Conscience, professionalism and corporate obligation.

Americans value individualism more than most, partly because they place an especially high value on freedom of conscience. America's roots in Puritanism help explain the durability of appeals to conscientious objection, with freedom to worship as one pleases one of the few rights that virtually all Americans can embrace. The notion of conscience so celebrated in the US has ancient roots in Socrates' refusal to leave Athens in spite of the unjust death sentence it imposed on him: His conscience, he said, did not allow him to leave a city he joined voluntarily and fought for and that gave him the circumstances in which to raise a family. Even though he disagreed with the state on one occasion, Athens nonetheless had the right to enforce its laws, even if that disagreement involved his own death.

The American founders were classicists who admired the enlightened attitudes of the Greeks, particularly concerning individual conscience. The early Christians, too, adopted this emphasis on conscience, especially in the philosophy of Augustine, whose self-examination in the Confessions (like all confessions) was predicated on the idea of conscience. The Catholic theology of conscience perhaps reaches its apex in Aquinas, who adopted and enlarged upon Aristotle's view that conscience is an internal conviction about what is right and wrong. We develop these convictions when we assess an act that we have done or might do, comparing that case with others. Our conscience emerges through the exercise of practical reason as we seek the morally better and worse. This tradition contrasts with the more intellectual notion of conscience in the philosophy of Immanuel Kant, for whom conscience is an intellectual faculty. Thus, unlike Anglo-American law, which accumulates cases and tries to assess a current case in light of precedent, German law involves the application of principles to facts in the manner of a geometric proof. Anglo-American law emphasizes induction from more and less similar cases, whereas German law emphasizes deduction from principles.

PROFESSIONAL OBLIGATION

The idea of a profession also has ancient Greek roots. The Hippocratic physicians seemed to be among the first to grasp the idea that a profession is granted certain rights and privileges by society in exchange for ensuring the provision of certain services. Thus professionals are given the opportunity, to self-regulate as long as the profession in which they participate serves societal needs. There is little room here for conscientious objection because all members of the profession have a duty to help ensure that the profession provides services, including those with which they might not agree. Further, to the extent that an individual professional does wish to opt out of a particular service, his or her duties to the profession require that this individual action not unduly burden colleagues who would have to step in to provide the service.

Just as professionals have little leeway for conscientious objection (the negative exercise of professional conscience) to medical practices, so they also have obligations that are superior to the law. For example, it might be morally required of physicians that they engage in a form of civil disobedience if the law interferes with their ability to serve their patients. I recall here the case of physicians in New York in the 1950s who let news organizations know that they were implanting IUDS in severely impaired patients who wanted them and would be put at risk by a pregnancy. This was a positive exercise of professional conscience.

The ability to exercise conscience is desirable for professionals in spite of their privileged role in our society, because we would he loath to require them to do only that which we "order" them to do. We want professionals to be thoughtful and reflective. We don't want to turn doctors into mere body mechanics. This is partly because we also recognize a difference between someone who is a member of a self-regulating profession and a technician with highly developed skills but who is not a member of a profession. So, for example, we want obstetricians to think for themselves, even though the duties they have toward their colleagues and the profession are such that they have little leeway for the exercise of conscientious objection. They must consider the obligation of physicians to serve the interests of their patients, which is what society properly expects of them. On the other hand, if society attempts to interfere with this obligation, they must engage in civil disobedience. It follows from this view that the medical profession has a duty to ensure that medical services are provided to patients in need. Abortion has been recognized as a medical service since the origins of the art of medicine and was certainly common in the ancient world and throughout the history of American medicine. The failure of the American medical profession to ensure this service is reasonably available in certain regions is a serious moral failure and a disservice to the profession. Similarly, modern hospitals, as extensions of the ability of physicians to exercise their art, have a roughly similar obligation that derives from that of the medical profession.

PHARMACISTS, PHARMACIES AND CORPORATE OBLIGATION

Recently, pharmacists' exercise of individual conscience with regard to the provision of birth control has come to be an issue. Here, the case is somewhat different. Pharmacists are technicians, not professionals who are self-regulating, and normally they have an affirmative obligation to take the "orders" of their clients. (Similarly, radiation technicians should do what radiologists tell them to do, even if they disagree, or should resign.) As technicians who are not professionals, pharmacists also have contractual obligations to their employers, and though their employers may indulge the individual conscience of the pharmacists for many reasons, including employee morale, an employer does not have a moral obligation to do so. Therefore a pharmacist can be said to have a moral right to follow the dictates of her or his conscience, but an employer has no obligation to change a policy in light of that conscientious commitment. A pharmacist who disagrees with company policy to sell a certain drug--or indeed not to sell it--may simply have to resign. What about the case of the company that declines to provide a certain product? Does that company have a moral obligation to sell it? According to a libertarian view, private entities may have moral obligations to the public but shouldn't be legally required to provide a particular service or product. On the other end of the ideological spectrum, socialists believe that the public interest is superior to virtually all private interests, including profits. However, American capitalism does not operate on the basis of either extreme view of industry obligations. Since at least the early 20th century, we have required that industry provide certain services or products at a reasonable rate where there is a compelling public interest and where otherwise people would be denied access to those goods, among other considerations. Thus pharmacies are required to carry appropriate stocks of a certain set of medications, even though for various reasons there are some they may prefer not to sell. These conditions might well apply to such products as Plan B. What counts as a compelling public interest is in part a political question. My guess is that "morning-after" contraceptives will be viewed by the vast majority of Americans as falling into this category.

JONATHAN D. MORENO is the Kornfeld professor and director of the Center for Biomedical Ethics at the University of Virginia and a senior fellow at the Center for American Progress. His most recent book is Is There an Ethicist in the House? (Indiana University Press, 2005).