Integrity: is it still relevant to modern healthcare?

Original article Integrity: is it still relevant to modern healthcare? nup_486 107..118 Stephen Tyreman PhD, MA, DO Dean of Osteopathic Education Development at the British School of Osteopathy (BSO), London, and Professor of Osteopathy and Philosophy, University of Bedfordshire, Bedfordshire, UK Abstract Personal integrity is often seen as a core value for delivering ethical healthcare.This paper will explore what this might mean and particularly what place integrity has in a multi-professional healthcare system. Two opposing arguments can be made: the first is that the multi-professional nature of modern healthcare means that personal integrity is at best a futile luxury and at worst, an obstacle to delivering affordable highquality care to large populations. The converse is that without personal integrity healthcare loses its humanity and becomes mere biological and social engineering. Part of the analysis rests on whether integrity is primarily a personally held moral framework or whether it is a social concept. Chester Calhoun’s analysis, in which she identifies the integrated-self, personal identity, and (morally) clean-hands as three pictures of integrity, is used as the basis for suggesting that integrity is a rich and complex social virtue through which the individual is able to demonstrate their relationship with the values and mores of the communities of which they are members. In addition, I will argue that integrity is not a value itself, but is a framework through which one or more sets of those values that characterize the communities of which the person is a part, can be expressed. Because a person may belong to many communities – nation, gender, religion, family, profession, trade, sport, etc. – each individual has their own unique meta-set of values that informs their personal sense of integrity. However, in specific circumstances, conflicts may arise between this personal global sense and the set of values associated with one community. Keywords: integrity, value, Calhoun, social values, professional values, personal values, authenticity, professional identity. Correspondence: Professor Stephen Tyreman, Dean of Osteopathic Education Development at the British School of Osteopathy, 275 Borough High Street, London SE1 1JE, UK.Tel.: +44 207 407 0222; fax: +44 207 089 5300; e-mail: [email protected] Introduction Integrity, both personal and professional, is regarded as a precondition for individuals working autonomously with vulnerable patients. In addition to © 2011 Blackwell Publishing Ltd Nursing Philosophy (2011), 12, pp. 107–118 107 108 Stephen Tyreman ensuring ethical care, it also underpins the notion of healthcare as a vocation rather than merely a ‘job’. The person with integrity is assumed to be virtuous with respect to the work they do, the regard they have for patients under their care and in ensuring that they provide the highest quality care. It might therefore seem unnecessary and churlish to question whether it still has a place in modern healthcare and, if it does, whether it should be revisited and reviewed. But there are good reasons for suggesting that this should be done. In the UK, a number of high-profile cases in health and social work – such as that of Harold Shipman, who murdered more than 200 elderly patients over several years while working as a general practitioner – shook public faith in health professionals always to act with integrity in the best interests of their patients, as well as confidence in the professions to monitor the behaviour of their members. It raised the question of whether people in need of healthcare are best served by relying on the integrity of individual practitioners or by introducing more rigorous codes of practice, protocols and guidelines? The adoption of more procedures is rapidly becoming the norm; trust in professional integrity appears to be reducing. Writing and policing policies to ensure ethical behaviour may be replacing the individual’s integrity in acting ethically, where integrity performs the work of personal motivation, or ‘conscience’, in ensuring good behaviour. Underlying this development is the (perhaps naïve) belief that professional values assimilated during training, plus the individual’s original altruistic motives for joining a healthcare profession, provide practitioners with a moral framework that forms the basis for acting with integrity throughout their professional life. What kinds of behaviours demonstrate integrity? The nurse who refuses to clean up a soiled patient because they find it unpleasant, or because there is a risk of infection, is clearly not acting out of integrity. In fact, integrity explicitly seems to exclude acts of self-interest. But where should the line be drawn between doing something that may be morally objectionable, such as assisting euthanasia or giving priority to wealthy patients, and doing something that one believes to be futile or unnecessary such as collecting data to complete government statistics, or persuading (perhaps with coercion) patients to participate in screening programmes or to take medication to reduce the risk of cardiovascular problems when the person has no illness and believes themselves to be healthy? A further reason for revisiting integrity concerns the changing nature of Western healthcare. Modern healthcare has become heavily reliant on multiprofessional and cross-disciplinary work. The roles of individuals acting professionally is very different today from how it was three or four decades ago. Even in primary care, it is rarely one individual who has sole responsibility for a patient; practice nurses, pharmacists, physiotherapists, and so on, work with doctors in a team to provide effective care. So is there still a place for the individual to demonstrate integrity or is it inevitable that healthcare behaviour should be codified and good practice only defined in terms of bureaucratic standards? There are two issues here: the first concerns integrity itself; what it is and what work it performs in healthcare. This is the aspect I will focus on in this paper. The second issue is whether the work that integrity is assumed to perform – ensuring safe, effective, and ethical care for patients – is best achieved through integrity, or some other means such as rigorous enforcement of codes of practice. Models of integrity Integrity only raises its head when there is conflict. This may be with another person, with ‘the system’, or when professional values conflict with personal ones, for example, in the medicalization of abortion. At other times healthcare practitioners perform their duties ethically, effectively and to the best of their ability without recourse to notions of integrity, which are implicit and assumed. If this is the case, what is entailed when integrity is an issue, when disobeying an order or performing an act contrary to normal expectations is justified by the claim that the person ‘acted with integrity’, meaning that what they did was morally good; and specifically, what does it mean in the context of healthcare? If it is assumed that the good of patients is the first priority, © 2011 Blackwell Publishing Ltd Nursing Philosophy (2011), 12, pp. 107–118 Integrity in Healthcare how can two people disagree over the right action to take, yet both claim to be acting ‘with integrity’, that is, both be acting for the good of patients? For example, a consultant and a manager may clash over a decision to close an operating theatre; the former because closing the theatre will lead to longer waiting times and the other because the money could be better used for more urgent needs, or to provide care for more people. In pursuing their causes they may support opposing actions with regard to going to the press, say, in order to achieve what they both see as good actions. In justification, both may appeal to professional and/or personal integrity. This goes beyond merely doing one’s job or carrying out instructions; it becomes an action that is felt to be justified at a personal and professional level. This tension has, in part, been put down to a clash between deontological and utilitarian ethical principles; the good of the individual versus the good of society, an issue that I will return to later. This raises four important questions about the role of integrity: Is integrity legitimate moral justification for taking a stand on something about which there is disagreement, or is it self-indulgence, self-interest, or bigotry? Is integrity a value equivalent to honesty or truthfulness; is it a virtue, or at least virtuous? What are the criteria defining what it is to act with integrity, distinguishing it from wilfulness, for example? Finally, is integrity a reasonable and ethical justification for, say, defying authority? In addition to these questions, there are two areas of potential conflict: the first concerns the difference (if any) between professional and personal values and the extent to which they should be one; and the other, already mentioned, concerns different outcomes that might result from deontological and utilitarian/ consequentialist moral reasoning. There are a number of terms related to integrity and some of them will be important in distinguishing what counts as acting with integrity. These include authenticity, dignity, respect, honour, honesty, truthfulness, and sincerity. These issues inform the agenda for this analysis. Chester Calhoun identifies three pictures of integrity in her paper, Standing for Something: the integrated-self picture (ISP), the identity picture (IP), and the clean-hands picture (CHP). (Calhoun, 1995) Although she admits valuable features in each of them, she ultimately rejects them as identifying the virtue of integrity on the grounds that they reduce to other conditions, viz. the conditions for unified agency, the conditions for consistency in being one’s self, and the conditions for resisting some evil. I will briefly outline each of the pictures, then add further comments to Calhoun’s critique. Integrated-self picture Put simply, I act with integrity if my actions and my declarations are consistent and coherent. The ISP is based on the etymological roots of integrity and integer. Derived from the Latin ‘integritas’ meaning ‘wholeness, completeness, unbroken’, the Oxford English Dictionary provides three different meanings for integrity: 1. The condition of having no part or element taken away or wanting; undivided or unbroken state; material wholeness, completeness, entirety. Something undivided; an integral whole. 2. The condition of not being marred or violated; unimpaired or uncorrupted condition; original perfect state; soundness. 3. In moral sense. 3.a Unimpaired moral state; freedom from moral corruption; innocence, sinlessness. Obs. 3.b Soundness of moral principle; the character of uncorrupted virtue, esp. in relation to truth and fair dealing; uprightness, honesty, sincerity. On this view, the person of integrity is a whole, undivided, fully integrated and complete individual in whom there is consistency of views and actions; what they say and what they do are one. The ‘integer’ person1 is not swayed by the crowd, but will stand up for what they believe no matter what the consequences may be. Amy Lavender Harris, using Webster’s Collegiate Dictionary definition (10th Edition) identifies what 1 I am grateful to Jaoa and Maria Calinas Correia for bringing this term to my attention. In Portuguese it is common to describe someone as an ‘integer person’, that is, someone whose beliefs, motives and actions are consistent. An integer person can be trusted because what they do truly represents what they believe. I will comment on this in the text. © 2011 Blackwell Publishing Ltd Nursing Philosophy (2011), 12, pp. 107–118 109 110 Stephen Tyreman she calls, ‘the three C’s of integrity: Compliance, Coherence and Consistency.’ (Harris, 2008) She argues that all three are necessary for integrity. I will argue that while they may be necessary they are not sufficient and that some behaviours, such as those of an obsessive person, might meet the criteria but not be regarded as having integrity. Nevertheless, consistency of belief and action is clearly important to our understanding of integrity. The point is that few people are wholly consistent in what they say and do. I may not live up to my beliefs and claims, not because I lack integrity, but because I fear for my safety or the safety of someone I hold dear, or because I do not apply the correct set of beliefs to the situation I am in. It seems harsh to accuse everyone who fails to live up to their ideals for what might be good reasons, to be lacking integrity. It also makes it unlikely that many people demonstrate integrity, as it seems to permit no failure. Perhaps the most famous recognition of this is from St. Paul (who it might be difficult to accuse of lacking integrity) who said, For I have the desire to do what is good, but I cannot carry it out. For what I do is not the good I want to do; no, the evil I do not want to do – this I keep on doing. (Romans 7: 18–19 NIV) Recognizing that human beings have a propensity to be inconsistent – what we might call human nature – makes integrity as defined by the ISP a rare or unrealistic virtue. There are further reasons why consistency, as demonstrated in the ISP, cannot be the core of integrity: the value of multiplicity, the need to overcome wrong actions by behaving contrary to psychological propensity, and the desirability of selfreflection and doubt in order to generate new and better actions. Multiplicity: Calhoun cites Maria Lugones’s example to support ‘the value of conceptualizing oneself as a duplicitous or multiplicitous being’. (ibid. p. 238) Lugones is a Latina within Hispanic culture, but also a lesbian. In Hispanic culture homosexuality is an abomination. She cannot be an integrated coherent individual – an integer person – and be true to both her Hispanic roots and her homosexuality. This does not mean, though that she lacks integrity. By recognizing the conflict and her inability to resolve the irresolvable, she is demonstrating her integrity; she acknowledges the value of each culture. Fudging the conflict by devising some kind of compromise or justification would require her to lack integrity in one or the other (and perhaps both) situations. Resisting evil desires: A person may realize that their desires or their psychological make-up may need to be resisted. The person who is sexually attracted to children, or over-controlling or compulsive, may demonstrate integrity by deliberately acting contrary to their natural thoughts and desires. This ambivalence between motives and actions, as Calhoun notes (p. 240) is a mark of integrity. Development through self-reflection: Retaining the right to refuse to conform to a single set of values and cultural mores is a necessary precondition for moral growth and development as Edgar and Pattison point out in their paper (this issue). What we might call the morbidly consistent person will not just be entirely predictable, they will also lack the ability to reflect on their beliefs and actions and to consider the possibility that they could be wrong, or that other values take precedence in this case. This might be because their original view was wrong, or, more commonly, because they have failed to respond to changing circumstances or acknowledge conflicting values in a complex situation. Such an individual would always be convinced of the rightness of their actions, because they assume that their set of values must always trump all others. The result would be a failure to learn from mistakes or adapt to changing circumstances and develop moral maturity. Integrity is not about being right or acting consistently no matter what, though clearly some degree of consistency to avoid what Harry Frankfurt refers to as wantonness (cited by Calhoun, p. 238), that is, avoiding being someone who is fickle, capricious and susceptible to public opinion (Frankfurt, 1971), is desirable. The ISP also fails to define what are the good reasons for acting with integrity. Power, money, or greed, for example, could be motives, which would mean that despots and tyrants as single-minded agents pursuing their agendas could be said to be integer persons. © 2011 Blackwell Publishing Ltd Nursing Philosophy (2011), 12, pp. 107–118 Integrity in Healthcare The idea of the consistent integer person is probably better captured by the word ‘sincere’. Sincerity is explicitly about being genuine though it does not necessarily require a moral basis. Someone who is strongly racist, for example, may be very sincere in that they genuinely believe that races are populated by fundamentally different kinds of human being, but it does not make them moral, merely consistent within the limitations of what they (wrongly) believe; they can be trusted to act in a racist way across a set of circumstances.The person who sincerely believes they are right does not necessarily act with integrity. Sincerity can be narrow and amoral in the sense that it is not about morality, that is, enhancing goodness, just consistency and a genuine belief that the act is right, whether or not it is. It is possible to be sincere but wrong, in a way that is less likely with integrity. Integrity entails a moral good, not just consistent intentions. Presumably Hitler sincerely believed he was right to try and rid the world of Jews, but it is counterintuitive to suggest that he therefore acted with integrity. I will return to the question of why Hitler cannot be considered a person of integrity later. This challenges the common assumption that the person of integrity is also a person of principle. As I will attempt to show, integrity is not just a matter of remaining true to one’s beliefs or principles, it is a question of having the right principles in the first place. The identity picture The second picture that is used to describe integrity is the IP. On this account, integrity means that my actions express something that is central to who I am, that I identify with wholeheartedly, that I believe in and endorse. In other words, it is something that I stand for, to use Calhoun’s expression. This answers the criticism of the ISP that trivial actions can demonstrate integrity. It insists that integrity is at the core of my identity. If I am a healthcare worker I have integrity because caring for needy people is fundamental to who I am. The meaning of my life is founded on certain things that I do and if I were to fail to do them, or gave them up, my life would lose meaning. The IP captures the sense that the person of integrity would rather die than act against their core identity. This view, articulated by Bernard Williams, is, in his opinion, opposed to both Kantian deontology and utilitarianism because both require the moral agent to give up their ‘ground projects’ for the sake of rational good ordering, or to maximize the greater good. (Williams, 1981b) Williams’s criticism of these two familiar moral systems is that both require too much of agents, and that having to give up deeply held ground projects for some impartial or greater good results in those agents failing to identify at a personal level with the moral choice. Calhoun questions this by asking whether ‘integrity really is, and is nothing but, being true to what one deeply identifies with.’ (op. cit. p. 242) Calhoun’s criticism is that the psychological sense of self is incidental to behaving with integrity. Having a psychological propensity to paedophilia, or pyromania is incidental to the judgement that acting in accordance with that propensity is morally wrong. To demonstrate integrity may require someone to act contrary to the core sense that they are a pyromaniac or a paedophile. My psychological sense of self, even when it is the core motivating force in my life, is distinct from my moral sense of acting with integrity. So how is integrity related to authenticity and sincerity (again)? With both of these, my identity is expressed through my behaviour, which in turn will match my beliefs and claims. Someone is authentic and acts with sincerity when the way they live – the decisions and choices they make – matches what they claim to believe. On this account, living with integrity is completely about expressing true identity. Someone who has argued against abortion, for example, will fail the test of authenticity as well as failing to act with integrity if she herself has an abortion. There have been many examples in political, religious, and sporting life, where the leaders’ behaviours have failed to match their public portrayal. They have lacked authenticity. The difference between authenticity and integrity here is twofold: first, authenticity is about consistency between my actions and what I claim to believe (not what I secretly might really believe); and second, that if, having been found out, a person sincerely admits their failure, resigns (if appropriate) © 2011 Blackwell Publishing Ltd Nursing Philosophy (2011), 12, pp. 107–118 111 112 Stephen Tyreman and tries to make amends, they will have acted with integrity though still lacking authenticity. Although the IP places the individual’s character and deeply held beliefs at the centre of integrity, thus nullifying the ISP’s problem of trivially held projects, it is unable to make a moral distinction between good and bad. On this account a despot or tyrant who passionately believes that he should destroy all who oppose him, acts with integrity if he commits genocide in achieving his ends. Hitler is still a man of integrity because his core personality is fully and completely expressed through his actions of genocide. Although the IP of integrity seems to capture the relationship between a person’s core sense of doing what they strongly hold dear by providing a reason to stand up for something, it fails to distinguish between morally good and bad actions. The clean-hands picture The third picture that Calhoun identifies is the CHP. Like the IP, it focuses on a person’s core beliefs, but emphasizes the bottom-line with regard to what they are prepared to do or not do. It identifies not just what a person stands for and what is central to their sense of identity, but what they endorse. The CHP does not mean that the person of integrity avoids getting their hands dirty doing unpleasant or disagreeable work; it is much more precise than that. It draws a line in the sand and says beyond this I cannot go without corrupting my identity. The CHP therefore seems to be an advancement on the IP while also strengthening the sense of being fully integrated. A key problem still remains. There are times, particularly in complex and multi-faceted situations such as healthcare, when whatever decision is made involves some greyness, when keeping clean simply is not possible. In such circumstances acting with integrity involves making a moral judgement that does not just avoid doing something bad, but positively tries to make the best of an inherently bad situation. Managers with limited resources have to make decisions that involve a degree of harm to some patients or staff.The simplistic approach is to take a naïve consequentialist view and weigh harm against benefit or to apply rigid deontological rules, to produce a defendable outcome. The problem is that integrity is implicitly personal. I am not acting with integrity when I do what I am told to do, or when I simply respond to external standards, which is Williams’s criticism of both utilitarianism and deontology (Williams, 1981a). The CHP is based on an externally imposed set of principles and beliefs that the moral agent can point to (or hide behind) as the reason for their action rather than the action resulting from their personally generated and owned moral reasons, which is implicit in integrity. It is not my principles or beliefs that are prompting me to act with integrity in the sense that I generated them and have moulded them to form my ground project; they are imposed externally by the requirement to be rational. I may, of course, agree with the principles, or adopt them as mine, but that does not avoid the point that they originate externally rather than being generated by my personal moral deliberation. It is also the case that I may agree with them as rational, but fail to identify with them personally. Integrity is not just a matter of keeping morally clean. Calhoun concludes that the CHP devolves to avoiding evil rather than positively doing good. Acting with integrity should require a reason to do something that is morally right, rather than a reason for avoiding something evil. It is a stand that one chooses to make because it is believed to be the morally positive response. Refusing to do something, such as participating in abortion for example, is not just a question of avoiding evil – there may be good utilitarian reasons for performing an abortion – it should be a question of taking a positive stand because it is the right thing to do. The next question is: what is it that makes it the right thing to do? Integrity as a social rather than a personal concept Although the three pictures of integrity identify important elements, they fail separately and jointly to fully capture its meaning. Calhoun, supported by Harris, believes that the mistake is in assuming that integrity is a personal virtue. She argues that integrity only makes sense for matters that are morally significant in a social context. There is a further criticism © 2011 Blackwell Publishing Ltd Nursing Philosophy (2011), 12, pp. 107–118 Integrity in Healthcare that can be made: making integrity a personal value assumes that the moral truth behind it is embedded within the individual, that is, that person can look into themselves to find the moral truth of the matter in order to know what to do. Using one’s conscience, or whatever, to guide moral behaviour presumes that conscience is the repository of moral truth. This contrasts with the intellectual task of grappling with complex, competing moral goods and coming to a just and rational outcome. Williams identifies Plato as the source of this (in his view) mistaken idea. (Williams, 1972, p. 72). Plato believed that the role of the creative philosophical thinker is to discover through rational reasoning transcendental a priori moral truths that make moral action right or wrong. Once these truths have been identified, the moral response is to adopt, personalize and act in accordance with them. Williams argues that such moral truths do not exist a priori,2 but are social and contextual and therefore subject to debate and review. This necessitates shifting from ensuring adherence to a putative standard of behaviour, to facilitating the best possible outcome in terms of goods achieved. It is here, I believe, where part of the argument about codes of practice versus professional (not just personal) integrity lies, I will return to this later. The person of integrity exercises their moral behaviour in the context of a community where those kinds of behaviours are deemed significant. In the case of integrity there is disagreement about what ‘good’ behaviour entails. (There has to be disagreement, otherwise integrity is not an issue.) There is therefore a tension between identifying with the values of the community and behaving in accordance with them on one side, and legitimately 2 Williams argues that philosophical debate on defining the stan- dard for the ‘good man’ has been either transcendental, that is, by ‘an appeal to some framework which lies outside human life and the empirical world’ (ibid. p. 68) as in religious or utopian claims; or non-transcendental, in which certain characteristics of human beings are identified as distinctive. The life of a good man will exemplify these characteristics to the fullest degree. He rejects both. (ibid. pp. 68–86) challenging some or all of the values (or the way they are interpreted), while still remaining a member of the community on the other. It is in the tension of this interface that integrity becomes significant. One of two things may be happening here: (1) values may be given different weighting or priority, or (2) a different set of values are being identified as characterizing the community. The 19th Century, Hungarian physician Ignaz Semmelweis is famous for identifying the causal link between puerperal fever following childbirth and obstetricians’ failure to wash hands and instruments after performing an autopsy. Despite clearly demonstrating the effectiveness of basic hygiene procedures on death rates, most of his contemporaries ignored his recommendation because it went against accepted custom and because they believed disease was unpreventable. Semmelweis eventually resigned from the hospital in Vienna to return to Pest rather than take up a non-clinical appointment. (Zoltan, 2010) Clearly, Semmelweis did not share the same value set as some of his colleagues: he was not resigned to the idea that disease was unpreventable; he was driven by the appallingly high death rates in the obstetric wards; he placed innovation above tradition; he used an evidence-based approach. Although the whole medical community accepted the premise that obstetrics is based on safe and effective delivery of babies, there were different interpretations of what that entailed. Evidence was valued below custom as the basis for praxis, for example. If integrity depends on an issue being morally significant in a community, it also means (at least in part) that a person’s identification of themselves as a member of a community by supporting the values of the community will also be a measure of their commitment to it. This does not necessarily mean that they must be in accord with the majority view. The history of the Christian Church, for example, provides examples of individuals who stood up against the prevailing values because they were committed to a different set of values, which they believed more truly represented the (Church) community and its reasons for existing. Clearly, it is the case that integrity is practised by individuals in a personal way rather than by groups © 2011 Blackwell Publishing Ltd Nursing Philosophy (2011), 12, pp. 107–118 113 114 Stephen Tyreman acting collectively.3 In situations where a group of people are described as acting with integrity, it is usually as a collection of individuals. For example, it might be said that doctors act with integrity when they put the needs of their patients before those of the institution for whom they work. But this only means that all doctors (or the vast majority) individually put the needs of patients before those of the institution. The problem is that the ways of describing integrity as personal – the ISP, IP, and CHP – fail to fully capture its meaning. Personal values are generated from a wide range of sources: family, culture, religion, social class, geography, education, lifecircumstances, and so on, many of which are so embedded that we are unaware of their significance. What, then, is the relationship between personal and social values and what bearing does it have for our understanding of integrity? Calhoun argues that personal values only have significance when those values are shared and agreed as significant in a social context. We are social beings; we live in social groupings and relate to one another in the context of those groups. Family commitment, for example, is one of the strongest bonds between people. Each group or community has a set of values that define the identity of the group and which are tacitly accepted to a greater or lesser extent by individuals within the community. The actions of an individual and the values that underpin those actions are judged in the context of the community’s values. Acting with integrity means acting in accordance with the set of values that I identify with, that is, those values that give me identity, and which, in turn, make me recognizable as a committed member of that community. Integrity is personal to the extent that it is my judgement on where I stand in relation to a set of values that I hold; but it is also about where I stand in 3 There can be occasions where integrity applies to the way a community acts. For example, the Parliament may act with integrity by deciding as a collective to allow access to sensitive information that is in the public interest but potentially embarrassing to individual members; the Roman Catholic Church was criticized for not acting with integrity over the alleged abuse of children by priests. relation to the community to which I have committed myself, and on whose behalf I act. Consider the example of someone who has an obsessive compulsive disorder (OCD). For them it may be of the greatest importance that their pencils are lined up on the desk in size order and equally separated; that they always go to work along the same route and at the same time, etc. This behaviour seems to meet the criteria of the ISP, IP, and CHP, in the sense that it is at the core of their personality, it defines their identity and unifies their belief with their action, and sets a very clear boundary beyond which they cannot go without undermining their sense of self. But it is not clear that this person therefore acts with integrity whenever they insist on straightening their pencils before doing their work. This person is a member of communities for which this behaviour has no moral significance. Even if there was a group of people with similar psychological propensities, there would not be agreement about which particular behaviours are significant. They would not be praised for their integrity in insisting that all pencils are straight and books lined up on their desk before they will begin to do their work. This kind of behaviour emanates from the individual rather than from society – even a society of OCD persons. Such behaviours are only significant to the individuals displaying them and do not generate a commonly held value. This idea is very similar to Charles Taylor’s account of authenticity where he believes personal identity develops through ‘dialogical relations’ with others. (Taylor, 1991) Our identity requires recognition by others through what Taylor calls ‘a horizon of significance’. (ibid. pp. 31–41) He argues that sense of personal identity only has meaning in a social context. There is no identity in isolation; identity only has meaning in relation to a community that recognizes that identity and agrees on its meaning. On the same basis, integrity is personal moral behaviour that only has significance in the context of a known community for whom that behaviour is widely agreed to be significant, even if not all members are agreed on what the right behaviour is. In fact, for both Taylor and Calhoun, it is the dialogue about it that makes it significant rather than any fact about it being agreed. © 2011 Blackwell Publishing Ltd Nursing Philosophy (2011), 12, pp. 107–118 Integrity in Healthcare Human being is social; we exist in multiple communities consisting of family, race, gender, nation, profession, sport, hobby, social class, and so on, and we relate within and across many of these at the same time. Perhaps it is the case that a ‘well-rounded’ individual needs to exist in multiple communities. The mature, developed person is someone who relates within several communities and the integrity (or lack of it) they demonstrate will result from the way they personally identify themselves in relation to those communities and the value systems each represents. To this extent, then, the IP is core to our understanding of integrity, but not in the sense that integrity is an expression of identity, but rather that our identity grows out of our relating within family, school, geographical community, workplace, sport club, and so on. On this account, integrity is the expression of our commitment to those relationships. The more closely someone identifies with the values and mores of a community, the more likely they are to demonstrate integrity in their acts. This understanding of integrity resonates with Alasdair MacIntyre’s contention that what he defines as human practices, which includes professional practices, entail both internal and external goods, that is, goods such as skills and knowledge that are internal to and which define the practice, and external goods such as monetary payment, prestige, and social status that are contingent. (MacIntyre, 1985, pp. 186–189) His point is that although both are necessary, it is the internal values and the pursuit of excellence rather than external values associated with effectiveness that should take precedence. MacIntyre uses the example of an artist whose life is that of a painter before being the producer of any particular picture. (op. cit. p. 190) What is important to a genuine, virtuous painter is the internal goods of painting rather than an external person’s judgement of effectiveness. The artist with integrity will only produce good art, that is, art that expresses the artist’s true artistic values. Producing art that is popular just to make money is often criticized. Derek Sellman takes MacIntyre’s idea and applies it to current trends in nursing where, in his view, external goods such as evidence-based practice and adherence to codes of practice are gaining dominance over nursing’s internal professional values and threatens to undermine the fundamental integrity of the profession (Sellman, 2010). My argument is similar, that is, that integrity entails commitment to an internal set of values that are socially owned by a practice community and which define the identity of that community. The final element that needs to be clarified is the relationship between integrity and moral values. Integrity as a moral value At first sight, integrity looks to be a value like honesty or truthfulness – something that one has or does not have – but there are important differences. It is meaningful to say that someone acted honestly in the context of what they knew at the time, but that with hindsight, which is in a different context, they would have acted differently. Or they might say that they told the truth ‘as they saw it’, with the inference, first, that it was not the (whole) truth and second, that in different circumstances or with additional knowledge they would have given a more truthful account. But such conditions do not seem to apply to integrity. Acting with integrity just is doing what is judged to be right. While I may do or say something that I later realize is dishonest or not the (whole) truth, I cannot look back on something and say that because I was mistaken I did not do it with integrity. I will always act with integrity, even if what I did proves to have been mistaken or wrong. It is therefore more akin to sincerity or honour than to truth and honesty. On the other hand if I do something that goes against what I believe to be right I will be acting without integrity. I could, of course, delude myself by looking for excuses or justification, but, if I am honest, I will acknowledge that I was not actually acting with integrity. But perversely, this expression of remorse is itself an act of integrity, which is only possible because integrity is not itself a value, but the expression of a related (and integrated) set of values. Values like honesty and truthfulness can be partial within a set of circumstances; someone can be more or less honest, more or less truthful, either deliberately or unknowingly, but it is not possible to have more or less integrity. I might say that I always tell the truth, but this claim will be conditional because truth is ‘as I © 2011 Blackwell Publishing Ltd Nursing Philosophy (2011), 12, pp. 107–118 115 116 Stephen Tyreman see it’. Integrity, though, seems to be something that someone either has (or acts in accordance with) or does not have. If someone acts with integrity why is not integrity an act-focused value like truth-telling or honesty? It is, I believe, because the focus for integrity is not on the object of the act, but the reasons for doing it, that is, it is one step removed from the act itself. The truth is the truth, whether or not we know it; an honest action is not judged by the intention of the person, but by the act itself – integrity on the other hand seems to operate on a different level. It is possible for someone to tell an untruth that they wrongly believe to be the truth and to justify it with the claim that they did so ‘with integrity’. The ‘honest mistake’ is justified on the grounds that it was done with integrity. Integrity can make good a moral deficit resulting from such an act. I therefore do not believe that integrity relates to the action itself despite the fact that it is frequently treated as such. You can have an honest, truthful, sincere, honourable and so on statement or act, but it does not make much sense to talk of an integrated act – or whatever the adverb should be. Integrity is a noun not an adverb or adjective. One acts with integrity; integrity is distanced from the act in a way that honesty, truthfulness, courage, and so on are not. This has the effect of enabling integrity to observe from a distance and take in the bigger picture. So what does ‘with integrity’ mean in this case? It is now time to draw together the various ideas I have been outlining. a practitioner and the more embedded my profession’s values and mores are within my behaviour, the more likely I am naturally to act with integrity to expound those values. So when I act ‘with integrity’ I am utilizing the set of values that define my profession in order to respond to a specific situation. My responsibility as a member of that community is to ensure that my behaviour is in accordance with the profession’s value-set – or at least those that are relevant to the situation – in order to achieve the moral purposes, or on MacIntyre’s account, the internal goods of that community. As a novice I start by considering each value separately, but with experience and familiarity the values become part of the natural way that I act. Integrity only becomes overt when conflicts emerge. The richness and complexity of this may make it difficult to predict exactly how integrity will be expressed in any given situation. If I live my life with integrity, it does not necessarily mean that I adhere to a rigid code of practice in a predictable way without deviation – that might make me an integer person (and probably very boring). Integrity is a richer and more complex concept than that. Integrity is the relational framework that enables sets of values to operate together in order to realize the goods of a community. And what are judged to be the goods of a community will be contingent on the circumstances at the time.4 4 As I write this we have an interesting political situation in the UK with a coalition government made up of Conservative and Integrity as relation Liberal-Democrat members. Both parties, but the Liberal- I am suggesting, along with Calhoun and Harris, that integrity is not itself a value. Calhoun argues that it is a social virtue. I do not want to deny that, but to add that it becomes a social virtue by the way it frames sets of values in the service of maintaining the internal goods of a profession. The point that I wish to add to Calhoun’s account is that integrity represents a complex set of values that have to be considered as a whole, a relational framework of values that exist for defined communities and individuals. As a healthcare professional my integrity expresses the internal values associated with my profession in a connected holistic way. The more experienced I am as Democrats in particular, have been accused of lacking integrity because promises made in election manifestos and speeches have been overturned in government. The Liberal-Democrats promised not to increase tuition fees for university students, but in power supported a trebling of fees. The party’s defence has been that the context in which the promises were made was very different from the situation they find themselves in now. Their claim is along the lines of: the internal values that define liberaldemocratic principles are inviolable, but the way these principles are interpreted is contingent on current circumstances. By contrast, specific policies and the promises that go with them are external goods, context-specific, and subject to change as circumstances change. It is therefore possible to act with integrity, that © 2011 Blackwell Publishing Ltd Nursing Philosophy (2011), 12, pp. 107–118 Integrity in Healthcare It also means that integrity may have a different meaning for the community and for the individual. In a community integrity represents the explicit and implicit core internal values that define that community, whether it be a nation, race, religion, sport or whatever, and are related to the purposes of that community. In this it most closely follows the IP of integrity. But for the individual who is a (more or less) committed member of several communities, integrity is much more complex as he or she may be required to make a judgement that entails different and potentially conflicting sets of values. Integrity over codes of practice Codes of practice define a set of behaviours that are assumed to be right in a given situation. They are not universal in that they apply to a given set of circumstances – care of children, say – but within that set, it is assumed that they cover all, or at least the vast majority of situations involving the care of children. This means that most of the time what a code of practice requires (assuming it is well designed) will be what the majority of professionals would do anyway. It is when a professional believes that a greater good can be achieved (or an evil avoided) by acting contrary to the code, or where there is clear conflict between internal and external values, that conflict arises and the appeal to integrity is made. It is precisely here that I believe integrity – if it is properly conceived – should take precedence over codes. The weakness of codes is similar to the arguments against the CHP, i.e., the implicit assumption that there is a set of moral behaviours that have an independent existence; that there is an objective standard that pre-exists the circumstance in which it is to be applied, and which is good in and of itself. The assumption that the standard is objective and independent is strengthened by the fact that codes of practice are written down with legal precision and used to judge specific circumstances. Although a code may have been designed originally with the explicit is, to act in accordance with the fundamental internal value-set of the party to achieve the broader goods of liberal-democracy, even if specific policies, that is, external goods, change. aim of ensuring a good outcome, once adopted it inevitably becomes an end in itself because of the implicit assumption that by following it, a good will be achieved. In other words, internal values have become external and contingent. The focus is shifted from the specific situation that requires moral deliberation, to the epistemological issue of identifying and applying the right code of behaviour. The consequence is that effectiveness in relation to external goods, that is, conformity to the code, rather than the morality of the outcome becomes the central issue. Integrity as a communitarian relational framework In conclusion then, I want to suggest that integrity remains a necessary virtue in society generally and healthcare in particular, but that the focus needs to shift from personal integrity, in the sense that integrity is all about the personal values and beliefs of the individual, and more explicitly onto the community the individual is representing (at that given time) and from which they gain their identity, including professional identity. Developing Calhoun’s idea, I believe that integrity is a social virtue expressed through the individual, determined both by the wider cultural community entailed by nation, gender, or colour of which that person is a member, and smaller communities such as a profession, religious organization, etc., or a subgroup of any of these. Each community has its own internal value-set that defines its identity and guides the expected behaviour of its members. Integrity entails a relational framework, a set of values that operates on two levels: the first defines a community’s goods and purposes and gives it identity; and the second focuses on the individual member of that community who is called on to expedite those values, but in the more complex context of the range of communities of which they are members. In so far as the institution, profession, association, or whatever manages to keep those values exercised in balance it will be operating with integrity. But institutions are reliant upon the individuals that comprise that community and the ways in which the set of values as a whole are demonstrated in relation to other commu- © 2011 Blackwell Publishing Ltd Nursing Philosophy (2011), 12, pp. 107–118 117 118 Stephen Tyreman nities of which the individual is a member and to which they have allegiance. The communitarian relational framework of values that define the profession or sport or whatever, forms the backdrop against which the individual defines their own identity and particularly where they stand in relation to that community. Integrity as the kinds of actions the individual believes to be morally justified will either reflect or challenge the set of values expounded by the profession. This opens the way for an individual to challenge the accepted values and mores of the profession – entering into a dialogical relation, to use Taylor’s term – or to comply wholeheartedly and willingly with them. References Calhoun C. (1995) Standing for something. The Journal of Philosophy, 92(5), 235–260. Frankfurt H. (1971) Freedom of the will and the concept of a person. The Journal of Philosophy, 68(1), 5–20. Harris A.L. (2008) Integrity. Outer Sanctum. Retrieved 13 February 2011 from http://outersanctum.blogspot.com/ 2005/12/on-integrity.html MacIntyre A. (1985) After Virtue: A Study in Moral Theory, 2nd edn. Duckworth, London. Sellman D. (2010) Values and adult general nursing. In: Emerging Values in Health Care: The Challenge of Professionals (eds S. Pattison, B. Hannigan & H. Thomas), pp. 129–140. Jessica Kingsley Publisher, London. Taylor C. (1991) The Ethics of Authenticity. Harvard, Cambridge, MA. Williams B. (1972) Morality: An Introduction to Ethics. Cambridge University Press, Cambridge. Williams B. (1981a) Moral Luck. In: Moral Luck: Philosophical papers 1973–1980. pp. 20–39. Cambridge University Press, Cambridge. Williams B. (1981b) Persons, character, and morality. In: Moral Luck: Philosophical Paper 1973–1980. pp. 1–19. Cambridge University Press, Cambridge. Zoltan I. (2010) Semmelweis, Ignaz Philipp Encyclopaedia Britannica (Vol. Encyclopaedia Britannica Ultimare Reference Suite). Encyclopaedia Britannica, Chicago, IL. © 2011 Blackwell Publishing Ltd Nursing Philosophy (2011), 12, pp. 107–118