A reasonable or rationalistic account of conscience takes ‘extended consciousness’ encompassing the gathering of knowledge (Damasio 1999: 232), rational moral principles and reason as the source of one’s moral convictions. Conscientious judgments, by this view, are really critically reflective moral judgments concerning right and wrong (Garnett 1965; Broad 1940). Rational insight can be either religious or non-religious in nature, depending on what a person’s world views are. Either way, a rational conscience typically manifests itself as ‘a little voice inside one’s head saying what one should and should not do’ — also called ‘the “voice” of conscience’ (Benjamin 2004: 513). Or, to put this in moral terms, it tells us what our moral obligations and duties are. Statements of conscientious objection then are, by this view, merely statements of moral duty which individuals recognise and commit themselves to fulfil. Whether the duties or obligations identified impose overriding or absolute demands, or only prima-facie demands on the individual is, however, another matter entirely, and one that is considered shortly.

There are two possible versions of a ‘moral feelings’ account of conscience — emotivist and intuitionist. Both consist of a tendency to spontaneously experience either emotions or intuitions ‘of a unique sort of approval of the doing of what is believed to be right and a similarly unique sort of disapproval of the doing of what is believed to be wrong’ (Garnett 1965: 81).

It is generally recognised that these feelings are quite different from the sorts of feelings we might have when, for example, looking at a beautiful painting (aesthetic approval) or an awful painting (aesthetic disapproval), or eating a favourite food (the feelings of mere liking) or smelling an awful smell (feelings of mere disliking), or witnessing an act of remarkable human achievement (feelings of admiration) or an act of extraordinary human failure (feelings of disdain). By contrast, in the case of wicked acts or the violation of duty, conscience may manifest itself in strong and distinguishable feelings of moral loathing, shame, remorse or even guilt (see Greenspan 1995), or, as Beauchamp and Childress (1989) suggest, the unpleasant feelings of ‘a loss of integrity, wholeness, peace, and harmony’ (p 387). To borrow from Fletcher (1966), conscience can manifest itself as ‘a sharp stone in the breast under the sternum, which turns and hurts when we have done wrong’ (p 54). In the case of virtuous acts, conscience may manifest itself as strong feelings of reassurance or moral goodness (Fletcher 1966: 54; Kant 1930: 130), or, as Beauchamp and Childress (1989) suggest, as feelings of integrity, wholeness, peace and harmony (p 387). Either way, moral feelings instruct individuals on what they ought and/or ought not to do. As with the rationalistic account, statements of conscience emerge as statements of obligation and duty.

The concept of conscience as a combination of reason and feelings basically involves an integrated response to ‘moral catalysts’ in the world. It does not rely on ‘blind emotive obedience’, as Kordig (1976) calls it, nor on an exclusive and blind devotion to reason. Rather, it relies on the mutually guiding and instructive forces of both moral sensibilities and moral reasoning. This account of conscience is, arguably, the most plausible of the three given, and is thus the one that underpins this discussion.

Now that we have briefly examined the essential nature of conscience, the next question is: How does conscience function as a moral authority?

It is generally recognised that conscience functions as a personal (internal) sanction and as a personal moral authority (Beauchamp & Childress 2001; Childress 1979). Claims of conscience typically identify individual people with their self-chosen or autonomously chosen standards and principles of conduct (Nowell-Smith 1954: 268). Further, they commit individual people to act in accordance with those principles. In other words, claims of conscience commit the individual person to act morally (Timms 1983: 41). Thus, when conscience is said to be ‘personal’ or ‘one’s own’, all that is being claimed is that a particular set of autonomously chosen moral standards has authority over a particular person — not, as is sometimes mistakenly thought, that the person has a unique and different set of moral standards from everybody else, and thus is a kind of ‘moral freak’.

Conscience can be appealed to both as a kind of ‘reviewer’ or ‘judge’ of past acts, and as an ‘authority on’ or as a ‘guide to’ future acts. Whether conscience is appealed to as judge or guide, however, it is important to understand that conscience is not morality itself, nor is it the ultimate standard (or even a standard) of morality. Rather, as Gonsalves explains (1985: 55), it is:

Or, as Childress explains (1979: 319), it is merely ‘the mode of consciousness resulting from the application of standards’.

Gonsalves’ and Childress’ views make it plain that statements of conscience are not statements of a unique moral faculty or of unique moral standards. Rather, they are statements of a particular application of adopted moral standards. Conscientious objection, by this view, essentially translates into a case of moral disagreement in regard to which moral statements apply and what one’s moral duty is in a particular situation. If this is so, the case for respecting a conscientious objector’s claims becomes compelling — particularly in instances where there are no clear-cut moral grounds for settling a specific disagreement (as sometimes occurs in the cases of abortion, organ transplantation, assisting with the involuntary administration of electroconvulsive therapy [ECT] or psychotropic medication, administering blood to Jehovah’s Witness patients, and similar cases) (see also Wicclair 2000).

It should be noted here that, once it is accepted that claims of conscience translate into claims of duty, it is conceptually incorrect to speak of conscientious objection as a right (as some nursing position statements on the subject do). To assert this would be to assert that an individual has a ‘right to have a duty’, which is conceptually incorrect. It is more correct to speak of others being bound to respect another’s claim of conscience, just as they are bound to respect another’s claim of moral duty.

The problem remains, however, that consciences are fallible and can make mistakes (Seeskin 1978). As Nowell-Smith (1954: 247) points out, some of the worst crimes in human history have been committed by people acting on the firm convictions of conscience. Hitler, for example, believed he was fulfilling a supreme moral duty by purging the German race of its ‘Jewish disease’ (Kordig 1976). Others also point out that, in some instances, what appears to be a claim of conscience may be nothing more than a claim of prudence or self-interest or convenience. This invariably raises the question: Should I always obey my conscience? Further to this, claims of conscience can be insincere or counterfeit, raising the additional questions of: How can I distinguish between genuine and bogus claims of conscientious objection? Should I always respect another’s conscientious claims? It is to answering these questions that this discussion now turns.

Nurses as employees are compelled by the principle of employment law to obey the lawful and reasonable directives of an employer or superior. The problem is, however, that nurses might not always agree morally with the lawful directives they have been given, and thus may sometimes find themselves in the uncomfortable position of having to perform acts which violate their reasoned moral judgments (Johnstone 1998, 1994).

There are many examples of nurses having been caught in both personal and professional dilemmas on account of legal demands to obey the lawful though morally controversial directives of doctors and nurse superiors. Examples have typically involved situations in which nurses have been directed, against their will, to assist with morally controversial procedures such as abortion, euthanasia, ECT and organ transplantation. The difficulties nurses have encountered in such situations have been compounded by the fact that they have had little, if any, avenue for officially expressing their conscientious refusal without fear of losing their jobs or facing other threats.

Situations involving nurses’ conscientious refusal to follow lawful but morally questionable directives invariably pose the age-old question of whether an individual can, all things considered, be decently expected to follow morally controversial or morally bad, although legally valid, laws — or, in this case, lawful directives.

As can be readily demonstrated, the problem of legal–moral conflict is not new to philosophy. Questions of, for example, what is the proper relationship of morality to law, what is to count as a good legal system, or whether individuals ought to be compelled to obey immoral laws, have long been matters of philosophical controversy. Hart, an Oxford scholar and professor of jurisprudence, for example, argued half a century ago that existing law must not supplant morality ‘as a final test of conduct and so escape criticism’ (Hart 1958). He also argued that the demands of law must be submitted to the scrutiny and guidance of sound morality before they can be justly enforced (Hart 1961). Not surprisingly, these kinds of views have sparked intense debates in both philosophy and law. It is beyond the scope of this text to discuss Hart’s views and address the interesting questions concerning the philosophy of law that they raise. Nevertheless, it is assumed for argument’s sake here that any law which fails the test of sound moral scrutiny should be either adjusted or rejected; it is also assumed that to punish autonomous moral agents for refusing to obey lawful but morally questionable directives is morally unjust.

A number of other important considerations are worthy of attention here. First, there is the persuasive view that forcing nurses to act against their reasoned or conscientious judgments is to not only ignore or diminish their moral autonomy, but also to violate the principles of morality itself — not least those of autonomy and reflectivity (Muyskens 1982a: 61). Perhaps even more troubling is the possibility that violating nurses’ consciences would also unjustly violate their integrity as moral agents (see also Wicclair 2000; Childress 1979).

Second, it is generally recognised that if people are forced constantly to violate their conscience then their conscience will gradually weaken and lose its authority (Kant 1930). This in turn makes it easier for individuals to avoid fulfilling their perceived moral duties and/or acting in accordance with autonomously chosen moral standards. As a result, there is likely to be a general breakdown in compliance with moral rules and principles, and a general erosion of individual moral responsibility and accountability. It takes little to imagine what would happen to the moral fabric of the community at large if all its members were forced, say, by order of the state, constantly to violate their reasoned moral judgments or consciences. No less consideration is due to what may ultimately happen to the moral fabric of the nursing profession if its individual members are constantly forced to abandon their reasoned moral judgments and consciences in favour of preserving the prescriptions and proscriptions of law and convention.

Related to this is a third consideration — that moral duty ‘is mainly concerned with the avoidance of intolerable results’ (Urmson 1958: 72). If fulfilling one’s supposed duty does not avoid or prevent intolerable results, it seems reasonable to question whether in fact it was one’s duty in the first place. As with the case of supererogatory acts (that is, acts above the call of duty, such as those performed by saints and heroes), care must be taken to distinguish those deeds which can be reasonably expected of ‘ordinary’ persons (or ‘ordinary’ nurses) from those which it would merely be nice of ‘ordinary’ persons (nurses) to perform, but which could never be reasonably expected of them (Urmson 1958: 68). On this point, Urmson (1958: 71) argues: ‘… a line must be drawn between what we can expect and demand of others and what we can merely hope for and receive with gratitude when we get it’.

Fourth, those who coerce others to act against their conscience erroneously presume that coercion vitiates moral responsibility. This, however, is not so. Just as more sophisticated claims of duty cannot be escaped or deceived, neither can claims of conscience. It is a mistake to hold that, if a person is forced to perform an act to which they are conscientiously opposed, they are less morally culpable for that act, and that they will feel less morally guilty for having performed it. What users of force fail to understand is that an instance of moral violation still stands, regardless of whether it has been caused by an act of coercion or an act of free will.

Fifth, nurses are not automata or robots, but thinking, reasoning, feeling, responsible human beings. Legal law recognises this by the very fact that it can and does hold nurses independently accountable for their actions (Johnstone 1994). Given this, it is a mistake to hold that nurses have an unqualified duty to obey the directives of a superior.

Lastly, it is ultimately more desirable than not to have a health care system comprised of conscientious nurses. Nurses comprise 70% of the health care workforce. The prospect of 70% of health care providers being morally unconscientious is a bleak one. Since most of us cannot be saints, but can be conscientious, we need to preserve and cultivate conscientiousness (Nowell-Smith 1954: 259; Garnett 1965: 91). Only by doing this can we be assured of achieving and maintaining some sort of moral order in health care domains. As Seeskin (1978) argues, ‘… we have no guarantee that our deliberations will be perfect or our moral sensibilities adequate’ (p 299); it is for this reason, among others, that conscience and moral conscientiousness should be given a place among the moral virtues. We might be condemned as fanatics if we hold conscience to be infallible, but if we do not at least acknowledge its ultimateness in the scheme of moral reasoning, we might be guilty of moral negligence and moral irresponsibility (Seeskin 1978; Kordig 1976).

The consequences of such views have interesting implications for policy makers attempting to respond to the conscientious objection problem. These views seem to suggest that, even if nurses’ consciences are mistaken, on balance there are moral benefits to be gained by permitting their conscientious objections — not least, the benefits of fostering moral sensitivity and moral responsibility in the workplace. These views also suggest that, if nurses are not permitted conscientiously to object, then health care contexts, not to mention the community at large, will be morally worse off by virtue of being more at risk of suffering moral harms on account of receiving care that is not informed or guided by conscientious ethical beliefs and standards.

It might be objected here that permitting conscientious objection is not conducive to the efficient running of hospitals and other health services. There is, however, little support for this kind of claim. In the case of military service, for example, it has been found that objectors are rarely amenable to threats and usually make unsatisfactory soldiers if coerced, and that in fact there are generally not enough objectors to frustrate the community’s purpose (Benn & Peters 1959: 193). There is room to suggest that something similar is probably true of objectors in nursing. As many examples in the nursing literature have shown, nurses have preferred to resign and risk dismissal than perform acts which they find morally offensive. Further to this, those nurses who have been coerced have not wholly complied with given orders. (For example, I know of nurses who have resuscitated patients in cases of controversial DNR directives, and not resuscitated patients in the case of controversial CPR orders.) It is also unlikely that there are enough objecting nurses to obstruct the efficient running of the hospital system.

Where lawful directives entail a demand to perform morally controversial procedures, there is considerable scope for suggesting that a nurse has a firm moral basis upon which to conscientiously object. Issues such as abortion, organ transplants, electroconvulsive therapy, the enforced and involuntary treatment of psychiatric patients and euthanasia are all morally controversial, and, as yet, no morally clear-cut grounds exist for resolving them. Until these issues can be resolved satisfactorily, it would be morally indefensible and unjust to insist that nurses must, when directed, assist with abortion, organ transplantation, electroconvulsive therapy and euthanasia work — or any other work which is morally controversial. In other words, where a so-called ‘standard’ or ‘reasonable’ medical or nursing procedure is morally questionable, nurses cannot decently be forced to perform or participate in that procedure. Further, it is worth noting once again that what we have in a situation of conscientious objection is moral disagreement — something which, as discussed in Chapter 6, may not be resolvable. The most amenable solution seems to be to permit conscientious objection.

The question of if, and when, and under what circumstances nurses may refuse to care for certain patients has become a particularly important and challenging one over the past two decades, largely because of the worldwide HIV/AIDS epidemic. Despite significant advancement in the care and treatment of people living with HIV/AIDS (estimated in 2006 to be around 39.5 million globally), the disease remains one of the most serious health problems in the world (United Nations [UN] & WHO 2006). Furthermore, although attitudes towards HIV/AIDS, and people living with HIV/AIDS are more positive and tolerant than they were two decades ago, discriminatory attitudes and practices by health workers towards patients with HIV/AIDS (especially those who are gay) are still a problem in some countries and contexts (Lohrmann et al 2000; Schuster et al 2005; Reis et al 2005; Röndahl et al 2003; Valois et al 2001; Walusimbi & Okonsky 2004). Research also shows that despite more progressive attitudes in society towards ‘diversity and difference’, gay, lesbian, bisexual and transgendered people are still regarded as ‘not yet equal’ (McNair & Thomacos 2005) and continue to experience significant prejudicial and discriminatory attitudes and behaviours on the part of nurses and doctors in health care contexts (Jones et al 2002; Mikhailovich et al 2001; Reis et al 2005; Schuster et al 2005). For example, when their sexual orientation is known by health care professionals, gay, lesbian and transgendered people in particular have reported such responses as ‘embarrassment by care providers, fear, ostracism, refusal to treat, demeaning jokes, avoidance of physical contact, rough physical handling, rejection of partners and friends, invasion of privacy, breaches of confidentiality, and feeling at risk of harm’ (Mikhailovich et al 2001: 182; see also McNair & Thomacos 2005; Reis et al 2005; Röndahl et al 2003; Schuster et al 2005).

Questions have been asked, both in Australia and overseas, about whether nurses can rightly refuse to care for HIV/AIDS patients (including infected newborns) (for an exhaustive discussion of this issue, see Crock 2001). During the early years of the HIV/AIDS epidemic, overseas research studies and opinion polls revealed that some nurses would rather abandon their practices and nursing careers than place themselves at risk by caring for HIV/AIDS patients (Huerta & Oddi 1992; Jemmott et al 1992; Melby et al 1992; Beard et al 1988; Lester & Beard 1988). In one US opinion poll, published in Nursing 88, it was revealed that 73% of nurses surveyed were concerned about their own safety, and 47% believed they had a right to refuse to care for HIV/AIDS patients; interestingly, an overwhelming majority (93%) stated that they had never refused to care for an HIV/AIDS patient, despite their fears (Brennan et al 1988). The poll also revealed that a staggering 80% of nurses surveyed stated that their own families were concerned about their (the nurses’) safety when caring for HIV/AIDS patients.

Other studies at the time also revealed that nurses caring for HIV/AIDS patients had been shunned by family, friends and neighbours, and even by other health care workers, who apparently feared association ‘with one who provides direct care’ (Huerta & Oddi 1992: 221; Nursing Times 1986a: 10). More recent research, however, has found that, even when concerned about contagion, most nurses and students of nursing have a positive attitude towards caring for patients with HIV/AIDS, are more empathic, less fearful and ‘are no longer worried about their relatives and friends after they come into contact with a person infected with AIDS’ (Lohrmann et al 2000: 700; Röndahl et al 2003; Walusimbi & Okonsky 2004). Even so, research is also showing that between 12% and 36% of health care workers would ‘feel uncomfortable’ working with a gay and/or HIV/AIDS positive patient and would refrain from providing care if given the opportunity to do so (Jones et al 2002; Reis et al 2005; Röndahl et al 2003; Schuster et al 2005).

Significantly, two of the most commonly cited reasons for refusing to care for HIV/AIDS patients are fear of contagion, and disapproval of patients’ lifestyles (especially those involving either homosexuality or intravenous drug use) (Crock 2001; Huerta & Oddi 1992: 223). A poignant example of how fear of contagion and disapproval of a patient’s lifestyle can affect the ability of nurses to care and, in turn, the patient’s overall wellbeing, is given below.

Although this is an American case, the prejudicial attitudes it demonstrates are not restricted to the national borders of the US. For example, when the AIDS epidemic started to evolve in Australia, a respected major hospital in Melbourne caused a public outcry when it imposed a ban on treating all people who had AIDS or who carried the HIV virus (Miller 1989b). The decision to impose the ban was made by the hospital’s medical advisory board, and was allegedly supported by both doctors and nurses working at the hospital, as well as by the Victorian branch of the Australian Medical Association (AMA) (Athersmith 1989a; Price 1989). As a point of interest, it was later revealed that nurses had not in fact been consulted about the decision to effect the ban (Curtis 1989). The hospital’s ban was the first case of its kind in Australia (Allender & Robinson 1989). Subsequently the Victorian Government took steps to outlaw hospital policies which effectively discriminated unjustly against HIV/AIDS patients.

It is doubtful whether HIV/AIDS (and/or other cases of infectious diseases — e.g. hepatitis B and C, drug-resistant tuberculosis, and SARS) presents a situation in which conscientious objection claims would be valid. Certainly, claims in these sorts of cases do not seem to satisfy all the five criteria of genuine conscientious objection listed earlier. For example, it is not clear that claims in these cases are based on a distinctive moral motivation aimed at maintaining sound moral standards or achieving a desired moral end. Nor is it clear that claims in these cases are based on informed and critically reflective choice (many may, in fact, be based on misinformed, fearful and arbitrary self-interested choice). It is also not clear that the claims of conscientious objection in these cases are necessary as a ‘last resort’ in ‘the defence of one’s moral integrity’. For one thing, it has yet to be shown how, if at all, caring for someone who is HIV positive threatens the moral integrity or standards of a caregiver (a point to be examined further shortly). Finally, it is far from clear that these cases involve a situation that is characteristically ‘morally uncertain’. (It has yet to be shown convincingly that it is unethical to care for someone who is seriously ill with an infectious disease.) While the objector may recognise that others’ conscientious claims are equally deserving in these cases, and thereby satisfy at least one of the five criteria listed, this is not enough to uphold a genuine claim of conscientious objection.

It should be noted, however, that, even though a claim of genuine conscientious objection might fail in cases of caring for people with potentially life-threatening infectious diseases, this does not necessarily mean that a given refusal to care by a nurse should not be permitted. One set of circumstances under which this might be so is where nurses are so distracted and so disturbed by their fear of contagion that they can no longer be relied upon to give safe, appropriate and therapeutically effective care. In such instances, it would obviously be better for the patient who has an infectious disease not to be cared for by such nurses. One reason for this is that the patient’s sense of wellbeing and self-worth — not to mention, his/her health outcomes — are not going to be maximised by nurses who are so overwhelmed by their own fear that they would neglect the patient (as happened in the case cited above). It needs to be noted, however, that nurses whose practice is ‘impaired’ by a personal fear of contagion have an obligation to seek remedial education and counselling to help address the problem of their ‘impaired practice’ (Johnstone 1998). In some jurisdictions, it might even result in a nurse’s deregistration. In 1990, for example, a nurse was deregistered by the United Kingdom Central Council (UKCC) for refusing to care for people who were ‘HIV, AIDS and hepatitis B positive’ (Young 1994: 103).

Another problem which needs to be addressed is that of homophobia (the ‘irrational fear of homosexuality’), which, as Huerta and Oddi (1992: 223) argue, can further compound the fear of caring for HIV/AIDS patients. Significantly, attitudinal studies conducted over the years have consistently found that some nurses feel uncomfortable with caring for male homosexuals and exhibit avoidance behaviour towards HIV/AIDS patients who belong to this group (Crock 2001; Lohrmann et al 2000; Huerta & Oddi 1992; Reis et al 2005). Nurses opposed to homosexuality also tend to believe that HIV/AIDS patients are ‘responsible’ for their disease, and, accordingly, these nurses ‘blame the victim’ (Crock 2001; Reis et al 2005; Viele et al 1984). Equally significant are research findings which show that nurses who are homophobic manifest ‘the greatest fear of HIV/AIDS and the least empathy for AIDS patients’ (Huerta & Oddi 1992: 224; Lohrmann et al 2000; Reis et al 2005).

While these studies are not conclusive, they nevertheless point to a need for nurses to examine their attitudes towards homosexuality and to explore ways in which prejudicial attitudes towards and fear of HIV/AIDS patients can be overcome (Crock 2001). One study has found, for example, that nurses can be helped to gain a more positive attitude towards and less fear of homosexuality by participating in sexuality workshops where opportunities can be provided to explore and share feelings about the issue, and to engage in other learning activities (Crock 2001; Valois et al 2001; Young 1988).

One group of people who may not be amenable to this kind of education, however, are those who are fundamentally opposed to homosexuality on religious grounds. I have, for instance, heard some nurses who hold conservative religious beliefs express the view that they ‘could not possibly care for a homosexual patient with HIV/AIDS, since to do so would be tantamount to condoning homosexuality, and thereby supporting a sinful practice’. (Similar arguments are used in the case of abortion; some nurses have expressed the view, for example, that caring for women who have had abortions is tantamount to condoning abortion.) The reasoning used here is, however, flawed. It is a fallacy to hold that caring for a particular class of patients is tantamount to condoning the lifestyles or life circumstances of those patients. If we were to accept this line of reasoning, we would be committed to accepting that, for example, caring for poor people is tantamount to condoning poverty, or that caring for unemployed people is tantamount to condoning unemployment, or that caring for homeless people is tantamount to condoning homelessness. We would, I think, reject the view that caring for these latter groups of people is tantamount to condoning their respective lifestyles, or to providing grounds upon which a morally defensible refusal to care for them could be based. Since the acts of caring for HIV/AIDS patients are demonstrably remote from the sexual acts to which some nurses are opposed on religious grounds, and since caring for patients who are homosexual does not entail performing acts proscribed by religious doctrine, it is not clear that a refusal to care for patients who are homosexual can be sustained (see also the collection of essays in Watt [2005] on the topic of conscience and the mediating Catholic principles of cooperation and complicity).

It might be objected here, however, that, unlike homosexuality, poverty, unemployment and homelessness are not ‘sins’ and therefore nurses opposed to sinful practices can care for people in these latter groups without compromising their religious beliefs and moral integrity. In fact, caring for these people might even be construed as ‘virtuous’. This, however, is not a satisfactory reply, since it fails to show why caring for these groups of people is not tantamount to condoning their lifestyles, which, significantly, can be shown to be injurious to these groups of people’s wellbeing and moral interests. Let us explore this further.

Why, for instance, is caring for a homosexual patient regarded as tantamount to condoning homosexuality, yet caring for an unemployed person is not regarded as tantamount to condoning unemployment? If we take out the descriptive statements referring to these groups whose respective lifestyles are in question, what we end up with is something like this: caring for members of group X is tantamount to condoning their lifestyles, but caring for members of group Y is not tantamount to condoning their lifestyles. No reasons are given why this is the case, however, demonstrating that the thinking being used here is at best arbitrary and at worst fallacious. Even if it is conceded that what makes a morally significant difference in this case is the ‘sinful’ nature of homosexuality, this will not help, since this seems to say that what makes caring for a particular group of people tantamount to condoning their lifestyles is the fact that what they do is ‘sinful’. If nurses holding conservative religious beliefs were to accept this, however, they would be committed logically to accepting that caring for a whole range of people would be tantamount to condoning their ‘sinful’ lifestyles, and thus that there exists a whole range of people for whom they should refuse to care. Nurses holding conservative religious beliefs would, for instance, be obliged to refuse to care for people who work on Sundays, bear false witness, steal, murder, covet their neighbours’ goods, fornicate, commit adultery, blaspheme, do not fear God, worship other gods, tell lies, take contraception, have attempted suicide, and have performed a whole range of other acts deemed sins in the Bible or other religious texts. Clearly, if nurses were to accept the view that caring for people who commit sins is tantamount to condoning the sins in question, they would probably have to give up nursing altogether, since many (if not most) people have committed at least some of the ‘sinful’ acts given above.

While the arguments presented here have had as their focus gay men, they could, of course, be applied equally to the cases of other groups of people whose lifestyles some nurses regard as being problematic or sinful — for example, intravenous drug users and prostitutes.

A final type of situation to be considered here involves the common problem of nurses being expected to work in unsafe working conditions, most notably those caused by severe staff shortages. Typically, nurses might be ordered to work in an area with which they are unfamiliar and/or in which they are not educated to work, such as in an intensive care unit. They might also be expected to work at a staffing level which places patient safety and quality of care at risk. These two situations are inextricably linked. For example, if there was not a shortage of properly educated intensive care nurses, nurse administrators would not have to order an inexperienced nurse to go and ‘help out’ in the hospital’s intensive care unit. A nurse’s obligation to object to working under certain conditions may not only be morally imperative, however, but a legal requirement under ‘duty of care’ and the demand to exercise ‘due care’ provisions.