short case study about individual moral dilemma

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Case Studies

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

A Million Little Pieces

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

Abramoff: Lobbying Congress

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

Apple Suppliers & Labor Practices

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

Approaching the Presidency: Roosevelt & Taft

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

Appropriating “Hope”

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

Arctic Offshore Drilling

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

Banning Burkas: Freedom or Discrimination?

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

Birthing Vaccine Skepticism

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

Blurred Lines of Copyright

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

Bullfighting: Art or Not?

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

Buying Green: Consumer Behavior

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

Cadavers in Car Safety Research

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

Cardinals’ Computer Hacking

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

Cheating: Atlanta’s School Scandal

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

Cheating: Sign-Stealing in MLB

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

Cheating: UNC’s Academic Fraud

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

Cheney v. U.S. District Court

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

Christina Fallin: “Appropriate Culturation?”

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

Climate Change & the Paris Deal

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

Cover-Up on Campus

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

Covering Female Athletes

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

Covering Yourself? Journalists and the Bowl Championship

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

Cyber Harassment

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

Defending Freedom of Tweets?

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

Dennis Kozlowski: Living Large

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

Digital Downloads

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

Dr. V’s Magical Putter

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

East Germany’s Doping Machine

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

Ebola & American Intervention

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

Edward Snowden: Traitor or Hero?

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

Ethical Pitfalls in Action

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

Ethical Use of Home DNA Testing

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

Flying the Confederate Flag

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

Freedom of Speech on Campus

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

Freedom vs. Duty in Clinical Social Work

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

Full Disclosure: Manipulating Donors

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

Gaming the System: The VA Scandal

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

German Police Battalion 101

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

Head Injuries & American Football

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

Head Injuries & the NFL

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

Healthcare Obligations: Personal vs. Institutional

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

High Stakes Testing

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

In-FUR-mercials: Advertising & Adoption

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

Krogh & the Watergate Scandal

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

Limbaugh on Drug Addiction

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

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

Meet Me at Starbucks

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

Myanmar Amber

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

Negotiating Bankruptcy

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

Pao & Gender Bias

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

Pardoning Nixon

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

Patient Autonomy & Informed Consent

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

Prenatal Diagnosis & Parental Choice

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

Reporting on Robin Williams

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

Responding to Child Migration

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

Retracting Research: The Case of Chandok v. Klessig

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

Sacking Social Media in College Sports

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

Selling Enron

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

Snyder v. Phelps

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

Something Fishy at the Paralympics

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

Sports Blogs: The Wild West of Sports Journalism?

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

Stangl & the Holocaust

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

Teaching Blackface: A Lesson on Stereotypes

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

The Astros’ Sign-Stealing Scandal

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

The Central Park Five

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

The CIA Leak

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

The Collapse of Barings Bank

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

The Costco Model

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

The FBI & Apple Security vs. Privacy

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

The Miss Saigon Controversy

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

The Sandusky Scandal

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

The Varsity Blues Scandal

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

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

Welfare Reform

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

Wells Fargo and Moral Emotions

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

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The Role of Worldview in Moral Case Deliberation: Visions and Experiences of Group Facilitators

Benita spronk.

1 Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Postbus 7057, 1007 MB Amsterdam, The Netherlands

Guy Widdershoven

2 Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1089 a, 1081 HV Amsterdam, The Netherlands

3 Department of Religion and Theology, Vrije Universiteit Amsterdam, De Boelelaan 1105, 1081 HV Amsterdam, The Netherlands

Associated Data

The dataset that supports the conclusion of the article is available in Dutch.

This study investigates the role of worldview in moral case deliberation (MCD). MCD is a form of clinical ethics support which aims to assist caregivers in reflection on moral dilemmas, experienced in daily practice. Bioethicists acknowledge that existential and religious aspects must be taken into account in the analysis of ethical questions, but it remains unclear how these elements are addressed in clinical ethics support. We investigated how facilitators of MCD address worldview in MCD. MCD facilitation is often done by spiritual caregivers, but not in their role as spiritual caregiver. Discussing worldview is no standard part of the procedure in MCD. This study was qualitative, focusing on the views and experiences of the facilitators of MCD. Semi-structured interviews ( N  = 12) were conducted with facilitators of MCD. Grounded theory was used for analysis. The results show that worldview plays both an explicit and an implicit role in the MCD process. The explicit role concerns the religious beliefs of patients and professionals. This calls for avoiding stereotyping and devoting attention to different visions. The implicit role comes to the fore in addressing core values and spiritual fulfillment. In order to clarify the fundamental nature of values, more explicit attention for worldview might be useful during MCD. However, this should be done with caution as the term ‘worldview’ might be interpreted by participants in terms of religious and personal beliefs, rather than as an invitation to reflect on one’s view of the good life as a whole.

Introduction

Care professionals frequently face difficult dilemmas. Do you agree to terminate a pregnancy at the parents’ request if the baby will be born with a disability? Should you tell a patient that his condition is terminal if the family has asked you not to? Dilemmas like these involve perceptions of the value of life and the individual’s worldview. “Worldview refers to fundamental beliefs about life, death and suffering that structure people’s ideas on how life events are related.” (Littooij et al., 2016a , p.7). “Worldview is part of ‘global meaning’, a basic set of beliefs and goals that guide the way in which people give meaning to their lives. (Littooij et al., 2016a , b ; Park, 2013a , b , p. 358.).” It concerns questions which touch upon the fundamentals of our existence, defining who we are and where we seek to belong (Alma, 2018 , p. 45; Aerts et al., 2007 , p. 5; Taves et al., 2018 ; Plante & McCreadie, 2019 , p. 321). Moral case deliberation is about reflecting on making professional choices and treatment decisions. Reflection on underlying values and norms is important in order to be able to make responsible choices. This reflection takes place in moral case deliberation. Values and norms can be formed by belief systems and are determined by the meanings people give and visions they have on life, death and suffering. That is the reason we opted to define worldview as part of global meaning. Bioethicists acknowledge the importance of worldview in clinical ethics support, both in a general sense (Kørup et al., 2018 ; Mustafa, 2014 ; Turner, 2003 ; White et al., 2018 ) and in specific areas (Bandini et al., 2017 ; Mathieu, 2016 ; Mohamed & Noor, 2014 ). They emphasize that existential and religious aspects must be taken into account in the analysis of ethical questions in clinical practice. The existing literature tends to focus on identifying and defining the various elements of worldview. It remains unclear how these elements are, or should be, addressed by those involved in clinical ethics support.

Moral case deliberation (MCD) has been developed as a component of clinical ethics to help care providers make morally conscionable choices. An MCD session explores an ethical issue described by one of the participants and drawn from his or her personal experience. The deliberation is structured by a specific method and is led by an experienced facilitator (Stolper et al., 2016 ). MCD facilitation is often done by spiritual caregivers, but not in their role as spiritual caregiver. Reflection on ethics can be part of spiritual care. Facilitating MCD, however, requires specific skills and knowledge of methodologies. Many spiritual caregivers are interested in MCD and are trained as facilitator. However, not every spiritual caregiver is a trained facilitator. In their role as facilitator, they are trained to address values, but not worldview, as this is no standard part of the procedure in MCD. The MCD session generally takes place within the clinical department concerned. It is attended by departmental staff and representatives of other disciplines involved in the case under discussion.

In this article, we examine how MCD facilitators approach worldview as a component of clinical ethics. Facilitators are a source of experience and knowledge, how worldview is addressed in MCD. Our choice was to rely on their experiences. In essence, MCD entails reflection on the right thing to do. It, therefore, considers the perspectives of all persons involved in the situation and explores their personal norms and values. The investigation of these values can be accompanied by a reflection on existential aspects. What importance do MCD facilitators attach to such existential aspects? How do they use them to enhance the deliberation?

Our first research question is therefore: What is the role of worldview in MCD? The second research question is: How do MCD facilitators act in response to worldviews?

We begin with a brief overview of MCD based on the literature, followed by a description of our research method and results. This is followed by a discussion of those results and the authors’ conclusions.

Moral Case Deliberation

Certain issues in healthcare practice can be perceived as morally problematic by healthcare providers. This concerns situations in which uncertainty occurs regarding what is right to do. These issues are apt for moral case deliberation (MCD). MCD is a structured method for investigating these moral issues. An MCD focuses on a case presented by one of the participants. This case must involve a concrete, personal experience from the past or present, not a hypothetical situation (Stolper et al., 2016 ). Participants in MCD in healthcare are often healthcare professionals (doctors, nurses, paramedics), but might also include managers, family members or even patients themselves. Under the guidance of a trained facilitator, the group will investigate the case.

The main purpose of MCD is not to arrive at a solution, but to foster critical reflection on the ethical issue at hand. Underlying values associated with the issue at stake in the case are scrutinized (Stolper et al., 2016 ). During MCD, participants explore what is important to themselves and other participants. The facilitator guides them in sharing and exchanging their moral considerations with each other. In this way, the issue is jointly examined and perspectives on the case are broadened. MCD is not about proposing statements or convincing an opponent, but about creating space to think about the case together. By exchanging various perspectives, a ‘fusion of horizons’ (Gadamer, 1960 ) among the participants can be achieved. The underlying aim is to search for common ground between one’s own and others’ experiential horizons, in order to understand one another better and develop a richer, more complete understanding of the situation.

To structure the discussion, the facilitator uses a specific conversation method. Several such methods have been developed (Van Dartel & Molewijk, 2014 ). A familiar option is the ‘dilemma method’ (Molewijk & Ahlzen, 2011 ; Stolper et al., 2016 ) in which a key step is the analysis of the case in terms of perspectives, values and norms. It is customary to produce a chart or table listing the perspectives of all persons involved in the case, known as the ‘stakeholders’. Cultural and religious norms and values can be part of personal perspectives. Our research concerns the extent to which this is addressed by facilitators and whether or not this is questioned by facilitators. The participants in the MCD session seek to identify the values which underpin those perspectives, the norms which serve to concretize the values, and possible courses of action. The norms and values concerned are the personal visions of the stakeholders. Those of stakeholders who are not actually present during the discussion, such as the patient or his family, can also be explored by the group by means of accounts provided by those who know them well (Widdershoven et al., 2016 , p.73). Other deliberation methods also explicitly address values.

Research Methodology

Data collection.

This study forms part of a larger research project examining the relationship between MCD and tragic situations. In healthcare practice, care providers can be confronted by a tragic situation in which they must make decisions which will have far-reaching consequences. To what extent can MCD help them make those decisions? We investigate the role of MCD in dealing with tragic situations by looking at harm, worldview and emotions. This article focuses on the aspect of worldview.

Semi-structured interviews were held with a number of MCD facilitators who were asked to give examples of MCD sessions they had conducted and to briefly explain the process and outcomes. Facilitators using the dilemma method were asked about the role of worldview. Respondents who do not use the dilemma method were asked whether the aspect of worldview is incorporated into their favored approach and, if so, how.

The following criteria were used to select respondents:

• A minimum of 1 year’s experience in MCD facilitation.
• Currently working in healthcare (hospital or psychiatric clinic).
• Representative distribution in terms of gender, age, professional background and field of operation.

Twelve facilitators were interviewed: six male and six female. They represent a wide range of disciplines and include three medical specialists, one nurse manager, one paramedic, two clinical ethicists, two healthcare managers and three spiritual counsellors. The respondents have acted as facilitators with various groups. Six work in hospitals, three in mental healthcare, and three in both. The facilitators use (or have used) a range of MCD methods: eight use the dilemma method alongside other methods, while four use only alternative methods. A summary of characteristics of respondents is given in Table ​ Table1 1 .

Baseline characteristics of respondents

With the respondents’ consent, all interviews were recorded, transcribed and anonymized by the first author and an assistant. The VU University Medical Research Ethics Committee determined that the study does not fall under the requirements of the Medical Research with Human Subjects Act ( WMO ) as no actual interventions were performed.

Data Analysis

The researchers aimed to identify the key elements of addressing worldview as part of MCD, based on facilitators’ personal experiences. Those experiences were defined as broadly and openly as possible using the grounded theory approach as developed by Charmaz ( 2006 ). The choice for grounded theory was made because we wanted to take the views and experiences of facilitators in moral case deliberation as a starting point in our research. The grounded theory approach implies not operationalizing the concept of worldview from a theoretical perspective beforehand. Data are collected by inviting respondents to present their own views and experiences and by subsequently analyzing this data.

Data analysis was carried out in three stages. The first stage involved open coding: the first two interviews were coded independently by two researchers and the results discussed by all three researchers. The topic list for subsequent interviews was then refined. The next two interviews were coded by the first researcher, after which the three researchers discussed the coding tree. The first researcher then conducted another eight interviews, two of which were co-coded by a research assistant.

During the second stage—focused coding—all codes were abstracted, overlapping themes and subthemes examined and their codes discussed by the first two researchers. This produced codes for 15 subthemes, formulated as gerunds or participles (verbs ending in ‘-ing’) in accordance with Tweed and Charmaz (Charmaz, 2006 ; Tweed & Charmaz, 2012 ). Gerund-based coding ensures a focus on actions rather than concepts, retaining a closer connection to the data (e.g., ‘devoting attention to different visions’ rather than just ‘different visions’). This approach suited our study since we sought to investigate how worldview is actually addressed in MCD practice.

The third phase—axial coding—examined the relationships among and patterns between the various themes, after which the over-arching themes and subthemes were refined and the final categories formulated. All authors agreed with the final set of categories, themes and subthemes.

This section describes the categories, themes and subthemes identified. The role of each theme in addressing worldview is discussed, as identified by both the respondents working with the dilemma method and those who favor other methods. A summary of the categories, themes and subthemes is given in Table ​ Table2 2 .

Summary of the key elements in addressing worldview

Explicit Role of Worldview

The first category is concerned with the explicit role of worldview within MCD. This role is linked to clearly visible forms of religious beliefs or traditional belief systems. We first consider the worldview of the participants before discussing how the facilitators use this aspect to steer the discussion.

Worldview of Participants

Worldview of the patient.

Worldview is relevant if it affects the specific case under discussion. This will certainly be the case where the dilemma involves patients with a clear religious background, such as practicing Jehovah’s Witnesses, Muslims or members of the Jewish community.

We have many patients with an Islamic background. We have also had Jehovah’s Witnesses on occasion, and have sometimes had to contend with the well-known dilemma of their unwillingness to accept blood transfusions. (8) Because we were discussing the Jewish community, we considered the tragic situation of a woman who experienced particularly lengthy menstrual periods. It is not permitted to have sex during menstruation. Ovulation occurs after the onset of menstruation, so if you are not permitted to have sex during this period there is very little chance of conceiving a child. (9)

Moral standpoints can also be directly linked to the patient’s worldview, as illustrated by the following quote concerning attitudes to homosexuality:

I recently had a discussion about a patient of a mental health clinic somewhere in the eastern Netherlands. He is gay. His family had great difficulty accepting him, as did his fellow patients. Worldview certainly plays a part in this situation. (1)

Worldview of the Professionals

The worldview of professionals plays an explicit role within MCD if there is a conflict between professional responsibility and personal religion.

The dilemma might concern a nurse who is not willing to assist in certain interventions due to her worldview. (1) So, in fact you’re being asked whether you would be kind enough to perform five abortions, bring five lives to a premature end, which we are supposed to find acceptable. The patient’s worldview has an effect on the entire nursing team. One member of that team is prepared to speak out. (11)

Approach of Facilitators

Avoid stereotyping.

The first subtheme is the need to be aware of, and to avoid, stereotyping. If the situation is one in which worldview plays an explicit role, facilitators warn against the danger of stereotyping.

Of course, we consider the patient’s religious beliefs and how they affect what he considers important. You must be wary of falling back on stereotypes or preconceptions. (-) He would not wish treatment to be withdrawn. You really do have to be very careful not to jump to conclusions. (1) I think that many preconceptions and prejudices are at play, whether about Christianity, Islam, Anthroposophy, or indeed any worldview that prompts you to place someone in a certain category. The danger is that any personal exchange about the values which underpin the worldview is overshadowed by the worldview itself. (5)

This can also happen because the facilitator omits to have the worldview explained by an MCD participant.

We have an analyst who is half Moroccan. And recently we have had dealings with some Moroccan couples. On one occasion there was an older gentleman who already had eleven children. He had a new, young wife and once again wanted to become a father. Due to his age, however—he was 80—his sperm was not up to the task. The analyst seemed to think that he was letting the Moroccan community down. I advised him not to think of himself as a representative of all Moroccans. We must also beware of allowing your personal vision of what it means to be Moroccan to prevail. (9)

Devoting Attention to Different Visions

The second subtheme is ‘devoting attention to different visions’. Respondents find it important for facilitators to address differences in worldview.

I think it is a very good thing when you look at those perspectives again and hear why someone is or is not willing or able to do something on the basis of their religion or other beliefs. I can appreciate that. It is laudable.(10) It actually depends on my own idea of the case and what it is about. My vision of life, for example. You might believe that being alive is always a good thing provided there is no pain. A lot of people think that way. But there are also people who say that life is worth living regardless of whether there is pain. And even if someone is in pain, that’s not to say that they want to end their life. Pain is part of life. This represents a significant difference in worldviews and in people’s vision of life itself. (2)

Implicit Role of Worldview

In the second category, we are concerned with the implicit role of worldview in the MCD process. In this category, worldview plays an implicit role in the background and is less clearly linked to world religions. It concerns the basis of core values investigated in MCD. Here, we first discuss core values and the inspiration behind them. The second theme is experiencing spiritual fulfillment. The third theme is the lack of appropriate terminology which would allow one’s worldview to be discussed openly, while the fourth theme is the question of how facilitators respond when implicit attention is devoted to worldview.

Core Values and Inspiration Behind Those Values

Core values within the dilemma.

The first subtheme concerns the implicit presence of worldview in the core values relevant to the dilemma. In essence, core values are fundamental beliefs about what makes life valuable and worth living. They are, therefore, a part of the worldview. Devoting attention to core values creates awareness of what is important.

I always find it a sort of revelation when I realize why I stand for the things I do. I think it is wonderful (-) that you become self-aware like this – oh yes, I understand now. I do this because I believe that, and I find it extremely important. I live on the basis of my norms and values, so I do things in a certain way. (10) It is actually the main consideration. (-) Yes, of course it’s about what you find important, what you consider worth pursuing. And it is about your own perspective of life. That might be a religious perspective or a secular one. It is all about worldview, nothing more or less. (1)

Professional Inspiration

The second subtheme is worldview as professional inspiration.

(-) and the other one says, ‘I have that at-home feeling’ I remember from nursing or whatever, why I actually do this work. I want the residents to have that same feeling. And he adds, I can’t remember finding that feeling so important.(5) If I ask people about it, they say, ‘at last we have some opportunity to talk openly about our work and we can link it to the reasons we opted for this profession in the first place.’ In other words, we talk about inspiration, or the values and principles that are important to our work. (7)

Foundation of Values

The third subtheme is worldview as the foundation of values. The respondent indicates that worldview is the inside, the basis providing nutrition to values. Values are inspired by worldview.

We must then try to realize that the worldview is actually the inspiration to arrive at certain values. And it is those values which form the basis for further discussion. (4)

This can be difficult to talk about, because worldview is personal and less readily articulated, as is illustrated by the following quote:

I could say that values form the exterior of one’s worldview. If you ask about worldview, you are actually asking about the inner part behind the values. We do dare to say something about our values. They are the outer casing and they are in contact with each other. We are used to stating them. Those values are fed, and what feeds them is the inside part of the worldview. This is rather more personal because it is often less logical, less readily articulated. Some people can be embarrassed by their worldview. Perhaps it is not fully developed, or so full of dogmatic reasoning it is entirely inflexible. (12)

Perspective of a Good Life

The fourth subtheme is the worldview as the perspective of a good life.

I remember one MCD which I found particularly difficult. It was about an unborn baby who had been diagnosed as having a cleft lip and palate. (-) That is something that cannot be repaired completely but it is possible to bring about a significant improvement. Nevertheless, the parents were insisting that the pregnancy should be terminated. I asked the group to imagine that child playing with his friends, normal and intelligent in every way apart from that one little defect. What is a ‘good life’?

Experiencing Spiritual Fulfillment

Fulfillment through connection.

As the first subtheme in this category, respondents suggest that worldview is an implicit consideration in terms of shared spiritual fulfillment. This is recognized as the experience of a mutual connection between the participants in the MCD process.

MCD offers a way forward as well as an opportunity to speak openly and to reflect on an issue together, whereupon everyone has a much clearer idea of where we stand. I think it is also an opportunity for emotional processing, which may sound high-flown, but MCD should allow time and space for this. In this sense, it is cathartic for the participants. (3)

Worldview forms a prominent component of MCD because the participants experience it as a unique moment, for which the facilitator might even use a word such as ‘sacred’.

I think of these as truly sacred moments. (-) Something actually occurs… I think it is mainly the emerging connection, not only with each other but with the tragic situation. (2)

The Spiritual and Existential Dimension

The second subtheme is the spiritual and existential dimension of seeking the ‘right’ course of action.

… That is something I find almost spiritual – that MCD sets out to determine what I consider to be right and proper, the part I wish to play with regard to others, and whether I will actually be able to do so. (6) But it is almost a sort of existential vision of the nature of reality. You’re saying that the world is not as it should be, whether by fault or design, so we can speak of a tragic situation. (-) You would need to be wearing blinkers to think that nothing is wrong. But the question is, how do we see precisely what is wrong? How do we describe the situation in words? Here, worldview plays a very significant implicit part, although in my experience it does not often manifest itself in an explicit way.(4)

Lack of Appropriate Terminology

Difficulty of open discussion.

The first subtheme in this category is the difficulty of discussing worldview due to the lack of a common terminology. Respondents indicate that in the current secularized society it is difficult to talk about worldview, because the religious language is no longer common.

I am convinced that worldview is a very important part of people’s lives, but my work has taught me that most people are unable to discuss their worldview fully because they cannot find the right words. For the same reason, it is difficult for me to broach the subject and I am reticent to do so. (12) I would like to learn more about how worldview can be expressed in words, and this would probably be similar to the language we use to describe values. I hope that we will develop appropriate terminology together, and by ‘together’ I mean as a society. I see a certain linguistic paucity and helplessness, or at least clumsiness, when it comes to talking about abstract concepts such as worldview. Society as a whole has no common language, although certain groups such as religious communities have made moves in this direction. Nevertheless, the terminology remains fragmented and inconsistent. (12)

Embarrassment

The second subtheme concerns the embarrassment that people might feel when discussing matters of worldview.

Personally, I never inquire about someone’s worldview, perhaps because I sense a certain embarrassment, possibly due to the sheer difficulty of articulating very more abstract concepts, intuitions and ideas.(12) Worldview in the general sense is sometimes brought up, but personal beliefs, religious or otherwise, are not. I get the impression that people find these matters too private to be discussed in an open setting such as an MCD group. As facilitator, one should probe and ask questions, but it would be wrong to embarrass participants or intrude in things they prefer to keep to themselves.(3) During one recent MCD session, worldview was certainly raised by the person whose case we were discussing. ‘I am religious’, he told us. I did not ask him to explain further. Faith and religion are very broad terms. However, it felt almost like an admission of vulnerability. It is nevertheless important to understand why he opts to take a certain course of action.(9)

Avoiding Emphasis

The first subtheme in this category is that the facilitator should avoid emphasizing worldview. There are various reasons for this. Doing so might, for example, hamper the discussion while some people may consider it inappropriate to talk about such matters in the hospital setting.

No, absolutely not because it really stands in the way of open discussion. If I announce that I am a protestant Christian, this creates all sorts of images in other people’s minds, none of which are likely to be particularly helpful. The other participants might jump to conclusions, or maybe I will suddenly think, ‘oh right, in that case I probably shouldn’t be in favor of euthanasia.’(6) I would be very wary of doing so. (-) I’m mindful of being in the hospital setting, which is not really the place to seek philosophical depth. You are satisfied if people realize that you believe in your point of view and are happy to accept it. That is often enough. You might wish to pursue greater depth but I don’t really see that as my task. And given the time involved, it would not be appreciated. However, if you all want to enter a monastic retreat for a weekend and seek depth there, why not? That might be useful. (2)

Thematization via Norms and Values

Although facilitators generally avoid using the term ‘worldview’, they do investigate worldview aspects by asking about norms and values.

I never ask directly about worldview or religion, but I do enquire about what a person considers important. And I use that information. Someone whose worldview is based on anthroposophy, for example, might believe that nature should be allowed to take its course and medical interventions kept to a bare minimum. Muslims might object to the administration of morphine because ‘when you die, you must be able to look Allah in the eye.’ That is my approach – I always take norms and values into account. (5) I do not ask about worldview to determine how a person sees a certain dilemma, but if we are discussing, say, euthanasia and someone says ‘no, I really couldn’t’, I find it useful to ask questions. What are the values on which he bases his objections?(10) If people want to say something based on their worldview, that’s fine too. But I would not ask about worldview outright, at least not immediately. I would be more inclined to ask what particular values are important in this situation. (7)

A similar worldview can result in different values.

What most interests me about someone’s worldview is the values that are important within it. I can say that I am a protestant Christian, and perhaps you are too. But you may be a member of an entirely different church or denomination, or have an entirely different family background. As a result, your views about right and wrong may differ from mine. (6)

One respondent stated that worldview is examined during a session by means of general questions about the participants’ core values.

But what I often do is to go around the group and invite people to say a few words about the values they find important based on their upbringing. I might also ask what values they try to instill into their own children. These are often the person’s core values. (6)

Using the grounded theory approach, we investigated the role of worldview in MCD.

The grounded theory approach implies not operationalizing the concept of worldview from a theoretical perspective beforehand. For our purpose, we defined worldview as “fundamental beliefs about life, death and suffering that structure people’s ideas on how life events are related.” (Littooij et al., 2016a , p. 7). We have chosen this definition, because it is broad, inviting respondents to present their own views and experiences. The concept as defined is not opposed to current approaches in religious studies. Smart distinguishes 7 dimensions of worldviews: philosophical or doctrinal (beliefs), ethical, experiential, material, social, mythic and ritual (Smart, 1991 ). Our concept of worldview is broad enough to encompass these dimensions, but it refrains from explicitly addressing them during the interviews. Our results show that respondents address most of the dimensions distinguished by Smart, although the material and ritual dimensions are not present. A reason for this may be that MCD focuses on words and conversation, not on material objects or rituals.

The results reveal that worldview plays both an explicit and an implicit role.

Worldview becomes relevant in a number of specific examples, all of which are linked to clearly visible forms of religious belief. Respondents cite cases involving followers of the Islamic and Jewish faiths, as well as Jehovah’s Witnesses. The examples often involve some moral issue, such as objections to abortion, euthanasia or homosexuality. A conflict between religion and professional responsibility can arise in care givers who have such objections to some degree, whereupon the fulfillment of their professional duties results in a crisis of conscience. There may also be situations in which the professional is unable to accept or respect the patient’s views or beliefs.

Specific examples of religious worldviews can all too easily lead to assumptions based on stereotypes. Schweda et al. ( 2017 ) draw attention to the risk of stereotyping in end-of-life decisions, describing the variation and complexity of the relevant cultural and religious aspects. “There are no clear-cut positions anchored in nationality, culture or religion. Instead, attitudes are personally decided on as part of a negotiated context representing the political, social and existential situatedness of the individual.” (p. 1) The MCD facilitator should, therefore, devote attention to the various perspectives at play within the group and remain alert to any preconceptions that may exist in order to avoid the pitfalls of stereotyping.

Facilitators state that they consider it important to take the various visions into consideration. The respondents emphasize that worldview colors our moral beliefs. This bears out the findings of Turner’s ( 2003 ) study examining bioethics in a multicultural world. He notes that “…religious convictions and cultural norms play significant roles in the framing of moral issues” (p. 99). Turner also stresses the importance of taking the particular moral world of patients and their family members into account. Cultural and religious traditions determine how people view birth, illness, suffering and death. A more anthropological approach to ethical issues can help to raise awareness of the role of culture and religion in MCD (Turner, 2003 ).

Worldview also plays an implicit role, being the basis of core values investigated in MCD. Those core values represent fundamental beliefs with regard to the value of life: what makes life worth living? Careful discussion of the core values can therefore help MCD participants to identify the crux of the issues at hand (Widdershoven et al., 2016 , p. 73, 79, Hartman et al., 2016 , p. 78).

One specific area in which worldview (in the form of core values) can further the MCD discussion is the professional inspiration of caregivers. Rushton ( 2017 ) points out that keeping sight of one’s original motivation for practicing a certain profession helps to promote resilience (Rushton, 2017 ) and the ability to function well. According to Geller et al. ( 2008 ), motivation includes the desire to be of significance to the patient.

Worldview is also seen as the inner part and inspiration behind values. It thus is tangent to the base of values and displays the foundation on which values are grounded. Worldview shows the fundamental nature of values. In order to clarify the fundamental nature of values, more explicit attention for worldview might be useful during MCD and contribute to the deliberation. We would advise facilitators to be alert to statements or terms which may reveal something about the speaker’s worldview (Alma, 2008 , p. 62). However, facilitators point out the difficulty in discussing this inspiration, which involves matters which are sensitive and do not lend themselves to verbal expression.

During the MCD process, participants attempt to identify what constitutes ‘a good life’. By encouraging explicit discussion of this topic, facilitators can thematize worldview. Doing so will also make participants more aware of their reasons for making choices.

MCD is also beneficial in that it can bring about fulfillment through connection and touch upon the spiritual and existential dimension of ethical issues. The element of connection implicitly refers to religion , in the sense of the Latin religare, one meaning of which is ‘to bind together’. This implies both the connection with important topics and the connection with each other. The spiritual and existential dimension touches upon hope, inspiration and healing (Alma, 2018 ). The relationship between worldview and healing shows marked similarities with that between worldview and coping (Pargament & Ano, 2006 ; Körver, 2013 ; Balboni et al., 2007 ; Puchalski et al., 2009 ). The literature on the relationship between worldview and coping notes that, next to support by talking, support based on rituals can be effective. Rituals can enhance social cohesion and the ‘sense of community’ (Ladd & Spilka, 2013 , p. 445). Perhaps the steps of MCD can themselves be regarded as creating a ritual which may enable participants to deal with difficult moral issues in life.

Addressing worldview is not a simple matter, for various reasons. There is no common language to describe the various aspects involved, and the use of a ‘high-blown’ term such as worldview may itself cause some embarrassment. These limitations account for the changing position of worldview—and in more general terms, religion—in today’s society. Under the influence of modern rationalism, existential themes have been banished to the private sphere. In the public domain, people are more concerned with understanding the causes and effects of more concrete phenomena (Vanheeswijck, 2008 ) rather than ‘the final questions’ (Alma, 2018 , p.53).

Bauman and Donskis ( 2013 ) suggest that there is growing reticence to discuss worldview, and a gradual loss of appropriate terminology, due to secularization and individualization. The search for moral and spiritual significance is increasingly a solo undertaking (Alma, 2018 , p. 54). The disappearance of institutionalized, organized worldviews with moral, existential and spiritual authority in western society means that there is no longer a common language which would enable people to talk to each other about their vision of a good life, or to reflect upon the social constructs which could inform their actions and decisions. (Alma, 2018 , p. 54).

Worldview is an implicit component of any discussion about norms and values. Values can form a starting point for a reflection on what is valuable and worthwhile in life. Here, we must ask whether a more explicit use of the term ‘worldview’ would increase the cohesion of the various values within someone’s vision of ‘a good life’, thus furthering their thematization. We propose to further explore this potential addition to the MCD methodology, as has been done regarding the explicit thematization of emotions (Molewijk et al. 2011a , b ).

Strengths and Limitations

As far as we know, this is the first study examining the visions and experiences of facilitators on addressing worldview in MCD. Our study, however, has some limitations. The interviews were conducted by a researcher with a background in pastoral care. This may have influenced the interviews. A second limitation is that the study was conducted in the Netherlands, in a largely secularized society. This may limit generalization to other countries. A third limitation is that the interviews were held with facilitators. Interviews with MCD participants might give information about their experiences and complement the results.

According to the facilitators taking part in this study, worldview plays both an explicit and an implicit role in the MCD process. The explicit role concerns the religious beliefs of patients and professionals. This calls for alertness in order to avoid stereotyping. The implicit role involves the core values, intentions and inspiration of the participants. Aspects of worldview are also at play in the creation of connection between participants, and their experience of the spiritual and existential dimension of ethical dilemmas. In order to clarify the fundamental nature of values, more explicit attention for worldview might contribute to the deliberation. Including aspects of worldview might enhance the methodology of MCD, allowing greater opportunity for reflection on aspects for which appropriate terminology is lacking in our modern society. However, this should be done with caution as the term ‘worldview’ might be interpreted by participants in terms of religious and personal beliefs, rather than as an invitation to reflect on one’s view of the good life as a whole.

Acknowledgements

We are grateful to all the respondents who contributed to this research by sharing their views on the role of worldview in moral case deliberation.

Authors' Contribution

BS contributed to the conception of the study and participated in its design, development and coordination and was involved in drafting and revising the manuscript. GW contributed to the conception and participated in the design and development of the study and was involved in drafting and revising the manuscript. HA contributed to the conception and participated in the design of the study and was involved in drafting and revising the manuscript. All authors read and approved the final manuscript.

There is no funding involved in the design of the study, the collection, analysis, and interpretation of data, and in writing the manuscript.

Availability of Data and Materials

Declarations.

The authors declare that they have no conflict of interest.

The respondents gave their approval and consent to participate. Respondents are indicated by number instead of by name or function. All names, places and other characteristics of the participants involved are changed and therefore untraceable. The VU University Medical Centre’s Medical Research Ethics Committee declared the study did not fall under the Medical Research (with Human Subjects) Act ( WMO ), as no interventions were performed.

The respondents gave their approval for publication.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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• Research article
• Open access
• Published: 09 August 2019

“I go into crisis when …”: ethics of care and moral dilemmas in palliative care

• Ludovica De Panfilis   ORCID: orcid.org/0000-0002-5509-7626 1 ,
• Silvia Di Leo 2 ,
• Carlo Peruselli 3 ,
• Luca Ghirotto 4 &
• Silvia Tanzi 5 , 6  

BMC Palliative Care volume  18 , Article number:  70 ( 2019 ) Cite this article

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Recognising and knowing how to manage ethical issues and moral dilemmas can be considered an ethical skill. In this study, ethics of care is used as a theoretical framework and as a regulatory criterion in the relationship among healthcare professionals, patients with palliative care needs and family members.

This study is a part of a larger project aimed at developing and implementing a training programme on “ethical communication” addressed to professionals caring for patients with palliative care needs. The aim of this study was comprehending whether and how the ethics of care informs the way healthcare professionals make sense of and handle ethical issues in palliative care.

Qualitative study employing a theoretically driven thematic analysis performed on semi-structured interviews.

The research was conducted in a clinical cancer centre in northern Italy. Eligible participants were physicians and nurses from eleven hospital wards who assisted patients with chronic advanced disease daily and had previously attended a 4-h training on palliative care held by the hospital Palliative Care Unit.

The researchers identified five themes: morality is providing global care; morality is knowing how to have a relationship with patients; morality is recognizing moral principles; moral dimension and communication; and moral dilemmas are individual conflicts.

Conclusions

Ethics of care seems to emerge as a theoretical framework that includes the belief systems of healthcare professionals, especially those assisting patients with palliative care needs; moreover, it allows the values of both the patients and professionals to come to light through the relationship of care. Ethics of care is also appropriate as a framework for ethical training.

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Palliative care is defined by the World Health Organization as “an approach that improves the quality of life of patients and their families facing problems associated with a life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual” [ 1 ]. Palliative care therefore requires many different competences, not only clinical but also relational, communicative and ethical [ 2 ].

Studies in the literature show that clear and honest communication about the diagnosis and prognosis of a fatal illness, which fully respects patients’ wishes and preferences, positively affects their quality of life and improves symptom management [ 3 ]. Good communication stems partly from innate quality and can improve with experience. Nevertheless, it can also be increased through specific training programmes that take into account all of the abovementioned domains. A number of studies have shown that healthcare professionals (HPs) recognise and address ethical issues and that their awareness of moral dilemmas that may arise in decision-making is part of effective communication [ 4 , 5 ].

From the Greek word ethos meaning habit or custom, ethics is the branch of philosophy that concerns human behaviour, customs, and habits, particularly with reference to the rules of conduct and their justification [ 6 ].

Ethical debate in palliative care has focused on several and sometimes opposing approaches, among which is the classical deontological approach of principlism, “virtue” ethics, and ethics of care.

Principlism is based on principles originally proposed by Beauchamp and Childress [ 7 ]: autonomy (to give an individual the freedom to make his or her own choices), beneficence (to do good and to act with the best interests of the other person in mind), non-maleficence (to do no harm to people), and justice (to promote fairness and equality among individuals). Each principle relates to each of the other three principles; therefore, they should be ordered according to the criteria of priority for each individual case, with the ultimate aim of “the best interests of the patient” [ 7 ]. As this approach provides a valid basis for assessing the appropriateness of behaviours concerning morality, it may have some limitations concerning its full applicability in the medical context, above all within palliative care. Indeed, conveying the concept of the human being as a subject in its own right, fully aware, competent and independent, can be considered inadequate in medicine and health care, where human complexity and interpersonal relations need to be considered. Some authors argued that the four principles suggest that the approach is imperialist, inapplicable, inconsistent and inadequate [ 8 ]; others argued that the four-principle approach does not consider the role of emotional reactions as an integral part of our moral perceptions and decision making [ 9 ].

Virtue ethics may be identified as the ethical theory that emphasises virtues or moral character [ 10 ]. All forms of virtue ethics are based on two concepts, i.e., virtue and practical wisdom: virtue ethics is a framework that focuses on the moral character rather than the rightness of an action [ 9 ]; it provides a broader ethical analysis and encourages more flexible and creative solutions than principlism [ 11 ]. Its main limitations are putting too much emphasis on a person’s moral character and on cultural judgement of values, and the inability to provide decisional elements to support the choice [ 10 ].

The ethics of care theoretical framework [ 12 ] represents an interesting ethics approach for reading and analysing ethical issues and moral dilemmas in palliative care. In our view, it could represent not only a valid theoretical framework but also a guiding criterion in the relationship among HPs, patients with palliative care needs, and their families.

The central concept of this approach is care, conceived both as an action concretely expressed towards the other, and as a value that has the goal of being universally shared, beginning with the awareness of the fragility and vulnerability of the human condition [ 13 ]. Ethics of care recognises that human beings are interdependent, and for this reason, they need respect, protection, and care [ 14 , 15 ]. Moreover, it highlights significant ethical aspects in the development of the relationship of care [ 14 , 15 ]. From this perspective, every moral choice or ethical issue is conceived as inserted in a network of interpersonal relationships, nurtured by communication, since both illness and the patient experience can be considered as the products of a set of interconnections.

To deepen the theoretical relationship between ethics of care and palliative care, we reviewed the literature by combining the terms “care ethics” or “ethics of care” with “palliative care”. We retrieved articles [ 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 ] concerning two main topics, i.e., a) the need to set medical ethics on a new foundation by grounding it on a different set of values, such as compassion, heedfulness, vulnerability, and the integrity of the person; and b) the specificity of the moral dilemmas often arising in medical care and the need for approaching them with moral notions different from the classical moral theory [ 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 ].

Lachman discussed the use of the theory of care ethics to help nurses determine if they are applying this theory effectively in their practice [ 16 ]. After having described care ethics and its evolution through the main authors’ theories, he/she presents a case study to illustrate the philosophical approach of Joan Tronto [ 18 ]. Lachman assumes that a care orientation is fundamental to the nurse-patient relationship and that Joan Tronto’s version of the ethics of care must/might be implemented in the care relationship. Although this paper does not mention the Palliative care field, it provides the reader with a practical use of the ethics of care in a healthcare field.

William T. Branch has argued that ethics based on caring for the patient needs to be grounded on the patient/physician relationship, making it necessary to rely on the physician’s moral sensitivity [ 17 ]. He also argued that HPs can recognise patients’ wishes and preferences, but equally important is their capacity for compassion, as well as honesty, integrity and a sense of humility. He defines this approach as “the ethics of patient care” and assumes that building medical ethics on this foundation leads to a framework of caring ethics.

On these bases, Branch built a theoretical frame to include ethics of care as a suitable approach to palliative care.

In their research project “Practical ethics of Palliative care”, Hermsen and Ten Have [ 19 ] suggest that palliative care does not fit well into the classical biomedical model and that it can rather be considered a new philosophy of care, introducing new moral notions of wider relevance into the healthcare context. As a consequence, they argue that it is possible to identify a moral dimension that is specific to palliative care.

To widen the moral horizon and increase moral sensitivity, de Vries and Leget [ 20 ] introduce an ethical framework to address elderly patients with cancer. This ethical approach stems from the ethics of care because it focuses on the caring relationship. Authors compare ethics of care with principlism, which is the ethical theory predominant in contemporary medicine. As opposed to principlism, ethics of care underlines not only the attention to the patient context but also a broader comprehension of the illness and a different concept of autonomy [ 20 ].

In a paper published in 2017, Inge van Nistelrooij et al. [ 21 ] express the need to reframe autonomy in a shared decision-making process as relational autonomy. Authors state that, to reconceptualise relationality, it is mandatory to “turn to care ethics” [ 22 ].

Schuchter and Heller [ 23 ] also use notions of the ethics of care. They affirm that “the solution” to a moral problem does not lie in judging actions on the basis of moral principles, but in intensifying relationships and enhancing empathetic involvement " .

The need to manage moral issues, such as respect for a broader meaning of autonomy, the central role of the patient’s concept of dignity, the role of choice, the importance of truth, the concept of quality of life, the value of emotions and the existential issue, is an integral part of the palliative care approach.

In this sense, we believe that Ethics of Care takes into consideration aspects that classical ethics have overshadowed: trust and responsibility, protection of individuality, the context in which the relationship takes place, and the quality of the relationship.

This study is part of a larger project aimed at developing and implementing an ethics communication training programme addressed to HPs who treat patients with palliative care needs.

The aim of this study was comprehending whether and how the ethics of care informs the way HPs make sense of and handle ethical issues in palliative care.

We employed a generic qualitative research design [ 24 ] using semi-structured interviews.

Study population

We conducted the study in a clinical cancer centre in northern Italy. The study was approved by the Ethics Committee of the Provincial Health Authority of Reggio Emilia.

Eligible participants were physicians and nurses from eleven hospital wards who were involved daily in the care of patients with chronic diseases with poor prognoses and had previously attended a 4-h training on palliative care held by the hospital Palliative Care Unit. A conveniently selected sample of a physician and a nurse per ward was chosen.

The heads of each hospital ward were informed by the Principal Investigator (PI) on the objectives and the request for collaboration in the research. After obtaining access to the field, the PI e-mailed the information and request for participation to selected professionals. The invited participants were then contacted by telephone by the PI who, after obtaining consent, agreed on the place and times for participating in the study. In the cases of refusal to participate, the researchers contacted potential replacements. All participants provided signed informed consent to participate in the qualitative interviews.

Sixteen out of twenty subjects agreed to participate in the study. We interviewed 9 physicians and 7 nurses from 11 wards. The participant characteristics are shown in Table  1 .

Data collection

We derived the thematic areas to discuss during the interview sessions with participants from the ethics of care framework, consequentially focusing on care relationship.

Thematic areas were developed by the P.I. (LDP), a researcher and bioethicist, and SDL, a clinical psychologist expert in qualitative research. They agreed on three broad topics: the perception of ethical issues, the experienced role of ethical issues within the care relationship, the way interviewees recognise and deal with ethical dilemmas within the care relationships.

We used open-ended, semi-structured interviews [ 25 ] because of their flexible structure, which allows the interviewer to adapt and change the questions according to the interviewee’s agenda and answers. For conducting the interview, we pre-planned some exemplifying questions that we report in Table  2 .

The P.I. conducted the semi-structured individual interviews. She did not know the participants.

The semi-structured individual interviews lasted a mean of 45 min.

Data analysis

Interviews were audio-recorded and transcribed verbatim. Data analysis was conducted by the P.I, together with S.T., palliative care physician with experience in qualitative research, and L.G, qualitative research methodologist. We performed a theoretically driven thematic analysis [ 26 ] by following these analytical stages:

L.D.P. transcribed the interviews verbatim and shared the transcripts with colleagues. They wrote comments and initial thoughts in a memo;

L.D.P., S.T. and L.G. extracted portions of the text individually and then shared their work to reach an initial agreement. During this stage, they inductively conducted the thematic analysis [ 26 ], providing their insights;

subsequently, they mapped the themes onto the ethics of care framework;

they independently reviewed themes and allocated portions of the text to the newly reconfigured themes;

together, they re-defined themes and re-named them to achieve internal consistency;

L.D.P. selected representative extracts from the interviews and drafted the final report, which was checked and amended by all the authors.

Sixteen out of twenty subjects agreed to participate in the study. We interviewed 9 physicians and 7 nurses from 11 wards. They were 10 female and six male; the mean age was 43,8 years old (range 21–70).

Five themes and related sub-themes have been identified: 1) morality is providing general care; 2) morality is knowing how to have a relationship with patients; 3) morality is recognizing moral principles; 4) moral dimension and communication; and 5) moral dilemma as individual conflicts. Themes and sub-themes are shown in Table  3 .

Morality is providing general care

Morality plays a crucial role in the relationship of care, which cannot be demanded and cannot be avoided.

“Morality is the first hurdle we face, together with ethics and deontology. Deontologically, it is the sick person who is at the centre of the care, and morally, one should try to work in an ethical manner, understood as good behaviour…. but these concepts do not always go hand in hand” (P01).

Morality emerges as the human side of care and deals with giving importance to aspects such as knowing how to tell the truth, knowing how to answer questions on the sense and meaning of suffering, and being able to have a dialogue with the patient. Respect for patient dignity and his or her values is the manifestation of morality in the care relationship. Although it is expressed in different ways, due to the different roles they play, morality has the same meaning for nurses and physicians, making the care truly global.

“Morality is respect for everything, the care of the patient’s morality, the care of everything, […]. I think that all professionals should first of all respect themselves, and then give this respect to others” (N02).

“I believe that there are ways or strategies to talk about morality, but we don’t have them. This is what is missing. But you realise that it is often enough just to listen to, and when you give answers, to give these with your heart” (N06).

“If I think of morality, I think of my professional ethics, which is expressed in giving the best from a scientific point of view, and then entering into empathy with patients, so that they feel at ease in a complex path of care and, finally, in creating a relationship of trust” (P05).

Morality is knowing how to have a relationship with patients

The relationship is an essential aspect of care, intended in a moral sense, and must involve all “actors” of the care process: patients, relatives and HPs. This perspective is very clear in some interviewees:

“I believe that everything revolves around a relationship based on affection. This type of affection must be transmitted in some way at every stage. And this is done through words, gestures, physical contact […]. You must know how to be in the relationship.” (P11)

“It is difficult to abstractly establish how to behave in certain situations with real protocols. However, in my opinion, some techniques, even relational ones, can certainly help. Although, we do not all agree on this point” (P14).

Knowing how to be in the relationship, knowing how to manage it, and considering it in emotional terms, emerges as a way to provide care. Some participants report that the relationship cannot become too personal, and a certain amount of professionalism must always be maintained. For this reason, the relationship is difficult, challenging and, as it is built, it must be nourished daily. Others conceive of personal involvement as a limit in the care relationship; although unavoidable, it comes with the risk of being overwhelmed.

“Involvement is always there. But it is not that kind of involvement that makes you say: “I will bring the pain of that patient home with me,” it consists of entering into a challenging and demanding relationship with that person” (N09).

“As soon as you establish a dialogue with the patient on moral issues and find out what is important to him/her, you enter into the patient’s subjective sphere which you must be able to perceive and manage” (P03).

Morality is recognizing moral principles

HPs show that they have a broader idea of the moral principles featuring the care relationship compared to being strictly principlist. Nevertheless, sometimes the definition of these principles is not entirely clear. The principle of autonomy, for example, was directly mentioned only once, and yet in what the interviewees reported, the influence of this regulatory principle appears evident:

“My first principle is to make people aware, to try and give a person the tools so that they can make an autonomous and independent choice” (P07).

“The principles that guide me are those of respect, of the attempt to understand the patients’ experience and trying to understand and evaluate their situation” (N10).

“Morality is respect for the patients’ way of thinking, their decisions and values, the ability to not make them suffer, to eliminate everything that is harmful by meeting their needs, even if it goes against what I think” (N08).

Relational autonomy, correctness, sincerity and humanity are among the moral principles that are most often highlighted:

“I would say, first of all, that we are talking about the human side of care. Yes, I would say the human and relational component. And then the honest side of care. Morality concerns the humanity in a relationship of care” (P12).

Morality is giving importance to dialogue and communication

Interviewees talk about morality through the different skills they use to put it into practice. These skills deal with the ability to dialogue and to listen to the patient, to give meaning to the patient’s narrative, to share his/her values, and to personalise communication exchanges; moreover, the professional awareness that telling the truth is not a univocal process, strongly emerges from the interviews.

“My strategy is to listen to, to explore the dimension of the sick patient’s existence, trying to understand how much that person is still anchored in his/her life […]. The patient’s value horizon guides the communication” (P15).

“Morality has many aspects, even of a personal and cultural nature. There is the way that you conceive your own morality and that of the patient. You have to learn to talk about it” (N13).

“To explore the values of a patient, it is important to understand their life experiences, their beliefs and interpretations” (P04).

“You also need to be able to see a desire, a wish emerging from the fragments of speech of the sick person. It is important for the communication to be gradual, to understand what truth is acceptable, and to know how to communicate it. The discourse of truth is a moral discourse, for example” (P16).

Moral dilemmas as individual conflicts

All interviewees define moral dilemma as an inner conflict, to which they frequently cannot find a solution or that they cannot manage; therefore, it’s not unusual that dilemma often remain unresolved and accepted as an inevitable aspect of healthcare profession. Some participants refer to moral dilemmas highlighting their difficulty in reading end-of-life situations.

The narrated dilemma often touches on a very personal sphere: rather than concerning deontology or a specific ethic framework, it is embodied in the life experience of each individual professional.

“I prefer to help young people with cancer and their suffering as quickly as possible, perhaps by means of terminal sedation. On the other hand, my Christian ethics tell me: “What are you thinking? It is not up to you to decide it”. Therefore, many times my decision, though painful, is somewhere between a treatment that alleviates suffering and the respect of my Christian ethics” (P15).

“It concerned a personal situation, with my father […]. I lied to him about whether he was going to die. I felt very bad and after 25 years I still don’t know if it would have been better to tell him, he would have died anyway… If he had been one of my patients, I would have told him, but it’s different with family members…” (P12).

“I go into crisis when family members ask me not to tell the truth to the patients. I mean, if I was in their position, I would want to know, I would want to make the decisions together with the doctor. I would like to choose how to live my life to the end” (N08).

“I go into crisis when I have to say that there are no more useful tools to cure them, then I invent atypical drugs, nothing special, but in practice we continue to treat the patient to give the illusion that we are doing something” (P16).

The aim of this study was to comprehend whether and how the ethics of care informs the way HPs make sense of and handle ethical issues in Palliative care.

In our findings, morality fully emerges as a multidimensional concept. Its different meanings can be summarised by the following themes: morality is providing general care; it is knowing how to have a relationship with patients; it means recognizing moral principles and giving importance to dialogue and communication. Moreover, HPs seems to perceive moral dilemmas as “inner conflicts” that they cannot manage.

Although morality arise as an unconscious and unstructured concept, it seems to play a significant role in the care relationship. No explicit reference emerges in favour of a single ethical framework used in daily clinical practice; HPs talk about ethical issues in palliative care using notions and concepts such as caring relationship, listening, dialogue. These aspects are strongly highlighted in the ethics of care approach, focusing - as Leget wrote – on the caring relationship as being constituted of both patient and professional, as well as on the larger context of a person’s life [ 20 ].

Ethics emerges as an aspect of care concerning not only existential issues at the end of life, but also a number of choices throughout the entire patient care pathway. These choices have to deal with patient’s comfort, body care, patient’s preferences toward the administration of treatments.

From our results, it emerges that HPs tend to balance patient empowerment, compassion and understanding with solicitude within the care relationship. Thought compassion or solicitude are key concepts not only of the ethics of care approach, nevertheless they address specific caring attitudes described by the ethics of care approach, i.e., telling the truth while keeping hope alive, respecting as much as possible the degree of patient autonomy and meeting the patient’s spiritual needs, especially at the end of life [ 4 , 27 , 28 , 29 ].

Our results seem to confirm the need for HPs for a step-by-step moral training. In fact, they tend to approach ethical issue with great emotional involvement, sometimes reporting on personal events; in addition, they seem to lack skills aimed at resolving dilemmas.

Without oversimplifying matters, principlism can help in reasoning about classical ethical principles and their application to a single moral dilemma [ 7 ]; the ethics of virtue can help in developing moral attitudes and “practical wisdom” [ 30 ]; the ethics of care underlines the importance of intensifying relationship and enhancing empathetic involvement [ 23 ]. These approaches, taking together, can be the basis for the development of a moral training providing HPs with ethical communication skills to interpret moral problems in a plural way.

As Leslie Bender [ 31 ] demonstrates, ethics is giving importance and focusing on care, compassion, availability, dialogue and communication, as well as learning the ability to listen carefully to others and to pay attention to the needs of others.

Strengths and limitations

The research was consistently designed and conducted as a theory-driven study: the ethics of care theory formed the basis of all the steps (from the definition of the study design to the construction of the interview guide and data analysis), and this made a contribution to the transparency. We are fully aware that biases may arise from a prestructured qualitative research [ 35 ] design, but the choice of conducting this type of study depended on several methodological choices and organisational constraints: the scarceness of qualitative research in this context, the time and resources available, the purpose of proving the relevance of ethics of care in practice, and a data analysis process that is coherent with the purpose.

Among methodological limitations, we should highlight the following. Interviews were conducted by one interviewer only. However, data were analysed and discussed by a multidisciplinary team of researchers, and this could ensure scientific rigour and intersubjective corroboration. Since the study included only sixteen participants for convenience, we could not evaluate saturation. Nonetheless, we recruited both physicians and nurses from ten different hospital wards, allowing us to maximise and vary the professional perspectives included in the study.

The results of this study suggest that for Health Professionals recognizing moral principles, dealing with ethical dilemmas and giving importance to dialogue and communication is paramount in the care relationship.

This requires developing and implementing effective educational programs focused on step-by-step moral training. The program should include at least the following objectives: empowering HPs with the ability to recognise ethical dilemmas and analyse conflicts; promoting sensitiveness to principles, values, goals and wishes of patients; and ensuring the ability of HPs to come to reasoned decisions in daily clinical practice [ 32 , 33 , 34 ].

Different ethical approaches can help in reaching the objectives described; the ethics of care framework also includes the belief systems of HPs; moreover, it allows the values of the patients and HPs to come to light through the relationship of care.

Availability of data and materials

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Healthcare Professionals

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Acknowledgements

The authors wish to thank the management of the following Reggio Emilia hospital wards: Oncology, Hematology, Internal-Medicine Oncology, Nephrology, Pneumology, Infection Diseases, Intensive Care, Long-term care, Cardiology, Rehabilitation, Obstetrics and Gynecology, for allowing this study to be carried out. The authors would also like to thank all the healthcare professionals who kindly participated in this study giving their time, experiences, and insights.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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Silvia Di Leo

Past President Italian Society of Palliative Care, Milano, Italy

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Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy

Luca Ghirotto

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LDP and SDL made a substantial contribution to the concept and the design of the work, they analysed and interpreted data, and drafted the article; LG designed the work and analysed data; CP revised the article critically and approved the version to be published; ST made a substantial contribution to the concept of the work and analysed data. All authors have read and approved the manuscript.

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The study was approved by the Ethics Committee of the Provincial Health Authority of Reggio Emilia (Protocol n. 2015/0003925, Feb., 19, 2015). All participants provided signed informed consent to participate in the qualitative interviews.

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De Panfilis, L., Di Leo, S., Peruselli, C. et al. “I go into crisis when …”: ethics of care and moral dilemmas in palliative care. BMC Palliat Care 18 , 70 (2019). https://doi.org/10.1186/s12904-019-0453-2

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Ethics has long been a catchphrase that has come to mean different things to different people. Business ethics, in particular, has been known to mutate according to the context and requirements of the business entity in question. This paper seeks to elucidate the concept and application of ethics within the context of a particular industry and uses a case study approach to investigate the workings of a company with a focus on the operations of a local company in terms of its alignment to ethical norms. The methodology used was content analysis of documents pertaining to the company’s operations. The findings revealed that the company did use an ethical approach in its business operations thereby proving that a business enterprise can succeed without having to resort to unethical practices to secure profits.

The third edition of Business Ethics: Decision Making for Personal Integrity and Social Responsibility, by Hartman, DesJardins, and MacDonald, offers a comprehensive, accessible, and practical introduction to the ethical issues arising in business. The text focuses on real-world ethical decision making at both the personal and policy levels and provides students with a decision-making process that can be used in any situation. In addition, practical applications throughout the text show how theories relate to the real world. The third edition features thoroughly updated statistics and coverage of timely issues and dilemmas throughout the text.

International Journal of Procurement Management

Mohammed T Nuseir

Journal of Business Ethics

INTERNATIONAL JOURNAL OF INNOVATION AND ECONOMIC DEVELOPMENT

JUSTIN GABRIEL

This paper reviewed the literature on ethics, ethical theories, ethical principles; as well as the implications of unethical practices in organizations. The study revealed that unethical business practices have devastating consequences on organizations; since they result in poor corporate image, financial losses; market failures and sometimes complete corporate collapse. It was further observed that corruption, bad leadership, poor corporate governance, conflict of interest, lack of accountability, inadequate CSR, abusive and intimating behaviors among others are common in most organizations. The paper concludes that it is beneficial and in the enlightened self -interest of organizations to adopt good ethical practices. The paper also recommends that managers’ should ensure that ethical standards are crafted in their business philosophy and strategic intents in order to build and maintain a good corporate image.

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ORIGINAL RESEARCH article

Moral judgment reloaded: a moral dilemma validation study.

• 1 Psychology, Evolution and Cognition (IFISC-CSIC), University of the Balearic Islands, Palma, Spain
• 2 School of Psychology and Neuroscience, University of St Andrews, St Andrews, UK
• 3 Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK

We propose a revised set of moral dilemmas for studies on moral judgment. We selected a total of 46 moral dilemmas available in the literature and fine-tuned them in terms of four conceptual factors ( Personal Force, Benefit Recipient, Evitability , and Intention ) and methodological aspects of the dilemma formulation ( word count, expression style, question formats) that have been shown to influence moral judgment. Second, we obtained normative codings of arousal and valence for each dilemma showing that emotional arousal in response to moral dilemmas depends crucially on the factors Personal Force, Benefit Recipient , and Intentionality . Third, we validated the dilemma set confirming that people's moral judgment is sensitive to all four conceptual factors, and to their interactions. Results are discussed in the context of this field of research, outlining also the relevance of our RT effects for the Dual Process account of moral judgment. Finally, we suggest tentative theoretical avenues for future testing, particularly stressing the importance of the factor Intentionality in moral judgment. Additionally, due to the importance of cross-cultural studies in the quest for universals in human moral cognition, we provide the new set dilemmas in six languages (English, French, German, Spanish, Catalan, and Danish). The norming values provided here refer to the Spanish dilemma set.

“… but what happens when we are exposed to totally new and unfamiliar settings where our habits don't suffice?”

Philip Zimbardo (2007) ; The Lucifer Effect, p. 6

Introduction

Moral dilemmas have become a standard methodology for research on moral judgment. Moral dilemmas are hypothetical short stories which describe a situation in which two conflicting moral reasons are relevant; for instance, the duty not to kill, and the duty to help. By inducing the participants to make a forced choice between these two reasons, it can be investigated which reason is given precedence in a particular situation, and which features of the situation matter for that decision. Accordingly, we assume that this kind of hypothetical “ticking bomb scenarios” can help to disentangle what determines human moral judgment. This is, however, only possible if the moral dilemmas are very well designed and potentially relevant factors are controlled for. The aim of this paper is to provide a set of such carefully designed and validated moral dilemmas.

The moral dilemmas commonly used in Cognitive Neuroscience experiments are based on what Foot (1967) and Thomson (1976) called the “Trolley Problem.” The trolley dilemma has two main versions. In the first one, a runaway trolley is heading for five railway workers who will be killed if the trolley pursues its course. The experimental participant is asked to take the perspective of a protagonist in the story who can choose the option to leap in and to pull a switch which will redirect the trolley onto a different track and save the five railway workers. However, redirected onto the other track, the trolley will kill one railway worker who would otherwise not have been killed. In an alternative version of the dilemma, the action the protagonist has to perform in order to stop the trolley is different. This time, there is no switch but a large stranger who is standing on a bridge over the tracks. The protagonist can now choose to push that person with his hands onto the tracks so that the large body stops the train. The outcome is the same: five individuals saved by sacrificing one. However, participants in this task more easily consent to pull the switch while they are much more reluctant to push the stranger with their own hands. The “action” that the protagonist of the story can choose to carry out—or not—is termed a moral transgression or moral violation . The choice itself, between the act of committing or omitting to carry out the moral transgression is a moral judgment . The decision to commit the harm is referred to as an utilitarian moral judgment, because it weights costs and benefits, while the decision to refrain from harm is a deontological moral judgment, because it gives more weight to the “not to kill” principle.

The influential work of Greene et al. (2001) , which introduced moral dilemmas into Cognitive Neuroscience, has been followed by many other studies as a way to deepen our understanding of the role of emotion in moral judgment (for a review, see Christensen and Gomila, 2012 ). However, results obtained with this methodological approach have been heterogeneous, and there is a lack of consensus regarding how to interpret them.

In our opinion, one of the main reasons for this lays in the simple fact that the majority of studies have relied on the initial set of moral dilemmas devised by Greene et al. (2001) . While this set indisputably provided invaluable evidence about the neural underpinnings of moral judgment, it was not validated. Thus, conceptual pitfalls and formulation errors have potentially remained unchallenged ( Christensen and Gomila, 2012 ). In fact, one of the key findings that have been reported (i.e., emotional involvement in moral judgment) might have been due to uncontrolled variations in the dilemma formulations, rather than to the factors supposedly taken into account (i.e., personal vs. impersonal versions of the dilemma). As a matter of fact, Greene and colleagues themselves have worded constructive self-criticism with respect to that initial dilemma set and suggested using only a subset of the initial dilemmas, however, without validating them either ( Greene et al., 2009 ). Still, researchers continue to use this initial set. Here we present our efforts to remedy this situation.

We have fine-tuned a set of dilemmas methodologically and conceptually (controlling four conceptual factors). The set was selected from previously used moral dilemma sets: (i) Greene et al. (2001 , 2004) and (ii) Moore et al. (2008) (this set was based on Greene et al.'s but optimized). Both sets have been used in a wealth of studies, however, without previous validation (e.g., Royzman and Baron, 2002 ; Koenigs et al., 2007 ; Moore et al., 2008 , 2011a , b ). After the dilemma fine-tuning, norming values were obtained for each dilemma: (i) of arousal and valence (to ascertain the differential involvement of emotional processes along the dimensions of the 4 conceptual factors) and (ii) of moral judgment (to confirm that moral judgment is sensitive to the four factors) 1 . Finally, in the Supplementary Material of this work, we provide the new set in six languages: English, French, Spanish, German, Danish , and Catalan in order to make it more readily available for cross-cultural studies in the field. Please note that the norming study was carried out with the Spanish dilemma version. We encourage norming studies in the other languages (and in other cultures).

Dilemma “Fine-Tuning”—Proposal of an Optimized Set

All dilemmas included in this set involved the decision to carry out a moral transgression which would result in a better overall numerical outcome. The participant was always the protagonist of this action (the moral transgression) 2 and all dilemmas involved killing (i.e., all social and other physical harm dilemmas were eliminated). Furthermore, of the initial 48 dilemmas, 2 were eliminated (the personal and impersonal versions of the cliffhanger dilemma) due to the unlikely acrobatics they involve.

In what follows we outline the changes we have made regarding (i) the instructions given to the participant (subsection Instructions to the Participant ); (ii) the dilemma design , i.e., adjustment of dilemma length, expression style , etc. (subsection Dilemma Design (1)—Formulation ), (iii) the dilemma conceptualization , i.e., thorough adaptation to the conceptual factors of Personal Force, Benefit Recipient, Evitability , and Intentionality (subsection Dilemma Design (2)—Conceptual Factors ), and (iv) the formulation of the question eliciting the moral judgment (subsection The Question Prompting the Moral Judgment ). In the end, we have produced 23 dilemmas with two versions each, one personal and one impersonal, 46 dilemmas in total.

Instructions to the Participant

To increase verisimilitude, we suggest that instructions at the beginning of the experiment ideally emphasize that participants are going to read short stories about difficult situations as they are likely to appear in the news or in the radio (for instance: “ in the following you will read a series of short stories about difficult interpersonal situations, similar to those that we all see on the news every day or may read about in a novel ”) ( Christensen and Gomila, 2012 , p. 14). This may help to put the participants “in context” for the task that awaits them. In addition, instructions could include a remark about the fact that participants will be offered one possible solution to the situation, and that their task will be to judge whether the proposed solution is acceptable, given the information available (such as: “ for each of the difficult situations a solution will be proposed. Your task is to judge whether to accept or not this solution” ). Indeed, the closure of options or alternatives is important. However, in previous dilemma sets, some dilemmas have included expressions such as “ the only way to avoid [death of more people] is to [action proposal],” while other dilemmas did not. Whereas this is important information, including that same sentence in all dilemmas could make the reading rather repetitive and result in habituation. On the other hand, including it only in some dilemmas could bias participants' responses to these dilemmas with respect to the others. Therefore, we suggest presenting it only in the general instructions to the participants.

Dilemma Design (1)—Formulation

Control for formal characteristics of dilemma formulation includes:

Word count across dilemma categories: in the original sets the dilemmas were rather long. This can entail an excessively long experimental session, resulting in participant fatigue. In Moore et al. (2008) an effort was made to control for mean word count: the Personal moral dilemmas (PMD) had 168.9 words and Impersonal moral dilemmas 169.3 (IMD). The maximum word count of a dilemma was 254 and the minimum was 123. We shortened the dilemmas removing information that was not strictly necessary and equalized the expression style of personal and impersonal versions of each dilemma. For instance, technical terms and long, non-familiar words were removed. Now the first three sentences of each dilemma are almost the same for both versions of a dilemma (personal and impersonal). For instance, the English version of the new dilemma set has a mean word count of 130 words in the Personal and 135 in the Impersonal moral dilemmas. Our maximum number of words in a dilemma is 169 and the minimum 93. See the Supplementary Material for the word counts for each translation.

Framing effects

A framing effect consists in that people may judge one and the same situation differently, just because of the way it is described ( Tversky and Kahneman, 1981 ; Petrinovich et al., 1993 ). Specifically, a clear risk of framing effects concerns the use of “kill” in some dilemmas, but “save” in others. People feel more inclined to choose inaction when kill is used, and more inclined toward action when save is emphasized ( Petrinovich and O'Neill, 1996 ). To avoid this, in all dilemmas the words kill and save are used in the second paragraph where the participant is given the information about the proposed action (i.e., the moral transgression) and its consequences. Conversely, the words are removed from the question (e.g., Rescue 911 scenario: instead of Is it appropriate for you to kill this injured person in order to save yourself and everyone else on board? the action verbs throw and keep were used). It is important to highlight the trade-off between cost (throw someone) and benefit (keep yourself and more people in the air) in the questions of all dilemmas. This was not accounted for in any of the previous dilemma sets.

Situational antecedents

In the original dilemma sets, keeping the situational antecedent used to present the characters constant was not accounted for. Thus, in the Personal version of the Nuclear reactor dilemma the situational antecedent could bias the participants' responses: you are the inspector of a nuclear power plant that you suspect has not met its safety requirements. The plant foreman and you are touring the facility when one of the nuclear fuel rods overheats … Later, it is this same foreman you are asked to consider to push into the fuel rod assembly. The participant was given knowledge about a badly kept nuclear plant, with an in-charge individual who did not bother to make the plant meet the safety requirements. This makes it easier to sacrifice the plant foreman to save the city than to sacrifice another, random, innocent person—which is the option to consider in all other dilemmas. Hence, prior information about the state of the power plant was removed, so that the foreman has no overt responsibility for the nuclear accident which is about to happen. Now he is a “random” person to be sacrificed, like in the other dilemmas. The Nobel Prize dilemma had a similar problem. A situational antecedent made the person in a position to be sacrificed (here, your fellow researcher ) appear a greedy bad person, so that it may be easier to sacrifice him than another innocent fellow researcher. The dilemma was reformulated so that the fellow researcher appeared not to know that the potential buyers would use the invention as a weapon and only the protagonist explicitly knows it and is now again the only person with the possibility to prevent greater harm from happening. In total, four dilemmas were modified to keep constant the situational antecedents of the characters in the dilemmas.

Trade-off across dilemmas: previous sets mixed different kinds of moral transgressions, like stealing or lying. It is important not to mix them with killing, in order to avoid the risk of a non-desired carry-over effect between dilemmas. For instance, stealing, lying, or lack of respect, may elicit less severe judgments when killing is also present in other dilemmas of the set, than when it's not. Therefore, all dilemmas now raise the conflict between the option to kill a person in order to save a larger number of people, and the option of doing nothing and letting that larger number of people die.

Number of individuals

Number of individuals saved if the moral transgression is carried out: in the set there now are the following categories (i) 5–10 people, (ii) 11–50 people, (iii) 100–150 people and (iv) “thousands” of people or “masses” of people. It is an important variable to control for. A utilitarian response should become easier as more people are saved. Conversely, if moral judgment is purely deontological, the number of people saved is totally irrelevant. This is an interesting question to have as a working hypothesis. Using different amounts of “saved individuals” in the formulations of the dilemmas allows researchers to explore at which point the positive consequences outweigh the transgression required to obtain them. For instance, it has been shown that attachment (“closeness of relationship”) to the victim determines moral judgment more than the number of beneficiaries involved. Still, this question needs further research, once closeness is controlled for ( Tassy et al., 2013 ). In this work, however, no specific analysis of this variable will be made, as it exceeds the limits of this norming study.

Information

Information supplied about the certainty of the consequences for the story character impersonated by the participant: in the Tycoon and Nobel Prize dilemmas it said that “ if you decide to [action of the dilemma], nobody will ever find out .” This implies information about the future which cannot really be given with certainty, while at the same time contrasting with other stories where no such commitments about the future are made. This kind of information can bias moral judgment and confuse it with legal punishment (or its lack). Therefore, this information was removed altogether from the dilemmas. Similarly, dilemmas were excluded that cannot be understood without the assumption of an extraordinary ability or an unlikely event (such as the Cliffhanger) 3 .

Dilemma Design (2)—Conceptual Factors

On the grounds of the literature about moral judgment ( Christensen and Gomila, 2012 ), four main factors need to be controlled for in moral dilemma formulation: Personal Force, Benefit Recipient (who gets the benefit), Evitability (whether the death is avoidable, or not), and Intentionality (whether the harm is willed and used instrumentally or a side-effect).

Personal force

Initially, Greene et al. (2001 , 2004) defined a Personal moral dilemma as one in which the proposed moral transgression satisfied three criteria: (i) the transgression leads to serious bodily harm; (ii) this harm befalls a particular person or group of people; and (iii) the harm is not the result of deflecting an existing threat onto a different party. Subsequently, Cushman et al. (2006) remarked that the crucial feature in a personal dilemma is whether physical contact between the victim and the aggressor is involved; a point also emphasized by Abarbanell and Hauser (2010) , while Waldmann and Dieterich (2007) focused on the Locus of Intervention (focus on the victim or on the threat) as the difference between personal and impersonal dilemmas. Another proposal contended that the difference between Personal and Impersonal is whether the action is mechanically mediated or not ( Royzman and Baron, 2002 ; Moore et al., 2008 ). In more recent work, Greene et al. have tried to offer an integrative definition ( Greene, 2008 ; Greene et al., 2009 ). Specifically, these authors propose that a Personal moral transgression occurs when (i) the force that impacts the victim is generated by the agent's muscles, (ii) it cannot be mediated by mechanisms that respond to the agent's muscular force by releasing or generating a different kind of force and applying it to the other person, and (iii) it cannot be executed with guns, levers, explosions, gravity…

However, it seems as if this redefinition is driven by an effort to keep the interpretation of the initial results, which results in a circular argument: that “personal” dilemmas induce deontological judgments by emotional activation, while “impersonal” ones induce utilitarian judgments by rational calculation. Yet, it is not yet clear which aspect of the personal involvement influences moral judgment through emotional activation, nor is it clear which kind of moral relevance emotions elicited by one's involvement may have in the judgment. Similar considerations apply to the introduction of the distinction between “high-conflict” and “low-conflict” dilemmas ( Koenigs et al., 2007 ), which also seem based on ex-post-facto considerations.

A principled way to clarify this distinction is in terms of the causal role of the agent in the production of the harm. What makes a dilemma impersonal is that the agent just initiates a process that, through its own dynamics, ends up causing the harm; while a dilemma is personal when the agent is required not just to start the action, but to carry it out by herself. According to this view, the presence of mediating instruments, by itself, does not make a dilemma personal or impersonal. It depends of the kind of active involvement of the agent they require and amounts to a difference in her responsibility of the caused harm, and in the resulting (felt) emotional experience of it. This can account for the different moral judgments to Personal and Impersonal Dilemmas, which are observed despite the fact that the same consequences occur. The best philosophical explanation of this difference is Anders (1962) 's reflection on the mass murders on the Second World War. He contended that these acts were made possible by the technical innovations that reduced the active involvement of soldiers in the killing to pushing a button to release a bomb. It is not just that the new arms were of massive destruction, but that their use was easier for us humans. Killing with one's hands is not just slower, but harder.

In the present dilemma set, the Personal dilemmas have been revised accordingly. Personal Moral Dilemmas now require that the agent is directly involved in the production of the harm. Impersonal Moral Dilemmas are those in which the agent is only indirectly involved in the process that results in the harm.

Benefit recipient

Self-interest is a well-known influence in moral judgments ( Bloomfield, 2007 ). People will be more prone to accept an action whose consequences benefit themselves (i.e., the agent herself) than one that benefits others, maybe complete strangers. This “Self-Beneficial” vs. “Other Beneficial” contrast has been introduced more clearly in the revised set. We reformulated the Modified Euthanasia dilemma due to a confound in the trade-off specification. Therefore, as the dilemma had to be an Other-beneficial dilemma, now the key secret evidence the soldier could reveal if tortured is the location of a particularly important base camp (and not the camp of the protagonist's group).

Evitability

This variable regards whether the death produced by the moral transgression is described as Avoidable or Inevitable . Would the person “to be sacrificed” have died anyway ( Inevitable harm), or not ( avoidable harm)? Transgressions that lead to inevitable consequences are more likely to be morally acceptable, by the principle of lesser evil ( Hauser, 2006 ; Mikhail, 2007 ). In the dilemma Rescue 911 , a technical error in a helicopter puts the protagonist in the situation of having to decide to throw off one of her patients for the helicopter to lose weight. Without that sacrifice the helicopter would fall and everybody— including that one patient —would die. Conversely, the dilemma can also be formulated in such a way that the individual to be sacrificed otherwise would not have been harmed ( Avoidable death), such as in the classical trolley dilemmas, where neither the bystander nor the innocent railway worker on the side track would have been harmed if the protagonist had not changed the course of events. This distinction has now been made more explicit in the dilemmas (for examples of work where this variable was discussed, see Moore et al., 2008 ; Huebner et al., 2011 ).

Intentionality

This factor refers to whether the harm is produced instrumentally, as something willed, or whether it happens as an unforeseen side-effect, as collateral damage, to an action whose goal is positive. This variable concerns the doctrine of the double effect that has been shown to be psychologically relevant ( Foot, 1967 ; Hauser, 2006 ; Mikhail, 2007 ). Causing harm is more acceptable when it is produced as collateral damage, than when it is the goal of an action. Accordingly, Accidental harm refers to the case where the innocent victim of the dilemma dies as a non-desired side effect of the moral transgression that the protagonist carries out to save others. Conversely, Instrumental harm occurs when the protagonist intentionally uses the harm (i.e., the death) of the innocent victim as a means (i.e., instrumentally) to save the others.

The reformulation of the dilemmas and the fine-tuning according to this factor is particularly relevant and one of the main contributions of this norming paper. In the modified set of Moore et al. (2008) , all Personal dilemmas were Instrumental , while Impersonal dilemmas included six Instrumental and six Accidental . The present set now allows a full factorial design including intentionality . To introduce Accidental vs. Instrumental harm in Personal dilemmas attention was paid to key aspects of the causal chain of the dilemma leading to the proposed salvation of the greatest number of people. First, the exact intention that the protagonist has in the very moment of committing the moral transgression was identified ( does she carry out an action with the intention to kill or not? ). Second, a differentiation was made between whether the harm is directly produced by the protagonist, or indirectly triggered by her action (do the positive consequences (the salvation of many) follow directly from the victim's death, or by some other event, an independent mechanism which was triggered by the protagonist's actions but not directly by her, nor directly willed by her?). The final point concerned by what means the larger number of people is saved (are they saved directly by the death of the victim, or for a different reason?).

Following this rationale, for a better comprehension of the Intentionality factor, the moral transgression is divided into a 5-part causal chain. This helps to disentangle the Accidental - Instrumental dichotomy (see Figure 1 ). The first thing to identify is the action by the protagonist ( what exactly does she do? ). Second, which is the exact intention behind that action ( why exactly does she do it? )? Third, does the victim die by the intervention of some intermediate (and protagonist- independent ) mechanism or is the death directly due to the action of the protagonist ( does she kill directly or by an independent mechanism? )? Fourth, how does the innocent victim die ( how does she die? )? Fifth, how is the larger number of people saved ( are they saved due to the death of the victim or for some other reason? )?

Figure 1. Example of the causal chain of the proposed moral transgression that leads to the salvation . In the Instrumental version of the Burning Building dilemma the proposed action is “to use the body of the victim.” The intention is “use the body to break down burning debris.” The victim dies directly by the fire and there is no independent mechanism in between. A larger number of people are saved due to the fact that the burning debris was eliminated with the victim . The harm to the victim was thus used as a means to save others. Said in different words, the body of the victim was literally used instrumentally with the intention to free the trapped group. Conversely, in the Accidental version of the Iceberg dilemma, the action of the protagonist is “to push the emergency access hatch.” The intention behind that action is “to make the oxygen flow to the upper section of the boat.” The victim dies due to a knock on the head by an independent mechanism which is the falling down of the hatch . Thus, the victim dies as a side-effect of the act of salvation that the protagonist carries out with the intention to get oxygen to the upper section of the boat.

To summarize the four factors Personal Force, Benefit Recipient, Evitability , and Intentionality , the illustration in Figure 2 provides a schematic overview over how the four factors are presented to the participant during the course of a moral dilemma.

Figure 2. The four factors in the dilemma set, adapted from Christensen and Gomila (2012) , reproduced with permission . (1) Personal Force : the kind of imaginary involvement with the situation: Personal, as direct cause, or Impersonal, as an indirect agent in the process of harm. (2) Benefit Recipient : concerns whether the protagonist's life is at stake (Self-Beneficial action), or not (Other-Beneficial action). (3) Evitability : regards whether the victim would die alongside the other individuals in the group if the moral transgression is not carried out (Inevitable death, the person would die anyway), or not (Avoidable death, the person would not die if no action is taken). (4) Intentionality : if the action is carried out intentionally with the explicit aim to kill the person as a means to save others, this is Instrumental harm (it explicitly needs the death of that person to save the others). If the innocent person dies as a non-desired side-effect of the action by some independent mechanism and not directly by the action of the protagonist, the harm is Accidental.

The Question Prompting the Moral Judgment

The formulation of the final question to elicit the moral judgment after reading the dilemma has also given rise to some controversy. The problem of the influence that the type of question exerts on participant's moral judgments has been addressed empirically (e.g., O'Hara et al., 2010 ). Four question formats were used: wrong, inappropriate, forbidden , and blameworthy and found that people judged moral transgressions more severely when the words “wrong” or “inappropriate” were part of the formulation, than when the words “forbidden” or “blameworthy” were used. Another study found different behavioral effects following the questions Is it wrong to…? vs. Would you? ( Borg et al., 2006 ). The question Would you…? resulted in faster RTs in judging moral scenarios as compared to judgments of non-moral scenarios, while the question Is it wrong to…? did not show any differences in RT comparing the moral to the non-moral condition. In view of these findings, it seems that deciding what to do is not processed in the same way as deciding whether an action is right or wrong , and that in moral dilemmas is the first that matters.

In recent work, two groups of researchers have addressed the related issue of whether “what we say is also what we do.” Thus, it was found that answering the question Is it acceptable to…? vs. the question Would you…? resulted in differential response tendencies ( Tassy et al., 2013 ). However, another study showed that increasing the contextual information available to the participant resulted in more coherence between what they said they would do and what they actually did ( Feldman Hall et al., 2012 ). In any case, it is clear that consistency is required.

For the present dilemma set a direct question was used Do you [action verb] so that … to emphasize the consequences of the choice made by the agent. Scales (Likert, Visual Analogical…) were used instead of a dichotomous answer format, as a way to uncover the degree of conflict experienced.

Summary: The Revised Set

The revised set consists of 46 dilemmas, of which 23 are Personal and 23 are Impersonal . As can be observed in Table 1 , we maintained the original dilemma numbers so that it is easy to compare across sets. In 23 of the 46 dilemmas, the protagonist's life is in danger and the moral violation results in saving not only a greater number of individuals, but also the protagonist herself ( Self-Beneficial dilemmas), whereas in the remaining 23, the protagonist's life is not in danger ( Other-Beneficial dilemmas). In turn, there are 11 Personal and 11 Impersonal Self - Beneficial dilemmas, and 12 Personal and 12 Impersonal Other-Beneficial dilemmas.

Table 1. Revised dilemmas .

There are 24 dilemmas where the death is Avoidable and 22 where it is Inevitable . Finally, there are 18 dilemma scenarios with Accidental harm (7 Personal and 11 Impersonal; 10 Self-Beneficial and 8 Other-Beneficial; 10 Avoidable and 8 Inevitable ) and 28 with Instrumental harm (16 Personal and 12 Impersonal; 12 Self-Beneficial and 16 Other-Beneficial; 14 Avoidable and 14 Inevitable ). See Table 1 for a summary. Please note that it was not possible to provide the same number (quantity) of dilemmas in each of the 16 categories because we relied on the materials of the former set. Refer to our discussion of this matter in the Supplementary Material (A) on limitations.

Arousal and Valence Norming Experiment

Peoples' moral judgment has been shown to be sensitive to the affective impact of a dilemma in the individual ( Moretto et al., 2010 ; Navarrete et al., 2012 ; Ugazio et al., 2012 ). However, no dilemma set has so far been assessed in terms of the affective arousal the individual dilemmas elicit in normal population as they are read—i.e., even if no moral judgment is required. Therefore, data points for affective arousal and valence were obtained for each dilemma of this set.

We know that peoples' moral judgments vary as a function of the four conceptual factors Personal Force, Benefit Recipient, Evitability , and Intentionality . However, how peoples' affective responses (valence and arousal) are modulated by these factors remains to be established. Besides, because inter-individual differences in emotional sensitivity and empathy can affect the subjective experience of arousal, participants in this experiment were assessed on these variables by means of self-report measures.

Participants

Sixty-two undergraduate psychology students participated in this study in exchange for a course credit in one of their degree subjects (43 females, 19 males; age range = 18–48 years; m = 21.0, SD = 5.35). Participants completed four self-report measures. First, the Interpersonal Reactivity Index (IRI) ( Davis, 1983 ), which has four scales that focus on perspective taking, tendency to identify with fictitious characters, emotional reactions to the negative experiences of others, and empathic concern for others. Second, the Questionnaire of Emotional Empathy ( Mehrabian and Epstein, 1972 ) that conceives empathy as the vicarious emotional response to the perceived emotional experience of others. It explicitly understands empathy as different from Theory of Mind (ToM) and focuses on emotional empathy where high scores indicate a high responsiveness to other peoples' emotional reactions. Third, the Questionnaire of Emotional Sensitivity (EIM) ( Bachorowski and Braaten, 1994 ), which refers to the intensity with which a person experiences emotional states irrespectively of their affective valence. Fourth, participants completed the Toronto Alexithymia Scale (TAS) in which a high score means difficulties in understanding and describing emotional states with words ( Taylor et al., 1985 ). For results on the self-report measures, see Table 2 . All were native Spanish speakers.

Table 2. Participant characteristics in terms of emotional sensitivity, empathy, and alexithymia .

The forty-six moral dilemmas were arranged to be presented in random order in the stimulus presentation program DirectRT ( www.empirisoft.com ) v. 2006.2.0.28. The experiment was set up to run on six PCs [Windows XP SP3 PC (Intel Pentium Dual Core E5400, 2.70 GHz, 4 GB RAM)] and stimuli were displayed on 19″ screens (with a resolution of 1440 × 900 p; color: 32 bits; refresh rate: 60 Hz). Data were analyzed using the statistical package SPSS v. 18 ( www.ibm.com ).

Participants signed up for the experiment in class after having completed the four self-report scales. The day of the experiment, participants provided demographic data regarding gender, age, and level of study. Informed consent was obtained from each participant prior to participation in any of the tasks and questionnaire procedures.

Participants were instructed as outlined in the section Instructions to the Participant . Each dilemma was presented in white Arial font, pt 16, on a black screen. By key press, the first paragraph of the dilemma appeared. With the next key press, the second paragraph appeared 4 . Participants read at their own pace, advancing from one screen to the other by pressing the space bar. With the third key press, the first two paragraphs of the dilemma disappeared and two Likert scales appeared on subsequent screens, the first asking participants to indicate their level of arousal (1 = not arousing at all; 7 = very arousing) and the second asking them to indicate the perceived valence of the dilemma (1 = very negative; 7 = very positive). The ratings were made by means of key press on the number keyboard of the computer. Four practice dilemmas were added in the beginning of the task. Data from these trials were discarded before data analysis.

The experiment was carried out in a laboratory of the university suited for experiments with six individual PCs separated in individual booths. Participants carried out the task in groups of 1–6 people. Viewing distance was of approximately 16 inches from the screen. The study was approved by the University's Ethics Committee (COBE280213_1388).

Factorial Repeated Measure (RM) 2 × 2 × 2 × 2 Analysis of Variances (ANOVA) were computed on subjective arousal and valence ratings (Likert scale data), and on the RT of the arousal ratings. The factors were (1) Personal Force (Personal vs. Impersonal harm); (2) Benefit Recipient (Self-Beneficial vs. Other-Beneficial); (3) Evitability (Avoidable vs. Inevitable harm); and (4) Intentionality (Accidental vs. Instrumental harm). As effect sizes we report Pearson's r , where 0.01 is considered a small effect size, 0.3 a medium effect and 0.5 a large effect ( Cohen, 1988 ).

To rule out any effect of Gender in the results, the above ANOVA was computed with the between-subjects factor Gender. There was no effect of gender in any of the interactions with the four factors, neither in the arousal ratings: Personal Force * gender : F (1, 60) = 1.47; p = 0.230; Benefit Recipient * gender : F (1, 60) = 0.774; p = 0.383; Evitability : F (1, 60) = 0.079; p = 0.780; Intentionality * gender : F (1, 60) = 0.101, p = 752; nor in the valence ratings: Personal Force * gender : F (1, 60) = 0.004; p = 0.949; Benefit Recipient * gender : F (1, 60) = 0.346; p = 0.558; Evitability : F (1, 60) = 0.019; p = 0.890; Intentionality * gender : F (1, 60) = 0.184, p = 0.670, nor in the RT. Therefore, data of female and male participants were aggregated.

All 16 dilemma categories were rated as being felt as of moderate to high arousal (range: m = 5.58–6.24; see Table 3 ). Two of the four factors showed significant effects on the arousal ratings. First, there was a significant main effect of Personal Force [ F (1, 61) = 6.031; p = 0.017; r = 0.30], PMD being rated as more arousing ( m = 5.92; SD = 0.12), than IMD ( m = 5.83; SD = 0.12). The second main effect was of Benefit Recipient [ F (1, 61) = 47.57; p < 0.001; r = 0.66], Self-Beneficial Dilemmas being rated as more arousing ( m = 6.02, SD = 0.12) than Other-Beneficial Dilemmas ( m = 5.70, SD = 0.13). See Figure S3. There were no significant main effects of Evitability [ F (1, 61) = 0.368; p = 0.546], nor of Intentionality [ F (1, 61) = 0.668; p = 0.417]. See Table S1 for the means and Figure S3 in the Supplementary Material.

Table 3. RM ANOVA of the RT of the arousal ratings .

There was a significant interaction of Benefit Recipient * Intentionality [ F (1, 61) = 15.24; p < 0.001; r = 0.44]. This indicates that Intentionality had different effects on participants' ratings of arousal depending on whether the dilemma was Self-Beneficial or Other-Beneficial . Figure S4 illustrates the results. Paired t -tests showed that when Self-Beneficial Harm was Accidental the dilemma was rated as more arousing than when it was Instrumental [ t (61) = 3.690, p < 0.001, r = 0.43]. For Other-Beneficial Harm , the pattern was reversed, as the Instrumental Harm dilemmas were more arousing than the Accidental Harm dilemmas [ t (61) = −1.878, p = 0.065, trend effect, r = 0.05]. When comparing the Accidental and Instrumental Harm conditions, we found that Self-Beneficial, Accidental Harm dilemmas resulted in higher arousal ratings than when dilemmas were Other-Beneficial [ t (61) = 7.626, p < 0.001, r = 0.49]. The same pattern emerged when the harm was Instrumental ; it was judged as more arousing when it was Self-Beneficial , than when it was Other-Beneficial [ t (61) = 3.494, p = 0.001, r = 0.17]. If correcting for multiple comparisons using the Bonferroni method, this would mean accepting a new significance level of α = 0.05/4 → α* = 0.0125. This should be taken into account when considering the result with the trend effect.

Descriptive statistics of the valence ratings confirmed that all 16 dilemma categories were rated as being of negative valence (range: m = 1.71–2.23; see Table S1).

There were significant main effects of Personal Force [ F (1, 61) = 28.00; p < 0.001; r = 0.57] and of Benefit Recipient [ F (1, 61) = 31.509; p ≤ 0.001; r = 0.58]. PMD were rated as significantly more negative ( m = 1.905, SD = 0.065) than IMD ( m = 2.054; SD = 0.068). Likewise, Self - Beneficial Dilemmas were rated as significantly more negative ( m = 1.884, SD = 0.068) than Other - Beneficial Dilemmas ( m = 2.075; SD = 0.067). The two other factors did not show main effects [ Evitability F (1, 61) = 1.201; p = 0.277; and Intentionality F (1, 61) = 0.135; p = 0.715]. See Table S1.

There were two significant interactions. The first was Personal Force * Intentionality [ F (1, 61) = 7.695, p = 0.007; r = 0.33]. The Figure S5 shows that Intentionality had different effects on how people rated the valence of PMD and IMD . Paired t -tests showed that Accidental harm was rated as significantly more negative than Instrumental harm in Impersonal Moral dilemmas [ t (61) = −2.297, p = 0.025, r = 0.08], while no such difference was found between Accidental and Instrumental harm for Personal Moral dilemmas [ t (61) = 1.441, p = 0.155, r = 0.03]. See Figure S5. If correcting for multiple comparisons using the Bonferroni method, this would mean accepting a new significance level of α = 0.05/4 → α* = 0.0125. This should be taken into account when considering the result of the first t -test ( p = 0.025).

The second significant interaction was Benefit Recipient * Intentionality [ F (1, 61) = 6.041, p = 0.017; r = 0.30]. This indicates that intention had different effects on the valence ratings depending on whether the dilemma was Self - or Other - Beneficial . Paired t -tests showed that for Self-Beneficial Dilemmas, harm was judged significantly more negative when it was Accidental as compared to Instrumental harm [ t (61) = −2.300, p = 0.025, r = 0.08]. No such difference in valence ratings of Accidental and Instrumental harm for Other-Beneficial dilemmas [ t (61) = 1.296, p = 0.200, r = 0.03]. See Figure S6. If correcting for multiple comparisons using the Bonferroni method, this would mean accepting a new significance level of α = 0.05/4 → α* = 0.0125. This should be taken into account when considering the result of these t -tests ( p = 0.017 and p = 0.025).

The assessment of valence was only carried out to confirm that all dilemmas were of a strongly negative valence. This has hereby been confirmed and no other analysis will be carried out involving this feature of the dilemmas. All values for both arousal and valence are available for each dilemma in the excel spreadsheet that accompanies this manuscript (Supplementary Material).

Reaction time

A RM ANOVA was carried out on the RT of the arousal ratings with the factors Personal Force, Benefit Recipient, Evitability , and Intentionality . Main Effects were found for Personal Force and Benefit Recipient , no interactions were significant. See Table 3 .

Next, a regression analysis was conducted to ascertain how much of the variance in the RT of the arousal ratings was explained by the arousal ratings. This procedure was executed for each of the 16 dilemma categories. Summary Table 4 shows that except for four of the categories, the arousal ratings significantly explained between 6 and 38% of the variance in the RT. Figure 3 shows how the overall correlation between the variables indicates that the more arousing a dilemma was, the faster participants indicated their rating. The correlation coefficient between the mean arousal ratings and the mean RT of arousal ratings was, p < 0.001; r = −0.434.

Table 4. Summary table of the regression analysis of arousal ratings as predictors of the arousal ratings' RT for each of the 16 dilemma categories .

Figure 3. Correlation between Arousal ratings and the RT . Color coding: Personal Moral Dilemmas (PMD; Blue/Red, circles); Impersonal Moral Dilemmas (IMD; Green/Yellow, squares). Arousal ratings are 1 = Not arousing, calm; 7 = Very arousing, on the x-axis. RT is in milliseconds (ms) on the y-axis. The numbers refer to the dilemma numbers in the dilemma set.

Inter-individual differences: emotional sensitivity and empathy

To ensure that the results of our arousal ratings were not driven by inter-individual differences, participants had been assessed on a series of emotion-related questionnaires. Of the four questionnaires, the level of empathy measured with the questionnaire by Mehrabian and Epstein had a significant effect on arousal ratings and on arousal rating RT. The overall correlation coefficients for arousal ratings and Empathy scores was r = 0.289; p = 0.025 and for arousal RT and empathy scores it was r = −0.325; p = 0.011. The higher the empathy scores, the higher the arousal ratings to the dilemmas in general, and the shorter the RT (negative correlation coefficient).

Summary: Arousal and Valence Norming Experiment

For a dilemma to be very negatively arousing (i.e., ratings very negative in valence and high in arousal), the proposed moral transgression had to be described as up-close and Personal . Besides, dilemmas where the protagonist's own life was at stake were perceived as more negatively arousing than those dilemmas where other peoples' lives were at stake. In particular, if the death of the innocent victim happened accidentally as a non-desired side-effect , the dilemma was perceived as more negatively arousing, specifically, if the protagonist's life was at stake, than if the accidental death of the victim happened in the intent to save other people. In detail:

Affective arousal and valence

- there were significant main effects of the factors Personal Force and Benefit Recipient both for arousal and valence ratings: Personal and Self-Beneficial dilemmas were perceived as more arousing and more negative than Impersonal and Other-Beneficial dilemmas, respectively;

- there were significant interactions between the two above factors and the factor Intentionality . Intentionality influences perceived arousal in such way that Self-Beneficial dilemmas (as compared to Other-Beneficial dilemmas) were rated as more arousing when harm happened as a non-desired side-effect ( Accidental harm), while Instrumental harm (harm used as a means) was equally arousing in both Self - and Other-Beneficial dilemmas. Furthermore, when harm was Personal (up-close and corporal), as compared to Impersonal (distant and abstract), and used as a means ( Instrumental harm), dilemmas were rated as more negative, than if harm was Impersonal . Conversely, participants found Accidental harm equally negative when it was Personal (up-close and corporal) and Impersonal (distant and abstract).

RT to a moral judgment task has previously been suggested as an indicator of emotional involvement. The more arousing a dilemma was, the faster participants were in making their rating.

Inter-individual differences

There was a correlation between inter-individual differences in empathy assessed by means of the Questionnaire of Emotional Empathy ( Mehrabian and Epstein, 1972 ) and the arousal ratings. It showed that the higher the levels of empathy, the more arousing were the dilemmas to the participant. This makes sense because this instrument describes sensitivity to others' emotional states. It specifically conceives empathy as the vicarious emotional response to the perceived emotional experience of others and understands empathy as different from ToM and perspective-taking, and focuses on emotional empathy where high scores indicate a high responsiveness to other peoples' emotional reactions. However, apart from this correlation between arousal ratings and empathy level, no other individual differences had an effect on perceived arousal (the other variables we assessed were gender, IRI, emotional sensitivity, alexithymia). We therefore conclude that—at least in this sample of Spanish Undergraduates- the arousal ratings of this dilemma set are rather robust across individual differences.

Discussion of Arousal and Valence Norming Experiment

While all dilemmas are rated similarly as negative in valence, significant differences were found in how they were rated in terms of felt arousal. This means, first, that at least part of the emotional involvement in moral judgment of the dilemmas can be due to the arousal triggered when reading the situational description. And second, results showed that differences in arousal are due to how the different conceptual factors are manipulated. Thus, Personal Force and Self-Beneficial dilemmas give rise to higher arousal ratings than Impersonal and Other-Beneficial ones. Prima facie this suggests that arousal has something to do with identification of the experimental participant with the perspective of the main character in the dilemmatic situation: it's when one feels more directly involved in the conflict, because of the action to be carried out or the consequences for oneself that the action will have, that one feels more aroused—even without having to make a judgment. However, this prima facie interpretion is too simplistic, for three reasons.

In the first place, it is clear that Personal Force dilemmas highlight the personal involvement in physically producing the harm. Similarly, Self-Beneficial dilemmas give rise to higher arousal ratings only when the harm produced is Accidental, rather than Instrumental. The latter case is one of self-interest: we experience less conflict when what's to be done is for our own benefit. Yet, it becomes difficult when a benefit cannot be produced without collateral damage. Third, whereas Self-Beneficial dilemmas take longer to be rated (than Other-Beneficial), Personal Force ones are rated faster than Impersonal ones. Jointly, these results suggest that arousal ratings can have several etiologies, and therefore cannot be interpreted simply as indication of degree of imaginary involvement with the situation or as a measure of experienced conflict. Both these causes need to be considered.

Dilemma Validation Study—Moral Judgment Experiment

To validate this moral dilemma set, a moral judgment task was set up to confirm the 4-factor structure in the dilemmas; i.e., the four conceptual factors Personal Force, Benefit Recipient, Evitability , and Intentionality .

Furthermore, to explore how the intentionality factor is understood by participants, two versions of the dilemma set were prepared: one version remained as has been described so far, while in the other the question eliciting the moral judgment included an “accidental harm specification” in the accidental harm dilemmas. For instance, in the dilemma Burning Building, the question is Do you put out the fire by activating the emergency system, which will leave the injured without air, so you and the five other people can escape? The sentence which will leave the injured without air is the accidental harm specification. This makes it clear to the reader the consequences of the proposed action. The analysis of this variable is included here, but in future researchers can choose to leave the accidental harm specification out of the question.

Additional analyses include (i) the analysis by Greene et al. (2001 , 2004) that gave rise to the Dual Process Hypothesis of Moral Judgment (DPHMJ), (ii) an additional analysis of the Intentionality factor, and (iii) an analyses of how interindividual differences influence moral judgment.

Forty-three undergraduate psychology and educational science students participated in this study in exchange for a course credit in one of their degree subjects (30 females and 13 males; age range = 18–54 years; m = 20.65, SD = 5.52). None of them had seen the dilemmas before. See Table 5 for participant characteristics including self-report measures of (i) the IRI ( Davis, 1983 ), (ii) the Questionnaire of Emotional Empathy ( Mehrabian and Epstein, 1972 ), (iii) the Questionnaire of Emotional sensitivity (EIM) ( Bachorowski and Braaten, 1994 ), (iv) the TAS ( Taylor et al., 1985 ), (v) the personality questionnaire Big Five ( McCrae and Costa, 1999 ), and (vi) the Thinking Style Questionnaire, Need For Cognition Scale (NFC) ( Cacioppo et al., 1984 ). All participants were native Spanish speakers.

Table 5. Participant characteristics .

Forty-six standard moral dilemmas and four practice dilemmas were presented in random order with the stimulus presentation program DirectRT ( www.empirisoft.com ) v. 2006.2.0.28. The experiment was set up to run on six PCs (Windows XP SP3 PC (Intel Pentium Dual Core E5400, 2.70 GHz, 4 GB RAM) and stimuli were displayed on 19″ screens (with a resolution of 1440 × 900 p; color: 32 bits; refresh rate: 60 Hz).

As in the previous experiment described in the section Arousal and Valence Norming Experiment . Additionally: after the second screen, the first two screens disappeared and the question appeared. The question eliciting the moral judgment was “ Do you [action verb] so that….” A 7-point Likert scale was displayed below the question with the labels “ No, I don't do it ” under the number “1” and “ Yes, I do it” under the number “7.” Half of the participants (22 participants) saw the question “ Do you [action verb] so that…,” while the other half (21 participants) saw a question that furthermore involved the Accidental harm specification in the case of the Accidental harm dilemmas, such as in: “ do you [action verb] which will [mechanism that will lead to the death] so that…” (Type of Question) . The ratings were made by means of key press on the using the number keys of the keyboard (top row of numbers) of the computer. Four practice dilemmas were added in the beginning of the task. Data from these trials were discarded before data analysis. The study was approved by the University's Ethics Committee (COBE280213_1388).

A factorial RM 2 × 2 × 2 × 2 ANOVA was computed with the Within-Subject factors Personal Force (PMD vs. IMD), Benefit Recipient (Self-Beneficial vs. Other Beneficial), Evitability (Avoidable vs. Inevitable harm), and Intentionality (Accidental vs. Instrumental harm). Question Type (with vs. without the Accidental harm specification) was the Between-Subject factor. As effect sizes we report Pearson's r, where 0.01 is considered a small effect size, 0.3 a medium effect and 0.5 a large effect ( Cohen, 1988 ).

Subjective ratings: moral judgment

There was no significant main effect of the between-group factor Type of Question (with or without accidental harm specification) [ F (1, 41) = 0.164, p = 0.688] and there were no significant interactions between the Between-Subjects factor Type of Question and the four within-subject factors: Personal Force * Question Type [ F (1, 41) = 0.09; p = 0.766; ns ]; Benefit Recipient * Question Type [ F (1, 41) = 0.296; p = 0.589; ns ]; Evitability * Question Type [ F (1, 41) = 0.010; p = 0.921; ns ]; Intentionality * Question Type [ F (1, 41) = 0.013; p = 0.911; ns ]. This means that the two question formats ( with and without the Accidental harm specification) are equivalent and do not affect the moral judgment a person makes. This means that the accidentality of the harm is understood from the narrative without the need to explicitly state it to the individual. Thus, data was aggregated for subsequent analyses.

There were significant main effects of all four Within-Subject factors: Personal Force [ F (1, 41) = 54.97; p < 0.001; r = 0.75]; Benefit Recipient [ F (1, 41) = 4.347; p = 0.043; r = 0.31]; Evitability [ F (1, 41) = 69.984; p < 0.001; r = 0.79]; and Intentionality [ F (1, 41) = 12.971; p = 0.001; r = 0.49]. Participants were less likely to commit harm in PMD ( m = 4.069; SD = 0.124) than in IMD ( m = 4.717; SD = 0.113) and they were more likely to commit a moral transgression to save themselves ( m = 4.508; SD = 0.103), than to save others ( m = 4.278; SD = 0.111). When the suggested harm was Inevitable , people were more likely to commit it ( m = 4.633; SD = 0.124) than when harm was Avoidable ( m = 4.152; SD = 0.103). Finally, when the death of the victim was Accidental , participants were more likely to commit the moral transgression ( m = 4.549; SD = 0.125) than when it was Instrumental ( m = 4.236; SD = 0.112). See Figures S7A–D.

Five of the six possible two-way interactions between the four factors were significant. See Table 6 for a summary of the means and interaction coefficients. Table 7 shows the t -tests to break down the interactions. Figure S8 summarizes the interactions graphically. If correcting for multiple comparisons using the Bonferroni method, this would mean accepting a new significance level of α = 0.05/4 → α* = 0.0125 for breaking down each interaction. This should be taken into account when considering the result of the t -test in Table 7D (Self-Beneficial Accidental vs. Instrumental harm; p = 0.022).

Table 6. Summary table of the interactions (dependent variable: moral judgment, Likert scale rating; range: 1;7) .

Table 7. Follow-up t -tests to break down the interactions in the moral judgment task .

First, the Benefit Recipient variable had a differential effect on the moral judgment for PMD and IMD (Figure S8A). Participants were more likely to commit harm if the harm was carried out to safe themselves ( Self - Beneficial , as compared to Other - Beneficial ), however, only if the dilemma was Impersonal . If harm was Personal , participants were equally likely to commit the harm both when it was Self - or Other-Beneficial .

Second, also the Evitability variable had a differential effect on the moral judgment for PMD and IMD (Figure S8B). Participants made more deontological responses for PMD in general; however, they were more likely to commit harm when the death of the innocent person was Inevitable (as compared to Avoidable ).

Third, also the Intentionality variable affected how participants judged PMD and IMD (Figure S8C). Again participants were overall more likely to make a deontological moral judgment in PMD than in IMD, however, participants were less likely to commit the moral transgression when harm was Instrumental (as compared to Accidental ), but specifically only in the case of PMD .

Fourth, the Intentionality variable affected how participants judged Self - and Other - Beneficial dilemmas (Figure S8D). If the proposed harm was Instrumental , participants were less likely to commit it when the dilemma involved harm toward Others (as compared to harm toward the participant herself), while for accidental harm, participants were less likely to commit harm if it was accidental to save herself, than if it was to save others.

Fifth, Intentionality also affected how participants judged Avoidable and Inevitable dilemmas ( Evitability factor), (Figure S8E). When harm was Avoidable (as compared to Inevitable ), participants were less likely to commit it when the harm described in the dilemma was Instrumental than when it was Accidental . However, participants were equally likely to commit harm to both Accidental and Instrumental harm dilemmas when the harm described in the dilemma was Inevitable .

That there was no interaction between Benefit Recipient and Evitability means that participants were equally likely to commit harm, irrespective of whether death was Avoidable or Inevitable for Self- or Other-Beneficial dilemmas.

There was one significant main effect [ Intentionality : F (1, 41) = 13.252; p = 0.001; r = 0.49] and one significant interaction [ Intentionality * Question Type: F (1, 41) = 13.629; p = 0.001; r = 0.50]. Participants in general needed longer to make moral judgments about actions involving Accidental harm ( m = 5803.223; SD = 424.081) than of actions involving Instrumental harm ( m = 5185.185; SD = 394.389). The interaction indicates that Intentionality had a differential effect on RT depending on the Question Type . The group that had the question with the Accidental harm specification, needed significantly longer to respond to Accidental harm ( m = 6356.081; SD = 578.441) than the group without such specification ( m = 5250.365; SD = 620.309). No such difference appeared between the groups for Instrumental harm ( m = 5112.582; SD = 537.941 and m = 5259.065; SD = 576.878, respectively).

Due to the fact that the only main effect and interactions that appear significant in the analysis of the RT data is the factor that regards the Between-Subject variable Type of Question , this effect was explored more closely. Therefore, the RM ANOVA was computed again, first with the participants in the With condition and afterwards with the participants in the Without condition. Again the factor Intentionality was significant in the With condition [ F (1, 22) = 21.208; p < 0.001; r = 0.70], but not in the Without condition [ F (1, 19) = 0.002; p = 0.964]. Hence, the effect was merely driven by the higher number of words in the questions in the With condition.

To ensure that RT was not conditioned by the word count of the questions in general, a regression was computed with word count in the question as a predictor and RT as the dependent variable. No significant relationship was found ( B = −27.695; B SD = 30.711; β = −0.234; p = 0.382). Hence, the word count of the questions did not influence the RT of participants except in this particular case of the Intentionality factor. Apart from this problematic effect, there were no other significant main effects or interactions.

As much research in the field of moral judgment with moral dilemmas suggests a relation between the type of moral judgment (deontological vs . utilitarian) and RT, this matter was explored further. First, a curvilinear regression was computed with Moral Judgment as predictor and the RT as dependent variable. The resulting model was significant [ F (1, 41) = 11.015; p < 0.001; r = 0.46] and moral judgment accounted for 33.9% of the variance in the RT. Both for very deontological (Likert ratings toward 1) and very utilitarian moral judgments (Likert ratings toward 7) participants were faster than when making a more intermediate moral judgment (Likert ratings around 4). See the illustration of the relation between moral judgment and RT in Figure 4 .

Figure 4. Curvilinar relationship between Moral Judgment and RT . Color coding: Personal Moral Dilemmas (Blue/Red, circles); Impersonal Moral Dilemmas (Green/Yellow, squares). Mean Likert scale responses: 1 = No, I don't do it , i.e., deontological moral judgment; 7 = Yes, I do it , i.e., utilitarian moral judgment. RT is in milliseconds (ms). PMD, Personal Moral Dilemmas; IMD, Impersonal Moral Dilemmas.

To assess RT as a function of the response given (deontological vs. utilitarian in absolute terms, not in a scale from 1 to 7 as presented above) as in Greene et al. (2001 , 2004) , the Moral Judgment values of the 7-point Likert scale were dichotomized. Judgments of values between 1 and 3 were considered “deontological,” and values between 5 and 7 were considered “utilitarian.” Values of 4 were discarded. Mean RT was calculated as a function of this re-coding. Subsequently, the ANOVA from Greene et al. (2001 , 2004) 2 × 2 ( Response Type and Personal Force ) was carried out. No significant main effects were found [ Response Type : F (1, 42) = 0.402; p = 0.529; Personal Force : F (1, 42) = 0.197; p = 0.659].

In previous analyses, the factor Intentionality has been shown to be of key relevance in moral judgment. Therefore, another 2 × 2 ANOVA with the variables Response Type and Intentionality was run. There was a significant main effect of Intentionality ( p = 0.015) and a significant interaction of Response Type*Intentionality ( p = 0.018), see Table 8 and Figure S9. Breaking down the interaction it was shown that participants took longer to make a deontological moral judgment when harm was then produced accidentally , than if it was instrumental ( p = 0.003). No such difference was found for utilitarian moral judgments ( p = 0.681), see Figure S9.

Table 8. Main Effects and Interactions of the RM ANOVA Question Type*Intentionality .

Inter-individual differences: gender

There was a significant interaction between the factor Benefit Recipient and the participants' gender [ F (1, 61) = 10.079; p = 0.003; r = 0.37]; male participants were more ready to commit a harm in the case of Self - Beneficial dilemmas ( m = 5.137; SD = 0.215), than female participants ( m = 4.235; SD = 0.142). In the Other-Beneficial dilemma category, no such gender differences were found (males: m = 4.439; SD = 0.203; females: m = 4.208; SD = 0.133). This effect is reported for the sake of completeness of the scientific record. However, first, we did not specifically contemplate this effect, so we did not have equal numbers of male and female participants. Second, we do not aim to make any assumptions about gender differences based on such preliminary data. There is no sound scientific evidence that supports why there should be gender differences in moral judgment, nor of what kind these may be, nor what should be the evolutionary basis for them. This is a sensitive issue that deserves thorough investigation that goes far beyond the scope of this paper. Therefore, we assume that there are no genuine gender differences in moral judgment in participants of one same culture and have chosen to analyze the data of female and male participants together.

Two other studies have reported an effect of gender in their data ( Fumagalli et al., 2009 , 2010 ). However, the dilemma set used in these studies was the originally used by Greene et al. (2001 , 2004) which has important methodological shortcomings (as pointed out by this paper; for a review see Christensen and Gomila, 2012 ), which is why ideally such claims on gender differences should really not be made. For such claims to be based on solid grounds a study should be designed controlling variables of empathy and other personality factors between genders, and of course, have an equal sample size of each gender.

Inter-individual differences: thinking style, personality traits, emotional sensitivity

To test the influence of inter-individual differences on moral judgment a regression was computed with all of the scores of the questionnaires assessing inter-individual differences in the model predicting the mean moral judgment of the participants. As shown in Table S2, the resulting regression model was significant [ F (10) = 2.954; p = 0.011; r = 0.47] and explained 50.5% of the variance in the moral judgments. However, only three of the 10 predictor variables were significant: Emotional Sensitivity ( p = 0.018), and two of the Big Five factors, Agreeableness ( p = 0.046) and Conscientiousness ( p = 0.001). The higher the scores in the EIM , the more deontological were the moral judgments (participants with higher scores in the EIM were less susceptible to commit the proposed harm). For the two factors of the Big Five, the pattern was reverse: the higher the scores, the more utilitarian were the judgments (participants with higher scores in these two dimensions were more likely to commit the proposed harm). However, considering the Beta coefficient, it can be observed that these effects were—although existent—rather small.

Arousal and Moral Judgment

In order to determine whether the levels of arousal of the dilemmas rated by one group of participants, would be related to the moral judgments of a different group of participants, the dataset was transposed and dilemmas treated as cases. A simple regression was conducted with the arousal ratings as predictor variable and the moral judgments as dependent variable. The resulting model was significant [ F (1, 44) = 22.613; p < 0.001; r = 0.58], showing that the level of arousal of a dilemma predicted 33.9% of the variance in the moral judgment variable. Figure 5 shows that the more arousing a dilemma was, the more likely participants were to refrain from action (i.e., not committing the moral transgression). See Table S3 for the model parameters.

Figure 5. Relationship between level of arousal of a dilemma and the moral judgment made to that dilemma. Color/shape coding: Personal Moral Dilemmas (Blue/Red, circles); Impersonal Moral Dilemmas (Green/Yellow, squares) . Mean Likert scale responses: 1 = No, I don't do it , i.e., deontological moral judgment; 7 = Yes, I do it , i.e., utilitarian moral judgment. Mean Arousal scale responses: 1 = Not arousing, calm ; 7 = Very arousing .

Summary: Moral Judgment Experiment

With this fine-tuned set of moral dilemmas it was confirmed that the four factors Personal Force, Benefit Recipient, Evitability , and Intention ality determined participants' moral judgment:

First, participants tended to exhibit a deontological response style (i.e., they refrained from committing harm) when harm was described as Personal (as compared to Impersonal ), Other-Beneficial (as compared to Self -Beneficial ), Avoidable (as compared to Inevitable ), and Instrumental (as compared to Accidental ). In other words, when harm was abstract and spatially and intentionally separated from the agent, participants were more likely to commit this moral transgression than if the harm was described as up-close and gave an impression of “bloody hands.”

Second, participants more readily sacrificed the life of another person if their own life was at stake than if the moral transgression would merely save other people. Besides, if harm to the victim would have happened anyway, irrespective of whether the moral transgression was carried out by the agent or not (as in “ or one person of 5 is killed or they all die ”), participants were more likely to incur in the moral transgression.

Third, participants more readily committed harm if harm happened as a non-desired side-effect of the action of the agent, it was more readily committed by the participants than if the proposed harm would result in using the death of the victim as a means to salvation of the others.

As regards the interactions between the factors:

First, the interaction between Personal Force and Benefit Recipient indicated that participants were equally likely to commit a moral transgression when the proposed harm involved “bloody hands,” both when the harm would result in salvation of oneself or of others. However, when the proposed harmful action was abstract and distant, participants made a difference in their moral judgment, depending on whether the salvation regarded themselves or others. Abstract harm commission made a utilitarian response more likely when it was executed to save themselves.

Second, the interaction between Personal Force and Intentionality indicated that harm that happened as a non-desired side-effect of the moral transgression was consented equally in IMD, both when harm was accidental and when it was instrumental. However, in PMD, if harm was used as a means (instrumentally), this made participants' moral judgments more deontological than when harm was accidental.

Third, the interaction between Benefit Recipient and Intentionality indicated that for Self-Beneficient Dilemmas, when harm happened as a non-desired side-effect of the proposed action, participants were less likely to commit the moral transgression, than when it was instrumental. Conversely, when the harm would benefit others, the pattern was reverse: more deontological moral judgments when harm was instrumental, than when it was accidental.

Fourth, the interaction between Personal Force and Evitability indicates that for both IMD and PMD, avoidable harm resulted in more deontological moral judgments than did inevitable harm.

Fifth, the interaction between Evitability and Intentionality indicates that both when harm to the victim could have been avoided, harm as a side-effect was more readily consented, than was the use of harm as a means. For inevitable harm no such difference between accidental and instrumental harm commission was found.

Furthermore, we found that the more arousing a dilemma was, the more likely it was that participants would choose a deontological response style.

Finally, there was no main effect of Type of Response found by Greene et al. (2001 , 2004) , indicating that with this optimized dilemma set deontological responding is not faster than utilitarian responding. Neither was there an interaction between Type of Response*Personal Force . However, with an additional ANOVA with the factors Type of Response and Intentionality it was shown that there was a significant main effect of Intentionality . Yet, more importantly, there was an interaction between Type of Response and Intentionality . This indicates that for dilemmas people were judging deontologically, it took them particularly long to make that judgment in the case when the proposed harm would result in accidental harm to the victim.

Discussion of the Moral Judgment Experiment

Summing up, results here show that that we are more prone to behave for our benefit, if the harm will take place in any case and producing the harm is not very demanding. Conversely, we are going to experience a conflict—indexed by a longer response—when we are forced to do the harm ourselves, or to do harm as collateral damage to benefit others. Moral principles can be broken but only in well-justified situations (when consequences are “big enough”). It's not that we are deontological or utilitarian thinkers, we are neither: moral judgments are better viewed from the point of view of casuistics, the particularist approach to morals that takes the details of each case into account. Any small detail may matter to our moral judgment. Results show, in any case, that rules are not applied algorithmically or in a strict order ( Hauser, 2006 ).

Overall Discussion

Apart from providing normative values of valence, arousal, moral judgment and RT for 46 moral dilemmas 5 , the results of this dilemma validation study challenge the DPHMJ proposed by Greene et al. (2001 , 2004) . According to this hypothesis, deontological moral judgments (refraining from harm) are fast and emotion-based, while utilitarian moral judgments (deciding to commit the harm) are slow as a result of deliberate reasoning processes. The assumptions of the DPHMJ were based on a reaction time finding where an interaction between the Type of Response given (deontological vs. utilitarian) and the Personal Force (Personal vs. Impersonal) showed that when harm was consented in a Personal Moral Dilemma (utilitarian response), RT was significantly longer than when harm was not consented (deontological response). No such difference in the response time was found for Impersonal Moral Dilemmas. However, in our study, while we also found that higher arousal correlates with deontological judgment (in line with Moretto et al., 2010 ), we failed to find the relationship with RT: both deontological and utilitarian decisions can be made equally fast, and both to personal and impersonal dilemmas, depending on the other factors involved. To put it another way, a fast judgment takes place when, either a deontological reason guides the judgment, or when utilitarian considerations clearly dominate. Therefore, while we agree that the dilemmas that take longer are those where the experienced conflict is greater, conflict, however, has a more complex etiology. In particular, judgment takes longer when people are torn between utilitarian considerations of the greater good (saving many), and the suffering produced in others as an accidental side-effect. An increased RT is likely to have been caused by reasoning processes in order to explore a way to avoid the conflict, in either case.

As a matter of fact, the DPHMJ's central result concerning personal vs. impersonal dilemmas has already been challenged. McGuire et al. (2009) reanalyzed the data sets from Greene and colleagues and removed what they called “poorly endorsed items” (those dilemmas not designed carefully enough). After this procedure by McGuire et al., the key effect disappeared from the data ( McGuire et al., 2009 ). Similarly, Ugazio et al. (2012) , on their part, showed that both deontological and utilitarian responding could actually be triggered by different emotions with different motivational tendencies. In their study, disgust induction (an emotion that triggers withdrawal tendencies) resulted in more deontological moral judgments (i.e., refraining from harm), while anger induction (an emotion that triggers approach tendencies) resulted in more utilitarian moral judgments (i.e., committing harm). This finding doesn't fit the Dual Process account either, because the study shows how different emotional phenomena trigger both deontological and utilitarian moral judgment tendencies.

Therefore, we propose that a potentially more suitable account of moral judgment is one that gives a different role to emotions in moral judgment, specifically, to the importance of the arousal response which is triggered in the individual by the dilemmatic situation along the way suggested by the Affect Infusion Model (AIM) by Forgas (1995) . This model posits that (i) arousal properties of the situation, (i) the motivational features of the emotions triggered by it, and (iii) the associated cognitive appraisal mechanisms, all play a crucial role in every judgment. This model also posits that affect infusion is a matter of degree: any judgment is also dependent on previous knowledge of the individual about the event or situation he or she is about to judge; this implies that it is dependent on deliberate reasoning as well as on the magnitude of the emotional arousal triggered by the event or situation.

See the Supplementary Material for a summary of limitations of the method.

In this work, we have followed Hauser et al. view of moral dilemmas: “… the use of artificial moral dilemmas to explore our moral psychology is like the use of theoretical or statistical models with different parameters; parameters can be added or subtracted in order to determine which parameters contribute most significantly to the output” ( Hauser et al., 2007 ). We have tried to control for the variables known to influence moral judgment, in order to find out which ones matter most, and how they interact.

One main result of this work is that, when dilemmas are validated, Greene's main effect of personal dilemmas partly disappears, for a more complex pattern, which casts doubt on the view that some moral judgments are the result of a deliberation, while others, the deontological ones, are reached emotionally. While higher arousal is related to deontological judgments, it is not true that deontological judgments are faster than utilitarian ones. Deontological judgments may take longer than utilitarian ones if, after taking time to weight the options, and to look for a way to minimize the transgression, one cannot find a way to choose not to violate one's principles.

Research with moral dilemmas holds fascinating possibilities to study the grounding psychological principles of human moral cognition. Contrary to the criticisms brought up against this methodology, and in line with an increasing number of other researchers, we believe that it is specifically the artificial nature of moral dilemmas that make this methodology so valuable. In any case, the scenarios described to us in moral dilemmas are not more artificial than the stories narrated in novels and movies where life-and death-decisions change the course of supposedly inevitable events. Besides, other abundant channels of information of that kind are the news on TV, radio, in the papers, and on the internet. They inform us of atrocities that happened around the corner of our house while we were sleeping, or of heartbreaking life-threatening situations that some individual in a war swept country has had to go through… Are moral dilemmas really all that unreal and artificial to us?

Author Note

All authors: Human Evolution and Cognition (IFISC-CSIC) and Department of Psychology, University of the Balearic Islands, Carretera de Valldemossa, km. 7.5, Building: Guillem Cifre de Colonya, 07122 Palma, Spain. Nadine K. Gut current affiliation: School of Psychology and Neuroscience, University of St Andrews, St Mary‘s Quad, South Street, St Andrews, KY16 9JP, UK; Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, 161 Cathedral Street, Glasgow, G4 0RE, UK.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

The study was funded by the research project FFI2010-20759 (Spanish Government: Ministry of Economy and Competitiveness), and by the Chair of the Three Religions (Government of the Balearic Islands) of the University of the Balearic Islands, Spain. Julia F. Christensen and Albert Flexas were supported by FPU PHD scholarships from the Spanish Ministry of Education, Culture and Sports (AP2009-2889 and AP2008-02284). Nadine K. Gut was supported by a scholarship of the School of Psychology and Neuroscience, University of St Andrews, UK. We want to thank Dr. Camilo José Cela-Conde for help and advice at different stages of this work; and a special thank you goes to Lasse Busck-Nielsen, Françoise Guéry and Trevor Roberts for help in the language editing process.

Supplementary Material

The Supplementary Material for this article can be found online at: http://www.frontiersin.org/journal/10.3389/fpsyg.2014.00607/abstract

1. ^ Please note that study with a preliminary version of the revised set has recently been published ( Christensen et al., 2012 ).

2. ^ For a detailed description of the dilemmas, see also Moore et al. (2008) . For clarity it should be said that these 48 dilemmas are made up of 24 different short stories, which have a personal and an impersonal version each.

3. ^ We also considered removing the Bike Week Dilemma due to the act of acrobatics that it involves, but finally left it in. However, we encourage researchers to potentially reconsider this.

4. ^ Please note: in this arousal and valence norming procedure participants did not see the question. This was to avoid confounds between the arousal and valence judgments and a moral judgment.

5. ^ Supplementary Material accompanies this manuscript with all data points presented in this work.

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Keywords: moral dilemmas, moral judgment, decision making, cross cultural, DPHMJ

Citation: Christensen JF, Flexas A, Calabrese M, Gut NK and Gomila A (2014) Moral judgment reloaded: a moral dilemma validation study. Front. Psychol . 5 :607. doi: 10.3389/fpsyg.2014.00607

Received: 17 April 2014; Accepted: 29 May 2014; Published online: 01 July 2014.

Reviewed by:

Copyright © 2014 Christensen, Flexas, Calabrese, Gut and Gomila. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Julia F. Christensen, Department of Psychology, University of the Balearic Islands, University Campus, Carretera de Valldemossa, km. 7.5, Building: Guillem Cifre de Colonya, 07122 Palma, Spain e-mail: [email protected]

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15 Ethical Dilemma Examples You See in the Real-World

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In your everyday life, and especially at work, have you faced ethical dilemmas that challenge your personal morals? If so, considering common ethical dilemma examples can go a long way to resolving your own.

You'll learn you must analyze the risks, rely on your convictions, and trust your instincts. Stepping back and removing yourself from the situation can help you gain a perspective that will aid in making your best decisions.

It's also important to be sure you act after thinking the situation through and not before. To help with this, take a look at our article, “7 Ways to Live Consciously in an Unconscious World.”

Drawing on the experience of others may empower you to navigate your struggle and arrive at the best decision.

This process exercises your critical thinking skills and the decisions you make can help you become respected as a person and a professional. Therefore, looking at ways that others have navigated those difficult moral decisions may be an excellent way to help you should you ever face similar circumstances.

In this article, you’ll learn about specific ethical dilemma examples that will help you understand the difficulty of making decisions that go against moral principles… which may make it less troublesome to make a decision when facing your next ethical dilemma.

Table of Contents

What Are Ethical Dilemmas?

Ethical dilemmas are all about difficulty in choosing between two courses of action, in which either choice involves disobeying a moral principle.

For instance, if you’re facing an ethical dilemma, it can affect you emotionally as you may struggle between what you consider to be right against what you consider to be necessary for a certain situation.

An ethical dilemma occurs when your moral principles are challenged. Some instances of the moral tenets are honesty, abstaining from and not promoting violence, caring for others, respecting the privacy of others, aiding people in trouble, and not harming others, whether humans or animals.

You may have heard of ethical dilemma examples called moral dilemmas or ethical paradoxes. In some instances, any choice you make is wrong in some sense.

In each ethical dilemma, the options are at odds with each other; they conflict with each other, causing a contradiction or paradox.

There are situations where you might have two choices; if you choose one, it would be impossible to choose the other.

Real-World Ethical Dilemma Examples

Often, the best way to mitigate ethical dilemmas is to learn about and seek understanding with real-world examples. Here are 15 examples of real-world ethical dilemmas we trust you’ll find useful. 

1. Monitoring Teens on Social Media.

Should a teenager using Snapchat, Instagram, or TikTok have their social media use monitored? This is an ethical dilemma many parents of teens face as teenagers spend many hours engaging in online activities daily. For some parents, the question may be: Do I trust my child to use social media responsibly or not?

For others, they may be asking themselves: From a safety standpoint as a parent, should I monitor my teenager’s online activities, or are they old enough to use social media responsibly?

Whichever ethical dilemma they are facing, a parent’s fear of cyberbullying and safety for their children is not unfounded. According to 2018 Pew Research , 21% of 13-15-year-olds, 16% of 16-17-year-olds, and 12% of 18-20-year-olds experienced cyberbullying.

While anyone utilizing the Internet risks cyberbullying, teens are ill-equipped to deal with such treatment as their brains are not yet fully developed. Therefore, it is a parent’s duty to protect their child from online attacks.

However, since the close monitoring of a teenager’s activities, online or otherwise, may be construed as a lack of trust toward the teen, it can potentially damage or at least put a strain on the parent-child relationship. Therein lies the ethical dilemma and the choices each parent must make.

One father of two teenaged girls chose to monitor their activities, sharing that, above all, “The devices belong to me and my wife, and we are entitled to see anything and everything on them.”

A good way to build trust with your teens may be to spend time playing games or asking “would you rather” questions ; trust will help them know that whether you monitor their online activity, you care.  

2. Ghosting.

This is when you end a relationship by not responding to the other person at all, by just ignoring them, rather than telling them you would like to end the relationship. While ghosting someone is not the nicest of ways to end a relationship, is it morally wrong?

If you believe in kindness, you may struggle as to whether you can live with your decision to ghost someone. Ghosting seems like the easy way out for the one ghosting, but it's hard for the one being ghosted to find closure and move on.

Someone may choose to ghost their soon-to-be ex because they want to avoid conflict. Or maybe they are afraid the other person might lash out and become violent. For whatever reason, facing that person is uncomfortable that they consider ghosting.

If you consider ghosting someone, think about how that could make them feel. Is that really who you are? Getting a fresh and honest perspective may make you think differently if you're considering ghosting someone.

If you've been ghosted, you find some benefit in reading our “ 55 Survival Quotes to Make You Tough in 2023 .”

3. Intentionally Misinterpreting Data.

There are several instances you may find yourself in where you’re tempted to fudge the numbers. Maybe you’re in the corporate world and are tempted or encouraged to share the data in such a way that will cause stockholders to believe their investments are more secure than they are.

Your ethical dilemma may be whether you misinterpret the data and secure your career or share the true numbers and risk losing your job.

An ethical dilemma example of misinterpreting or outright lying about data is the FTX scandal where investors lost billions of dollars on the digital currency platform after being misled  by founder Sam Bankman-Fried. 

4. Selling a Car Without Disclosing All Known Negative Details.

Let's say you're selling your car to upgrade to a newer model. Nothing much is wrong with it, so you fail to disclose the fact that it has trouble starting from time to time; or, that it was involved in an accident.

Should you disclose whatever is wrong with it to potential buyers or do you consider purchasing a used car to be a ‘buyer beware' situation? Uphold your moral standards and make sure you aren’t the subject of someone’s used car sales gone bad story.

5. Cheat on Your Significant Other.

Your relationship has gone south but you're still considered a couple. You meet someone that, well, if you weren't married… But you are; and you stood before an entire congregation of people promising fidelity “til death do us part'.

A few years have passed and you just don't have the same romantic feelings anymore. Whether he's changed or you've changed or you've both changed, you can't quite put your finger on it. Now, you feel like you'd rather get out than stay in.

Since the relationship is rocky, can you justify starting a new relationship? Or, should you stay faithful and risk letting the potential new love of your life get away? Sometimes a person will cheat on their significant other as an act of revenge when they are mad at each other. And sometimes, the decision to cheat ends badly.

If you've made the decision not to cheat, try solidifying your relationship with our advice on relationships. 

6. Should You Lie to a Sick Loved One?

Usually, if someone considers lying, whether they do it or not, it goes against their belief system and in their heart they know that it's wrong. However, whenever the truth would hurt someone you love, it often presents a gray area or a moral dilemma.

There have been instances where family members have either lied or withheld the truth in order to spare the feelings of a sick loved one, particularly in cases of Alzheimer's patients.

If an Alzheimer's patient asks about a loved one, and that loved one is deceased, finding out about their death all over again can cause them pain. Because of that, some family members will lie to spare their loved one's feelings. Is it ever compassionate to withhold information from your loved one with Alzheimer's?

This may be a dilemma you should discuss with your family members to help make your own personal decision. However, make sure you follow your own moral compass rather than doing what others wish you to do .

7. To Share or Not to Share Political Leanings.

Have you noticed how passionate people are about politics? If you choose to share your political leanings online or in person, you would lose followers, friends, and/or family members.

Some people weigh the options and decide it's not worth it to speak what's on your mind and lose the close contact of others.

Some say it's best to be real, to be authentic, and share any and all beliefs, loud and proud. Before choosing either option, weigh your options. Which choice can you live with? Which one could you not live with?

No matter what you decide, take time to consider the consequences of each choice before firmly making your decision. Then, be prepared to live with those consequences. 

8. Whether to Report an Accident.

If you're in a rush and you pass by and an accident, would you report it? Or would you not, knowing that the next person that passes by most likely would call the authorities?

The moral dilemma would be: risk getting to your meeting late, especially if you have to give an account of what happened to the police; or risk feeling guilty because you chose not to stop and help in a situation and caused the authorities to arrive sooner rather than later or even too late.

If you're struggling about whether you should report an accident as a witness, put yourself in the shoes of those affected by the accident to discover what you should do and how you can help. 

9. To Share or Not to Share Religious Beliefs.

It's been said to never discuss politics or religion. Yet there comes a time in close relationships where the question of whether to share what your beliefs are may come to mind, bringing you face to face with a moral dilemma.

If you know the person you'll be sharing with has beliefs that are different from yours, you may wonder if sharing your beliefs will push them away.

Withholding the information as you grow closer in a relationship may cause several problems: the other person in the relationship may feel you haven't been as open and honest as you should have been, or you may feel conflicted as you want to share but are hesitant to do so.

However, if you feel a kinship with a person on a spiritual level , you may consider sharing your religious views.

If the question of whether you should share your religious views at work arises, you may want to ask yourself why you would consider sharing.

While there are employment laws against discrimination of religion, you need to be careful not to proselytize, which is to try to convert someone, and would be frowned upon in the workplace. 

10. Should You Lie to Your Boss?

Being less than truthful with your boss can have repercussions, depending on the lie. The moral dilemma you may face may be whether you should lie about your experience and education, which could easily be verified. If the lie is less impactful, as in, you call in sick but aren't, you are less likely to get caught in the lie.

In employing your critical thinking skills you may find that you agree its fine to lie to your boss in certain situations. However, does lying to your boss on any level go against your personal moral beliefs? If so, that will create your moral dilemma. 

11. Recalling a Faulty Product.

Let's say you own a business, and it has come to your attention that the product you've shipped and sold has a faulty part.

What would you do? If the part's faultiness would cause harm to someone using the product, that's a serious consideration. If, however, the faultiness may not be noticed and would not cause harm, that may cause you to consider not recalling the product.

The moral dilemma is presented as you determine how you feel about not making the product right and looking out for the best interests of your customers. There is also the legal side of recalling a product.

12. Taking Credit for Your Coworker’s Work.

You've collaborated on a project at work. Your team members have given valuable input that has drawn attention from your management team. You know this recognition could move you closer to a promotion.

Although one of your teammates had the most eye-catching input, should you claim credit for it? After all, it was a team effort, and you'd really like that promotion.

The moral dilemma is doing what's right by giving your teammates the credit they deserve, which would preserve your working relationship or risk your working relationship by claiming the credit for yourself.

To help you make your decision ask yourself whether taking credit for someone else's work is ethical. It would be more beneficial to pursue your own path to promotion without detracting from someone else. 

13. Aborting a Child with Down Syndrome.

When you're expecting a baby, it's generally a joyous occasion. If you find out your baby will be living with life-changing challenges, such as Down syndrome, you may find you're facing a moral dilemma.

According to the Centers for Disease Control (CDC), the life expectancy of babies with Down syndrome increased from 10-years-old in 1960 to 47-years-old in 2007.

While there are additional challenges associated with a child with Down syndrome, the dilemma basically comes down to the question: how does an abortion fit into your moral beliefs?

You may want to read this article showcasing three families struggling with the moral dilemma of aborting a Down syndrome child. 

14. Should You Tell Your Friend if Her Husband is Cheating?

It's a heavy burden to carry and keep a secret from a friend, especially if you feel that she will be hurt by finding out the truth. You may also be worried about how the information you're intending to share will be received.

If not received well, you could lose a friend. At best, it would likely be an emotional conversation.

Or your moral dilemma might be: should you speak to your friend about the situation or speak to her husband or just do nothing?

No matter what your choice is according to your moral beliefs, I think you can agree this is a sticky situation. If you do decide to tell your friend, do it with finesse.

15. Is It Okay to Take Supplies from Your Office?

Many people work in office settings and for their job functions to be fulfilled, their companies supply tools they need. These tools may be something as simple as paper clips to pens, notebooks, office chairs, and computers.

The moral dilemma becomes when you question whether you should take some of these office supplies home for your own personal use.

According to your belief system, would that be stealing from the company or would it be acceptable? Would it matter if the item you'd like to take is a small item or do you believe, right or wrong, any item would carry the same weight in your decision? 

Final Thoughts on Real-World Ethical Dilemmas

While ethical dilemma examples may go from two difficult choices, to almost impossible choices, I'm sure you and I can agree that it helps to arm yourself with the knowledge of how others have faced similar situations.

In reading through the ethical dilemma examples we've provided, you may have found a pathway to your own answers.

When making your choices, it's in your best interest to keep honesty, integrity, and morality paramount.  The ability to weigh each choice and try to objectively choose for the greater good is beneficial.

Your critical thinking skills will come into play and possibly be challenged when making difficult choices. As you can see from the examples we've provided in this article, some moral dilemmas are quite difficult and the answers are not always clear-cut choices. 

The bottom line is that the examples detailed in this article may help you in making decisions as they arise in your own life, especially when you find them challenging.

A good starting point is to get yourself in the right mindset , consider all the facts, then figure out whether you have the control to make the decision needed before moving forward. Having done that, once you've made your choice, you'll have the satisfaction that you've chosen wisely.