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.

I. Introduction

There are many important concerns for employees when balancing their professional obligations

with misgivings 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 tasks are interwoven with foundational

human issues surrounding life and death, and individual providers often hold strong moral beliefs

about these practices. Thus cases of conscientious objection, in which providers refuse to

perform actions that violate their consciences, have become a growing controversial issue 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

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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 Sartrean existential 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 a robust existentialist decision-

making model for healthcare providers that 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 deny their 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

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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 services that 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 on integral human needs

should be placed front and center in healthcare decisions, and conscience-based refusals should

be a rare occurrence.

II. Situation of the Problem

1 Andrew West, “Sartre's Existentialism and Ethical Decision-Making in Business,” Journal of Business Ethics 81 (2008).

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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 Davis and Kevin Gibson2, 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

2 Kevin Gibson “Contrasting Role Morality and Professional Morality: Implications for Practice,” Journal of Applied Philosophy, 20.3 (2003): 17-29. 3 Michael Davis, “Professional Responsibility: Just Following Rules?” Business and Professional Ethics 18.1 (1991).4 Davis, 79.

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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

5 Ibid., 79-80. 6 Gibson, “Contrasting Role Morality”7 Gibson, “Contrasting Role Morality,” 28.

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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.

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

8 James Childress, “Civil Disobedience, Conscientious Objection, and Evasive Non-compliance: A Framework for the Assessment of Illegal Actions in Healthcare,” Journal of Medicine and Philosophy 10 (1985): 68.

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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, Thomas Hemphill and Waheeda Lillevik

provide 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.

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

9 Mark Wicclair, Conscientious Objection in Health Care: An Ethical Analysis, (Cambridge: Cambridge UP, 2011), 5.10 Thomas Hemphill and Waheeda Lillevik, “U.S. Pharmacists, Pharmacies, and Emergency Contraception: Walking the Business Ethics Tightrope,” Business and Professional Ethics 25.1/4 (2006). 11 Hemphill and Lillevik “U.S. Pharmacists,” 46-47.

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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

12See Julian Savulescu, “Conscientious Objection in Medicine” BMJ 332 (2006); Robert Card, “Conscientious Objection and Emergency Contraception,” American Journal of Bioethics 7.6 (2007); J.P. Kelleher, “Emergency Contraception and Conscientious Objection,” Journal of Applied Philosophy 27.3 (2010); and Corrado Del Bó, “Conscientious Objection and the Morning After Pill,” Journal of Applied Philosophy 29.2 (2012). 13A moderate version of conscience absolutism is taken by Natasha Morton and Kenneth Kirkwood, who defend the view that any restriction of conscience promotes an inconsistency in the way that healthcare professionals exercise their conscience. See Natasha Morton and Kenneth Kirkwood, “Conscience and Conscientious Objection in Health Care: Professionals Refocusing the Issue,” HEC Forum 21.4 (2009).14 See Julie Cantor and Ken Baum, “The Limits of Conscientious Objection: May Pharmacists Refuse to Sell Emergency Contraception? The New England Journal of Medicine 351.19 (2004): 2008-2012. John Davis, “Conscientious Refusal and a Doctor's Right to Quit,” Journal of Medicine And Philosophy 29.1 (2004): 75-91. See also Wicclair. 15 Hemphill and Lillivek argue that this can ease the personal identify/professional identity conflict in some cases. See p. 54.

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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.

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

Evaluating conscience-based refusals through a Sartrean lens requires understanding

Sartre’s theory about being and human freedom.  Sartre’s ontology drawn from his early work

introduces two different modes of being: being in-itself and 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-itself conversely, 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  In Being 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 beings are 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

16 Jean-Paul Sartre, Being and Nothingness, trans. Hazel E. Barnes, (New York: Philosophical Library, 1956).17 Sartre, Being, 60. 18 Sartre, Being, 127-131. 19 Sartre, Being, 86-96.

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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 accepts

himself as only facticity, and denies the ability of his consciousness 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.

…the waiter in the cafe cannot be immediately a café waiter in the sense that this inkwell is an inkwell or the glass is a glass…it is not that I do not wish to be this person or that I want this person to be different. But rather there is no common measure between his being and mine…But if I represent myself as him, I am not he; I am separated from him as the object from the subject…Yet there is no doubt that I am in a sense a café waiter—otherwise could I not just as well call myself a diplomat or a reporter? But if I am one, this cannot be in the mode of being in-itself. I am a waiter in the mode of being what I am not.21

The waiter is in bad faith if he considers himself simply a waiter—because his free

consciousness can transcend his situation as a waiter. But he is also in bad faith if he denies that

he is in some way a waiter—it is a part he plays, it is part of his situation, facticity, and

professional role. However, it is a role that his free consciousness is able to transcend. Whereas

here Sartre suggests that identifying too closely with a professional role rather than accepting

individual responsibility is a form of bad faith, through a discussion of his later conception of a

pledged group I show that role morality can be acceptable when it comes to upholding collective

practices of a group.

Sartre’s later thought develops his claim that “existence precedes essence” in light of his

increased awareness of the effect of social and material conditions on human interaction,

20 Sartre, Being, 127.21 Sartre, Being, 102-103.

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decisions, and identify-formation. He focuses heavily on the physical needs of individuals and

the formation of social collectives when giving an account of human experience. His increased

focus on sociality lays the groundwork for understanding the necessity of collective group

practice and expectations placed on our behavior as members of various social groups, including

as workplace professionals. In The Critique of Dialectical Reason Vol.1 (CDR), Sartre’s earlier

position of radical freedom is more realistically revised to a position of relative freedom:

freedom to act within the constraints of one’s material and social situation.22 Sartre replaces the

In-tself/For-Itself distinction with what he calls the practico-inert and praxis. The practico-inert

refers to the physical and material conditions and social structures with which we interact. This

can be understood as the traces of past praxis that have structured the physical environment and

social institutions in a particular way. The practico-inert is contrasted with human praxis, which

is the actions, decisions, projects, and goals of human beings.23 Praxis can refer to both

individual actions and collective group actions. Individual identity emerges through an

interaction of interpreting one’s environment and social influences and then modifying this

environment in light of the individual’s ends and goals. Praxis affects the practico-inert, and the

practico-inert shapes praxis; our own personal identity and values cannot be abstracted from the

social and material circumstances through which we experience the world. Our immediate

relationship with our environment is characterized by our physical needs, and we meet our needs

through the limitations of the practico-inert. Sartre is clear that collective action is imperative to

effectively navigating within these restrictions.

In CDR, the formation of groups is portrayed as a potential way for people with common

needs to bond together and combat against scarcity and increase the ability of more people to

22 Jean Paul Sartre, A Critique of Dialectical Reason, Vol. 1, trans. Alan Sheridan-Smith, (London: Verso, 2004), 180-181. 23 Sartre, Critique, 81-85.

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meet basic human needs. These different social collectives form and disperse, functioning by

enhancing or diminishing the practical possibilities for action. The first social collective that

Sartre identifies is a “series”. A group of people loosely united around the same object, but who

have no other bond are referred to as a series. Individuals remain alone and atomic, and have no

united purpose or cause. Sartre gives the examples of individuals loosely grouped at a bus stop.

They are united only in the respect that they are all waiting for the same bus. Members of a series

are unified around some aspect of the practico-inert, in this case the bus which gets them where

they are going, but have no forceful unifying bond beyond that of the bus stop. In a series people

often interpret themselves as interchangeable and dispensable, as individuals bound to and

controlled by the practico-inert.24 Employees who only feel themselves united to their co-workers

or clients because they work in the same building or are forced to interact with them remain in a

state of seriality. Similarly, healthcare workers who see themselves united with other workers

only as members of an institution with no chosen communal goals also remain in seriality.

Seriality can increase the alienating factors of the practico-inert. Seriality may be common in

workplace in which individuals are primarily motivated a paycheck and feel no connection to the

purpose of the organization. Healthcare workers are usually motivated by a deeper dedication to

human welfare, and thus can and should move beyond seriality.

Sartre argues that the most active response to the feebleness of a series is for individuals

to bond together to form a group. Group formation allows individuals to have more control over

the practico-inert forces that condition their existence. Members of groups remain ontologically

distinct individuals; however they are not as isolated as members in a series because they are

united through common goals and common praxis.25 Group members see themselves in one

24 Sartre, Critique, 256-270. 25 Sartre, Critique, 377.

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another, yet do not feel that they or others in the group are dispensable.  A pledged group is a

group which is deliberately chosen by individuals who make a pledge to one another to uphold

the common praxis of the group. Sartre calls the pledged group “the victory of man as common

freedom over seriality.”26 The primary characteristic of a pledged group is that individuals come

together freely and make a pledge to each other reciprocally. “I give my pledge to all the third

parties of forming the group of which I am a member, and it is the group which enables everyone

to guarantee the statute of permanence to everyone.”27 Through the pledge, each member agrees

to limits on her practical freedom, but these limits at the same time maximize the proper use of

resources for the group as a whole. Here we see that healthcare employees can overcome serial

relations and consider themselves members of pledged groups if they strive toward common

goals and uphold collective practices. However, the concept of a pledged group makes one weary

that if individual responsibility is deferred to the group, this may lead to unquestioned praxis,

which amounts to nothing more than slavish obedience to workplace rules, professional codes, or

a boss’s orders. This is reflective of Davis’ and Gibson’s assertion that acceptable professional

morality requires deep reflection by the moral agent. Thus in order for the concept of a pledged

group to be morally useful we must introduce standards for reflecting on the worthiness of a

pledged group’s praxis. A foundation for such standards is outlined in Sartre’s Lecture Notes

from Rome.

Sartre’s Lecture Notes from Rome definitively emphasize the ideal moral value as

“integral humanity.” Integral humanity refers to fulfilling that which is fundamental to being

human-- which is achieved only through the satisfaction of foundational human needs. Sartre

argues that the ultimate moral goal of collective group praxis should be for people to have as

26 Sartre, Critique, 437. 27 Sartre, Critique, 421.

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many of their needs met in order to be fulfilled as human. This maximizes their practical options

for freedom and identity formation.28 Practical freedom cannot be fully realized if there is not

fulfillment of needs, which can only come about through cooperation with others. This is

elucidated in the following passage of Lecture Notes from Rome,

There will be no integral man as long as the practico-inert alienates man, that is, as long as men, instead of being their product, are only the products of their products, as long as they do not unite into an autonomous praxis which will submit the world to the satisfaction of their needs without being enslaved and divided by their practical objectification. There will be no integral man as long as each man is not totally a man for all men.29

Here it is clear that in order to avoid alienation of the practico-inert that leaves humans existing

only in a series, it is imperative that we join together into groups that work to satisfy physical,

social, and emotional needs to enhance the practical possibilities for everyone. The consequences

of Lecture Notes from Rome on the pledged group entail that the group must consistently make

sure its praxis is in line with the promotion of integral humanity. As each member of a pledged

group is fully responsible for being in the pledged group, he should leave the group if its praxis

deviates from fulfillment of human needs. Even though there can potentially be consequences for

leaving a group, Sartre argues those consequences are worth bearing if the praxis of the group

has deviated away from promotion of human fulfillment. Here we see that adhering to role

morality does not necessarily mean one is in bad faith if he is reflecting on his actions in light of

upholding the collective practices of the group.

With the incorporation of group praxis, we can establish criteria for authentic workplace

decisions in healthcare which properly balance individual freedom with the constraints of

professional role and group praxis. Authenticity, a concept derived from Sartre’s earlier thought

28 Jean Paul Sartre, Lecture Notes from Rome, May 1964 at the Gramsci Institute. Available at the Biblotheque Nationale, Paris, and the Marquette University Library in Milwauke,WI, 78. 29 Sartre, Lecture Notes from Rome, 135.

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but still operative in his later, involves ridding oneself of bad faith and acting true to oneself,

realizing that one is comprised of both facticity and transcendence. In Notebooks for an Ethics,

Sartre writes, “The new way of being one self and for oneself is an ‘authentic’ way which

transcends the dialectic of sincerity and bad faith.”30 Authentic decisions recognize freedom,

facticity, and pledged group praxis, and further look to foster relationships with others that

recognize their importance and worth. Authenticity includes recognizing the freedom and

autonomy of others and acknowledging that their ends and projects have worth just as do your

own.31 In order to be authentic, healthcare workers must recognize that they are doctors, nurses,

and pharmacists because it is part of their facticity. As a doctor, pharmacist, or nurse, they are

bound by certain constraints and obligations to their patients and their fellow healthcare

professionals. But they lie to themselves if they refuse to recognize that they are a free

consciousness and ultimately choose to accept this role. Therefore it is imperative to authenticity

that healthcare workers both take full responsibility for the group to which they belong

(healthcare field) and further recognize that as members of this group, certain expectations

accompany their praxis (professional obligations).

Trust and respect for authentic patient/provider relationships require that healthcare

professionals work toward understanding their patients’ values and ends. In authentic interaction

within group praxis, healthcare professionals should not treat their patients only as specimens to

be cured, but fellow free individuals to be treated holistically. Thus some understanding of what

is important to the patient will help the provider treat the patient well, which is an important part

of the role they play in the pledged group. This does not necessitate merely giving patients any

treatment they want, but integrating things patients find important into care decisions. Bad faith

30 Jean-Paul Sartre, Notebooks for an Ethics, trans. David Pelauer, (Chicago: University of Chicago, 1992), 474. 31 Sartre, Notebooks, 280.

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of providers not only involves a failure to properly balance personal responsibility and role, it

can have negative effects on fellow providers and patients.

We see that a Sartrean existential approach includes a conception of human beings as free

by nature, without inherent identities. However we also are bound by our facticity (limitations

given to us by the practico-inert) which affects our essence. Bad faith arises when we fail to

recognize both of these key aspects of ourselves: we are free, but we also are bound by many

constraints. Our basic social interactions include seriality, in which we only relate to others

through practico-inert structures, or can be comprised of collective group praxis in which we

bond together for commonly held goals. The highest moral good to pursue through collective

group ends are fulfillment of integral human needs, including their basic physical needs and

maximization of others’ freedom and autonomy. Healthcare is one of the most important

professions for meeting such goals. Authentic workplace decisions will take group praxis as front

in center in the decision making process because they recognize the importance of professional

roles for successful operation of the group. At the same time authenticity requires periodic

reflection on the moral worthiness of the group’s praxis as it relates to integral humanity. With

the Sartrean framework in place, I will now discuss more in more detail its implications for

conscience-based refusals in healthcare.

IV. A Sartrean Analysis of Conscience-Based Refusals in Healthcare

When focusing on the consciences of providers, relying on the incompatibility approach,

conscience absolutism, or a harms/benefits compromise approach as a starting point for decisions

by healthcare providers inevitably leads to bad faith. Bad faith is undesirable, especially in

healthcare, because it leads to alienated human relations, lack of trust and reciprocity, and

potential patient harm. This can be illustrated in the following table.

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Approach Why Bad Faith? Potential Harm ExamplesIncompatibility Approach: Conscience based refusals are incompatible with a healthcare worker’s professional responsibilities.

-The healthcare professional argues that he “is” a doctor with no reflection other than conformity to role.-Does not examine the decision in its broader context as part of group praxis.

-Can lead to unquestioned practices which harm patients.-Discouraging reflection by providers runs the risk of praxis deviated from human fulfillment.

A clinic begins rationing AIDS treatment on the basis of perceived social worth. A nurse intuitively feels this is morally wrong, but sees following the clinic’s rules as just part of the job.

Conscience Absolutism: No duty to perform any action that the provider believes to be morally wrong.

-Failure to recognize the constraints of facticity and group praxis.-Does not adequately account for duties and tasks that are part of chosen professional role.

-Lack of concern for professional obligations can lead to neglect of patients.-Failure to understand one as member of a pledged group can lead to serial relations with colleagues.

A doctor who has a lifelong relationship with a patient refuses to prescribe the patient a medication for death with dignity. The patient suffers unnecessarily and loses lifelong trust in provider.

Compromise Approach: Refusals are acceptable if they do not result in unreasonable patient harm and another professional can perform the task.

-Substitution of moral formula (harms/benefits) calculation for individual responsibility.-Shifts responsibility to other providers and relinquishes all responsibility for the choice.

-Reliance on others to perform job tasks. -Can lead to fractured relations with co-workers. -Loss of patient trust in the patient/provider relationship.

A pharmacist morally opposed to filling emergency contraception refers patient to a co-worker. The co-worker does not like that the pharmacist is passing on required job tasks, and the patient is ashamed and loses trust and respect for the pharmacist.

B. Group Praxis and Authenticity in Healthcare

We can now introduce criteria for properly incorporating group praxis and authenticity

into provider decisions. Authenticity For healthcare as a collective organization that seeks to

compassionately heal and help others, cooperative praxis between various providers is not

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optional, but a necessity in order to benefit patients. Health care providers should always put the

collective praxis of their pledged group primary importance when making authentic workplace

decisions. Authenticity includes viewing one’s work as a healthcare professional both in terms of

its specificity and in the larger context in which it occurs. Recall the characteristics of a pledged

group: individuals freely pledge to one another to dedicate themselves to group goals which in

term maximize the options and flourishing of everyone. Individuals agree to place limits on their

freedom in order to achieve the broader goals of the group. Pledged groups involve recognition

of the inherent worth of others, an adoption of others’ projects, and a dedication to group ends.

These practices should be committed to fulfilling integral human needs, maximize the practical

freedom of others, and should not leave individuals feeling atomic and interchangeable. Thus, if

particular medical procedures are part of the pledged group praxis, authenticity would necessitate

participating in a practice, such as Death with Dignity, rather than refusing. Authenticity further

warrants that this participation must be accompanied by dedication and attention to the well-

being of the specific patient, and not simply be considered a routine job task.

Advocating a pledged-group approach to existentialist decision-making gives rise to the

potential concern that the group praxis of health care may become alienated or deviate so far

from integral humanity that healthcare workers may perform clearly harmful medical practices as

part of the group. An example would be female genital mutilation, a cultural practice that is

shown to cause lifelong infection and health problems in females. This practice is sanctioned by

some societal beliefs and so a provider may feel pressure to perform it, especially when

considering the values of the patient’s culture. There is also the related concern that introducing

“human need” as the root of integral humanity requires some standard for evaluating genuine and

potentially conflicting human needs.

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I suggest a starting point for evaluating collective praxis for a pledged group of

healthcare can be derived from generally accepted goals of healthcare, as well as commonly

accepted principles for healthcare ethics. These goals and principles are consistent with Sartre’s

vision of integral humanity, and will both introduce a framework for evaluating human needs

and exclude abhorrent medical practices from becoming acceptable group praxis.Commonly

accepted goals of health care endorsed by contemporary ethicists and members of the medical

community include the allevation of suffering, the prolongation of life, the promotion of well-

being and the prevention of disease.32 All of these goals are consistent with Sartre’s vision for

human fulfillment and freedom. These goals can serve as a sufficient starting point for evaluating

group praxis. Sartre’s vision of the moral ends of praxis can further be evaluated in terms of

their conformity with heavily supported principles for health care ethics, the principle of non-

maleficence (do no harm), the principle of beneficence (patients should be benefitted and

healed), the principle of autonomy (patients’ self-determination should be respected) and

principle of justice (no patient is given unfair preference over another).33 These principles are

compatible with achieving human fulfillment in health care. If any of these principles are being

violated, it is likely that the goals of healthcare are not being met, and praxis is not in line with

human fulfillment. An identification of needs that are foundational (needs which constitute our

integral humanity) include access to sufficient food, clean water, shelter and general physical

well-being; but also love, social worth, and emotional fulfillment. Evaluating group praxis in

light of these healthcare goals and principles clearly excludes an abhorrent practice such as

genital mutilation, which is not in conformity with any of the accepted goals of healthcare, and

32 Rosemary Tong, New Perspectives in Healthcare Ethics: An Interdisciplinary and Crosscultural Approach, (New Jersey: Pearson Education, 2007) 61-65. 33 Tom Beauchamp and James Childress, Principles of Biomedical Ethics, (New York: Oxford University Press, 1994), 38.

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further is an evident violation of the principle of non-maleficence. This would give a healthcare

provider sufficient ground to refuse to participate in such a practice, in spite of some cultural or

institutional pressures. In is important to note that I am not suggesting the goals of medicine and

healthcare principles serve as a substitute for individual responsibility or provide some type of

rule-book for properly aligned praxis. I am rather arguing that they are compatible with Sartre’s

vision of fulfilling human needs, and can serve as a foundation for evaluating the overall praxis

of the pledged group of healthcare.

In addition to pursuing human fulfillment through healthcare goals and principles, praxis

can further be evaluated on whether or not it gives rise to reciprocal interactions of trust and

respect with others that characterize authentic relationships. The relationship between one’s

conscience and this particular version of fulfilling human needs requires that the healthcare

provider should evaluate the goals of group praxis in relation to this framework. The remainder

of this article will present an existentialist model for workplace decisions, focusing on healthcare

workers, which will bring further clarity to the issues of group praxis, authenticity, and

conscience-based refusals.

II. Sartrean Existentialist Decision Making and Conscience-Based Refusals:

Further Implications

A recent existentialist model for authentic decision-making in the workplace has been

developed by Andrew West. This model provides an outline for authentic decision-making in the

workplace, and incorporating Sartre’s later social thought increases its cogency. West’s model

has six steps: 1) Acknowledge and identify one’s freedom to act, 2) Accept one’s responsibility,

3) Consider one’s prior choices, projects, and goals, 4) Consider the pressures and expectations

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of others 5) Consider the practical constraints of the situation, and 6) Proceed with the choice

that best reflects an awareness of one’s freedom, an acceptance of personal responsibility, and is

most consistent with the goals and projects that one freely chooses.34 I suggest the following

revised version of the existentialist decision making model that incorporates a wider scope of

Sartre’s thought and enhances an existentialist analysis: 1) Acknowledge and identify one’s

freedom to act, 2) Accept one’s responsibility, 3) Consider the worthiness of the praxis of the

group to which one belongs 4) Consider whether the action contributes to the group praxis 5)

Consider the practical constraints of the situation, and 6) Proceed with the choice that best

reflects an awareness of freedom, an acceptance of personal responsibility, and is most consistent

with the goals and projects of the group whose praxis one freely chooses to uphold. Examining

conscience-based refusals in healthcare through this model will show that healthcare providers

who consider group praxis will most likely find the authentic decision is to perform generally

accepted procedures, in spite of individual moral qualms.

Step Recognition Examples Implications for Bad Faith

1: Acknowledge one’s freedom to act

Providers are free to perform the action or refuse. Options are always available, even if they are not always desirable. Pledged group membership does not eliminate freedom.

A pharmacist is free to fill a prescription for woman’s EC or to refuse. A doctor is free to prescribe a drug for Death with Dignity or to refer patient to another provider.

Failure to acknowledge freedom is bad faith.

2: Accept one’s responsibility

Providers are responsible for their behavior and are not forced to perform actions by the pledged group or by their professional role.

Providers cannot rely on the incompatibility approach or a harm/benefit analysis. The incompatibility approach defers responsibility to professional role. Harms/benefits analysis defers responsibility to moral formula.

Acknowledging responsibility is part of recognizing the relationship of freedom and facticity.

3: Consider Reflective: Does group Pharmaceutical praxis:

34 West, “Sartre’s Existentialism,” 19-20.

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worthiness of group praxis

praxisa) Contribute to integral human fulfillment?b) Foster relations of trust and reciprocity?c) Respect autonomy and freedom of the others?d) Align with goals of medicine and principles for healthcare ethics?

dispensing medication to patients to relieve suffering and promote health.Physician praxis: Alleviation of pain and suffering, prolongation of life, prevention of disease.Nursing praxis:

4: Consider the action in the context of group praxis

Reflective: Does the action in question contribute to group praxis? Does the action conform to fellow employees’ and patients’ expectations?

Filling EC prescription: contributes to alleviation of pain and suffering, respecting patient autonomy. Death with Dignity: contributes to physician’s praxis (alleviation of suffering, respect of patient autonomy).Early abortions: respect of patient autonomy and bodily integrity.

Providers with moral qualms about these practices can perform them as part of role without being in bad faith.

5: Consider practical constraints

Reflective: What are the constraints from other group members? From patients? From the practico-inert?

-Practico-inert: rules of medical institutions and the resources available for treatment. Scarce resources necessitate just rationing. Health insurance plans and financial costs to patients.-Group members: Fellow healthcare providers expect co-workers to uphold their professional tasks.-Patients: Expect certain treatments. May want treatments that are not good for them or will not properly treat their condition.

-Ignoring practical constraints fails to properly consider all aspects of facticity.

6: Proceed with choice that balances 1-5.

Decision should-Show awareness of one’s freedom and responsibility-Display dedication to pledged group praxis-

A doctor who has personal individual qualms about prescribing drugs for Death with Dignity recognizes that he freely chooses to be a physician and is responsible for that choice, that communal healthcare goals are important

-Group praxis receives equal attention as individual projects-Healthcare workers can authentically perform actions that about which they

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for the pledged group of medicine

have individual qualms-Bad faith is avoided

A key characteristic of a pledged group is that group members pledge to each other

reciprocally. A refusal to provide a service is breaking a pledge to other members of the group—

one’s fellow healthcare workers. This means that a practice must clearly violate principles of

healthcare and the ends of medicine if a refusal is to be justified as authentic. Unless there are

clearly harmful, unjust practices taking place (genital mutilation or a similarly abhorrent

practice), Steps Three, Four, and Five show that upholding group praxis properly balances

individual conscience with professional role. An alternative to refusing to perform certain

services would be for authentic healthcare workers to attempt to change elements of the praxis

that they find violate their conscience through discourse. Policies and procedures are constantly

changing in the medical community, and there is no reason that a healthcare worker could not

vocalize her concerns. Utilization of discourse is important for ensuring the conformity of group

praxis with the integral humanity ideal, and could lead to necessary reforms. However,

expressing concern or disapproval over an action is not equivalent to refusing to perform that

action outright.

More than any other line of employment, healthcare is vital to societal actualization of

integral human needs. From ensuring basic nutrition, vaccines and routine check-ups and

screenings, alleviating pain and suffering of illness and injuries, curing when possible or healing

when there is no cure—all of these practices contribute to combatting scarcity and promoting

human flourishing. Thus consideration of how individual job tasks are part of broader pledged

group ends must be front and center in all of healthcare workers’ decisions, including potentially

refusing job tasks. But since healthcare deals with foundational human issues surrounding our

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life and death, there is a lot at stake. Thus the proper alignment of the group’s praxis should

always be a concern. If a healthcare worker does think that individual actions being required

have significantly deviated from integral humanity and the fulfillment of needs, provider

authenticity and prevention of patient harm may require refusing the action in spite of potential

sanctions, or in more extreme circumstances, leaving the group.

Thus, we can see how the modified existentialist decision-making model elucidates the

phenomenon of conscientious objection in healthcare as it relates to group praxis, bad faith, and

authenticity. The incorporation of the pledged group model means there are two different ways

for a professional to understand the nature of her actions: only in their specificity, or in their

broader context-- as promotion of group praxis. However if reflection reveals that practices

constitute alienated moral praxis—practice that fails to mitigate the limitations of the practico-

inert, fails to promote fulfillment of human needs through the goals and ethical principles of

healthcare, and fails to establish relationships of trust and reciprocity with others--a provider

should refuse in order to meet the demands of her conscience. This may entail leaving the group

entirely. This is because identification with role is only acceptable so long as the overall goals of

the pledged group are sound.

VI. Conclusion

I have shown that, according to Sartre’s existential thought, providers who perform tasks

they intuitively feel are wrong as part of role are not necessarily doomed to the inauthentic

implications of bad faith. The incorporation of Sartre’s later social thought, which emphasizes

the importance of group praxis for maximizing overall social welfare, demonstrates that

providers should consider the broader context of their actions when exercising their consciences.

Being a member of a pledged group means that workers can perform actions they might feel are

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against their personal moral beliefs and remain authentic, because they recognize that they have

chosen to take on roles in a profession that requires group cooperation for human fulfillment. A

robust social existentialist decision making model includes viewing one’s actions as an element

of group praxis, and acknowledging that the overarching goals of a group should be given

priority over individual moral qualms.

This does not mean that individual responsibility is removed, however, and reflection of

providers upon group praxis is extremely important. The improved existential decision making

model includes provider responsibility to reflect on whether or not a certain practice clearly and

directly violates any of the foundational principles for healthcare or conflicts with the goals of

medicine. Ethical decisions in healthcare necessitate finding the delicate balance between

individual responsibility and professional role. To maintain provider authenticity and maximum

benefit to patients, a conscience-based refusal in healthcare should only occur when there has

been a clear deviation of praxis from integral human fulfillment and the goals and principles of

healthcare.

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