role morality. Conscience-based refusals in healthcare involve healthcare workers refusing to perform actions based on core moral beliefs. Initially this appears in line with Sartrean authenticity, which requires acknowledgment that one is not identical with professional role. However, by appealing to Sartre’s later social thought, I show that professional role morality is authentic when one considers common group practices, which Sartre refers to as pledged group praxis. I demonstrate that for healthcare providers, authenticity mandates putting the goals and generally accepted praxis of healthcare front and center in the workplace decision process. I conclude by strengthening Andrew West’s existentialist decision-making model with Sartre’s later social thought. With the updated model, I show that for healthcare workers most often the authentic decision is to perform generally accepted healthcare procedures in spite of individual moral qualms. This is because working in healthcare necessitates viewing one’s professional tasks in their broader social context—as unified, communal group praxis.

  1. Introduction

There are many important concernsfor employeeswhen balancing their professional obligations withmisgivings about certain practices that they intuitively see as wrong. Professional role morality, in which one is pressured to abide by a set of moral standards as part of a job, often leads to employees being pressured to perform actions that go against their consciences. Though the tension between doing one’s job and following one’s conscience is present in many careers, it is especially prominent in healthcare. In healthcare,job tasksare interwoven with foundational human issues surrounding life and death, and individual providers oftenhold strongmoral beliefs about these practices. Thus cases of conscientious objection, in which providers refuse to perform actions that violate their consciences, have become a growing controversialissue within various healthcare professions, including general practice, nursing, and pharmaceuticals.The traditional philosophical problem of acting in a certain way because of identification with one’s role is closely related to the existentialist concepts of authenticity and bad faith. Conscientious objection in healthcare further wrestles with the question of the proper relationship of individual freedom with shared collective goals. Thus,Jean-Paul Sartre’s existentialist philosophy provides an enlightening framework for examining this important manifestation of the tension between individual conscience and professional role morality.The objective of this article is threefold: 1) to evaluate whether or not, in a Sartreanexistential framework, healthcare employees who perform actions as part of their jobs that they feel are morally wrong are doomed to the inauthentic implications of bad faith, 2) to show the strengths and applicability of Sartre’s later social thought to approaching this question, and 3) to provide arobust existentialist decision-making model for healthcare providersthat incorporates the strengths of both Sartre’s early and later social thought, and draw out the implications of this model.

According to Sartre, bad faith arises when human beings denytheir freedom to act, or deny an aspect of the concrete characteristics of their existence. Sartre asserts that individuals should avoid bad faith and be authentic, which involves recognition of their freedom and recognition of their constraints in all of their choice making. Because authenticity requires accepting that your free consciousness transcends your professional role, intuition suggests that healthcare professionals who perform actions against their consciences as part of a role morality are in bad faith, and authentic healthcare employees must not perform actions that go against their consciences. However, Sartre’s later social thought suggests that members of a socially bonded group, or a “pledged group,” who dedicate themselves to the fulfillment of integral human needs, may be authentic even as they perform actions against conscience. The apparent contradiction between role morality and authenticity can be resolved with an analysis of why cooperative group action is necessary to achieve human fulfillment and can, with appropriate reflection, require individual actions that providers feel go against their consciences. Although this argument may initially appear counterintuitive, I demonstrate that authenticity in healthcare requires consideration of and dedication to communal goals.In this context, Andrew West’s existentialist decision making model offers a framework for authentic decisions in a work place setting.[1] I present West’s model as a foundation for understanding conscience-based refusals in healthcare, and further show that the existential model he provides becomes significantly more robust and convincing when Sartre’s later social thought is incorporated. After strengthening his model with Sartre’s later thought, I use it to demonstrate that provider authenticity in healthcare most often involves performing servicesthat test one’s conscience rather than refusing to do the procedures.

I begin by properly situating the problem at stake within the discussion of role morality in professional ethics and current approaches to conscience-based refusals in healthcare ethics. I then introduce the concepts necessary for a Sartrean existential analysis: bad faith, group praxis, a pledged group, and authenticity. I then provide a Sartrean analysis of conscientious objection in healthcare: first, showing why current approaches to the problem inevitably lead to bad faith and why bad faith is harmful in a healthcare setting, and second, introducing pledged group praxis as a superior foundation for avoiding bad faith and establishing provider authenticity. Last, using a version of West’s existentialist decision making model that I strengthen with Sartre’s later social thought, I demonstrate that group praxis focused onintegral human needs should be placed front and center in healthcare decisions, and conscience-based refusals should be a rare occurrence.

  1. Situation of the Problem

The moral dilemma that arises when there is tension between following professional rules or standards and acting in accordance with one’s personal moral beliefs is a perennial problem in business ethics. Role morality generally refers to adhering to a different set of moral values in one’s work life than in one’s personal life. Pressure to perform tasks one sees as wrong may take the form of orders from direct supervisors, general company or workplace policies, or rulebooks and codes of conduct. Pressure to assume role for professionals such as doctors, lawyers, or judges often come in the form of reputational or financial losses, or pressure to uphold general principles (such as the Hippocratic oath, justice, and honesty) of the profession.

Healthcare includes cooperation from both employees who take direct orders from their superiors and professionals with more flexibility, such as doctors or pharmacy owners. Conscience-based refusals include providers directly refusing a job task delegated to them by their supervisor, such as a nurse refusing to assist with an abortion after being ordered to by a doctor or director of nursing. It can also take the form of a doctor, who is relieved of the pressures of taking orders from superiors, refusing to prescribe a patient a certain medication, such as emergency contraception or a lethal drug for Death with Dignity.

This role morality conflict is discussed by Michael Davisand Kevin Gibson[2], who both explore the tension between individual responsibility and pressure from a profession’s code or rules.[3] Davis advances the thesis that following rules is generally enough for determining standards of responsible conduct for employees, provided the profession’s code of ethics is reasonably well-written and formulated. Davis advocates that professionals adhere to an “interpretative obedience”[4] to professional ethics codes. This interpretive obedience includes knowing the context of which the rules are applied, the history of the profession they are being applied to, the expectations of other professionals, the purpose and structure of the rules, and the interpretive strategies that are acceptable. This means that in order for appealing to role for moral rules to follow, the rules themselves and their correct application have to be at least periodically reflected upon by employees.[5]Gibson argues that we should focus on moral awareness at an abstract level and further emphasize the primacy of individual choice in workplace decisions. Gibson argues that it is unreasonable to expect individuals to follow one set of moral principles in both their professional and personal life, and to such an approach is also an oversimplification of the issue. Gibson emphasizes the autonomy of all employees and the ability to act contrary to their professional role, even if sanctions may be imposed for doing so.[6] However at the same time, they can claim some level of moral immunity because they are acting in accordance with a profession. Choosing to act according to professional rules rather than conscience often comes with a degree of loyalty to one’s employer or to one’s profession. Gibson argues that such loyalty must be given intelligently, with adequate time, research, and reflection. Gibson emphasizes the importance of individual responsibility and the fact that neither professional codes nor boss’s demands can make immoral actions moral. He argues that neither blind obedience to authority nor slavish obedience to a professional code are sufficient, and advocates for employees to make a cumulative assessment of difficult workplace decisions in their broader social context.[7]

I am in agreement with Davis that following rules or guidelines for one’s specific profession (what Sartre refers to as the goals of “group praxis”) is often the correct action for individuals, given that these rules are reflected upon in their specific context and with proper consideration given to practical constraints. My argument will go beyond Davis’ contribution by showing the importance of the individual in making sure the broader collective goals of one’s profession are properly aligned. My analysis also supports Gibson’s argument that social context is an important aspect of understanding the acceptability of role morality and that tests of conscience must consider the overall collective goals of the organization to which an individual belongs. My analysis shows what Sartre’s existential philosophy can add to this discussion, focusing more heavily on the complexities of individual conscience, freedom, and the balance between individual and collective responsibility. It also offers insights on how role morality manifests in health care in particular, a profession which deals most significantly with important moral and existential issues surrounding life and death. I show how existential bad faith, which involves a form of lying to oneself and failure to properly balance individual responsibility and the constraints of role, is especially undesirable in a healthcare, where the effects of bad faith can significantly harm patients. Authenticity, which properly balances and acknowledges one’s freedom and responsibility, is extremely important for healthcare professionals. The stakes are high. The advantages of the model I will suggest for work-place decisions are of particular significance to healthcare, because the ends and goals of healthcare are of utmost importance in each provider’s work.[A1]

In contemporary healthcare practices, the tension between role morality and conscience manifests in the form of conscience-based refusals. The standard definition of conscientious objection in healthcare that is used in the literature comes from James Childress, who defines it as a refusal to comply with a medical request based on personal moral or religious reasons.[8] Contemporary medical ethicist Mark Wicclair echoes this notion, confirming that conscientious objection occurs when providers refuse to perform an action or provide a service because it goes against their core personal moral beliefs.[9]In addition to the previous examples, common examples of conscience-based refusals include a pharmacist who refuses to fill a prescription for emergency contraception (EC) because of moral beliefs that life begins at the fertilization of an egg, or a doctor who refuses to put a suffering patient into an unconscious, pain-free state until passing away, because doing so could hasten the patient’s death.

Within the professional ethics literature, ThomasHemphill andWaheedaLillevikprovide a recent descriptive analysis of different conceptual issues at stake with regard to pharmacists’ professional obligations to fill prescriptions for emergency contraceptives and the right of employees to refuse to dispense the drugs.[10] Hemphill and Lillevik illustrate that pharmacists have multiple loyalties to attend to when balancing their identities and systems of belief with their professional roles. They further point out that the primary tension in potential refusal is that employees have both personal and professional identities to uphold. The conflict arises when deciding if the personal or professional identity should take precedence. Further, Hemphill and Lillevik point out that when making a decision, providers often feels conflict between a desire to maintain their personal identities and a desire to uphold the “common good.”[11] We see in Hemphill and Lillevik’s analysis why a Sartrean lens is so useful for this issue: there are tensions between individual identity (staying true to oneself), professional identity or role, and group practices that are beneficial to society overall[A2].

In addition to Hemphill and Lillevik, who convincingly identify what is at stake, other literature taking a normative stand on conscience-based refusals generally falls into one of three camps. These three positions have been labeled the incompatibility approach, the conscience absolutism approach, or a compromise approach. The incompatibility approach argues that individuals who are not willing to provide a healthcare service should simply choose another profession. The grounding for this claim is that conscience based refusals to provide all legally permitted goods and services that a professional is competent to perform is incompatible with that worker’s professional obligations.[12]Conscience absolutism, on the other hand, claims that providers have no obligation to provide a service that violates their conscience, nor do they have the duty to refer patients to other providers.[13] A third approach in the literature takes a middle ground between conscience absolutism and the incompatibility approach. These accounts are consequentialist and generally argue that conscience-based refusals should not result in harms or burdens to the patient beyond an acceptable limit. This position focuses on the consequences of the actions and how conscience-based refusals have the potential to harm patients. If a patient will suffer unreasonable harms or burdens as a result of the provider’s refusal, then the provider has a moral obligation to perform the act. However if there is another provider who can perform the act or service without resulting in severe harm of the patient, the provider is justified in refusing.[14] This is the position recommended by Hemphill and Lillivek, who suggest that conscience-based refusals should be tolerated as long as they “do no harm” to patients.[15] Ultimately all of these approaches are inadequate. After introducing the concepts necessary for a Sartrean existential analysis, in the next section I show how none of these current approaches properly account for the existential import of bad faith in relation to conscience-based refusals, or the balance of individual freedom in relation to professional role and collective goals.

  1. Sartre: Group Praxis, Pledged Group, and Authenticity

Evaluating conscience-based refusals through a Sartrean lens requires understandingSartre’s theory about being and human freedom. Sartre’s ontology drawn from his early work introduces two different modes of being: being in-itselfand being for-itself. Being in-itself is something that simply is what it is; this includes objects such as a table, a rock, a tree, or a bench. Being for-itselfconversely, has the ability to question and make choices. This category of being includes only human consciousness. Sartre’s early works are particularly known for his assertion that existence precedes essence. Humans are not born with an innate nature and build their own essences and identities as they live.[16]InBeing and Nothingness, the For-itself is described as spontaneous consciousness that has the ability to transcend its concrete situation by affirming and negating certain possibilities, and imagining a state of affairs beyond the current one. The defining characteristic of the For-itself or human consciousness is that it creates its being as it lives. “Man does not exist first in order to be free subsequently; there is no difference between the being of man and his being-free.”[17]Therefore human beingsare comprised of their actions and choices.[18]The relevance of Sartre’s early existential thought to role morality in health care includes his concept of “bad faith” or a state of lying to oneself.[19]Sartre argues that a human being consists of both free consciousness and facticity. Facticity refers to the concrete characteristics of one’s existence, including one’s physical body, historical conditions, cultural norms, or social role.[20]The person in bad faith denies one of these dimensions: either he acceptshimself as only facticity, and denies the ability of hisconsciousness to transcend this essence; alternatively he focuses only on his free consciousness while denying or ignoring his current circumstances and characteristics of his identity. Sartre’s famous example is of a waiter in a café. In one sense he is a waiter because it is a part of his facticity. However, his role as a waiter is not an unchanging or inherently necessary trait.