20 Common Examples of Ethical Dilemmas in Nursing + How to Deal With Them

case study with ethical dilemma in healthcare

If you are a nurse, chances are you have faced situations where you had to make decisions based on your belief of whether something is right or wrong, safe or unsafe. This type of decision is based upon a system of ethical behavior. It is essential that all nurses develop and implement ethical values into nursing practice. If this sounds familiar, you may be asking, "What are the common examples of ethical dilemmas in nursing?" There are many things that could be considered an ethical dilemma in nursing, and it is important for nurses to know how to address them when they occur. In this article, I will share the 20 most common examples of ethical dilemmas in nursing and offer some insight into handling them.

What Is An Ethical Dilemma In Nursing?

5 main reasons why nurses face with ethical dilemmas in nursing.

1. Patients or their loved ones must make life or death decisions 2. The patient refuses treatment 3. Nursing assignments may contradict cultural or religious beliefs 4. Nursing peers demonstrate incompetence 5. Inadequate staffing

How To Identify Ethical Dilemmas In Nursing?

What are the common examples of ethical dilemmas in nursing, example #1: pro-life vs. pro-choice, ethical dilemma:, how to deal with this ethical dilemma:, example #2: protecting the adolescent’s right to privacy, example #3: empirical knowledge vs. religious beliefs, example #4: parent refuses to vaccinate child, example #5: personal and professional boundaries related to social media, example #6: nurse is instructed to have patient with low literacy level to sign consent for treatment, example #7: end-of-life decision-making, example #8: inadequate resources to provide care, example #9: former patients - to date or not to date, example #10: informed consent, example #11: inadequate staffing, example #12: spirituality vs. science, example #13: patient addicted to prescription pain medication, example #14: duty and compassion do not align with facility safety protocols, example #15: patient does not have an advanced directive, example #16: incompetence among nursing peers, example #17: disclosing the seriousness of medical conditions, example #18: questioning physician orders, example #19: asked to work in a department without training, example #20: beneficence vs. autonomy, 4 consequences of avoiding ethical dilemmas in nursing, 1. nurses can quickly experience burnout., 2. avoiding ethical dilemmas in nursing can lead to legal issues., 3. nurses who avoid ethical dilemmas could lose their jobs., 4. loss of licensure:, my final thoughts.

case study with ethical dilemma in healthcare

Respecting patient autonomy versus protecting the patient's health: a dilemma for healthcare providers

Affiliation.

  • 1 Department of Nursing, Rhode Island Hospital, Providence, Rhode Island 02903, USA. [email protected]
  • PMID: 19935216
  • DOI: 10.1097/NHL.0b013e3181c1b542

A 74-year-old man with multiple chronic medical problems was hospitalized for respiratory distress. He experienced recurrent aspiration and required frequent suctioning and endotracheal intubation on several occasions. The patient was deemed competent and steadfastly refused feeding tube placement. The patient demanded that he be allowed to eat a normal diet despite being told that it could lead to his death. The patient wanted to go home, but there was no one there to care for him. Additionally, neither a nursing home nor hospice would accept him in his present condition. The case is especially interesting because of the symbolic value of food and the plight of the patient who has no alternative to hospitalization. The hospital staff experienced considerable stress at having to care for him. They were uncertain whether their obligation was to respect his autonomy and continue to provide food or to protect his health by avoiding aspiration, pneumonia, and possible death by denying him food. This ethical dilemma posed by the professionals' duty to do what is in the patient's best interest versus the patient's right to decide treatment serves as the focus for this case study. Ethical, legal, and healthcare practitioners' considerations are explored. The case study concludes with specific recommendations for treatment.

Publication types

  • Case Reports
  • Enteral Nutrition
  • Mental Competency / legislation & jurisprudence*
  • Nursing Care / ethics
  • Personal Autonomy*
  • Respiratory Aspiration / nursing*
  • Respiratory Aspiration / prevention & control*
  • Treatment Refusal / ethics
  • Treatment Refusal / legislation & jurisprudence*

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

  • Open access
  • Published: 15 January 2021
  • Volume 43 , pages 36–63, ( 2021 )

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  • Megz Roberts   ORCID: orcid.org/0000-0002-1121-2063 1  

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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.

figure 1

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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Moral dilemmas and trust in leaders during a global health crisis

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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.

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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.

figure 1

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%).

figure 2

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.

figure 3

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 ).

figure 4

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.

Author information

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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Received : 09 September 2020

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 with ethical dilemma in healthcare

case study with ethical dilemma in healthcare

  • Cases in Medical Ethics: Student-Led Discussions
  • Markkula Center for Applied Ethics
  • Focus Areas
  • Bioethics Resources

Cases in Medical Ethics

Student-led discussions.

A selection of medical ethics cases designed to help determine whether medicine is the correct calling for pre-medical students.

I was a Hackworth Fellow for the Markkula Center for Applied Ethics at Santa Clara University. I was also a pre-medical student, and am currently attending the Loyola University Chicago Stritch School of Medicine. During my senior year at Santa Clara, I led discussions on medical ethics with students interested in medicine. The purpose of these discussions was two-fold. First, they were created to help bring current ethical issues onto our campus. Second, they were intended to help students who were interested in a career in the health sciences determine whether or not medicine is their correct calling. Most of the discussions followed a simple format. One to two cases were formulated for the students to read. Then I presented the students with various questions related to some of the ethical issues contained in the situations described. The following cases are the ones that I presented to the groups. Each case also has a short history and summary of the ethical issues being reviewed. The questions I asked of the students are included as well. These cases and questions are public domain, and can be re-used or modified for educational purposes. I hope that you find them useful, and that they spawn the same thoughtful enjoyment in you as they did in me.

Note: The cases were not based on specific events. However, it is possible that they share similarities with actual events. These similarities were not intended.

Autonomy essentially means "self rule," and it is a patient's most basic right. As such, it is a health care worker's responsibility to respect the autonomy of her patients. However, at times this can be difficult because it can conflict with the paternalistic attitude of many health care professionals. The following two cases address patient autonomy. The first involves the rights of an individual to decide her own fate, even against her physicians' judgments. The second case involves the rights of a parent to care for her child in the manner that she sees fit.

A woman enters the emergency room with stomach pain. She undergoes a CT scan and is diagnosed with an abdominal aortic aneurysm, a weakening in the wall of the aorta which causes it to stretch and bulge (this is very similar to what led to John Ritter's death). The physicians inform her that the only way to fix the problem is surgically, and that the chances of survival are about 50/50. They also inform her that time is of the essence, and that should the aneurysm burst, she would be dead in a few short minutes. The woman is an erotic dancer; she worries that the surgery will leave a scar that will negatively affect her work; therefore, she refuses any surgical treatment. Even after much pressuring from the physicians, she adamantly refuses surgery. Feeling that the woman is not in her correct state of mind and knowing that time is of the essence, the surgeons decide to perform the procedure without consent. They anesthetize her and surgically repair the aneurysm. She survives, and sues the hospital for millions of dollars. Questions for Case 1:

Do you believe that the physician's actions can be justified in any way?

Is there anything else that they could have done?

Is it ever right to take away someone's autonomy? (Would a court order make the physicians' decisions ethical?)

What would you do if you were one of the health care workers?

You are a general practitioner and a mother comes into your office with her child who is complaining of flu-like symptoms. Upon entering the room, you ask the boy to remove his shirt and you notice a pattern of very distinct bruises on the boy's torso. You ask the mother where the bruises came from, and she tells you that they are from a procedure she performed on him known as "cao gio," which is also known as "coining." The procedure involves rubbing warm oils or gels on a person's skin with a coin or other flat metal object. The mother explains that cao gio is used to raise out bad blood, and improve circulation and healing. When you touch the boy's back with your stethoscope, he winces in pain from the bruises. You debate whether or not you should call Child Protective Services and report the mother.

Questions for Case 2:

Should we completely discount this treatment as useless, or could there be something gained from it?

When should a physician step in to stop a cultural practice? (If someone answers "when it harms the child" remind that person that there is some pain in many of our medical procedures, for example, having one's tonsils removed)

Should the physician be concerned about alienating the mother and other people of her ethnicity from modern medicine?

Do you think that the physician should report the mother?

Autonomy Part 2 Maintenance of patient autonomy is one of the major ethical focuses of physicians. Therefore, a second discussion was also held that focused primarily on patient autonomy. This discussion also took a superficial look at euthanasia. For this discussion, a 58 minute video, Dax's Case (produced by Unicorn Media, for Concern for Dying ; produced by Donald Pasquella, Keith Burton ; directed by Donald Pasquella New York : Filmakers Library, c1984) was used. The video tells the story of Dax Cowart, a man who was severely burned by an accidental propane explosion. The burns disabled Dax, and the physicians forced treatment on him. Though he survived the treatment, he still argues that he should have been allowed to refuse it so that he could die. The video is very useful; however, the videos of Dax's burn treatments are very graphic and the video should be reviewed before it is shown to a group of students.

In the video, one of the physicians says that burn patients are incompetent to make decisions when they first enter the hospital because they are in such a great deal of pain. However, patients such as Dax can be in a great deal of pain for a very long time. In such cases, what should be done to determine competence, and when should this be done?

Do you think the fact that Dax could not see a future for himself should have been taken into account when determining his competency? Could this have clouded his judgment? (He thought that he would end up on the street corner selling pencils)

Do you think that the fact that Dax was going to recover, and had the possibility of living a happy life, made not treating Dax like suicide… or murder? What if he did not have this possibility?

After his recovery, Dax attempted suicide. Should the physicians have let him die? Is it ever correct for a doctor to allow a patient to kill himself?

Do you ever think that it is correct for a physician to break a competent patient's autonomy? If so, is this one of those cases?

Do you think that in this case, that the ends justified the means?

The word "euthanasia" draws its roots from Greek meaning "good death." As it is used in this discussion, it means "the act of ending the life of a person suffering from either a terminal illness, or an incurable disease." The AMA is against physicians assisting in euthanasia. There is currently only one state in the US that allows for euthanasia, and that is Oregon, where in 1997, the "Death With Dignity Act" went into effect. Euthanasia advocates stress that it should be allowed as an extension of a person's autonomy. Those who are against euthanasia often say that it can lead to the devaluation of human life, and to a slippery slope in which the old and disabled will be killed on the whims of healthy people. We examined one case and the Oregon law to view the ethics of euthanasia.

Case One: A woman was diagnosed with motor neurone disease (the same disease that Stephen Hawking has) 5 years ago. This is a condition that destroys motor nerves, making control of movement impossible, while the mind is virtually unaffected. People with motor neurone disease normally die within 4 years of diagnosis from suffocation due to the inability of the inspiratory muscles to contract. The woman's condition has steadily declined. She is not expected to live through the month, and is worried about the pain that she will face in her final hours. She asks her doctor to give her diamorphine for pain if she begins to suffocate or choke. This will lessen her pain, but it will also hasten her death. About a week later, she falls very ill, and is having trouble breathing.

Questions for Case 1:

Does she have a right to make this choice, especially in view of the fact that she will be dead in a short while (say six hours)? Is this choice an extension of her autonomy?

Is the short amount of time she has to live ethically relevant? Is there an ethical difference between her dying in 6 hours and dying in a week? What about a year, and how do you draw this distinction?

Is the right for a patient's self-determination powerful enough to create obligations on the part of others to aid her so that she can exercise her rights? She clearly cannot kill herself. She can't move, but should someone be FORCED to help her, or to find someone to help her?

Should the money used to care for this woman be taken into account when she is being helped? Do you think that legalizing euthanasia could create conflicts of interest for the patient/ or the doctor? Will people feel that they need to end their lives earlier to save money?

Ask each student: If you were the physician, what would you do? Note: if you would pass her off to another doctor knowing he or she would do it, does this free you from you ethical obligations?

Oregon's Death With Dignity Act: We discussed the following questions pertaining to the Death With Diginity Act.

Death With Dignity Questions:

Look at the requirements for the request. Do you see any problems with them? (The woman from case 1 would not qualify.)

Why would they put in these guidelines? Should they be there, if they keep a competent person like the woman above from living her autonomy? (Is it to protect the doctors so they will not have to GIVE the medication?)

Is there a moral difference between prescribing the drug and actually giving it to the patient? If not, why put in the rules?

Why do you think they wouldn't let a person who is terminally ill and in pain with possibly more than 6 months receive assistance in dying? Say someone is diagnosed with HIV?

Does the justification of euthanasia necessarily justify the assisted suicide of a healthy person?

Do you think a weakness of this law is the probability of patients being influenced by family members? (For example, for financial or other reasons?) Note: Approximately 60% of Oregonians in 2000 said (before they died) that they used the prescription at least in some part due to fear of being a burden on their family.

The AMA says that euthanasia is fundamentally incompatible with the physician's role as healer. What do you think about this statement? Why should a physician have to be the one who does this?

Assisted Reproduction:

This is a difficult subject because it involves reproductive issues. In our culture, reproductive liberty, the freedom to decide when and where to conceive a child is highly protected, and this can make these cases much more difficult.

Case 1: There are two types of surrogacy. One type involves a surrogate mother who uses her own egg and carries the baby for someone else. The other type is a "gestational surrogacy" in which the mother has no genetic tie to the child she carries. In the case presented, a gestational surrogate is used.

A woman, after a bout with uterine cancer had a hysterectomy (surgical removal of the uterus). Before, its removal, however, she had several eggs removed for possible fertilization in the future. Now married, the woman wishes to have a child with her husband. Obviously she cannot bear the child herself, so the couple utilizes a company to find a surrogate mother for them. The husband's sperm is used to fertilize one of the wife's eggs, and is implanted in the surrogate mother. The couple pays all of the woman's pregnancy-related expenses and an extra $18,000 as compensation for her surrogacy. After all expenses are taken into account the couple pays the woman approximately $31,000 and the agency approximately $5,000. Though the surrogate passed stringent mental testing to ensure she was competent to carry another couple's child, after carrying the pregnancy to term, the surrogate says that she has become too attached to "her" child to give it up to the couple. A legal battle ensues.

In the United States it is illegal to pay a person for non-replenishable organs. The fear is that money will influence the poor to harm their bodies for the benefit of the rich. Do you see a parallel between this case and this law? Can allowing surrogate mothers to be paid for their troubles allow poorer women to be oppressed?

Does paying the surrogate harm her and/or the child's dignity?

Is it selfish/conceited for this couple to want children of their own genetic make-up? If yes, does this change if you can "easily" have a child? (Note: Over 100,000 children in the U.S. are waiting to be adopted. However, most are older, have several siblings, or have special needs.)

On their website, the AMA says "that surrogacy contracts [when the surrogate uses her own egg], while permissible, should grant the birth mother the right to void the contract within a reasonable period of time after the birth of the child. If the contract is voided, custody of the child should be determined according to the child's best interests." Do you see any problems with this? (What's a reasonable time? In a way can you steal the surrogate's child?)

One of the main arguments against the use of surrogate mothers is that carrying and giving birth to a child is such an emotional event that it is impossible to determine if the surrogate will be able to give up the child. Though adults enter into the contract, the child could ultimately suffer if a long custody battle ensues (as it could in states where surrogacy contracts hold no legal value, such as Virginia). With the possibility of such battles, do you think it is acceptable for parents to use a surrogate mother?

Do you think that if the surrogate is awarded the baby, this could cause emotional harm to the child?

Who do you think should receive the child, and why?

A married couple wishes to have a child; however, the 32 year old mother knows that she is a carrier for Huntington's disease (HD). HD is a genetic disorder that begins showing signs at anywhere from 35-45 years of age. Its symptoms begin with slow loss of muscle control and end in loss of speech, large muscle spasms, disorientation and emotional outbursts. After 15-20 years of symptoms HD ends in death. HD is a dominant disorder which means that her child will have a 50% chance of contracting the disorder. Feeling that risking their baby's health would be irresponsible, the couple decides to use in vitro fertilization to fertilize several of the wife's eggs. Several eggs are harvested, and using special technology, only eggs that do not have the defective gene are kept to be fertilized. The physician then fertilizes a single egg, and transfers the embryo to the mother. Approximately 9 months later, the couple gives birth to a boy who does not carry the gene for the disorder.

Is this a case of eugenics? "Eugenics" is defined as "the hereditary improvement of the human race controlled by selective breeding" (dictionary.com)

Would it be acceptable for the parents to select for sex as well, or should they only select an embryo that does not have HD? How would this be different?

Is it ethical for this couple to have a baby when the mother could begin showings signs of HD when the baby is just a few years old?

With this technology possible, would it be ethical for this couple to have a child without genetically ensuring it would not have the disease? What if we did not have this technology, would it be ethical for a known carrier to have a child? (If not, how far should this carry? a carrier for cystic fibrosis ( which is recessive)? )

Weighing everything we have discussed, do you believe the couple acted ethically?

Response To Bio-Terrorism

The possibility of terrorists using biological weapons on the citizens of the United States has been a major topic in the press for the last several years. Smallpox has been speculated to be the perfect biological terror agent because of the potency of the virus, and because of the lack of herd immunity present in the US population. The following case presents a possible way in which the virus could be released in the population and a possible response. The questions following the case involve the ethics surrounding the government's response.

Smallpox Facts:

Smallpox initially has flu-like symptoms, which are recognizable 7-19 days after exposure. After 2-4 days of flu-like symptoms, the fever begins to decrease, and pox will form.

An infected person is contagious one day before the characteristic pox appear.

Approximately 30-50% of unvaccinated people exposed to smallpox will contract the disease.

The mortality rate for smallpox was approximately 20-40%.

The vaccine that was used was approximately 90% effective.

It is possible that if terrorists were to use the smallpox virus, that they would genetically modify it. If this were the case, then the vaccine may not prevent all of the disease symptoms for those vaccinated.

Facts gathered from: http://www.vbs.admin.ch/ls/e/current/fact_sheet/pocken/

Date: June 22, 2005. A 27-year-old man is brought into a New York City emergency room with a 101-degree fever, and what he believes is chickenpox (Varicella). After a brief examination, the 35-year-old physician is puzzled because the pox do not appear to be typical of the varicella-zoster virus. Worried, he calls in another physician for her opinion. She takes one look at the patient, determines he has small pox, and immediately orders him to be quarantined. She notifies the Centers for Disease Control and Prevention (CDC) and asks them what should be done. While doing background on the patient, he tells the physicians that he is a flight attendant and that he has flown to Orlando, FL, Los Angeles, CA, Chicago, IL, and Seattle, WA in the past few weeks while working. Though he is given excellent treatment, and had been in perfect health a few days earlier, the patient dies 7 hours after admittance to the hospital.

The CDC decides that mandatory small pox vaccines will be administered to all workers in the NYC hospital, and to all patients who were in the ER. His co-workers are all given mandatory vaccines as well, as are all people living in his apartment complex. They also ship stored quantities of the vaccine to all of the cities where the man had flown to for work. The vaccines are offered to citizens of these cities. Finally, all people, along with their families who had been on the man's flights in the weeks preceding the appearance of the disease are forced to receive the vaccine.

Questions: Note: The flight attendant was most likely given small pox by a bio terrorist who flew on his plane sometime during the past week/week and a half. The terrorist would have been contagious but would not have shown symptoms. Virtually every person the man came into contact with would have gotten the virus.

Is it ethical for the CDC to force people to get the vaccine?

An LA woman on the flight is religiously opposed to vaccines. Under California law she can normally refuse vaccines on religious or personal grounds. However, the government says she must receive the vaccine or face mandatory quarantine. What do you think of this?

Do you think that for more common diseases, for example measles, that it is ethical for the state to allow people to refuse vaccines (even for religious grounds)? What if their refusal can harm others who cannot have the vaccine, such as people who are immunocompromised like AIDS patients?

Is it ethical for someone to refuse the vaccine?

You had driven down to Los Angeles 5 days ago to visit a friend for the weekend. While in town, you visited many tourist attractions. You are worried and you try to get the vaccine, but are denied it because of limited resources. What do you think of this?

Citizens begin calling for the mandatory quarantining of people directly exposed to the victim, i.e those living in his apartment complex, those working in the ER, those who flew on the plane in the prior week. What do you think of this?

The smallpox vaccine, like many other vaccines (example: oral polio vaccine) can actually transmit the virus to others. In light of this, is it ethical for people to get the vaccine? (Note: they are vaccinating those who may not want to be vaccinated)

Today, should health care workers be allowed/forced to get the smallpox vaccine? What about non-health care worker citizens?

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Ethics Case Studies & Education Resources

ACP ethics education resources cover a broad range of issues in clinical ethics, professionalism, teaching, research, health care delivery, and other topics. Each resource can be used as a learning activity and completed for free CME/MOC credits as indicated or used as a teaching tool.

  • Ethics Case Studies for CME/MOC
  • Ethics Manual Activity for CME/MOC
  • Position Paper Activities for CME/MOC

Additional Ethics Case Studies

Acp ethics case study series.

Each case study draws on an ethical challenge encountered by physicians in everyday practice, teaching or research. Free CME/MOC credits are available from ACP’s Online Learning Center. Free CME/MOC credits are available for completion of case studies on Medscape as indicated (a free Medscape login is required for access and completion).

  • Pain Management Near the End-of-Life: What Would Mom Want? CME/MOC
  • Ethics, Professionalism, Physician Employment and Health Care Business Practices CME/MOC
  • Show Codes, Slow Codes, Full Codes, or No Codes: What Is a Doctor to Do? CME/MOC
  • When Resources Are Limited During a Public Health Catastrophe: Nondiscrimination and Ethical Allocation Guidance CME/MOC
  • Patient Prejudice? The Patient Said What?... and What Comes Next CME/MOC
  • Lab Results Reporting, Ethics, and the 21st Century Cures Act Rule on Information Blocking CME/MOC
  • Physician Suicide Prevention: The Ethics and Role of the Physician Colleague and the Healing Community CME/MOC
  • Ethics, Electronic Health Record Integrity and the Patient-Physician Relationship CME/MOC
  • Ethics, Professionalism, and the Physician Social Media Influencer CME/MOC
  • Professional Attire and the Patient-Physician Relationship CME/MOC
  • When the Family Caregiver Is a Physician: Negotiating the Ethical Boundaries CME/MOC
  • ”Doctor, Can’t You Just Phone a Prescription In?” and Other Ethical Challenges of Telemedicine Encounters CME/MOC
  • Serving as an Expert Witness: Is there a Duty? CME  

Ethics Manual (CME/MOC)

The ACP Ethics Manual is the core of College ethics policy. The seventh edition examines issues in medical ethics, reflecting on the ethical tenets of medicine and their application to emerging challenges while also revisiting older issues that are still very pertinent. It helps physicians be prepared to deal with ethical challenges: to identify and reaffirm the fundamentals of medical ethics—such as the patient-physician relationship—and apply principles and reasoned arguments in resolving dilemmas and in debate about ethics topics.

A 25-question quiz module on the seventh edition of the Ethics Manual is available for up to 10 AMA PRA Category 1 Credits TM and MOC Points. The activity is free for ACP members and Annals subscribers.

Annals of Internal Medicine offers the following CME/MOC activity for ACP members and Annals subscribers:

  • Ethical and Professionalism Implications of Physician Employment and Health Care Business Practices (Ann Intern Med. published online 15 March 2021) CME/MOC

Additional position papers cover a broad range of health care ethics issues and can be used as a teaching tool.

  • Pandemic Treatment Resource Allocation Ethics and Nondiscrimination
  • Confidentiality and Privacy: Beyond HIPAA to Honey, Can We Talk?  
  • Secret Recordings of Office Visits by Patients  
  • Addressing a Colleague's Unprofessional Behavior During Sign-Out  
  • Patient Requests for Specific Care: 'Surely You Can Explain to My Insurer That I Need Boniva?'  
  • Maintaining Medical Professionalism Online: Posting of Patient Information  
  • Banning Harmful Health Behaviors as a Condition of Employment: Where There's Smoke There's Fired?  
  • Addressing a Colleague's Sexually Explicit Facebook Post  
  • Wellness Programs and Patient Goals of Care  
  • Resident Duty Hours: To Hand Over or Gloss Over?
  • When an Aging Colleague Seems Impaired  
  • Preventive Health Screening, Ethics and the Cognitively Impaired Patient  
  • Stewardship of Health Care Resources: Allocating Mechanical Ventilators During Pandemic Influenza  
  • Copied and Pasted and Misdiagnosed (or Cloned Notes and Blind Alleys)  
  • Stewardship of Health Care Resources: Responding to a Patient’s Request for Antibiotics
  • Who Should Get What? Mammography and the Stewardship of Health Care Resources  
  • Patient/Physician/Family Caregiver Relationships: When the Family Caregiver Is a Physician  
  • Physician Work Stoppages and Political Demonstrations -- Economic Self-Interest or Patient Advocacy? Where Is the Line?  
  • To Be or Not to Be: Should I Serve as an Expert Witness?  
  • Author! Author! Who Should Be Named in a Published Study? An Ethics Case Study  
  • The Difficult Patient: Should You End the Relationship? What Now? An Ethics Case Study  
  • Dealing with the "Disruptive" Physician Colleague  
  • Must You Disclose Mistakes Made by Other Physicians?
  • Providing Care to Undocumented Immigrants
  • Twenty-eight additional case studies are published in the book  Ethical Choices: Case Studies for Medical Practice (2nd edition)

For more information on these and other educational content, please contact Lois Snyder Sulmasy, JD, at  [email protected]  or at 215-351-2835.

Ethics Sessions at Internal Medicine Meeting 2020

April 23 – 25, 2020, Los Angeles, CA

Sponsored by the Ethics, Professionalism & Human Rights Committee (EPHRC)

  • Ethical Case Challenges: Precision Medicine and Genetics in Primary Care
  • Ethics Year in Review
  • Spirituality in End-of-Life Care: What is the Physician’s Role?
  • Practical Palliative Care: Managing Pain at the End of Life

Ethics education sessions on different topics are offered at the annual Internal Medicine Meeting each year. Information on past Internal Medicine Meeting ethics sessions is available upon request at [email protected] .

Attending the Internal Medicine Meeting is an excellent way to fulfill your state CME relicensure requirements. The ethics sessions may fulfill specific CME content requirements of your state’s licensure renewal. Letters of participation documenting attendance are available online .

For more information on these and other educational content, please contact Lois Snyder Sulmasy, JD, at [email protected] or at 215-351-2835.

case study with ethical dilemma in healthcare

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  • Ethical Dilemmas in Nursing:...

Ethical Dilemmas in Nursing: Case Studies

Definition of ethical dilemmas in nursing.

Table of Contents

Ethical dilemmas are complex situations that occur in nursing practice, where nurses are confronted with conflicting moral obligations or values. These dilemmas arise when there is a clash between what is considered right or wrong, and the nurse must make a difficult decision.

Explaining the Concept

In nursing, ethical dilemmas can arise from various situations, such as:

  • Confidentiality: Nurses may face dilemmas when a patient’s right to privacy conflicts with the need to share information with other healthcare professionals.
  • End-of-life care: Deciding whether to continue life-sustaining treatments or respect a patient’s wishes for palliative care can present ethical challenges.
  • Resource allocation: Limited resources can force nurses to make difficult decisions about prioritizing patient care.
  • Cultural and religious beliefs: Nurses must navigate dilemmas when patient preferences clash with their own beliefs or institutional policies.
  • Research ethics: Ethical dilemmas can arise when conducting research involving human subjects, ensuring informed consent, and protecting participants’ rights.

Factors that Lead to Ethical Dilemmas

Several factors contribute to the emergence of ethical dilemmas in nursing:

  • Advances in technology and medicine: The rapid pace of medical advancements often outpaces the development of ethical guidelines, leaving nurses to grapple with novel situations.
  • Moral distress: Nurses may experience moral distress when they are aware of the ethically right course of action but face barriers preventing them from following through.
  • Conflicting values and obligations: Nurses work within a complex web of values, including professional codes of ethics, personal beliefs, and organizational policies, which can sometimes collide.
  • Interdisciplinary collaboration: Collaborating with other healthcare professionals may introduce differences in values and perspectives, leading to ethical conflicts.

How Nurses Navigate Ethical Dilemmas

Nurses must employ strategies to effectively navigate ethical dilemmas and make ethically sound decisions. Here are some approaches:

  • Ethics committees: Hospitals and healthcare institutions often have ethics committees that provide guidance and support to nurses facing ethical dilemmas. These committees consist of healthcare professionals, ethicists, and community representatives who collaborate to find ethical solutions.
  • Utilizing ethical frameworks: Nurses can apply ethical frameworks, such as the principle-based approach (autonomy, beneficence, non-maleficence, justice) or the ethical decision-making model, to systematically analyze and resolve ethical dilemmas.
  • Consulting with colleagues: Seeking input from colleagues and engaging in ethical discussions can help nurses gain different perspectives and insights into complex situations.
  • Continuing education: Staying informed about current ethical issues and participating in continuing education programs equips nurses with the knowledge and skills necessary to navigate ethical challenges effectively.

Navigating ethical dilemmas in nursing requires critical thinking, ethical reasoning, and a commitment to patient advocacy. It is essential for nurses to engage in ongoing self-reflection and professional development to enhance their ethical decision-making abilities.

For further information on ethical dilemmas in nursing, you can refer to authoritative sources like the American Nurses Association (ANA) Code of Ethics for Nurses (insert link: www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/) or consult your institution’s ethics committee.

Remember, being prepared to face and resolve ethical dilemmas is an integral part of a nursing career, and developing these skills will contribute to providing high-quality and patient-centered care.

Case Study 1: Nursing Considerations and Outcome

A. overview of case study.

In this case study, we examine a scenario that highlights the ethical dilemmas nurses may face in their practice. The case revolves around a nurse who discovers that a patient has been prescribed an incorrect dosage of medication by a physician. The nurse is torn between reporting the error and potentially damaging the relationship with the physician, or staying silent and risking harm to the patient.

B. Nursing Considerations when Faced with Dilemma

When confronted with such ethical dilemmas, nurses must carefully consider their professional obligations and responsibilities. Here are some key nursing considerations:

1. Patient Advocacy: The primary duty of nurses is to advocate for the well-being and safety of their patients. Nurses should prioritize patient care over personal relationships or concerns about potential conflicts.

2. Ethical Principles: Nurses should adhere to ethical principles such as autonomy, beneficence, non-maleficence, and justice. These principles guide decision-making and help nurses navigate difficult situations.

3. Communication: Open and honest communication with healthcare team members is crucial in resolving ethical dilemmas. Nurses should approach the physician involved in a respectful manner, expressing concerns about patient safety and seeking a collaborative solution.

4. Chain of Command: If initial attempts to address the issue directly with the physician are unsuccessful or if the nurse feels uncomfortable doing so, it is important to follow the established chain of command within the healthcare facility. This ensures that appropriate steps are taken to rectify the situation while protecting patient safety.

5. Documentation: Nurses should document all relevant details regarding the medication error, including the steps taken to address the issue. Accurate documentation serves as a legal record and helps in identifying areas for improvement in the healthcare system.

C. Outcome of Case Study

In this case study, the nurse chose to prioritize patient safety and reported the medication error to the appropriate authorities within the healthcare facility. The incident was thoroughly investigated, and corrective measures were implemented to prevent similar errors in the future.

The nurse’s decision to address the dilemma head-on not only ensured patient safety but also reinforced professional integrity. It demonstrated the nurse’s commitment to upholding ethical standards and serving as a patient advocate.

It is important for nurses to remember that ethical dilemmas are not uncommon in healthcare settings. By carefully considering their obligations, communicating effectively, and following established protocols, nurses can navigate these challenges while maintaining their professionalism and commitment to patient care.

For additional resources on ethical decision-making and nursing considerations, we recommend visiting reputable websites such as the American Nurses Association (ANA) at www.nursingworld.org/practice-policy/ethics/ or the National Council of State Boards of Nursing (NCSBN) at www.ncsbn.org/nclex.htm . These organizations provide valuable guidelines and resources for nurses facing ethical dilemmas in their practice.

Remember, as a nurse, your decisions have a profound impact on patient outcomes. Upholding professional standards and ethical principles is essential for providing safe and effective care.

Case Study 2: Nursing Considerations and Outcomes

In this case study, we will explore a scenario that highlights the ethical dilemmas nurses may encounter in their practice. Understanding the nursing considerations and the ultimate outcome of such situations is crucial for nursing professionals to deliver effective care.

The case study involves a nurse working in an emergency department. A patient arrives with severe injuries from a car accident and requires immediate attention. However, the patient’s family insists on delaying treatment until their religious leader arrives to perform a prayer for healing. The nurse finds herself facing a dilemma, torn between respecting the patient’s religious beliefs and providing timely medical intervention.

Nurses encounter complex situations where they must balance patient autonomy, cultural beliefs, and the urgency of medical intervention. In this case, the nurse should consider the following factors:

1. Respect for patient autonomy: Nurses must respect the patient’s right to make decisions about their own healthcare. This includes considering their religious beliefs and practices.

2. Cultural competence: Being culturally competent allows nurses to understand and appreciate diverse cultural perspectives. It enables effective communication, builds trust, and promotes collaborative decision-making.

3. Ethical principles: Nurses should apply ethical principles such as beneficence (doing good), non-maleficence (avoiding harm), and justice (fairness) when making decisions. Balancing these principles can be challenging but is essential for providing quality care.

4. Collaboration with interdisciplinary team members: Consulting with other healthcare professionals, such as chaplains, social workers, or ethicists, can help nurses navigate complex situations and find appropriate solutions.

5. Legal considerations: Familiarity with local laws and regulations related to patient rights, informed consent, and religious accommodations is crucial in making informed decisions.

In this case study, the nurse engaged in open communication with the patient’s family, acknowledging their religious beliefs and concerns. She consulted with the healthcare team and the patient’s attending physician to address the situation effectively.

Ultimately, a compromise was reached where the nurse arranged for a chaplain to be present during the medical intervention. This approach respected the patient’s religious beliefs while ensuring timely medical care. The family appreciated the nurse’s efforts to accommodate their needs while prioritizing the patient’s well-being.

By approaching the situation with empathy, cultural competence, and collaboration, the nurse successfully navigated this ethical dilemma, demonstrating the importance of ethical decision-making in nursing practice.

For further reading on ethical dilemmas in nursing and strategies for resolution, you may find these resources helpful:

– American Nurses Association (ANA): https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/ – National Council of State Boards of Nursing (NCSBN): https://www.ncsbn.org/Professional_Standards_Doc.pdf

Remember, ethical dilemmas are complex and unique to each situation. Seeking guidance from ethics committees or experienced mentors can further enhance your decision-making skills as a nursing professional.

IV. Case Study 3: Nursing Considerations in Ethical Dilemmas

In this case study, we will explore a challenging ethical dilemma that nurses may encounter during their careers. The scenario involves a nurse working in a busy emergency department (ED) who is faced with a decision that raises ethical concerns.

The situation revolves around a patient who arrives at the ED in critical condition after sustaining severe injuries in a car accident. The patient requires immediate surgery to save their life. However, due to limited resources and a high patient load, the ED is struggling to provide timely care to all patients.

When confronted with an ethical dilemma like this, nurses must carefully consider several factors before making a decision. Some key considerations include:

1. Patient Advocacy: As patient advocates, nurses should prioritize the well-being and best interests of the patient. This involves ensuring the patient receives the necessary care in a timely manner, despite any resource constraints.

2. Ethical Principles: Nurses should apply ethical principles such as beneficence, non-maleficence, autonomy, and justice to guide their decision-making process. Balancing these principles can be challenging, especially when resources are limited.

3. Communication and Collaboration: Nurses should engage in open and honest communication with the healthcare team to discuss the ethical dilemma and potential solutions. Collaborative decision-making involving all relevant stakeholders can help find the best course of action.

4. Legal and Professional Guidelines: Nurses must adhere to legal and professional guidelines when faced with ethical dilemmas. Familiarity with the nursing code of ethics and local regulations can provide guidance in making difficult decisions.

5. Resource Allocation: Nurses need to consider the allocation of scarce resources fairly and equitably among patients. They should follow established protocols or guidelines in determining the priority of care based on the severity of patients’ conditions.

In this case study, the nurse collaborated with the healthcare team to address the ethical dilemma. The team recognized the critical condition of the patient and the urgency of surgical intervention. They worked together to reallocate resources, including personnel and equipment, to ensure the patient received prompt care.

Although challenging, the nurse’s commitment to patient advocacy and ethical decision-making led to a positive outcome. The patient underwent successful surgery and eventually made a full recovery.

It is important for nurses to remember that ethical dilemmas are inevitable in healthcare settings. By staying informed about ethical principles, legal guidelines, and professional standards, nurses can navigate these challenges with integrity and provide optimal care for their patients.

For more information on nursing ethics and professional development, please visit the following resources:

– American Nurses Association (ANA): https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/ – National Council of State Boards of Nursing (NCSBN): https://www.ncsbn.org/ethics.htm – International Council of Nurses (ICN): https://www.icn.ch/

Remember, ethical dilemmas require careful consideration and collaboration. By upholding professional standards and advocating for their patients, nurses play a crucial role in ensuring ethical decision-making in healthcare settings.

Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN) Programs  in

Common courses for lpn/lvn programs include:.

  • Fundamentals of Nursing
  • Anatomy and Physiology
  • Medical-Surgical Nursing
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Common courses for adn programs include:.

  • Foundations of Nursing Practice
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  • Nursing Leadership and Management

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Common courses for bsn programs include:.

  • Health Assessment and Promotion
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Common courses for absn programs include:.

  • Transition to Professional Nursing
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  • Open access
  • Published: 29 September 2021

Defining ethical challenge(s) in healthcare research: a rapid review

  • Guy Schofield   ORCID: orcid.org/0000-0002-9055-292X 1 , 3 ,
  • Mariana Dittborn   ORCID: orcid.org/0000-0003-2903-6480 2 ,
  • Lucy Ellen Selman   ORCID: orcid.org/0000-0001-5747-2699 3 &
  • Richard Huxtable   ORCID: orcid.org/0000-0002-5802-1870 1  

BMC Medical Ethics volume  22 , Article number:  135 ( 2021 ) Cite this article

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Despite its ubiquity in academic research, the phrase ‘ethical challenge(s)’ appears to lack an agreed definition. A lack of a definition risks introducing confusion or avoidable bias. Conceptual clarity is a key component of research, both theoretical and empirical. Using a rapid review methodology, we sought to review definitions of ‘ethical challenge(s)’ and closely related terms as used in current healthcare research literature.

Rapid review to identify peer-reviewed reports examining ‘ethical challenge(s)’ in any context, extracting data on definitions of ‘ethical challenge(s)’ in use, and synonymous use of closely related terms in the general manuscript text. Data were analysed using content analysis. Four databases (MEDLINE, Philosopher’s Index, EMBASE, CINAHL) were searched from April 2016 to April 2021.

393 records were screened, with 72 studies eligible and included: 53 empirical studies, 17 structured reviews and 2 review protocols. 12/72 (17%) contained an explicit definition of ‘ethical challenge(s), two of which were shared, resulting in 11 unique definitions. Within these 11 definitions, four approaches were identified: definition through concepts; reference to moral conflict, moral uncertainty or difficult choices; definition by participants; and challenges linked to emotional or moral distress. Each definition contained one or more of these approaches, but none contained all four. 68/72 (94%) included studies used terms closely related to synonymously refer to ‘ethical challenge(s)’ within their manuscript text, with 32 different terms identified and between one and eight different terms mentioned per study.

Conclusions

Only 12/72 studies contained an explicit definition of ‘ethical challenge(s)’, with significant variety in scope and complexity. This variation risks confusion and biasing data analysis and results, reducing confidence in research findings. Further work on establishing acceptable definitional content is needed to inform future bioethics research.

Peer Review reports

Methodological rigour within research is a cornerstone in the production of high-quality findings and recommendations. Across the range of empirical methodologies, a broad collection of protocol development tools, methodology guidelines, and reporting guidelines have been developed and evidence of their use is increasingly required by journals [ 1 , 2 , 3 , 4 , 5 , 6 ]. Within both empirical bioethics and descriptive ethics, there has been an accompanying increase in the acknowledgment of the importance of methodological rigour in the empirical elements, including within the recent consensus statement on quality standards in empirical bioethics research by Ives et al. [ 7 , 8 , 9 ]. Aligned with this aim for rigour, definitional clarity of key terms used within a research project is a component of research quality [ 10 , 11 ]. Improving the quality of empirical bioethics is also itself an ethical imperative [ 9 ].

We recently conducted a systematic review examining ‘ethical challenges’ as reported by specialist palliative care practitioners [ 12 ]. Our review, alongside our initial scoping search findings and reading of the literature, suggested that, although many authors use the term ‘ethical challenge(s)’ in empirical ethics research, there appeared to be no commonly described or accepted definition. Furthermore, papers retrieved rarely defined ‘ethical challenge(s)’ explicitly , which has also been noted by other researchers examining other topic areas [ 13 , 14 , 15 ]. Our review further suggested that authors frequently use terms closely related to ‘ethical challenge(s)’—such as ‘moral dilemmas’ or ‘ethical issues’—interchangeably with ‘ethical challenge(s)’ throughout manuscripts, rather than staying with the original term. Research shows that non-philosophers may understand these related terms in heterogeneous ways which may additionally affect understanding of texts across different readerships [ 16 , 17 ].

Without a clear definition of an ethical challenge, each researcher must use individual judgement to ascertain whether they have identified an instance of one within their dataset. This potentially generates an unnecessary source of bias, particularly if multiple researchers are involved in data collection, extraction, or analysis. This risks generating misleading ethical analyses, evaluations, or recommendations. Additionally, and more broadly, if primary studies do not define the term, then work based on these—such as systematic reviews of individual studies or those undertaking secondary data analysis—may unknowingly compare different phenomena without a mechanism for mitigating the effects this introduces.

In the hope of prompting a debate on this topic, we therefore undertook a rapid review, which aimed to explore existing definitions of “ethical challenge(s)” and the use of other closely related terms within recent empirical healthcare ethics literature.

We conducted a rapid review examining the usage of the term ‘ethical challenge(s)’ over the last 5 years in published research articles, in order to identify and summarise if, and how, the term was defined. As a secondary aim, we examined authors’ uses of closely related alternative terms within the included article texts separate to their use within any explicit definitions that may be present.

Rapid reviews use abridged systematic review methodology to understand the evidence base on a particular topic in a time and resource efficient manner [ 18 , 19 , 20 , 21 , 22 ]. Comparative reviews of topics in which both a rapid review and a systematic review had been undertaken demonstrated that the overall conclusions were similar, although rapid reviews were less likely to contain social and economic data, and systematic reviews contained more detailed recommendations [ 18 , 19 , 20 , 23 , 24 ]. The Cochrane Rapid Review Methods Group has recently released interim methodological guidelines for undertaking rapid reviews [ 6 ], advising authors to describe where their protocol deviates from a systematic review and detail any biases that these deviations may introduce [ 18 , 19 , 21 ]. We have followed the Cochrane recommended methodology [ 6 ]. A rapid review reporting guideline is currently under development [ 25 ] and this review is therefore reported based on the PRISMA 2020 statement for systematic reviews, with justifications provided where our approach deviated [ 26 ].

Prospective review protocol registration on the PROSPERO database is the current gold standard, but, at the time of writing, PROSPERO does not accept records for rapid reviews [ 27 ]. The protocol was therefore not published in advance.

Eligibility criteria

The inclusion and exclusion criteria are summarised in Table 1 . We used Strech et al.’s Methodology, Issues, Participants (MIP) structure for our eligibility criteria, which is recommended for systematic reviews in ‘empirical bioethics’ [ 28 ]. The criteria reflect three assumptions. First, that the inclusion of ‘ethical challenge(s)’ in the title would increase the likelihood that this was the authors’ preferred term for the concept under investigation, and therefore increase the probability of a definition being provided. Second, that studies aiming to describe empirical data and identify ethical challenges in real-world contexts are most likely to contain a definition to guide researchers in identifying these challenges as they collect and analyse data. Third, that structured reviews of studies of ethical challenges are likely to include a definition to allow researchers to reliably recognise an ethical challenge in retrieved records. We used a 5-year timeframe as a date restriction. This reflected a balance between adequately covering recent use of the term and time and resource restrictions of the rapid review.

Information sources

The search strategy was as follows:

‘ethical challenge’.ti OR ‘ethical challenges’.ti.

We searched Medline (Ovid interface), Philosopher’s Index (OVID interface), EMBASE (OVID interface), and CINAHL (Cumulative Index to Nursing and Allied Health Literature, EBSCO interface) for studies indexed over a five-year period between April 2016 and April 2021. These resources cover the breadth of healthcare research. Including Philosopher’s Index increased coverage of the bioethics literature. We did not search the grey literature [ 6 ]. The search strategy was tested by successfully retrieving three sentinel studies known to the research team.

Study selection

Retrieved studies were imported into Endnote X9.2 [ 29 ]. Records unavailable through institutional subscriptions were requested from corresponding authors. If unavailable 14 days after the request, the record was excluded. A random sample of 20% of records were dual screened at the title/abstract level by GS/MD. After discussion, the remainder were screened by GS. At full-text screening, a further 20% were dual screened by GS/MD and, again after discussion, the remaining studies were screened by GS.

Data extraction and analysis

Data extraction was undertaken using a pre-piloted form, with the first 5 records dually extracted by GS and MD. Data from the remaining included studies was then extracted by GS, with correctness and completeness checked by MD. We collected data on date of publication, authors, journal, country (for primary studies), methodology, definition of ‘ethical challenge(s)’ (present (yes/no)) and (where offered) the definition provided, and any closely related terms used, with counts of all terms used in each article. For closely related terms, data was extracted from the authors’ text, but not from direct quotations from qualitative research. Where definitions of ‘ethical challenge(s)’ were offered and/or related terms were identified, these were categorised and counted following the principles of summative content analysis [ 30 ]. Summative content analysis combines both the quantitative counting of specific content or words/terms with latent content analysis to identify and categorise their meanings. We identified keywords (‘ethical challenge(s)’ and closely related terms) deployed by the authors of the included papers, both prior to and during data analysis, and analysed the retrieved definitions. This approach allowed for exploration of both the content of definitions and development of insights into the use of related terms.

Risk of bias assessment

The focus of the rapid review was the definition of the term ‘ethical challenge(s)’ within retrieved records. We therefore did not undertake quality assessment for the included studies and reviews.

831 records were retrieved, reduced to 393 after de-duplication. 238 records were excluded after reviewing the title and/or abstract. 157 records were identified for full text screening, with 3 unavailable [ 31 , 32 , 33 ]. 82 records were excluded at full text stage and 72 records were included for analysis. See Fig.  1 for the PRISMA flowchart.

figure 1

PRISMA flow diagram of record identification

Record characteristics

Of the 72 included records, 53 were empirical studies [ 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 ], 10 non-systematic reviews [ 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 ], 7 systematic reviews [ 12 , 13 , 14 , 97 , 98 , 99 , 100 ], 1 systematic review protocol [ 101 ], and 1 non-systematic review protocol [ 102 ]. Of the 53 empirical studies, 42 (79%) were qualitative studies [ 34 , 35 , 36 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 47 , 48 , 50 , 51 , 52 , 54 , 55 , 56 , 57 , 58 , 60 , 62 , 63 , 64 , 65 , 66 , 67 , 69 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 79 , 80 , 81 , 83 , 84 , 85 , 86 ], 6 (12%) used a mixed methods approach [ 45 , 46 , 53 , 59 , 61 , 68 ], and 5 (10%) were quantitative [ 37 , 49 , 70 , 78 , 82 ]. 7/56 empirical studies, all qualitative interview studies, recruited participants internationally with no specific location stated [ 40 , 54 , 55 , 58 , 60 , 63 , 73 ]. Of the remaining studies, all but one were single-country studies: Botswana [ 75 ], Canada [ 41 , 65 ], China [ 57 ], Denmark [ 39 , 43 ], Dominican Republic [ 44 ], Germany [ 51 , 84 ], India [ 61 ], Iran [ 38 , 46 , 49 , 68 , 70 , 71 , 72 , 78 , 82 , 98 ], Italy [ 45 ], Mexico [ 87 ], the Netherlands [ 76 ], New Zealand [ 47 ], Norway [ 42 , 52 , 56 , 64 , 80 , 81 , 83 ], Saudi Arabia [ 34 , 35 , 36 , 37 ], Tanzania [ 69 , 74 ], Uganda [ 67 ], UK [ 86 ], and USA [ 50 , 53 , 59 , 62 , 66 , 77 , 79 , 85 , 85 ]. The remaining study was undertaken in both Sierra Leone and the UK [ 48 ]. See Table 2 for a summary.

12/72 (17%) of retrieved studies offered an explicit definition for ‘ethical challenge(s)’ [ 12 , 13 , 14 , 48 , 50 , 56 , 57 , 66 , 69 , 81 , 98 , 101 ]. Definitions were more likely to be found in more recent publications, with 4/12 included studies published in 2016–2018 [ 14 , 48 , 56 , 81 ], and 8/12 published in 2019–2021 [ 12 , 13 , 50 , 57 , 66 , 69 , 98 , 101 ]. The included study locations were evenly distributed, matching the overall pattern of retrieved studies, with studies from high- [ 48 , 50 , 56 , 66 , 81 ], middle- [ 57 , 98 ], and low-income settings [ 48 , 69 ]. The identified studies included eight qualitative studies [ 48 , 50 , 56 , 57 , 66 , 69 , 81 , 98 ], 3 systematic reviews [ 12 , 13 , 14 ], and 1 systematic review protocol [ 101 ]. Two of these records were the systematic review protocol and the report from our group, which accordingly contained the same definition [ 12 , 101 ], leaving 11 unique definitions. Definitions of ‘ethical challenge(s)’ identified in included studies are provided in Table 3 . Additionally, 68/72 (94%) reports used closely related terms synonymously in place of ‘ethical challenge(s)’ throughout their manuscript text, with between 1 and 8 different terms used within each report, and 32 different terms were identified. This occurred in both those reports that contained a definition and those that did not. See Table 4 for terms and frequencies.

Those records that offered explicit definitions used four approaches: (1) definition through concepts [ 12 , 57 , 66 ]; (2) reference to moral conflict, moral uncertainty or difficult choices [ 13 , 14 , 48 , 57 , 69 , 98 ]; (3) definition by study participants [ 12 , 48 , 50 , 56 ]; or (4) challenges as linked to their ability to generate emotional or moral distress within healthcare practitioners [ 14 , 14 , 66 , 81 ]. Each definition was associated with one or more of the identified elements, although none covered all four approaches. We describe these approaches below.

Approach 1: definition through concepts

This approach involves primarily defining ‘ethical challenge(s)’ in terms of related concepts. All three definitions using this approach defined ‘ethical challenge(s)’ as a summative collection of related concepts, including ‘ethical dilemmas’, ‘moral dilemmas’, ‘moral challenges’, ‘ethical issues’, and ‘ethical conflicts’ [ 12 , 57 , 66 ], for example:

‘The expression “ethical challenges” mainly refers to ethical dilemmas and ethical conflicts as well as other scenarios where difficult choices have to be made’ [ 57 ] p34

Only one went on to define the other concepts they utilised, ‘ethical dilemmas’ and ‘ethical conflicts’:

‘Ethical dilemmas are described as situations that cannot be solved; decisions made between two options may be morally plausible but are equally problematic due to the circumstances. Ethical conflicts, on the contrary, arise when one is aware of the necessity of proper actions but he or she may have trouble exercising these actions because of certain internal or external factors.’ [ 57 ] p34

Approach 2: moral conflict, moral uncertainty or difficult choices

This approach anchors an ethical challenge to the requirement for an agent to make a (difficult) choice in a situation where moral principles conflict, or there is moral uncertainty as to the ‘right’ way forward.

‘In this context, ethical challenge refers to the situation whereby every alternative is morally wrong and still one has to make a choice’ [ 69 ] p676 ‘An ethical challenge occurs when one does not know how to behave and act in the best way…’ [ 14 ] p93

Approach 3: definition by study participants

Four of the definitions involved research participants themselves defining something as an ‘ethical challenge’ [ 12 , 48 , 50 , 56 ], with three studies explicitly stating that participants would lead this definitional work [ 48 , 50 , 56 ]. Draper & Jenkins offer a starting definition, adopted from Schwartz et al. [ 103 ] with which to prime participants, while Forbes and Phillips [ 50 ] and Jakobsen and Sørlie [ 56 ] left the definition fully with their participants (Table 3 ). Finally, Schofield et al. proposed a very broad definition (Table 3 ), alongside the specific statement that either participants or researchers could nominate something as an ‘ethical challenge’ [ 12 ].

Approach 4: emotional or moral distress

This final approach was to tie ethical challenges to situations where participants feel ‘discomfort’, emotional distress or more specifically moral distress or moral residue [ 14 , 66 , 81 ]. Larkin et al. are clear that this distress must be tied to moral causes, but Hem et al. and Storaker et al. also refer more broadly to ‘discomfort’ [ 14 ] and ‘emotional stress’ [ 81 ] respectively. For example:

‘In this article, ethical challenges refer to values that entail emotional and moral stress in healthcare personnel.’ [ 81 ] p557

To the authors’ knowledge, this is the first rapid review to examine the use of the term ‘ethical challenge(s)’ in empirical healthcare research literature. Notably, only 12/72 (17%) of included studies published in the last 5 years contained a definition for ‘ethical challenge(s)’, despite this being the focus of the research being reported. The definitions identified were found in qualitative studies and systematic reviews and were evenly distributed geographically across high-, middle- and low-income settings. Definitions contained one or more of the identified approaches, although none contained elements from all four. Taken together, these findings suggest that a clear definition of ‘ethical challenge(s)’, and consistent use thereof, is currently lacking.

The four approaches indicate the diverse approaches to understanding ‘ethical challenge(s)’. Approaches 1 and 2 explore the concept from opposite viewpoints, with approach 1 looking from the conceptual perspective, through terms such as ‘dilemmas’ and ‘conflict’, and approach 2 from a participant perspective, specifically in those situations in which someone is trying to make a decision in circumstances where the preferred option is not possible or when they perceive there to be clash in values they feel are important. Within the concept-led definitions (approach 1), the use of a plurality of terms highlights a potential risk of bias, as different readers may interpret these differently. For example, some terms, such as ‘moral dilemma’, have relatively well understood specific meanings for some readers, particularly those with philosophical training [ 104 , 105 , 106 ]. The presence in the literature of specific and multiple meanings for some related terms highlights the importance of empirical studies providing a definition of these additional terms alongside their primary definition for ‘ethical challenge(s)’. This is more likely to be relevant where an a priori definition is used, but may be relevant to any prompting text for studies using a participant-led process, as in the study by Draper and Jenkins [ 48 ]. This clarity is important for both readers and future researchers who may undertake a secondary analysis of the data.

Approach 3 involves facilitating participants to nominate something as an ethical challenge [ 12 , 48 , 50 , 56 ]. This speaks to an important question about who, in a research context, is permitted to define or describe the object of interest, in this case ‘ethical challenge(s)’. Restricting the identification of ‘ethical challenge(s)’ to researchers alone may introduce bias by excluding input from those without bioethical ‘expertise’, but with important lived experience of the context under investigation. There is evidence that although clinicians can be sensitive to major ethical dilemmas, they can be less sensitive to small everyday ethical elements in clinical practice, and that ethical awareness varies between individuals [ 107 , 108 ]. Additionally, there is evidence in healthcare ethics research that patients and carers identify ethical challenges in situations that healthcare workers do not [ 109 ]. Therefore, relying entirely on a particular stakeholders’ perspectives (such as clinicians’) may risk missing important ethical challenges present in a scenario (assuming, of course, that we can settle what counts as an ‘ethical challenge(s)’).

In Approach 4, ethical challenges were linked to situations in which participants felt discomfort [ 14 ], emotional stress [ 81 ], moral distress or moral residue [ 66 ]. These concepts are themselves defined in quite varied ways (see, for example, definitions of ‘moral distress’ in a systematic review by Morley et al. [ 110 ]), potentially leading to additional conceptual confusion. Identifying triggers for moral distress is important, as high levels of moral distress are known to have negative impacts on work environments and lead to increased levels of compassion fatigue, increased staff turnover rates and poorer patient outcomes [ 110 , 111 , 112 ]. However, it is also possible that the requirement that, to be identified as an ethical challenge, the situation must invoke stress or distress might result in the under-identification of ethical challenges. We anticipate that many practitioners will daily manage multiple low-level ethical challenges, many of which will not generate moral distress or leave a moral residue. As such, the presence of moral distress may not be sufficient or even necessary in order to label a moral event an ‘ethical challenge’. However, the relationship between ‘ethical challenge(s)’ and moral distress is complex, and some might argue that the latter has an important relationship to the former. For example, moral distress, as conceived by Jameton and others [ 110 , 113 , 114 ], is linked to the after-effects of having to handle ethical challenge(s), so some researchers might view the generation of moral distress as relevant to identifying ethical challenges.

Although our review revealed these four approaches, the wider literature indicates there may be alternative approaches available. For example, other potential approaches would define ethical challenges as events that interact with moral principles, such as autonomy, beneficence, non-maleficence or justice, as proposed by Beauchamp and Childress [ 115 ], or as events in which those principles clash, for example as used by Klingler et al. in their research focusing on ethical issues in health surveillance [ 116 ]. However, these approaches were not seen amongst our included papers.

Returning to our included papers, the high rates of use of closely related terms within included manuscript texts may add to difficulties in understanding the exact object of interest if these terms are being used as synonyms for ‘ethical challenge(s)’. This may be particularly the case if terms used include those such as ‘moral dilemma’, which (as shown above) will have specific meanings for some readers. Interchangeable, undefined usage of these terms by study authors within study texts risks further exacerbating the problems caused by a lack of definitional clarity.

Strengths and limitations

This rapid review is the first systematic attempt to describe the definitions of ‘ethical challenge(s)’ available within the recent published literature.

There are, however, five limitations to note. First, the review only includes results from the past 5 years, which inevitably means that older publications, which may have contained further definitions of ‘ethical challenge(s)’, were excluded. The focus on the previous 5 years does, however, allow for an assessment of the term’s use(s) within a reasonable period of time and was felt to be appropriate given the aims and resources available to this project.

Second, our three assumptions listed in the methodology section may have excluded some records that contained a relevant definition. However, these assumptions, and the resulting focus on two search terms, allowed for a balance between retrieved record numbers and team resources.

Third, the four databases searched were chosen for their focus on the healthcare ethics literature; we may therefore may have missed relevant usage in other fields or disciplines. Similarly, we did not search the grey literature, which might have excluded relevant research.

Fourth, for resource reasons, the assessment as to whether a related term was being used interchangeably in the text was undertaken by a single researcher (GS). This subjective assessment risks miscalculating both the number of interchangeable terms identified and the frequency counts.

Finally, we did not review the theoretical literature for conceptual definitions of ‘ethical challenge(s)’, hence the definitions we identified might not match completely conceptual understandings of the term. However, our review shows how the term is currently being used in the research literature. Indeed, if there are strong conceptual definitions within the theoretical literature, then it is clear that they are currently not reaching the researchers whose work was identified by our review.

This review is the first, to our knowledge, to identify and describe definitions (and uses) of the widely-utilised concept of ‘ethical challenge(s)’ within healthcare research. Only 17% (12/72) of retrieved papers presented an explicit definition of ‘ethical challenge(s)’ before beginning to investigate this concept in context. The definitions found contained one or more of four identified approaches, with significant cross-reference to related terms and concepts which themselves have variation in their accepted meanings. We recommend that researchers define the phenomenon of interest—in this case, ‘ethical challenge(s)’—to help ensure clarity. This should either be a priori, or, if using an approach that includes participant participation in the generation of the definition, reporting their final working definition a posteriori. The choice of definition should be justified, including the decision as to whether to include participants in this process. Additionally, if a definition references other conceptual terms, then consideration should be given to defining these as well.

The results of this rapid review suggest that a common conceptual understanding of the term ‘ethical challenge(s)’ is lacking within empirical bioethical research and that there is a need for researchers in this area to consider what conceptual formulations might be most useful. Again, failure to use definitions of crucial research concepts within empirical bioethics research potentially generates confusion and avoidable bias within research outputs, risking misleading ethical analyses, evaluations, and resulting recommendations. We therefore hope this review will help stimulate debate amongst empirical bioethics researchers on possible definitional content for such a commonly used term and prompt further discussion and research. Additionally, given the central role of patient and public partnership and involvement in research, further thought should be given to who should be involved in nominating something as a challenge worthy of study.

Following on from this work, there would be value in conducting an empirical bioethical project combining a full systematic review of definitions of ‘ethical challenge(s)’ (and related terms) integrated with an exploration of the conceptual literature to generate recommendations for approaches towards the content of potential definitions, perhaps related to the identified approaches above. Such a project could also ask authors who currently use the term ‘ethical challenge(s)’ in their research how they conceptualise this. Furthermore, work to better understand the benefits of including study participants in the definition process is also important. Finally, whilst researchers should justify whatever approach they choose to take, there may be merit in examining whether anything is lost if studies lack a robust or agreed definition, or whether doing so affords a flexibility and openness that allows for a broader range of ethical challenges to be identified.

Availability of data and materials

All data is presented in this manuscript.

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GS is supported by a Wellcome Trust Research Award for Health Professionals (208129/Z/17/Z). LES is funded by a Career Development Fellowship from the National Institute for Health Research. RH is part-funded by the Wellcome Trust (209841/Z/17/Z) and the NIHR Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol. He serves on various local, regional, and national ethics committees and related groups. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research, the Department of Health, or any of the other organisations with and for whom the authors work.

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Schofield, G., Dittborn, M., Selman, L.E. et al. Defining ethical challenge(s) in healthcare research: a rapid review. BMC Med Ethics 22 , 135 (2021). https://doi.org/10.1186/s12910-021-00700-9

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case study with ethical dilemma in healthcare

case study with ethical dilemma in healthcare

Health Management, Ethics and Research Module: 8.  Ethical Dilemmas in Health Service Delivery

Study session 8  ethical dilemmas in health service delivery, introduction.

In Study Session 7 of this Module you learnt about some of the basic concepts and principles of healthcare ethics that you will meet in your work with individuals, groups and communities. In this study session you are going to learn more about some of the ethical dilemmas that you may well face in your day-to-day activities while providing healthcare services as a Health Extension Practitioner.

This study session will also help you to identify some of the common ethical conflicts that may arise in your day-to-day practice and hopefully learn how to resolve them. You will be able to learn additional useful ethical theories and a specific method of decision making that should help you resolve ethical problems that arise in your work.

Learning Outcomes for Study Session 8

When you have studied this session, you should be able to:

8.1  Define and use correctly all of the key words printed in bold . (SAQ 8.1)

8.2  Identify the ethical dilemmas that exist in a case study presented to you. (SAQs 8.2, 8.3 and 8.4)

8.3  Describe two theories that can help you resolve ethical dilemmas that may arise in your health work. (SAQ 8.3)

8.4  Understand a decision making process that may be able to help you to resolve ethical conflicts. (SAQ 8.4)

8.1  Ethical dilemmas and conflicts

In the previous study session you learnt about some of the core ethical concepts. You will remember that these are autonomy, beneficence, nonmaleficence and justice. In this section you will study more about ethical dilemmas, sometimes called ethical conflicts.

Ethical dilemmas arise when a difficult problem cannot be solved in a way that will satisfy everyone who is involved. The same dilemma might occur when a situation arises that involves a choice between equally unsatisfactory alternatives.

In ethical conflicts, the decision maker is confronted with more than one course of action that respects personal, professional and societal morality, but by deciding on one course of action the other course is harmed in some way. For example, as a Health Extension Practitioner you may face confidentiality conflicts. You are morally and legally obliged to keep patient information confidential; at the same time, you may be required to disclose sensitive information because breaking the rules of confidentiality would benefit the family or the wider community. You will be able to understand the subject better when you go through each of the following common ethical issues listed in Box 8.1. For each of these issues you will be presented with a case study to think about.

Box 8.1  Common ethical issues

  • Practitioner–client relationship.
  • Privacy and confidentiality.
  • Shared decision making.
  • Allocation of scarce resources.
  • Stigma and illness.
  • Reproductive health care.

8.2  Practitioner–client relationship

In the previous study session you learnt about the core ethical concepts of autonomy, beneficence, nonmaleficence and justice. These basic principles should always form the basis for your working relationships. In addition to the above principles there are issues like confidentiality, privacy and trust that you also have to think about at all times.

The following case study will help you to explore some ethical conflicts and ways it might be possible to resolve these conflicts.

Case Study 8.1  Difficult patients

Lemlem, a Health Extension Practitioner at Laelay Michew kebele , Central Zone, Tigray Regional State, is approached by Hailemariam, the son of Ato Gebregziabher, a well known Gena player in his locality. Hailemariam asks Lemlem to provide him with some paracetamol tablets because of pain in his knees. In fact Hailemariam doesn’t have any pain, but he is trying to accumulate enough tablets to commit suicide. He has also bought additional tablets at a market and asked another Health Extension Practitioner for even more tablets. Sometime later Hailemariam swallowed all the tablets at one time and for a while he was very ill, near to death. Hailemariam didn’t die and when he recovered he didn’t want others in the community to discover that he had attempted suicide. He began to spread rumours that Lemlem, the Health Extension Practitioner, was incompetent and had prescribed medication that she does not know how to use and that she had harmed him.

Although this is quite a complicated situation, and hopefully you will never be faced with such a difficult case, people in the community may make false accusations against you. For poor Lemlem the dilemma is something like this: she has done nothing wrong at all. She has prescribed some painkilling tablets with the best of intentions when Hailemariam pretended to have some pains. It is Hailemariam who has deceived her, but then gone on to accuse her, falsely, of being an incompetent practitioner. If she does not defend herself then her position in the community may be damaged. People might believe Hailemariam and start to think that she is not very good at her job. But how can she defend herself while still being professional and ethical in relation to her relationship with her patient Hailemariam?

Can Lemlem’s ethical principles help her in this situation? Perhaps there are principles of justice involved? Lemlem is certainly in the right and should have the opportunity to defend herself against these charges. But defending herself might harm her patient. If she successfully wins her struggle against Hailemariam he might lose face in the community and feel that he has to try to commit suicide again. He does sound as though he is very troubled. He has deep psychological problems and has already tried to kill himself - and now he’s making trouble for Lemlem. Lemlem doesn’t want to harm him (nonmaleficence), but she also feels that she should keep her job and continue to help lots of people in the community (beneficence).

Which of the following actions do you think that it would be ethical and appropriate for Health Extension Practitioner Lemlem to do? Explain your reasons.

  • a. Nothing, but let the accusations pass without further comment.
  • b. Attack Hailemariam publicly and make sure that everyone knows about his psychological troubles.
  • c. Ask for help from an experienced healthworker at the hospital or health centre.

It would be a really good idea for Health Extension Practitioner Lemlem to get some help from an experienced practitioner. They will be able to help clarify her ideas and support her in any action she takes in the future to clear her name. If she responds to her patient in any public way then this could be considered to be a breach of confidentiality and may bring about a complaint against her that would be hard to defend.

8.3  Privacy and confidentiality

The professional relationship between a Health Extension Practitioner and a client in a rural community is frequently long-term, and may involve the wider families and mutual friends. This closeness may well affect professional responsibilities (Figure 8.1). In this section you will study the ethical conflicts involving privacy and confidentiality in rural healthcare relationships. Confidentiality may involve more complex issues in rural rather than urban settings. People who live in rural areas may well know many of the details of each other’s lives and this intimacy makes ethical conflicts related to privacy and confidentiality more challenging compared to urban settings.

case study with ethical dilemma in healthcare

Case Study 8.2  Confidentiality and trust

Ali has been a soldier for the last five years. He’s now returned to his rural village and started to help his father on their farm. He’s a strong and handsome man and soon starts to see a new girlfriend Kedija. Ali comes to the Health Post and shows the Health Extension Practitioner, Workinesh, the results of his recent HIV test – which is positive. Workinesh also has information through her work that neither Kedija nor Ali have asked for, or been given any, condoms. What should Workinesh do?

Almost anything that Workinesh does actively will risk breaking confidentiality. But doing nothing will potentially harm one of her patients, Kedija. If she doesn’t warn Kedija that Ali is HIV positive then Kedija might become infected and become seriously ill and even die (Figure 8.2). Several ethical principles are at stake here including trust, confidentiality and autonomy. Nobody can force Kedija or Ali to act in a particular way because they each have their own autonomy.

case study with ethical dilemma in healthcare

Which of the following actions do you think that it would be ethical and appropriate for the Health Extension Practitioner to do? Explain your reasons.

  • a. Do nothing and hope that her patient Kedija doesn’t get infected.
  • b. Make sure that Ali is aware of his responsibilities and also offer him condoms.
  • c. Go round to Kedija’s house and tell her that Ali is HIV positive and that she should use condoms.
  • d. Ask for help from an experienced healthworker at the hospital or Health Centre.

Although answer d. is appropriate in this case and Workinesh should always seek appropriate support and assistance in difficult matters, perhaps she can also use her ethical principles to help her decide what else to do. Answer a. is not appropriate ethically. This course of action risks harming her patient. If she does make sure that Ali is made aware of his responsibilities (answer b.), and that he will always use condoms in the future, then she has followed ethical principles and protected her patients to the best of her abilities. Answer c. is probably only possible ethically if she also does b. To tell Kedija the test results of her partner is not ethically acceptable unless this is cleared by the person who has been tested.

8.4  Shared decision making

The key feature of the shared decision making process is a dialogue in which both client and practitioner share information, leading to a decision regarding the client’s healthcare. Shared decision making is based on trust, truthfulness and respect for the client’s choice. For this to be effective, good communication skills are crucial. If some decisions have to be made, for example about transfer to a hospital for further treatment, the patient might be concerned about their own issues, such as their values, religious and cultural beliefs and finances (Figure 8.3). For the Health Extension Practitioner, the discussion should include the risks and benefits of being transferred for better treatment as well as the likely outcome of no treatment. How information is shared, and what information is shared, may influence the patient’s choice. At an ethical level, there is a tension between client autonomy, beneficence and confidentiality that may not be easily resolved. Ethical conflicts, especially involving family members, should be anticipated in shared decision making.

case study with ethical dilemma in healthcare

Case Study 8.3  Managing your own decisions

Tadelech is a member of your local community. She is usually a strong woman who is a good mother to her seven children and an active member of the community. Recently she has become seriously ill with a chest infection that has turned into pneumonia. Although the Health Extension Practitioner, Hadas, has tried to convince her that she needs to go to hospital, Tadelech is determined to stay in her own home.

Hadas is in a difficult position. Of course Tadelech should be able to decide about her own health and her own body – this is the basic ethical value of autonomy. But the healthworker knows that without proper treatment she might die and then all Tadelech’s children would suffer. Indeed the whole community would lose one of their important members.

Which of the following actions do you think that it would be ethical and appropriate for Hadas to do? Explain your reasons.

  • a. Do nothing and hope that Tadelech recovers from the pneumonia.
  • b. Force Tadelech to go to the hospital by carrying her there against her will.
  • c. Explain to Tadelech’s husband and parents about the serious nature of her chest infection and hope that they will be able to persuade her to take up the offer of hospital treatment.
  • d. Ask for help from an experienced healthworker at the hospital or health centre.

Answer d. will always be appropriate if you are having problems with an ethical dilemma. Seeking the advice of someone more senior or more experienced is almost always helpful. But before seeking advice, answer c. would be well worth trying. Doing extra tasks in order to try to save a life (beneficence) is an ethical principle that is always worth pursuing. Using force, as in answer b., is not correct. This would certainly be against the ethical principle of autonomy. However ill the person is, they still have rights to decide about their own issues.

8.5  Allocation of scarce resources

Health resources, such as financial or human resources, are always scarce whether you are working in developed or developing countries. Using resources to their best effect needs appropriate planning and allocation of resources to areas where they bring about the best outcomes. As a manager and healthcare provider in the Health Post you may be faced with a scarcity of resources (Figure 8.4) and need to make judgements to use your resources wisely so that you are able to satisfy the healthcare needs of the majority of your community (the principle of utility). As a manager and healthcare provider in your community, you may face ethical conflicts with regard to resource allocation.

Following some simple steps for decision making may help you resolve these difficulties (Box 8.2).

Box 8.2  Steps for decision making

  • Identify the nature of the problem.
  • Gather information and consider the possible ways to resolve the problem.
  • Communicate openly and honestly with the community served.
  • Involve an expert if possible.
  • Implement the decision.

case study with ethical dilemma in healthcare

Case Study 8.4  Deciding priorities

Imagine that you are a Health Extension Practitioner in a rural area and you are planning to conduct a vaccination campaign and also a malaria control campaign. Both are necessary to improve the health of your local community, but there are only limited human resources available and it is not possible to do both of these campaigns immediately.

In this situation you need to decide: should you continue with the malaria campaign or the vaccination campaign, or share your resources in some way between both campaigns? There may be ethical principles that you can use to help you make your decision. Both campaigns may be beneficial for members of the community (beneficence), and none of the decisions seem to involve potential breaches of confidentiality. You may need to gather more information about the situation in order to be helped to make the correct decision.

Box 8.2 sets out the steps that can be used in decision making over ethical issues. How might following these steps help you to make the best decision about how to proceed in Case Study 8.4?

Following these steps might give you additional information that will help you take the decision. For example, you might find out that doing both campaigns using reduced resources would make both campaigns ineffective. When you consult both the community and the expert it might become apparent that you should give priority to the malaria control campaign, because this disease cannot wait. If it is not controlled speedily it may kill, or make many people in the community ill within a short period of time. Vaccination of children, on the other hand, can be postponed for another time because if the children are not vaccinated right away this will not necessarily bring about a disastrous health outcome. Remember that there will always be other people who can help you make important decisions, including ethical problems. Often it will help you if you ask your community what they prefer when there are options.

8.6  Stigma and illness

As a Health Extension Practitioner, you will be working in the rural areas where 80–85% of the population of Ethiopia lives. The healthcare practice in rural areas is different from that of urban centres. The closeness you create with individuals, families and the community may make it difficult to decide about any ethical conflicts (dilemmas) that may occur in your day-to-day practice.

One of the serious ethical issues that you may encounter is stigma. Stigma is defined as a negative perception that is assigned to an individual because of any feature that, in the view of others, discredits and diminishes them from other people. The stigmatised person becomes a person who is discounted. In rural healthcare settings, stigma takes on special importance because of the close relationships that exist in small communities. To be viewed negatively by others, to be avoided, and to be seen as less than a full member of the community is a major burden for a person in a rural community.

Case Study 8.5  HIV and stigma

Jemila, a Health Extension Practitioner who is working at one of the Health Posts in Gambella Regional State, attends Ato Ojul’s family. When she visited Ato Ojul’s family she found that W/ro Hawa, the wife of Ato Ojul, is very depressed and tearful. Jemila tried to reassure her but Hawa was not willing to tell her the reason why she was depressed and crying. Later in the course of their discussion, Hawa told Jemila that she is HIV positive and that she is worried what will happen to her because of the stigmatising effect of HIV. If people in the wider community find out that she is HIV positive she fears that she will be an outcast and treated badly.

This is a complicated situation for Jemila to cope with, but there are some ethical principles that she can use to help her. Firstly, Hawa is her patient and must not be harmed by anything that Jemila does now or in the future. She must reassure Hawa about total confidentiality and establish a situation of trust between the two of them. Hawa’s status is safe with Jemila and she can get treatment for her HIV without anyone else being aware.

What steps could Jemila take to address a stigmatising illness such as the HIV that has infected Hawa?

In the short term it is important that trust is established and that Hawa knows that she can rely on Jemila to support her without her problem becoming widely known. In the longer term Jemila can put in place a series of community-based educational activities designed to reduce stigma about diseases such as HIV. When the correct facts about HIV are known by the community they should be able to accept Hawa and not fear or reject her.

8.7  Reproductive healthcare

One of the primary healthcare services that Health Extension Practitioners are expected to provide is reproductive healthcare. During this part of your work it is essential to develop trust with each individual and with the community as a whole. This service requires appropriate levels of care, confidentiality and truth-telling– possibly more than any other part of the health services. However, you may face conflicting situations and ethical issues that hinder you from providing appropriate reproductive healthcare services.

Case Study 8.6  Conflict in the family

Leila, a Health Extension Practitioner, works in a Health Post within the Southern Nations, Nationalities and People’s Region (SNNPR) and provides community health services including family planning support. One Friday she had made a visit to Ato Olano’s family to discuss family planning issues with Ato Olano’s wife, W/ro Abebech. When she finished her discussion, Ato Olano’s oldest daughter, Bekelech (aged 15), came over to Leila and talked about something that was obviously worrying her. She confided in Leila that she has started a loving relationship with Wajo, a student, over the last six months. She says that she really likes him a lot. However she has not started sexual relations, but she has been thinking about it. She is wondering if she could start taking birth control pills. Bekelech also explained that her parents do not know anything about this relationship. She says her mother would be very upset if she knew about it, and asked that this information should not be told to her parents. At the doorway on the way out Abebech and Olano ask Leila what their daughter has been talking about with her.

Although this is a potentially difficult situation for Leila to deal with, this is a common problem and Leila will be able to use some ethical principles to work out the way that she should act in these circumstances. There is definitely a conflict of ethical principles involved in this situation. Ato Olano and his wife Abebech need to be sure that Leila, their healthcare worker, will always tell the truth. Truthfulness is a very important part of all health work. However, Bekelech has been discussing issues that she wants to keep secret from her parents who might be angry. Confidentiality should be expected of all health workers. If Leila tells Bekelech’s parents about the content of the discussion then this is a clear breach of confidentiality whatever the age of the client. Bekelech is exhibiting her own autonomy that is separate from that of her parents.

In this situation how should Leila react? Explain your reasons.

  • a. Say nothing and just walk past Bekelech’s parents at the door.
  • b. Tell the parents the truth about the discussions she has been having with their daughter.
  • c. Tell the parents that they will have to find out what the conversation has been about from their daughter themselves.
  • d. Tell the parents that their daughter was worried about some spots on her face or some other common problem to avoid telling them the truth.

Each Health Extension Practitioner will find ways for themselves of dealing with difficult situations. Some people may think that d. is an acceptable solution because they feel that telling a lie (about the spots) will cause less damage for Bekelech than telling the truth in this situation. Solution a. is almost certainly going to lose Leila her good reputation as an approachable healthworker, while b. involves a breakdown in trust between her and her patient, Bekelech. If Leila tells the parents that they will have to find out the subject of the discussion from their own daughter (answer c.), this accepts the autonomy of the daughter herself. Bekelech will be put in a situation of having to decide for herself whether to tell her own parents what she has been thinking about and the reality of her relationship with Wajo. In an ideal world, of course, the parents would come to accept that asking advice about family planning has been a responsible thing for Bekelech to do and support her decision to ask before starting a sexual relationship.

Summary of Study Session 8

In Study Session 8, you have learned that:

  • Healthworkers will be faced with difficult decisions during their working lives. Some of these will involve ethical dilemmas or conflicts.
  • Using ethical principles may help to resolve some of the complex problems that may occur during your work.
  • Confidentiality, privacy and trust are issues that all healthworkers should strive to maintain at all times.
  • There are some areas of responsibility in healthworkers’ lives that are more likely to cause ethical dilemmas than other parts of their work.
  • Asking for help when difficult ethical matters arise is almost always a good idea.

Self-Assessment Questions (SAQs) for Study Session 8

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the following questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

SAQ 8.1 (tests Learning Outcome 8.1)

Can you give an example of a stigma that can be caused by a medical condition? How might stigma be avoided?

There are lots of examples of stigma following medical conditions that you could have chosen. Often people with infectious diseases, such as HIV or AIDS, are stigmatised because of their medical condition. Stigma can be reduced or avoided if proper education is given to the community. If they understand about an infection such as HIV then there is no reason why a person with HIV should be stigmatised.

Read Case Study 8.7 and answer the questions that follow.

Case Study 8.7  Ethical dilemmas

Amarech is providing antenatal care for W/ro Alemach, wife of Ato Feleke. Alemach is 26 weeks pregnant. This is her third pregnancy and the previous two deliveries were safe. When W/ro Alemach comes to the Health Post for her appointment, she complains of a burning sensation during urination and a yellowish discharge from her birth canal. Amarech has told W/ro Alemach that this is almost certainly caused by an infection acquired by sexual intercourse. She asks W/ro Alemach to tell the truth if she has had extra-marital sex because this might be the source of infection and the cause of her symptoms. W/ro Alemach eventually admits that she has had an affair with Ato Tadesse, a well-known community member, who is the likely source of the infection. Her husband does not know about the extra-marital relationship and she does not want him to know. She is certain her husband is the father of the child she is carrying. She asks Amarech to provide treatment for her infection and not to tell her husband about her situation.

SAQ 8.2 (tests Learning Outcome 8.2)

What is an ethical dilemma or ethical conflict? Identify the main ethical dilemmas and conflicts in Case Study 8.7.

From Case Study 8.7 you can extract a number of ethical issues or conflicts. Amarech has the responsibility to keep W/ro Alemach’s medical secret. Confidentiality is the core ethical principle in this case study. If Amarech tells Ato Feleke about his wife’s infection, W/ro Alemach may end up being divorced. The principle of nonmaleficence would be violated. If Amarech keeps the secret there is a probability of transmitting the infection to Ato Feleke and the principles of beneficence and nomaleficence would be violated. The best solution to those conflicting issues is to encourage Alemach to tell her husband herself. This would involve the principle of a utonomy .

SAQ 8.3 (tests Learning Outcomes 8.2 and 8.3)

Which ethical theories might be helpful to resolve the ethical dilemmas that you have identified in Case Study 8.7? Describe at least one theory that might be helpful.

There are several ethical theories that could be used to resolve the dilemmas that have been identified in Case Study 8.7. Confidentiality and truthfulness are at the centre of the case study, but autonomy, beneficence and nonmalefience may also be useful.

SAQ 8.4 (tests Learning Outcomes 8.2 and 8.4)

Describe how the decision-making steps found in Box 8.2 might help the resolution of the ethical conflicts that you have identified in Case Study 8.7.

The decision-making steps found in Box 8.2 might help the resolution of the ethical conflicts in Case Study 8.7 because a logical approach to sorting out the problems will help you think clearly about the problem and how to solve it.

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Case Study: An Ethical Dilemma

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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 lifethreatening 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.

Related Papers

Peter Odion Ubuane

The Jehovah’s Witnesses are a rapidly growing religious group in the Western world and in Nigeria with an estimated 7 million members worldwide in over 230 countries. Treatment generally regarded as unacceptable by Jehovah’s witnesses include transfusion of whole blood, packed red cells, white cells, plasma, platelets and preoperative autologous blood collection and storage for later reinfusion. When a patient refuses a treatment option and could die in a potentially treatable situation creates an ethical dilemma for the health care professional, as well as being a frustrating experience. The basic common law right of bodily self-determination establishes that every person of sound mind is master over his own body. Central to modern medical ethics is a respect for the patient’s autonomy and the fundamental principle of informed consent. While the Physician respects this, he also wants to abide with the principle of beneficence, non-maleficence and the principle of Justice. The children of Jehovah’s Witnesses requiring blood transfusion for Medical or Surgical emergencies present the most difficult management problem. A standard of care procedure should be designed to have a prompt response to patients requiring both emergency care and elective procedures. A clear organogram should be designed outlining clear steps to take, both legal and otherwise. The Ethics Committee of every hospital must formulate hospital policy concerning the Jehovah’s Witnesses and blood transfusion. This report examines two cases of Jehovah’s Witnesses minors whose parents refused a much needed blood transfusion for emergency procedures due to religious reasons.

case study with ethical dilemma in healthcare

Medical Education

Bernice S Elger

Pielegniarstwo XXI wieku / Nursing in the 21st Century

Beata Dobrowolska

Opinions of pediatric nurses about Jehovah’s Witnesses refusal of blood transfusion for their child Introduction. Jehovah’s Witnesses absolutely refuse having blood transfusion performed. The situation is even more difficult when the refusal of blood transfusion concerns a child. Despite existing legal solutions, medical staff experiences value conflicts. Aim. To analyze the opinions of pediatric nurses about problems that may arise in case of Jehovah’s Witnesses refusal of blood transfusion for their child. Material and methods. Quantitative research was based on a diagnostic survey method. The variables were measured with the use of a survey questionnaire co-developed by the authors. A group of 104 pediatric nurses from the South-East Poland participated in the study. Results. To the question “Have you ever encountered the situation throughout all your working career when parents refused their child to undergo a blood treatment due to their beliefs?”, 67.31% (n = 70) of the respon...

Journal of Medical Ethics

Osamu Muramoto

Orient Journal of Medicine

Cajetan Nwadinigwe

Background : Major surgical treatment in Jehovah’s Witnesses (JW) presents complex ethical and legal issues to the physician. The Jehovah’s Witness is willing to accept all medical treatment except blood transfusion; and so, the physician is often confronted with a difficult task especially in emergency settings and among minors. This paper looks at the ethical and legal aspects of this peculiar religious sect in relation to surgical treatment. It also provides guidelines for contemporary management of JW using transfusion avoidance strategies. Methodology : Medical literature on the subject was reviewed using manual library search, articles in journals and internet search. The search words were: Jehovah’s Witness + blood transfusion +legal and ethical issues. The search was done using Pubmed, Medline, Hinari and Medscape, as search engines. The search covered a period between 1940 and 2013. Results : Jehovah&#39;s witnesses do not argue that blood transfusions have not kept alive p...

John Moskop

Nursing Ethics

Marsha Fowler

Journal of Religion and Health

Marisa Cordella

University of San Fernando Valley College of Law Law Review

Barry D Silbermann

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Some virtual care companies putting patient data at risk, new study finds

Canadian researchers have patient privacy concerns as industry grows post-covid.

case study with ethical dilemma in healthcare

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This story is part of CBC Health's Second Opinion, a weekly analysis of health and medical science news emailed to subscribers on Saturday mornings. If you haven't subscribed yet, you can do that by  clicking here .

If you visit a doctor virtually through a commercial app, the information you submit in the app could be used to promote a particular drug or service, says the leader of a new Canadian study involving industry insiders.

The industry insiders "were concerned that care might not be designed to be the best care for patients, but rather might be designed to increase uptake of the drug or vaccine to meet the pharmaceutical company objectives," said Dr. Sheryl Spithoff, a physician and scientist at Women's College Hospital in Toronto.

Virtual care took off as a convenient way to access health care during the COVID-19 pandemic, allowing patients to consult with a doctor by videoconference, phone call or text.

It's estimated that more than one in five adults in Canada —  or 6.5 million people — don't have a family physician or nurse practitioner they can see regularly, and virtual care is helping to fill the void.

But the study's researchers and others who work in the medical field have raised concerns that some virtual care companies aren't adequately protecting patients' private health information from being used by drug companies and shared with third parties that want to market products and services.

A female doctor with long, brown hair standing in a medical office.

Spithoff co-authored the study in this week's BMJ Open , based on interviews with 18 individuals employed or affiliated with the Canadian virtual care industry between October 2021 and January 2022. The researchers also analyzed 31 privacy documents from the websites of more than a dozen companies.

The for-profit virtual care industry valued patient data and "appears to view data as a revenue stream," the researchers found.

One employee with a virtual care platform told the researchers that the platform, "at the behest of the pharmaceutical company, would conduct 'A/B testing' by putting out a new version of software to a percentage of patients to see if the new version improved uptake of the drug."

case study with ethical dilemma in healthcare

Many virtual care apps pushing products, selling personal data, research finds

Concerns about how data might be shared.

Matthew Herder, director of the Health Law Institute at Dalhousie University in Halifax, said he hopes the study draws the public's attention to what's behind some of these platforms.

"All of this is happening because of a business model that sees value in collecting that data and using it in a variety of ways that have little to do with patient care and more to do in building up the assets of that company," Herder said.

Bearded man standing in front of a chalkboard.

Other industry insiders were concerned about how data, such as browsing information, might be shared with third parties such as Google and Meta, the owner of Facebook, for marketing purposes, Spithoff said.

The study's authors said companies placed data in three categories:

  • Registration data, such as name, email address and date of birth.
  • User data, such as how, when and where you use the website, on what device and your internet protocol or IP address.
  • De-identified personal health information, such as removing the name and date of birth and modifying the postal code.

Some companies considered the first two categories as assets that could be monetized, employees told the researchers.

  • Many Canadians welcomed virtual health care. Where does it fit in the system now?
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Not all of the companies treated the third category the same way. Some used personal health information only for the primary purpose of a patient's virtual exchange with a physician, while others used it for commercial reasons, sharing analytics or de-identified information with third parties.

The study's authors said while each individual data point may not provide much information, advertisers and data analytic companies amalgamate data from browsing history and social media accounts to provide insights into an individual's mental health status, for example.

One study participant described how a partnership for targeted ads might work: "If an individual is coming through our service looking for mental health resources, how can we lean them into some of our partnerships with corporate counselling services?"

case study with ethical dilemma in healthcare

Nurses’ union says virtual care is a move toward privatization of health care

Conflict-of-interest questions.

Lorian Hardcastle, an associate professor of law and medicine at the University of Calgary, studied  uptake of virtual care in 2020. She highlighted issues of continuity of care, privacy legislation and consent policies.

Since then, she said, uptake in virtual care accelerated during the COVID-19 pandemic.

"I think that the commercialization of the health-care system raises concerns around conflicts of interest between what is best for patients on the one hand and then on the other hand, what has the best return for shareholders," said Hardcastle, who was not involved in the BMJ Open study.

A woman with long brown hair wearing a blouse and jacket.

Hardcastle said it is helpful to have industry insiders acknowledge problems that health professionals and academics have expressed about commercialization.

The Office of the Privacy Commissioner of Canada, which funded the study, said in an email that privately funded health professionals are generally considered to be conducting commercial activities.

Hospitals, long-term care facilities and home care services that are publicly funded are not considered to be engaged in commercial activities and are covered by provincial privacy legislation, the office said. Health information falls into many categories and may be subject to different privacy laws across various jurisdictions.

Hardcastle also suggested that self-regulatory bodies, such as provincial colleges of physicians and surgeons, may need to revisit policies around relationships between health providers and industry.

Virtual care industry responds

CBC News heard from some Canadian virtual care companies that said they take the privacy of individuals seriously.

"Patient data is only used with patients' explicit consent and only when it's required for health-care interactions between a patient and a doctor," a spokesperson for virtual care platform Maple said. "We do not exploit patient data for marketing or commercial gain."

  • Is virtual care a cure for Canada's battered health-care system?

In a statement, Rocket Doctor said it is important to note that the company "does not do any of the things listed by the researchers as common in the telehealth industry."

Telus said that all of the data collected from its virtual care service is treated as personal health information.

"Telus Health doesn't receive any funds from pharmaceutical companies for our virtual care service and we do not sell any patient data collected," said Pamela Snively, the company's chief data and trust officer.

Source of information hard to pin down

Hardcastle said it may be difficult for some people to distinguish between receiving reliable and accurate information from a health-care provider on an app and getting services marketed to them that the health provider may or may not find useful.

"Your family doctor isn't trying to collect superfluous information in order to market services to you," she said.

Some provinces and territories pay for the virtual services. In other cases, patients pay themselves or are covered by employer or private insurance.

  • Patients tapping into alternative care options, but N.S. emergency departments still face challenges

Nova Scotia's government, for example, has a contract with Maple to provide residents without a primary care provider with unlimited virtual visits. Those who do have a regular provider can have two visits per year paid for by the province.

Tara Sampalli, senior scientific director at Nova Scotia Health Innovation Hub, said the province's contract with Maple means residents' data can't be used in other ways, such as by third-party providers.

The province doesn't have that level of control over other providers of virtual care, said Sampalli, who holds a PhD in health informatics.

Calls for an opt-out choice

Herder, of Dalhousie University, said users should be able to easily opt out of having their data used for commercial purposes. He also said that if the data doesn't represent the full diversity of Canada, algorithms shaping clinical decision-making could be racially biased.

Spithoff said while patient awareness is important, patients aren't in a position to fix this problem.

  • 140,000 Nova Scotians are waiting for a family doctor. Can virtual care help?

"We need better legislation, regulation, and we need better funding for primary care," she said. "Or people can get virtual care integrated into their offline care."

Spithoff and her co-authors said self-regulation by the industry is unlikely to lead to change. 

The researchers acknowledged they were limited to publicly available documents and that they did not interview those affiliated with the third-party advertisers.

case study with ethical dilemma in healthcare

Canadian Medical Association calls for health-care system overhaul

Corrections.

  • An earlier version of this story suggested that all health professionals conduct commercial activities under federal legislation. In fact, some publicly funded health services are not commercial and are covered by various other legislation. Feb 12, 2024 6:11 PM ET

ABOUT THE AUTHOR

case study with ethical dilemma in healthcare

Amina Zafar covers medical sciences and health topics, including infectious diseases, for CBC News. She holds an undergraduate degree in environmental science and a master's in journalism.

With files from CBC's Christine Birak

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Reproductive rights in America

Research at the heart of a federal case against the abortion pill has been retracted.

Selena Simmons-Duffin

Selena Simmons-Duffin

case study with ethical dilemma in healthcare

The Supreme Court will hear the case against the abortion pill mifepristone on March 26. It's part of a two-drug regimen with misoprostol for abortions in the first 10 weeks of pregnancy. Anna Moneymaker/Getty Images hide caption

The Supreme Court will hear the case against the abortion pill mifepristone on March 26. It's part of a two-drug regimen with misoprostol for abortions in the first 10 weeks of pregnancy.

A scientific paper that raised concerns about the safety of the abortion pill mifepristone was retracted by its publisher this week. The study was cited three times by a federal judge who ruled against mifepristone last spring. That case, which could limit access to mifepristone throughout the country, will soon be heard in the Supreme Court.

The now retracted study used Medicaid claims data to track E.R. visits by patients in the month after having an abortion. The study found a much higher rate of complications than similar studies that have examined abortion safety.

Sage, the publisher of the journal, retracted the study on Monday along with two other papers, explaining in a statement that "expert reviewers found that the studies demonstrate a lack of scientific rigor that invalidates or renders unreliable the authors' conclusions."

It also noted that most of the authors on the paper worked for the Charlotte Lozier Institute, the research arm of anti-abortion lobbying group Susan B. Anthony Pro-Life America, and that one of the original peer reviewers had also worked for the Lozier Institute.

The Sage journal, Health Services Research and Managerial Epidemiology , published all three research articles, which are still available online along with the retraction notice. In an email to NPR, a spokesperson for Sage wrote that the process leading to the retractions "was thorough, fair, and careful."

The lead author on the paper, James Studnicki, fiercely defends his work. "Sage is targeting us because we have been successful for a long period of time," he says on a video posted online this week . He asserts that the retraction has "nothing to do with real science and has everything to do with a political assassination of science."

He says that because the study's findings have been cited in legal cases like the one challenging the abortion pill, "we have become visible – people are quoting us. And for that reason, we are dangerous, and for that reason, they want to cancel our work," Studnicki says in the video.

In an email to NPR, a spokesperson for the Charlotte Lozier Institute said that they "will be taking appropriate legal action."

Role in abortion pill legal case

Anti-abortion rights groups, including a group of doctors, sued the federal Food and Drug Administration in 2022 over the approval of mifepristone, which is part of a two-drug regimen used in most medication abortions. The pill has been on the market for over 20 years, and is used in more than half abortions nationally. The FDA stands by its research that finds adverse events from mifepristone are extremely rare.

Judge Matthew Kacsmaryk, the district court judge who initially ruled on the case, pointed to the now-retracted study to support the idea that the anti-abortion rights physicians suing the FDA had the right to do so. "The associations' members have standing because they allege adverse events from chemical abortion drugs can overwhelm the medical system and place 'enormous pressure and stress' on doctors during emergencies and complications," he wrote in his decision, citing Studnicki. He ruled that mifepristone should be pulled from the market nationwide, although his decision never took effect.

case study with ethical dilemma in healthcare

Matthew Kacsmaryk at his confirmation hearing for the federal bench in 2017. AP hide caption

Matthew Kacsmaryk at his confirmation hearing for the federal bench in 2017.

Kacsmaryk is a Trump appointee who was a vocal abortion opponent before becoming a federal judge.

"I don't think he would view the retraction as delegitimizing the research," says Mary Ziegler , a law professor and expert on the legal history of abortion at U.C. Davis. "There's been so much polarization about what the reality of abortion is on the right that I'm not sure how much a retraction would affect his reasoning."

Ziegler also doubts the retractions will alter much in the Supreme Court case, given its conservative majority. "We've already seen, when it comes to abortion, that the court has a propensity to look at the views of experts that support the results it wants," she says. The decision that overturned Roe v. Wade is an example, she says. "The majority [opinion] relied pretty much exclusively on scholars with some ties to pro-life activism and didn't really cite anybody else even or really even acknowledge that there was a majority scholarly position or even that there was meaningful disagreement on the subject."

In the mifepristone case, "there's a lot of supposition and speculation" in the argument about who has standing to sue, she explains. "There's a probability that people will take mifepristone and then there's a probability that they'll get complications and then there's a probability that they'll get treatment in the E.R. and then there's a probability that they'll encounter physicians with certain objections to mifepristone. So the question is, if this [retraction] knocks out one leg of the stool, does that somehow affect how the court is going to view standing? I imagine not."

It's impossible to know who will win the Supreme Court case, but Ziegler thinks that this retraction probably won't sway the outcome either way. "If the court is skeptical of standing because of all these aforementioned weaknesses, this is just more fuel to that fire," she says. "It's not as if this were an airtight case for standing and this was a potentially game-changing development."

Oral arguments for the case, Alliance for Hippocratic Medicine v. FDA , are scheduled for March 26 at the Supreme Court. A decision is expected by summer. Mifepristone remains available while the legal process continues.

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Journal Retracts Studies Cited in Federal Court Ruling Against Abortion Pill

The journal found that the studies, which had suggested that medication abortion is unsafe, included incorrect factual assumptions and misleading presentation of the data.

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An orange box of Mifeprex (Mifepristone) sits on a table with papers nearby.

By Pam Belluck

An academic journal publisher this week retracted two studies that were cited by a federal judge in Texas last year when he ruled that the abortion pill mifepristone should be taken off the market .

Most of the authors of the studies are doctors and researchers affiliated with anti-abortion groups, and their reports suggested that medication abortion causes dangerous complications, contradicting the widespread evidence that abortion pills are safe .

The lawsuit in which the studies were cited will be heard by the Supreme Court in March. The high court’s ruling could have major implications for access to medication abortion, which is now the most common method of pregnancy termination.

The publisher, Sage Journals, said it had asked two independent experts to evaluate the studies, published in 2021 and 2022 in the journal Health Services Research and Managerial Epidemiology, after a reader raised concerns.

Sage said both experts had “identified fundamental problems with the study design and methodology, unjustified or incorrect factual assumptions, material errors in the authors’ analysis of the data, and misleading presentations of the data that, in their opinions, demonstrate a lack of scientific rigor and invalidate the authors’ conclusions in whole or in part.”

The publisher also retracted a third study by many of the same authors that was published in 2019 in the same journal, which did not figure in the mifepristone lawsuit.

Sage said that when it had begun examining the 2021 study, it confirmed that most of the authors had listed affiliations with “pro-life advocacy organizations” but had “declared they had no conflicts of interest when they submitted the article for publication or in the article itself.”

Sage said it had also learned that one of the reviewers who evaluated the article for publication was affiliated with the Charlotte Lozier Institute, the research arm of Susan B. Anthony Pro-Life America.

The institute denied that the studies were flawed, as did the lead author, James Studnicki, who is vice president and director of data analytics at the institute.

“Sage is targeting us,” Dr. Studnicki, who has a doctor of science degree and a master’s degree in public health, said in a video defending the team’s work.

Noting that the studies had been used in legal actions, he said: “We have become visible, people are quoting us, and for that reason we are dangerous, and for that reason they want to cancel our work. What happened to us has little or nothing to do with real science and has everything to do with political assassination.”

In a statement, Dr. Studnicki said, “The authors will be taking appropriate legal action,” but he did not specify what that would be.

The lawsuit seeking to bar mifepristone — the first pill in the two-drug medication abortion regimen — was filed against the Food and Drug Administration by a consortium of groups and doctors who oppose abortion. In fighting the lawsuit, the federal government has defended its approval and regulation of mifepristone, provided years of evidence that the pill is safe and effective and argued that the plaintiffs have no legal standing to sue because they are not abortion providers and have not been harmed by mifepristone’s availability.

In his opinion last April, Judge Matthew J. Kacsmaryk cited the 2021 study to support his conclusion that the plaintiffs had legal standing to sue. That study reported a higher rate of emergency room visits after medication abortions than after procedural abortions. Citing it, Judge Kacsmaryk wrote that the plaintiffs “have standing because they allege adverse events from chemical abortion drugs can overwhelm the medical system and place ‘enormous pressure and stress’ on doctors during emergencies and complications.”

In another section of his ruling, Judge Kacsmaryk cited the 2022 study, writing that “plaintiffs allege ‘many intense side effects’ and ‘significant complications requiring medical attention’ resulting from Defendants’ actions.”

Judge Kacsmaryk’s opinion was criticized by many legal experts, and an appeals court struck parts of it but said significant restrictions should be placed on mifepristone that would prevent it from being mailed or prescribed by telemedicine.

Legal experts said it was unclear if Sage’s action would affect the Supreme Court’s decision. Mary Ziegler, a law professor at the University of California, Davis, said the retractions might simply “reinforce a position they were already ready to take.”

For example, she said, there were already strong arguments that the plaintiffs lacked legal standing, so if a justice was “willing to overlook all that other stuff, you may be willing to overlook the retractions too,” she said. For justices already “bothered by various other problems with standing, you probably were potentially going to say the plaintiffs didn’t have standing as it was.”

Similarly, she said, some justices would already have concluded that the vast majority of studies show mifepristone is safe, so if a justice was “prepared to say that, notwithstanding the weight of the evidence, mifepristone is really dangerous, you could easily do that again if you lose a couple of studies.”

Pam Belluck is a health and science reporter, covering a range of subjects, including reproductive health, long Covid, brain science, neurological disorders, mental health and genetics. More about Pam Belluck

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Title: differential private federated transfer learning for mental health monitoring in everyday settings: a case study on stress detection.

Abstract: Mental health conditions, prevalent across various demographics, necessitate efficient monitoring to mitigate their adverse impacts on life quality. The surge in data-driven methodologies for mental health monitoring has underscored the importance of privacy-preserving techniques in handling sensitive health data. Despite strides in federated learning for mental health monitoring, existing approaches struggle with vulnerabilities to certain cyber-attacks and data insufficiency in real-world applications. In this paper, we introduce a differential private federated transfer learning framework for mental health monitoring to enhance data privacy and enrich data sufficiency. To accomplish this, we integrate federated learning with two pivotal elements: (1) differential privacy, achieved by introducing noise into the updates, and (2) transfer learning, employing a pre-trained universal model to adeptly address issues of data imbalance and insufficiency. We evaluate the framework by a case study on stress detection, employing a dataset of physiological and contextual data from a longitudinal study. Our finding show that the proposed approach can attain a 10% boost in accuracy and a 21% enhancement in recall, while ensuring privacy protection.

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A laminated yellow sign with black writing and a headline saying "Plague Warning!!!", with red circles crossing out both an icon of a person walking and an icon of a dog.

A case of bubonic plague was reported in Oregon. Here’s what to know

US cases of plague are exceedingly rare, and modern therapies are effective when patients are treated in time

  • Oregon resident caught bubonic plague from cat, officials say

A case of bubonic plague – the disease that killed tens of millions of people in medieval Europe – was reported in rural Oregon last week . The afflicted individual was promptly treated, and health officials believe that there is “little risk to the community” that the disease will spread.

Though the disease, which officials believe was likely passed on to the individual from a sick pet cat, is exceedingly rare in the modern day, a few cases are reported each year. But in 2024, doctors know much better how to treat the disease and prevent its spread.

Here what to know about how an illness once known as the “black death” became treatable:

What is the plague?

The bubonic plague is an infectious disease that can affect mammals , caused by the Yersinia pestis bacteria. It is often transmitted via fleas infected with the bacteria. It can also be caught by inhaling respiratory droplets after close contact with animals or humans sick with pneumonic plague, the most severe form of the disease. Another way it can be caught is “from direct contact with infected tissues or fluids while handling an animal that is sick with or that has died from plague”, according to the Centers for Disease Control and Prevention.

Plague symptoms can manifest in a few ways. Bubonic plague – the kind contracted by the Oregon resident – happens when the plague bacteria get into the lymph nodes. It can cause fever, headache, weakness and painful, swollen lymph nodes. It usually happens from the bite of an infected flea, according to the CDC.

Septicemic plague symptoms happen if the bacteria get into the bloodstream. It can occur initially or after bubonic plague goes untreated. This form of plague causes the same fever, chills and weakness, as well as abdominal pain, shock and sometimes other symptoms like bleeding into the skin and blackened fingers, toes or nose. The CDC says this form comes from flea bites or from handling an infected animal.

Pneumonic plague is the most serious form of the disease, and it occurs when the bacteria get into the lungs. Pneumonic plague adds rapidly developing pneumonia to the list of plague symptoms. It is the only form of plague that can be spread from person to person by the inhalation of infectious droplets.

All forms of plague are treatable with common antibiotics, and people who seek treatment early have a better chance of a full recovery, according to the CDC.

Who is at risk?

In the US, an average of seven cases of human plague are reported each year, according to the CDC, and about 80% of them are the bubonic form of the disease. Most of those cases are reported in the rural western and south-western US.

A welder in central Oregon contracted bubonic plague in 2012 when he pulled a rodent out of his choking cat’s mouth – he survived but lost his fingertips and toes to the disease. A Colorado teen contracted a fatal case while hunting in 2015, and Colorado officials confirmed at least two cases last year – one of them fatal.

Worldwide, most human cases of plague in recent decades have occurred in people living in rural towns and villages in Africa, particularly in Madagascar and the Congo, according to the Cleveland Clinic.

People can reduce the risk of plague by making their homes and outdoor living areas less inviting for rodents, by clearing brush and junk piles, and by keeping pet food inaccessible. Ground squirrels, chipmunks and wood rats can carry plague, as can other rodents, and so people with bird and squirrel feeders may want to consider the risks if they live in an area with a plague outbreak.

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The CDC says repellent with Deet can also help protect people from rodent fleas when camping or working outdoors.

Flea-control products can help keep fleas from infecting household pets. If a pet gets sick, it should be taken to a vet as soon as possible, according to the CDC.

Isn’t plague from the middle ages?

The black death in the 14th century was perhaps the most infamous plague epidemic, killing up to half the population as it spread through Europe, the Middle East and northern Africa. It began devastating communities in the Middle East and Europe between 1347 and 1351 , and significant outbreaks continued for roughly the next 400 years.

An earlier major plague pandemic, dubbed the Justinian plague, started in Rome around 541 and continued to erupt for the next couple of hundred years.

The third major plague pandemic started in the Yunnan region of China in the mid-1800s and spread along trade routes, arriving in Hong Kong and Bombay about 40 years later. It eventually reached every continent except Antarctica, according to the Cleveland Clinic, and is estimated to have killed roughly 12 million people in China and India alone.

In the late 1800s, an effective treatment with an antiserum was developed. That treatment was later replaced by even more effective antibiotics a few decades later.

Though plague remains a serious illness, antibiotic and supportive therapies are effective for even the most dangerous pneumonic form when patients are treated in time, according to the World Health Organization.

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  • v.32(1); 2021

How do healthcare professionals respond to ethical challenges regarding information management? A review of empirical studies

Cornelius ewuoso.

a Department of Medicine, University of Cape Town, South Africa

b Center for Applied Ethics, Stellenbosch University, Western-Cape, South Africa

Kris Dierickx

c Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven, Leuven, Belgium

This study is a systematic review that aims to assess how healthcare professionals manage ethical challenges regarding information within the clinical context.

Method and Materials

We carried out searches in PubMed, Google Scholar and Embase, using two search strings; searches generated 665 hits. After screening, 47 articles relevant to the study aim were selected for review. Seven articles were identified through snowballing, and 18 others were included following a system update in PubMed, bringing the total number of articles reviewed to 72. We used a Q-sort technique for the analysis of identified articles.

This study reveals that healthcare professionals around the world generally employ (to varying degrees) four broad strategies to manage different types of challenges regarding information, which can be categorized as challenges related to confidentiality, communication, professional duty, and decision-making. The strategies employed for managing these challenges include resolution, consultation, stalling, and disclosure/concealment.

There are a variety of strategies which health professionals can adopt to address challenges regarding information management within the clinical context. This insight complements current efforts aimed at enhancing health professional-patient communication. Very few studies have researched the results of employing these various strategies. Future empirical studies are required to address this.

Abbreviations

CIOMS: Council of International Organization of Medical Sciences; WHO: World Health Organization; AMA: American Medical Association; WMA: World Medical Association; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analysis; ISCO: International Standard Classification of Occupations; ILO: International Labour Office; SPSS: The Statistical Package for the Social Sciences

Information management in the clinical setting is essential to good patient care. Poor management of information can negatively affect the health professional-patient relationship or jeopardize patient health. However, it is not always clear how information should be managed within the clinical context. Information management here is understood as the power of health professionals to control the disclosure or withholding of information to their patients (Ewuoso et al., 2017 ). This encompasses information about diagnosis, prognosis, and preferred available therapy (Swaminath, 2008 ).

Current inter/national regulations and professional bodies 1 generally require health professionals such as physicians to disclose information with significant welfare implications, whether health-related or psychological, fully and accurately to their patients. Such disclosure, these bodies hold, would significantly strengthen patient autonomy and enhance informed decision-making. This obligation is a matter of ethics and law. Withholding relevant information from patients that may guide them in making decisions about what course of treatment to pursue, represents a violation of the patient’s right to informed decision-making (Ewuoso et al., 2017 ).

A failure to disclose information could also expose a health professional to legal liability (Murray, 2012 ). However, regulations such as The Healthcare Professions Council of South Africa’s Guidelines for Good Practice in the Healthcare Professions (2008, Booklet 4), permit a health professional to withhold information in circumstances where disclosure is medically contraindicated 2 for example, where disclosure may lead to harm or compromise the patient’s recovery process.

However, there are some clinical encounters where deciding what course of action to take with respect to the management of information may prove extremely difficult. This is the situation when a health professional encounters a genuine moral dilemma, such as when incidental information with significant implications is accidentally discovered within the clinical context (for example, where misattributed paternity is discovered in the course of genetic testing). Disclosing such incidental information, where establishing such information is not the purpose of the test conducted, could be taken as a breach of one’s right “not to know”, as discussed, for example, by Andorno ( 2004 ) and Laurie ( 2014 ). Non-disclosure, on the other hand, could also be taken as a violation of one’s right to know. Beauchamp and Childress ( 2009 , p. 10f) define a genuine moral dilemma as a puzzling circumstance “in which moral obligations demand or appear to demand that a person adopt each of two (or more) alternative but incompatible actions, such that the person cannot perform all the required actions.” In other words, a genuine dilemma is a situation in which an individual competently judges that they are morally obligated to perform A, but cannot due to other compelling arguments mandating “not A”. Other contingent circumstances also negate performing A and not A at the same time (Ewuoso et al., 2017 ).

This project sets out to assess the management of ethical challenges regarding information by health professionals. Specifically, this project is concerned with the question: how do healthcare professionals respond to ethical challenges regarding information management that arise in the clinical context? There is a large body of empirical literature that has attempted to answer this question in various ways. This study attempts to synthesize these findings in the form of a systematic review, carefully highlighting the broad types of challenges that health professionals face in this regard. Additionally, this study aims to provide insight into the various approaches/strategies used by professionals to deal with these challenges, as well as the moral framework(s) underlying those approaches/strategies. In the next section, the study describes its methodology for retrieving and including relevant literature.

Literature Search

This study will adopt the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) framework. The quality assessment for each study will be based on Appendix C of Hawker and colleagues’ (Hawker et al., 2002 ) Appraising the evidence: reviewing disparate data systematically. This assessment tool comprises of nine questions, each of which can be answered with “good”, “fair”, “poor”, and “very poor”. These ratings were converted into numerical figures: good (7-10); fair (5-6); poor (2-4); and very poor (1). The numbers were summed up to create an overall quality grade: 70–90 being high-quality grade, 50–69 medium quality, and below 50 low-quality grade.

Two searches were conducted in PubMed on the 27th of October and 28th of October 2016, to identify empirical studies that focus on the management of ethical challenges regarding information by health professionals in the clinical context. The term “health professional” is defined by the International Standard Classification of Occupations (ISCO, 2012 ) as generalists and special practitioners, pharmacists, nurses, and dentists. We developed our search strings for retrieving relevant literature by adopting the approach established by Pillastrini et al. ( 2015 ). This approach consists of (1) framing a research question, (2) looking up Medical Subject Heading (MeSH) terms for the components which make up the research question, (3) reading published literature for alternative terms and finally, (4) combining these MeSH terms with Boolean operators (AND, OR, and NOT) in a database to deliver relevant articles. These search strings generated several hits. A detailed description of these is provided in Table 1 .

Search for literature.

Table 1 shows a detailed description of the literature search; that, is search date, search string, search number, filters applied and hits generated.

The study conducted additional searches using a broad search string in Google Scholar (generating 210 hits) and Embase (generating 35 hits). After screenings for language (22 articles excluded), title and abstract (535 articles excluded), year of publication (only empirical articles published between 2000 and 2016 included – 28 articles excluded), duplicates (10 articles excluded), and full text (12 articles excluded), 47 articles were included. Seven articles were identified through snowballing. Six other articles were identified on January 13, 2018, and 12 more articles on the 19th of May 2020, following a system update in PubMed. 72 articles were eventually included in this systematic review (See Table 2 above).

Selection process.

Table 2 shows how exclusion and inclusion criteria, such as language, date of publication, full-text screenings, etc., were applied to identify articles for review.

Inclusion and Exclusion Criteria

This systematic review focuses only on empirical studies 3 that, (1) aim to address how health professionals (as defined by ISCO) manage dilemmas or challenges regarding information in the clinical context, (2) identify factors influencing the choice of strategy by healthcare professionals for dealing with such challenges, and (3) study various forms of ethical challenges regarding information experienced by healthcare professionals. Non-empirical studies, such as concept-based articles, ethical guidelines, commentaries, case analyses, opinion papers, editorials, panel discussions, summary reports, letters, argument-based studies, or theoretical studies relating to ethical challenges in information management were excluded from this review.

The first author was responsible for the selection of articles for review, but this was discussed extensively with the co-authors to ensure consistency with regard to inclusion and exclusion criteria. Articles that met our selection criteria were pooled together in the EndNote database (version X6; Thomson Reuters).

Data Extraction

Articles that met our inclusion criteria were conventionally analyzed using Q-sort methodology to extract data. Q-sort technique is a useful technique for qualitatively sorting large volumes of varying opinions into broader groups, by identifying common themes or highlighting how viewpoints are interconnected or related. As Watts and Stenner ( 2005 , p. 74f) explain, Q-sort is mainly an exploratory methodology. The goal of this approach is to bring a sense of coherence to individual viewpoints or research questions that have many potentially complex and socially contested answers (Ewuoso et al., 2017 ; Roberts et al., 2015 Watts & Stenner, 2005 ;). Q-sort technique also has vertical and horizontal methodological usefulness. It involves a vertical progression from a well-defined research question to method, result, and discussion. Horizontally, this technique proceeds by coding relevant studies and sorting them into themes or groups. Given this two-fold usefulness, this technique is a relevant technique for understanding the broad range of ethical issues regarding information, as well as how health professionals manage such challenges, within the clinical context.

Using this methodological approach, the broad areas of challenges which health professionals experience with respect to information, strategies and approaches for managing these challanges, as well as the moral reasoning behind those approaches, were identified and categorized into meaningful themes in Atlas.ti. Other information such as author(s), title, country of origin, study aims, participant description, year of publication, and participants’ specialties, were extracted using a data extraction form (to ensure some level of standardization). The result of this endeavor is provided in the results section below.

In this section, we shall present the result of our review by highlighting the broad types of challenges health professionals experience within the clinical context, the broad strategies employed to address these challenges, and the moral reasoning behind these strategies.

The study identified four broad types of challenges regarding information which have been experienced by various health professionals in a variety of clinical contexts. They include: (1) confidentiality-related challenges, (2) decision-making related challenges, (3) communication-related challenges, and (4) professional duty-related challenges.

Each broad category comprises a number of ethical issues. The broad issues in communication-related challenges are: “how much to disclose”, “to whom to disclose”, “what to disclose”, and “when to disclose”. For example, when clinically significant (and hereditary) information is discovered, clinical geneticists (Akpinar & Ersoy, 2014 ; Alliman et al., 2009 ; Bower et al., 2002 ; Elger et al., 2015 ; Erde et al., 2006 ; Falk et al., 2003 Fennig et al., 2004 ; Lapid et al., 2009 ; Lisker & Carnevale, 2006 ; Williams et al., 2002 ) often face the difficulty of deciding how much of this information to disclose. Should individuals aged 50 years and over be informed of these results if the condition is not clinically actionable? Should patients aged 12 years and under be informed of adult-onset diseases? Is there a duty to warn at-risk relatives? Would warning third parties lead to a breach of their rights not to know? Communication challenges also arise in the health professional-patient context when prognosis is unclear (Jurchak et al., 2017 ), or when health professionals are unsure of the “right” thing to do. For example, Australian general practitioners (Pickles et al., 2016 ) reported that they felt unsure about what the “right” thing to do is when asymptomatic men ask about prostate cancer screening. Some health professionals express frustration regarding the lack of formal guidance to direct their practice, and many have found that talking with men about prostate-specific antigen (PSA) testing is a challenging experience because of this underlying uncertainty. This lack of formal guidance may be due to an absence of clinical ethics consultancy services in some clinical contexts. For example, a majority of emergency physicians interviewed by Joseph et al. ( 2019 ), claim that they have no institutional guidelines or education on how to access patients’ decision-making capacities. Similarly, a majority of medical oncologists in a study conducted by George & Demir Kureci ( 2020 ) claim that the most common issue for them was the absence of clinical ethics consultancy to guide them when they encounter ethical challenges (regarding information).

Three main sub-categories in confidentiality related challenges include: (1) informing patients about the limits of confidentiality, (2) disclosing patient health information to an insurance company, public authority or employer, and (3) deciding between breaching confidential patient information to benefit significant others or at-risk third parties, or maintaining patient confidentiality. Doctors practicing sports medicine (Malcolm & Scott, 2014 ), for example, report experiencing extreme difficulty in maintaining patient’s confidential health information due to the physical environment they operate in. Confidentiality-related challenges are also frequently encountered by Mental Health professionals (Akpinar & Ersoy, 2014 ; Alliman et al., 2009 ; Bower et al., 2002 ; Elger et al., 2015 ; Erde et al., 2006 ; Falk et al., 2003 Fennig et al., 2004 ; Lapid et al., 2009 ; Lisker & Carnevale, 2006 ; Lützén et al., 2000 Nash & Romanos, 2010 ; Vaga et al., 2016 ). One commonly reported ethical challenge in the preceding studies has to do with breaching confidential patient information to benefit a third party or to prevent harm to others. For example, deciding whether to ensure public safety by reporting a driver’s alcohol addiction without consent to their employer (a transport company), or to maintain the patient’s confidentiality, can be an ethical nightmare for these professionals.

The broad issues involved in professional duty-related challenges include conflicts between concealing emotions and fulfilling obligations towards patients. Yang et al. ( 2016 ), for example, have found that nurses are sometimes unable to express their personal beliefs regarding abortion. The delivery room routines and norms sometimes require nurses to participate in abortion, such as in cases of abortion due to non-chromosomal abnormalities. Other professional-duty related challenges include conflicts between the duty to report a colleague’s error and the desire to maintain their trust/friendship; and value conflicts, such as disagreements between the health professional and the patient or family members over the termination of pregnancy or pre-symptomatic testing of minors (Bower et al., 2002 ; Groepper et al., 2015 ). Honoring one’s duty to report abuse to the state can also be difficult for health professionals. For example, in Sweden (Kvist et al., 2014 ) where studies have linked child maltreatment or abuse to poor oral health, dentists are required to report any suspicion of child abuse in any child with poor oral health. Dentists (Kvist et al., 2014 ), however, express ethical difficulty in distinguishing a parent’s concern for a child’s wellbeing from child maltreatment; or child abuse from poor parenting.

In decision-making related challenges, the issues include disagreements within the medical team over treatment decisions (Huijer et al., 2000 ). For example, a majority of nurses in one study expressed the belief that an egalitarian model, in which nurses’ opinions are frequently sought, and in which patients and family members are not excluded from decision-making, is vital in enhancing communication within the clinical contexts. This belief sometimes brings nurses into conflict with physicians who believe themselves to be the experts, and upon whom others (including nurses) must depend (Molina-Mula et al., 2017 ). Communication difficulties amongst health professionals can also lead to poor communication with patients and family members. Even when information about treatment plans is communicated to patients and family members, disagreements can occur between professionals (who may, for example, consider a treatment plan to be in the best interest of the patients) and patients or family members (who may hold the view that the proposed treatment plan conflicts with their religious or cultural beliefs). Yoon et al. ( 2010 ) have found that conflicts or disagreements over treatment decisions are overlooked sources or signs of burnout among obstetricians and gynaecologists. These disagreements are also often reported to lead to treatment delays, as reported in some studies (Jurchak et al., 2017 ; Odeniyi et al., 2017 ; Span-Sluyter et al., 2018 )

The four types of challenges identified above are described as occurring frequently by professionals in 17 different fields of practice within the clinical context, namely gynaecology/obstetrics, sports medicine, anaesthesiology, nursing, cardiology, oncology/palliative/intensive care medicine, family medicine, paediatrics, dentistry, general surgery, general practice, organ/tissue donation, mental healthcare, gerontology, laboratory genetics, clinical genetics, and among interns/medical students. The health professionals working in these areas describe their experience of these challenges in various ways. Paediatricians report that their experience of challenges regarding information is frustrating (Sørlie et al., 2000 ), surgeons in one study (Torjuul et al., 2005b ) described their experience as stressful, tragic, and guilt-laden, while male nurses (Nordam et al., 2005 ) and mental health practitioners (Elger et al., 2015 ) complain that these challenges often lead to burnout. These emotions have been associated with moral distress by Prentice et al. ( 2016 ); Epstein and Hamric ( 2009 ); and Thomas and Mccullough ( 2015 ). Moral distress can also arise as a result of disagreements with family members. Lokker et al. ( 2018 ) have found that nurses experience moral distress in contexts in which they cannot act in a way which would, in their professional judgment, benefit their patients, because of disagreements (over treatment plans) with patients’ family members.

This review identified four broad strategies for managing the challenges discussed above. These include: (1) consultation (with colleagues, ethics committees or other professionals), (2) stalling (using delaying tactics such as using distraction to relax patients, continuing futile treatment, and pretending to have a plan), (3) resolution (having a prior discussion with patients or avoiding ethical dilemmas by referring patients to another hospital or health professional, seeking a court order or deferring decision-making to senior colleagues, and overriding patient’s autonomy), and (4) disclosure/concealment (honest disclosure, concealment, and lying).

Some oncologists, paediatrists, and other healthcare professionals in the intensive and palliative care units sometimes stall or consult with other colleagues or professionals (or ethics committees), when confronted with ethical challenges around withholding or continuing treatment, resource allocation, and other decision-making dilemmas (Morparia et al., 2012 ; Sørlie et al., 2000 ). A majority of nursing students maintain that most of the time, they defer to staff nurses when they experience micro-ethical dilemmas regarding patient autonomy or honoring best practices (Krautscheid & Brown, 2014 ). Staff nurses sometimes strive towards resolution by deferring to physicians when confronted with decision and communication-related challenges (Krautscheid & Brown, 2014 ; Van Zuuren & Van Manen, 2006 ; Watermeyer, 2015 ). Most mental healthcare practitioners, geneticists and clinicians address confidentiality-related challenges (Akpinar & Ersoy, 2014 ; Alliman et al., 2009 ; Elger et al., 2015 ; Erde et al., 2006 ; Falk et al., 2003 ; Groepper et al., 2015 ; Lützén et al., 2000 ), communication-related challenges (Erde et al., 2006 ; Swetz et al., 2007 ) and professional duty-related challenges (Bower et al., 2002 ; Lapid et al., 2009 ) through resolution (specifically, by having pre-discussions with patients or educating patients about advanced care planning before the occurrence of dilemmas), and consultation with family members and other colleagues or professionals. Registered nurses, physiotherapists, physicians and occupational therapists in studies conducted by Gronlund et al. ( 2016 ) and Velan ( 2019 ) expressed the belief that their professional experiences helped them to engage with patients and family members properly and handle ethical difficulties around value differences (which sometimes frustrate communication between health professionals and their patients). Lack of experience has been found by Kadivar et al. ( 2017 ) to negatively affect how paediatric residents address ethical dilemmas regarding information. A majority of dentists in a study conducted by Camoin et al. ( 2018 ) claimed that they sometimes sacrificed ethical values (such as patient autonomy) in order to provide beneficial care to anxious children with intellectual disabilities and to address decision-making related challenges; while Australian pharmacists (Hattingh & King, 2019 ) claim that they generally avoid situations they perceive as requiring complex management. Many Japanese physicians believe that few problems result when they honestly tell cancer patients about their poor prognosis (Elwyn et al., 2002 ).

Finally, our review shows that consultation is a widely used strategy by health professionals in oncology/palliative/end-of-life care, nursing, clinical genetics, laboratory genetics, paediatric, anaesthesiology, cardiology, dentistry, gynaecology, mental healthcare, general surgery, and among medical interns, to address challenges related to communication, professional duty, confidentiality, and decision-making.

Moral Reasoning and Influencing Factors

Professionals justify the use of these strategies in a variety of ways. In a study conducted by Kagan et al. ( 2008 ), physicians and nurses said they would require colleagues with a confirmed diagnosis of a blood borne pathogen infection to disclose their medical situation to patients prior to surgery. These professionals claim that such infected colleagues should be restricted from performing invasive surgery since they constitute a danger to patients. 4 Mental Health professionals in Elger et al. ( 2015 ) maintain that they would have a prior discussion with patients to inform them about the limits of confidentiality. Patients, these professionals maintain, have a right to know that confidentiality rules may not cover some information.

Furthermore, a majority of nurses in Helft and colleagues (Helft et al., 2011 ) said they could help patients prepare for the end of life by answering prognosis-related questions truthfully. Communicating in this way, these health professionals maintain, will allow patients to make informed decisions about their care. Similarly, Torjuul et al. ( 2005b ) reported that surgeons who consulted with senior colleagues gained insights on how to handle incompetent colleagues or disagreement with patients or family members over treatment. Finally, Sørlie et al. ( 2000 ) reported that paediatricians sometimes stall when there is pressure to treat seriously ill new-born babies. That is, they pretend to have a solution or take their time. This, in their opinion, will give dying children and parents time to achieve death with dignity, and ensure fair distribution of resources.

In addition to the examples of moral reasoning identified above, there are other factors that health professionals claim sometimes influence their choice of strategy. For example, oncologists and professionals in intensive and palliative care units will also consider the age of patients, as well as patient comorbidity, the aggressiveness of the disease, and the effectiveness of treatment in their decision to withhold or continue treatment (Halvorsen et al., 2008 Lotz et al., 2016 ; Mccahill et al., 2002 ; Schimmer et al., 2012 ). Patients’ wishes and competencies are essential factors gastroenterologists and gynaecologists or obstetricians will consider in the decision to withhold or disclose information (Palmboom et al., 2007 ). Time pressure 5 , restricted space for privacy (owing to the role that family members play in treatment decisions 6 ), reliance on traditional and religious treatments, and patient’s dependency on relatives for communication and decision-making regarding healthcare, are other factors (Kebede et al., 2020 ; Kwon et al., 2019 ; Wuensch et al., 2013 ) that sometimes cause delays in treatment (or preventive measures), or cause an unwillingness to discuss problems with health professionals openly.

Finally, 41 studies recommended additional training/education for health professionals. For example, donation physicians in one study (Macdonald & Shemie, 2017 ) believe that additional education on death determination (Chiu et al., 2009 ) for physicians and nurses, will minimize any risk of diagnostic errors, and enhance donation advocacy and donation conversion rates. Nineteen studies recommended new/additional guidelines and frameworks for managing challenges regarding information within the clinical context; 23 studies specifically recommended more ethics training that focuses on improving health professionals’ competence in different contexts (Beck et al., 2008 ; Cantini & Ells, 2007 ; Chih et al., 2016 ; Duval et al., 2004 ; Martin et al., 2014 Pye, 2013 ). Yildiz ( 2019 ), for example, recommended additional professional ethics training for nurses so that these professionals can better understand the ethical aspects of nursing. This will also enhance their competence in managing ethical dilemmas. Five studies strongly recommended that ethics education should focus on enhancing professionals’ competence in managing cultural/religious divides, which often exist between health professionals and patients. Cultural differences, as some studies (Buken & Balseven-Odabasi, 2013 ; Hurst et al., 2007 Malcolm & Scott, 2014 ; Ruhnke et al., 2000 ) have found, do indeed influence how doctors perceive or address ethical dilemmas. Health professionals require assistance in improving their practical competency in managing these differences.

This study provides insight into how healthcare professionals conceptualize the various challenges, with specific regard to information, which they experience within the clinical context, and the various strategies they employ for managing these challenges.

We observe, however, that our presentation of results in the previous section was weighted towards some of the 17 different fields of practice idenitified within the clinical context. It is not practically possible to discuss the ethical challenges experienced in each of the 17 fields of practice, as we lacked the space for such an enormous task. Our inability to discuss the ethical challenges in each of the 17 fields of practice may be taken as one limitation of this study. Regardless of this, we are optimistic that the insights gained through this study will significantly complement efforts aimed at enhancing healthcare professional-patient communication within the clinical context.

This discussion – as was the case with the presentation of findings – will be guided by our research question, which is: how do healthcare professionals respond to ethical challenges regarding information management that arise in the clinical context? This study identified challenges related to communication, decision-making, confidentiality, and professional duty as key themes for ethical reflection. It explored the experiences of healthcare professions in 17 different fields of practice within the clinical context. The study also identified four strategies – resolution, stalling, disclosure/concealment, and consultation – for managing these challenges.

Information management is an integral part of good patient care. The four broad types of challenges identified reveal the various ways in which communication 7 amongst health professionals; or between health professionals and patients/families, could break down, or lead to the provision of information to a patient who is either unwilling or unprepared to receive such information, thus leading to avoidable harm or jeopardizing patient care. Hence, communication break-down, as well as the importance of forestalling this break-down, is the underlying ethical challenge regarding information experienced by professionals within the clinical context. The four broad strategies for managing ethical challenges around information show how professionals endeavor to prevent this harm from occurring, thereby improving professional-patient communication. Very few studies have considered the question as to whether these strategies lead to satisfactory outcomes in which all stakeholders – health professionals, patients, and family members – are made better-off. Further research is required to fill this gap.

The recommendation for new/additional frameworks or guidelines, as well as ethics education and training which focuses on enhancing health professional’s competence in clinical contexts (such as those contexts in which health professionals and patients are influenced by different religious/cultural beliefs), aligns with various calls (Godfrey et al., 2013 ; Westra et al., 2009 ) for theoretical diversity, as well as multiculturalism, in clinical ethics support systems and within the clinical context in general. For example, Westra and colleagues (Westra et al., 2009 ) have remarked that in non-religious ethics, the principle of non-maleficence may be used to justify withholding or withdrawing futile or damaging treatments or withholding damaging information. In contrast, Islamic ethics applies this principle to forbid all actions that may harm life. Similarly, Jegede (Jegede, 2009 ) has also expressed the concern that in some African contexts, autonomy would be understood as social autonomy, rather than individual self-determination, as is promoted by Beauchamp and Childress ( 2009 ). Additionally, ethics training in communication skills and ethical judgment will significantly improve health professionals’ ethical competence in managing such clinical situations. As Pettersson et al. ( 2018 , p. 1) rightly observe,

ethical education and discussions for further development of a common ethical language and a good ethical working climate can improve ethical competence and help nurses and physicians cooperate better with regard to patients … in their efforts to act in the best interest of patients.

This additional training could also focus on enhancing health professionals’ multicultural competency. This is required to address social contexts, cultural milieu, religious beliefs, as well as other important values, which sometimes complicate how information is managed within the clinical context, or which could lead to communication break-down between health professionals and their patients. Additional ethics training can also complement the current medical ethics framework by focusing on providing grounds for justification of any loss of value that may occur in the event of ethical dilemmas. Given the current definition of genuine dilemmas (Beauchamp & Childress, 2009 , p. 10f), it is unlikely that a loss of value can be prevented in the event of a real dilemma. As rightly observed by some of the reviewed studies (Cahana et al., 2008 ; Wuensch et al., 2013 ), in a real dilemma, some values or beliefs would be breached or suppressed in favor of others. What is needed – while not entirely foreclosing the possibility of developing a universal framework that embraces all beliefs and practices – is an adequate justification for such a violation or loss. Such justification will provide relief for healthcare professionals who experience these dilemmas and restore their confidence in a way that minimizes moral distress. Finally, in order for these additional ethical frameworks to have a lasting effect, this study recommends reform of healthcare guidelines/policies, and medical ethics education curricula to accommodate these new or additional theories.

In addition to the limitation already stated in this section, other limitations must also be noted. The eligibility criteria adopted by this study may have resulted in the exclusion of potentially relevant studies. For example, we included in this study only articles published between 2000 and 2018; this resulted in the exclusion of potentially relevant articles published before 2000. Notwithstanding the stated limitations, this study greatly complements efforts aimed at enhancing healthcare professional-patient communication, as well as clinical ethics support services. Future studies can build on the outcome of this study by focussing on developing training manuals and ethics education programs for enhancing health professional-patient communication.

Insight has been gained, through this study, into how healthcare professionals respond to ethical dilemmas regarding information. This study complements efforts aimed at enhancing healthcare professional-patient communication. This review of empirical studies has identified challenges related to communication, decision-making, confidentiality, and professional duty as ethical issues that can affect healthcare professional-patient communication, in 17 different fields of practice within the clinical context. The study also identified four strategies – resolution, stalling, disclosure/concealment, and consultation – for managing these challenges.

Research, however, is needed to study whether these strategies will indeed enhance healthcare professional-patient communication. Studies can also focus on developing strategies for properly adjusting current medical ethics frameworks to address concrete social contexts, cultural milieu, religious beliefs, and other essential values that can complicate how information is managed within the clinical context. Notwithstanding these recommendations, health professionals should know that there are strategies they can adopt to address a variety of ethical challenges regarding information within the clinical context.

Ethics approval and consent to participate

This study is a systematic review of the literature and does not involve human participants. No ethical approval was sought for this study.

Acknowledgments

The authors appreciate the contributions of the faculty members at the Centre for Biomedical Ethics and Law, Katholieke Universitet De Leuven, Belgium, for their critical feedback and appraisals. CE and SH developed the project proposal upon which this study is based CE and KD adopted a proposal for this particular study and developed its method section of this work. CE was responsible for selecting articles for review but discussed extensively with KD to ensure consistency with inclusion and exclusion criteria. A second revision of the process was done by SH to ensure consistency with selection criteria, as well as with the larger project aims and objectives. All authors critically revised this manuscript, raised no objections for its submission for publication, and are responsible for its intellectual content.

1 For example, the Australian Good Medical Practice: Code of Conduct for Doctors in Australia (2004: 9ff); the Council of International Organization of Medical Sciences” (CIOMS) “International Ethical Guidelines for Biomedical Research Involving Human Subjects” (2002, Commentaries on Guidelines 5, 16, 18 & 21) and “International Ethical Guidelines for Epidemiological Research (2009, Commentaries on Guidelines 4, 5, 21); the World Health Organization’s (WHO) “Draft Guidelines for Adverse Event Reporting and Learning System” (2005: 12ff) and “Ethical issues in Patient Safety Research” (2013: 30ff); the American Medical Association's (AMA) Code of Medical Ethics (Council on Ethical and Judicial Affairs, 2001:1ff); the World Medical Association's (WMA) International Code of Medical Ethics (1995); the Nigerian Code of Medical Ethics (2004); and the South African Guidelines for Good Practice in the Healthcare Professions (2008, Booklet 3: 2; Booklet 9: 4), to mention a few.

2 Disclosure is medically contraindicated if it would cause a depressed patient, for example, to become actively suicidal, or if it would compromise a patient's recovery process, for example, telling a hypertensive patient receiving critical care in the Intensive Care Unit that their spouse has just died.The American Medical Association's (AMA) Code of Medical Ethics (2010), for example, counsels that physicians have a “sacred duty … to avoid all things which have a tendency to discourage a patient's recovery and depress his spirits.” Disclosing news of the death of a loved one to a patient recieving care in an intensive care unit is therefore medically contraindicated if such news may hasten the death of patient or otherwise harm them.

3 We have previously published a separate study focusing on theoretical studies. See xxx.

4 See Also Klitzman & Weiss, 2006 .

5 For example, more than half of respondents in one empirical study (Chaiyamahapurk et al., 2011 ), claim that they do not have enough time to provide required preventive and disclosure counselling for people living with HIV and AIDS. When patients refuse to disclose their sero-conversion to their partners, a majority of these health professionals kept the seroconversion confidential from the partner. Chaiyamahapurk et al., 2011 .

6 The current practice in China is that family members receive bad news first. They then decide whether the patient should be informed or not.

7 This study defines communication broadly to include the content of communication, necessary communicative skills, and the judgment required for determining when communication is appropriate.

Disclosure statement

No potential conflict of interest was reported by the author(s).

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IMAGES

  1. (PDF) Ethical Dilemma for a Medical Resident: A Case Study Analysis

    case study with ethical dilemma in healthcare

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    case study with ethical dilemma in healthcare

  4. Ethical Dilemma in Nursing: Case Study

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  5. Ethical Dilemma in Nursing: Case Study

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VIDEO

  1. Ethical Dilemma Case Study

  2. Ethics Case study and Example (part-1)

  3. Research Ethics

  4. Promoting Inclusion and Equity in Healthcare (Inaugural Business Ethics Conference)

  5. Important cases for professional ethics

  6. ethics issues

COMMENTS

  1. The patient suicide attempt

    The case study demonstrates an ethical dilemma when nursing staff are taking care of an end stage aggressive prostate cancer patient Mr Green who expressed the suicide thoughts to one of the nurses and ask that nurse keep secret for him in Brisbane, QLD, Australia. Ethical dilemma identification

  2. Case Study Application of an Ethical Decision-Making Process for a

    To better understand the underlying ethical complexities which arise from critical decisions in the acute care setting, this paper will examine a case study to demonstrate application of the Corey et al. ( 8) 8-step framework (see Appendix A) for ethical decision-making. Case Study Ms. Jones is 93 years old and lives in a Long Term Care residence.

  3. Ethical Dilemma In Healthcare Case Study

    Ethical Dilemma In Healthcare Case Study Info: 1389 words (6 pages) Nursing Case Study Published: 13th Apr 2021 Reference this Tagged: ethics Share this: Facebook Twitter Reddit LinkedIn Dr Simons was the new Surgical Consultant at a large public hospital. He was trained in the USA, and came with a reputation for being very fierce.

  4. Ethical Problems and Moral Distress in Primary Care: A Scoping Review

    Three main focus areas were identified: (a) frequent ethical conflicts and moral distress episodes among nurses working in primary care settings; (b) frequent moral distress measures here employed; (c) coping strategies here adopted to prevent or manage moral distress.

  5. How health care professionals confront and solve ethical dilemmas

    A study at the University Medical Center Rijeka found similar main ethical dilemmas in Croatian nurses and physicians, which included limiting life-sustaining therapy, euthanasia, and physician-assisted suicide ( 11 ). Except these two studies, little to nothing is known about the ethical dilemmas of HCPs in Slovenia and Croatia.

  6. Nurses experiences of ethical dilemmas: A review

    Volume 27, Issue 1 https://doi.org/10.1177/0969733019832941 PDF / ePub More Abstract Background: Nursing care is rapidly evolving due to the advanced technological and medical development, and also due to an increased focus on standardization and the logic of production, permeating today's hospital cultures.

  7. Case study: an ethical dilemma involving a dying patient

    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 His …

  8. 20 Most-Common Examples of Ethical Dilemmas in Nursing

    1. Patients or their loved ones must make life or death decisions 2. The patient refuses treatment 3. Nursing assignments may contradict cultural or religious beliefs 4. Nursing peers demonstrate incompetence 5. Inadequate staffing How To Identify Ethical Dilemmas In Nursing? Nurses in all disciplines face ethical challenges from time to time.

  9. Cases

    Jan 2024 Why Competency Frameworks Are Insufficiently Nuanced for Health Equity Teaching and Assessment Zareen Zaidi, MD, PhD, Daniele Ölveczky, MD, MS, Nicole A. Perez, PhD, Paolo C. Martin, PhD, Andres Fernandez, MD, MSEd, Philicia Duncan, MD, and Hannah L. Anderson, MBA

  10. Respecting patient autonomy versus protecting the patient's health: a

    This ethical dilemma posed by the professionals' duty to do what is in the patient's best interest versus the patient's right to decide treatment serves as the focus for this case study. Ethical, legal, and healthcare practitioners' considerations are explored. The case study concludes with specific recommendations for treatment.

  11. Embodied Ethical Decision-Making: A Clinical Case Study of ...

    The purpose of this clinical case study was to explore how Hervey's 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.

  12. The top 10 most-read medical ethics articles in 2021

    Ethics in Health Care Explore the AMA Journal of Ethics for articles, podcasts and polls that focus on ethical issues that affect physicans, physicians-in-training and their patients. Get Email Alerts Below, find the 10 most popular AMA Journal of Ethics articles published this year.

  13. Moral dilemmas and trust in leaders during a global health crisis

    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 ...

  14. Cases in Medical Ethics: Student-Led Discussions

    Case 1: A woman enters the emergency room with stomach pain. She undergoes a CT scan and is diagnosed with an abdominal aortic aneurysm, a weakening in the wall of the aorta which causes it to stretch and bulge (this is very similar to what led to John Ritter's death).

  15. Ethics Case Studies & Education Resources

    ACP medical ethics education and case study resources cover a range of issues in clinical ethics, professionalism, research and more. Earn CME/MOC credits here. ... professionalism, teaching, research, health care delivery, and other topics. Each resource can be used as a learning activity and completed for free CME/MOC credits as indicated or ...

  16. Ethical Dilemmas, Moral Distress, and the Risk of Moral Injury

    Introduction: Ethical Challenges Since the beginning of the COVID-19 pandemic, ethical dilemmas for medicine and public health policy have been at the forefront of public, political, and medical discourse. As with all ethical dilemmas, moral goods have been at odds with each other.

  17. Ethical Dilemmas in Nursing: Case Studies

    C. Outcome of Case Study. In this case study, the nurse collaborated with the healthcare team to address the ethical dilemma. The team recognized the critical condition of the patient and the urgency of surgical intervention. They worked together to reallocate resources, including personnel and equipment, to ensure the patient received prompt care.

  18. Defining ethical challenge(s) in healthcare research: a rapid review

    Background Despite its ubiquity in academic research, the phrase 'ethical challenge(s)' appears to lack an agreed definition. A lack of a definition risks introducing confusion or avoidable bias. Conceptual clarity is a key component of research, both theoretical and empirical. Using a rapid review methodology, we sought to review definitions of 'ethical challenge(s)' and closely ...

  19. Health Management, Ethics and Research Module: 8. Ethical Dilemmas in

    Study Session 8 Ethical Dilemmas in Health Service Delivery ... From Case Study 8.7 you can extract a number of ethical issues or conflicts. Amarech has the responsibility to keep W/ro Alemach's medical secret. Confidentiality is the core ethical principle in this case study. If Amarech tells Ato Feleke about his wife's infection, W/ro ...

  20. (PDF) Case Study: An Ethical Dilemma

    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 lifethreatening situations. A 20-year-old, pregnant. Black Hispanic female presented to the Emergency Department (ED) in critical condition following a single-vehicle car ...

  21. Some virtual care companies putting patient data at risk, new study

    Dr. Sheryl Spithoff, a physician and scientist at Women's College Hospital in Toronto, co-authored a new study that found the for-profit virtual care industry valued patient data and 'appears to ...

  22. Abortions by Telemedicine and Mailed Pills Are Safe and Effective

    The study, led by researchers at the University of California, San Francisco, looked at the experience of more than 6,000 patients in the months after the federal government began allowing ...

  23. Abortion pills prescribed via telehealth are safe and effective, study

    The study looks at 6,000 patients who got abortion pills after an online appointment. It found that 99.7% of those abortions were not followed by any serious adverse events.

  24. Ethical dilemmas faced by health care workers during COVID-19 pandemic

    1. Dilemma 3 - If I have some respiratory symptoms and I think I may have been exposed, should I open up about my symptoms and stay at home, risking social and workplace discrimination, or continue to go about my work as usual, risking my colleague's health, till my test comes positive?

  25. The abortion pill case on its way to the Supreme Court cites a

    The study was cited three times by a federal judge who ruled against mifepristone last spring. That case, which could limit access to mifepristone throughout the country, will soon be heard in the ...

  26. Journal Retracts Studies Cited in Federal Court Ruling Against Abortion

    Feb. 9, 2024. An academic journal publisher this week retracted two studies that were cited by a federal judge in Texas last year when he ruled that the abortion pill mifepristone should be taken ...

  27. Differential Private Federated Transfer Learning for Mental Health

    Mental health conditions, prevalent across various demographics, necessitate efficient monitoring to mitigate their adverse impacts on life quality. The surge in data-driven methodologies for mental health monitoring has underscored the importance of privacy-preserving techniques in handling sensitive health data. Despite strides in federated learning for mental health monitoring, existing ...

  28. A case of bubonic plague was reported in Oregon. Here's what to know

    Last modified on Tue 13 Feb 2024 20.48 EST. A case of bubonic plague - the disease that killed tens of millions of people in medieval Europe - was reported in rural Oregon last week. The ...

  29. How do healthcare professionals respond to ethical challenges regarding

    This study is a systematic review that aims to assess how healthcare professionals manage ethical challenges regarding information within the clinical context. Method and Materials We carried out searches in PubMed, Google Scholar and Embase, using two search strings; searches generated 665 hits.