There are several reasons for accommodating health professionals’ conscientious objections. They range from promoting diversity in the health professions to not discouraging morally sensitive individuals from entering the health professions. However, several authors, including me, have argued that enabling health professionals to maintain their moral integrity is among the most important and compelling reasons. Accommodation provides “moral space” in which health professionals can practice without compromising their moral integrity. Footnote 1 According to this view, moral-integrity-based claims provide a prima facie case for accommodation. It is only a prima facie case because other factors can override or trump the health professional’s interest in maintaining his or her moral integrity. These factors include the health and well-being of patients and the impact on colleagues and institutions.
Whereas it is generally acknowledged that a moral-integrity-based claim can provide a prima facie case for accommodation, there are alternative conceptions of moral integrity and corresponding different criteria for moral-integrity-based claims. Footnote 2,Footnote 3 I will argue that the identity conception provides a suitable criterion in the specific context of conscientious objection in healthcare, and I will defend that conception against several criticisms. My objective, however, is not to offer the best philosophical account of moral integrity. My aim is considerably more limited and practical. I simply want to argue that one conception of moral integrity, the identity conception, is sound and suitable in the specific context of responding to health professionals’ conscientious objections and requests for accommodation.
Moral-Integrity-Based Accommodation Claims
An accommodation claim can be moral integrity based only if the objection is based on the health professional’s ethical beliefs. Suppose, for example, that a surgeon refuses to operate to remove a brain tumor on clinical grounds. In the surgeon’s judgment, the tumor is “inoperable.” There is only a 5% chance that the patient will survive surgery, and even if the patient were to survive, substantial cognitive impairment would be likely. In the surgeon’s judgment, performing surgery in those circumstances would be contrary to sound clinical practice. To be sure, the surgeon may also believe that it would be unethical to operate, but that belief would be secondary, based on his or her understanding of accepted clinical norms. The latter are the primary grounds for the refusal to operate, and it is only in virtue of the surgeon’s belief that operating would violate those standards that he or she also believes that it would be unethical to do so. Insofar as surgery would violate standards of sound clinical practice, a refusal to operate would be expected, and the surgeon would not need to seek an accommodation for his or her ethical beliefs. Generally, conscience-based refusals arise only when health professionals object to providing legal, professionally accepted, and clinically appropriate services within the scope of their clinical competence.
The Identity Conception of Moral Integrity
For a health professional’s moral integrity to be at stake, the ethical beliefs at issue must be among his or her most important core moral beliefs. One can violate peripheral ethical beliefs without undermining one’s moral integrity. It is only when one violates one’s most important, self-defining ethical beliefs that one fails to maintain one’s moral integrity. Lynne McFall draws a useful distinction between defeasible and identity-conferring commitments. Footnote 4 The former can be “sacrificed without remorse” and without undermining one’s integrity. Footnote 5 By contrast, the latter, according to McFall, “reflect what we take to be the most important and so determine, to a large extent, our identities.” Footnote 6 One’s moral integrity is compromised only if one acts contrary to one’s identity-conferring commitments. The following two cases illustrate this distinction:
Case 1. An 89 year-old nursing home resident with advanced Alzheimer’s disease is admitted to a hospital intensive care unit (ICU) after presenting at the emergency department (ED) with pneumonia and kidney failure. An intensivist believes that providing life support would be wasteful and an unjust allocation of scarce resources. The patient’s family members insist on providing life support, and hospital policy does not permit unilateral refusals by individual clinicians in such circumstances. However, the intensivist asks for an accommodation. He requests assigning the care of the patient to other intensivists who do not object. Although providing the requested life support would be unjust in the eyes of the intensivist, it would comprise an injustice of a type that he routinely tolerates rather than a perceived grave injustice such as discrimination based on race or sexual orientation. Accordingly, it would only require violating a defeasible commitment. Providing life support might give rise to moral distress, but it would not compromise his moral integrity, and he would not have a moral-integrity-based accommodation claim. However, there are other reasons for permitting clinicians to transfer care of patients in such situations. For example, allowing clinicians to transfer the care of patients to other physicians even when their identity-conferring commitments and moral integrity are not at stake might be good for patient care and clinician morale.
Case 2. An intensivist requests an exemption from offering palliative sedation to unconsciousness. Her request is based on her firm and unshakable belief that palliative sedation to unconsciousness is morally equivalent to unjustified killing. The belief that unjustified killing is wrong is among her most deeply held moral convictions, and she would feel morally obligated to refuse to offer palliative sedation to unconsciousness even if she would thereby risk disciplinary action or dismissal. As she explains it, “Offering palliative sedation to unconsciousness is something I simply cannot do. I couldn’t live with myself if I were to offer it.” Offering palliative sedation to unconsciousness is contrary to the intensivist’s identity-conferring commitments and incompatible with maintaining her moral integrity.
The notion of core, identity-conferring ethical beliefs is central to the identity conception of moral integrity. According to that conception, a health professional can legitimately claim that an accommodation is needed to enable him or her to maintain moral integrity if and only if: (1) this professional has core or identity-conferring moral convictions, (2) this professional consistently acts in accordance with his or her core or identity-conferring moral convictions, and (3) denying an accommodation will require acting contrary to core or identity-conferring moral convictions.
Criticisms of the Identity Conception
The identity conception has been subject to a number of criticisms that might call into question its suitability as a standard for determining whether health professionals have genuine moral integrity based accommodation claims. I will examine five objections to the identity conception: (1) it does not include a social component, (2) it is a conception of subjective rather than objective integrity, (3) it does not include a reasonableness condition, (4) it does not include any substantive moral constraints, and (5) it does not include any intellectual integrity requirement. I will argue that with one possible exception, none establishes the unsuitability of the identity conception as a basis for valid prima facie claims for accommodation.
The Identity Conception Does Not Include a Social Component
One criticism maintains that the identity conception fails to include a social component. Cheshire Calhoun has voiced this objection and endorses a social conception of integrity as “standing for something.” Footnote 7 People who consistently act in accordance with their core moral commitments and thereby maintain their moral integrity (understood as identity) might be said to “stand for something” (i.e., their core moral commitments). However, they nevertheless might not stand for something in relation to others. Standing for something in this social sense requires interacting with others and engaging in a process of community deliberation; and, according to Calhoun, standing for something in this social sense is an essential characteristic of integrity. As she puts it, integrity is “tightly connected to viewing oneself as a member of an evaluating community and to caring about what that community endorses.” Footnote 8
Calhoun’s justification of this social conception of integrity is based in part on a process understanding of moral knowledge according to which we discover what is “worth doing” through a process of social deliberation: individuals contribute their best judgment, but a commitment to the deliberative process requires openness to the views of others. According to Calhoun, “Integrity calls us simultaneously to stand behind our convictions and to take seriously others’ doubts about them.” Footnote 9
This is not the place to assess Calhoun’s deliberative conception of moral knowledge. Of more relevance in the present context is her assumption that understanding integrity as identity cannot account for what is said to be the primary value of integrity: participation in community deliberation about what has worth and value. Defenders of the identity conception of integrity can respond as follows. They need not question the value of participation in community deliberation along the lines advocated by Calhoun. They can grant that a disposition to engage in community deliberation is a (social) virtue. However, they can question whether it is warranted to incorporate such a disposition or virtue into a conception of integrity. That is, they might claim that there is no conceptual connection between integrity and “viewing oneself as a member of an evaluating community and…caring about what that community endorses.” Footnote 10
Because my aim is not to offer an account of the best philosophical account of moral integrity, I will not pursue this conceptual issue. Nor will I consider another issue associated with Calhoun’s conception of integrity: what would count as the relevant community for a health professional who requests a moral-integrity-based accommodation? Would it be an organization or institution, such as a hospital, nursing home, or health plan; a professional group or association, such as the American Academy of Pediatrics, the British Medical Association, or the American Nurses Association; a community of patients; or a community of citizens? Instead, I want to consider another key question: Is moral integrity valuable and worth protecting only if it is understood to include participation in a community deliberative process about what is worth doing? More specifically, do health professionals’ moral-integrity-based refusals merit accommodation only if they are committed to engage in the kind of community deliberative process that Calhoun advocates?
Suppose a health professional is not willing to engage in a community deliberative process in which that professional presents and defends his or her views and considers the views of others. It might be argued that this unwillingness is a sign of a flaw or shortcoming in that professional’s moral character. Footnote 11 But is it a sufficient reason to refuse to grant an accommodation that will enable that professional to practice his or her profession and maintain his or her moral integrity understood as identity?
Calhoun herself suggests a negative answer when she identifies a number of reasons for thinking that integrity as identity is valuable and worth protecting.
The thought might be that the depth of character that comes with deep commitments is an admirable characteristic of persons. Or the thought might be that deep attachments are part of any life that could count for us as a good, full, and flourishing human life. Or the thought might be that only a life containing deep attachments will be rich enough to compel our continuing interest in staying around and participating in morality. Having and acting on identity-conferring commitments is thus valuable, not because of the sheer fact that they are one’s own, but because having and acting on deep commitments is part of any admirable, flourishing life worth living, and that kind of life is what has value. Footnote 12
There is at least one additional, and perhaps even more important, reason for thinking that moral integrity as identity is valuable and worth protecting. Acting contrary to one’s identity-conferring commitments can have considerable psychological and personal costs, such as feelings of guilt and shame, a sense of self-betrayal and personal disintegration, and loss of self-respect. Arguably, then, it is unjustified to hold that a moral-integrity-based claim fails to establish a prima facie case for accommodation if integrity is understood as identity.
Like Calhoun, Carolyn McLeod criticizes the identity conception and endorses a social conception according to which persons of integrity must stand for their moral convictions by engaging in a process of community deliberation. Footnote 13 McLeod argues that an unwillingness to engage in a deliberative process with others indicates a suspicion that one lacks a cohesive, integrated set of moral convictions. “The worry about people who avoid rather than respond to controversy is that they must sense that problems exist in their belief systems, but they try to ignore those problems. Their purpose may be to maintain some mental order, but the fact that they aim (however consciously) to avoid controversy suggests that they already experience some disorder. Hence, they are not as integrated as they could be. They will need to respond to the challenge they face in order to achieve higher levels of integration.” Footnote 14
It is doubtful that a reluctance to subject one’s moral convictions to a deliberative process is a reliable indicator of a fear that one lacks a cohesive, integrated set of core moral convictions. Putting this problem aside, however, insofar as it is plausible to claim that a cohesive, integrated set of core moral convictions is a condition of integrity as identity, McLeod’s analysis does not pose a challenge to that conception. Absent cohesiveness and integration, it is questionable that one has an identity rather than a fragmented self. Hence, insofar as cohesiveness and integration of core moral convictions are conditions of integrity as identity, even if McLeod is right, it would follow only that a willingness to engage in a deliberative process is a condition of integrity as identity, and the identity conception would not be susceptible to the criticism that it fails to include a deliberation condition.
The Identity Conception is a Conception of Subjective Rather than Objective Integrity
A second criticism of the identity conception can draw on Elizabeth Ashford’s distinction between objective and subjective integrity. She explains the distinction as follows. “For the agent to have objective integrity, her self-conception must be grounded in reality: it must not be based on her being seriously deceived either about empirical facts or about the moral obligations she actually has. In particular, her self-conception as being morally decent must be grounded in her leading a genuinely morally decent life. By contrast, the mere possession of a coherent self-conception, however mistaken, can be called subjective integrity.” Footnote 15
Moral integrity understood as identity is subjective integrity. Ashford compares the two conceptions from the perspective of what agents value. She claims that objective integrity “is a considerably more plausible candidate than subjective integrity for what agents actually take to be valuable.” Footnote 16 Agents are said to value objective integrity rather than subjective integrity: “we value having objective integrity, as opposed to merely having a self-conception according to which we are leading a worthwhile life.” Footnote 17 Accordingly, it might be claimed, because agents value objective integrity rather than integrity understood as identity, only the former merits protection and accommodation.
In response, Ashford’s claim about the value of integrity to an agent is plausible only if it is modified to refer to what agents take to be objective integrity. Even when agents are mistaken about the nature of a morally decent life, they might nevertheless believe that their conception is genuine (i.e., correct or justified). Therefore, at most believing that one satisfies the conditions of objective moral integrity, rather than actually satisfying them, is crucial when assessing the value to an agent of integrity and the cost to the agent of failing to maintain it. It seems unlikely that agents who have core moral convictions associated with their self-conception do not believe that they are committed to a “genuinely morally decent life.” Hence, if the primary consideration is the value to agents of maintaining their moral integrity, both objective integrity and integrity understood as identity can merit protection.
Ashford does not apply the distinction between objective and subjective integrity to conscientious objection. Instead, she uses that distinction to respond to Bernard Williams’s claim that utilitarianism is incompatible with integrity. Footnote 18 Ashford maintains that this would be a fatal flaw in utilitarianism, or any ethical theory, only in relation to objective integrity. Whereas objective integrity may be an appropriate conception of moral integrity in the context of identifying constraints on an acceptable ethical theory, it is not an appropriate conception in the context of conscientious objection. To understand moral integrity as objective integrity would sound the death knell for conscientious objection in healthcare and the practice of accommodating health professionals with diverse conceptions of a morally decent life.
The Identity Conception Does Not Include a Reasonableness Condition
Lynne McFall provides the basis for a third criticism of the identity conception. Footnote 19 She endorses a substantive requirement, a reasonableness condition, which is weaker than objective integrity. According to her, “When we grant integrity to a person we need not approve of his or her principles or commitments, but we must at least recognize them as ones a reasonable person might take to be of great importance and ones that a reasonable person might be tempted to sacrifice to some lesser yet still recognizable goods. It may not be possible to spell out these conditions without circularity, but that this is what underlies our judgments of integrity seems clear enough.” Footnote 20
McFall presents the reasonableness requirement as a means to block counterintuitive judgments about integrity. She considers the case of a wine connoisseur who fought a strong temptation to abandon his principles and drink a soda rather than a fine wine. Even if a core component of his self-conception is to be a connoisseur of fine wine and it would be shameful to him to prefer soda to a premium wine, McFall maintains that it would be counterintuitive to assert that resisting his strong temptation to choose soda over wine displayed integrity. Insofar as the principle of connoisseurship is not sufficiently important to satisfy the reasonableness requirement, that requirement serves to block the counterintuitive claim that the wine connoisseur displayed integrity.
As McFall suggests, when moral integrity is at issue and principles are limited to moral principles, blocking such counterintuitive judgments about integrity may not require a reasonableness requirement. However, if a reasonableness requirement is accepted in relation to moral convictions, it may unjustifiably limit the scope of those who qualify for moral-integrity- based accommodation. As McFall admits, it may not be possible to specify the criterion of reasonableness “without circularity.” In the absence of a justifiable specified criterion, determining whether moral convictions are “sufficiently important” to warrant accommodation may be unacceptably subjective. To avoid risking that unacceptably subjective judgments about an agent’s moral convictions will affect the determination of whether that agent’s moral integrity is at stake, it is warranted not to include a reasonableness condition among the criteria for moral integrity.
The Identity Conception Does Not Include Any Substantive Moral Constraints
As a fourth criticism of the identity conception, it can be objected that insofar as that conception includes no substantive moral constraints, it is unacceptable. Calhoun offers an objection along these lines. “Those who endorse the identity picture of integrity admit that, on this view, one might have integrity even though one’s identity-conferring projects are nonmoral or even morally despicable. This is because deeply identifying with what one does, puts one’s integrity beyond question.” Footnote 21
Individuals who consistently act in accordance with core, identity-conferring convictions that are racist, sexist, or anti-Semitic might satisfy the identity criterion of moral integrity, but they clearly are deficient in moral virtue. Hence, it might be argued, any acceptable conception of moral integrity must include some substantive moral constraint, and the identity conception must be rejected.
In the context of conscientious objection in healthcare, however, it is not necessary to incorporate a substantive moral constraint within the conception of moral integrity. An alternative approach is to maintain that unacceptable moral beliefs are not incompatible with moral integrity, and to assert that it is justified to deny accommodation when a health professional’s core moral convictions include abhorrent moral beliefs. In such cases, it can be held either that moral-integrity-based claims fail to establish even a prima facie case for accommodation, or that the prima facie case for accommodation is outweighed by the importance of not facilitating morally despicable behavior. The latter response assumes that the primary reason for enabling health professionals to maintain their moral integrity understood as identity is not that it is thought that moral integrity in that sense is always a desirable character trait or virtue. Rather the primary reason is taken to be the importance to agents of maintaining their moral integrity understood as identity and the cost to them of failing to maintain it. Because there is some disagreement about whether (moral) integrity is an unconditional virtue or an admirable character trait, Footnote 22 arguably it is preferable to justify a refusal to accommodate by citing settled moral principles rather than by relying on a contested conception of moral integrity.
The Identity Conception Does Not Include Any Intellectual Integrity Requirement
The fifth and last criticism faults the identity conception for not including any intellectual integrity requirement. If we understand moral integrity simply as a consistent commitment to one’s core moral convictions, it would follow that fanatics can be considered paragons of moral integrity. However, it is argued, attributing moral integrity to anyone who is blindly and uncritically committed to principles is counterintuitive. Whereas moral integrity is said to be an admirable character trait, fanaticism clearly is not. One of the reasons that Calhoun offers to support her social conception of integrity as standing for something is that it rules out fanaticism. A commitment to the process of community deliberation associated with the standing for something conception of integrity is incompatible with fanatically adhering to one’s core moral convictions.
Mark Halfon excludes fanatics by adopting a conception of moral integrity that includes a critical reasoning requirement. Footnote 23 According to him, persons of integrity
embrace a moral point of view that urges them to be conceptually clear, logically consistent, apprised of relevant empirical evidence, and careful about acknowledging as well as weighing relevant moral considerations. Persons of integrity impose these restrictions on themselves since they are concerned, not simply with taking any moral position, but with pursuing a commitment to do what is best. In other words, it is not the case that persons of integrity are committed to some predetermined principle or ideal, but are instead committed to an ‘open’ moral perspective for the sake of doing what is best—all things considered. Footnote 24
Greg Scherkoske supports a critical reasoning requirement by conceptualizing integrity as an “excellence of reason,” consisting in a cluster of epistemic virtues. Footnote 25 According to this conception, a person can be said to possess integrity only if he or she is the kind of person who seeks to have justifiable and correct convictions, has the appropriate regard for his or her own capacity to identify justifiable and correct convictions, is reliably disposed to act on his or her convictions on the basis of the reasons that ground those convictions, is reliably disposed to take challenges to his or her convictions seriously, and takes seriously the discursive responsibilities that one undertakes in the course of giving others reasons to believe or act on the basis of what one asserts to another. Footnote 26
In response to the specific concern about fanaticism, it can be granted that fanaticism is a character flaw; however, it can be questioned whether that character flaw is incompatible with moral integrity. To assume incompatibility begs the question. An alternative approach would be to allow for the possibility that moral integrity is not conceptually incompatible with fanatically clinging to one’s core moral convictions, and to argue that when moral integrity rises to the level of fanatical commitment to a person’s core moral convictions, it does not warrant protection. Once again, it is arguable that it is preferable to rely on settled moral principles rather than a contested conception of moral integrity.
In response to broader reasoning requirements such as those proposed by Halfon and Scherkoske, it is undeniably highly desirable for agents to accept moral convictions only if they can withstand a thorough critical assessment, such as considering reasons for and against moral beliefs, ascertaining whether moral beliefs are coherent and internally consistent, and assuring that beliefs are compatible with available empirical evidence. However, there are two reasons for not requiring health professionals who seek moral-integrity-preserving accommodations to satisfy such epistemic requirements. First, in view of the importance to agents of maintaining their moral integrity understood as identity, it may be unwarranted to reject integrity-based claims for accommodation if a health professional does not satisfy such stringent epistemic conditions. Second, if health professionals are required to demonstrate to supervisors or committees that they satisfy epistemic requirements, there is a danger that such determinations will not be objective and unbiased, and will result in inappropriate denials of accommodation. In any event, if epistemic requirements are thought to be warranted, they should be supported by arguing that they are justified epistemic conditions on accommodation and not by incorporating them into a conception of moral integrity. The former strategy is preferable insofar as it is not based on a contested conception of moral integrity, and it more accurately identifies the primary issue as the justifiability of epistemic constraints. Moreover, lest it be thought that epistemic requirements are needed to protect patients from unwarranted harm, this objective is more directly and effectively accomplished by constraints on accommodation that explicitly protect patients. For example, a constraint might state that an accommodation will be granted only if it will not interfere with a patient’s timely access to clinically appropriate healthcare services. Another constraint might disallow accommodation if granting it will interfere with a patient’s timely access to information about clinically relevant healthcare services.
Although I have questioned the justifiability of incorporating a relatively stringent epistemic requirement into the concept of moral integrity, there is a weaker requirement that strikes me as both reasonable and defensible: a requirement that empirical beliefs not be demonstrably false. I am suggesting this as a constraint on accommodation, and not a conceptual component of moral integrity. A failure to satisfy this constraint is illustrated by pharmacists who refused to dispense Plan B, an emergency contraception (EC), based on the mistaken belief that the mechanism of Plan B is identical to the mechanism of mifepristone, an abortifacient. Footnote 27 Arguably, insofar as a pharmacist’s conscientious objection to dispensing Plan B is based on this demonstrably false clinical belief, no accommodation is warranted.
Conclusion
Unlike many of the philosophers I have cited, my aim has not been to offer the best philosophical account of moral integrity. My aim is considerably more limited and practical: to show that one conception of moral integrity, the identity conception, is sound and suitable in the context of responding to health professionals’ conscientious objections and requests for accommodation. I critically examined five objections to the identity conception: (1) it does not include a social component, (2) it is a conception of subjective rather than objective integrity, (3) it does not include a reasonableness condition, (4) it does not include any substantive moral constraints, and (5) it does not include any intellectual integrity requirement. With the exception of the fourth objection, I have argued that none establishes the unsuitability of the identity conception as a basis for valid prima facie claims for accommodation. In the case of morally abhorrent moral convictions, I argued that one need not reject the identity conception of moral integrity to deny accommodation. Two options are available to justify denying accommodation without denying that the agent’s moral integrity is at stake. It can be held that: (1) moral-integrity-based claims fail to establish even a prima facie case for accommodation in such extreme cases, or (2) the prima facie case for accommodation is outweighed by the importance of not facilitating morally despicable behavior.
