Complicity Research Paper

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Complicity occurs widely across different cultures and nations as a moral problem in healthcare. The problem of moral complicity arises as much for individual professionals as for organizations. From the perspective of individuals, there can be many different forms of complicity related to conflicts of interest or commitment and to conflicts of conscience. From the perspective of organizations, different forms of complicity arise from partnership relations between organizations or from government policies that impose services with which organizations have value conflicts. Over centuries of discourse on this topic, a moral principle was developed specifically to address problems of complicity – the principle of cooperation. By considering the different components of this principle, a variety of solutions emerge to resolve situations of moral complicity, whether for individuals or for organizations globally in healthcare.


The problem of complicity in global bioethics ranges extensively across cultures and within varying forms of healthcare, extending from professional practice, to organizational behavior, to research endeavors. The discussion of complicity here deals with the moral dilemmas raised when personal, professional, organizational, or cultural values are compromised. Complicity typically refers to being involved in wrongdoing while morally intending a different good action. However, it does not mean that to avoid moral complicity in bioethics, there can be no involvement with perceived wrongdoing. Herein lies the core issue: to what extent can involvement in wrongdoing be justified by seeking good? Some examples can help to shape the discussion.

When clinicians have conflicts of interest or conflicts of commitment, does that necessarily constitute moral complicity? When health professionals find themselves involved in practices that include some wrongdoing from their perspective, does that necessarily constitute moral complicity? When healthcare organizations, whether involved in the delivery of care or research purposes, are involved with others engaging in wrongdoing, does that necessarily constitute moral complicity?


Complicity in healthcare arises in a variety of ways that impact individual professionals as well as healthcare organizations. One of the most common forms of moral complicity relates to conflict of interest or commitment and conflicts of conscience. This form of complicity can occur for individuals, for example, when a physician accepts a large gift from a pharmaceutical company to prescribe its drugs or when a pharmacist appeals to conscientious objection to refuse to fill a legal prescription for a patient (such as the morning-after pill to prevent pregnancy). This form of complicity also can occur, for example, if a healthcare organization partners with another organization to remain financially viable – if the partnering organization undertakes practices that are construed as wrongdoing, the partnership has to ascertain whether it is involved in moral complicity. Or if a country’s government insists that healthcare must provide specific services that are contrary to the beliefs of religious organizations, those organizations need to clarify whether their acquiescence with the government policy constitutes moral complicity.

The analysis is divided into related components to shed cumulative light on the meaning of moral complicity in global bioethics. Over centuries of discourse about moral complicity, ethics discourse generated the principle of cooperation. The principle is discussed to see how it can clarify situations of moral complicity for individual professionals as well as for organizations in healthcare. To establish the extent of the problem of moral complicity, the discussion begins with conflicts of interest or commitment and conflicts of conscience.

Conflicts Of Interest Or Commitment

In global, public, and corporate governance when individuals find themselves in situations that generate a potential conflict of interest or conflict of commitment, they have a duty to acknowledge the conflict and manage it appropriately (Peters and Handschin 2012). Otherwise, there could be moral complicity in the sense that the conflict raises a dilemma that is contrary to their personal, professional, or organizational values. There are several aspects here that need to be unpacked. To begin, there is a difference between conflicts of interest and conflicts of commitment. A conflict of commitment in healthcare arises when there is a commitment of time, expertise, or services outside of routine work or a job description that prevents ordinary obligations from being fulfilled. For example, if a clinician undertakes extensive consulting obligations that compromise the clinician’s routine duties, there can be a conflict of commitment. In contrast, a conflict of interest occurs when there are competing elements between primary and secondary duties, such as when a researcher seeks to balance research funding and research reporting. For example, if a researcher selectively reports research data to strengthen the case for approving a drug when the researcher has financial interests in the pharmaceutical company producing the drug, there can be a conflict of interest. There are many complexities that need to be addressed to avoid conflicts of interest in the dynamic environment that pursues medical innovation (IOM 2014).

However, an apparent or potential conflict does not mean there is a real conflict. Even if a real conflict exists, it does not mean that the conflict is necessarily to be avoided. Rather, conflicts are morally neutral, and the core duty is to deal with them objectively in a balanced manner. To do so, several points need to be noted. First, for decisions to be made in a moral way in healthcare, deliberation needs to occur in an honest and objective manner. Hence, there is a duty to recognize whether there is a conflict in professional decisions, deliberations, and activities. Second, if there is a conflict (perceived, potential, or real), there needs to be appropriate disclosure to a supervisor to review the situation in an objective manner. Third, the result of the disclosure and review can be either to avoid or eliminate the conflict or to manage the conflict in a reasonable manner. If the latter occurs, and it does so frequently in the complex environment of healthcare, a neutral third party needs to monitor the disclosure in an objective manner so that the individual’s duties can be pursued appropriately, albeit in a complicated scenario.

An example can illustrate these three steps. A clinician may have financial interests that are related to the design, conduct, or reporting of the individual’s research. First, the individual needs to recognize the potential or real conflict that the financial interests could have on the research or other responsibilities such as clinical practice (Murray and Johnston 2010). Second, the clinician needs to disclose the potential or real conflict to a supervisor or review body – that typically occurs by completing a conflict of interest form. Third, the conflict has to be avoided, eliminated, or managed under third-party supervision to protect the objectivity of research as well as the rights and interests of others who may be involved, such as students or research subjects. The result is that conflicts of interest or commitment can be managed effectively to uphold research objectivity and to respect the autonomy and dignity of those involved (Lemmens and Waring 2006). The integrity of this process enables the clinician to avoid moral complicity. Not surprisingly, there is a plethora of situations in global bioethics that not only illustrate the extensive range of conflicts of interest and commitment but also delineate effective management strategies in different nations and cultures (Rodwin 2011).

Conflicts Of Conscience

Another widespread form of complicity occurs in professional practice in healthcare where cultures and values can generate a variety of conflicts between clinicians and patients. This type of complicity deals with conflicts of conscience (Lynch 2010). Here, clinicians seek to avoid complicity in what they perceive as immoral actions. These issues can range from the general to the particular.

An example of a general conflict of conscience is the long-standing debate over patient autonomy and physician paternalism. In many nations, this tension has been resolved in favor of protecting patient dignity and autonomy or in favor of emphasizing physician paternalism. The issue of complicity with immoral actions can arise at this very general level. For example, in a culture that fosters autonomous decision-making by patients, if a nurse on duty does nothing when seeing an attending physician enacting paternalism to withhold medical information (such as advanced cancer diagnosis to avoid scaring the patient), the nurse may be complicit in the action of the physician. The physician’s own cultural beliefs may explain the paternalistic approach as being well-intentioned, but nonetheless it may be mistaken in a culture where patients seek to deliberate and make decisions about their own healthcare. The nurse may personally support patient autonomy over paternalism, but by doing nothing in such a scenario becomes morally complicit with the physician’s paternalistic action.

However, the moral complicity that arises from conflicts of conscience tends to be related with much more practical issues (Lynch 2010). Clinicians often encounter situations in which professionals have a conscientious objection about specific treatments for patients. There are many examples that range from vaccinations to euthanasia. An obvious case would arise when a patient requests an elective abortion or reproductive services from a physician who has a moral objection (based on religious belief or culture) to providing the requested services. These moral dilemmas can arise not only in medical practice but also in training programs for future clinicians.

The problem is nuanced in this sense. If a clinician yields to the demands of a patient for services that the clinician deems to be morally wrong, then moral complicity with the perceived wrongdoing occurs. Yet, if a clinician refuses services for a patient (albeit based on a decision of conscience), the patient encounters a restriction of legal access to care. In healthcare globally, typically there are professional policies that vary by profession and organizational policies that vary by hospital that try to honor the wishes of patients while protecting the conscientious objection of a professional. If a pharmacist in a hospital or a large pharmacy group has a conscientious objection to filling a particular type of prescription, such as the so-called morning-after pill to avoid pregnancy, then institutional policy can be planned to arrange for another pharmacist to be available to meet the patient’s needs. The concept of the “conscience clause” refers to such situations to protect the conscientious objection of the clinician while providing the patient with the relevant services required. But if the pharmacist who objects in conscience provides the prescription to the patient when a replacement pharmacist without similar conscience constraints is available, the issue of moral complicity arises.

These sorts of institutional policies often do not resolve the multiple issues that professionals encounter in patient care that can be construed as involving moral complicity with wrongdoing. There is a principle that has been developed and applied over centuries to resolve situations where there appears to be moral complicity to enable professionals and institution alike to resolve dilemmas.

Principle Of Cooperation

Moral complicity has generated a great deal of theoretical discussion on accountability, conspiracy, and liability (Kutz 2007) as well as on compromise (Lepora and Goodwin 2013) regarding institutions and individuals. Over centuries of discourse, a moral principle emerged to deal with complicity in multiple forms – the principle of cooperation. The core issue deals with the relation between conscience, complicity, and cooperation (Watt 2006).

This principle enables individuals and organizations to resolve situations in which there are good and bad effects that intersect (Magill 2012, 2013, 2016) – some of the concepts from these publications have been incorporated and developed for this contribution. To explain this principle, it can be helpful to recall a more widely known principle in healthcare – the principle of double effect. When a medical intervention involves a good and bad effect, professionals and patients can make prudent decisions to intend the good despite foreseeing the unavoidable reality of the bad effect.

An example is when a pregnant woman has a cancerous womb that needs to be removed, the death of a previable fetus is inevitable. From religious and secular perspectives, such an intervention is generally permitted. The mother’s and clinician’s intention is not to kill the fetus – that occurs as an unavoidable side effect. Even though the death of the fetus is foreseen, it is not intended. There is a crucial moral difference between what is foreseen and what is intended – because something is foreseen (as an unavoidable side effect) does not mean that it is intended (Magill 2011). The purpose of the intervention is to save the mother’s life by removing the offending organ, the cancerous womb – that is the minimal intervention that is required to save the mother. Hence, there is proportionality between the good effect (saving the mother) and the bad effect (the unavoidable and foreseen but unintended death of the fetus).

The combination of intention and proportion here is crucial for the principle to be justifiably applied. That is, when two effects intersect, the principle of double effect justifies pursuing the good effect as the minimum intervention necessary to save the mother. The bad effect of the fetus dying is construed as an unavoidable but unintended side effect. In other words, the intersection of a good and bad effect does not prevent the good effect from being pursued.

A similar argument occurs with the principle of cooperation. There are two actions that intersect, one is good and the other is construed as being wrong. The principle of cooperation permits seeking the good despite the unavoidable intersection with what is seen to be wrong, provided there is due proportion between them, and the bad action is not intended (even if it is unavoidable). Two examples can help to clarify how the principle of cooperation functions to clarify whether there is moral complicity with the wrongdoing that occurs.

One example is that of paying taxes in a society that engages in an enterprise that is construed as being morally wrong. Such a situation can arise in some nations that build and threaten the use of nuclear weapons. Many perspectives in secular and religious global bioethics condemn the use of nuclear weapons as inherently wrong because of the death of very large numbers of innocent civilians. There are many citizens in those nations who oppose nuclear weapons but effectively support building them through paying their taxes to the government. Does this mean that they are morally complicit in the wrongdoing of nuclear weapons?

The principle of cooperation can help to resolve the dilemma. Taxes can be paid legitimately to a government that uses some of those funds for nuclear weapons, despite the citizens being opposed to those weapons. Several points can be drawn. The citizens who oppose nuclear weapons do not intend to build and threaten them – they intend to pay legitimate taxes to their government. There is proportionality in paying their taxes because so much other social good is accomplished. The intention and proportionality here are for the citizens to pay taxes for the social good that results. If their government uses some of the tax revenue for nuclear weapons, the citizens are usually unable to prevent that from occurring. They construe the government action as being wrong, but they are under duress in the sense of having to live in their own country. They are materially connected with the nuclear weapons insofar as some of their tax funding supports the wrongdoing. But there is no culpable link with the wrongdoing – there is no moral complicity. In this situation the principle of cooperation clarifies that they are under duress, they do not intend the wrongdoing, and there is proportionality in paying taxes for the common good of society. Hence, the principle concludes that there is no moral complicity, even if there is a material connection between their taxes and the funds for nuclear weapons.

This example illustrates a basic distinction in the principle of cooperation – if there is only a material connection with the wrongdoing (such as the citizen who pays government taxes), there is no moral complicity with the wrongdoing involved (building nuclear weapons). There is a fundamental distinction between material cooperation where there is only a material connection with the wrongdoing and formal cooperation whereby the wrongdoing is intended. The principle of cooperation helps to determine when there is moral complicity with wrongdoing. That is, when two actions intersect and one is bad, the principle explains when that intersection can be justified. If the wrongdoing is intended, the cooperation is formal and unjustifiable. When the wrongdoing occurs under duress and is not intended, provided there is a reasonable proportionality between the two actions, the cooperation is merely material and can be justified.

An example in healthcare regarding professional practice can be helpful. Consider the situation where a nurse believes that elective abortion is wrong. The nurse works in a facility that provides elective abortions to a small percentage of patients, with the vast majority of the female patients seeking other pregnancy-related services. The usual nurse who supports abortion personally, and provides support for abortion services professionally in the facility, is absent due to sickness. The nurse in question who opposes abortion personally is offered on a voluntary basis an increased salary to provide temporary nursing support for the physician who will perform an abortion on a willing patient.

Here, the patient and physician intend the abortion. Insofar as the nurse considers such circumstances to be wrong but provides clinical services that are indispensable for the abortion to occur, there would appear to be moral complicity in the wrongdoing. Insofar as the nurse provides services that are crucial for the abortion, those services could be construed as being morally complicit. The nurse may not actually perform the abortion, but is so closely involved (without providing support services, the abortion likely would not occur) as to effectively intend it and thereby be complicit with it. This is tantamount to formal cooperation with abortion (despite the nurse’s personal opposition to abortion) and constitutes moral complicity.

In contrast, a secretary at the front desk who admits every patient for pregnancy-related services in the facility is in a different situation. If the secretary believes that elective abortion is wrong but is unable to obtain employment elsewhere to support family, merely knowing of the provision of abortion services to a small number of female patients who visit the facility does not mean intending those services. In this situation, there is a material connection because of the work at admissions, but there is distance from the wrongdoing, no intention to support it, and there is a proportionate need for employment to support family. Their interaction could merely be material cooperation and may not constitute moral complicity.

Another example might be the nurse providing support services for a physician who withdraws life-sustaining measures from a dying patient. If the nurse realizes that the treatments are not yet futile and that the physician acts against the will of the family and the patient, the nurse would be obliged to intervene to prevent the avoidable death of the patient. If the nurse does nothing, there could be formal cooperation, effectively intending the patient’s death that would constitute moral complicity. In contrast, some non-clinical staff may transport the life-sustaining equipment to another location at the instruction of the physician. Insofar as they do not understand the clinical situation, they do not intend the patient’s death. This could be merely material cooperation and would not constitute moral complicity.

There are many cases that could illustrate the distinction between formal and material in order to shed light on the moral complicity of healthcare professionals. Increasingly, the problem of moral complicity extends to organizations when involved in activities that intersect with perceived wrongdoing by others. There are two types of problems that can arise, problems between different organizations and problems between healthcare organizations and the government. Each is worth consideration in turn.

Complicity Between Organizations

Moral complicity can arise between organizations in healthcare when different institutions have to work together, but the actions of one are construed as being wrong from the perspective of the other.

An example is when a religious hospital is under duress to affiliate with a secular hospital to survive in a competitive market, but the secular organization performs surgeries that are deemed immoral by the religious hospital. Commonly, in many countries across the world, healthcare organizations provide reproductive services that religious hospitals consider as wrong (e.g., sterilizations or in vitro fertilization services). However, the religious hospitals can find themselves to be under duress, typically because of market or policy pressure, to partner with secular organizations that provide these services.

The use of the principle of cooperation helps to identify further distinctions that enlighten the meaning of complicity when healthcare organizations partner together. In particular, the concept of “mediate” material cooperation is used to emphasize when material cooperation is justified – there should not be too close or immediate a connection with the perceived wrongdoing. Another distinction is between material cooperation that is either remote or proximate. That is, the closer the organization is to wrongdoing, the greater the justification that is needed (Magill 2013).

An example of remote cooperation might be as follows. A rural religious hospital will close unless it partners with a larger regional secular hospital. However, the secular facility provides services that are construed as being wrong by the religious hospital – these services could be specific forms of reproductive services or certain types of blood-related services. For the principle of material cooperation to be applied, the religious hospital may not intend the perceived wrongdoing. In other words, if the purpose of the partnership is intended by the religious hospital to circumvent its religious teachings in order to provide the forbidden services, that would be tantamount to formal cooperation, and it would constitute moral complicity with wrongdoing. In reality, usually the religious hospital simply needs to partner with a larger secular hospital to survive. The only eligible partner is the regional secular hospital that provides services forbidden by the beliefs of the religious hospital.

The principle of material cooperation would permit the partnership, provided the intention is to survive and not to provide the forbidden services. Typically, the issue of intentionality can be tested by the measures that are put in place to prevent any profit sharing by the religious facility from partnership revenue that accrues from the forbidden services in the secular facility. The purpose of preventing any revenue sharing from the forbidden services is to clarify and highlight the intention of the religious hospital in joining the partnership. Also, there needs to be genuine duress in the sense that the religious hospital truly would have to otherwise close. This means that sufficient data must be provided to demonstrate the financial duress that threatens the religious hospital with closure. Finally, there must be proportionality in the sense that there is sufficient good that results to balance the material cooperation with forbidden services. Typically, this means the religious hospital will be able to continue its mission for the common good by outreach to the poor and vulnerable populations in the region that otherwise might lose effective access to healthcare.

The principle of material cooperation justifies the partnership based on the coalescence of the following issues. The religious facility does not intend the forbidden services, and there is no profit sharing from the forbidden services in the secular hospital. There is genuine duress that means the religious hospital would close without the partnership and that with the partnership its mission continues for the common good by outreach to the poor and vulnerable populations in the region. The perceived wrongdoing occurs only in the secular hospital’s facilities that are many miles away from the religious facility. The physical distance between the religious hospital and the secular facilities means that the type of material cooperation is remote. The more remote the cooperation, the easier it is to justify such a partnership.

However, even if the secular partner is very close to the religious hospital, a partnership can be justified using a slightly different version of the principle of material cooperation. In such a case, the material cooperation would be described as being proximate rather than being remote. An example can clarify what this means. It may be that the stronger hospital in a region is a religious hospital. For the local secular community hospital to survive, it seeks a lease merger with the religious hospital. This means that the secular facility is leased to the religious hospital to manage both the religious and the secular hospitals together in the lease partnership. However, the secular community hospital insists upon continuing several reproductive services to the local community that are deemed to be wrong by the religious hospital. The religious hospital is under duress to accept this arrangement because the lease merger would otherwise collapse, and a significant population would be deprived of effective access to healthcare services.

One solution might be to isolate a floor at the top of the secular community hospital to provide the services that are demanded by the secular hospital and forbidden by the religious hospital. There is a separate entrance and elevator to the isolated floor, with no signage indicating any connection with the religious hospital. Also, no profit sharing accrues to the religious hospital from the provision of the services forbidden by its religious beliefs. Because the forbidden services are provided on the isolated top floor of the secular hospital that is now lease managed by the religious hospital, the material cooperation with the perceived wrongdoing is much closer – this is called proximate material cooperation.

There are several features that need to be highlighted to clarify how the principle functions. The religious hospital does not intend the services that are required by the secular hospital but forbidden by the beliefs of the religious hospital, and there is no profit sharing from these services. The secular hospital genuinely is about to close due to financial duress, and the religious hospital wants to retain the secular hospital’s healthcare services for its population of vulnerable people that it previously served as a community hospital. Because the forbidden services are provided in the same building that is now operated by the religious hospital, the justification is referred to as proximate material cooperation. This means that a greater justification of the principle is needed – the more proximate the cooperation, the greater the justification required. In this case, the more serious justification is the threatened loss of a large community hospital that serves a sizeable poor population that would otherwise lose effective access to healthcare.

In these scenarios of material cooperation (remote or proximate) between religious and secular healthcare organizations, one further clarification needs to be made about moral complicity. Some argue that a religious hospital should not plan any arrangement to be separate from services in a secular facility that are forbidden by the beliefs of the religious hospital. The concern appears to be that if the religious hospital is involved in planning a separation of forbidden services, the religious hospital effectively intends the perceived wrongdoing. That would be tantamount to formal cooperation that is forbidden.

However, such an argument overlooks the core insight of the principle of material cooperation. The core insight is that when there is sufficient duress, the principle permits cooperation provided specific conditions are met. An obvious condition is the continuation of services that are forbidden by the beliefs of the religious hospital. To apply the principle of cooperation in a manner that meets these requirements, the religious facility may need to design an appropriate arrangement – simply to ensure that the required conditions are met. Hence, the religious hospital may need to become involved with planning when and where the forbidden services are provided and by whom. The core purpose of being involved in such arrangements is tiered: to ensure the religious hospital does not intend the perceived wrongdoing, to create sufficient distance from the services (either by remote or proximate cooperation), and to guarantee that no profits are received from those services. All of this requires careful planning and meticulous management. It would be naïve to argue that by doing so the religious hospital intends the wrongdoing.

It is worth recalling the principle of double effect here to highlight the distinction between planning with foresight and intending. In the case of removing a cancerous pregnant womb, the surgeon needs to meticulously plan the intervention. The planning includes foreseeing the unavoidable death of the fetus in the womb – but planning and foreseeing the unavoidable death of the fetus is very different from intending it. The purpose of the principle of double effect is to make the crucial distinction between planning and foresight of the bad effect (the death of the fetus) and intending it. Similarly, when using the principle of cooperation, the planning and foresight of a religious facility to establish distance and avoid profit sharing from forbidden services must be distinguished from intending those services. In other words, to argue that planning is tantamount to intending undermines the core meaning of the principle of double effect and the principle of cooperation.

Complicity With Government

Distinct from complicity between organizations, complicity with a government is not an unusual occurrence that requires the principle of cooperation. It is not uncommon for a religious denomination to establish a formal relationship or concordat with a country’s government to enable the religious group to flourish – but the arrangement typically means intersecting with secular activities deemed to be immoral by the religious group. The principle of cooperation enables religious groups to live in a secular and pluralistic society with cultural diversity without being morally complicit with perceived wrongdoing in those societies (illustrated by the previous discussion regarding paying taxes that contribute to nuclear weapons).

An example of such an arrangement is when religious healthcare organizations are obliged by government policy to provide services that conflict with their religious values, such as contraception. Government policy can require the provision of contraceptive services as a preventive health measure for all employees, including employees in religious healthcare or religious schools. Prior to such policies being enacted, typically those religious organizations provided health insurance for their employees excluding contraceptive services – if their employees wanted those services, they had to purchase separate healthcare insurance.

When there is a government mandate to provide health insurance that includes contraceptive services, religious organizations can comply using the principle of cooperation to avoid moral complicity with the perceived wrongdoing (contraception). The principle would work in the following manner. First, the government mandate constitutes a form of external duress that, even after appropriate protest, is unavoidable. That is a crucial condition to employ the principle of cooperation. Second, there needs to be proportionality for the religious organizations to justify using the principle of cooperation – the proportionality would reflect the provision of healthcare or education to large numbers that otherwise might be compromised if the religious organization closed to avoid the government mandate. Third, there must be no intention on the part of the religious organization – the religious group may not use the mandate to surreptitiously intend the provision of the forbidden services that conflict with the organization’s proclaimed values. Fourth, the religious organization should avoid any potential profit sharing that might accrue from legitimate cooperation with the forbidden services. Finally, there must be distance (proximate or remote) between the religious organization and the provision of the forbidden services. The distance can be created in different ways. To establish distance, the religious organizations may need to work with government agencies to implement appropriate steps, such as claiming a religious exemption through a third party that would provide the relevant services. In other words, the principle of cooperation enables religious organizations to comply with government mandates about services they deem to be immoral without being morally complicit (Magill 2013).


For centuries, the principle of cooperation has been used to protect individuals and organizations from moral complicity when their actions intersect with the behavior of others that is deemed to be immoral. Cultural diversity in the pluralistic world of global bioethics will continue to raise many professional and organizational dilemmas. These occur not only with regard to conflicts of interest or commitment and conflicts of conscience but also with regard to being involved with the wrongdoing of others in healthcare, whether in relations between organizations or with governments. The principle of cooperation provides a nuanced and flexible process to avoid moral complicity in such complex dilemmas.

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