case study of an ethical dilemma

McCombs School of Business

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Case Studies

More than 70 cases pair ethics concepts with real world situations. From journalism, performing arts, and scientific research to sports, law, and business, these case studies explore current and historic ethical dilemmas, their motivating biases, and their consequences. Each case includes discussion questions, related videos, and a bibliography.

A Million Little Pieces

James Frey’s popular memoir stirred controversy and media attention after it was revealed to contain numerous exaggerations and fabrications.

Abramoff: Lobbying Congress

Super-lobbyist Abramoff was caught in a scheme to lobby against his own clients. Was a corrupt individual or a corrupt system – or both – to blame?

Apple Suppliers & Labor Practices

Is tech company Apple, Inc. ethically obligated to oversee the questionable working conditions of other companies further down their supply chain?

Approaching the Presidency: Roosevelt & Taft

Some presidents view their responsibilities in strictly legal terms, others according to duty. Roosevelt and Taft took two extreme approaches.

Appropriating “Hope”

Fairey’s portrait of Barack Obama raised debate over the extent to which an artist can use and modify another’s artistic work, yet still call it one’s own.

Arctic Offshore Drilling

Competing groups frame the debate over oil drilling off Alaska’s coast in varying ways depending on their environmental and economic interests.

Banning Burkas: Freedom or Discrimination?

The French law banning women from wearing burkas in public sparked debate about discrimination and freedom of religion.

Birthing Vaccine Skepticism

Wakefield published an article riddled with inaccuracies and conflicts of interest that created significant vaccine hesitancy regarding the MMR vaccine.

Blurred Lines of Copyright

Marvin Gaye’s Estate won a lawsuit against Robin Thicke and Pharrell Williams for the hit song “Blurred Lines,” which had a similar feel to one of his songs.

Bullfighting: Art or Not?

Bullfighting has been a prominent cultural and artistic event for centuries, but in recent decades it has faced increasing criticism for animal rights’ abuse.

Buying Green: Consumer Behavior

Do purchasing green products, such as organic foods and electric cars, give consumers the moral license to indulge in unethical behavior?

Cadavers in Car Safety Research

Engineers at Heidelberg University insist that the use of human cadavers in car safety research is ethical because their research can save lives.

Cardinals’ Computer Hacking

St. Louis Cardinals scouting director Chris Correa hacked into the Houston Astros’ webmail system, leading to legal repercussions and a lifetime ban from MLB.

Cheating: Atlanta’s School Scandal

Teachers and administrators at Parks Middle School adjust struggling students’ test scores in an effort to save their school from closure.

Cheating: Sign-Stealing in MLB

The Houston Astros’ sign-stealing scheme rocked the baseball world, leading to a game-changing MLB investigation and fallout.

Cheating: UNC’s Academic Fraud

UNC’s academic fraud scandal uncovered an 18-year scheme of unchecked coursework and fraudulent classes that enabled student-athletes to play sports.

Cheney v. U.S. District Court

A controversial case focuses on Justice Scalia’s personal friendship with Vice President Cheney and the possible conflict of interest it poses to the case.

Christina Fallin: “Appropriate Culturation?”

After Fallin posted a picture of herself wearing a Plain’s headdress on social media, uproar emerged over cultural appropriation and Fallin’s intentions.

Climate Change & the Paris Deal

While climate change poses many abstract problems, the actions (or inactions) of today’s populations will have tangible effects on future generations.

Cover-Up on Campus

While the Baylor University football team was winning on the field, university officials failed to take action when allegations of sexual assault by student athletes emerged.

Covering Female Athletes

Sports Illustrated stirs controversy when their cover photo of an Olympic skier seems to focus more on her physical appearance than her athletic abilities.

Covering Yourself? Journalists and the Bowl Championship

Can news outlets covering the Bowl Championship Series fairly report sports news if their own polls were used to create the news?

Cyber Harassment

After a student defames a middle school teacher on social media, the teacher confronts the student in class and posts a video of the confrontation online.

Defending Freedom of Tweets?

Running back Rashard Mendenhall receives backlash from fans after criticizing the celebration of the assassination of Osama Bin Laden in a tweet.

Dennis Kozlowski: Living Large

Dennis Kozlowski was an effective leader for Tyco in his first few years as CEO, but eventually faced criminal charges over his use of company assets.

Digital Downloads

File-sharing program Napster sparked debate over the legal and ethical dimensions of downloading unauthorized copies of copyrighted music.

Dr. V’s Magical Putter

Journalist Caleb Hannan outed Dr. V as a trans woman, sparking debate over the ethics of Hannan’s reporting, as well its role in Dr. V’s suicide.

East Germany’s Doping Machine

From 1968 to the late 1980s, East Germany (GDR) doped some 9,000 athletes to gain success in international athletic competitions despite being aware of the unfortunate side effects.

Ebola & American Intervention

Did the dispatch of U.S. military units to Liberia to aid in humanitarian relief during the Ebola epidemic help or hinder the process?

Edward Snowden: Traitor or Hero?

Was Edward Snowden’s release of confidential government documents ethically justifiable?

Ethical Pitfalls in Action

Why do good people do bad things? Behavioral ethics is the science of moral decision-making, which explores why and how people make the ethical (and unethical) decisions that they do.

Ethical Use of Home DNA Testing

The rising popularity of at-home DNA testing kits raises questions about privacy and consumer rights.

Flying the Confederate Flag

A heated debate ensues over whether or not the Confederate flag should be removed from the South Carolina State House grounds.

Freedom of Speech on Campus

In the wake of racially motivated offenses, student protests sparked debate over the roles of free speech, deliberation, and tolerance on campus.

Freedom vs. Duty in Clinical Social Work

What should social workers do when their personal values come in conflict with the clients they are meant to serve?

Full Disclosure: Manipulating Donors

When an intern witnesses a donor making a large gift to a non-profit organization under misleading circumstances, she struggles with what to do.

Gaming the System: The VA Scandal

The Veterans Administration’s incentives were meant to spur more efficient and productive healthcare, but not all administrators complied as intended.

German Police Battalion 101

During the Holocaust, ordinary Germans became willing killers even though they could have opted out from murdering their Jewish neighbors.

Head Injuries & American Football

Many studies have linked traumatic brain injuries and related conditions to American football, creating controversy around the safety of the sport.

Head Injuries & the NFL

American football is a rough and dangerous game and its impact on the players’ brain health has sparked a hotly contested debate.

Healthcare Obligations: Personal vs. Institutional

A medical doctor must make a difficult decision when informing patients of the effectiveness of flu shots while upholding institutional recommendations.

High Stakes Testing

In the wake of the No Child Left Behind Act, parents, teachers, and school administrators take different positions on how to assess student achievement.

In-FUR-mercials: Advertising & Adoption

When the Lied Animal Shelter faces a spike in animal intake, an advertising agency uses its moral imagination to increase pet adoptions.

Krogh & the Watergate Scandal

Egil Krogh was a young lawyer working for the Nixon Administration whose ethics faded from view when asked to play a part in the Watergate break-in.

Limbaugh on Drug Addiction

Radio talk show host Rush Limbaugh argued that drug abuse was a choice, not a disease. He later became addicted to painkillers.

U.S. Olympic swimmer Ryan Lochte’s “over-exaggeration” of an incident at the 2016 Rio Olympics led to very real consequences.

Meet Me at Starbucks

Two black men were arrested after an employee called the police on them, prompting Starbucks to implement “racial-bias” training across all its stores.

Myanmar Amber

Buying amber could potentially fund an ethnic civil war, but refraining allows collectors to acquire important specimens that could be used for research.

Negotiating Bankruptcy

Bankruptcy lawyer Gellene successfully represented a mining company during a major reorganization, but failed to disclose potential conflicts of interest.

Pao & Gender Bias

Ellen Pao stirred debate in the venture capital and tech industries when she filed a lawsuit against her employer on grounds of gender discrimination.

Pardoning Nixon

One month after Richard Nixon resigned from the presidency, Gerald Ford made the controversial decision to issue Nixon a full pardon.

Patient Autonomy & Informed Consent

Nursing staff and family members struggle with informed consent when taking care of a patient who has been deemed legally incompetent.

Prenatal Diagnosis & Parental Choice

Debate has emerged over the ethics of prenatal diagnosis and reproductive freedom in instances where testing has revealed genetic abnormalities.

Reporting on Robin Williams

After Robin Williams took his own life, news media covered the story in great detail, leading many to argue that such reporting violated the family’s privacy.

Responding to Child Migration

An influx of children migrants posed logistical and ethical dilemmas for U.S. authorities while intensifying ongoing debate about immigration.

Retracting Research: The Case of Chandok v. Klessig

A researcher makes the difficult decision to retract a published, peer-reviewed article after the original research results cannot be reproduced.

Sacking Social Media in College Sports

In the wake of questionable social media use by college athletes, the head coach at University of South Carolina bans his players from using Twitter.

Selling Enron

Following the deregulation of electricity markets in California, private energy company Enron profited greatly, but at a dire cost.

Snyder v. Phelps

Freedom of speech was put on trial in a case involving the Westboro Baptist Church and their protesting at the funeral of U.S. Marine Matthew Snyder.

Something Fishy at the Paralympics

Rampant cheating has plagued the Paralympics over the years, compromising the credibility and sportsmanship of Paralympian athletes.

Sports Blogs: The Wild West of Sports Journalism?

Deadspin pays an anonymous source for information related to NFL star Brett Favre, sparking debate over the ethics of “checkbook journalism.”

Stangl & the Holocaust

Franz Stangl was the most effective Nazi administrator in Poland, killing nearly one million Jews at Treblinka, but he claimed he was simply following orders.

Teaching Blackface: A Lesson on Stereotypes

A teacher was put on leave for showing a blackface video during a lesson on racial segregation, sparking discussion over how to teach about stereotypes.

The Astros’ Sign-Stealing Scandal

The Houston Astros rode a wave of success, culminating in a World Series win, but it all came crashing down when their sign-stealing scheme was revealed.

The Central Park Five

Despite the indisputable and overwhelming evidence of the innocence of the Central Park Five, some involved in the case refuse to believe it.

The CIA Leak

Legal and political fallout follows from the leak of classified information that led to the identification of CIA agent Valerie Plame.

The Collapse of Barings Bank

When faced with growing losses, investment banker Nick Leeson took big risks in an attempt to get out from under the losses. He lost.

The Costco Model

How can companies promote positive treatment of employees and benefit from leading with the best practices? Costco offers a model.

The FBI & Apple Security vs. Privacy

How can tech companies and government organizations strike a balance between maintaining national security and protecting user privacy?

The Miss Saigon Controversy

When a white actor was cast for the half-French, half-Vietnamese character in the Broadway production of Miss Saigon , debate ensued.

The Sandusky Scandal

Following the conviction of assistant coach Jerry Sandusky for sexual abuse, debate continues on how much university officials and head coach Joe Paterno knew of the crimes.

The Varsity Blues Scandal

A college admissions prep advisor told wealthy parents that while there were front doors into universities and back doors, he had created a side door that was worth exploring.

Providing radiation therapy to cancer patients, Therac-25 had malfunctions that resulted in 6 deaths. Who is accountable when technology causes harm?

Welfare Reform

The Welfare Reform Act changed how welfare operated, intensifying debate over the government’s role in supporting the poor through direct aid.

Wells Fargo and Moral Emotions

In a settlement with regulators, Wells Fargo Bank admitted that it had created as many as two million accounts for customers without their permission.

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Case Studies

Case study discussion.

Below is a list of the case study articles that have been published in NIB , each with keywords, a set of discussion questions, and further resources. To search page contents with keywords, select "Control-F" from a PC, or "Command-F" from a Mac.

• Accommodating Religious Beliefs in the ICU: A Narrative Account of a Disputed Death
• When Ethics Consultation and Courts Collide: A Case of Compelled Treatment of a Mature Minor
• Advance Directives, Preemptive Suicide, and Emergency Medicine Decision Making
• Healing the Physician’s Story: A Case of Narrative Medicine and End-of-Life Care
• The Efficacy of Ethics Discernment in the Organizational Context: The Case of Post-Offer Nicotine Screening
• Can We Talk About Sex?
• Should We Tell Annie?: Preparing for Death at the Intersection of Parental Authority and Adolescent Autonomy
• A Case of Deceptive Mastectomy
• Do Everything
• Responding to the Refusal of Care in the Emergency Department
• I Don’t Know Why I Called You
• Undocumented and at the End of Life
• Dax’s Case Redux: When Comes the End of the Day?
• Desperately Seeking a Surrogate— For a Patient Lacking Decision-Making Capacity
• What to Say When: Responding to a Suicide Attempt in the Acute Care Setting
• Conversation and the Jehovah’s Witness Dying From Blood Loss
• Caregivers’ Role in Maternal-Fetal Conflict
• The Surgeon as Stakeholder: Making the Case Not to Operate
• The Enduring Case
• Military Health Care Dilemmas and Genetic Discrimination: A Family’s Experience with Whole Exome Sequencing
• Conflicting Values: A Case Study in Patient Choice and Caregiver Perspectives
• Ethical Dilemmas Relating to the Management of a Newborn with Down Syndrome and Severe Congenital Heart Disease in a Resource-Poor Setting
• System Failure: No Surgeon To Be Found
• Ethical Challenges in the Care of the Inpatient with Morbid Obesity
• A Life Below the Threshold? Examining Conflict Between Ethical Principles and Parental Values in Neonatal Treatment Decision Making
• The Clinical Bioethicist’s Role: Should We Aim to Relieve Suffering?
• To Enroll or Not to Enroll?: A Researcher Struggles with the Decision to Involve Study Participants in a Clinical Trial That Could Save Their Lives
• Sometimes Those Hoofbeats Are Zebras: A Narrative Analysis
• A Jehovah’s Witness Adolescent in the Labor and Delivery Unit: Should Patient and Parental Refusals of Blood Transfusions for Adolescents Be Honored?
• Reframing Medical Appropriateness: A Case Study Concerning the Use of Life-Sustaining Technologies for a Patient With Profoundly Diminished Quality of Life
• "We Didn't Consent to This"
• Screen Shots: When Patients and Families Publish Negative Health Care Narratives Online
• A Personal Narrative on Living and Dealing with Psychiatric Symptoms after DBS Surgery
• The Will Reconsidered: Hard Choices in Living Organ Donation
• Malleable Transplant Criteria: At What Cost?
• Responding to Requests for Aid-in-Dying: Rethinking the Role of Conscience
• Getting to the Heart of the Matter: Navigating Narrative Intersections in Ethics Consultation
• Speaking for Our Father
• Forcible Amputation in Delusional Patients: A Narrative Analysis of Decisional Capacity
• A Health Care Systems Approach to Improving Care for Seriously Ill Patients
• An Ethics of Unknowing: Discerning Ethical Patient-Provider Interactions in Clinical Decision-Making
• How Should Physicians Manage Neuro-prognosis with ECPR?
• The Ethics of Choosing a Surrogate Decision Maker When Equal-Priority Surrogates Disagree
• A Gay Epidemiologist and the DC Commission of Public Health AIDS Advisory Committee
• Shared Decision-Making in Palliative Care: A Maternalistic Approach
• Phantom Physicians and Medical Catfishing: A Narrative Ethics Approach to Ghost Surgery
• It Takes Time to Let Go
• An American’s Experience with End-of-Life Care in Japan: Comparing Brain Death, Limiting and Withdrawing Life-Prolonging Interventions, and Healthcare Ethics Consultation Practices in Japan and the United States
• The Sword of King Solomon
• Appreciating the Dynamicity of Values at the End of Life: A Psychological and Ethical Analysis
• Serendipity and Social Justice: How Someone with a Physical Disability Succeeds in Clinical Bioethics
• The Right to Be Childfree
• Undisclosed Placebo Trials in Clinical Practice: Undercover Beneficence or Unwarranted Deception?
• What Do We Owe to Patients Who Leave Against Medical Advice? The Ethics of AMA Discharges?
•  "Jehovah's Witnesses and the Normative Function of Indirect Consent"
• "Parental Refusals of Blood Transfusions from COVID-19 Vaccinated Donors for Children Needing Cardiac Surgery"
• "Withdrawing Life Support After Attempted Suicide: A Case Study and Review of Ethical Consideration"

1. Accommodating Religious Beliefs in the ICU: A Narrative Account of a Disputed Death

Martin L. Smith, Anne Lederman Flamm

Abstract: Despite widespread acceptance in the United States of neurological criteria to determine death, clinicians encounter families who object, often on religious grounds, to the categorization of their loved ones as “brain dead.” The concept of “reasonable accommodation” of objections to brain death, promulgated in both state statutes and the bioethics literature, suggests the possibility of compromise between the family’s deeply held beliefs and the legal, professional and moral values otherwise directing clinicians to withdraw medical interventions. Relying on narrative to convey the experience of a family and clinical caregivers embroiled in this complex dilemma, the case analyzed here explores the practical challenges and moral ambiguities presented by the concept of reasonable accommodation. Clarifying the term’s meaning and boundaries, and identifying guidelines for its clinical implementation, could help to reduce uncertainty for both health care professionals and families and, thereby, the incremental moral distress such uncertainty creates.

Keywords: Brain death, clinical ethics, ethics consultation, reasonable accommodation, religious conflict

Link to Case on MUSE

Reflection Questions:

• How might have the nurses’ and physicians’ initial frank commentary about Sarah’s condition affected the family’s interpretation of the clinicians’ opinions later on in the care process?
• In what ways might the new hospital have provided support to Sarah’s family in order to avoid the religion vs. medicine standoff that eventually developed?
• How much patience are physicians obligated to have with family members who extensively question the medical decision-making process? Was the hospital staff correct in labeling Rebekah as “manipulative”?
• Is it ethically appropriate for financial considerations to affect the family’s decision-making? Why or why not? To what extent should the healthcare team discuss the financial impact of decisions with families?

Web Resources:

• New York State Department of Health Guidelines for Determining Brain Death. (2011). Retrieved from: http://www.health.ny.gov/professionals/hospital_administrator/letters/2011/brain_death_guidelines.pdf
• Olick, RS, Braun, EA, and Potash, J. (2009). Accommodating Religious and Moral Objections to Neurological Death. The Journal of Clinical Ethics. Retrieved from: http://www.upstate.edu/bioethics/pdf/faculty/olick_accommodating-religious-and-moral-objections-to-neurological-death.pdf
• Breitowitz, YA. Jewish Medical Ethics: The Brain Death Controversy in Jewish Law. Jewish Virtual Library. Retrieved from: https://www.jewishvirtuallibrary.org/jsource/Judaism/braindead.html

2. When Ethics Consultation and Courts Collide: A Case of Compelled Treatment of a Mature Minor

Jeffrey P. Spike

Abstract: A fourteen year old is diagnosed with aplastic anemia. The teen and his parents are Jehovah’s Witnesses. An ethics consult is called on the day of admission by an ethically sophisticated social worker and attending. The patient and his parents see this diagnosis as “a test of their faith.” The ethical analysis focuses on the mature minor doctrine, i.e. whether the teen has the capacity to make this decision. The hospital chooses to take the case to court, with a result that is at odds with the ethics consultation recommendations. Ethics was never deposed or otherwise invited to be involved with the hearing. Thus the larger question of the relation of ethics and law was brought into stark relief.

Keywords: Adolescent, Capacity, Child Neglect, Decision-making Capacity, Ethics Consultation, Informed Consent, Jehovah’s Witnesses, Mature Minor, Religion, Religious Belief, Right to Refuse Treatment, Teen, Teenager

• What is the relationship between law and ethics? When they conflict, which should prevail?
• At one point, the author of this case study says, of trying to convince his young patient of the benefit of treatment: “…but that seemed coercive. In fact, far too many patients act out of fear and accept treatment that has virtually no choice of benefit.” In this case, where Luke would have greatly benefitted from treatment, where is the line to be drawn between thoroughly informing him and coercing him?
• Are there ever circumstances where it might be disadvantageous to have an ethics consultation?
• Anderson & Associates, P.C. (2015). Illinois Recognizes the “Mature Minor Doctrine” in Some Cases. Retrieved from: http://www.andersondivorcelawchicago.com/chicagodivorceattorney/2015/01/29/illinois-mature-minor-doctrine-states/

Pauley, M. (2011). National Health Care Decisions Day, Jehovah’s Witnesses & Mature Minors. Marquette University Law School Faculty Blog. Retrieved from: http://law.marquette.edu/facultyblog/2011/04/14/national-health-care-decisions-day-jehovahs-witnesses-mature-minors/

• Jehovah’s Witnesses: The Surgical/Ethical Challenge. (1981). JW.org. Retrieved from: http://www.jw.org/en/publications/books/blood/jehovahs-witnesses-the-surgical-ethical-challenge/

3. Advance Directives, Preemptive Suicide, and Emergency Medicine Decision Making

Richard L. Heinrich, Marshall T. Morgan, Steven J. Rottman

Abstract: As the United States population ages, there is a growing group of aging, elderly, individuals who may consider "preemptive suicide"(Prado, 1998). Healthy aging patients who preemptively attempt to end their life by suicide and who have clearly expressed a desire not to have life -sustaining treatment present a clinical and public policy challenge. We describe the clinical, ethical, and medical-legal decision making issues that were raised in such a case that presented to an academic emergency department. We also review and evaluate a decision making process that emergency physicians confront when faced with such a challenging and unusual situation.

Keywords: Aging, Autonomy, Advance Directives, Emergency Department, Preemptive Suicide

• Can we rely on the perspective of a patient to trust that a logical decision about preemptive suicide is being made?
• In this case, the family supported the patient’s decision, and thus gave it more credence. When the patient and family disagree, which view should prevail?
• What could the medical team have done prior to providing treatment in order to clarify their patient’s DNR wishes?
• Suicide is currently illegal in the United States. Does the fact that it is illegal mean that it is wrong? Is there an ethical right to suicide, despite the fact that it is illegal?
• Gabbatt, A. (2009). Doctors acted legally in ‘living will’ suicide case. The Guardian. Retrieved from: http://www.theguardian.com/society/2009/oct/01/living-will-suicide-legal
• Tolchin, M. (1989). When long life is too much: suicide rises among elderly. The New York Times. Retrieved from: http://www.nytimes.com/1989/07/19/us/when-long-life-is-too-much-suicide-rises-among-elderly.html?pagewanted=all&src=pm
• Appleby, J. (2014). ‘Prophylactic’ Suicide. The New York Times, Sunday Review. Retrieved from: http://www.nytimes.com/2014/11/16/opinion/sunday/prophylactic-suicide.html

4. Healing the Physician’s Story: A Case of Narrative Medicine and End-of-Life Care

Lori A. Roscoe

Abstract: Telling stories after a loved one’s death helps surviving family members to find meaning in the experience and share perceptions about whether the death was consistent with the deceased person’s values and preferences. Opportunities for physicians to evaluate the experience of a patient’s death and to expose the ethical concerns that care for the dying often raises are rare. Narrative medicine is a theoretical perspective that provides tools to extend the benefits of storytelling and narrative sense–making to physicians. This case study describes narrative writing workshops attended by physicians who care for dying patients. The narratives created revealed the physicians’ concerns about ethics and their emotional connection with patients. This case study demonstrates that even one–time reflective writing workshops might create important opportunities for physicians to evaluate their experiences with dying patients and families.

Keywords: Death and Dying, End–of–Life Issues, Healthcare Professionals, Narrative Inquiry, Stories, Storytelling

• This piece extensively discusses the effects that narrative medicine can have for a practicing physician. What potential effects can it have on the other side of the doctor-patient interaction?
• What does the Japanese physician’s story suggest about the role that culture plays in the doctor-patient experience?
• Is it possible for a physician to be truly empathetic with his or her patients? Why or why not?
• Should medical schools across the country include narrative medicine in their curriculum? Why or why not?
• Chen, PW. (2008). Stories in the Service of Making a Better Doctor. The New York Times. Retrieved from: http://www.nytimes.com/2008/10/24/health/chen10-23.html?pagewanted=all
• Geisler, SL. (2006). The Value of Narrative Ethics to Medicine. The Journal of Physician Assistant Education. Retrieved from: http://www2.paeaonline.org/index.php?ht=action/GetDocumentAction/i/25232

5. The Efficacy of Ethics Discernment in the Organizational Context: The Case of Post-Offer Nicotine Screening

David M. Belde

Abstract: This article examines the efficacy of an ethics discernment process in the organizational context, a practice referred to in the paper as "mission due diligence." This type of ethics discernment is a structured process intended to awaken the ethical concerns that a particular issue raises within moral agents and to give voice, directly and indirectly, to those who will be impacted by, and responsible for, strategic decision-making. The efficacy of this particular ethics discernment practice is contingent upon several realities, including, but not limited to 1) the timing in which it is undertaken, 2) the degree of importance and relevance attributed to it, and 3) the skills of the person leading it. This case report examines how this process was used to highlight and address the ethical issues related to a new hiring policy, namely, a mandatory nicotine screening test for prospective employees in the healthcare context. Framed by the Bon Secours Virginia Health System hiring process, the author explores the importance of diligently focusing on ethical considerations in the organizational realm while still maintaining true to the virtues of the network.

Keywords: Ethics Discernment, Nicotine Screening, Organizational Ethics

• The author says, “Virtually all organizational ethics programs have to grapple with their overall importance and relevance within an organization.” How much authority should an ethics program within a hospital be afforded?
• If an employer can show sufficient empirical results for why a drug test is necessary, is it warranted? Do the sufficient reasons have to be related to the patients’ best interests?
• What are the different ways that Catholicism affects the ethical considerations in this case? What role does religion play in ethical consultations in general?
• Why does the author say balancing advocacy and inquiry are so important?
• Tucker, M & Salazar, L. (2014). Cotinine testing may violate the American with Disabilities Act (ADA), the ADA Amendments Act (ADAAA), and state laws. Wells Fargo Insights. Retrieved from: https://wfis.wellsfargo.com/insights/clientadvisories/pages/cotininetestingmayviolateadaandotherlaws.aspx
• Our Values. Bons Secours Health System. Retrieved from: http://hso.bonsecours.com/about-us-our-mission-our-values.html
• Framework for Ethical Discernment. (2014). The Taylor University Center for Ethics. Retrieved from: http://ethics.taylor.edu/framework-for-ethical-discernment/

6. Can We Talk About Sex?

Mindy B. Statter

Abstract: A three–year–old female undergoes elective inguinal hernia repair and unexpectedly is found to have testes in the hernia sacs. A recommendation is made not to disclose the patient’s genotype to her mother. This case study addresses the ethical conflict of whether to disclose the patient’s male genotype to the parent that has been raising the child as female.

Keywords: Autonomy, Beneficence, Complete Androgen Insensitivity Syndrome, Disclosure, Informed Consent, Intersex, Nonmaleficence

• In what—if any—circumstances is it ethically acceptable to withhold medical information about a child from the primary caretaker?
• Now that disclosure of a CAIS diagnosis is mandatory, what responsibility would a parent potentially have to override a doctor’s recommendations for gender maintenance?
• This case highlights the ethical risks and potential consequences later in life of not disclosing a patient’s CAIS diagnosis and treatment. Conversely, what would the consequences be for disclosing?
• Ignoring the medical precedents set now, do you believe the doctor in this case should have felt remorse for not disclosing the full nature of the girl’s condition to her mother? Would her mother have been equipped to handle that knowledge at that time?
• Dreger, AD. (1998). “Ambiguous Sex”—or Ambivalent Medicine? The Hastings Center Report. Retrieved from: http://www.isna.org/articles/ambivalent_medicine
• Intersex Conditions, Human Diversity Resources. UConn Health Center. http://uchc.libguides.com/humandiversity/intersex
• Georgiann Davis. "Normalizing Intersex: The Transformative Power of Stories." Narrative Inquiry in Bioethics 5.2 (2015): 87-89. Project MUSE. Web. 8 Dec. 2015

7. Should We Tell Annie?: Preparing for Death at the Intersection of Parental Authority and Adolescent Autonomy

Erica K. Salter

Abstract: This case analysis examines the pediatric clinical ethics issues of adolescent autonomy and parental authority in medical decision–making. The case involves a dying adolescent whose parents request that the medical team withhold diagnosis and prognosis information from the patient. The analysis engages two related ethical questions: Should Annie be given information about her medical condition? And, who is the proper decision–maker in Annie’s case? Ultimately, four practical recommendations are offered.

Keywords: Adolescent, Decision-making Capacity, End of Life Care, Mature Minor, Parental Consent

• At what age do teens develop the ability to make autonomous decisions for themselves? What factors unique to adolescence might enhance or detract from this ability?
• What factors should be considered in deciding whether an adolescent should be given decision-making authority? Why?
• Is it ever appropriate for medical practitioners to lie to a child (or actively conceal the truth from a child)? Why or why not?
• Was it appropriate of the new attending doctor to call the palliative care physician? How could that miscommunication have been prevented?
• Hill, JB. (2012). Medical Decision Making by and on Behalf of Adolescents: Reconsidering First Principles. Faculty Publications. Retrieved from: http://scholarlycommons.law.case.edu/cgi/viewcontent.cgi?article=1081&context=faculty_publications
• Leonard, K. (2015). Case Sparks Debate About Teen Decision Making in Health. U.S. News and World Report. Retrieved from: http://www.usnews.com/news/articles/2015/01/22/case-sparks-debate-about-teen-decision-making-in-health

8. A Case of Deceptive Mastectomy

Rebecca Volpe, Maria Baker, George F. Blackall, Gordon Kauffman, Michael J. Green

Abstract: This paper poses the question, “what are providers’ obligations to patients who lie?” This question is explored through the lens of a specific case: a 26–year–old woman who requests prophylactic bilateral mastectomy with reconstruction reports a significant and dramatic family history, but does not want to undergo genetic testing. Using a conversational–style discussion, the case is explored by a breast surgeon, genetic counselor/medical geneticist, clinical psychologist, chair of a hospital ethics committee and director of a clinical ethics consultation service.

Keywords: Clinical Ethics, Deceit, Lying, Provider/Patient Relationship, Providers’ Obligations

• Do you believe that the patient-doctor relationship should be reciprocal? Does the Hippocratic Oath mandate that doctors uphold their duties regardless of patient behavior?
• This case study asks us to consider typical signals that the doctors relied on when initially deciding whether or not to trust the patient. They cite qualities like her attractiveness, her maturity, and her husband’s support in order to explain their initial trust. Should they have been more skeptical in the beginning? Why were they so willing to believe the patient’s story at face value?
• Aside from the guilt that the surgeon himself would likely have felt, what might have been some potential consequences for the ethics team and hospital in general if the surgery had been successfully performed? What if it had gone badly?
• Polta, A. (2014). Lying to the Doctor. Center for Advancing Health, Prepared Patient Blog. Retrieved from: http://www.cfah.org/blog/2014/lying-to-the-doctor
• Ludwig, M & Burke, W. (2013). Physician-Patient Relationship. Ethics in Medicine, University of Washington School of Medicine. Retrieved from: http://depts.washington.edu/bioethx/topics/physpt.html
• Observer Staff. (2000). What Should Plastic Surgeons Do When Crazy Patients Demand Work? Observer. Retrieved from: http://observer.com/2000/07/what-should-plastic-surgeons-do-when-crazy-patients-demand-work/

9. Do Everything

H. Rex Greene

Abstract: A 57–year–old with an incurable cancer suffered an abdominal catastrophe, putting him in the ICU, comatose with no chance of survival. His attending oncologist had only met him once and had no knowledge of his goals of care. Lacking an advance directive the staff turned to his family, who said, “Do everything.” This loaded statement was thought to be a demand for futile care even though it ultimately proved a reflection of their emotional response to a terrible, unanticipated event, not an irrational demand for useless care. A sympathetic exploration of the patient’s goals and expectations with his family using Buckman’s SPIKES format disclosed that their major concern was that he not die on his wife’s birthday. The family agreed to withdraw him from ventilator support the following day. Unraveling a medical conflict requires a sensitive process of shared decision–making based on a transparent process of clinical reasoning that synthesizes patient and family values with medical knowledge and ethical duties. Properly done, the outcome usually is a satisfactory experience for all concerned.

Keywords: Abandonment, Advance directives, Catastrophic Illness, Clinical Reasoning, Conflict Resolution, Decisional Capacity, Do Everything, Futility, Paternalism, Shared Decision Making, SPIKES, Substituted Judgment

• This case explains that responding appropriately to a request to “do everything” requires doctors to ensure that patients’ families “know the medical facts, delivered in a kind, caring fashion.” Sometimes, it can take many meetings over several days for the family to absorb the medical facts. How should decisions be made in the meantime?
• The conclusion of this case seems to reaffirm that emotion is more important than reason when approaching difficult conversations with patients’ families. Should emotion-based education and empathy training be offered in the modern medical school curriculum? Is it even possible to train physicians to be more emotionally intelligent?
• Why is the establishment of the goal of treatment so important to the unity of a patient, their family, and their doctor? What are the barriers to establishing goals of care?
• Baile, WF. et al. (2000). SPIKES—A Six Step Protocol for Delivering Bad News: Application to the Patient with Cancer. The Oncologist. Retrieved from: http://theoncologist.alphamedpress.org/content/5/4/302.full
• Medical Futility. (2007). ACOG Committee Opinion No. 362. American College of Obstetricians and Gynecologists. Obstet Gynecol. Retrieved from: http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Ethics/Medical-Futility
• Enhancing Communication and Coordination of Care. (2013). Cardinal Glennon. Retrieved from: http://www.cardinalglennon.com/Documents/Forms/AllItems.aspx?RootFolder=http%3a%2f%2fwww%2ecardinalglennon%2ecom%2fDocuments%2femergency-medicine&FolderCTID=0x0120000161C93D9B68B34BA6E74A98204CE2A1

10. Responding to the Refusal of Care in the Emergency Department

Jennifer Nelson, Arvind Venkat, Moira Davenport

Abstract: The emergency department (ED) serves as the primary gateway for acute care and the source of health care of last resort. Emergency physicians are commonly expected to rapidly assess and treat patients with a variety of life–threatening conditions. However, patients do refuse recommended therapy, even when the consequences are significant morbidity and even mortality. This raises the ethical dilemma of how emergency physicians and ED staff can rapidly determine whether patient refusal of treatment recommendations is based on intact decision–making capacity and how to respond in an appropriate manner when the declining of necessary care by the patient is lacking a basis in informed judgment. This article presents a case that illustrates the ethical tensions raised by the refusal of life–sustaining care in the ED and how such situations can be approached in an ethically appropriate manner.

Keywords: Decision–making Capacity, Emergency Department, Emergency Physician, Informed Consent, Treatment Refusal

• Does coming to the Emergency Department constitute implied consent to treatment? Why would a patient come to the ED if not to receive potentially life-sustaining treatments at a physician’s recommendation?
• If it is evident that a patient lacks decision-making capacity, is it paternalistic to administer life-saving treatment even if the patient refuses?
• In this case, would it be ethically appropriate for the physicians to consult the patient’s family, in order to bring in one more agent of authority?
• Cooper, S. (2010). Taking No for an Answer—Refusal of Life-Sustaining Treatment. AMA Journal of Ethics/Virtual Mentor. Retrieved from: http://journalofethics.ama-assn.org/2010/06/ccas2-1006.html
• ACEP Code of Ethics for Emergency Physicians. (2008). Retrieved from: https://www.acep.org/Clinical---Practice-Management/Code-of-Ethics-for-Emergency-Physicians/

11. I Don’t Know Why I Called You

Jeffrey S. Farroni, Colleen M. Gallagher

Abstract: This case study details a request from a patient family member who calls our service without an articulated ethical dilemma. The issue that arose involved the conflict between continuing further medical interventions versus transitioning to supportive or palliative care and transferring the patient home. Beyond the resolution of the ethical dilemma, this narrative illustrates an approach to ethics consultation that seeks practical resolution of ethical dilemmas in alignment with patient goals and values. Importantly, the family’s suffering is addressed through a relationship driven, humanistic approach that incorporates elements of compassion, empathy and dialog.

Keywords: End of life, Empathy, Relationships, Clinical Ethics

• How can healthcare providers and ethicists strike a balanced middle-ground between being too detached and too empathetic? Which side of this split should they err on? Why?
• In this case, how did the patient’s family’s expectations influence the decision-making of the ethicist and the doctors?
• How can an ethicist’s varied background bring new knowledge and insight to a collaborative ethical deliberation?
• Shelton, WN & White, BD. (2015). Realistic Goals and Expectations for Clinical Ethics Consultations: We Should Not Overstate What We Can Deliver. The American Journal of Bioethics. Retrieved from: http://www.tandfonline.com/doi/pdf/10.1080/15265161.2014.974773
• American Society for Bioethics and Humanities Clinical Ethics Task Force. Improving Competence in Clinical Ethics Consultation: A Learner’s Guide. Retrieved from: http://www-3.unipv.it/centrodibioetica/resources/Improving_Competence_in_Ethics.pdf

12. Undocumented and at the End of Life

Annette Mendola

Abstract: Three of the most contentious issues in contemporary American society—allocation of medical resources, end of life care, and immigration—converge when undocumented immigrant patients are facing the terminal phase of chronic illness. The lack of consistent, pragmatic policy in each of these spheres leaves us with little guidance for how to advocate for undocumented patients at the end of life. Limited resources and growing need compound the problem. Care for patients in this unfortunate situation should be grounded in clinical and economic reality as well as respect for the dignity of the individual to avoid exacerbating inequalities.

Keywords: Allocation of Resources, Dialysis, ESRD, End–of–Life Care, Undocumented Patients

• How does Henri’s lack of citizenship or permanent residence in the United States limit not only his access to, but his knowledge of, the full range of medical options available to him? Does this make him vulnerable, and therefore deserving of increased protections, in a way that other patients are not?
• Was it Henri’s right to refuse hospice, considering the lack of other options available? Why or why not?
• Should the ethics consulting team have made more of an effort to communicate to Henri that Lucia was no longer willing to be his caregiver? Why would this matter?
• Is a partial treatment of a severely ill patient worth the effort, or just a waste of time and resources? What is the apparent stance of the ethics committee on this question?
• Kimball, C. “End-of-Life Health Care Disparity: A Case Study”. Nursing Economics. Retrieved from: https://www.nursingeconomics.net/necfiles/news/End-Of-Life_Care_Kimball.pdf
• Ortega, AM. (2014). “Stay or Go? Terminally Ill Undocumented Immigrants Face Dilemma”. New America Media. Retrieved from: http://newamericamedia.org/2014/01/undocumented-and-dying-latinos-may-find-comfort-in-final-journey-home.php

13. Dax’s Case Redux: When Comes the End of the Day?

Ashley R. Hurst, Dea Mahanes, Mary Faith Marshall

Abstract: Forty years after Dax Cowart fought to have his voice heard regarding his medical treatment, patient autonomy and rights are at the heart of patient care today. Yet, despite its centrality in patient care, the tension between a severely burned patient’s right to stop treatment and the physician’s role in saving a life has not abated. As this case study explores, barriers remain to hearing and respecting a patient’s treatment decisions. Dismantling these barriers involves dispelling the myths that burn patients must grin and bear intense pain to recover and that a patient’s choice to discontinue treatment equals physician failure. Moreover, in these situations, sustained, direct engagement between physician and patient can reduce the moral distress of all involved and enable physicians to hear and better accept when a patient is calling for the end of the day.

Keywords: Dax Cowart, Ethics Consultation, Moral Distress, Palliative Care, Patient Autonomy

• Communication between a patient and his or her care team is crucial in cases like this. Why did the avenues of communication break down in this piece? What could have been done to improve the relationship between the patient and the medical team?
• What obligation did the physicians have to be visiting the patient and witnessing the implications of his wound care? If their behavior had been different, how might that have changed the course of treatment for the patient?
• Was the sheer number of people in the room for the patient’s first consult coercive? What could have been done differently to understand both the patient’s wishes and the team’s perspective earlier in the process?
• Does the possibility of a high quality of life post-treatment warrant or justify doctors’ prescribing painful treatment over a patient’s objections?
• “Dax’s Case” preview. (1984). Retrieved from: http://search.alexanderstreet.com/view/work/1630976
• Kavan, MG, Elsasser, GN, Barone, EJ. (2012). The Physician’s Role in Managing Acute Stress Disorder. Am Fam Physician. Retrieved from: http://www.aafp.org/afp/2012/1001/p643.html
• Requests to Die: Non-Terminal Patients. Mhhe. Retrieved from: http://novella.mhhe.com/sites/dl/free/0078038456/1037408/Pen38456_Ch02.pdf

14. Desperately Seeking a Surrogate— For a Patient Lacking Decision-Making Capacity

Martin L. Smith, Catherine L. Luck

Abstract: Our hospital’s policy and procedures for “Patients Without Surrogates” provides for gradated safeguards for managing patients’ treatment and care when they lack decision–making capacity, have no advance directives, and no surrogate decision makers are available. The safeguards increase as clinical decisions become more significant and have greater consequences for the patient. The policy also directs social workers to engage in “rigorous efforts” to search for surrogates who can potentially provide substituted judgments for such patients. We describe and illustrate the policy, procedures, and kinds of expected rigorous efforts through our narration of an actual but disguised case for which we provided clinical ethics guidance and social work expertise. Our experience with and reflection on this case resulted in four recommendations we make for health care facilities and organizations that aim to provide quality care for their own patients without surrogates.

Keywords: Clinical Ethics, Decision–Making Capacity, End–of–Life Decisions, Ethics Committee, Ethics Consultation Service, Patients Without Surrogates, Rigorous Efforts, Social Work, Surrogate Decision Maker, Unbefriended Patient, Unrepresented Patient

• While this author cautions against using social media to determine a surrogate, do you think it could be a reliable method of determining a close relationship?
• Does your state allow non-family members to serve in the role of surrogate decision-maker?
• If there had been sufficient grounds for Sally to be Jacob’s surrogate, do you think she would have come to the same conclusions as Jacob’s brother? Could the process have been expedited, and yet be just as reliable?
• Stanford Hospitals and Clinics. (2009). Health Care Decisions for Patients Who Lack Capacity and Lack Surrogates. Retrieved from: http://www.thaddeuspope.com/images/Stanford_Health_Care_Decisions_For_Patients_Who_Lack_Capacity_and_Surrogates_7_09.pdf
• Varma, S & Wendler, D. (2007). “Medical Decision Making for Patients Without Surrogates”. Arch Intern Med. Retrieved from: http://ogg.osu.edu/site_documents/sage/course3/wk8_varma.pdf

15. What to Say When: Responding to a Suicide Attempt in the Acute Care Setting

Arvind Venkat, Jonathan Drori

Abstract: Attempted suicide represents a personal tragedy for the patient and their loved ones and can be a challenge for acute care physicians. Medical professionals generally view it as their obligation to aggressively treat patients who are critically ill after a suicide attempt, on the presumption that a suicidal patient lacks decision making capacity from severe psychiatric impairment. However, physicians may be confronted by deliberative patient statements, advanced directives or surrogate decision makers who urge the withholding or withdrawal of life sustaining treatments based on the patient’s underlying medical condition or life experience. How acute care providers weigh these expressions of patient wishes versus their own views of beneficence, non–maleficence and professional integrity poses a significant ethical challenge. This article presents a case that exemplifies the medical and ethical tensions that can arise in treating a patient following a suicide attempt and how to approach their resolution.

Keywords: Advanced Directives, Critical Care, Life–sustaining Treatment, Suicide, Surrogate Decision Maker

• Can suicide ever be a rational, autonomous decision? Why or why not?
• How can patient/family relationships pose a challenge for doctors trying to establish the best course of action for a patient?
• How did the family’s perspective affect the patients’ treatment in this case? Was the outcome of their input positive or negative?
• In the absence of both a clear patient advance directive and familial knowledge of patient preferences, how should medical decisions be made? What did the doctors do in this case?

Web resources:

• Carrigan, CG & Lynch, DJ. (2003). Managing Suicide Attempts: Guidelines for the Primary Care Physician. Primary Care Comparnion to The Journal of Clinical Psychiatry. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC419387/
• Sokol, D et al. (2011). Ethical dilemmas in the acute setting: a framework for clinicians. BMJ. Retrieved from: http://www.medicalethicist.net/documents/Tattoo%20BMJ%20PDF.pdf
• Forster, PL & Wu, LH. Assessment and Treatment of Suicidal Patients in an Emergency Setting. Gateway Psychiatric Services. Retrieved from: https://www.gatewaypsychiatric.com/pdf/Assessment%20and%20Treatment%20of%20Suicidal%20Patients%20in%20an%20Emergency%20Setting.pdf

16. Conversation and the Jehovah’s Witness Dying From Blood Loss

D. Malcolm Shaner, Jateen Prema

Abstract: Religious belief can complicate the usual management of seriously ill patients when the patient is a Jehovah’s Witness and the treatment is a blood transfusion. This narrative highlights critical points in a discussion of two cases wherein the process to promote an exercise of free will also becomes an exercise for the ethics consultant and healthcare team. Despite a medical care program’s carefully considered additions to an electronic healthcare record, additional conversation, investigation, preparation, and an open mind are required. Helping conflicted family members and considering whether and in what context to contact the Jehovah’s Witness Hospital Liaison Committee complicates the approach.

Keywords: Blood Transfusion, Jehovah’s Witness, Religious Rights

• Consider the differences between the two cases with regard to how the hospital handled the patient requests. What did the hospital do well, and what could it have improved?
• In Case 1, what was the effect of attempting the surgery once the patient had changed his mind? How did that change influence the perspective of both the doctors and the patient’s mother?
• In Case 1, was the medical officer’s frankness with the patient appropriate, taking into consideration the beliefs that the patient already expressed?
• How did the doctors in Case 2 actively facilitate moral decision making on the part of the patient?
• Panico, ML et al. (2011). “When a Patient Refuses Life Saving Care”. Am J Kidney Dis. Retrieved from: http://www.medscape.com/viewarticle/751273
• Robinson, BA. (2010). “Jehovah’s Witnesses’ (WTS) opposition to blood transfusions”. Ontario Consultants on Religious Tolerance. Retrieved from: http://www.religioustolerance.org/witness11.htm

17. Caregivers’ Role in Maternal-Fetal Conflict

Abstract: The case, which occurred in a public hospital in Turkey in 2005, exhibits a striking dilemma between a mother’s and her fetus’ interests. For a number of reasons, the mother refused to cooperate with the midwives and obstetrician in the process of giving birth, and wanted to leave the hospital. The care providers evaluated the case as a matter of maternal autonomy and asked the mother to give her consent to be discharged from the hospital, which she did despite the fact that her cervix was fully open. She left the hospital and gave birth shortly thereafter. Subsequently, the baby died two days later. In light of contemporary ethical principles, the mother’s competency could be debatable due to the physical and psychological conditions the mother confronted. Furthermore, protection of the fetus’ life should have been taken into account by the caregivers when making a decision concerning discharging of the mother.

Keywords: Ability to Consent, Autonomy, Beneficence, Decision Making Capacity, Ethical Dilemma, Fetal Beneficence, Fetal Rights, Maternal Autonomy, Maternal–Fetal Conflict, Pregnancy

• Did the mother have the right to demand to leave? Would your answer to this question change if discharging the mother endangered the fetus? Why or why not?
• Was the mother in a position to make an autonomous choice? Other than autonomous patient decision-making, are there models of decision-making that might have been considered in this case? How might they be applied?
• How could the care team have done better? Should a hospital have policies to help prevent or address such a situation? If so, what would these policies look like?
• Schetter, CD & Tanner, L. (2012). Anxiety, depression, and stress in pregnancy: Implication for mothers, children, research, and practice. Current Opinion in Psychiatry. Retrieved from: http://health.psych.ucla.edu/CDS/documents/DunkelSchetterTanner-2012COPsychiatry.pdf
• Post, LF. (1996). Bioethical Consideration of Maternal-Fetal Issues. Fordham Urban Law Journal. Retrieved from: http://ir.lawnet.fordham.edu/cgi/viewcontent.cgi?article=2171&context=ulj

18. The Surgeon as Stakeholder: Making the Case Not to Operate

Abstract: Surgeons are in a unique position, serving as gatekeepers to the operating room. They determine if operations are possible, are indicated, and have a reasonable risk–to–benefit profile. When an operation is indicated and the patient is amenable to it, the conversation between surgeon and patient is usually straightforward. On the other hand, when a patient’s co–morbidities substantially increase the risk of operative intervention, surgeons often question the utility of offering their services. These situations become immensely more difficult when patients have the expectation of being offered surgical treatment. This case describes the clinical encounter between an endocrine surgeon and an 83–year–old woman who has been incidentally found to have adrenal metastasis from melanoma. The patient wants an operation that the surgeon is reluctant to offer because of her frailty and high operative risk. The case focuses on the ethical dilemma that arises when a patient wants an operation that a surgeon does not want to perform.

Keywords: Metastatic Melanoma, Palliative Care, Respect for Autonomy, Shared Decision–Making, Surgical Ethics

• What reasons are acceptable for refusing to operate on a patient? Why?
• How should surgeons approach situations in which they are consulted for operative interventions that they do not want to provide?
• When surgeons think the risk of surgery is too great and not justified but patients think the risks are worthwhile, whose assessment should prevail? Why?
• Louden, K. (2015).“Risk Calculator Does Not Alter Surgeons’ Choice to Operate". Medscape. Retrieved from: http://www.medscape.com/viewarticle/852708
• Kasman, DL. (2004).“When is Medical Treatment Futile?: A Guide for Students, Residents, and Physicians." Journal of General Internal Medicine. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1492577/

19. The Enduring Case

Craig M. Nelson

Abstract: In clinical ethics an enduring case takes on a life of its own and comes to closure over a long period of time. This essay describes the evolution of such a case over a 1–year period. The case involves a 90–year old male patient with multiple chronic medical conditions who lacked decision–making capacity, was a resident of a long–term care facility, and did not have known previously expressed wishes regarding medical treatment. The ethics consultation initially revolved around this question: What method or process must be employed so that medical treatment decisions could be ethically reviewed and could include a shared decision–making process for Mr. Smith? This case analysis describes the evolution of this case and argues that the good of the patient must remain paramount throughout an enduring case.

Keywords: Ethical Appropriateness, Ethical Process, Moral Community, Treatment Planning

• What kinds of processes might help an incapacitated patient’s voice be heard, especially when the patient’s values were never formally documented?
• Why might it be important to try to give voice to an incapacitated patient’s values?
• What went well with the process in this clinical ethics consultation? Might there be opportunities for improving the processes deployed in this case, and if so, what might they be?
• Ten Myths About Decision-Making Capacity: A Report by the Natioanl Ethics Committee Of the Veterans Health Administration. (2002). Retrieved from: http://www.ethics.va.gov/docs/necrpts/nec_report_20020201_ten_myths_about_dmc.pdf
• California Advance Health Care Directive Probate Code Section 4701. Retrieved from: https://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=PROB&division=4.7.&title=&part=2.&chapter=2.&article=

20. Military Health Care Dilemmas and Genetic Discrimination: A Family’s Experience with Whole Exome Sequencing

Benjamin M. Helm, Katherine Langley, Brooke B. Spangler, Samantha A. Schrier Vergano

Abstract: Whole–exome sequencing (WES) has increased our ability to analyze large parts of the human genome, bringing with it a plethora of ethical, legal, and social implications. A topic dominating discussion of WES is identification of “secondary findings" (SFs), defined as the identification of risk in an asymptomatic individual unrelated to the indication for the test. SFs can have considerable psychosocial impact on patients and families, and patients with an SF may have concerns regarding genomic privacy and genetic discrimination. The Genetic Information Nondiscrimination Act of 2008 (GINA) currently excludes protections for members of the military. This may cause concern in military members and families regarding genetic discrimination when considering genetic testing. In this report, we discuss a case involving a patient and family in which a secondary finding was discovered by WES. The family members have careers in the U.S. military, and a risk–predisposing condition could negatively affect employment. While beneficial medical management changes were made, the information placed exceptional stress on the family, who were forced to navigate career–sensitive “extra–medical" issues, to consider the impacts of uncovering risk–predisposition, and to manage the privacy of their genetic information. We highlight how information obtained from WES may collide with these issues and emphasize the importance of genetic counseling for anyone undergoing WES.

Keywords: Genetic Discrimination, Genetic Information Nondiscrimination Act of 2008 (GINA), Genetic Testing, Incidental Findings, Military, Secondary Findings

• It is clear that this type of genetic testing is revolutionizing diagnoses, but it comes with ethical concerns. Do the advantages of WES outweigh the possible disadvantages? Why or why not?
• Do you agree that pre–test conversations should be required in every scenario? Why or why not?
• When the SCN5A gene mutation was found, should the father have told his superiors? Why or why not?
• The SCN5A mutation is probabilistic–not all individuals who have the mutation will develop symptoms. However for some patients, the only presenting feature is sudden cardiac death. What are some reasons patients might have for—and against—wanting this information?
• National Human Genome Research Institute. (2014a). Fact sheet: Genetic discrimination. Retrieved from: http://www.genome.gov/10002077
• Majewski, J. et al., (2011). What Can Exome Sequencing Do For You? Journal of Medical Genetics. Retrieved from: http://www.medscape.com/viewarticle/749695_1
• Collins, F. (2007). The threat of genetic discrimination to the promise of personality medicine. Testimony to the United States House of Representatives Committee on Ways and Means. Retrieved from: http://waysandmeans.house.gov/Media/pdf/110/3-14-07/CollinsTestimony.pdf

21. Conflicting Values: A Case Study in Patient Choice and Caregiver Perspectives

Margot Eves, Phoebe Day Danziger, Ruth M. Farrell, Cristie M. Cole

Abstract: Decisions related to births in the “gray zone" of periviability are particularly challenging. Despite published management guidelines, clinicians and families struggle to negotiate care management plans. Stakeholders must reconcile conflicting values in the context of evolving circumstances with a high degree of uncertainty within a short time period. Even skilled clinicians may struggle to guide the patient in making value–laden decisions without imposing their own values. Exploring the experiences of one pregnant woman and her caregivers, this case study highlights how bias may undermine caregivers’ ability to meet their obligation to enhance patient autonomy and the moral distress they may experience when a patient’s values do not align with their own. Management strategies to mitigate the potential impact of bias and related moral distress are identified. The authors then describe one management strategy used in this case, facilitated ethics consultation, which is focused on thoughtful consideration of the patient’s perspective.

Keywords: Bias, Ethics Consultation, “Gray Zone", Moral Distress, Perspective–Taking

• How can we distinguish between concerns that reflect bias versus concerns that reflect legitimate differences in values?
• Does it matter if a patient’s choices reflect bias, or do patients have the right to have their decisions respected even if they are based on potentially unsubstantiated biases or beliefs?
• Given the controversial nature of the patient’s viewpoint regarding life with disabilities, did the providers have an obligation to try to mitigate the patient’s bias? Why or why not?
• What are some of the ways that the providers could have tried to address the patient’s biases regarding life with a disability? For example, should the patient have been offered the opportunity to speak to parents of children with disabilities, specifically those disabilities more likely to be a result of complications from prematurity? Would it be ethically permissible to require that she do so?
• Are there other, more effective ways to support professionals who take care of patients whose values and choices differ so significantly from their own?
• Lyerly, AD. (2008). Reframing neutral counseling. Virtual Mentor. Retrieved from: http://virtualmentor.ama–assn.org/2008/10/ccas3–0810.html
• Guttmacher Institute. (2015). State policies in brief: An overview of abortion laws. New York: Guttmacher Institute. Retrieved from: http://www.guttmacher.org/statecenter/spibs/spib_OAL.pdf

22. Ethical Dilemmas Relating to the Management of a Newborn with Down Syndrome and Severe Congenital Heart Disease in a Resource-Poor Setting

Ama K. Edwin, Frank Edwin, Summer J. McGee

Abstract: Decision-making regarding treatment for newborns with disabilities in resource-poor settings is a diffi cult process that can put parents and caregivers in confl ict. Despite several guidelines that have helped to clarify some of the medical decision-making in Ghana, there is still no clear consensus on the specifi c moral criteria to be used. This article presents the case of a mother who expressed her wish that her child with Down syndrome should not have been resuscitated at birth. It explores the ethical issues at stake in both her misgivings about the resuscitation and her unwillingness to consider surgical repair of an atrioventricular (AV) canal defect. Knowing that children born with Down syndrome are able to pursue life’s goals, should our treatment of complete AV canal defect in such children be considered morally obligatory, even in resource-poor settings like Ghana?

Keywords: Atrioventricular Septal Defect, Down Syndrome, Ethical Duty, Newborn, Withholding Treatment

• What is the difference between a substantiated concern and one that reflects bias? How can providers assess the difference?
• The mother’s views about the relative lack of value of a person with disabilities are controversial and seem to reflect an unfair or unfounded bias. In light of this, did the provider have an obligation to try to address the mother’s bias?
• If health care providers had an obligation to try to mitigate or address the mother’s bias, how should they have attempted to do so? Should the mother have been required to speak to other parents of children with disabilities?

23. System Failure: No Surgeon To Be Found

Carol Bayley

Abstract: A woman admitted to the emergency room of a hospital died because no surgeon could be found to stop the bleeding from injuries she sustained in a farming accident. The case points to ethical shortcomings both institutionally and professionally. The call system is inadequate, and physician fears of being sued or insufficiently compensated contribute to the overall problem. Potential responses include the institutional equivalent of a root cause analysis and an understanding of the pressures brought to bear on physicians to treat emergencies.

Keywords: Emergency Call, Institutional Ethics, John Glaser, Organizational Ethics, Root Cause Analysis

• Do you think a physician has an ethical obligation to try to help a patient who will otherwise die, even when the patient’s problem is not within the physician’s specialty? If so, how do you ground this obligation? If not, why not?
• If physicians have such an obligation, what ought they to do when they face barriers to fulfilling it?
• People often see themselves in the best light; it’s very human to see one’s self favorably, and to try to explain away one’s own responsibility when an error occurs. In light of this natural tendency, what structures could be set into place to help physicians and other stakeholders take responsibility in these types of situations?

24. A Life Below the Threshold?: Examining Conflict Between Ethical Principles and Parental Values in Neonatal Treatment Decision Making

Thomas V. Cunningham

Abstract: Three common ethical principles for establishing the limits of parental authority in pediatric treatment decision–making are the harm principle, the principle of best interest, and the threshold view. This paper considers how these principles apply to a case of a premature neonate with multiple significant co-morbidities whose mother wanted all possible treatments, and whose health care providers wondered whether it would be ethically permissible to allow him to die comfortably despite her wishes. Whether and how these principles help in understanding what was morally right for the child is questioned. The paper concludes that the principles were of some value in understanding the moral geography of the case; however, this case reveals that common bioethical principles for medical decision–making are problematically value-laden because they are inconsistent with the widespread moral value of medical vitalism.

Keywords: Harm Principle, Best Interests, Threshold View, Neonatal Decision Making, Values, Medical Vitalism

• How should the ethicist think through the relationship between apparently competing bioethical views in particular clinical circumstances?
• Should there be a competency evaluation for parents, guardians, surrogates, or other proxy medical decision makers?
• Should society develop policies to limit health care in circumstances where there is an appreciable likelihood of extremely poor outcomes?

25. Ethical Challenges in the Care of the Inpatient with Morbid Obesity

Paul L. Schneider, Zhaoping Li

Abstract: Objective: To provide a thorough analysis of the range of ethical concerns that may present in relation to the care of the morbidly obese inpatient over the course of several years of care. Methods: A narrative of the patient’s complex medical care is given, with particular attention to the recommendations of three separate ethics committee consultations that were sought by his health care providers. An ethical analysis of the relevant issues is given within the Principles of Biomedical Ethics framework, highlighting the principles of autonomy, beneficence, non–maleficence, and justice. Results: The case study presents a patient with morbid obesity, obesity hypoventilation syndrome, and numerous ICU admissions. The first ethics consultation was requested regarding the permissibility of forcing bariatric surgery on him against his will. The second consultation was regarding a request by nursing staff to no longer attempt to mobilize him. The third was regarding the patient’s refusal to be discharged. Conclusions and Recommendations: The care of inpatients with morbid obesity presents a unique set of practical and ethical challenges to health care personnel. A disciplined approach to ethical analysis using the Principles of Biomedical Ethics framework may be helpful in dealing with these challenges. Recommendations for improvement are made for the individual and local settings, as well as nationally.

Keywords: Autonomy, Beneficence, Ethics, Justice, Morbid Obesity, Non–Maleficence, Paternalism, Professionalism

• Sometimes in health care there is a mismatch between a units’ ideal admission criteria and the actual patients admitted. Is it appropriate to try to help health care workers feel more comfortable with patients who are not ideal in some way? If so, are there limits to this approach?
• A “hard paternalism” approach in this case might have involved placing this patient on a locked unit so that he could not have restaurant deliveries. Given his dire clinical circumstances, could this have been ethically supported?
• Do you agree that providers were overly reliant on the principle of autonomy in allowing this patient to be poorly compliant with dietary therapy in the on–campus nursing home? If not, can you suggest alternate rationales?

26. The Clinical Bioethicist’s Role: Should We Aim to Relieve Suffering?

Deborah L. Kasman

Abstract: Bioethics consultants arrive at their profession from a variety of prior experiences (e.g., as physicians, nurses, or social workers), yet all clarify ethical issues in the care of patients. The integrated bioethicist’s role often extends beyond case consultations. This case presents a young person suffering a prolonged and gruesome end–of–life journey, which raised questions regarding the bioethicist’s role in alleviating suffering as part of the health care team. The case is used to illuminate forms of suffering experienced by patients, families, and health care providers. The question arises as to whether it is in the ethicist’s jurisdiction to alleviate suffering, and if the answer is “yes,” then whose suffering should be addressed? The discussion addresses one approach taken by an integrated bioethicist toward promoting delivery of ethical and compassionate care to the patient.

Keywords: Clinical Ethics Consultation, Healing, Meaning in Death, Provider Well–Being, Suffering

• Is relief of suffering part of a clinical ethics consultation? Should it be? Why or why not?
• How do you respond to suffering? What are your most productive responses? Unproductive responses?
• Should a clinical ethicist be involved in clinical care without maintaining direct patient contact? If patients/families refuse ethics involvement, what role can the clinical ethicist play in promoting ethical medical decision–making?
• When a clinical ethicist is also trained as a licensed health provider (e.g., physician, nurse, chaplain, or social worker), can prior clinical experience affect the ethicist’s role in responding to suffering? Can this be an advantage, a hindrance, or both?

27. To Enroll or Not to Enroll?: A Researcher Struggles with the Decision to Involve Study Participants in a Clinical Trial That Could Save Their Lives

Roberto Abadie

Abstract: Hundreds of thousands of clinical trials are conducted annually around the world, working to further scientific knowledge and expand medical treatment. At the same time, clinical trials also present novel challenges to researchers who have access to large pools of research participants and are routinely approached by pharmaceutical companies seeking to recruit subjects for clinical trials. This case study discusses the ethical dilemmas faced by a community health investigator who received an invitation to enroll people who inject drugs (PWID) into a clinical trial of a drug that promised a new treatment option for Hepatitis C. The author elaborates on the ethical tensions that he confronted between “doing good” and “avoiding harm. The paper suggests that issues of distributive justice should also be considered, particularly when the drugs being tested might eventually command prices that place them out of reach of the population enrolled in the trial. This case does not attempt to provide an ethical road map to assist researchers in similar circumstances, but rather to illustrate some of the considerations involved in making a decision about whether or not to participate in clinical trials research.

Keywords: Beneficence, Clinical Trials, Enrollment, Justice, Non-Maleficence

• Since they were originally formulated a few decades ago, the principle of respect for autonomy seems to have gained priority in detriment of the principle of justice. With drug prices reaching exorbitant levels—more than eighty thousand dollars for a full HCV treatment—placing access beyond the reach of many, shouldn’t bioethicists reconsider the way we think about justice?
• The principle of beneficence establishes the requirement of a social good, as one of if its main criteria. But drug prices seem to benefit the pharmaceutical industry while depriving many of much needed drugs. With this in mind, how do you think we should interpret this principle?
• Imagine you or somebody you know has the opportunity to participate in a clinical trial. What elements would you need in order to make an informed decision? And an ethical one?

28. Sometimes Those Hoofbeats Are Zebras: A Narrative Analysis

Abstract: The case of BB, an 11-year-old girl who was hospitalized because of sudden odd seizure-like symptoms and catatonic affect, highlights several ethical issues and communication problems. The correct diagnosis was initially missed, partly because physicians are trained to think of the most common explanation for a patient’s symptoms; the medical education truism “when you hear hoofbeats, think horses, not zebras” was not helpful in BB’s case. The common habit of medical professionals to not revisit a diagnosis once one is established also led to missed opportunities to provide appropriate care for this young patient. The difficulty nurses and/or family members have in questioning a diagnosis and treatment plan are also discussed.

Keywords: Clinical Ethics, Ethical Focus, Case Study, Communication, Medical Error, Moral Distress, Two-Challenge Rule

• Hospitals are generally reluctant to admit patients known to have problematic behavior or unknown diagnoses, yet in this case, having a new physician on her case was the key to making an accurate diagnosis. How might transfers between medical facilities be reimagined to improve patient care, rather than being seen as “dumping” of undesirable problematic patients and families?
• What interventions or changes in protocol might empower nurses and family members to productively question a physician’s diagnosis and treatment plan for a patient?

29. A Jehovah’s Witness Adolescent in the Labor and Delivery Unit: Should Patient and Parental Refusals of Blood Transfusions for Adolescents Be Honored?

Johan Christiaan Bester, Martin Smith, Cynthia Griggins

Abstract: A 15-year-old was admitted to the labor and delivery unit for induction of a 41-week-gestation pregnancy. Her parents, members of Jehovah’s Witnesses, and the patient, who had been studying the religion but had not yet been baptized, were adamant that no blood transfusions would be accepted even if a life-threatening hemorrhage were to occur. In our analysis, we examine the underlying ethical conflict and issues raised by this case. We considered two important ethical questions in analyzing the dilemma: first, whether adolescents are capable of providing autonomous and authentic refusals for lifesaving interventions; and second, whether parents can refuse such interventions for their adolescent children based on their religious beliefs. We provided justifications for not considering the adolescent’s refusal as autonomous and for overruling the parental refusal, concluding that there was ethical support for providing potentially lifesaving transfusions should they become clinically indicated. We also suggested strategies to avoid blood loss and the need for transfusions in order to respect the stated values and preferences of the patient and her family to the greatest degree possible. In order to protect the privacy of the patient and her family, details in this case have been changed and no identifiable information has been used.

Keywords: Best Interests, Blood Transfusions, Jehovah’s Witnesses, Principlism, Religious Conflict

• The authors have defended a principle that it should generally be presumed that adolescents lack the necessary decision–making capacity to provide autonomous refusals for life–saving treatments, unless convincing evidence to rebut this presumptionis present. Do you agree with this principle, and if so, why? What would count as convincing evidence? If not, what reasons can you provide for dismissing this principle?
• In the article a threshold is described for parental decision–making. Beyond that threshold, it is the duty of clinicians to challenge the parental decision, and the duty of the state to overrule the parental decision. Do you agree that the threshold to overrule parental decision–making was reached in this case? Why or why not? What might have changed your view?
• Different jurisdictions have reached different conclusions in cases regarding the authority of adolescents to refuse life–saving treatments. States also have different stances on the “mature minor” rule. How does the neurodevelopment and cognitive development evidence the authors briefly discuss in the article influence your thinking on these issues, and specifically on whether states should have a “mature minor” rule and how they should interpret and apply it?

30. Reframing Medical Appropriateness: A Case Study Concerning the Use of Life-Sustaining Technologies for a Patient With Profoundly Diminished Quality of Life

Colleen M. Gallagher, Elijah Weber, Nisha Rathi

Abstract: This case study considers the clinical ethics issues of medical appropriateness and quality of life for patients who are critically ill. The case involves a terminally ill cancer patient with a profoundly diminished quality of life and an extremely poor prognosis; his spouse desires to bring him home, where she will arrange to keep him alive for as long as possible via life-sustaining interventions. The analysis engages with the complicated notion of medical appropriateness, both in general and as it pertains to life-sustaining interventions in a critical care setting, and considers the ethical implications of the various ways in which one might understand this concept. It also addresses the significance of quality-of-life determinations, emphasizing the role of individualized values in determining the importance of quality of life for clinical decision-making. The discussion concludes with a description of the two strategies employed by the ethics team in helping to alleviate the medical team’s concerns about this case.

Keywords: Case Study, Method, Clinical Ethics Focus

• Is the goal of keeping a terminally ill patient, with a profoundly diminished quality of life, alive for as long as possible via life-sustaining technologies a medically appropriate goal of care?
• Is “medical appropriateness” a useful term for conducting an ethical analysis of a particular case?
• What is the ethical significance of a profoundly diminished quality of life for determining goals of care for a particular patient?
• Do quality of life considerations ever outweigh patient or surrogate decision-maker preferences regarding the ethical justifiability of continuing with life-sustaining interventions?

31. "We Didn't Consent to This"

Shalini Dalal, Jessica A. Moore, Colleen M. Gallagher

Abstract: Patients and their families have identified the need for ongoing and effective communication as one of the important aspects of medical care, especially when the cessation of disease–modifying therapies is being considered at the end–of–life (EOL). Despite recognizing that this communication is extremely important, clinicians are uneasy and find themselves inadequately trained to “break bad news” and manage emotional responses from the patient/family. The inherent difficulties in accurately predicting prognosis and discussing potential complications make these conversations even more challenging. In most circumstances, patients and their families want to know the truth about their disease and what will be done to make them feel better, and to receive enough information to help them choose a course of action. For many terminally ill patients and their families who have elected to transfer to the palliative care unit (PCU) for EOL care, the assumption is that most of these conversations have already been held, and the ongoing focus becomes managing these patients’ physical and psychological sources of distress, validating their and their families’ emotional responses and preparing them for what is to come. This case report illustrates the need for cultural understanding and clear communication among physicians, members of the clinical team, and patients and their family members.

Keywords: Communication, Cultural Competence, End–of–Life, Palliative Care

• What can/should one do to determine if communication of a poor prognosis has been provided in a manner and to the extent that the patient or surrogate decision–maker wants and allows him/her to make a fully informed decision? How can one go about exploring the extent of patient/family understanding and goals/expectations? What would you do if you discovered that the poor prognosis has not been explained in enough detail to facilitate informed decision–making?
• What resources are available in your institution to help health care providers improve upon their cultural competence with the patient populations seen most often in your area? What resources are available to assist in the care, real–time, of patients from various faith traditions and cultures in your hospital?
• Have you experienced a situation similar to the one presented here? What did you do in that case or would you do in future cases to improve communication and outcomes? Is this a personal practice, or has it been implemented as a “standard practice/ process” in your group, when applicable?

32. "Screen Shots: When Patients and Families Publish Negative Health Care Narratives Online"

Marleen Eijkholt, Jane Jankowski, Marilyn Fisher

Abstract: Social media sites and their relationship to health care is a subject of intense debate. Common discussions regarding social media address patient privacy, or e-professionalism. This case study explores the tensions that arise for health care providers when negative patient statements surface in social media and blog forums. Recognizing that patients and families often find relief in sharing personal illness narratives, we contemplate if, and how, individual health care professionals and institutions should address complaints aired in public, unmoderated media. Our discussion begins by presenting a case of a family blogging on the Internet to share grievances (to deidentify the case, we have changed some details). Next, we offer an exploration of the impact on health care delivery when professionals become aware of specific criticisms published online. Strategies for managing electronic criticisms are then proposed. We conclude by proposing a novel E-THICS approach to address negative patient expressions via electronic word of mouth (eWOM). Our examination of this evolving issue focuses on maintaining satisfactory relationships between health care providers and patients/families when dealing with health care narratives published in open online media.

Keywords: Care-Ethics, Ethics, Internet, Negative Comments, Online, Patient Blogs, Social Media

• What strategies does your institution offer to deal with publicly displayed negative comments from patients?
• To what extent should institutional support be offered to HCPs in interacting with negative eWOM?
• Should providers communicate their distress to a patient (or to family members) about negative expressions in narrative formats, and if so, how can this be done?

33. "A Personal Narrative on Living and Dealing with Psychiatric Symptoms after DBS Surgery"

Frédéricand Gilbert, John Noel M. Viaña

Abstract: Although deep brain stimulation (DBS) may result in dramatic motor improvement in people with Parkinson's disease (PD), it has been correlated with a number of postoperative psychiatric side effects. We report a case of a person with PD experiencing depression and hypomania following DBS surgery. We provide a detailed report of the patient's personal experiences dealing with and managing these psychiatric side effects for three years. Providing a personal narrative focusing on detailed patient subjective experiences complements reports that give insight into the short- and long-term effects of DBS on established psychiatric measures and neurologic activity. But, most importantly, such a qualitative approach provides prospective patients and clinicians with a broader ethical picture of real-life challenges faced and coping strategies employed by PD patients treated with DBS who are experiencing psychiatric adverse events. This case study reinforces the ethical need to disclose the potential risk of harm to prospective patients as well as the importance of establishing a multidisciplinary postoperative supportive group.

Keywords: Deep Brain Stimulation, Identity, Neuropsychiatric Effects, Parkinson's Disease, Self, Side Effects

• What obligations do DBS providers and researchers have to offer follow-up care aimed at addressing potential personality and behavior changes that can cause patients distress?
• What are the trade-offs between the motor ben-efts of DBS and the potential psychological harm induced by treatments?
• Should decision aids be developed to help patients weigh the pros and cons? What would you put into such a decision aid?
• Should family members have a greater voice in DBS decision-making than in ordinary healthcare decision-making given the potential impact of DBS on personality and behavior?

34. "The Will Reconsidered: Hard Choices in Living Organ Donation"

Robert M. Guerin, Elizabeth O’Toole, Barbara Daly

Abstract: In the following article, we illustrate an interview between a living donor advocate and a potential living organ donor in which the donor faced a hard choice: the reasons to donate and the reasons not to donate were equally persuasive. In the discussion that follows, we analyze the act of willing, what differenti-ates coercion and willing, and how the case study highlights a different, but by no means rare, instance in which donors feel paralyzed by the choice at hand. In such cases, we suspect that donor advocates either do not approve the potential donor for transplantation or simply remain neutral. But we think that this approach benefits neither the donor nor the recipient. We conclude this study with recommendations for living donor advocates, providing questions that might solicit donors’ deeper values and suggesting that in these situations donors may benefit from additional time for reflection.

Keywords: Coercion, Donor Advocate, Hard Choice, Living Donor, Self, Willing, Persuasive Communication, Shared Decision Making, Competing Values

35. "Malleable Transplant Criteria: At What Cost?"

Angel Alsina, Rebekah Apple, Nyingi Kemmer and James P. Orlowski

Abstract: An 18-year-old male who had been diagnosed at age 7 with a rare, progressive liver disease was referred to the transplant center and received a transplant, even though he did not meet the center’s criteria for a patient with hepatopulmonary syndrome (HPS). Complications required relisting the patient urgently, but he eventually fully recovered; total hospital charges for his treatment exceeded $5 million. Reflection upon the case resulted in analysis of two ethical questions: primarily, clinician obligation to balance the provision of actuarially fair health care to society against the healing of a single patient; secondarily, the effects of malleable transplant criteria on trust in the patient selection process. We affirmed that physicians should not be principally responsible for justifying financial investment to society or for upholding beneficence beyond the individual physician and patient relationship in order to contain costs. We concluded, however, that such instances, when combined with manipulation of transplant center criteria, pose a potential threat to public trust. We therefore suggested that transplant centers maintain independent ethics committees to review such cases.

Keywords: Beneficence, Organ Donation, Organ Transplant, Rationing, Transplant Criteria, Ethics Committees, Hospital Charges, Moral Obligations, Hepatopulmonary Syndrome

• The authors mention rationing and affirm the tenet that it is unethical to withhold care because of exorbitant costs. What are the ethical implications of this practice, given that the United States has acknowledged the current system as unsustainable? Would you defend providing heroic, expensive care to every patient, regardless of the effect such behavior would have on the future of health care?
• The authors noted the difference between the allocation of organs and patient selection. A number of ethical principles are applied to donation and transplantation, and they often contradict each other. Is it possible to reconcile utilitarianism and deontology? What other principles collided in this case, and how could these conflicts have been avoided?
• A recent study in JAMA found that “prices of labor and goods, including pharmaceuticals and devices, and administrative costs appeared to be the main drivers” of high health care costs in the United States (Papanicolas, Woskie, & Jha, 2018, p. 1024). Growing attention is being paid to the income of nonclinical health care professionals, and Commins (2018) noted that compensation for nonclinician chief executive officers in over 20 US health systems almost doubled between 2005 and 2015. How much of an issue is compensation for nonclinicians, given the rising amount of health care spending in the country? Would adjustments to administrative costs necessarily result in more money being spent on patient care?

36. "Responding to Requests for Aid-in-Dying: Rethinking the Role of Conscience"

Elizabeth R. Brassfield, Manisha Mishra, and Mara Buchbinder

Abstract: This case study illustrates the complex role that a physician’s conscience can play in end-of-life care. We examine a case from Vermont in which a terminally ill patient requests aid-in-dying from her primary care physician under the state’s “Patient Choice and Control at End of Life” Act (Act 39). The physician feels conflicted: she is opposed to prescribing death-hastening medication but does not want to abandon her patient. Much of the medical ethics literature on conscience focuses on whether health care professionals should be permitted to abstain from providing morally contested medical services. Our analysis highlights the interplay of conflicting values that inform the physician’s engagement with aid-in-dying, demonstrating that the issue is often more nuanced than the question of whether or not a physician can (or should) opt out.

Keywords: Conscience; End-of-Life Care; Medical Ethics; Nonabandonment; Patient-Provider Relationship; Physician Aid-in-Dying/Physician-Assisted Suicide; Terminal Illness

• How does Dr. Jones’s response to Mary challenge conventional bioethical views of conscientious objection?
• What are the limits of a commitment to nonabandonment?
• Given a more robust understanding of the role of conscience in medical care, what form, if any, should protections for conscience take?

37. "Getting to the Heart of the Matter: Navigating Narrative Intersections in Ethics Consultation"

Leslie A. Kuhnel

Abstract: Ethics consultants can apply a narrative ethics approach to address ethical challenges that arise in critical situations. This approach recognizes how those involved in the narrative make sense of, keep faith with, and try on new identities and new understanding of their stories. This case study explores the ways in which the stories of patient, provider, and clinical ethics consultant intersect, and considers how the organic nature of the narrative ethics approach allows ethics consultants to navigate the stories of multiple stakeholders as they grapple with complex health care decisions. This essay also suggests that clinical ethics consultants applying the lens of narrative ethics have an obligation to approach consultations with courage, professional humility, intellectual curiosity, and an appreciation for the narratives of as many of the stakeholders as possible (including one’s own).

Keywords: Ethics Consultation, Intersecting Stories, Narrative Ethics

Discussion Questions:

• When have you experienced making sense, keeping faith, and trying on in your own personal or professional health care encounters?
• What narrative traps have you experienced in the course of clinical ethics consultation?
• How has your own personal narrative shaped your perceptions of this case?

38. "Speaking for Our Father"

Nico Nortjé

Abstract: A living will is a document in which an individual can communicate his or her health care choices to loved ones in the event that he or she is unable to do so directly. Many surrogate decision-makers use living wills as guides; however, the existence of such documents does not entirely relieve them of their burden. Surrogate decision-makers often need to consider the impact of the personal and family burdens entailed by their decisions, and the stress accompanying these burdens regularly creates high levels of anxiety and depression. This stress can be exacerbated when two surrogate decisionmakers are at loggerheads as to the best way forward. This case study illustrates the effects of stress accompanying disagreement among surrogate decision-makers—here, the patient’s adult sons—and demonstrates that a process of listening can help the bioethicist identify the values that are important to the patient and, consequently, to the surrogate as well, and use these values to help address the issue.

Keywords: Ethics, Intensive Care Unit, Living Will, Medical Power of Attorney, Surrogate Decision-Making

• Have you experienced similar cases where parties disagreed as to what was best for the patient? What did you do?
• Do you think it is better for surrogate decisionmakers to have leeway in interpreting the wishes of a patient, or should they have explicit instructions?
• There may be disagreement and tension within the health care team as to the best way forward. How can you assist team members in presenting a unified message to the family?

39. "Forcible Amputation in Delusional Patients: A Narrative Analysis of Decisional Capacity"

Lori A. Roscoe, David P. Schenck, Joel L. Eisenberg

Abstract: This case study concerns the predicaments faced by two women who each had been advised by her physicians to have a gangrenous foot amputated to prevent the potentially fatal spread of infection. In both cases, the determination of the patients' decisional capacity was a critical component in judging whether or not to honor their medical treatment decisions. The communicative complexity of navigating a double bind, a situation in which a person confronts a choice between two undesirable courses of action, is also discussed. The patients in these cases had no medically appropriate choice that also respected other valued outcomes, such as independence, a sense of dignity, or control over one's destiny. Taken together, these cases raise issues about the context-specific meaning of decisional capacity and its role in informed consent.

Keywords: Decisional Capacity, Double Bind, Amputation, Communication

• Under what circumstances might a decision to amputate over the patient's objections be appropriate?
• Under what circumstances can a delusional or cognitively impaired patient give informed consent for medical treatment?
• Suppose the patient was not delusional but nonetheless believed that merely washing the wound with soap and water would make it better. Would it then be ethical to perform the amputation against her will? What role does rationality play in determining competence and giving informed consent?
• How can a patient's wishes be acknowledged in a plan for treatment, even if she or he is deemed to lack decisional capacity?

40. "A Health Care Systems Approach to Improving Care for Seriously Ill Patients"

Lisa Soleymani Lehmann, Jill Lowery, Virginia Ashby Sharpe, Kenneth A. Berkowitz

Abstract: Health care systems can go beyond advance care planning to create mechanisms for eliciting and documenting the goals of care and life-sustaining treatment decisions of patients with serious life-limiting illnesses. These systems can help ensure that patients receive care that is consistent with their values and preferences. We describe a case in which even though a patient with a serious illness had completed an advance directive and had discussed preferences with family, clinicians failed to identify the patient's authentic preferences for life-sustaining treatment. We offer a stepwise framework for communication with seriously ill patients and describe a systems approach to transforming the process of eliciting, documenting, and honoring patients' life-sustaining treatment preferences in the U. S. Veterans Health Administration.

Keywords: Advance Care Planning, Communication, End-of-Life Care

41. "An Ethics of Unknowing: Discerning Ethical Patient-Provider Interactions in Clinical Decision-Making"

Abstract: There is an irreducible amount of uncertainty in clinical decision-making. Both health care providers and patients experience anxiety elicited by clinical uncertainty, and this can lead to missed opportunities for healthy shared decision-making. In order to improve the patient-provider relationship and the ethical qualities of decision-making, the provider first needs to recognize where his/her "unknowing" exists. This article presents a model for a unique ethics of unknowing by identifying three levels at which the provider's knowledge or lack thereof impacts clinical decision-making. The model illuminates ethical choices that providers can make to promote healthy patient-provider relationships. The means by which an ethics of unknowing informs shared decision-making in patient care will be exemplified through a case study of one patient's encounters with several physicians while making difficult decisions throughout her breast cancer journey.

Keywords: Clinical Ethics, Uncertainty, Epistemology, Shared-Decision Making, Patient-Provider Relationship, Patient Care, Medical Decision-Making, Breast Cancer

42. "How Should Physicians Manage Neuro-prognosis with ECPR?"

Ian J. McCurry, Jason Han, Andrew Courtwright

Abstract: Rapidly advancing technologies in the field of extracorporeal cardiopulmonary resuscitation (ECPR) have presented a new challenge in accurate neuroprognostication following cardiac arrest. Determination of brain state informs the prognostic picture and allows providers to begin effective communication regarding likelihood of meaningful neurological recovery as defined by patients or family members. The evolving role of sedation during ECPR and its impacts on ethical tension in decision-making is reviewed. Work surrounding the advancing field of neuroprognostication after cardiac arrest and hypothermia is summarized and implications of premature withdrawal of life-sustaining treatments are discussed. Advances that improve predictive value for neurological recovery are utilized in affirming and discussing the implications for end-of-life wishes of individuals in the setting of intensive resuscitative therapies.

Keywords: End Of Life, Resuscitation, Ethics, Critical Care, ECMO

43. "The Ethics of Choosing a Surrogate Decision Maker When Equal-Priority Surrogates Disagree"

Matthew Shea

Abstract: When decisionally incapable patients need a surrogate to make medical decisions for them, sometimes the patient has not appointed a healthcare agent and there is intractable disagreement among potential surrogates of equal priority, legal rank, or relation to the patient (e.g., child vs. child, sibling vs. sibling). There is no ethical, legal, or professional consensus about how to identify the appropriate surrogate in such circumstances. This article presents a case study involving an elderly female patient whose four children disagree about whether to continue life-sustaining treatment for their mother, along with an ethical analysis of various strategies for selecting the appropriate surrogate in cases of conflicting equal-rank family members. It critically examines three different strategies—chance, majority rules, and quality of relationship with the patient—and defends the third approach.

Keywords: Surrogate Decision Making, Equal-Priority Surrogates, Family Disagreement, Conflict Resolution, Substituted Judgment, Clinical Ethics, Ethics Consultation

44. "A Gay Epidemiologist and the DC Commission of Public Health AIDS Advisory Committee"

Steven S. Coughlin, Paul Mann, and Bruce Jennings

Abstract: Based upon the lead author's deep personal and professional experience, this case narrative illustrates the importance of engagement between public health practitioners and members of affected populations and their advocates. The case underscores the need to build strong coalitions to address serious public health and social issues. It also illustrates how decisions about control groups in research raise ethical issues. In addition, the case illustrates the reality that public health and social services are sometimes inadequate in the face of dire circumstances. Justice in public health has both a distributive aspect (how to allocate limited resources and distribute potential benefits as fairly as possible) and a procedural dimension (ensuring public participation, especially of those most affected). Frameworks for public health ethics, which post-date the events detailed in the autobiographical case narrative, highlight both distributive justice and procedural justice.

Keywords: African Americans, AIDS, HIV, Community Prevention, Prevention, Public Health, Social Justice

45. "Shared Decision-Making in Palliative Care: A Maternalistic Approach"

Laura Specker Sullivan, Mary Adler, Joshua Arenth, Shelly Ozark, and Leigh Vaughan

Abstract: During goals of care conversations, palliative care clinicians help patients and families determine priorities of care and align medical care with those priorities. The style and methods of communicating with families and negotiating a care plan can range from paternalistic to entirely patient driven. In this paper, we describe a case in which the palliative care clinician approached decision-making using a paradigm that is intuitive to many clinicians and which seems conceptually sound, but which has not been fully explored in the bioethics literature. This paradigm, termed maternalism, allows the clinician to direct decision-making within a relationship such that best interests and autonomy are mutually reinforced, thus reflecting relational autonomy as opposed to individual autonomy. We explore whether this method is appropriate in this case and explain how it captures significant ethical features of the case that might be missed by other approaches.

Keywords: Shared Decision-Making, Palliative Care, End of Life, Paternalism, Relational Autonomy

46. "Phantom Physicians and Medical Catfishing: A Narrative Ethics Approach to Ghost Surgery"

Saljooq M. Asif

Abstract: The concerns raised by ghost surgery, an unethical practice in which someone other than the surgeon who obtains consent performs an operative procedure without the patient’s knowledge, have long been ignored by bioethics and other related disciplines. Indeed, ghost surgery is neither tracked nor studied in the United States, and the practice itself remains underreported. Ghost surgery represents a corporeal transgression as well as a relational rift: what was communicated by physicians is rendered null and void, and the surgical narrative that patients thought they knew is disrobed as a lie and revealed to be a catfish. In order to combat this practice and prevent any form of medical catfishing, physicians must guarantee effective communication and transparency and view themselves as storytellers alongside their patients. By following such a framework, physicians can ideally end the simulation and suture an ethic of accountability within a co-constructed narrative.

Keywords: Ghost Surgery, Narrative Ethics, Accountability, Catfishing, Medical Harm

47. "It Takes Time to Let Go"

Tiffany Meyer, Laura Walther-Broussard, Nico Nortjé

Abstract: Futile or nonbeneficial treatment is often a source of contention between care teams and family members of ICU patients. This narrative describes such a case at a cancer center. In the midst of the COVID-19 crisis, the psychosocial team had to act as a bridge between a patient's surrogate decision maker and the care team. In light of COVID-19 visitor restrictions, the psychosocial team, the surrogate/family, and the care team had to respectfully work towards what was best for the patient.

Keywords: Nonbeneficial treatment, COVID-19, Psychosocial team, Values, Goals of Care

48. "An American’s Experience with End-of-Life Care in Japan: Comparing Brain Death, Limiting and Withdrawing Life-Prolonging Interventions, and Healthcare Ethics Consultation Practices in Japan and the United States"

Alexander A. Kon, Keiichiro Yamamoto, Eisuke Nakazawa, Reina Ozeki-Hayashi, Akira Akabayashi

Abstract: American and Japanese laws, customs, and practices in end-of-life decision-making differ significantly. We present a case with which one of the authors was involved to illustrate some of the key legal and cultural differences in the declaration of brain death, limiting and withdrawing life-prolonging interventions, and healthcare ethics consultation practices. The analysis presented facilitates understanding of similarities and differences between Japanese and American healthcare ethics specifically in regards to end-of-life care. Further, the analysis provides insights that can aid in developing policies and practices in regions where multiple cultures coexist.

Keywords: Brain Death, Organ Transplantation, Withholding Treatment, Japan, Ethics Consultation

49. "The Sword of King Solomon"

Maria Susana Ciruzzi

Abstract: Conjoined twin pregnancies are one of the greatest dilemmas we face in healthcare practice. Thanks to scientific knowledge and evolution, technology and the higher level of wealth in our society, conjoined twins have a chance to survive, albeit with the risk of major consequences on their lifespan and quality of life. Particularly, in the case of newborns with extreme prematurity or congenital malformations, special care must be taken in the use of treatments that offer little to no benefit. This is especially the case with procedures and techniques of unproven efficacy that could create unfounded expectations and hopes in parents and health professionals. It is within this conceptual framework that the author presents a case submitted to a bioethics committee at a pediatric hospital in a Latin American metropolis and analyzes the ethical challenges posed to the treating team and the consensual approach determined by the team.

Keywords: Conjoined Twins, Parental Decision Making, Do No Harm Principle, Ethical Dilemma, Quality of Life

50. "Appreciating the Dynamicity of Values at the End of Life: A Psychological and Ethical Analysis"

Austin Burns, Natalie Hardy & Nico Nortjé

Abstract: It can be difficult for families to accept when loved ones experience a change in saliency of values due to serious illness and inevitable death. When patients lose decision-making capacity, family members often refuse to withdraw care and insist on the continuation of non-beneficial treatment. Through a joint ethical and psychological analysis, this case study examines the narrative of a husband and wife, wed for over 50 years, and how the patient’s values, his life’s story, and the wife’s interpretation of his preferences were reconciled to achieve a resolution that respected the patient’s autonomy and previously expressed wishes.

Keywords: Ethics, Anticipatory Grief, Serious Illness, Decision-Making, Values

51. "Serendipity and Social Justice: How Someone with a Physical Disability Succeeds in Clinical Bioethics"

Kevin T. Mintz

Abstract: Trainees with disabilities in health-related professions are often subjected to structural ableism in medicine: the discriminatory manifestation of lowered expectations towards people with disabilities by medical professionals. In this case study, I reflect on my experiences as the first individual with significant disabilities to be offered a postdoctoral fellowship in clinical bioethics at the National Institutes of Health. I focus on the following question: What arrangements need to be in place in order for someone with my level of disability to thrive as a clinical bioethicist? By telling my story, I show how the process of accommodating trainees with disabilities often requires creative problem-solving and a considerable amount of institutional resources. I also describe the team-based method that my mentors and I developed to enable me to complete rotations on the NIH’s bioethics consultation service. If more trainees with disabilities are to succeed in clinical bioethics trainee programs, the field will have to grapple with how to develop an infrastructure for providing disability-related support across training programs. This article is the beginning of a dialogue about how to build such an infrastructure.

52. "The Right to Be Childfree"

Andrea Eisenberg & Abram L. Brummett

Abstract: In this manuscript, we start with a real life account of an Ob/Gyn experience with a young patient from the childfree movement requesting permanent sterilization. A narrative ethics approach invites the reader to experience the encounter in an immersive way for this growing issue. This approach allows readers to reflect on their reaction to the patient and consider how that can affect other patient encounters. Additionally, it explores the stigma these young patients encounter making a permanent decision to never have children. In the commentary, we explore the ethical issues in this case including why we question the permanent decision to refrain from having children. We also discuss informed consent and patient education along with the various approaches to physician-patient relationships with an emphasis on shared decision making, which allows space for both patient and physician to question and reason through their health decisions.

Keywords: Childfree, Permanent Sterilization, Shared Decision Making, Regret, Narrative Ethics

53. "Undisclosed Placebo Trials in Clinical Practice: Undercover Beneficence or Unwarranted Deception?"

Daniel Edward Callies

Abstract: A placebo is an intervention that is believed to lack specific pharmacological or physiological efficacy for a patient’s condition. While placebo-controlled trials are considered the gold standard when it comes to researching and testing new pharmacological treatments, the use of placebos in clinical practice is more controversial. The focus of this case study is an undisclosed placebo trial used as an attempt to diagnose a patient’s complex and unusual symptomology. In this case, the placebo was used not just as a treatment, but as a diagnostic intervention in order to determine the best course of treatment for a patient. Could the deceptive use of a placebo be justified in clinical practice on the grounds of beneficence?

Keywords: Placebo, Beneficence, Deception, Trust, Disclosure

54. " What Do We Owe to Patients Who Leave Against Medical Advice? The Ethics of AMA Discharges?"

Leenoy Hendizadeh, Paula Goodman-Crews, Jeannette Martin, Eli Weber

Abstract:  Discharges against medical advice (AMA) make up a significant number of hospital discharges in the United States, and often involve vulnerable patients who struggle to obtain adequate medical care. Unfortunately, much of the AMA discharge process focuses on absolving the medical center of liability for what happens to these patients once they leave the acute setting. Comparatively little attention is paid to the ethical obligations of the medical team once an informed decision to leave the acute care setting AMA has been made. Via a case narrative, we offer an ethical framework that we believe can help guide an ethically defensible AMA discharge process. By emphasizing our duty to provide the best care possible under the circumstances, we contend, our ethical obligations to promote the patient’s best interests can still be met despite their decision to leave the acute setting against medical advice.

Keywords:  Beneficence, Narrative Ethics, Case Study, AMA Discharges, Shared Decision-Making

  Link to Case on MUSE

55. "Jehovah's Witnesses and the Normative Function of Indirect Consent"

Joanna Smolenski

Abstract:  In this case study, I consider Mr. A, a Jehovah's Witness with chronic vertebral osteomyelitis in need of surgical debridement. Prior to proceeding to the OR, he was unwilling either to explicitly consent to or refuse blood transfusion, while indicating he was open to transfusion intraoperatively, if the team judged it necessary. Ethics was consulted to determine if it would be morally justifiable for the team to proceed with blood transfusion during the course of surgery without Mr. A's documented consent to being transfused. I argue that in this case, what might be termed indirect consent—namely, delegating decision-making regarding some possible course of action without explicitly consenting to the course of action itself—may be sufficient for discharging the clinician's ethical obligation to obtain consent. Identifying information has been changed or omitted to protect patient confidentiality.

Keywords:  Blood Transfusions, Jehovah's Witnesses, Informed Consent, Indirect Consent, Self-Sovereignty

56. "Parental Refusals of Blood Transfusions from COVID-19 Vaccinated Donors for Children Needing Cardiac Surgery"

Daniel H. Kim, Emily Berkman, Jonna D. Clark, Nabiha H. Saifee, Douglas S. Diekema, Mithya Lewis-Newby

Abstract: There is a growing trend of refusal of blood transfusions from COVID-19 vaccinated donors. We highlight three cases where parents have refused blood transfusions from COVID-19 vaccinated donors on behalf of their children in the setting of congenital cardiac surgery. These families have also requested accommodations such as explicit identification of blood from COVID-19 vaccinated donors, directed donation from a COVID-19 unvaccinated family member, or use of a non-standard blood supplier. We address the ethical challenges posed by these issues. We describe the current screening and safety processes for standard blood donation and explore the importance of donor anonymity and challenges with directed donation and non-standard blood suppliers. We present an ethical framework using the Best Interest Standard, the Zone of Parental Discretion, and the Harm Principle when considering these refusals. Finally, we provide recommendations for how to approach these requests as they potentially become more commonplace in pediatrics.

Keywords:  Medical Ethics, Critical Care, Pediatrics, Innovation, Cardiac Surgery, Cardiac Catheterization

57. “Withdrawing Life Support After Attempted Suicide: A Case Study and Review of Ethical Consideration"

David A. Oxman & Benjamin Richter

Abstract: Ethical questions surrounding withdrawal of life support can be complex. When life support therapies are the result of a suicide attempt, the potential ethical issues take on another dimension. Duties and principles that normally guide clinicians’ actions as caregivers may not apply as easily. We present a case of attempted suicide in which decisions surrounding withdrawal of life support provoked conflict between a patient’s family and the medical team caring for him. We highlight the major unresolved philosophical questions and contradictory normative values about suicide that underlie this conflict. Finally, we show how these considerations were practically applied to this particular case.

Keywords: Medical Ethics, Critical Care, Life Support Therapies, Suicide

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• Registered Report
• Published: 01 July 2021

Moral dilemmas and trust in leaders during a global health crisis

• Jim A. C. Everett   ORCID: orcid.org/0000-0003-2801-5426 1   na1 ,
• Clara Colombatto   ORCID: orcid.org/0000-0003-3293-8741 2   na1 ,
• Edmond Awad   ORCID: orcid.org/0000-0001-7272-7186 3 ,
• Paulo Boggio 4 ,
• Björn Bos   ORCID: orcid.org/0000-0003-0242-474X 5 ,
• William J. Brady 2 ,
• Megha Chawla   ORCID: orcid.org/0000-0001-9358-8015 2 ,
• Vladimir Chituc   ORCID: orcid.org/0000-0002-5316-6245 2 ,
• Dongil Chung   ORCID: orcid.org/0000-0003-1999-0326 6 ,
• Moritz A. Drupp   ORCID: orcid.org/0000-0001-8981-0496 5 ,
• Srishti Goel   ORCID: orcid.org/0000-0003-4697-8840 2 ,
• Brit Grosskopf   ORCID: orcid.org/0000-0002-6535-5676 3 ,
• Frederik Hjorth   ORCID: orcid.org/0000-0003-4063-4983 7 ,
• Alissa Ji   ORCID: orcid.org/0000-0001-9368-8454 2 ,
• Caleb Kealoha   ORCID: orcid.org/0000-0002-3438-3519 2 ,
• Judy S. Kim   ORCID: orcid.org/0000-0001-5808-4081 2 ,
• Yangfei Lin 3 ,
• Yina Ma   ORCID: orcid.org/0000-0002-5457-0354 8 , 9 ,
• Michel André Maréchal   ORCID: orcid.org/0000-0002-6627-0252 10 ,
• Federico Mancinelli   ORCID: orcid.org/0000-0002-4606-5876 11 ,
• Christoph Mathys   ORCID: orcid.org/0000-0003-4079-5453 11 , 12 , 13 ,
• Asmus L. Olsen   ORCID: orcid.org/0000-0002-7365-6161 7 ,
• Graeme Pearce   ORCID: orcid.org/0000-0002-4701-2629 3 ,
• Annayah M. B. Prosser   ORCID: orcid.org/0000-0003-2381-9556 14 ,
• Niv Reggev   ORCID: orcid.org/0000-0002-5734-7457 15 ,
• Nicholas Sabin   ORCID: orcid.org/0000-0002-6702-976X 16 ,
• Julien Senn   ORCID: orcid.org/0000-0003-3571-4444 10 ,
• Yeon Soon Shin   ORCID: orcid.org/0000-0002-7456-9254 2 ,
• Walter Sinnott-Armstrong   ORCID: orcid.org/0000-0003-2579-9966 17 ,
• Hallgeir Sjåstad 18 ,
• Madelijn Strick   ORCID: orcid.org/0000-0002-3861-2235 19 ,
• Sunhae Sul   ORCID: orcid.org/0000-0001-5286-4343 20 ,
• Lars Tummers   ORCID: orcid.org/0000-0001-9940-9874 21 ,
• Monique Turner 22 ,
• Hongbo Yu   ORCID: orcid.org/0000-0002-3384-7772 23 ,
• Yoonseo Zoh   ORCID: orcid.org/0000-0002-3659-5638 2 &
• Molly J. Crockett   ORCID: orcid.org/0000-0001-8800-410X 2  

Nature Human Behaviour volume  5 ,  pages 1074–1088 ( 2021 ) Cite this article

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Trust in leaders is central to citizen compliance with public policies. One potential determinant of trust is how leaders resolve conflicts between utilitarian and non-utilitarian ethical principles in moral dilemmas. Past research suggests that utilitarian responses to dilemmas can both erode and enhance trust in leaders: sacrificing some people to save many others (‘instrumental harm’) reduces trust, while maximizing the welfare of everyone equally (‘impartial beneficence’) may increase trust. In a multi-site experiment spanning 22 countries on six continents, participants ( N  = 23,929) completed self-report ( N  = 17,591) and behavioural ( N  = 12,638) measures of trust in leaders who endorsed utilitarian or non-utilitarian principles in dilemmas concerning the COVID-19 pandemic. Across both the self-report and behavioural measures, endorsement of instrumental harm decreased trust, while endorsement of impartial beneficence increased trust. These results show how support for different ethical principles can impact trust in leaders, and inform effective public communication during times of global crisis.

Protocol Registration Statement

The Stage 1 protocol for this Registered Report was accepted in principle on 13 November 2020. The protocol, as accepted by the journal, can be found at https://doi.org/10.6084/m9.figshare.13247315.v1 .

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During times of crisis, such as wars, natural disasters or pandemics, citizens look to leaders for guidance. Successful crisis management often depends on mobilizing individual citizens to change their behaviours and make personal sacrifices for the public good 1 . Crucial to this endeavour is trust: citizens are more likely to follow official guidance when they trust their leaders 2 . Here, we investigate public trust in leaders in the context of the COVID-19 pandemic, which continues to threaten millions of lives around the globe at the time of writing 3 , 4 .

Because the novel coronavirus is highly transmissible, a critical factor in limiting pandemic spread is compliance with public health recommendations such as social distancing, physical hygiene and mask wearing 5 , 6 . Trust in leaders is a strong predictor of citizen compliance with a variety of public health policies 7 , 8 , 9 , 10 , 11 , 12 . During pandemics, trust in experts issuing public health guidelines is a key predictor of compliance with those guidelines. For example, during the avian influenza pandemic of 2009 (H1N1), self-reported trust in medical organizations predicted self-reported compliance with protective health measures and vaccination rates 13 , 14 . During the COVID-19 pandemic, data from several countries show that public trust in scientists, doctors and the government is positively associated with self-reported compliance with public health recommendations 15 , 16 , 17 , 18 . These data suggest that trust in leaders is likely to be a key predictor of long-term success in containing the COVID-19 pandemic around the globe. However, the factors that determine trust in leaders during global crises remain understudied.

One possible determinant of trust in leaders during a crisis is how they resolve moral dilemmas that pit distinct ethical principles against one another. The COVID-19 pandemic has raised particularly stark dilemmas of this kind, for instance whether to prioritize young and otherwise healthy people over older people and those with chronic illnesses when allocating scarce medical treatments 19 , 20 . This dilemma and similar others highlight a tension between two major approaches to ethics. Consequentialist theories – of which utilitarianism is the most well-known exemplar 21 – posit that only consequences should matter when making moral decisions. Because younger, healthier people are more likely to recover and have longer lives ahead of them, utilitarians would argue that they should be prioritized for care because this is likely to produce the best overall consequences 22 , 23 , 24 . In contrast, non-utilitarian theories of morality, such as deontological theories 25 , 26 , 27 , 28 , 29 , argue that morality should consider more than just consequences, including rights, duties and obligations (see Supplementary Note 1 for further details). Non-utilitarians, on deontological grounds, could argue that everyone who is eligible (for example, by being a citizen and/or contributing through taxes or private health insurance) has an equal right to receive medical care, and therefore it is wrong to prioritize some over others 30 . While it is unlikely that ordinary citizens explicitly think about moral issues in terms of specific ethical theories 21 , 31 , past work shows that these philosophical concepts explain substantial variance in the moral judgements of ordinary citizens 32 , 33 , including those in the context of the COVID-19 pandemic 34 .

There is robust evidence that people who endorse utilitarian principles in sacrificial dilemmas – deeming it morally acceptable to sacrifice some lives to save many others – are seen as less moral and trustworthy, chosen less frequently as social partners and trusted less in economic exchanges than people who take a non-utilitarian position and reject sacrificing some to save many 35 , 36 , 37 , 38 , 39 , 40 . This suggests that leaders who take a utilitarian approach to COVID-19 dilemmas will be trusted less than leaders who take a non-utilitarian approach. Anecdotally, some recent case studies of public communications are consistent with this hypothesis. In the United States, for example, public discussions around whether to reopen schools and the economy versus remain in lockdown highlighted tensions between utilitarian approaches and other ethical principles, with some leaders stressing an imperative to remain in lockdown to prevent deaths from COVID-19 (consistent with deontological principles) but others arguing that lockdown also has costs and these need to be weighed against the costs of pandemic-related deaths (consistent with utilitarian principles; Supplementary Note 2 ). Those who appealed to utilitarian arguments – such as President Donald Trump, who argued “we cannot let the cure be worse than the problem itself” 41 and Texas Lieutenant Governor Dan Patrick, who suggested that older Americans might be “willing to take a chance” on their survival for the sake of their grandchildrens’ economic prospects 42 – were met with widespread public outrage 43 . Likewise, when leaders in Italy suggested prioritizing young and healthy COVID-19 patients over older patients when ventilators became scarce, they were intensely criticized by the public 44 . Mandatory contact tracing policies, which have been proposed on utilitarian grounds, have also faced strong public criticisms about infringement of individual rights to privacy 45 , 46 , 47 .

While past research and recent case studies suggest that utilitarian approaches to pandemic dilemmas are likely to erode trust in leaders, other evidence suggests this conclusion may be premature. First, some work shows that utilitarians are perceived as more competent than non-utilitarians 38 , and to the extent that trust in leaders is related to perceptions of their competence 2 , it is possible that utilitarian approaches to pandemic dilemmas will increase rather than decrease trust in leaders. Second, utilitarianism has at least two distinct dimensions: it permits harming innocent individuals to maximize aggregate utility (‘instrumental harm’), and it treats the interests of all individuals as equally important (‘impartial beneficence’) 21 , 33 . Indeed, preliminary evidence suggests these two dimensions characterize the way ordinary people think about moral dilemmas in the context of the COVID-19 pandemic 34 . These two dimensions of utilitarianism not only are psychologically distinct in the general public 33 but also have distinct impacts on perception of leaders. Specifically, when people endorse (versus reject) utilitarian principles in the domain of instrumental harm they are seen as worse political leaders, but in some cases are seen as better political leaders when they endorse utilitarian principles in the domain of impartial beneficence 37 .

Another dilemma that pits utilitarian principles against other non-utilitarian principles – this time in the domain of impartial beneficence – is whether leaders should prioritize their own citizens over people in other countries when allocating scarce resources. The utilitarian sole focus on consequences mandates a strict form of impartiality: the mere fact that someone is one’s friend (or their mother or fellow citizen) does not imply that they have any obligations to such a person that they do not have to any and all persons 48 . Faced with a decision about whether to help a friend (or family member or fellow citizen) or instead provide an equal or slightly larger benefit to a stranger, this strict utilitarian impartiality means that one cannot morally justify favouring the person closer to them. In contrast, many non-utilitarian approaches explicitly incorporate these notions of special obligations, recognizing the relationships between people as morally significant. Here, President Trump went against utilitarian principles when he ordered a major company developing personal protective equipment (PPE) to stop distributing it to other countries who needed it 49 , or when he ordered the US government to buy up all the global stocks of the COVID-19 treatment remdesivir 50 . His actions generated outrage across the world and stood in contrast to statements from many other Western leaders at the time. The Prime Minister of the UK, Boris Johnson, for example, endorsed impartial beneficence when he argued for the imperative to “ensure that the world’s poorest countries have the support they need to slow the spread of the virus” (3 June 2020) 51 . In a similar vein, the Dutch government donated 50 million euros to the Coalition for Epidemic Preparedness Innovations, an organization that aims to distribute vaccines equally across the world 52 .

In sum, public trust in leaders is likely to be a crucial determinant of successful pandemic response and may depend in part on how leaders approach the many moral dilemmas that arise during a pandemic. Utilitarian responses to such dilemmas may erode or enhance trust relative to non-utilitarian approaches, depending on whether they concern instrumental harm or impartial beneficence. Past research on trust and utilitarianism is insufficient to understand how utilitarian resolutions to moral dilemmas influence trust during the COVID-19 pandemic – and future crises – for several reasons. First, it has relied on highly artificial moral dilemmas, such as the ‘trolley problem’ 53 , 54 , that most people have not encountered in their daily lives. Thus, the findings of past studies may not generalize to the context of a global health crisis, where everyone around the world is directly impacted by the moral dilemmas that arise during a pandemic. Second, because the vast majority of previous work on trust in utilitarians has focused on instrumental harm, we know little about how impartial beneficence impacts trust. Third, most previous work on this topic has focused on trust in ordinary people. However, there is evidence that utilitarianism differentially impacts perceptions of ordinary people and leaders 37 , 38 , 40 , which means we cannot generalize from past research on trust in utilitarians to a leadership context. Because leaders have power to resolve moral dilemmas through policymaking, and therefore can have far more impact on the outcomes of public health crises than ordinary people can, it is especially important to understand how leaders’ approaches to moral dilemmas impact trust. Finally, past work on inferring trust from moral decisions has been conducted in just a handful of Western populations – in the United States, Belgium, and Germany – and so may not generalize to other countries that are also affected by the COVID-19 pandemic. We need, therefore, to assess cross-cultural stability by testing this hypothesis in different countries around the world. Indeed, given observations of cultural variation in the willingness to endorse sacrificial harm 32 , it is not a foregone conclusion that utilitarian decisions will impact trust in leaders universally. For further details of how the present work advances our understanding of moral dilemmas and trust in leaders, see Supplementary Notes 3 – 5 .

The goal of the current research is to test the hypothesis that endorsement of instrumental harm would decrease trust in leaders while endorsement of impartial beneficence would increase trust in leaders, in the context of the COVID-19 pandemic. Testing this hypothesis across a diverse set of 22 countries spanning six continents (Fig. 1a and Supplementary Fig. 1 ) in November–December 2020, we aim to inform how leaders around the globe can communicate with their constituencies in ways that will preserve trust during global crises. Given the public health consequences of mistrust in leaders 7 , 8 , 9 , if our hypothesis is confirmed, leaders may wish to carefully consider weighing in publicly on moral dilemmas that are unresolvable with policy, because their opinions might erode citizens’ trust in other pronouncements that may be more pressing, such as advice to comply with public health guidelines.

a , Regions of recruitment for online samples broadly nationally representative with respect to age and gender. KSA, the Kingdom of Saudi Arabia. UAE, the United Arab Emirates. b , Running 7-day average of new COVID-19 confirmed global infections from 29 January 2020 to 14 March 2021, with highlighted data collection window (red; from 26 November 2020 to 22 December 2020). Number of COVID-19 confirmed infections were taken from the COVID-19 Data Repository by the Center for Systems Science and Engineering at Johns Hopkins University 71 (last update 14 March 2021). c , Summary of the five COVID-19 dilemmas employed in the experimental tasks. d , Voting task: participants were asked to vote for a leader who would later be entrusted with a group’s charitable donation and be able to ‘embezzle’ some of the donation money for themselves.

Source data

To test our hypothesis empirically, we drew on case studies of public communications to identify five moral dilemmas that have been actively debated during the COVID-19 pandemic (Fig. 1c ). Three of these dilemmas involve instrumental harm: the Ventilators dilemma concerns whether younger individuals should be prioritized to receive intensive medical care over older individuals when medical resources such as ventilators are scarce 23 , 44 , the Lockdown dilemma concerned whether to consider reopening schools and the economy or remain in lockdown 23 , 55 and the Tracing dilemma concerned whether it should be mandatory for residents to carry devices that continuously trace the wearer’s movements, allowing the government to immediately identify people who have potentially been exposed to the coronavirus 45 , 46 , 47 . The other two dilemmas involved impartial beneficence: the PPE dilemma concerned whether PPE manufactured within a particular country should be reserved for that country’s citizens under conditions of scarcity, or sent where it is most needed 23 , 56 , 57 , 58 , and the Medicine dilemma concerned whether a novel COVID-19 treatment developed within a particular country should be delivered with priority to that country’s citizens, or shared impartially around the world 56 , 59 , 60 . Participants in our studies read about leaders who endorsed either utilitarian or non-utilitarian solutions to the dilemmas (Table 1 ) and subsequently completed behavioural and self-report measures of trust in the respective leaders (Extended Data Fig. 1 ). For example, some read about a leader who endorsed prioritizing younger over older people for scarce ventilators and were then asked how much they trusted that leader. While there are many similar dilemmas potentially relevant to the COVID-19 crisis, we chose to focus on the five described above because they (1) have been publicly debated at time of writing, and (2) apply to all countries in our planned sample. For further details of why we chose these specific dilemmas and how they can test our theoretical predictions, see Supplementary Notes 2 and 6– 9 .

We measured trust in two complementary ways. First, we asked participants to self-report their general trust in the leaders, in terms of both an overall character judgement (“How trustworthy do you think this person is?”) and how likely they would be to trust this person on other issues not related to the dilemma (“How likely would you be to trust this person’s advice on other issues?”). Second, we used a novel, incentivized voting task designed to measure public trust in leaders (Fig. 1d ). Following past work, we define leaders as people who are responsible for making decisions on behalf of a group 61 , 62 . In the voting task, participants were invited to cast a vote to appoint a leader who would be responsible for making a charitable donation on behalf of a group. Crucially, the leader had the opportunity to ‘embezzle’ some of the donation money for themselves. Participants were asked to vote for either a person who endorsed a utilitarian or a non-utilitarian position on a COVID-19 dilemma; the person who received the most votes would have control over the group’s donation. By measuring preferences for a leader who was responsible for a group’s donations to help those in need, the voting task captures trust in leaders in a specific context that is highly relevant to our central research question: during a health crisis, effective leadership requires responsible stewardship of public resources to help those in need. For further details of why we designed our trust measures in this way, see Supplementary Notes 10 – 12 .

Our analyses therefore tested two complementary hypotheses. First, we predicted that self-reported trust would be lower for leaders who endorse utilitarian over non-utilitarian approaches to dilemmas involving instrumental harm, while the reverse pattern would be observed for impartial beneficence, with greater trust for leaders who endorse utilitarian approaches to dilemmas involving impartial beneficence (hypothesis 1). Second, we predicted that participants would be less likely to vote for leaders who endorse utilitarian over non-utilitarian views on dilemmas involving instrumental harm, while the reverse pattern would be observed for dilemmas involving impartial beneficence (hypothesis 2). Pilot studies conducted in the United States and the United Kingdom in July 2020 provided initial support for these hypotheses (see Pilot Data in Supplementary Information and Supplementary Figs. 2 – 6 for details). All analyses controlled for participants’ demographics and own policy preferences in each dilemma (Table 2 ).

Finally, we note that the framing of both the self-report and behavioural measures of trust are deliberately unrelated to the pandemic dilemmas we use to highlight the moral commitments of the leader. This crucial design choice allowed us to measure the impact of utilitarian versus non-utilitarian endorsements of pandemic dilemmas on subsequent trust in leaders. In this way, the current design illuminates an important real-life question: if a leader weighs in publicly on a moral dilemma during a crisis, how likely are they to be trusted later on other matters of public concern?

Analysed dataset

Donations task.

A few days prior to running the main experiment, we recruited a convenience sample of donor participants (total N  = 100; 58 women, 40 men, 2 with another gender identity; mean age 33.95 years) in the United States via Prolific ( www.prolific.co ). The donor participants chose to contribute a total of US$87.89 to the United Nations Children’s Fund (UNICEF). We displayed this amount to voter participants in the main experiment.

Participants

Following the pre-registered sampling plan ( Methods ), we recruited participants via several online survey platforms from 26 November 2020 to 22 December 2020, as new cases of COVID-19 in 2020 were peaking globally (Fig. 1b ). In total, we recruited a sample of 24,809 participants across the following countries: Australia, Brazil, Canada, Chile, China, Denmark, France, Germany, India, Israel, Italy, the Kingdom of Saudi Arabia, Mexico, the Netherlands, Norway, Singapore, South Africa, South Korea, Spain, the United Arab Emirates, the United Kingdom and the United States (Fig. 1a and Supplementary Tables 1 and 2 ).

As specified in our pre-registered sampling plan ( Methods ), participants who did not pass the attention checks were screened out immediately prior to beginning the survey, but due to platform and institutional review board requirements, participants in the United States and the United Kingdom were able to complete the survey even if they failed such checks, and so they were excluded post hoc, after data collection ( N  = 101 for attention check 1, N  = 118 for attention check 2). In addition, participants were excluded according to our exclusion criteria if they (1) took the survey more than once ( N  = 565), (2) reported living in a country different from that of intended recruitment ( N  = 96, of which 4 did not answer the question) or (3) failed to answer more than 50% of the questions ( N  = 0). The sample size after applying these exclusion criteria was 23,929; we then excluded participants from specific analyses if they (4) did not provide a response for one of our main dependent variables ( N  = 177 for self-report, N  = 201 for voting) or (5) failed the comprehension check for the task being analysed ( Design ; N  = 6,161 for self-report, N  = 11,090 for voting). This resulted in a total final sample of N  = 17,591 for the self-report task and N  = 12,638 for the voting task. Crucially, the comprehension check failure rates were balanced across experimental conditions for each task (failure rate for self-report task comprehension check: 25.30% after instrumental harm dilemmas, utilitarian argument (final N  = 4,499); 26.08% after instrumental harm, non-utilitarian argument (final N  = 4,299); 25.25% after impartial beneficence, utilitarian argument (final N  = 4,461); 27.13% after impartial beneficence, non-utilitarian argument (final N  = 4,332); fail rate for voting task comprehension check: 46.46% after instrumental harm dilemmas (final N  = 6,373); 47.02% after impartial beneficence dilemmas (final N  = 6,265)).

Representativeness

As stated in the stage 1 report, while we aimed to recruit samples broadly representative for age and gender in all countries, we anticipated that it would be difficult to obtain fully representative quotas in all countries for some demographic categories. To evaluate the representativeness of our samples across age and gender categories, we examined the differences between our targeted quotas (based on available published population characteristics) and actual quotas in the data, separately for each country. We achieved broadly representative samples for gender, with most differences between the observed and targeted proportions being less than or equal to 5% in all but two countries (Singapore and the United Arab Emirates). Note that, because available population data across countries primarily report binary gender categories, our estimates of representativeness were not able to account for those identifying as non-binary, which is a limitation. Similarly, in 15 countries we obtained broadly representative samples for age, with the difference between targeted and actual proportions being less than or equal to 5%. In six countries (the Kingdom of Saudi Arabia, Singapore, South Korea, the United Arab Emirates, the United Kingdom and the United States), older participants were underrepresented in our sample by 6–15%. In one country (Germany), older participants were overrepresented by 6% (for details, see Supplementary Results ; for figures depicting expected versus obtained counts in each gender and age category, see Supplementary Figs. 7 and 8 )

Main analyses

The main results are depicted in Figs. 2 and 3 , across both the self-report and behavioural measures, respectively. As predicted, participants showed more trust in leaders who endorsed utilitarian views in impartial beneficence dilemmas and less trust in leaders who endorsed utilitarian views in instrumental harm dilemmas. This pattern of results was observed for each dilemma (Figs. 2b and 3c ) and was robust across countries (Fig. 4a,b ). Following our pre-registered analysis plan ( Analysis plan for hypothesis testing ), we examined self-report and behavioural measures of trust in two separate models, with results passing a corrected α of P  ≤ 0.005 being interpreted as ‘supportive evidence’ for our hypotheses, and results passing a corrected α of P  < 0.05 being interpreted as ‘suggestive evidence’ (all the CIs reported below are 97.5%).

a , b , Average trust in utilitarian versus non-utilitarian leaders, with results collapsed across instrumental harm and impartial beneficence dilemmas ( a ) and separately for each of the instrumental harm dilemmas (Lockdown, Tracing and Ventilators) and impartial beneficence dilemmas (PPE and Medicine) ( b ) in the self-report task ( N  = 17,591). Non-utilitarian leaders were seen as more trustworthy than utilitarian leaders for instrumental harm dilemmas, while the reverse was observed for impartial beneficence dilemmas. Bars correspond to median scores; lower and upper hinges correspond to the first and third quartiles, respectively; and whiskers ends correspond to the most extreme data points within 1.5 times the interquartile range.

a , Percentage of participants who chose to trust utilitarian versus non-utilitarian leaders, separately for instrumental harm and impartial beneficence dilemmas in the voting task ( N  = 12,638). b , Choices for utilitarian versus non-utilitarian leaders as estimated from a logit model including demographic variables (gender, age, education, subjective SES, political ideology and religiosity) and policy support as covariates, and dilemmas and countries as random intercepts (for details, see “ Hypothesis 2: voting measure ”). c , Percentage of participants who chose to trust utilitarian versus non-utilitarian leaders, separately for each of the instrumental harm dilemmas (Lockdown, Tracing and Ventilators) and impartial beneficence dilemmas (PPE and Medicine). Non-utilitarian leaders were more likely to be voted for in instrumental harm dilemmas, but not in impartial beneficence dilemmas. Error bars represent standard error of the percentages ( a ) and ( c ), and the 97.5% CIs of the model estimates ( b ).

a , Predicted effect of moral dimension (instrumental harm versus impartial beneficence) and argument (utilitarian versus non-utilitarian) on trust in the self-report task ( N  = 17,591) for each country and overall. Dots represent model coefficients extracted from a model including country as a random slope of the interactive effect of moral dimension and argument ( Exploratory analyses ); error bars represent standard errors of the model coefficients. b , Odds ratio of the effect of moral dimension (instrumental harm versus impartial beneficence) on trust for the utilitarian versus non-utilitarian leader in the voting task ( N  = 12,638) for each country and overall. Dots represent odds ratios extracted from a model including country as a random slope of moral dimension ( Exploratory analyses ); error bars represent exponentiated standard errors of the model coefficients. c , Correlation between the country-level effect size estimates in the self-report task ( x axis; also depicted in a ) and voting task ( y axis; also depicted in b ). UAE, the United Arab Emirates; KSA, the Kingdom of Saudi Arabia.

Hypothesis 1: self-reported trust

To examine participants’ self-reported trust in the leaders, we fitted a linear mixed-effects model of the effect of argument type (utilitarian versus non-utilitarian), dimension type (instrumental harm versus impartial beneficence) and their interaction on the composite score of trust, adding demographic variables (gender, age, education, subjective socio-economic status (SES), political ideology and religiosity) and policy support as fixed effects and dilemmas and countries as random intercepts, with participants nested within countries (for details, see Analysis plan for hypothesis testing ). As specified in Analysis plan , we also ran a model that included countries as random slopes of the two main effects and the interactive effect; the results were consistent with the simpler model, but due to convergence issues with the more complex model, we report the simpler model.

We observed a significant main effect of argument type ( B  = −0.53, s.e. 0.02, t (17,562) = −24.81, P  < 0.001, CI [−0.58, −0.48]), no significant main effect of dimension type ( B  = 0.10, s.e. 0.10, t (3) = 0.95, P  = 0.408, CI [−0.15, 0.35]) and, crucially, a significant interaction between argument and dimension type ( B  = 2.12, s.e. 0.04, t (17,558) = 49.44, P  < 0.001, CI [2.03, 2.22]). Post hoc comparisons with Bonferroni corrections confirmed that, in instrumental harm dilemmas, utilitarian leaders were seen as less trustworthy than non-utilitarian leaders (mean trust for utilitarian leaders 3.35, s.e. 0.09, CI [3.05, 3.65]; mean trust for non-utilitarian leaders 4.95, s.e. 0.09, CI [4.64, 5.25]; B  = −1.60, s.e. 0.03, t (17,559) = −52.51, P  < 0.001, CI [−1.66, −1.53]), but in impartial beneficence dilemmas this effect was reversed, such that utilitarian leaders were seen as more trustworthy than non-utilitarian leaders (mean trust for utilitarian leaders 4.51, s.e. 0.10, CI [4.14, 4.88]; mean trust for non-utilitarian leaders 3.98, s.e. 0.10, CI [3.61, 4.35]; B  = 0.53, s.e. 0.03, t (17,560) = 17.41, P  < 0.001, CI [0.46, 0.60]; see Fig. 2a ; for results by dilemma, see Fig. 2b ; for results by country, see Fig. 4a ).

Hypothesis 2: voting measure

To examine participants’ trust in the leaders as demonstrated by their voting behaviour, we fitted a generalized linear mixed-effects model with the logit link of the effect of dimension type (instrumental harm versus impartial beneficence) on leader choice in the voting task (utilitarian versus non-utilitarian), adding demographic variables (gender, age, education, subjective SES, political ideology and religiosity) and policy support as fixed effects and dilemmas and countries as random intercepts, with participants nested within countries (for details, see Analysis plan for hypothesis testing ). This yielded a singular fit, so following our analysis plan, we reduced the complexity of the random-effects structure by only including dilemmas and countries as random intercepts. As specified in Analysis plan , we also ran a model that included countries as random slopes of the effect of dimension type; the results were consistent with the simpler model, but due to singularity issues (both with and without participants nested within countries), we report the simpler model.

We observed a significant main effect for dimension type ( B  = 1.37, s.e. 0.32, z  = 4.21, P  < 0.001, CI [0.41, 2.33], odds ratio (OR) 3.93) such that participants were almost four times more likely to choose the utilitarian leader in impartial beneficence dilemmas compared with instrumental harm dilemmas. Post hoc comparisons with Bonferroni corrections confirmed that, in instrumental harm dilemmas, participants were less likely to vote for utilitarian leaders than non-utilitarian leaders (probability of choosing utilitarian leader 0.21, s.e. 0.04, CI [0.13, 0.31]), but in impartial beneficence dilemmas this effect vanished (probability of choosing utilitarian leader 0.50, s.e. 0.07, CI [0.34, 0.67]; see Fig. 3a ; for model estimates, see Fig. 3b ; for results by dilemma, see Fig. 3c ; for results by country, see Fig. 4b ).

Based on suggestions that logit and linear models should converge and that linear models can in some cases be preferable 63 , 64 , we had also pre-registered the same analysis using a linear model (instead of a model with the logit link) with the identical fixed- and random-effects structures. However, the linear model yielded non-significant results for the main effect of dimension type with our Bonferroni-corrected alpha ( B  = 0.18, s.e. 0.05, t (3) = 3.73, P  = 0.034, CI [0.07, 0.30]; probability of choosing utilitarian leader in instrumental harm dilemmas 0.30, s.e. 0.03, CI [0.16, 0.45], in impartial beneficence dilemmas 0.49, s.e. 0.04, CI [0.31, 0.67]). This discrepancy was unusual, since binomial and linear approaches most often give converging results 65 , 66 . Following our pre-registered analysis plan, we followed up on this non-significant result using the two one-sided tests (TOST) procedure to differentiate between insensitive versus null results. Given the equivalence bounds set by our smallest effect size of interest (SESOI) ( Δ L  = −0.15 and Δ U  = 0.15; Power analysis ), the effect of dimension on leader choice (a 32% difference) was statistically not equivalent to zero ( z  = 20.77, P  = 1.000 for the test with Δ U ). This analysis, however, does not take into account the covariates specified in the models.

To resolve the discrepancy between our pre-registered binomial and linear models, we ran a number of additional exploratory models. These are described in Exploratory analyses section and summarized in Table 3 .

Robustness checks

Following our analysis plan, we verified the robustness of our findings in several ways. First, due to the changes in country-specific lockdown policies that were implemented between pre-registration and data collection, we ran a variation of our models which omitted the Lockdown dilemma. The results were substantially unchanged, both for the self-report task (interaction between argument and dimension type: B  = 2.26, s.e. 0.05, t (17,640) = 48.56, P  < 0.001, CI [2.16, 2.37]) and the voting task (main effect for dimension type in binomial model: B  = 1.29, s.e. 0.39, z  = 3.33, P  < 0.001, CI [0.06, 2.52], OR 3.63) tasks.

In addition, because some countries had already implemented mandatory contact tracing schemes at the time of data collection, we ran a variation of our models in those countries only (namely China, India, Israel, Singapore and South Korea) with and without the Tracing dilemma. The results in those countries were similar when including and omitting the Tracing dilemma from the analysis, both for the self-report task (Tracing included: interaction between argument and dimension type: B  = 1.13, s.e. 0.10, t (3,267) = 11.62, P  < 0.001, CI [0.91, 1.35]; Tracing excluded: interaction between argument and dimension type: B  = 1.55, s.e. 0.10, t (3,266) = 14.86, P  < 0.001, CI [1.32, 1.78]) and voting task (Tracing included: main effect for dimension type in binomial model: B  = 0.98, s.e. 0.36, z  = 2.70, P  = 0.007, CI [−0.09, 2.07], OR 2.67; Tracing excluded: main effect for dimension type in binomial model: B  = 1.32, s.e. 0.14, z  = 9.26, P  < 0.001, CI [0.88, 1.78], OR 3.74). Finally, we also checked that the results in these countries were robust to order effects (that is, regardless of whether participants had seen the tracing dilemma prior to other dilemmas). To do this, we analysed participants’ responses with an additional covariate indicating whether the participant had seen the tracing dilemma in the prior task. Again, the results were substantially unchanged both for the self-report task (interaction between argument and dimension type: B  = 1.13, s.e. 0.10, t (3,266) = 11.62, P  < 0.001, CI [0.91, 1.35]) and the voting task (main effect for dimension type in binomial model: B  = 1.11, s.e. 0.37, z  = 3.01, P  = 0.003, CI [0.03, 2.20], OR 3.03).

Exploratory analyses

Additional models for voting task.

As noted above, our main pre-registered analysis for the voting task was a generalized linear mixed-effects model with the logit link of the effect of dimension type (instrumental harm versus impartial beneficence) on the leader choice (utilitarian versus non-utilitarian), with demographics and participants’ own policy preferences as fixed effects and dilemmas and countries as random intercepts (Table 2 ). This analysis confirmed our predictions, but we had also pre-registered the same analysis using a linear model (instead of logit link) with the identical fixed- and random-effects structure. As described above, the results from this model did not pass our pre-registered Bonferroni-corrected significance threshold. This discrepancy was unusual, given prior reports that linear and binomial models yield identical results in the vast majority of cases 63 , 66 . As a first check on this discrepancy, we assessed the fits of the binomial and linear models by fitting each with half the data, and predicting the leader choices in the remaining half. The mean difference between the predicted and observed values was lower in the binomial model (mean error 0.25) compared with the linear model (mean error 0.27; t (6,318) = −32.53, P  < 0.001), suggesting that the binomial model is a better fit to our data.

Next, we ran a series of follow-up analyses to supplement our pre-registered, theoretically informed models. There are a variety of opinions for how to best level complex nested binary data like ours. For example, while random effects aid generalizability 67 , some advocate for modelling country variables as fixed rather than random effects to prevent increases in model bias 68 , 69 or overly complex random-effects structures 70 . Moreover, while controlling for demographic variables is important for generalizability of our findings, some advocate for minimal use of covariates to prevent type 1 error inflation 71 . Due to the discrepancy in the theoretically justified models that we had pre-registered and ongoing debates over the specifications of modelling such complex data, we ran a variety of models (described in detail in Supplementary Results and summarized in Table 3 ) with different link functions and different specifications of fixed and random effects, as well as robust random effects and randomization inference. Overall, all models led to the same conclusion: participants voted for the non-utilitarian leader more than the utilitarian leader in dilemmas about instrumental harm, but the reverse in impartial beneficence dilemmas, with the utilitarian leader trusted more than the non-utilitarian leader – suggesting that the discrepancy between our pre-registered binomial and linear models was due to an overly complex random-effects structure.

Effects by country

To explore cross-cultural variation in trust in utilitarian versus non-utilitarian leaders, we ran additional models with country as a random slope and extracted the coefficients of interest (Fig. 4a,b ). For the self-report task, we conducted a linear mixed-effects model of the effect of argument type (utilitarian versus non-utilitarian), dimension type (instrumental harm versus impartial beneficence) and their interaction on the composite score of trust, adding demographic variables (gender, age, education, subjective SES, political ideology and religiosity) and policy support as fixed effects and countries as a random slope of the interactive effect of argument and dimension. First, we confirmed that there was a significant interaction between argument and dimension type ( B  = 2.08, s.e. 0.16, t (21) = 13.08, P  < 0.001, CI [1.71, 2.45]), consistent with our pre-registered model. Next, we extracted the interaction coefficients for each country, as well as the standard errors of the coefficients, with the estimates plotted in Fig. 4a . While there were some variations in the effect sizes, the results were remarkably consistent across countries. The predicted pattern of results was observed in all 22 countries, with Israel, South Korea and China showing the smallest effects and Brazil, the UAE and Norway showing the largest effects.

For the voting task, we conducted a generalized linear mixed-effects model with the logit link of the effect of dimension type (instrumental harm versus impartial beneficence) on leader choice (utilitarian versus non-utilitarian), adding demographic variables (gender, age, education, subjective SES, political ideology and religiosity) and policy support as fixed effects and countries as a random slope of dimension. First, we confirmed there was a significant main effect for dimension type ( B  = 1.34, s.e. 0.07, z  = 17.88, P  < 0.001, CI [1.16, 1.51], OR 3.81), as in our pre-registered model. Next, we extracted the coefficients for each country, as well as the standard errors of the coefficients, and exponentiated them to get the odds ratios, with the resulting estimates plotted in Fig. 4b . Again, the results were remarkably consistent with the predicted pattern of results seen across all 22 countries, with China, Israel and Canada showing the smallest effects and Norway, the UAE and the United States showing the largest effect size.

Correlations between self-report and behavioural measures across countries

The self-report and behavioural tasks employed in the current study are highly complementary in several ways: for example, the former is more generalizable across different situations, while the latter is incentivized and more concrete (see Supplementary Note 10 for further details). To ensure that despite their superficial differences the tasks targeted the same construct, that is, trust in leaders, and measured robust preferences across countries, we checked that the effects of moral arguments and utilitarian dimensions on these measures were correlated across countries. Indeed, we found that the coefficients of the interaction between moral argument and moral dimension on trust in the self-report task were significantly correlated with the effect of moral dimension on leader choice in the voting task ( r  = 0.76, P  < 0.001; Fig. 4c ).

Effects of participant exclusions in voting task

The main analyses reported above were performed on a subset of participants who passed the comprehension checks, as per our pre-registered sampling plan (criterion 5; see Sampling plan ). For the voting task, the observed pass rate (53.26%) was lower than the pre-registered expected pass rate (60%), suggesting that the comprehension check may have been overly stringent. Therefore, we conducted additional analyses to explore whether this pre-registered exclusion criterion might have affected the generalizability of our results across the study population in terms of education level.

Participants who failed the voting task comprehension check reported slightly lower educational attainment on average (mean 5.32, s.e. 1.39, CI [5.30, 5.35]) than those who passed the comprehension check (mean 5.42, s.e. 1.37, CI [5.40, 5.45]; t (23,224) = 5.51, P  < 0.001, d  = 0.07). However, we observed similar results in our pre-registered models when including participants who failed the voting task comprehension check (main effect for dimension type in binomial model: B  = 1.26, s.e. 0.28, z  = 4.55, P  < 0.001, CI [0.44, 2.08], OR 3.53; main effect for dimension type in linear model: B  = 0.17, s.e. 0.04, t (3) = 4.11, P  = 0.026, CI [0.07, 0.27]).

The COVID-19 pandemic has raised a number of moral dilemmas that engender conflicts between utilitarian and non-utilitarian ethical principles. Building on past work on utilitarianism and trust, we tested the hypothesis that endorsement of utilitarian solutions to pandemic dilemmas would impact trust in leaders. Specifically, in line with suggestions from previous work and case studies of public communications during the early stages of the pandemic, we predicted that endorsing instrumental harm would decrease trust in leaders, while endorsing impartial beneficence would increase trust. Experiments conducted during November–December 2020 in 22 countries across six continents (total N  = 23,929; valid sample for self-report task 17,591; valid sample for behavioural task 12,638) provided robust support for our hypothesis. In the context of five realistic pandemic dilemmas, participants reported lower trust in leaders who endorsed instrumental sacrifices for the greater good and higher trust in leaders who advocated for impartially maximizing the welfare of everyone equally. In a behavioural measure of trust, only 28% of participants preferred to vote for a utilitarian leader who endorsed instrumental harm, while 60% voted for an impartially beneficent utilitarian leader. These findings were robust to controlling for a variety of demographic characteristics as well as participants’ own policy preferences regarding the dilemmas. Although we observed some variation in effect sizes across the countries we sampled, the overall pattern of results was highly robust across countries. Our results suggest that endorsing utilitarian approaches to moral dilemmas can both erode and enhance trust in leaders across the globe, depending on the type of utilitarian morality.

We designed our set of dilemmas to rule out several alternative explanations for our findings, such as a general preference for less restrictive leaders (Supplementary Note 7 ), leaders who treat everyone equally (Supplementary Note 8 ) and leaders who seek to minimize COVID-19-related deaths (Supplementary Note 9 ). In addition, all of our results survived planned robustness checks to account for the possibility that local policies related to lockdowns or contact tracing could bias participants’ responses. Post hoc analyses demonstrated that our findings were highly consistent across the different dilemmas for instrumental harm (Lockdown, Tracing and Ventilators) and impartial beneficence (Medicine and PPE).

While the robustness of our findings across countries speaks to their broad cultural generalizability, further work is needed to understand the observed variations in effect sizes across countries. It seems plausible that both economic (for example, gross domestic product or socio-economic inequality) and cultural (for example, social network structure) differences across countries could explain some of the observed variations. One possibility, for example, is that country-level variations in tightness–looseness 72 , which have been associated with countries’ success in limiting cases in the COVID-19 pandemic 73 , might moderate the effects of moral arguments on trust in leaders. Another direction for future research could be to explore how country-level social network structure might influence our results. Individuals in countries with a higher kinship index 74 and a more family-oriented social network structure, for example, might be less likely to trust utilitarian leaders, especially when the utilitarian solution conflicts with more local moral obligations.

There are several important limitations to the generalizability of our findings. First, although our samples were broadly nationally representative for age and gender (with some exceptions; see Results ), we did not assess representativeness of our samples on a number of other factors including education, income and geographic location. Second, while our results do concord with the limited existing research examining the effects of endorsing instrumental harm and impartial beneficence on perceived suitability as a leader 37 , and held across different examples of our pandemic-specific dilemmas, it of course remains possible that different results would be seen when judging leaders’ responses in other types of crises (for example, violent conflicts, natural disasters or economic crises) or at different stages of a crisis (for example, at the beginning versus later stages). Third, the reported experiments tested how responses to moral dilemmas influenced trust in anonymous, hypothetical political leaders. In the real world, however, people form and update impressions of known leaders with a history of political opinions and behaviours, and it is plausible that inferences of trustworthiness depend not just on a leader’s recent decisions but also on their history of behaviour, just as classic work on impression formation shows that the same information can lead to different impressions depending on prior knowledge about the target person 75 . Furthermore, we did not specify the gender of the leaders in our experiments (except in the voting task for China and for the Hebrew and Arabic translations, where it is not possible to indicate ‘leader’ without including a gendered pronoun; here it was translated in the masculine form). Past work conducted in the United States suggests that participants may default to an assumption that the leader is a man 76 , but it will be important for future work to assess whether men and women leaders are judged differentially for their moral decisions. Because women are typically stereotyped as being warmer and more communal than men 77 , it is plausible that women leaders would face more backlash for making ‘cold’ utilitarian decisions, especially in the domain of instrumental harm. Fourth, because the current work focused on trust in political leaders, it remains unclear how utilitarianism would impact trust in people who occupy other social roles, such as medical workers or ordinary citizens. Fifth, and finally, it could be interesting to explore further the connection between impartial beneficence and intergroup psychology, especially with regards to teasing apart ‘impartiality’ and ‘beneficence’. For example, even holding beneficence constant, a leader who advocates for impartially sharing resources with a rival country may be perceived differently from one who impartially shares with an allied country (and, while speculative, this distinction might explain why Israel was an outlier in impartial beneficence, being a country in a region with ongoing local conflicts).

Our results have clear implications for how leaders’ responses to moral dilemmas can impact how they are trusted. In times of global crisis, such as the COVID-19 pandemic, leaders will necessarily face real, urgent and serious dilemmas. Faced with such dilemmas, decisions have to be made, and our findings suggest that how leaders make these judgements can have important consequences, not just for whether they are trusted on the issue in question but also more generally. Importantly, this will be the case even when the leader has little direct control over the resolution. While a national leader (for example, a president or prime minister) has the power and responsibility to resolve some moral dilemmas with policy decisions, not all political leaders (for example, as in our study, local mayors) have that power. A leader with little ability to directly impact the resolution of a moral dilemma might consider that voicing an opinion on that dilemma could reduce their credibility on other issues that they have more power to control.

To conclude, we investigated how trust in leaders is sensitive to how they resolve conflicts between utilitarian and non-utilitarian ethical principles in moral dilemmas during a global pandemic. Our results provide robust evidence that utilitarian responses to dilemmas can both erode and enhance trust in leaders: advocating for sacrificing some people to save many others (that is, instrumental harm) reduces trust, while arguing that we ought to impartially maximize the welfare of everyone equally (that is, impartial beneficence) increases trust. Our work advances understanding of trust in political leaders and shows that, across a variety of cultures, it depends not just on whether they make moral decisions but also which specific moral principles they endorse.

Ethics information

Our research complies with all relevant ethical regulations. The study was approved by the Yale Human Research Protection Program Institutional Review Board (protocol IDs 2000027892 and 2000022385), the Ben-Gurion University of the Negev Human Subjects Research Committee (request no. 20TrustCovR), the Centre for Experimental Social Sciences Ethics Committee (OE_0055) and the NHH Norwegian School of Economics Institutional Review Board (NHH-IRB 10/20). Informed consent was obtained from all participants.

An overview of the experiment is depicted in Extended Data Fig. 1 . After selecting their language, providing their consent and passing two attention checks, participants were told that they would “read about three different debates that are happening right now around the world”, that they would be given “some of the justifications that politicians and experts are giving for different policies”, and that they would be “ask[ed] some questions about [their] opinions”. They then completed two tasks measuring their trust in leaders expressing either utilitarian or non-utilitarian opinions (one using a behavioural measure and one using self-report measures, presented in a randomized order); these tasks were followed by questions about their impressions about the ongoing pandemic crisis, as well as individual difference and demographic measures, as detailed below. Data collection was performed blind to the conditions of the participants.

Both behavioural and self-report measures of trust involved five debates on the current pandemic crisis, three of which involved instrumental harm (IH) and two impartial beneficence (IB) (summarized in Fig. 1c and Table 1 ; for full text, see Supplementary Methods ). Each of these five dilemmas were based on real debates that have been occurring during the COVID-19 pandemic, and we developed the philosophical components of each argument in consultation with moral philosophers.

Lockdown (instrumental harm): whether the country should maintain severe restrictions on social gatherings until a vaccine is developed to prevent COVID-related deaths, or consider relaxing restrictions to maximize overall well-being

Ventilators (instrumental harm): whether doctors should give everyone equal access to COVID treatment, or prioritize younger and healthier people

Tracing (instrumental harm): whether the government should make it mandatory for residents to wear contact tracing devices to prevent pandemic spread, or make tracing devices optional to respect residents’ right to privacy

Medicine (impartial beneficence): whether medicine developed in the home country should be reserved for treating the home country’s citizens, or sent wherever it can do the most good, even if that means sending it to other countries

PPE (impartial beneficence): whether PPE manufactured in the home country should be reserved for protecting the home country’s citizens, or sent wherever it can do the most good, even if that means sending it to other countries

See Supplementary Notes 2 and 6 – 9 for further details of why we chose these specific dilemmas and how they can test our theoretical predictions.

Translations

Where the survey was administered in a non-English-speaking country, study materials were translated following a standard forward- and back-translation procedure 78 . First, for forward translation, a native speaker translated materials from English to the target language. Second, for back translation, a second native translator (who had not seen the original English materials) translated the materials back into English. Results were then compared, and if there were any substantial discrepancies, a second forward- and back-translation was conducted with translators working in tandem to resolve issues. Finally, the finished translated and back-translated materials were checked by researchers coordinating the experiment for that country.

Experimental design

Participants were randomly and blindly assigned to one of four conditions in the beginning of the experiment. These conditions corresponded to a 2 × 2 between-subjects design: 2 (moral dimension in the voting task: instrumental harm/impartial beneficence) × 2 (argument in the self-report task: utilitarian/non-utilitarian). In addition, we randomized the order of tasks (voting or self-report task first), the order of arguments in the voting task (utilitarian or non-utilitarian first), the order of dilemmas in the self-report task (Lockdown, Ventilators or Tracing first if instrumental harm, and PPE or Medicine first if impartial beneficence) and the dilemmas displayed (two in the self-report task and one in the voting task randomly chosen among Lockdown, Ventilators and Tracing if instrumental harm, and PPE and Medicine if impartial beneficence). This design allowed us to minimize demand characteristics with between-subjects manipulations of key experimental factors while at the same time maximizing efficiency of data collection.

Attention checks

We included two attention checks prior to the beginning of the experiment. Any participants who failed either of these were then screened out immediately. First, participants were told:

“In studies like ours, there are sometimes a few people who do not carefully read the questions they are asked and just ‘quickly click through the survey.’ These random answers are problematic because they compromise the results of the studies. It is very important that you pay attention and read each question. In order to show that you read our questions carefully (and regardless of your own opinion), please answer ‘TikTok’ in the question on the next page”

Then, on the next page, participants were given a decoy question: “When an important event is happening or is about to happen, many people try to get informed about the development of the situation. In such situations, where do you get your information from?”. Participants were asked to select among the following possible answers, displayed in a randomized order: TikTok, TV, Twitter, Radio, Reddit, Facebook, Youtube, Newspapers, Other. Participants who failed to follow our instructions and selected any answer other than the instructed one (“TikTok”) were then screened out of the survey. Second, participants were asked to read a short paragraph about the history and geography of roses. On the following page, they were asked to indicate which of six topics was not discussed in the paragraph. Participants who answered incorrectly were then screened out of the survey (with the exception of those who participated via Prolific, who were instead allowed to continue due to platform requirements).

Dilemma introduction

Both the voting and self-report tasks began with an introduction to a specific dilemma. In the voting task, participants viewed a single dilemma, and in the self-report task, participants viewed two dilemmas in randomized order (see Extended Data Fig. 1 for details). No participant saw the same dilemma in both the voting and self-report tasks.

The dilemma introduction consisted of a short description of the dilemma (for example, in the PPE dilemma: “Imagine that […] there will soon be another global shortage of personal protective equipment [… and] political leaders are debating how personal protective equipment should be distributed around the globe.”), followed by a description of two potential policies (for example, in the PPE dilemma, US participants read: “[S]ome are arguing that PPE made in American factories should be sent wherever it can do the most good, even if that means sending it to other countries. Others are arguing that PPE made in American factories should be kept in the U.S., because the government should focus on protecting its own citizens.”).

After reading about the dilemma, participants were asked to provide their own opinion about the best course of action (“Which policy do you think should be adopted?”), answered on a 1–7 scale, with the endpoints (1 and 7) representing strong preferences for one of the policies (for example, in the PPE dilemma, they were labelled “Strongly support U.S.-made PPE being reserved for protecting American citizens” and “Strongly support U.S.-made PPE being given to whoever needs it most”, respectively), and the midpoint (4) representing indifference (“Indifferent”). See Supplementary Note 13 for further details. As an exploratory measure that is not analysed for the purposes of the current report, participants also indicated how morally wrong it would be for politicians to endorse the utilitarian approach in each dilemma.

For full text of dilemmas and introduction questions, see Supplementary Methods .

Voting task

Our behavioural measure of trust in the current studies is based on a novel task with two types of participants: voters and donors. Voters were asked to cast a vote for a leader who would be responsible for making a charitable donation to UNICEF on behalf of a group of donors and would have the opportunity to ‘embezzle’ some of the donation money for themselves (Fig. 1d ).

We collected data from donors first. A few days before we ran our main experiment, a convenience sample of US participants ( N  = 100) was recruited from Prolific and was provided with a US$2 bonus endowment. They were given the opportunity to donate up to their full bonus to UNICEF. After making their donation decision, they read about the five COVID-19 dilemmas, in randomized order, and indicated which policy they thought should be adopted. Finally, they were instructed that they might be selected to be responsible for the entire group’s donations to UNICEF. Participants were told that, if they were selected, they would have the opportunity to keep up to the full amount of total group donations for themselves, and were asked to indicate how much of the group’s donations they would keep for themselves if they were selected to be responsible.

Our main experiment focused on the behaviour of voter participants. In the voting task, participants were randomly assigned to read about one dilemma, randomly selected amongst the five dilemmas summarized in Table 1 . After completing the dilemma introduction, participants were asked to “make a choice that has real financial consequences” and told that “[a] few days ago, a group of 100 people were recruited via an international online marketplace and invited to make donations to the charitable organization UNICEF. In total, they donated an amount equivalent to $87.89”. We instructed participants that we would like them to “vote for a leader to be responsible for the entire group’s donations”. Crucially, they were also told that “[t]he leader has two options: They can transfer the group’s $87.89 donation to UNICEF in full, or [t]hey can take some of this money for themselves (up to the full amount) and transfer whatever amount is left to UNICEF”. The exact donation amount was determined by the actual donation choices of the donor participants.

Following these details, participants were asked to cast a vote for the leadership position between two people who had also read about the same dilemma they had just read about. Participants were instructed that one person agreed with the utilitarian argument while the other person agreed with the non-utilitarian argument. This information was displayed to participants on the same page, in a randomized order. Participants were then asked to vote for the person they wished to be responsible for the group’s donations. We instructed participants that we would later identify the winner of the election, and implement their choice by distributing payments to the leader and UNICEF accordingly.

After completing the voting task, voter participants were asked the following comprehension question: “In the last page, you were asked to choose a leader that will be entrusted with the group’s donation. Please select the option that best describes what the leader will be able to do with the donation”. They were asked to select between three options, displayed in randomized order:

The leader can transfer the full donation to UNICEF or take some of the money for themselves.

The leader is not able to do anything with the donation.

The leader chooses how much of the group’s donation to keep for themselves and how much to return to the people who donated the money.

We excluded voter participants who failed to select the correct answer (1), as per our exclusion criteria (Exclusions). Note that in our stage 1 Registered Report the answer choices were slightly different, but we revised them after discovering in a soft launch that participants were systematically choosing one of the incorrect options, suggesting that the question was poorly worded. In consultation with the editor, we clarified the response options and began the data collection procedure anew. This was one of only three deviations from the stage 1 report (the others being that data collection took four weeks instead of the two weeks we had anticipated, and the use of Prolific instead of Lucid for recruitment in the United Kingdom and the United States).

After collecting the votes from the voter participants, we randomly selected ten donor participants to be considered for the leadership position: one who endorsed the utilitarian position for each of the five dilemmas and one who endorsed the non-utilitarian position for each of the five dilemmas. After tallying the votes from voter participants, we implemented the choices of each of the elected leaders and made the payments accordingly. For full text of instructions and questions for both the donor and the voting task, see Supplementary Methods .

Self-reported trust

Participants read about two dilemmas on the dimension of utilitarianism that they did not encounter in the voting task. That is, participants assigned to an instrumental harm dilemma (Lockdown, Ventilators or Tracing) for the voting task read both impartial beneficence dilemmas (PPE and Medicine) for the self-report task, while participants assigned to an impartial beneficence dilemma (PPE or Medicine) for the voting task read a randomly assigned two out of three instrumental harm dilemmas (Lockdown, Ventilators and Tracing) for the self-report task. The structure of the introduction to the dilemmas was identical to that in the voting task: they read a short description of the issue, followed by a description of two potential policies. On separate screens, they were asked which policy they themselves support.

After providing their own opinions, participants were asked to imagine that the mayor of a major city in their region was arguing for one of the two policies, providing either a utilitarian or non-utilitarian argument. Each participant was randomly assigned to read about leaders making either utilitarian or non-utilitarian arguments in both dilemmas presented in the self-report task. After reading about the leader’s opinion and argument, they were then be asked to report their general trust in the leader (“How trustworthy do you think this person is?”), to be answered on a 1–7 scale, with labels “Not at all trustworthy”, “Somewhat trustworthy” and “Extremely trustworthy” at points 1, 4 and 7, respectively. On a separate page they were then asked to report their trust in the leader’s advice on other issues (“How likely would you be to trust this person’s advice on other issues?”), to be answered on a 1–7 scale, with labels “Not at all likely”, “Somewhat likely” and “Extremely likely” at points 1, 4 and 7, respectively.

After completing the self-report task, participants were asked the following comprehension question: “In the last page, you read about a mayor in a city in your region, and were asked about them. Please select the option that best describes the questions you were asked”. Their options, displayed in a randomized order, were: (1) “How much I agreed with the mayor”, (2) “How much I trusted the mayor”, and (3) “How much I admired the mayor”. This allowed us to exclude participants who failed to select the correct answer (2), as per our exclusion criteria (Exclusions).

For full text of instructions and questions for the self-report task, see Supplementary Methods .

COVID concern

To assess their attitudes toward and experience with the pandemic, participants were asked three questions. Two measured how concerned participants currently felt about the pandemic, on both health-related and economic grounds (“How concerned are you about the health-related consequences of the COVID-19 pandemic?” and “How concerned are you about the financial and economic consequences of the COVID-19 pandemic?”, both to be answered on a 1–7 scale, with labels “Not at all” and “Very much” at points 1 and 7, respectively). The third question measured their personal involvement (“Have you or anyone else you know personally suffered significant health consequences as a result of COVID-19?”, to be answered by selecting one of three options: “Yes”, “No” and “Unsure”).

Oxford Utilitarianism Scale

All participants then completed the Oxford Utilitarianism Scale 33 . The scale consists of nine items in two subscales: instrumental harm (OUS-IH) and impartial beneficence (OUS-IB). The OUS-IB subscale consists of five items that measure endorsement of impartial maximization of the greater good, even at great personal cost (for example, “It is morally wrong to keep money that one doesn’t really need if one can donate it to causes that provide effective help to those who will benefit a great deal”). The OUS-IH subscale consists of four items relating to willingness to cause harm so as to bring about the greater good (for example, “It is morally right to harm an innocent person if harming them is a necessary means to helping several other innocent people”). Participants viewed all questions in a randomized order, and answered on a 1–7 scale, with labels “Strongly disagree”, “Disagree”, “Somewhat disagree”, “Neither agree nor disagree”, “Somewhat agree”, “Agree” and “Strongly agree”.

Demographics

All participants were asked to report their gender, age, years spent in education, subjective SES, education (on the same scale, but with minor changes in the scale labels across countries), political ideology (using an item from the World Values Survey) and religiosity. These questions were the same across countries and represent the demographics used as covariates in the main analyses. Additionally, participants were asked to indicate their region of residence (for example for the United States, “Which US State do you currently live in?”), and ethnicity/race, with the specific wording and response options depending on the local context (in France and Germany, this was not collected due to local regulations). In addition, participants were asked to confirm their country of residence, which allowed us to exclude participants who reported living in a country different from that of intended recruitment, as per our exclusion criteria (Exclusions).

Debriefing questions

Finally, participants were asked a series of debriefing questions. Two of these assessed their participation in other COVID-related studies (“Approximately how many COVID-related studies have you participated in before this one?”, answered by selecting one of the following options: “0”, “1–5”, “6–10”, “11–20”, “21–50”, “More than 50” and “I don’t remember”, and “If you have participated in any other COVID-related studies, how similar were they to this one?”, to be answered by selecting one of the following options: “Extremely similar”, “Very similar”, “Moderately similar”, “Slightly similar”, “Not at all similar” and “Not applicable”).

An additional question assessed participants’ attitudes towards the charity involved in the voting task (“How reliable do you think UNICEF is as an organization in using donations for helping people?”, answered on a 1–5 scale, with labels “Not reliable at all”, “Somewhat reliable” and “Very reliable” at points 1, 3 and 5, respectively).

Analysis plan

Pre-processing.

We planned to exclude data either at the participant level as outlined in Sampling plan section, based on criteria 1 (duplicate response), 2 (different residence) and 3 (partial completion), or on an analysis-by-analysis basis as outlined in criteria 4 (missing variables) and 5 (failed comprehension checks).

All participants’ responses were analysed, regardless of whether they were statistical outliers.

Computation of composite measures

Composite measures of self-reported trust were created by averaging responses to the two trust questions (trustworthiness of the leader and trust in the leader’s advice on other issues), separately for each participant and dilemma. In addition, we created composite OUS scores for each participant by averaging their responses on the scale items, separately for the instrumental harm (four items) and impartial beneficence subscales (five items).

Analysis plan for hypothesis testing

We planned to examine behavioural measures and self-report measures of trust in two separate models. For testing our hypotheses across all countries, we set a significance threshold of α  = 0.0025 (Bonferroni corrected for two tests). All analyses were conducted in R using the packages lme4 79 , lmerTest 80 , estimatr 81 , emmeans 82 , ggeffects 83 , ri2 84 and glmnet 85 . We planned that, in the event of convergence or singularity issues, we would supplement the theoretically appropriate models described below with simplified models by reducing the complexity of the random-effects structure 86 .

To examine participants’ self-reported trust in the leaders, we planned to examine the composite measure of their trust in each leader (that is, the average of the two trust questions, computed separately for each participant and dilemma). We hypothesized that participants would report higher trust in non-utilitarian leaders compared with utilitarian leaders in the context of dilemmas involving instrumental harm, while the opposite pattern would be observed for impartial beneficence. To test this hypothesis, we planned to conduct a linear mixed-effects model of the effect of argument type (utilitarian versus non-utilitarian), dimension type (instrumental harm versus impartial beneficence) and their interaction on the composite score of trust, adding demographic variables (gender, age, education, subjective SES, political ideology and religiosity) and policy support as fixed effects and dilemmas and countries as random intercepts, with participants nested within countries. In addition, we planned to run a model that included countries as random slopes of the two main effects and the interactive effect. We said that, should the model converge and should the results differ from the simpler model proposed above, we would compare model fits using the Akaike information criterion (AIC) and retain the model that better fits the data, while still reporting the other in supplementary materials. We planned to follow up on significant effects with post hoc comparisons using Bonferroni corrections. For the purposes of the analysis, we used effect coding such that, for argument type, the non-utilitarian condition was coded as −0.5 and the utilitarian condition as 0.5, and for the dimension type, instrumental harm was coded as −0.5 and impartial beneficence as 0.5. The demographic covariates were grand-mean-centred; the gender variable was dummy coded with “woman” as baseline. P values were computed using Satterthwaite’s approximation for degrees of freedom as implemented in lmerTest. For analysis code, see https://osf.io/m9tpu/ .

To examine participants’ trust in the leaders as demonstrated by their behaviour, we planned to examine their choices in the voting task, where they were asked to select which of two leaders (one making a utilitarian argument and the other a non-utilitarian one) to entrust with a group charity donation. We hypothesized that participants would be more likely to select the non-utilitarian leader over the utilitarian leader when reading about their arguments for dilemmas involving instrumental harm, while the opposite pattern would be observed for impartial beneficence. To test this hypothesis, we planned to conduct a generalized linear mixed-effects model with the logit link of the effect of dimension type (instrumental harm versus impartial beneficence) on the leader choice (utilitarian versus non-utilitarian), adding demographic variables (gender, age, education, subjective SES, political ideology and religiosity) and policy support as fixed effects and dilemmas and countries as random intercepts, with participants nested within countries. In addition, we said we would also run a model that includes countries as random slopes of the effect of dimension type. Should the model converge and should the results differ from the simpler model proposed above, we planned to compare model fits using the Akaike information criterion (AIC) and retain the model that better fits the data, while still reporting the other in supplementary materials. Based on recent reports that linear models might be preferable to logistic models in treatment designs 63 , 64 , we said we would run the same analysis using a linear model (instead of logit link) with the identical fixed and random effects and again adjudicate between the models using the AIC. We planned to follow up on any significant effects observed with post hoc comparisons using Bonferroni corrections. For the purposes of this analysis, we planned to use effect coding such that, for the binary response variable of argument type, the non-utilitarian trust response was coded as 0 and the utilitarian trust response as 1, and for the dimension type, instrumental harm was coded as −0.5 and impartial beneficence as 0.5. Again, the demographic covariates were grand-mean-centred; the gender variable was dummy coded with “woman” as baseline. P values were computed using Satterthwaite’s approximation for degrees of freedom as implemented in lmerTest. For analysis code, see https://osf.io/m9tpu/ .

Because there was evidence that public perceptions of lockdowns at the time of data collection were changing relative to July 2020 when we ran our pilots 87 , 88 , which may affect responses to the Lockdown dilemma, we planned to examine the robustness of our findings using two variations of the models described above, one that includes the Lockdown dilemma and another that omits it.

As some of the countries in our sample already implement mandatory and/or invasive contact tracing schemes at the time of writing (China, India, Israel, Singapore and South Korea), which may affect responses to the Tracing dilemma, we also planned to examine the robustness of our findings in these countries using two variations of the models described above, one that includes the Tracing dilemma and another that omits it. Furthermore, in this subset of countries we planned to examine an order effect to test whether completing the Tracing dilemma in the first task affects behaviour on the subsequent task.

Null hypothesis testing

In the event of non-significant results from the approaches outlined above, we planned to employ the TOST procedure 89 to differentiate between insensitive versus null results. In particular, we planned to specify lower and upper equivalence bounds based on standardized effect sizes set by our SESOI ( Power analysis and Table 2 ). For each of our two tasks, should the larger of the two P values from the two t tests be smaller than α  = 0.05, we would conclude statistical equivalence. For example, the minimum guaranteed sample size ( N  = 12,600; see Sample size for details) would give us over 95% power to detect an effect size of d  = 0.05 in the self-report task, yielding standardized Δ L  = −0.05 and Δ U  = 0.05, and an OR of 1.30 in the voting task, yielding standardized Δ L  = −0.15 and Δ U  = 0.15.

Sampling plan

We planned to complete the study online with participants in the following countries: Australia, Brazil, Canada, Chile, China, Denmark, France, Germany, India, Israel, Italy, the Kingdom of Saudi Arabia, Mexico, the Netherlands, Norway, Singapore, South Africa, South Korea, Spain, the United Arab Emirates, the United Kingdom and the United States (Fig. 1a ). We sampled on every inhabited continent and included countries that have been more or less severely affected by COVID-19 on a variety of metrics (Supplementary Fig. 1 ). Country selection was determined primarily on a convenience basis. In April 2020, the senior author put out a call for collaborators via social media and email. Potential collaborators were asked whether they had the capacity to recruit up to 1,000 participants representative for age and gender within their home country. After the initial set of collaborators was established, we added additional countries to diversify our sample with respect to geographic location and pandemic severity.

We planned to recruit participants via online survey platforms (Supplementary Table 1 ) and compensate them financially for their participation in accordance with local standard rates. We aimed to recruit samples that were nationally representative with respect to age and gender where feasible. We anticipated that this would be feasible for many but not all countries in our study (see Supplementary Table 1 for details). We originally anticipated sampling to take place over a 14-day period, but to allow for more representative sampling (after discussion with the editor), we collected data over a period of 27 days (26 November 2020 to 22 December 2020). All survey materials were translated into the local language (see Translations for details). Prior to the survey, all participants read and approved a consent form outlining their risks and benefits, confirmed they agreed to participate in the experiment and completed two attention checks. Participants who failed to agree to the consent or failed to pass the attention checks were not permitted to complete the survey (with the exception of participants in the United States and the United Kingdom, who due to recruitment platform requirements were instead allowed to continue the survey, and were only excluded after data collection).

Expected effect sizes

We informed our expected effect sizes by examining the published literature on utilitarianism and trust. Previous studies of social impressions of utilitarians reveal effect sizes in the range of d  = 0.19–0.78 (mean d  = 0.78 for the effect of instrumental harm on self-reported moral impressions; mean d  = 0.19 for the effect of impartial beneficence on self-reported moral impressions; mean d  = 0.55 for interactive effects of instrumental harm and impartial beneficence on self-reported moral impressions) 35 , 36 , 37 , 38 , 39 . However, there are several important caveats with using these past studies to inform expected effect sizes for the current study. First, past studies have measured trust in ordinary people, while we study trust in leaders, and there is evidence that instrumental harm and impartial beneficence differentially impact attitudes about leaders versus ordinary people 37 . Second, past studies have investigated artificial moral dilemmas, while we study real moral dilemmas in the context of an ongoing pandemic. Third, past studies have been conducted in a small number of Western countries (the United States, the United Kingdom and Germany), while we sample across a much wider range of countries on six continents. Finally, for the voting task, it is more challenging to estimate an expected effect size because no previous studies to our knowledge have used such a task.

Because of the caveats described above, we also informed our expectations of effect sizes with data from pilot 2, which was identical to the proposed studies in design apart from using The Red Cross instead of UNICEF in the voting task and the omission of the Tracing dilemma (see Pilot data in Supplementary Information for a full description of the pilot experiments). Pilot 2 revealed a conventionally medium effect size for the interaction between argument and moral dimension in the self-report task ( B  = 2.88, s.e. 0.24, t (452) = 11.80, P  < 0.001, CI [2.41, 3.35], d  = 0.55) and a conventionally large effect size for the effect of moral dimension in the voting task ( B  = 2.41, s.e. 0.33, z  = 7.30, P  < 0.001, CI [1.77, 3.13], OR 11.13, d  = 1.33).

Sample size

Sample size was determined based on a cost–benefit analysis considering available resources and expected effect sizes that would be theoretically informative 89 ( Expected effect sizes ). We aimed to collect the largest sample possible with resources available and verified with power analyses that our planned sample would be able to detect effect sizes that are theoretically informative and at least as large as expected based on prior literature ( Power analysis ). We expected to collect a sample of 21,000 participants in total, which conservatively accounting for exclusion rates up to 40% (Exclusions) would lead to a final guaranteed minimum sample of 12,600 participants.

Power analysis

We conducted a series of power analyses to determine the smallest effect sizes that our minimum guaranteed sample of 12,600 participants would be able to detect with 95% power and an α level of 0.005, separately for each main model (see Analysis plan for further details). To account for these two hypothesis tests, for all power analyses we applied Bonferroni corrections for two tests, thus yielding an α of 0.0025. Following recent suggestions 90 , 91 , results passing a corrected α of P  ≤ 0.005 are interpreted as ‘supportive evidence’ for our hypotheses, while results passing a corrected α of P  < 0.05 are interpreted as ‘suggestive evidence’. Power analyses were conducted using Monte Carlo simulations 92 via the R package simr 93 , with 1,000 simulations, using estimates of means and variances from pilot 2 (see Pilot data in Supplementary Information for a full description of the pilot experiments; note that, for the purposes of the current simulations, the race variable was omitted from data analysis because this variable is not readily comparable across countries). Data and code for power analyses can be found at https://osf.io/m9tpu/ .

First, we considered the interactive effect of moral dimension (instrumental harm versus impartial beneficence) and argument (utilitarian versus non-utilitarian) on trust in the self-report task. We estimated that a sample of 12,600 participants would provide over 95% power to detect an effect size of d  = 0.05 (power 99.3%, CI [98.56, 99.72]). This effect size is 9% of what we observed in pilot 2 and is the SESOI for the self-report task.

Next, we considered the effect of moral dimension (instrumental harm versus impartial beneficence) on leader choice in the voting task. We estimated that a sample of 12,600 participants would provide over 95% power to detect an odds ratio of 1.30 (power 95.8%, CI [94.36, 96.96]). This effect size is 9% of what we observed in pilot 2 and is the SESOI for the voting task.

Given that these SESOI values are detectable at 95% power with our guaranteed sample (total N  = 12,600), are theoretically informative and are lower than our expected effect sizes ( Expected effect sizes ), we concluded that our sample is sufficient to provide over 95% power for testing our hypotheses and that our study is highly powered to detect useful effects.

At the time of submission, online survey platform representatives indicated that, while it is normally feasible to recruit samples nationally representative for age and gender in most of our target countries, due to the ongoing pandemic, final sample sizes may be unpredictable and in some countries it would not be possible to achieve fully representative quotas for some demographic categories, including women and older people (see Supplementary Table 1 for details). We planned that, if this issue arose, we would prioritize statistical power over representativeness. If we were unable to achieve representativeness for age and/or gender in particular countries, we planned to note this explicitly in the Results section.

We planned to exclude participants from all further analyses if they met at least one of the following criteria: (1) they had taken the survey more than once (as indicated by IP address or worker ID); (2) they reported in a question about their residence (further described in Design ) that they lived in a country different from that of intended recruitment; (3) they did not answer more than 50% of the questions. In addition, participants would be selectively excluded from specific analyses if they (4) did not provide a response and are thus missing variables involved in the analysis or (5) failed the comprehension check (further described in Design ) for the task involved in the specific analysis.

Reporting Summary

Further information on research design is available in the Nature Research Reporting Summary linked to this article.

Data availability

All data and materials are openly available on the Open Science Framework (OSF) website at this link: https://osf.io/m9tpu/ . Source data are provided with this paper.

Code availability

All analysis code (completed in R) are openly available on the Open Science Framework (OSF) website at this link: https://osf.io/m9tpu/ .

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Acknowledgements

Pilot data collection was supported by Prolific Academic. Data collection for the main study was supported by grants from the Yale Tobin Center for Economic Policy (M.C.); the British Academy, Leverhulme Trust and the Department for Business, Energy and Industrial Strategy (SRG19\190050; J.A.C.E.); the Institutions for Open Science at Utrecht University (L.T. and M.S.), central internationalization funds of the Universität Hamburg and the Graduate School of its Faculty of Business, Economics and Social Sciences (B.B. and M.A.D.); and CAPES PRINT (88887.310255/2018 – 00; P.B.) and CAPES PROEX (1133/2019; P.B.). L.T. furthermore acknowledges funding from NWO grant (016.VIDI.185.017) and the National Research Foundation of Korea Grant, funded by the Korean Government (NRF-2017S1A3A2067636). H.S. was partly supported by the Research Council of Norway through its Centres of Excellence Scheme, FAIR project (262675). D.C. was partly supported by the National Research Foundation of Korea (NRF-2018R1D1A1B0704358). E.A., B.G., Y.L. and G.P. thank the University of Exeter Business School for funding their contribution to this research. N.S. gratefully acknowledges funding support provided by the Department of Management, Faculty of Management and Economics, Universidad de Santiago de Chile, and ANID FONDECYT de Iniciación en Investigación 2020 (Folio 11200781). A.L.O. and F.H. gratefully acknowledge support from the Independent Research Fund Denmark (0213-00052B and 8046-00034A) and the Faculty of the Social Sciences at the University of Copenhagen. N.R. was partly supported by the Israel Science Foundation (540/20). A.M.B.P. was supported by the ESRC. W.J.B. was supported by a postdoc fellowship from the National Science Foundation (#1808868). V.C. was supported by the National Science Foundation graduate research fellowship under grant no. DGE1752134. S.S. was partly supported by the National Research Foundation of Korea (NRF-2018R1C1B6007059). P.B. gratefully acknowledges support from CNPq (researcher fellowship 309905/2019-2). Y.M. gratefully acknowledges support from the National Natural Science Foundation of China (no. 31771204) and Major Project of National Social Science Foundation (19ZDA363). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. The authors thank members of the Crockett laboratory for feedback on previous drafts of this manuscript; J. Monrad for advice on scenario design; R. Gomila for statistical advice; J. Okoroafor, D. Shao and X. Wang for assistance; and J. Apel, A. Bidani, N. Breedveld, R. Calcott, R. Carlson, L. Alfaro Cui cui, A. A. Gálvez, N. Kim, F. Michelsen, M. Meinert Pedersen, A. Mokady, A. Oline Ervik, J. Yang, X. Zeng and M. Zoccali for assistance with survey translations.

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These authors contributed equally: Jim A. C. Everett, Clara Colombatto

Authors and Affiliations

School of Psychology, University of Kent, Canterbury, UK

Jim A. C. Everett

Department of Psychology, Yale University, New Haven, CT, USA

Clara Colombatto, William J. Brady, Megha Chawla, Vladimir Chituc, Srishti Goel, Alissa Ji, Caleb Kealoha, Judy S. Kim, Yeon Soon Shin, Yoonseo Zoh & Molly J. Crockett

Department of Economics, University of Exeter, Exeter, UK

Edmond Awad, Brit Grosskopf, Yangfei Lin & Graeme Pearce

Social and Cognitive Neuroscience Laboratory, Mackenzie Presbyterian University, São Paulo, Brazil

Paulo Boggio

Department of Economics, University of Hamburg, Hamburg, Germany

Björn Bos & Moritz A. Drupp

Department of Biomedical Engineering, Ulsan National Institute of Science and Technology, Ulsan, South Korea

Dongil Chung

Department of Political Science, University of Copenhagen, Copenhagen, Denmark

Frederik Hjorth & Asmus L. Olsen

State Key Laboratory of Cognitive Neuroscience and Learning, IDG/McGovern Institute for Brain Research, Beijing Key Laboratory of Brain Imaging and Connectomics, Beijing Normal University, Beijing, China

Chinese Institute for Brain Research, Beijing, China

Department of Economics, University of Zurich, Zurich, Switzerland

Michel André Maréchal & Julien Senn

Scuola Internazionale Superiore di Studi Avanzati (SISSA), Trieste, Italy

Federico Mancinelli & Christoph Mathys

Interacting Minds Centre, Aarhus University, Aarhus, Denmark

Christoph Mathys

Translational Neuromodeling Unit (TNU), Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland

Department of Psychology, University of Bath, Bath, UK

Annayah M. B. Prosser

Department of Psychology and Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Be’er Sheva, Israel

Department of Management, Faculty of Management and Economics, Universidad de Santiago de Chile, Santiago, Chile

Nicholas Sabin

Department of Philosophy and Kenan Institute for Ethics, Duke University, Durham, NC, USA

Walter Sinnott-Armstrong

Department of Strategy and Management, Norwegian School of Economics, Bergen, Norway

Hallgeir Sjåstad

Department of Psychology, Utrecht University, Utrecht, The Netherlands

Madelijn Strick

Department of Psychology, Pusan National University, Busan, South Korea

School of Governance, Utrecht University, Utrecht, The Netherlands

Lars Tummers

Department of Communication, Michigan State University, East Lansing, MI, USA

Monique Turner

Department of Psychological and Brain Sciences, University of California Santa Barbara, Santa Barbara, CA, USA

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Contributions

M.J.C., J.A.C.E., C.C., V.C. and W.J.B. conceived the research. M.J.C., J.A.C.E., C.C., E.A., P.B., B.B., W.J.B., M.C., V.C., D.C., M.A.D., S.G., F.H., Y.M., M.A.M., C.M., A.L.O., A.M.B.P., N.R., N.S., J.S., W.S.-A., H.S., M.S., S.S., L.T., M.T., H.Y. and Y.Z. designed the research. M.A.M., J.S., M.J.C., J.A.C.E., C.C., H.S., L.T., N.S. and E.A. developed the voting task. J.A.C.E., V.C., M.J.C., C.C. and W.S.-A. wrote the moral dilemmas. C.C. conducted the power analysis in consultation with M.J.C., W.J.B., C.M. and N.R. C.C., J.A.C.E., M.J.C., W.J.B., C.M. and N.R. developed the analysis plan. C.C. analysed the data in consultation with M.J.C., J.A.C.E., W.J.B., C.M., N.R., M.A.M., J.S., N.S., E.A., A.J., Y.S.S. and J.S.K. J.A.C.E., C.C. and M.J.C. prepared the manuscript with feedback from all co-authors. M.J.C., J.A.C.E., C.C. and C.K. coordinated the implementation of the project. M.J.C., J.A.C.E., C.C., E.A., P.B., B.B., M.C., D.C., M.A.D., S.G., B.G., F.H., C.K., J.S.K., Y.L., Y.M., M.A.M., F.M., C.M., A.L.O., G.P., N.R., N.S., J.S., Y.S.S., H.S., M.S., S.S., L.T., H.Y. and Y.Z. contributed to data collection and/or translation. All co-authors reviewed and approved the final manuscript.

Corresponding author

Correspondence to Molly J. Crockett .

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Additional information

Peer review information Nature Human Behaviour thanks Arne Roets, Onurcan Yilmaz and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

Extended data

Extended data fig. 1 overview of experimental design..

Across subjects, we randomized the order of the voting and self-report tasks, the order of dilemmas in the self-report task, and the order of leaders in the voting task.

Supplementary information

Pilot data; Supplementary Methods, Supplementary Results, Supplementary Notes 1–13, Supplementary Tables 1 and 2 and Supplementary Figs. 1–8.

Reporting summary

Peer review information, source data fig. 1.

Statistical source data

Source Data Fig. 2

Source data fig. 3, source data fig. 4, rights and permissions.

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Everett, J.A.C., Colombatto, C., Awad, E. et al. Moral dilemmas and trust in leaders during a global health crisis. Nat Hum Behav 5 , 1074–1088 (2021). https://doi.org/10.1038/s41562-021-01156-y

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Accepted : 07 June 2021

Published : 01 July 2021

Issue Date : August 2021

DOI : https://doi.org/10.1038/s41562-021-01156-y

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Case study: an ethical dilemma involving a dying patient

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• 1 Lehman College, City University of New York, Bronx, NY, USA.
• PMID: 19105511

Nursing often deals with ethical dilemmas in the clinical arena. A case study demonstrates an ethical dilemma faced by healthcare providers who care for and treat Jehovah's Witnesses who are placed in a critical situation due to medical life-threatening situations. A 20-year-old, pregnant, Black Hispanic female presented to the Emergency Department (ED) in critical condition following a single-vehicle car accident. She exhibited signs and symptoms of internal bleeding and was advised to have a blood transfusion and emergency surgery in an attempt to save her and the fetus. She refused to accept blood or blood products and rejected the surgery as well. Her refusal was based on a fear of blood transfusion due to her belief in Bible scripture. The ethical dilemma presented is whether to respect the patient's autonomy and compromise standards of care or ignore the patient's wishes in an attempt to save her life. This paper presents the clinical case, identifies the ethical dilemma, and discusses virtue ethical theory and principles that apply to this situation.

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• Blood Transfusion / ethics*
• Cesarean Section / ethics*
• Fatal Outcome
• Hemorrhage / therapy*
• Jehovah's Witnesses*
• Treatment Refusal / ethics*

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O'Mathúna D, Iphofen R, editors. Ethics, Integrity and Policymaking: The Value of the Case Study [Internet]. Cham (CH): Springer; 2022. doi: 10.1007/978-3-031-15746-2_1

Ethics, Integrity and Policymaking: The Value of the Case Study [Internet].

Chapter 1 making a case for the case: an introduction.

Dónal O’Mathúna and Ron Iphofen .

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Published online: November 3, 2022.

This chapter agues for the importance of case studies in generating evidence to guide and/or support policymaking across a variety of fields. Case studies can offer the kind of depth and detail vital to the nuances of context, which may be important in securing effective policies that take account of influences not easily identified in more generalised studies. Case studies can be written in a variety of ways which are overviewed in this chapter, and can also be written with different purposes in mind. At the same time, case studies have limitations, particularly when evidence of causation is sought. Understanding these can help to ensure that case studies are appropriately used to assist in policymaking. This chapter also provides an overview of the types of case studies found in the rest of this volume, and briefly summarises the themes and topics addressed in each of the other chapters.

1.1. Judging the Ethics of Research

When asked to judge the ethical issues involved in research or any evidence-gathering activity, any research ethicist worth their salt will (or should) reply, at least initially: ‘It depends’. This is neither sophistry nor evasive legalism. Instead, it is a specific form of casuistry used in ethics in which general ethical principles are applied to the specifics of actual cases and inferences made through analogy. It is valued as a structured yet flexible approach to real-world ethical challenges. Case study methods recognise the complexities of depth and detail involved in assessing research activities. Another way of putting this is to say: ‘Don’t ask me to make a judgement about a piece of research until I have the details of the project and the context in which it will or did take place.’ Understanding and fully explicating a context is vital as far as ethical research (and evidence-gathering) is concerned, along with taking account of the complex interrelationship between context and method (Miller and Dingwall 1997 ).

This rationale lies behind this collection of case studies which is one outcome from the EU-funded PRO-RES Project. 1 One aim of this project was to establish the virtues, values, principles and standards most commonly held as supportive of ethical practice by researchers, scientists and evidence-generators and users. The project team conducted desk research, workshops and consulted throughout the project with a wide range of stakeholders (PRO-RES 2021a ). The resulting Scientific, Trustworthy, and Ethical evidence for Policy (STEP) ACCORD was devised, which all stakeholders could sign up to and endorse in the interests of ensuring any policies which are the outcome of research findings are based upon ethical evidence (PRO-RES 2021b ).

By ‘ethical evidence’ we mean results and findings that have been generated by research and other activities during which the standards of research ethics and integrity have been upheld (Iphofen and O’Mathúna 2022 ). The first statement of the STEP ACCORD is that policy should be evidence-based, meaning that it is underpinned by high-quality research, analysis and evidence (PRO-RES 2021b ). While our topic could be said to be research ethics, we have chosen to refer more broadly to evidence-generating activities. Much debate has occurred over the precise definition of research under the apparent assumption that ‘non-research projects’ fall outside the purview of requirements to obtain ethics approval from an ethics review body. This debate is more about the regulation of research than the ethics of research and has contributed to an unbalanced approach to the ethics of research (O’Mathúna 2018 ). Research and evidence-generating activities raise many ethical concerns, some similar and some distinct. When the focus is primarily on which projects need to obtain what sort of ethics approval from which type of committee, the ethical issues raised by those activities themselves can receive insufficient attention. This can leave everyone involved with these activities either struggling to figure out how to manage complex and challenging ethical dilemmas or pushing ahead with those activities confident that their approval letter means they have fulfilled all their ethical responsibilities. Unfortunately, this can lead to a view that research ethics is an impediment and burden that must be overcome so that the important work in the research itself can get going.

The alternative perspective advocated by PRO-RES, and the authors of the chapters in this volume, is that ethics underpins all phases of research, from when the idea for a project is conceived, all the way through its design and implementation, and on to how its findings are disseminated and put into practice in individual decisions or in policy. Given the range of activities involved in all these phases, multiple types of ethical issues can arise. Each occurs in its own context of time and place, and this must be taken into account. While ethical principles and theories have important contributions to make at each of these points, case studies are also very important. These allow for the normative effects of various assumptions and declarations to be judged in context. We therefore asked the authors of this volume’s chapters to identify various case studies which would demonstrate the ethical challenges entailed in various types of research and evidence-generating activities. These illustrative case studies explore various innovative topics and fields that raise challenges requiring ethical reflection and careful policymaking responses. The cases highlight diverse ethical issues and provide lessons for the various options available for policymaking (see Sect.  1.6 . below). Cases are drawn from many fields, including artificial intelligence, space science, energy, data protection, professional research practice and pandemic planning. The issues are examined in different locations, including Europe, India, Africa and in global contexts. Each case is examined in detail and also helps to anticipate lessons that could be learned and applied in other situations where ethical evidence is needed to inform evidence-based policymaking.

1.2. The Case for Cases

Case studies have increasingly been used, particularly in social science (Exworthy and Powell 2012 ). Many reasons underlie this trend, one being the movement towards evidence-based practice. Case studies provide a methodology by which a detailed study can be conducted of a social unit, whether that unit is a person, an organization, a policy or a larger group or system (Exworthy and Powell 2012 ). The case study is amenable to various methodologies, mostly qualitative, which allow investigations via documentary analyses, interviews, focus groups, observations, and more.

At the same time, consensus is lacking over the precise nature of a case study. Various definitions have been offered, but Yin ( 2017 ) provides a widely cited definition with two parts. One is that a case study is an in-depth inquiry into a real-life phenomenon where the context is highly pertinent. The second part of Yin’s definition addresses the many variables involved in the case, the multiple sources of evidence explored, and the inclusion of theoretical propositions to guide the analysis. While Yin’s emphasis is on the case study as a research method, he identifies important elements of broader relevance that point to the particular value of the case study for examining ethical issues.

Other definitions of case studies emphasize their story or narrative aspects (Gwee 2018 ). These stories frequently highlight a dilemma in contextually rich ways, with an emphasis on how decisions can be or need to be made. Case studies are particularly helpful with ethical issues to provide crucial context and explore (and evaluate) how ethical decisions have been made or need to be made. Classic cases include the Tuskegee public health syphilis study, the Henrietta Lacks human cell line case, the Milgram and Zimbardo psychology cases, the Tea Room Trade case, and the Belfast Project in oral history research (examined here in Chap. 10 ). Cases exemplify core ethical principles, and how they were applied or misapplied; in addition, they examine how policies have worked well or not (Chaps. 2 , 3 and 5 ). Cases can examine ethics in long-standing issues (like research misconduct (Chap. 7 ), energy production (Chap. 8 ), or Chap. 11 ’s consideration of researchers breaking the law), or with innovations in need of further ethical reflection because of their novelty (like extended space flight (Chap. 9 ) and AI (Chaps. 13 and 14 ), with the latter looking at automation in legal systems). These case studies help to situate the innovations within the context of widely regarded ethical principles and theories, and allow comparisons to be made with other technologies or practices where ethical positions have been developed. In doing so, these case studies offer pointers and suggestions for policymakers given that they are the ones who will develop applicable policies.

1.3. Research Design and Causal Inference

Not everyone is convinced of the value of the case study. It must be admitted that they have limitations, which we will reflect on shortly. Yet we believe that others go too far in their criticisms, revealing instead some prejudices against the value of the case (Yin 2017 ). In what has become a classic text for research design, Campbell and Stanley ( 1963 ) have few good words for what they call the ‘One Shot Case Study.’ They rank it below two other ‘pre-experimental’ designs—the One-Group Pretest–Posttest and the Static-Group Comparison—and conclude that case studies “have such a total absence of control to be of almost no scientific value” (Campbell and Stanley 1963 , 6). The other designs have, in turn, a baseline and outcome measure and some degree of comparative analysis which provides them some validity. Such a criticism is legitimate if one prioritises the experimental method as the most superior in terms of effectiveness evidence and, as for Campbell and Stanley, one is striving to assess the effectiveness of educational interventions.

What is missing from that assessment is that different methodologies are more appropriate for different kinds of questions. Questions of causation and whether a particular treatment, policy or educational strategy is more effective than another are best answered by experimental methods. While experimental designs are better suited to explore causal relationships, case studies are more suited to explore “how” and “why” questions (Yin 2017 ). It can be more productive to view different methodologies as complementing one another, rather than examining them in hierarchical terms.

The case study approach draws on a long tradition in ethnography and anthropology: “It stresses the importance of holistic perspectives and so has more of a ‘humanistic’ emphasis. It recognises that there are multiple influences on any single individual or group and that most other methods neglect the thorough understanding of this range of influences. They usually focus on a chosen variable or variables which are tested in terms of their influence. A case study tends to make no initial assumptions about which are the key variables—preferring to allow the case to ‘speak for itself’” (Iphofen et al. 2009 , 275). This tradition has sometimes discouraged people from conducting or using case studies on the assumption that they take massive amounts of time and lead to huge reports. This is the case with ethnography, but the case study method can be applied in more limited settings and can lead to high-quality, concise reports.

Another criticism of case studies is that they cannot be used to make generalizations. Certainly, there are limits to their generalisability, but the same is true of experimental studies. One randomized controlled trial cannot be generalised to the whole population without ensuring that its details are evaluated in the context of how it was conducted.

Similarly, it should not be assumed that generalisability can adequately guide practice or policy when it comes to the specifics of an individual case. A case study should not be used to support statistical generalizations (that the same percentage found in the case will be found in the general public). But a case study can be used to expand and generalize theories and thus have much usefulness. It affords a method of examining the specific (complex) interactions occurring in a case which can only be known from the details. Such an analysis can be carried out for individuals, policies or interventions.

The current COVID-19 pandemic demonstrates the dangers of generalising in the wrong context. Some people have very mild cases of COVID-19 or are asymptomatic. Others get seriously ill and even die. Sometimes people generalise from cases they know and assume they will have mild symptoms. Then they refuse to take the COVID-19 vaccine, basically generalising from similar cases. Mass vaccination is recommended for the sake of the health of the public (generalised health) and to limit the spread of a deadly virus. Cases are reported of people having adverse reactions to COVID-19 vaccines, and some people generalise from these that they will not take whatever risks might be involved in receiving the vaccine themselves. It might be theoretically possible to discover which individuals WILL react adversely to immunisation on a population level. But it is highly complex and expensive to do so, and takes an extensive period of time. Given the urgency of benefitting the health of ‘the public’, policymakers have decided that the risks to a sub-group are warranted. Only after the emergence of epidemiological data disclosing negative effects of some vaccines on some individuals will it become more clear which characteristics typify those cases which are likely to experience the adverse effects, and more accurately quantify the risks of experiencing those effects.

Much literature now points to the advantages and disadvantages of case studies (Gomm et al. 2000 ), and how to use them and conduct them with adequate rigour to ensure the validity of the evidence generated (Schell 1992 ; Yin 2011 , 2017 ). At the same time, legitimate critiques have been made of some case studies because they have been conducted without adequate rigor, in unsystematic ways, or in ways that allowed bias to have more influence than evidence (Hammersley 2001 ). Part of the problem here is similar to interviewing, where some will assume that since interviews are a form of conversation, anyone can do it. Case studies have some similarities to stories, but that doesn’t mean they are quick and easy ways to report on events. That view can lead to the situation where “most people feel that they can prepare a case study, and nearly all of us believe we can understand one. Since neither view is well founded, the case study receives a lot of approbation it does not deserve” (Hoaglin et al., cited in Yin 2017 , 16).

Case studies can be conducted and used in a wide range of ways (Gwee 2018 ). Case studies can be used as a research method, as a teaching tool, as a way of recording events so that learning can be applied to practice, and to facilitate practical problem-solving skills (Luck et al. 2006 ). Significant differences exist between a case study that was developed and used in research compared to one used for teaching (Yin 2017 ). A valid rationale for studying a ‘case’ should be provided so that it is clear that the proposed method is suitable to the topic and subject being studied. The unit of study for a case could be an individual person, social group, community, or society. Sometimes that specific case alone will constitute the actual research project. Thus, the study could be of one individual’s experience, with insights and understanding gained of the individual’s situation which could be of use to understand others’ experiences. Often there will be attempts made at a comparison between cases—one organisation being compared to another, with both being studied in some detail, and in terms of the same or similar criteria. Given this variety, it is important to use cases in ways appropriate to how they were generated.

The case study continues to be an important piece of evidence in clinical decision-making in medicine and healthcare. Here, case studies do not demonstrate causation or effectiveness, but are used as an important step in understanding the experiences of patients, particularly with a new or confusing set of symptoms. This was clearly seen as clinicians published case studies describing a new respiratory infection which the world now knows to be COVID-19. Only as case studies were generated, and the patterns brought together in larger collections of cases, did the characteristics of the illness come to inform those seeking to diagnose at the bedside (Borges do Nascimento et al. 2020 ). Indeed case studies are frequently favoured in nursing, healthcare and social work research where professional missions require a focus on the care of the individual and where cases facilitate making use of the range of research paradigms (Galatzer-Levy et al. 2000 ; Mattaini 1996 ; Gray 1998 ; Luck et al. 2006 ).

1.4. Devil’s in the Detail

Our main concern in this collection is not with case study aetiology but rather to draw on the advantages of the method to highlight key ethical issues related to the use of evidence in influencing policy. Thus, we make no claim to causal ‘generalisation’ on the basis of these reports—but instead we seek to help elucidate ethics issues, if even theoretical, and anticipate responses and obstacles in similar situations and contexts that might help decision-making in novel circumstances. A key strength of case studies is their capacity to connect abstract theoretical concepts to the complex realities of practice and the real world (Luck et al. 2006 ). Ethics cases clearly fit this description and allow the contextual details of issues and dilemmas to be included in discussions of how ethical principles apply as policy is being developed.

Since cases are highly focussed on the specifics of the situation, more time can be given over to data gathering which may be of both qualitative and quantitative natures. Given the many variables involved in the ‘real life’ setting, increased methodological flexibility is required (Yin 2017 ). This means seeking to maximise the data sources—such as archives (personal and public), records (such as personal diaries), observations (participant and covert) and interviews (face-to-face and online)—and revisiting all sources when necessary and as case participants and time allows.

1.5. Cases and Policymaking

Case studies allow researchers and practitioners to learn from the specifics of a situation and apply that learning in similar situations. Ethics case studies allow such reflection to facilitate the development of ethical decision-making skills. This volume has major interests in ethics and evidence-generation (research), but also in a third area: policymaking. Cases can influence policymaking, such as how one case can receive widespread attention and become the impetus to create policy that aims to prevent similar cases. For example, the US federal Brady Law was enacted in 1993 to require background checks on people before they purchase a gun (ATF 2021 ). The law was named for White House Press Secretary James Brady, and his case became widely known in the US. He was shot and paralyzed during John Hinckley, Jr.’s 1981 assassination attempt on President Ronald Reagan. Another example, this time in a research context, was how the Tuskegee Syphilis Study led, after its public exposure in 1971, to the US Department of Health, Education and Welfare appointing an expert panel to examine the ethics of that case. This resulted in federal policymakers enacting the National Research Act in 1974, which included setting up a national commission that published the Belmont Report in 1976. This report continues to strongly influence research ethics practice around the world. These examples highlight the power of a case study to influence policymaking.

One of the challenges for policymakers, though, is that compelling cases can often be provided for opposite sides of an issue. Also, while the Belmont Report has been praised for articulating a small number of key ethical principles, how those principles should be applied in specific instances of research remains an ongoing challenge and a point of much discussion. This is particularly relevant for innovative techniques and technologies. Hence the importance of cases interacting with general principles and leading to ongoing reflection and debate over the applicable cases. At the same time, new areas of research and evidence generation activities will lead to questions about how existing ethical principles and values apply. New case studies can help to facilitate that reflection, which can then allow policymakers to consider whether existing policy should be adapted or whether whole new areas of policy are needed.

Case studies also can play an important role in learning from and evaluating policy. Policymakers tend to focus on practical, day-to-day concerns and with the introduction of new programmes (Exworthy and Peckam 2012 ). Time and resources may be scant when it comes to evaluating how well existing policies are performing or reflecting on how policies can be adapted to overcome shortcomings (Hunter 2003 ). Effective policies may exist elsewhere (historically or geographically) and be more easily adapted to a new context instead of starting policymaking from scratch. Case studies can permit learning from past policies (or situations where policies did not exist), and they can illuminate various factors that should be explored in more detail in the context of the current issue or situation. Chaps. 2 , 3 and 5 in this volume are examples of this type of case study.

1.6. The Moral Gain

This volume reflects the ambiguity of ethical dilemmas in contemporary policymaking. Analyses will reflect current debates where consensus has not been achieved yet. These cases illustrate key points made throughout the PRO-RES project: that ethical decision-making is a fluid enterprise, where values, principles and standards must constantly be applied to new situations, new events and new research developments. The cases illustrate how no ‘one point’ exists in the research process where judgements about ethics can be regarded as ‘final.’ Case studies provide excellent ways for readers to develop important decision-making skills.

Research produces novel products and processes which can have broad implications for society, the environment and relationships. Research methods themselves are modified or applied in new ways and places, requiring further ethical reflection. New topics and whole fields of research develop and require careful evaluation and thoughtful responses. New case studies are needed because research constantly generates new issues and new ethics questions for policymaking.

The cases found in this volume address a wide range of topics and involve several disciplines. The cases were selected by the parameters of the PRO-RES project and the Horizon 2020 funding call to which it responded. First, the call was concerned with both research ethics and scientific integrity and each of the cases addresses one or both of these areas. The call sought projects that addressed non-medical research, and the cases here address disciplines such as social sciences, engineering, artificial intelligence and One Health. The call also sought particular attention be given to (a) covert research, (b) working in dangerous areas/conflict zones and (c) behavioral research collecting data from social media/internet sources. Hence, we included cases that addressed each of these areas. Finally, while an EU-funded project can be expected to have a European focus, the issues addressed have global implications. Therefore, we wanted to include cases studies from outside Europe and did so by involving authors from India and Africa to reflect on the volume’s areas of interest.

The first case study offered in this volume (Chap. 2 ) examines a significant policy approach taken by the European Union to address ethics and integrity in research and innovation: Responsible Research and Innovation (RRI). This chapter examines the lessons that can be learned from RRI in a European context. Chapter 3 elaborates on this topic with another policy learning case study, but this time examining RRI in India. One of the critiques made of RRI is that it can be Euro-centric. This case study examines this claim, and also describes how a distinctively Indian concept, Scientific Temper, can add to and contextualise RRI. Chapter 4 takes a different approach in being a case study of the development of research ethics guidance in the United Kingdom (UK). It explores the history underlying the research ethics framework commissioned by the UK Research Integrity Office (UKRIO) and the Association of Research Managers and Administrators (ARMA), and points to lessons that can be learned about the policy-development process itself.

While staying focused on policy related to research ethics, the chapters that follow include case studies that address more targeted concerns. Chapter 5 examines the impact of the European Union’s (EU) General Data Protection Regulation (GDPR) in the Republic of Croatia. Research data collected in Croatia is used to explore the handling of personal data before and after the introduction of GDPR. This case study aims to provide lessons learned that could contribute to research ethics policies and procedures in other European Member States.

Chapter 6 moves from policy itself to the role of policy advisors in policymaking. This case study explores the distinct responsibilities of those elevated to the role of “policy advisor,” especially given the current lack of policy to regulate this field or how its advice is used by policymakers. Next, Chap. 7 straddles the previous chapters’ focus on policy and its evaluation while introducing the focus of the next section on historical case studies. This chapter uses the so-called “race for the superconductor” as a case study by which the PRO-RES ethics framework is used to explore specific ethical dilemmas (PRO-RES 2021b ). This case study is especially useful for policymakers because of how it reveals the multiple difficulties in balancing economic, political, institutional and professional requirements and values.

The next case study continues the use of historical cases, but here to explore the challenges facing innovative research into unorthodox energy technology that has the potential to displace traditional energy suppliers. The wave power case in Chap. 8 highlights how conducting research with integrity can have serious consequences and come with considerable cost. The case also points to the importance of transparency in how evidence is used in policymaking so that trust in science and scientists is promoted at the same time as science is used in the public interest. Another area of cutting-edge scientific innovation is explored in Chap. 9 , but this time looking to the future. This case study examines space exploration, and specifically the ethical issues around establishing safe exposure standards for astronauts embarking on extended duration spaceflights. This case highlights the ethical challenges in policymaking focused on an elite group of people (astronauts) who embark on extremely risky activities in the name of science and humanity.

Chapter 10 moves from the physical sciences to the social sciences. The Belfast Project provides a case study to explore the ethical challenges of conducting research after violent conflict. In this case, researchers promised anonymity and confidentiality to research participants, yet that was overturned through legal proceedings which highlighted the limits of confidentiality in research. This case points to the difficulty of balancing the value of research archives in understanding conflict against the value of providing juridical evidence to promote justice. Another social science case is examined in Chap. 11 , this time in ethnography. This so-called ‘urban explorer’ case study explores the justifications that might exist for undertaking covert research where researchers break the law (in this case by trespassing) in order to investigate a topic that would remain otherwise poorly understood. This case raises a number of important questions for policymakers around: the freedoms that researchers should be given to act in the public interest; when researchers are justified in breaking the law; and what responsibilities and consequences researchers should accept if they believe they are justified in doing so.

Further complexity in research and evidence generation is introduced in Chap. 12 . A case study in One Health is used to explore ethical issues at the intersection of animal, human and environmental ethics. The pertinence of such studies has been highlighted by COVID-19, yet policies lag behind in recognising the urgency and complexity of initiating investigations into novel outbreaks, such as the one discussed here that occurred among animals in Ethiopia. Chapter 13 retains the COVID-19 setting, but returns the attention to technological innovation. Artificial intelligence (AI) is the focus of these two chapters in the volume, here examining the ethical challenges arising from the emergency authorisation of using AI to respond to the public health needs created by the COVID-19 pandemic. Chapter 14 addresses a longer term use of AI in addressing problems and challenges in the legal system. Using the so-called Robodebt case, the chapter explores the reasons why legal systems are turning to AI and other automated procedures. The Robodebt case highlights problems when AI algorithms are built on inaccurate assumptions and implemented with little human oversight. This case shows the massive problems for hundreds of thousands of Australians who became victims of poorly conceived AI and makes recommendations to assist policymakers to avoid similar debacles. The last chapter (Chap. 15 ) draws some general conclusions from all the cases that are relevant when using case studies.

1.7. Into the Future

This volume focuses on ethics in research and professional integrity and how we can be clear about the lessons that can be drawn to assist policymakers. The cases provided cover a wide range of situations, settings, and disciplines. They cover international, national, organisational, group and individual levels of concern. Each case raises distinct issues, yet also points to some general features of research, evidence-generation, ethics and policymaking. All the studies illustrate the difficulties of drawing clear ‘boundaries’ between the research and the context. All these case studies show how in real situations dynamic judgements have to be made about many different issues. Guidelines and policies do help and are needed. But at the same time, researchers, policymakers and everyone else involved in evidence generation and evidence implementation need to embody the virtues that are central to good research. Judgments will need to be made in many areas, for example, about how much transparency can be allowed, or is ethically justified; how much risk can be taken, both with participants’ safety and also with the researchers’ safety; how much information can be disclosed to or withheld from participants in their own interests and for the benefit of the ‘science’; and many others. All of these point to just how difficult it can be to apply common standards across disciplines, professions, cultures and countries. That difficulty must be acknowledged and lead to open discussions with the aim of improving practice. The cases presented here point to efforts that have been made towards this. None of them is perfect. Lessons must be learned from all of them, towards which Chap. 15 aims to be a starting point. Only by openly discussing and reflecting on past practice can lessons be learned that can inform policymaking that aims to improve future practice. In this way, ethical progress can become an essential aspect of innovation in research and evidence-generation.

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PRO-RES is a European Commission-funded project aiming to PROmote ethics and integrity in non-medical RESearch by building a supported guidance framework for all non-medical sciences and humanities disciplines adopting social science methodologies. This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 788352. Open access fees for this volume were paid for through the PRO-RES funding.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

• Cite this Page O’Mathúna D, Iphofen R. Making a Case for the Case: An Introduction. 2022 Nov 3. In: O'Mathúna D, Iphofen R, editors. Ethics, Integrity and Policymaking: The Value of the Case Study [Internet]. Cham (CH): Springer; 2022. Chapter 1. doi: 10.1007/978-3-031-15746-2_1
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• Judging the Ethics of Research
• The Case for Cases
• Research Design and Causal Inference
• Devil’s in the Detail
• Cases and Policymaking
• The Moral Gain
• Into the Future

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Embodied Ethical Decision-Making: A Clinical Case Study of Respect for Culturally Based Meaning Making in Mental Healthcare

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How does embodied ethical decision-making influence treatment in a clinical setting when cultural differences conflict? Ethical decision-making is usually a disembodied and rationalized procedure based on ethical codes (American Counseling Association, 2014; American Dance Therapy Association, 2015; American Mental Health Counseling Association, 2015) and a collective understanding of right and wrong. However, these codes and collective styles of meaning making were shaped mostly by White theorists and clinicians. These mono-cultural lenses lead to ineffective mental health treatment for persons of color. Hervey’s (2007) EEDM steps encourage therapists to return to their bodies when navigating ethical dilemmas as it is an impetus for bridging cultural differences in healthcare. Hervey’s (2007) nonverbal approach to Welfel’s (2001) ethical decision steps was explored in a unique case that involved the ethical decision-making process of an African-American dance/movement therapy intern, while providing treatment in a westernized hospital setting to a spiritual Mexican–American patient diagnosed with PTSD and generalized anxiety disorder. This patient had formed a relationship with a spirit attached to his body that he could see, feel, and talk to, but refused to share this experience with his White identifying psychiatric nurse due to different cultural beliefs. Information gathered throughout the clinical case study by way of chronological loose and semi-structured journaling, uncovered an ethical dilemma of respect for culturally based meanings in treatment and how we identify pathology in hospital settings. The application of the EEDM steps in this article is focused on race/ethnicity and spiritual associations during mental health treatment at an outpatient hospital setting. Readers are encouraged to explore ways in which this article can influence them to apply EEDM in other forms of cultural considerations (i.e. age) and mental health facilities. The discussion section of this thesis includes a proposed model for progressing towards active multicultural diversity in mental healthcare settings by way of the three M’s from the relational-cultural theory: movement towards mutuality, mutual empathy, and mutual empowerment (Hartling & Miller, 2004).

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Embodied ethical decision-making (EEDM) can effectively influence treatment in a clinical setting when cultural differences conflict. Professional ethics are the standards of care and rules that govern the expectations for professionals, protect patients from harm, and guide ethical decision-making when faced with an ethical dilemma (Welfel, 2016 ). The two determinants of ethical decision-making are biological make-up and cultural norms (Ayala, 2010 ). Biological make-up includes our capacity to 1. Anticipate consequences of actions taken; 2. Make valuable judgments; and 3. Possess the ability to choose between courses of action (Ayala, 2010 ). Cultural norms are learned standards based on our shared experiences with family, friends, school systems, and other social environments (Sieck, 2019 ). Typically cultural norms of dominant cultures and are used to assist therapists with decision-making when faced with ethical dilemmas (Laws & Chilton, 2013 ).

Ethical decision-making is usually a disembodied and rationalized procedure based on ethical codes and a collective understanding of right and wrong. Trahan and Lemberger ( 2014 ) recognized that professional ethics codes are incomplete when considering underrepresented populations. Many studies have provided examples that point to insufficient measures taken in academic settings to address cultural competency, therefore producing counselors, psychologists, doctors, and nurses who are inadequately culturally sensitive and ignore cultural complexities (Alqahtani & Altamimi, 2015 ; Carmichael, 2012 ; Harris, 2016 ; Hebenstreit, 2017 ; Laws & Chilton, 2013 ; McEldowney & Connor, 2011 ; Dominguez, 2017; Wadley, 2016 ). The underlying somatic and intuitive constructs of our cultural norms, morals, and values are what guide our ethical decisions (Robson, Cook, Hunt & Alred, 2000 ). Hervey ( 2007 ) positioned that we can enhance the ethical decision making process by shifting from a rule-based approach to an embodied approach to address dilemmas in a more effective manner.

The purpose of this clinical case study was to explore how Hervey’s ( 2007 ) EEDM steps influenced ethical decision-making when cultural differences conflicted during treatment for a spiritual Mexican–American patient. My intersectional identities as an African-American, non-heterosexual woman have inspired my ambition towards creating change within healthcare systems. Healthcare systems have a long history of creating unsafe environments for people with diverse cultural identities; consequently the construct of cultural safety was established in the 1980′s in an effort to protect people of color from these harmful practices (McEldowney & Connor, 2011 ).

Embodied Ethical Decision-Making

As movers and body-based practitioners, it is difficult to ignore the intelligence held within the body. To explore knowledge surfacing from the body during an ethical dilemma grants vital data and, “using the body as a teacher puts the mover in charge of the process” (Goldman, 2004 , p. 131). It further allows us to use our body for inter-affectivity and empathetic understanding (Schmidsberger & Loffler-Stastka, 2018 ), thereby experiencing and sensing the perspectives of other individuals. Hervey outlined Welfel’s ( 2001 ) nine ethical decision-making steps and paired them with corresponding embodiment suggestions collected from roughly 80 dance/movement therapists and student participants (Table 1 ). These participants attended Hervey’s EEDM workshops, and from there, she analyzed the records of their movement responses and rationales to hypothesized ethical dilemmas (Hervey, 2007 ). I included these movement suggestions from the participants for each step in this article to provide readers with movement stimulating recommendations that may be helpful while engaging in the ethical steps as they were for me. At the time of Hervey’s ( 2007 ) article, Welfel ( 2001 ) identified nine ethical decision-making steps to thoroughly guide counselors in the process of making ethical decisions. In 2012, Welfel added an extra step that includes clarifying socio-cultural contexts of the dilemma. However, since this article is embedded with cultural context, I encourage readers to consider socio-cultural contexts for their patient, the situation, and themselves throughout the entire ethical decision-making process, and how one’s cultural lens can further deepen the movement suggestions presented by Hervey ( 2007 ).

Clinical Case

The case where the ethical dilemma arose involved a Mexican–American male patient, Juan. (Juan is a pseudonym used to protect this patient’s privacy.) Juan hesitantly disclosed having a spirit attached to his right shoulder that he could regularly see, feel, and talk to. Juan was being treated in an urban outpatient hospital facility for generalized anxiety disorder and post-traumatic stress disorder (PTSD), which involved individual therapy and medication management. Neighboring communities that the hospital served were made up of majority Latino and African American identifying populations. As reported by the Chicago Community Trust ( 2018 ), social and economic resources are historically and unjustly distributed in this area, and have resulted in health inequities that nearly three times the well-being concerns of the U.S. on average.

Juan mentioned in the beginning of our work together that he did not trust hospital systems, specifically, employees who identified as White. Therefore, the patient did not disclose important information regarding his mental health to the hospital and me, as his therapist. I reflected on my own mistrust of the medical system and assured Juan that his apprehension was valid and accepted in our therapeutic space. We met once a week for two months to assist Juan with developing coping skills to manage his anxiety and to support his recovery from traumatic experiences. Our sessions included movement experientials that drew from Laban Movement Analysis (LMA) techniques, improvisational movement, and mindfulness-based activities, and were supplemented with verbal processing. Many of our sessions involved evocative verbal exploration into Juan’s interpretation of his life experiences; this helped to strengthen our therapeutic relationship and build trust. During our seventh individual session, one of his deepest secrets was revealed. He stared me in the eyes and stated, “I have a spirit attached to my right shoulder. I can see him and feel him. He’s talking to you. Can you hear him?” I was thunderstruck and became curious about his unexpected disclosure. The spirit had attached to Juan two months prior after he prayed to his God for companionship and guidance. What started out as a positive human-spirit friendship turned into daily negative comments from the spirit, which led the patient to share his experience with me, but not without hesitation.

Juan communicated that he would not return to treatment if the divulgence of his private information had to be revealed as he had his own codes that he lived by. Identified as street codes, or rules regulating interpersonal public behavior (Anderson, 1994 ), these rules evolved from street culture as an adaptation to the lack of faith and trust in America’s oppressive systems. Street codes recognize that toughness is a virtue and that vulnerability equaled death; thus, privacy is a necessary survival skill amongst cultures that are dependent upon street living (Anderson, 1994 ). Additionally, Juan closely identified with being spiritually gifted since childhood. He talked about seeing people’s auras (even mine) and sightings of spiritual entities throughout his upbringing and adulthood. This was the first time Juan had confided in anyone, aside from his mother, about seeing spirits.

Culture Interfaces in Ethical Decision Making

Spirituality, religion, and culture have been omitted from psychology for many decades. Current mental health models are built upon, and view patients through, a mono-cultural lens (Dominguez, 2017) and this miscommunication results in increased and worsened health disparities for populations who identify as non-White. Ethical decisions become harmful when they disempower the cultural identity of a patient and insensitively discount individual and cultural views of treatment (McEldowney & Connor, 2011 ). Although my dance/movement therapy program often brought awareness to culture, I still did not feel prepared or adequately trained to know what to do with Juan’s disclosure.

While the support and involvement of practitioners who identify as persons of color are insufficient, there are new efforts being made to reduce these deficits in mental health programs (Dominguez, 2017; Walker, Burman & Gowrisunkur, 2002 ). For example, Frame and Williams ( 2005 ) introduced an ethical decision-making model from a multicultural perspective that helps therapists view differently the Eurocentric, one-dimensional, and ruled-based way of approaching ethics. The counseling profession has begun to support the idea of spiritual needs in counseling for patients and has shown an increase in therapy effectiveness, both spiritually and psychologically (Giordano & Cashwell, 2014 ).

Theoretical Orientation

Informed by a humanistic/existential paradigm and a relational-cultural theory (RCT) and positive psychology clinical approach, my spirituality, intersectional identities, and familial experiences motivated me to fully engage in this clinical case study and to advocate for increased multicultural competency amongst healthcare practitioners. From a relational-cultural perspective, our goal when Juan and I worked together was to build our relationship, so as to increase the patient’s sense of safety and trust within the treatment facility and me. My positive psychology approach served to foster the patient’s happiness and well-being in addressing his adverse life experiences. Both approaches led to a strong therapeutic relationship between Juan and me, and helped to increase his ability to open up and share with me his circumstance with the spirit.

Exploration of Ethical Decision-Making with Juan

It was clear that further culturally based ethical decisions needed to be made in order to provide ethical, safe and cultural focused care to Juan. This article identifies and evaluates the EEDM process by working through the case using the embodied ethical steps as outlined by Hervey ( 2007 ). Along with the movement recommendations from Hervey ( 2007 ), I also explored my own movement experiences as I embodied each step in response to my ethical dilemma during the process of writing this article.

Step One: Become Familiar

Given how violently ethical conflicts can be experienced in the body, (Hervey, 2007 ), clinicians are drawn away from their embodied experience and shift towards more cognitive approaches to solve ethical dilemmas. Instead of allowing this mind/body disconnect to happen, dance/movement therapists are able to embrace the body using EEDM steps. Hervey ( 2007 ) reminds readers that true ethics started as a body-based experience of wrong and right, and in order to find appropriate solutions for ethical dilemmas, one must return to the body for guidance. Embodiment permits us to move past the rational thinking brain (prefrontal cortex) and enter the body. This allows us to develop ethical sensitivity and recognize that there is an ethical dilemma in existence (Hervey, 2007 ). Step one involves attending to our body’s experience (Csrodas, 1993) by being present and engaged with its perceptual experience. This takes place in the form of movement.

Analytic and somatic movements are two avenues to consider when analyzing bodily movements (Moore, 2014 ). Moore ( 2014 ) introduces analytics as the observation of body movement from an external perspective and somatics as the first-person perspective of internal movement. Csordas ( 1993 ) adds that the somatic dimension of movement not only includes attending to one’s internal bodily experiences but also involves attending to the bodies of others, called the somatic modes of attention. Humans are gifted with the ability to interpersonally connect in a way that allows us to feel what others feel when we exercise our use of mirror neurons. Analytic and somatic movement shifts from one’s self and their environment provide evidence that deepens the collection of information and tell us when we have an ethical dilemma on our hands. Again, in this first step of EEDM, it is suggested to postpone any type of action, only to recognize the existence of an ethical dilemma in order to prevent premature and inappropriate action (Hervey, 2007 ). Instead, Hervey ( 2007 ) positions that “vertical containment” of just attending to the body signals and exploring movement in the horizontal plane is ideal for the initial development of an ethical dilemma.

Embodiment of Step One

In the initial stage of the ethical dilemma presented in this article, my movements became accelerated in the sagittal plane, specifically in my upper limbs, torso, and core. There was a sense of urgency I felt to confide in someone about Juan’s release of private information regarding the spirit attached to his shoulder. I was fascinated by my in-session encounter and wrote in my journals about feelings of excitement and tingling surges running through my body. I also recorded my impression of shaky sensations in my arms, knots in my throat and core, and decreasing pressure in my lower body. Tortora ( 2006 ) explains that weight assumes the physical intention of executing an action; the decreasing pressure I experienced in my legs indicated how careful I was to move forward in the dilemma. The vibratory action in my arms implied feelings of anxiousness, and the knots in my throat and core signified some sort of blockage. In my journal I reported feeling a sense of imprisonment; my body felt the restraint of navigating such a cultural dilemma in a hospital setting embedded with Eurocentric forms of healthcare. Though I was excited to learn more about Juan’s experience with the spirit, my movement observations for my core, arms, and legs suggested and confirmed a hesitancy to approach and navigate the disclosure about the spirit. I was motivated and empowered to advocate for him, but I also felt sad and angered by my thoughts of foreseeable outcomes that would be adverse to our therapeutic relationship. Given the cultural context of the dilemma and its tendency to be overlooked in westernized hospital settings, my thoughts held weight. I avoided making any decisions to address Juan’s case, except to obtain support in supervision.

Step Two: Define the Dilemma

After identifying that an ethical dilemma exists, we are encouraged to define the dilemma and identify potential problem solving opportunities. For this case, the ethical dilemma was respect for culturally based meanings in treatment and how mental health clinicians identify pathology. Juan believed his seeing the spirit was a gift given to him by God; he refused to accept any diagnosis that labeled it otherwise. What Juan described as a spiritual experience is usually understood as a form of psychosis in hospital systems that rely on symptom identification and diagnosis for the treatment of symptoms. Despite encouragement from me, he opposed the idea of talking to his psychiatric nurse about his spiritual experience. I felt stalled between my own spiritual and cultural awareness, Juan’s spirituality, his safety, and having to uphold the policies and procedures of the hospital where I was interning. I understood Juan’s story as a spiritual person, as a clinician, and as a Black woman from the inner city of Chicago; but I wondered if I resonated with his story all too well because we shared the people of color in the American healthcare system narrative. I wanted to make sure he felt heard and included in his treatment. On the other hand, I wanted to avoid compromising his safety in an effort to advocate for him and for increasing cultural awareness at my site. This case with Juan was a culturally embedded ethical dilemma that required my full participation with the embodied ethical steps.

Embodiment of Step Two

My body and my mind felt uneasy about making a decision; there was a fight between my cultural background and my emergence as a clinician. The idea of both weighed heavy on my shoulders and drained my energy. My upper torso gradually sank downward along the vertical dimension and my entire body wanted to enclose itself and curl like a ball. I encountered feelings of isolation as one of few Black clinicians at my internship site as well as in the academic program at my college. I felt lonely in my ethical dilemma. There are very few articles that talk about a Black clinician’s experience of loneliness during a culturally situated ethical dilemma. Smith ( 2012 ), communicated in her thesis about a similar struggle she felt during an ethical dilemma when battling between holding on to her cultural identity as an African American woman versus choosing an identity as a clinician and abiding by ethical codes. I thought with frustration: Why does there have to be a choice? Why cannot my cultural background and my developing identity as a clinician co-exist? Hervey ( 2007 ) acknowledged the need to cope with one’s bodily felt experiences when managing complex cases. She concluded that dance/movement therapist found value in moving out the dilemma with full embodiment to support determining the next direction to take. In my attempt to release my body from the enclosed ball and fully embody the dilemma, I encountered hesitation and emotional discomfort. I felt my anger and frustration expand with my movement in the form of increased pressure and restricted affect. My body was reluctant to engage in an emotionally overwhelming, cultural dilemma, but there was a sense of freedom in knowing that I was not giving up.

Step two further required the embodiment of my patient as well as my supervisors and the treatment team to provide an empathic approach to decision-making and deciding the best course of action. In her workshops, Hervey ( 2007 ) noted that in this step participants commonly collaborated with one another using creative movement to unlock alternatives to ethical dilemmas. I recall deliberating about the advice of my supervisors, unsure if they realized the substance of my patient’s fear and request for confidentiality given that they did not identify as people of color. For them, it appeared simple: make sure he’s not homicidal or suicidal and inform the nurse practitioner. Juan denied suicidal (SI) and homicidal ideation (HI). But again, one of my supervisors informed me that regardless of his denial of SI and HI, it was imperative that I report his spiritual experience to his nurse due to the fact that she prescribed him medication and that operating as a team in our department was a requirement.

Embodying Juan, my supervisors, and others who played part in the dilemma, such as the psychiatric nurse, helped to increase my understanding of their positioning in the case. My movement consisted of taking on each person’s postures and gestures, and verbalizing notable statements from our encounters. My kinesthetic empathy allowed me to view the case from their perspective. I felt each person’s concern for safety: safety for the patient, the hospital, the college, and each person involved in the dilemma, including myself. To consider safety for everyone and everything taking part in the ethical dilemma, it required diverse methods of examination, risk management, and knowledge. My movement responded with openness to the varying perspectives of stakeholders.

Identifying the Options

Lastly in step two, Hervey found it helpful to encourage participants to imagine the most ludicrous option and move it (Hervey, 2007 , p. 103). In this way, options disregarded due to fear and being premeditated as unethical decisions become spontaneous possibilities to solving one’s ethical dilemma (Hervey, 2007 ). Identifying options will help counselors focus their energy during complex ethical dilemmas. In Table 2 , I present options considered for Juan’s case. Ultimately, I wanted to avoid causing harm to him and his beliefs by providing space for autonomy and cultural advocacy. Conversely, I was thoughtful about improperly treating a patient who may in fact benefit from receiving a diagnosis in alignment with his symptoms.

Step Three and Four: Search, Evaluate, and Determine

Hervey ( 2007 ) joins steps three and four of Welfel’s ( 2001 ) ethical decision-making model into one complete phase to evaluate options and to determine the best solution. It requires dance/movement therapists to utilize professional literature, ethical codes and regulations, and agency policies to provide structure for later deliberating processes (Hervey, 2007 ). Referencing codes, regulations and policies, as implied by Constable, Kreider, Smith & Taylor (2011), helps novice therapists navigate the uncertainties associated with ethical decision-making. Even for experienced counselors, this step remains a priority for continued growth and development and enhanced ethical judgment (Oramas, 2017 ). Ethical standards are designed to protect professionals and patients; yet, these standards usually result in more reactive than proactive ethical decision-making (Trahan & Lemberger, 2014 ). So in addition, seeking guidance from ethics scholarship enables counselors to vicariously learn by trial and error from practiced professionals. Aside from providing clarity, focus, and structure, this step also increases confidence through skill building and acquisition of ethical knowledge, and further limits risky decision-making. Once all relevant information has been obtained regarding options identified in step two, dance/movement therapists are to move out those possibilities. It is essential to utilize this step as an explorative measure with movement to create more available options than to rely on rules to quickly resolve the dilemma (Hervey, 2007 ).

Codes and Scholarship

The ethical dilemma of respect for culturally based meanings in treatment and how mental health clinicians identify pathology is related to the American Dance Therapy Association’s (ADTA, 2015) ethical standard of display of integrity within the therapeutic relationship. It states, “Dance/movement therapists encourage the patient’s voice in treatment and respect the patient’s right to make decisions based on personal values” (ADTA, 2015 , p. 3). The ADTA ( 2015 ) Code of Ethics additionally encourages dance/movement therapists to continuously reexamine their own biases and worldviews to avoid imposing them onto patients, and to consider the impact of oppressive systems on individual patient experiences. According to these ethical codes, Juan had every right to name his spiritual experience as he saw most fitting with his beliefs. Providing space for Juan to do that directly aligned with my obligations as an intern dance/movement therapist. However, the hospital did not ascribe to these standards. Though Juan experienced a sense of safety in my office space, we were a part of a larger operating system that he relied on for treatment.

The American Counseling Association’s (ACA, 2014 ) ethical code Avoiding Harm and Imposing Values states that counselors work to avoid harm and minimize potential harm to patients. I perceived there could be potential harm in revealing Juan’s undisclosed information to the treatment team. Counselors are trusted with the safety of each patient as they enter our therapeutic spaces, and as humans who have accepted the responsibilities of a counselor as a life calling, we feel competent enough to complete this task. Avoiding harm requires more than providing evidence-based interventions, private and clean spaces for therapy, judgment-free zones, and upholding ethical standards. It requires constant self-awareness and reflection, and honoring cultural differences.

The ADTA ( 2015 ) Codes of Ethics are informed by and parallel the ACA ( 2014 ) Code of Ethics. It is acknowledged that the ACA Code of Ethics was constructed and shaped by an individualistic, Western society (Birrell & Bruns, 2016 ) and remains firmly established in a modern society that accordingly places emphasis on rules, independence, and power-over rather than relational engagement and power-with patients in treatment. Ergo, complex situations in treatment settings become central when persons in power are compelled to make ethical decisions regarding the well-being of a patient, even when cultural beliefs conflict (Laws & Chilton, 2013 ). The patient in this case had a different cultural meaning of issues regarding his psyche than that of the hospital setting where he received treatment.

The Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association (APA) is a manual of classified mental disorders that serves as a guide for interventions and treatment recommendations. In the DSM-5 (APA, 2013 ), a practical diagnosis for Juan’s case would fall under schizophrenia spectrum and psychotic disorders given his presentation of what the mental health field considers visual, auditory, and somatic hallucinations. Overtime, the DSM-5 has integrated cultural factors into disorders in the form of V-codes, described as supplementary conditions influencing a disorder. V-code 62.89, “Religious or Spiritual Problem”, accounts for loss or questioning of religion or spirituality (APA, 2013 , p. 725), however, this code does not encompass religious or spiritual factors as it pertains to this case. The option of diagnosing Juan carried the risk of deterring him from seeking therapy and decreasing his overall well-being. A diagnosis would suggest that his cultural interpretation of his spiritual experience was either false or meaningless. Timimi ( 2014 ) and Allmon ( 2013 ) are clear that these types of interpretations of culturally based beliefs disempower the patient and could increase negative symptoms.

The second professional value listed in the ACA’s ( 2014 ) code of ethics honors and supports, “the worth, dignity, potential, and uniqueness of people within their social and cultural contexts” (p. 3). Since values are the cornerstone of which ethical decisions are carried out, counselors are to refrain from submitting a diagnosis if they know that it will cause harm to the patient in some way (ACA, 2014 ). It is rational to consider how the stigmatization of an oppressive label from the western culture will cause individual, cultural, and societal adverse consequences for some patients (Ratts & Hutchins, 2009 ).

Social consequences for the patient must be taken into consideration when making ethical decisions (Zheng, Gray, Zhu & Jiang, 2014). Usually in the decision-making process, the counselor identifies the ethical dilemma, takes the necessary steps to problem-solve outside of the therapy room, and decides on a resolution to the dilemma absent the patient’s voice (Birrell & Bruns, 2016 ). Yet, the ACA’s ( 2014 ) code of ethics states that counselors work collaboratively with patients to promote growth and development during an ethical decision-making process. Shared decision-making (SDM) is a model that was first developed in the 1980′s to improve the experience of patients in treatment settings by encouraging a collaborative process between the patient and health professional (Bradley & Green, 2018 ). This comes with controversy regarding the risks of granting access to a patient, which allows them to collaborate with doctors regarding their treatment, given their level of competency of medical knowledge may be limited (Christine & Kaldjian, 2013 ; Herlitz, Munthe, Torner & Forsander, 2016). The same is true to consider when patients are invited to autonomously collaborate in counseling settings.

Embodiment of Steps Three and Four

As I embodied the Effort weight, for this ethical dilemma, I found strong feelings surfacing about my cultural identity and the desire to advocate for marginalized groups. There was increasing pressure in my upper body and I associated this with the idea of fighting oppressive systems at my site, as well as healthcare systems in general. I let that increasing pressure sink downward into my lower body and invited decreasing pressure to my upper body. The anger and frustration of having to engage with such a system did not disappear, however, awareness of my embodied experience encouraged me to take a gentler approach to ethical decision-making.

I had a lot mixed feelings that were reflected in my movement while searching the ethics codes and gathering information. I felt confused and surrounded by information as I turned in circles reaching and pulling. The information seemed full of loose ends and, to a great extent, required interpretation. There was increased tension in my shoulders, and I eventually distanced myself from the imaginary visual of the ethics codes and scholarship. I entered into a remote state of increased bound flow and directing as I gazed at the information from a far. I began to move in my preferred style of popping and locking while visualizing the information regarding the clinical case. I was able to bring in my culture when understanding and interpreting the codes. Although complete clarity of the codes was not realized, I experienced increased confidence and intention for working through the dilemma with this new knowledge.

Step Five: Ethical Principles

Step five requires reference to the five ethical principles identified by Kitchener ( 1984 ). They are: autonomy, nonmaleficence, beneficence, justice, and fidelity, along with the added principle: veracity. Ethics involves cultural norms, personal morals, and values during the decision-making process, and these will serve counselors in the self-exploration process of relating to the guiding principles (Evans et al., 2012 ). Ethical principles were conceptualized to provide a foundation of morals to help interpret ethical codes and adjust routine responses to unconventional ethical dilemmas (Chmielewski, 2004 ).

Each ethical principle has been layed out with common movement qualities that were found by dance/movement therapists when they moved out the principles separately (Table 1 ; Hervey, 2007 ). A key part of step five is to be attentive to any embodied responses that are experienced while moving each principle. Principles have the potential to draw out essential details to help us strengthen our understanding of the dilemma and where the conflict is coming from, externally, and internally within ourselves in the form of values (Miller & Davis, 2016 ).

Another key factor is to acknowledge that these principles were created as a guide to culture-specific standards of behavior, and that ethical principles will be prioritized differently within varying cultures (Gauthier, Pettifor, & Ferrero, 2010 ). The new age invites new rules of behaviors, and these rules are changing rapidly (Hoose, 1986 ). It is important to be aware of the cultural body’s response to each principle and how it shapes our experience with them.

Autonomy describes mutual respect in a relationship, where both individuals honor one another’s ability to make autonomous decisions (Kitchener, 1984 ). During complex ethical dilemmas, counselors may feel an urgency to act on impulses, yet feel the tension of respecting the autonomy of the patients, others involved, and that of themselves (Hervey, 2007 ). Indeed, the act of yielding and pushing through movement, which can be realized in dance/movement therapy, informs our boundaries and asserts greater independence (Schwartz, 2018 ).

There was constant pushing in my movement to create boundaries while embodying autonomy. I used my arms to separate and push back on the healthcare system to provide space for Juan and myself. It felt like I was taking on the role of advocate: working to gain autonomy for two people of color in a Eurocentric hospital setting. While moving I wondered how much autonomy could I actually encourage Juan to have given his presentation of symptoms and possible limitations of mental health information. Juan had previously omitted important details regarding his symptoms because he did not feel safe. I cautioned myself against allowing too much space as I thought about what other information might be unknown about him. As I moved and created space for myself, I realized I needed separation from both Juan and my internship site to be free in my own autonomy. In a cultural sense, autonomy for me meant expressing and standing strong with my own beliefs. I had responsibilities as an intern clinician to uphold the policies at the hospital, policies that I understood to be Eurocentric cultural norms and did not fully agree with. However, as a novice clinician, how much autonomy could I possess given my own limitation concerning the knowledge of policies and procedures regarding the clinical case? I engaged in a back and forth movement, suggesting the tug between inviting space for autonomy and enclosing space where autonomy may have been less beneficial to resolving the dilemma.

Nonmaleficence

Nonmaleficence means not causing harm to patients, including intentional actions to harm or carrying out risky actions that have the potential to harm them (Kitchener, 1984 ). This ethical principle corresponded with careful, cautious, and tentative movement responses (Hervey, 2007 ).

I attuned to my visceral experience of decreasing pressure and binding flow, as suggested by Hervey ( 2007 ), as I moved carefully. There were multiple pieces to consider to avoid harm. I wanted to culturally empower Juan and I wanted to keep him safe; however, safety could have looked like many things from the different perspectives of everyone involved in the dilemma. Safety could look like Juan feeling empowered and gaining trust in the healthcare system because he felt heard and believed by his treatment team. Safety could look like diagnosing Juan and giving him medication from the nurse’s perspective. Safety could look like informing Juan’s treatment team and engaging in ongoing investigation of his symptoms from my supervisors’ perspective. Safety could also look like keeping the information to myself and linking Juan to spiritual healers in nearby communities. I engaged in movements that looked like dipping and dodging as I moved, carefully considering all of these pieces that surfaced. I further examined my own safety in relationship to nonmaleficence. A decision to inform Juan’s treatment team would potentially cause harm to my cultural identity; I would feel like I betrayed my values and my community by going against street codes and abiding by rules of a mistrusted healthcare system. On the other hand, a decision to not inform the treatment team would leave me feeling disconnected as a team member at the hospital and also feeling like I am not doing my job correctly as a clinician; both would cause harm to my professional identity.

Beneficence

Beneficence is the act of reducing human suffering by supporting the welfare of others and enhancing their sense of empowerment (Jennings et al, 2005 ). This was a principle that I found myself sitting on during the time of my ethical dilemma. There is a two-sided impression of what doing good actually looks like; it could be the literal act of taking action to do good, or it could involve being good in a time of complexity and chaos (Hervey, 2007 ). Naturally I wanted to advocate for Juan by taking action, and I deemed it necessary for a culturally embedded case. Robson et al., ( 2000 ) argues that beneficence carries the obligation for counselors to seek substantial knowledge and perform in the best interest of the patient’s welfare. On the other hand, I felt that beneficence was just being good for my patient by offering a therapeutic space where his cultural interpretation of his experience was true, regardless whether the site was willing to change its process of labeling pathology. My upper torso instantly advanced forward in the sagittal plane without hesitation, my head shook side to side suggesting the word no, my limbs supported me with increased weight. My body gladly considered no other option but to actively engage in this clinical case by advocating for Juan and other underserved people who could benefit from a change in the healthcare system.

Justice, as an ethical principle, means fairness, treating others as equals, and promoting equality counseling. This ethical principle was most challenging for me to embody. In my body I felt stuck with increased bound flow at thoughts of how inequalities in healthcare systems continue to persist. In my exploration of balancing movements for justice, my body maintained its bound flow in every part except my arms. My bound flow was accompanied by rage and sadness. I attempted to take on the posture of the scales of justice with my hands held outward to the side; they felt empty and light. I brought my hands in front of me, side-by-side, and gazed at the emptiness for a moment. The ethical codes themselves require revamping to address the inequalities that exist within them (Kitchener, 1984 ; Robson, et al., 2000 ; Trahan & Lemberger, 2013). ‘It started to become clear that Juan’s case was a step forward in advocating for others like him who want and deserve fair and culturally sensitive treatment. This clinical case study was a component of seeking justice in itself.

Fidelity is an act of faithfulness; it is about remaining loyal and keeping promises to patients (Kitchener, 1986). This was another challenging principle to embody. The moment a counseling relationship is established, there is an obligation on the part of the therapist to honor commitments and promises, and to fulfill the responsibility of trust and accountability (Wade, 2015 ). While some dance/movement therapists affiliated fidelity with commitment, honesty, and integrity, others associated it with retaining secrets. I considered how this principle could relate to one of my options: doing nothing and disregarding my patient’s spiritual experience in an effort to protect Juan from harm. During my embodied experience, I felt the sensation of being pulled in different directions with an uncomfortable tingling sensation in my stomach. I was confounded, caught in the middle of both my developed and emerging identities. On one end, I felt a pull from my patient to be with him in our marginalized identities. On another end, I felt pulling from my internship site and the counseling field to be an ethical therapist. Lastly, I saw an image of me pulling myself to just be me and to separate from both. I resorted back to autonomy and engaged in boundary setting movements, realizing that being faithful and honest to myself was my first responsibility.

Healthy disconnections are a key factor in the RCT framework. I refused the idea of becoming enmeshed with either the hospital or my patient during process of navigating the dilemma. I desired a healthy balance of connecting and disconnecting, which meant standing in my own identity while engaging with the clinical case. I reflected back to autonomy while moving this dilemma; fidelity helped me see where multiple truths encountered and overlapped one another. The nurse practitioner’s truth may be helping others in an informed way by assigning diagnostic labels in order to effectively treat multiple patients and prescribe medication. The nurse’s truth overlapped Juan’s truth of seeing his mental concerns as something spiritual, but not having many resources to turn to for support. I understood fidelity as a principle to encourage all involved in the case to be true to themselves and not place rules and labels above being human.

Veracity was added to the most recent addition of the ACA’s ( 2014 ) Code of Ethics and is defined as dealing truthfully with individuals during professional interactions. In my embodiment of veracity, I discovered a vertical stance that turned into spiraling movements of my spine with free flow and lightness. I felt authentic and vulnerable in my movement, and I also felt the willingness to share myself and connect with others involved in the ethical dilemma. True veracity requires authenticity to be effective; vulnerability is a bonus. It goes back to fidelity and being aware of placing rules above respect for human differences. The dilemma in this clinical case rose from a lack of acknowledgement of cultural differences and viewing ethical dilemmas through intellectualized codes instead of the truth within the human body.

Step Six: Consult and Share

When does spirituality become pathology? How do we ethically honor a patient’s cultural meaning of spirituality in a westernized medical system? These were the questions that had surfaced for me in supervision. Interestingly, I had three White identifying supervisors, and I was one of very few Black clinicians in training at my academic setting and the only Black supervisee at my site. There is an established power differential that comes with a supervisee-supervisor relationship which was compounded by Black-White dyads that constituted each of my supervisory relationships. Clinicians of color in training commonly experience their voices being silenced in clinical and academic settings, especially when topics of culture and race need to be addressed (Estrada, 2005 ; Hardy, 2015 ; Hernández, 2003 ; Jernigan, Green, Helms, & Perez-Gualdron, 2016 ). This is likely a consequence of practiced cultural conditioning in Western societies as well as a lack of cultural awareness and training that has persisted throughout the counseling field, thus continuing the cycle of supervisors overlooking cultural issues (Estrada, 2005 ; Vereen, Hill, & McNeal, 2008 ; Jernigan, et al., 2016 ; Ivers, Rogers, Borders, & Turner, 2017). As a result of being a therapist in training, a therapist of color, and dealing with an ethical dilemma involving a cultural conflict, I was very hesitant to confide in my supervisors due to our cultural differences.

I struggled with feelings of discomfort when it came time to discuss the dilemma with my supervisors. Supervision felt like an unsafe setting to express my anger and frustrations of being a Black woman working to resolve an ethical situation deeply embedded with cultural conflict. My experience was not normalized. When I brought up the cultural factors of the case, the room seemed to either become silently heavy or the conversation deflected to an idea outside of culture. That only led to more frustration. I wanted to avoid the angry Black woman stereotype that accompanied my skin tone and aesthetic appearance and affected the way others perceived me interpersonally. I knew it would only hurt my professional career if my expressions were perceived outside of professional behavior, whatever professional behavior is according to Eurocentric standards. Consequently, I eventually suppressed my feelings and operated from a place of numbness whenever I had to discuss the clinical case further. I thought it was pointless to continue to take my body through a wave of unheard, misunderstood emotions. Suppressing my feelings and emotions was not the best coping strategy, but it was healthier and less exhausting than continuing to feel shut down or deflected. I objectively shared all the facts about the case with Juan. I did not share my subjective experiences, at least not nearly to the extent of how they lived in my body during supervision.

Embodiment of Step Six

Hervey ( 2007 ) recommends that dance/movement therapists share their ethical dilemma with trusted colleagues or supervisors through authentic movement, verbal communication, or by designing their own way of sharing. Step six aims to increase the mover’s confidence for consultation.

While engaging in this step during my journey of writing this article, I experienced step six to be helpful with extracting the dilemma from my body and putting into movement. I shared the dilemma alone first, and then I shared my movement with a peer. By first moving the dilemma alone, I was able to see what I wanted to share and how I wanted to share it, absent the influence of another body in the room. When I offered my movement to my confidant, I was again nervous, worried about their criticism of my choice of movement, as they were unfamiliar with embodiment practices. The art of moving past internal and external criticism of who I am as a dance/movement therapist allowed me to connect deeper to how the dilemma lived in my body. I could extract it and put it into an art form in which I have always experienced healing. It allowed me to gain control over what was suppressed inside of my Black body.

Step Seven and Eight: Deliberate, Decide, and Rehearse

Steps seven and eight of Welfel’s ( 2001 ) ethical model prompt therapists to deliberate and decide the best plan of action, and Hervey ( 2007 ) puts emphasis on taking responsibility of the final decision. Ethical thinking is a complicated process and we must consider the impact of our decisions on individuals and the institution we serve (Chmielewski, 2004 ). Without careful acknowledgement of the responsibility we hold in these types of situations, counselors run the risk of creating unsafe environments for current and future patients, and further risk producing adverse consequences for institutions. (Chmielewski, 2004 ). This step precedes any action to promote clarifying our intentions while solidifying our final decision.

Decision Made for the Case with Juan

I decided to inform Juan’s nurse practitioner of his spiritual experiences. Ultimately, it felt like I was without much choice as I had already informed my internship site supervisor before I was aware this clinical case was an ethical dilemma, and one that would affect me deeply from a cultural perspective. I abided by the rules of the hospital and complied with directions given to me regarding the next steps to take. Before disclosing Juan’s information, I talked with him in one of our sessions about my obligation as an interning clinician to inform his nurse. Again, I provided the option for him to tell his nurse, alone or accompanied by me; however he refused both. Juan stated he understood and respected my responsibilities, but he would not return to therapy. I informed him of the sadness that his decision brought me and expressed that I also understood his responsibility to protect himself. In the end, Juan ended up coming back to therapy. The relationship we built in our therapeutic space of allowing our cultural identities to exist freely without judgment surmounted the undesired ethical decision that was executed, and led to Juan’s return.

Honestly, if I could go back and engage in this ethical decision-making process and change something, I would not. The process has taught me so much about who I am as a clinician and an advocate of cultural needs in healthcare systems. I also believe that Juan benefitted greatly from our therapeutic relationship that involved increased sensitivity to and active inclusion of cultural differences. Though he felt our trust was broken, we were able to rebuild it in our proceeding sessions by repairing the rupture that had taken place. Repairing our rupture contributed to strengthening our therapeutic alliance even further. From an RCT perspective, the therapeutic relationship was the healing factor to the decision made in this culturally situated ethical dilemma.

Embodiment of Steps Seven and Eight

In order to clarify intentions and solidify a plan, dance/movement therapists are directed to move alone, journal, or do both while deliberating (Hervey, 2007 ). This is a resourceful point in the ethical decision-making process to connect all of the important pieces of the case and evaluate the risks involved for one’s self, the patient, and treatment team. The deliberation process can create feelings of reconnection and groundedness as we reach for clarity. Once deliberation has been finalized and intention clarified, the next measure is to commit to a plan of action (Hervey, 2007 ). It is recommended to rehearse acting out the final decision through movement or imagination to increase one’s confidence before implementing the plan (Hervey, 2007 ). After the decision has been carried out, counselors are to head into the final step of the EEDM process for reflection. In an effort to support a reconnection to my own intentions, it was helpful for me to ask myself questions as a way to facilitate my movement. For instance: What motivated me to engage in this ethical decision-making process? Why and how will this benefit my patient? How will my decision support future patients and therapists who encounter a similar ethical dilemma? It was interesting to notice my arms reaching outward in all directions of the dimensional scale, and then carving their way back to my core, as if they were bringing me something back. I experienced a sense of clarity, and moreover, I experienced a sense of knowing who I am in this dilemma, and on a spiritual plane, what purpose this dilemma has brought to my career as a dance/movement therapist.

Step Nine: Reflect and Evaluate

Though Hervey ( 2007 ) excluded this final step from her workshops, it is important to engage in this reflective step to evaluate how effective the entire EEDM process has been, and doing so in an embodied fashion (Hervey, 2007 ). While understanding what parts of the process were effective, it is also possible to learn what steps can be done differently for future dilemmas (Hervey, 2007 ; Constable et al., 2011 ). Cottone ( 2001 ) agrees that the reflection process is not one of the mind, but an appraisal process of actions and a continued process of seeking alternative perspectives. Cottone ( 2001 ) encourages clinicians to go beyond the perspectives of supervisors, peers, and respected colleagues, and consider the cultural context in which the decision was implemented and how it affects the community at large.

For one, extending an open conversation to the patient in an effort to understand how the final decision affected them can increase feelings of safety and empathy for both the patient and counselor, especially if the ethical decision was contrary to the stated desire of that patient. Furthermore, I also suggest reaching out to community members and persons who identify within that associated culture. Shah (2011), described inviting pushback, where a group of people express resistance or redirection, as a way to show care and feelings of importance to the perspectives of underserved communities that may otherwise go unnoticed. Shah (2011) also brings attention to the fact that mistakes are inevitable during ethical decision-making, and it is essential that counselors prepare themselves for this kind of feedback. If not, the fear of criticism will keep counselors oblivious to the needs of patients, community members, and different cultures, therefore creating greater barriers that could potentially aid in the progression of mental healthcare for those in need.

Embodiment of Step Nine

In my movement reflection, I discovered that I was able to remove the heaviness of my culture from my back and place it in my hands in front of me. I now saw it as a tangible construct, something I could work with and move through. My body felt mobile with free flow as I integrated movements from the previous steps as a way to reflect on my experiences. There was a sense of gained knowledge and tools to assist me with navigating future complex ethical dilemmas in a culturally informed and embodied way.

By engaging in this in-depth exploration with the EEDM steps, I learned how meaningful this case was to me and possibly to underserved populations who engage in healthcare services. As opposed to intellectually escaping my bodily felt responses to the dilemma, these steps encouraged me to listen to and engage with them. Without doing so, I would not have reached the conclusions I have presented in this article. My connection to this clinical case was a deep visceral experience that had been silenced by an oppressive healthcare system and me, but illuminated through an embodied process. Current healthcare practices disempower and affect the long-term health of people of color because they are expected to comply with mono-cultural views of mental health and treatment. I made a decision to share Juan’s spiritual experiences with his nurse against his will. My therapeutic approach of displaying respect and giving prominence to Juan’s culturally based meaning-making of his spiritual experience was what encouraged Juan to return to treatment. Still, it is essential to examine potential harmful outcomes and how they can be prevented or diminished until healthcare systems modify their operations.

Throughout the ethical dilemma, I was the intermediary between my patient, the psychiatric nurse, and my site supervisor. ACA’s ( 2014 ) Code of Ethics assert a collaborative process between counselors and patients, yet, in most ethical dilemmas, the counselor makes decisions in isolation (Birrell & Bruns, 2016 ). Most clinical guidelines similarly recommend involving patients in decisions regarding assessment and treatment thus supporting collaborative and informed goals (Elwyn et al., 2006 ). This type of patient-centered care has been increasingly adopted as interdisciplinary teams realize how valuable shared decision-making (SDM) is for patient success and well-being (Adisso et al., 2018 ; Chewning et al., 2012 ; Elwyn, Edwards, Kinnersley, 1999; Elwyn, Edwards, Kinnersley, Grol, 2000; Légaré et al., 2011 ). Persons directly involved in an ethical dilemma have great potential to effectively influence the decision-making process, and no one voice should be given exclusive privilege over another (Birrell & Bruns, 2016 ). From an RCT perspective, interconnection during ethical decision-making processes can invite real change in a positive direction for not only the patient, but for the counselor and institution as well.

RCT acknowledges that growth-fostering relationships, relationships that include increased understanding and empathy for one another’s thoughts and feelings, display respect for the multitude of sociocultural aspects that each individual brings to the experience (Duffey & Somody, 2011 ). As humans, we are wired to move through and toward connection with others, and it is the connection and relational experience that contributes to healthy functioning and flourishing (McCauley, 2013 ).

What I desired most during my ethical decision-making process was to have all the people involved in the dilemma to be in one room listening to each other with openness, curiosity, and empathy. I was the intermediary of all communication amongst my supervisors, Juan, and the nurse. It was exhausting relaying information, and a lot of the time I was repeating the same information to a different person. So much of my time and energy was expelled in this back and forth communication, only to implement the decision alone. As the intermediary, I additionally witnessed statements from my encounters with each of them that made me feel uncomfortable or suggested a lack of empathy for one another. I wished they were able to learn of one another’s circumstances to create more understanding and empathy within the case. I understood that our workloads prevented a collaborative decision-making meeting that would have included my site supervisor, the nurse, Juan, and myself in one room discussing the details of the case and all the possible solutions to working with Juan’s spiritual experience. I further understood that such a meeting would have been quite frightening for Juan who wanted to keep his experience a secret. I wondered how that might have been different if Juan discovered the hospital altered their policies to accept and consider his meaning making of his spiritual experience? A joint meeting could have saved me much time, energy, and stress over a dilemma that affected others and me deeply.

Based on my experiences with this ethical dilemma, I developed a model for active multicultural diversity (AMD), a term credited to Carmichael ( 2012 ), as a guide for ethical decision-making aimed at increasing effective outcomes for patients by taking culture from a concept that exists in one’s awareness to a concept acted upon (Fig.  1 ). It incorporates the EEDM steps with SDM and the three M’s of RCT: movement to mutuality, mutual empathy, and mutual empowerment. With the embodied ethical decision making steps at the center of decision-making, I encourage the patient, therapist, and treatment team to equally collaborate when making ethical decisions. In this way, the burden of resolving the ethical dilemma is not placed in the hands of one person, but instead, all are responsible for reaching a conclusion, therefore increasing the vitality of each person through involvement and interconnectedness.

Active multicultural diversity in ethical decision-making

Movement Towards Mutuality

Hartling and Miller (2004) describe non-mutual relationships as dominate/subordinate or power-over relationships, which the more powerful or dominant participant in the relationship receives greater benefit. Instead, movement towards mutuality calls for all participants of the relationship to engage in, and take emotional and cognitive action towards change (Hartling & Miller, 2004). This movement towards mutuality benefits people by preventing humiliation while supporting growth, healing, and human rights. All participants in the ethical dilemma must be willing to change where possible and appropriate in order to see each other as equal individuals while collaborating to resolve the ethical dilemma.

Mutual Empathy

Mutual empathy is the ability to be impactful and to be impacted in the relationship through seeing and feeling within the experience (Duffey & Somody, 2011 ). It is through acceptance and validation that an authentic relationship can be built and become a priority (Duffey & Somody, 2011 ; Hartling & Miller, 2004). This is an essential piece to navigating complex ethical dilemmas.

Mutual Empowerment

Empowerment is the feeling of having control and understanding over one’s life (World Health Organization, 2010 ). The World Health Organization ( 2010 ) realizes that institutions have a responsibility of operating in ways that empower the people and communities they serve to encourage vitality, health and well-being. Empowerment in relationships must be mutual so that all parties feel competent, heard, seen and respected as they collectively shape and develop the experience (Hartling & Miller 2004). Decision-making is best done when those engaging in the collaborative process do so feeling confident and empowered.

I envision healthcare facilities employing a designated ethical dilemma consultant, to mediate the collaboration process. Clinicians, nurses, doctors, and even patients could send the consultant a notification that a potential ethical dilemma arose. From there, the consultant would initiate communication for all involved in the dilemma to decide on a date and time to meet and work through the AMD model to resolve the case. The consultation session could be structured according to the persons participating in the meeting. A session may involve a lot of movement or minimal movement with mostly postures and gestures. A simplified version might employ mindfulness techniques to identify body-felt sensations to each embodied step. The three M’s should be illustrated at the beginning of each consultation to help clarify the intent and goal of engaging in the EEDM process. The three M’s, movement to mutuality, mutual empathy, and mutual empowerment, effectively work to create an open and safe atmosphere that encourages full participation in the EEDM steps.

Active Multicultural Diversity for Juan’s Case

In order for AMD to work in this clinical case with Juan, increased funding for mental health programs leading to less overworked professionals is a definite necessity. Professionals at the hospital were consistently double booked with patients for the majority of the workday. The oppressive system in which the hospital was situated, affected patients and employees alike. The hospital consistently treated people of color with limited support service options. It is feasible that if the hospital had sufficient funding for mental health services, increasing staff and office space, the AMD model could have been implemented in this clinical case. Further, to participate in a collaborative process, the patient, nurse, and clinical supervisor would have to be willing to engage with one another with an increased open mind and non-judgmental attitude. This would help cultivate a collaborative process insofar as Juan would have been able to communicate his desires to resolving the dilemma in a way that would also increase his trust for the hospital setting through our relational experience.

Limitations and Possibilities

Active multicultural diversity in ethical decision-making does not come without its challenges and limitations when considering the integral components of how westernized healthcare systems have been operating for decades. For one, SDM requires more time for collective consultations between healthcare professionals and patients (Elwyn et al., 1999 ). Most healthcare professionals are occupied with required treatment planning, writing notes, other consultations, case management, and other daily tasks. Counselors may also experience the obligation to educate patients on mental health to increase competency levels for ethical decision-making, which also requires more time (Elwyn et al., 1999 ). In light of this, patient decision aids, new technologies designed to prepare patients and to increase their knowledge of information related to treatment, are used to assist in making informed choices when collaborating with healthcare providers (Elwyn et al., 2006 ; Adisso et al., 2018 ). In an effort to increase active multicultural diversity in healthcare settings, patient decision aids should be made accessible to all communities, all populations, and in all forms of healthcare. Another limitation of active multicultural diversity is the perceived threat to power in professional-patient relationships (Elwyn et al., 1999 ). This is associated with a lack of cultural competence, caring knowledge, mono-cultural embedded lenses, and power-over preferences from health professionals and institutions. Moreover, just like cultural competency training is deficient in mental health programs, SDM is also deficient in programs and skill building workshops, and is further absent in modeling from older, more experienced clinicians (Elwyn et al., 1999 ). It is possible that with an ethical decision-making consultant on site, regular trainings could be provided to keep professionals and patients informed on ethical decision-making and cultural competency.

Finally, embodiment is a skill that dance/movement therapists and other body-based practitioners are accustomed to, and it could be a challenging to engage non-body-based practitioners and patients in movement during an ethical decision-making process without significant willingness or training. This could reshape healthcare systems requiring leadership figures to provide more resources, education/training, and time to healthcare professionals so they are prepared and available to engage patients and team members in active multicultural diversity for ethical decision-making.

I can embrace the AMD model moving forward by including my patients in the EEDM process as a part of our therapy sessions, if a dilemma happens to emerge during our work together. We could collaborate to identify options to resolve the dilemma. I would then present those options in consultations with the treatment team to include and discuss their viewpoints. Another possibility is having someone from the treatment team join one of the therapy sessions with my patient and have them witness our movement, as identified in step six of sharing the dilemma. After, we might engage in a discussion to decide on an action to take, invite the team member to join the movement, or both. In this manner, there is an inclusion of multiple voices to collectively resolve a dilemma in an embodied way. Inviting a treatment team member into a session also indicates movement towards mutuality as each person shows initiative by taking time out of their day to dedicate to the safety and care of the patient. Mutual empathy happens in the process of moving and witnessing movement; illuminating how the movement affected each person in the room can deepen the process. Mutual empowerment is experienced in the feelings of inclusion, displaying respect and interest in one another’s opinion.

The purpose of this clinical case study was to illustrate how the EEDM steps influenced ethical decision-making when cultural differences conflicted. I found that by engaging in the embodied ethical steps, I was able to deepen the decision-making process by accessing the lived experience of the dilemma in my body. I carried the heaviness of a silenced cultural identity until it was able to speak through movement. The ethical dilemma in this case was respect for culturally based meanings in treatment and how we name pathology. Culture is inadequately considered in healthcare operations, treatment models, and educational programs. We must actively consider how this deficiency affects patient health over time and disempowers underserved populations from engaging in treatment. The EEDM steps provide an effective way for working with diverse populations as we can connect to our bodies to explore new possibilities for complex situations. In this clinical case with Juan, though the decision to inform his nurse practitioner of his spiritual experience was against his will, our relationship encouraged his continued engagement with treatment services. To consider culturally based meanings in treatment, the relational experience is essential in order to receive support from different perspectives. Sharing the embodied decision-making process can be most effective for culturally situated ethical dilemmas. As suggested in the AMD model presented here, engaging in the EEDM steps through a RCT lens benefits silenced and underserved patients, and healthcare professionals with an increased sense of mutuality through a meaningful process.

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Roberts, M. Embodied Ethical Decision-Making: A Clinical Case Study of Respect for Culturally Based Meaning Making in Mental Healthcare. Am J Dance Ther 43 , 36–63 (2021). https://doi.org/10.1007/s10465-020-09338-3

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Accepted : 24 October 2020

Published : 15 January 2021

Issue Date : June 2021

DOI : https://doi.org/10.1007/s10465-020-09338-3

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Module 12: integrity, ethics and law.

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Case studies.

Choose one or more of the following case studies and lead a discussion which allows students to address and debate issues of integrity, ethics and law. If time allows, let the students vote on which case studies they want to discuss.

For lecturers teaching large classes, case studies with multiple parts and different methods of solution lend themselves well to the group size and energy in such an environment. Lecturers can begin by having students vote on which case study they prefer. Lecturers could break down analysis of the chosen case study into steps which appear to students in sequential order, thereby ensuring that larger groups stay on track. Lecturers may instruct students to discuss questions in a small group without moving from their seat, and nominate one person to speak for the group if called upon. There is no need to provide excessive amounts of time for group discussion, as ideas can be developed further with the class as a whole. Lecturers can vary the group they call upon to encourage responsive participation.

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Ethics Ethics Case Studies

The SPJ Code of Ethics is voluntarily embraced by thousands of journalists, regardless of place or platform, and is widely used in newsrooms and classrooms as a guide for ethical behavior. The code is intended not as a set of "rules" but as a resource for ethical decision-making. It is not — nor can it be under the First Amendment — legally enforceable. For an expanded explanation, please follow this link .

For journalism instructors and others interested in presenting ethical dilemmas for debate and discussion, SPJ has a useful resource. We've been collecting a number of case studies for use in workshops. The Ethics AdviceLine operated by the Chicago Headline Club and Loyola University also has provided a number of examples. There seems to be no shortage of ethical issues in journalism these days. Please feel free to use these examples in your classes, speeches, columns, workshops or other modes of communication.

Kobe Bryant’s Past: A Tweet Too Soon? On January 26, 2020, Kobe Bryant died at the age of 41 in a helicopter crash in the Los Angeles area. While the majority of social media praised Bryant after his death, within a few hours after the story broke, Felicia Sonmez, a reporter for The Washington Post , tweeted a link to an article from 2003 about the allegations of sexual assault against Bryant. The question: Is there a limit to truth-telling? How long (if at all) should a journalist wait after a person’s death before resurfacing sensitive information about their past?

A controversial apology After photographs of a speech and protests at Northwestern University appeared on the university's newspaper's website, some of the participants contacted the newspaper to complain. It became a “firestorm,” — first from students who felt victimized, and then, after the newspaper apologized, from journalists and others who accused the newspaper of apologizing for simply doing its job. The question: Is an apology the appropriate response? Is there something else the student journalists should have done?

Using the ‘Holocaust’ Metaphor People for the Ethical Treatment of Animals, or PETA, is a nonprofit animal rights organization known for its controversial approach to communications and public relations. In 2003, PETA launched a new campaign, named “Holocaust on Your Plate,” that compares the slaughter of animals for human use to the murder of 6 million Jews in WWII. The question: Is “Holocaust on Your Plate” ethically wrong or a truthful comparison?

Aaargh! Pirates! (and the Press) As collections of songs, studio recordings from an upcoming album or merely unreleased demos, are leaked online, these outlets cover the leak with a breaking story or a blog post. But they don’t stop there. Rolling Stone and Billboard often also will include a link within the story to listen to the songs that were leaked. The question: If Billboard and Rolling Stone are essentially pointing readers in the right direction, to the leaked music, are they not aiding in helping the Internet community find the material and consume it?

Reigning on the Parade Frank Whelan, a features writer who also wrote a history column for the Allentown, Pennsylvania, Morning Call , took part in a gay rights parade in June 2006 and stirred up a classic ethical dilemma. The situation raises any number of questions about what is and isn’t a conflict of interest. The question: What should the “consequences” be for Frank Whelan?

Controversy over a Concert Three former members of the Eagles rock band came to Denver during the 2004 election campaign to raise money for a U.S. Senate candidate, Democrat Ken Salazar. John Temple, editor and publisher of the Rocky Mountain News, advised his reporters not to go to the fundraising concerts. The question: Is it fair to ask newspaper staffers — or employees at other news media, for that matter — not to attend events that may have a political purpose? Are the rules different for different jobs at the news outlet?

Deep Throat, and His Motive The Watergate story is considered perhaps American journalism’s defining accomplishment. Two intrepid young reporters for The Washington Post , carefully verifying and expanding upon information given to them by sources they went to great lengths to protect, revealed brutally damaging information about one of the most powerful figures on Earth, the American president. The question: Is protecting a source more important than revealing all the relevant information about a news story?

When Sources Won’t Talk The SPJ Code of Ethics offers guidance on at least three aspects of this dilemma. “Test the accuracy of information from all sources and exercise care to avoid inadvertent error.” One source was not sufficient in revealing this information. The question: How could the editors maintain credibility and remain fair to both sides yet find solid sources for a news tip with inflammatory allegations?

A Suspect “Confession” John Mark Karr, 41, was arrested in mid-August in Bangkok, Thailand, at the request of Colorado and U.S. officials. During questioning, he confessed to the murder of JonBenet Ramsey. Karr was arrested after Michael Tracey, a journalism professor at the University of Colorado, alerted authorities to information he had drawn from e-mails Karr had sent him over the past four years. The question: Do you break a confidence with your source if you think it can solve a murder — or protect children half a world away?

Who’s the “Predator”? “To Catch a Predator,” the ratings-grabbing series on NBC’s Dateline, appeared to catch on with the public. But it also raised serious ethical questions for journalists. The question: If your newspaper or television station were approached by Perverted Justice to participate in a “sting” designed to identify real and potential perverts, should you go along, or say, “No thanks”? Was NBC reporting the news or creating it?

The Media’s Foul Ball The Chicago Cubs in 2003 were five outs from advancing to the World Series for the first time since 1945 when a 26-year-old fan tried to grab a foul ball, preventing outfielder Moises Alou from catching it. The hapless fan's identity was unknown. But he became recognizable through televised replays as the young baby-faced man in glasses, a Cubs baseball cap and earphones who bobbled the ball and was blamed for costing the Cubs a trip to the World Series. The question: Given the potential danger to the man, should he be identified by the media?

Publishing Drunk Drivers’ Photos When readers of The Anderson News picked up the Dec. 31, 1997, issue of the newspaper, stripped across the top of the front page was a New Year’s greeting and a warning. “HAVE A HAPPY NEW YEAR,” the banner read. “But please don’t drink and drive and risk having your picture published.” Readers were referred to the editorial page where White explained that starting in January 1998 the newspaper would publish photographs of all persons convicted of drunken driving in Anderson County. The question: Is this an appropriate policy for a newspaper?

Naming Victims of Sex Crimes On January 8, 2007, 13-year-old Ben Ownby disappeared while walking home from school in Beaufort, Missouri. A tip from a school friend led police on a frantic four-day search that ended unusually happily: the police discovered not only Ben, but another boy as well—15-year-old Shawn Hornbeck, who, four years earlier, had disappeared while riding his bike at the age of 11. Media scrutiny on Shawn’s years of captivity became intense. The question: Question: Should children who are thought to be the victims of sexual abuse ever be named in the media? What should be done about the continued use of names of kidnap victims who are later found to be sexual assault victims? Should use of their names be discontinued at that point?

A Self-Serving Leak San Francisco Chronicle reporters Mark Fainaru-Wada and Lance Williams were widely praised for their stories about sports figures involved with steroids. They turned their investigation into a very successful book, Game of Shadows . And they won the admiration of fellow journalists because they were willing to go to prison to protect the source who had leaked testimony to them from the grand jury investigating the BALCO sports-and-steroids. Their source, however, was not quite so noble. The question: Should the two reporters have continued to protect this key source even after he admitted to lying? Should they have promised confidentiality in the first place?

The Times and Jayson Blair Jayson Blair advanced quickly during his tenure at The New York Times , where he was hired as a full-time staff writer after his internship there and others at The Boston Globe and The Washington Post . Even accusations of inaccuracy and a series of corrections to his reports on Washington, D.C.-area sniper attacks did not stop Blair from moving on to national coverage of the war in Iraq. But when suspicions arose over his reports on military families, an internal review found that he was fabricating material and communicating with editors from his Brooklyn apartment — or within the Times building — rather than from outside New York. The question: How does the Times investigate problems and correct policies that allowed the Blair scandal to happen?

Cooperating with the Government It began on Jan. 18, 2005, and ended two weeks later after the longest prison standoff in recent U.S. history. The question: Should your media outlet go along with the state’s request not to release the information?

Offensive Images Caricatures of the Prophet Muhammad didn’t cause much of a stir when they were first published in September 2005. But when they were republished in early 2006, after Muslim leaders called attention to the 12 images, it set off rioting throughout the Islamic world. Embassies were burned; people were killed. After the rioting and killing started, it was difficult to ignore the cartoons. Question: Do we publish the cartoons or not?

The Sting Perverted-Justice.com is a Web site that can be very convenient for a reporter looking for a good story. But the tactic raises some ethical questions. The Web site scans Internet chat rooms looking for men who can be lured into sexually explicit conversations with invented underage correspondents. Perverted-Justice posts the men’s pictures on its Web site. Is it ethically defensible to employ such a sting tactic? Should you buy into the agenda of an advocacy group — even if it’s an agenda as worthy as this one?

A Media-Savvy Killer Since his first murder in 1974, the “BTK” killer — his own acronym, for “bind, torture, kill” — has sent the Wichita Eagle four letters and one poem. How should a newspaper, or other media outlet, handle communications from someone who says he’s guilty of multiple sensational crimes? And how much should it cooperate with law enforcement authorities?

A Congressman’s Past The (Portland) Oregonian learned that a Democratic member of the U.S. Congress, up for re-election to his fourth term, had been accused by an ex-girlfriend of a sexual assault some 28 years previously. But criminal charges never were filed, and neither the congressman, David Wu, nor his accuser wanted to discuss the case now, only weeks before the 2004 election. Question: Should The Oregonian publish this story?

Using this Process to Craft a Policy It used to be that a reporter would absolutely NEVER let a source check out a story before it appeared. But there has been growing acceptance of the idea that it’s more important to be accurate than to be independent. Do we let sources see what we’re planning to write? And if we do, when?

SPJ News –  SPJ condemns arrest of freelance reporter at UCLA and demands charges be dropped –  SPJ-led coalition demands Texas authorities drop charges against photojournalist Carlos Sanchez –  Region 8 Mark of Excellence Awards 2023 winners announced

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Ethical Dilemma: 10 Heartbreaking Case Studies

Last updated on April 2, 2024 by Alex Andrews George

In a small village in Maharashtra, a teacher named Ravi and his wife Maya, a nurse, faced a tough choice after an earthquake.

The only hospital in the village was damaged, and they could only save one life with the limited medical supplies: Maya’s critically injured mother or a young and bright boy from Ravi’s school, who also needed urgent surgery.

Choosing between saving Maya’s mother, who meant everything to her, or the young boy, who represented the village’s future, was heartbreakingly difficult.

This story highlights the painful decisions we sometimes must make, where saving one life means losing another, testing our deepest values and principles.

Based on this story, we dive into the complex world of ethical dilemmas and moral conflicts, where choices are never black and white, and every decision carries the weight of unforeseen consequences.

Table of Contents

What is an ethical dilemma?

An ethical dilemma occurs when a person is faced with a situation that requires a choice between two or more conflicting ethical principles or values .

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In such dilemmas, no matter what choice is made, some ethical principle is compromised.

The essence of an ethical dilemma is that it involves a difficult decision-making process where, typically, a clear-cut right or wrong answer doesn’t exist, or if it does, it may carry significant negative consequences for someone involved.

Definition of ethical dilemma

An ethical dilemma is a complex situation that often involves an apparent mental conflict between moral imperatives, in which to obey one would result in transgressing another.

It’s characterized by:

• Conflicting Values: Individuals or organizations must choose between competing ethical principles or values.
• No Perfect Solution: Each choice involves a compromise or violation of an ethical principle.
• Significant Consequences: The choices have significant potential impacts on the well-being or rights of individuals or groups.

5 Cases of Ethical Dilemma

Ethical dilemmas can arise across various fields and situations, reflecting the complexity of moral decisions in real-world scenarios. Here are more examples:

1. Loyalty to the employer vs. the moral obligation to protect the public and the environment

• An employee discovers that their company is engaging in illegal activities, such as dumping toxic waste into a river, which is both environmentally damaging and a serious health hazard to nearby communities.
• The employee faces an ethical dilemma between reporting the misconduct, potentially leading to legal action against the company and safeguarding public and environmental health, and remaining silent to protect their job and the livelihoods of their colleagues.
• Ethical Dilemma: Loyalty to the employer vs. the moral obligation to protect the public and the environment.

2. Upholding academic integrity vs. loyalty to a friend.

• A student witnesses a close friend cheating during an important exam.
• If the friend is reported and found guilty, they could face severe consequences, including failing the course or expulsion, which might ruin their academic career and future prospects.
• The student is torn between reporting the cheating, which is an honest action, and protecting their friend’s future.
• Ethical Dilemma: Upholding academic integrity vs. loyalty to a friend.

3. The safety of passengers vs. the safety of pedestrians

• Programmers of autonomous vehicles face an ethical dilemma in creating algorithms for unavoidable accidents.
• For example, if an accident is inevitable and the choice is between altering the vehicle’s path to avoid hitting a pedestrian, thereby endangering the passengers, or protecting the passengers at the cost of the pedestrian’s life, how should the car be programmed to act?
• Ethical Dilemma: The safety of passengers vs. the safety of pedestrians.

4. The duty to report news truthfully vs. the potential harm to public safety and societal peace

• A journalist obtains exclusive footage of a terrorist group committing an atrocity.
• Publishing the footage could inform the public about the severity of the situation and the threat posed by the terrorist group, but it could also spread fear, possibly lead to public panic, and serve the terrorists’ goal of gaining attention for their cause.
• Dilemma: The duty to report news truthfully vs. the potential harm that such reporting might cause to public safety and societal peace.

5. Upholding the client-lawyer confidentiality vs. the moral responsibility to prevent future crimes.

• A defence attorney knows their client is guilty of a serious crime and intends to commit similar crimes in the future.
• The attorney faces an ethical dilemma between maintaining client confidentiality, a cornerstone of legal ethics, and the moral obligation to prevent future harm.
• Ethical Dilemma: Upholding the client-lawyer confidentiality vs. the moral responsibility to prevent future crimes.

These examples highlight the range and depth of ethical dilemmas that individuals can face, requiring them to weigh competing values and principles against the backdrop of potential consequences for their actions or inactions.

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Moral Conflicts

Ethical dilemmas and moral conflicts are closely related concepts that often overlap in discussions of ethics and morality, but they can be distinguished by their context and the nature of the choices they involve.

Ethical Dilemma

An ethical dilemma arises when a person must choose between two or more actions that have ethical implications, making it difficult to decide what is the right or wrong course of action.

Ethical dilemmas often involve a decision-making process where each option violates some ethical principle or value, leading to a situation where no choice is entirely free from ethical fault.

These dilemmas typically occur within a specific professional, societal, or organizational context and involve considering external codes of ethics, laws, or social norms.

Moral Conflict

Moral conflict, on the other hand, refers to a situation where an individual’s values, principles, or beliefs conflict, leading to an internal struggle about the right course of action.

Moral conflicts are deeply personal and subjective, focusing on an individual’s conscience and moral reasoning rather than external rules or codes.

While ethical dilemmas might require an individual to choose between competing external obligations or duties, moral conflicts involve a more introspective struggle with one’s values and beliefs.

Key Differences Between Ethical Dilemmas and Moral Conflict

• Context: Ethical dilemmas often involve a choice between actions in a professional or social context, where external codes of conduct or laws must be considered. Moral conflicts are internal struggles over personal values and beliefs.
• Nature of Conflict: Ethical dilemmas typically involve competing ethical principles or obligations, where adhering to one may lead to the violation of another. Moral conflicts are about reconciling conflicting personal morals or values.
• Resolution: Resolving an ethical dilemma often involves choosing the “lesser evil” or the option that upholds the most critical ethical principle in a given context. Solving a moral conflict might require personal reflection, growth, and a deeper understanding of one’s own values.

While they are distinct, ethical dilemmas and moral conflicts can occur simultaneously, complicating the decision-making process further.

A person might face an ethical dilemma at work (e.g., whether to report a colleague’s wrongdoing) that also triggers a moral conflict (e.g., loyalty to a friend versus commitment to honesty).

This interplay underscores the complexity of ethical and moral reasoning in real-world situations.

5 Cases of Moral Conflicts

Moral conflicts arise when individuals face situations requiring them to choose between two or more conflicting moral principles or values. Here are five examples illustrating such conflicts:

1. Honesty vs. Compassion

• Situation: You find out that a close friend has lied on their resume to get a job they desperately need.
• Conflicting Morals: The value of honesty (telling the truth or reporting the lie) conflicts with compassion (understanding your friend’s desperate situation and wanting to support them).

2. Loyalty vs. Justice

• Situation: A family member is involved in a minor legal infraction and asks you to provide them with an alibi to avoid consequences.
• Conflicting Morals: Loyalty to your family member, wishing to protect them, conflicts with your sense of justice and the importance of facing legal consequences for one’s actions.

3. Self-sacrifice vs. Self-preservation

• Situation: During a disaster, you have the opportunity to save others by putting yourself in significant danger, or ensure your own safety, knowing others might not survive.
• Conflicting Morals: The principle of self-sacrifice, putting the needs of others before your own, conflicts with self-preservation, the instinct to protect oneself from harm.

4. Equality vs. Meritocracy

• Situation: In a workplace, you must decide between promoting an employee who has worked longer at the company (seniority) and another who has shown exceptional skill and productivity but has less tenure.
• Conflicting Morals: The value of treating everyone equally and fairly conflicts with meritocracy, where rewards are based on individual achievement and capabilities.

5. Freedom vs. Security

• Situation: In governing a community, you must decide whether to implement strict security measures that infringe on personal freedoms to ensure public safety.
• Conflicting Morals: The importance of individual freedom and autonomy conflicts with the collective need for security and protection from harm.

These examples highlight the complexity of moral conflicts, where deciding in favour of one value inevitably leads to the compromise or negation of another , reflecting the nuanced nature of ethical decision-making.

Also read: Ethical Concerns and Dilemmas In Government And Private Institutions

The moments of ethical dilemmas and moral conflicts challenge us to weigh our values against the harsh realities of our circumstances, pushing us to make decisions that can redefine who we are and what we stand for.

The story of Ravi and Maya, the couple torn between family and community, serves as a poignant reminder of the complex nature of ethical decision-making .

Such dilemmas compel us to question not just our morality but the very essence of what it means to be human.

They remind us that there are no easy answers in the pursuit of doing what is right.

Whether it’s choosing between fairness and loyalty, or the welfare of one versus the greater good, these decisions are laden with the weight of potential regret and the hope for understanding and forgiveness.

In conclusion, ethical dilemmas and moral conflicts are not mere philosophical quandaries to be pondered from afar; they are real, lived experiences that test our integrity , empathy , and courage.

As we tread this precarious path, let us strive for a balance between our duties to others and our commitment to our principles, recognizing that we can confront and navigate these dilemmas that ultimately define our humanity.

The journey through these challenges is arduous and fraught with uncertainty, but it is also a testament to the strength and resilience of the human spirit, ever aspiring to a higher standard of morality and justice.

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About Alex Andrews George

Alex Andrews George is a mentor, author, and social entrepreneur. Alex is the founder of ClearIAS and one of the expert Civil Service Exam Trainers in India.

He is the author of many best-seller books like 'Important Judgments that transformed India' and 'Important Acts that transformed India'.

A trusted mentor and pioneer in online training , Alex's guidance, strategies, study-materials, and mock-exams have helped many aspirants to become IAS, IPS, and IFS officers.

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• Business Ethics Cases
• Markkula Center for Applied Ethics
• Focus Areas
• Business Ethics
• Business Ethics Resources

Find ethics case studies on bribery, sourcing, intellectual property, downsizing, and other topics in business ethics, corporate governance, and ethical leadership. (For permission to reprint articles, submit requests to [email protected] .)

In this business ethics case study, Swedish multinational company IKEA faced accusations relating to child labor abuses in the rug industry in Pakistan which posed a serious challenge for the company and its supply chain management goals.

A dog may be humanity’s best friend. But that may not always be the case in the workplace.

A recent college graduate works in the finance and analytics department of a large publicly traded software company and discovers an alarming discrepancy in sales records, raising concerns about the company’s commitment to truthful reporting to investors. 

What responsibility does an employee have when information they obtained in confidence from a coworker friend may be in conflict with the needs of the company or raises legal and ethical questions.

A manager at a prominent multinational company is ethically challenged by a thin line between opportunity for economic expansion in a deeply underserved community, awareness of child labor practices, and cultural relativism.

A volunteer providing service in the Dominican Republic discovered that the non-profit he had partnered with was exchanging his donor money on the black market, prompting him to navigate a series of complex decisions with significant ethical implications.

The CFO of a family business faces difficult decisions about how to proceed when the COVID-19 pandemic changes the business revenue models, and one family shareholder wants a full buyout.

An employee at an after-school learning institution must balance a decision to accept or decline an offered gift, while considering the cultural norms of the client, upholding the best interests of all stakeholders, and following the operational rules of his employer. 

A senior vice president for a Fortune 500 savings and loan company is tasked with the crucial responsibility of representing the buyer in a multi-million dollar loan purchase deal and faces several ethical challenges from his counterpart representing the seller.

Extensive teaching note based on interviews with Theranos whistleblower Tyler Shultz. The teaching note can be used to explore issues around whistleblowing, leadership, the blocks to ethical behavior inside organizations, and board governance.

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