A Narrative Approach to the Clinical Reasoning Process in Pediatric Intensive Care: The Story of Matthew

This paper offers a narrative approach to understanding the process of clinical reasoning in complex cases involving medical uncertainty, moral ambiguity, and futility. We describe a clinical encounter in which the pediatric health care team experienced a great deal of conflict and distrust as a result of an ineffective process of interpretation and communication. We propose a systematic method for analyzing the technical, ethical, behavioral, and existential dimensions of the clinical reasoning process, and introduce the Clinical Reasoning Discussion Tool—a dialogical and interpretive device aimed at improving communication, understanding, empathy, and moral deliberation in the clinical setting.     

Case method and casuistry: The problem of bias

Case methods of reasoning are persuasive, but we need to address problems of bias in order to use them to reach morally justifiable conclusions. A bias is an unwarranted inclination or a special perspective that disposes us to mistaken or one-sided judgments. The potential for bias arises at each stage of a case method of reasoning including in describing, framing, selecting and comparing of cases and paradigms. A problem of bias occurs because to identify the relevant features for such purposes, we must use general views about what is relevant; but some of our general views are biased, both in the sense of being unwarranted inclinations and in the sense that they are one of many viable perspectives. This reliance upon general views to determine relevancy creates additional difficulties for defenders who maintain that case methods of moral reasoning are not only useful, but more basic, reliable or prior to other forms of moral reasoning. If we cannot identify the case's relevant features and issues independently of our general views or biases, we need further explanation about why a case method or casuistry should be viewed as prior to or more basic or reliable than other forms of moral reasoning. Problems of bias also arise for other methods of reasoning. In medical science, case reviews are regarded as an unreliable way to form generalizations, and methods such as clinical trials are used to address bias.     

Medical Ethics Education: A Survey of Opinion of Medical Students in a Nigerian University

In Nigeria, medical education remains focused on the traditional clinical and basic medical science components, leaving students to develop moral attitudes passively through observation and intuition. In order to ascertain the adequacy of this method of moral formations, we studied the opinions of medical students in a Nigerian university towards medical ethics training. Self administered semi-structured questionnaires were completed by final year medical students of the College of Medicine, University of Ibadan, Nigeria. There were 82 (64.1%) male and 44 (34.4%) female respondents. The median age was 26 years. Most students (80.5%) responded that they did not receive enough training in medical ethics. The ethics instructions they received did not sufficiently prepare them for the ethical challenges they came across as medical students. Though inadequate, the few hours of lecture and discussion on human values and professional etiquette which they received positively influenced their moral reasoning. They identified end-of-life issues, dealing with financial issues and handling socio-cultural beliefs of patients and relations as some challenges that medical doctors are ill-prepared for by their current training. Most, 85.9% believed that formal medical ethics education would be worthwhile as it would enhance the making of complete and better doctors. They recommended incorporating bioethics as a course in the medical school curriculum. Nigerian medical students encounter ethical challenges for which they have not been adequately trained to resolve. They recommended formal medical ethics training in their curriculum and a uniform bioethics programme in the country.     

Sensitizing Medical Residents to Fantasies and Alignments in the Family: Mastering Psychosocial Skills in the Medical Encounter

In this paper, it is proposed that a) psychosocial medicine is best taught in a setting that provides technical and emotional support, while seizing for teaching only those moments when the learner is most receptive; and b) that the setting should avoid the development of a separate psychosocial skills curriculum, but should take the student where he or she is and integrate the psychosocial skills into his or her everyday biomedical practice. The paper gives specific case examples in which family based psychosocial issues were preeminent in the clinical problem-solving medical residents faced.     

GENDER DIFFERENCES IN MORAL REASONING Stable or Situational?

Some researchers have proposed that women prefer care reasoning, which considers issues of need and sacrifice, and men prefer justice reasoning, which considers issues of fairness and rights. However, differences in approach to moral reasoning may be due to the different types of dilemmas women and men encounter rather than to differences in the ways men and women approach moral problems. The present study employed parenting dilemmas to determine whether restriction of domain would reduce gender differences in moral reasoning orientation. Dilemmas were presented or elicited and differed in difficulty, importance, and personal relevance to investigate the relationship between situational characteristics and care or justice reasoning. Women and men did not differ in their use of care or justice reasoning when the domain was restricted, supporting the conclusion that differences in moral reasoning orientation result from differences in current life situations rather than from stable gender characteristics.     

From indifference to goodness

In this paper, delivered as the 1995 Philip Hallie Memorial Lecture at Wesleyan University's College of Letters, the author reflects on Hallie's philosophical legacy and introduces clinical pragmatism as a method for moral problem-solving in medicine and medical ethics. director of medical ethics at The New York Hospital, and associate for medicine at the Hastings Center.     

Transcendence and the Moral Self: Identity Integration, Religion, and Moral Life

Although moral reasoning is able to account for some of the variability in moral behavior, much remains unexplained. Recently, a number of components of personality have been proposed as bridging the gap between moral reasoning and moral behavior. The present study investigates the role that identity integration (the extent to which one's moral values have become integrated into identity) and religious orientation (one's motivation for engaging in religious practice) play in moral functioning. A sample of 60 undergraduates was assessed on identity integration, religious orientation, moral reasoning, and self-reported altruism. We found positive correlations among moral reasoning, identity integration, intrinsic religious orientation, and self-reported altruism. A hierarchical regression analysis, however, revealed moral reasoning to be the only significant predictor of self-reported altruistic behavior. We discuss the relationship between moral reasoning and identity integration and the extent to which the intrinsic religious orientation scale may be a measure of identity integration in the religious domain.     

Addressing moral problems through practical reasoning

In this paper, following the work of Hare, we consider moral reasoning not as the application of moral norms and principles, but as reasoning about what ought to be done in a particular situation, with moral norms perhaps emerging from this reasoning. We model this situated reasoning drawing on our previous work on argumentation schemes, here set in the context of Action-Based Alternating Transition Systems. We distinguish what prudentially ought to be done from what morally ought to be done, consider what legislation might be appropriate and characterise the differences between morally correct, morally praiseworthy and morally excusable actions. We also describe an implementation which simulates this reasoning and discuss some issues arising from the simulation.     

Thinking critically in medicine and its ethics: relating applied science and applied ethics

ABSTRACT While interest in philosophy and medicine has burgeoned in the past two decades, there remains a need for an analysis of the intellectual activity embodied in good medical practice. In this setting, ethical and scientific decision-making are complexly interrelated. The following paper, collaboratively written by physicians and philosophers, presents a view of applied (clinical) science and applied ethics. Making extensive use of illustrations drawn from routine case material, we seek to indicate a variety of philosophic issues to be found in daily practice, elucidate various levels of critical reasoning within the medical setting, and demonstrate a remarkable similarity between medical and ethical decision-making.     

WHO CARES? THE EFFECT OF GENDER AND CONTEXT ON THE SELF AND MORAL REASONING

Theorists suggest that gender differences in moral reasoning are due to differences in the self-concept, with women feeling connected to others and using a care approach, whereas men feel separate from others and adopt a justice approach. Using a self-categorization analysis, the current research suggests that the nature of the self–other relationship, rather than gender, predicts moral reasoning. Study 1 found moral reasoning to be dependent upon the social distance between the self and others, with a care-based approach more likely when interacting with a friend than a stranger. Study 2 suggests that when individuals see others as ingroup members they are more likely to utilize care-based moral reasoning than when others are seen as outgroup members. Further, traditional gender differences in moral reasoning were found only when gender was made salient. These studies suggest that both the self and moral reasoning are better conceptualized as fluid and context dependent.     

The Moral Implications of Immorality

This essay focuses on the issue of immorality, an issue that has largely been understudied in anthropology. It examines two types of immoral behavior in contemporary Chinese society, drawing on cases widely agreed upon by ordinary people to be morally wrong. Next, it analyzes moral experiences and moral sentiments among individuals who either were victims of immoral acts or recalled their own feelings of being immoral. Ethnographic evidence shows that immorality tends to be intuitive and emotional in actual social actions but in recollections of moral experiences it is reflected upon with rational reasoning and justification. Immorality is essentially the violation of the social, which may explain why ordinary people use immorality to define and defend their social behavior in everyday life. The recent emphasis on moral reasoning and ethical choice in anthropological studies of moralities has overlooked the social in the moral as well as the role of moral sentiments and intuitions in social actions.     

Reasoning in the personal and moral domains: Adolescent and young adult women's decision-making regarding abortion

The present investigation of adolescent and young adult women's reasoning, and decision-making about abortion was conducted to determine whether reasoning about abortion could be described by moral, social-conventional, and personal concepts and to examine relationships between domain of reasoning and action choices. Seventy single women, ranging in age from 13 to 31 and divided between 25 women having abortions, 23 women continuing their pregnancies, and 22 never-pregnant women, were administered a semi-structured clinical interview about abortion and two hypothetical moral judgement dilemmas. A classification task was developed to provide an additional measure of reasoning in different domains. Another 29 single, first-pregnant women provided a comparison of the effects of these procedures on decision-making. Content analysis of the protocols revealed that responses to the abortion interview could be reliably distinguished between concepts of morality and personal issues and their coordination or lack of coordination. Subjects treating abortion as a moral issue were more likely to continue their pregnancies while subjects treating abortion as a personal issue were more likely to obtain an abortion. Differences in reasoning between pregnant and nonpregnant subjects were not observed. Moral responses to the abortion interview were found to be highly related to hypothetical moral judgments.     

Medical ethics in Norway: Modern medicine — Traditional morality

In Norway, by tradition a Lutheran country, the puritan ethics of a “moral minority” has a strong influence on the development and manifestations of medical ethics. Those who exert this influence are found primarily among politicians, the clergy, and, last but certainly not least, among nurses and doctors. The focus of interest is not so much on problems of bioethical moral theory or the teaching of bioethics to students, but very much on attitudes and policies with regard to substantive issues traditionally regarded in Norway as burning bioethical issues, such as: medical research ethics, abortion, prenatal diagnosis, euthanasia, definitions of death, and reproductive technologies.     

Healthy and unhealthy forms of religiousness manifested by psychotherapy clients: An empirical investigation

This study investigated whether 49 Mormon psychotherapy clients and 51 Mormon nonclients differed on a number of religious and psychological variables. The data were analyzed using analysis of covariance, controlling for social desirability, education level, and occupation status. Clients scored higher than nonclients on shame and lower on existential well-being. There were no significant differences between clients and nonclients on religious orientation, religious wellbeing, moral reasoning, and guilt. Females scored much higher on guilt, and female clients scored much higher on shame; there were no other gender differences. Subjects showed a preference for Stage 4 moral reasoning, and 92% were intrinsically motivated in their religious worship. The psychotherapy clients' religious beliefs and motivations appeared healthy and functional and could be an asset during therapy. The clients manifested some psychological issues which could predispose them to unhealthy reactions to some of the doctrines and influences of their religion. The gender differences observed were also discussed.     

Moral growth in medical students

Although students bring to medical school a fairly well established value system, the potential for moral growth through the medical school environment and experience is substantial. The educational environment poses a succession of developmental and adaptive tasks to be accomplished. Several of these tasks are discussed here, tasks that are value-laden and involve, directly or indirectly, the interplay of ethical theory and practice. During the past quarter century, the two influences that have had the greatest impact on the moral growth and moral reasoning capacity of medical students have been the incorporation into the medical school curriculum of courses in medical humanities and the admission to medical school of an increasing number of female students. The female students have brought to medical school a level or dimension of moral reasoning (morality as care or responsibility for others) to augment the male students' focus on rights and justice considerations.     

Moral judgment and self-reported moral events in adulthood

As part of a 13-year study of the development of reasoning about the Good Life and moral judgment, 29 middle-class, well-educated adults, ranging in age from 18 to 80 years, were interviewed twice, 4 years apart on Standard Form Moral Judgment interviews and were asked to describe their own moral events that occurred recently. Both times, the average moral judgment score on the hypothetical dilemmas was about stage 4. The reasoning in the spontaneously reported moral events was significantly lower, although the two scores were highly correlated. Difference scores between the two were not related to scores on the hypothetical dilemmas. While there were no significant gender differences in scores on the hypothetical dilemmas, there were in scores on spontaneously reported events favoring males. The philosophic quality of the reported events could be easily categorized by traditional moral-philosophic categories; about half of the events contained traditional deontic moral content (moral right); the other half contained material defined as the moral good. The context of most events was interpersonal as opposed to societal. The most frequent issue discussed concerned honesty about financial issues, particularly income tax evasion. Ways to expand the research on adult moral experience are discussed.     

Gender bias and moral decision making: The moral orientations of justice and care

This study investigated gender related moral reasoning in student essays containing arguments on moral issues. Undergraduate students in a medical ethics course viewed two films on morally controversial issues. The students wrote brief essays about the films which were transcribed and numerically coded to conceal the author's gender from the evaluator. Using a coding scheme originated by Lyons, the evaluator classified each essay as a justice/right essay or a care/response essay or an equal response essay. Subsequently, calculations were made to determine the percentage of male authored essays that were justice/rights essays or care/response essays and the percentage of female authored essays that were justice/rights or care/response essays. The males (87.7%) tended to exhibit the justice/rights moral orientation, and the females (69.4%) exhibited the care/response moral orientation. Several different calculations were made to determine various degrees of gender related orientations also. The difference in orientation was highly statistically significant (p≤0.001). These data contribute to understanding moral orientation and development. Interpretations are given to explain some differences between the genders and help explain the traditional roles in society that males and females have played historically.     

Yearning for certainty and the critique of medicine as “science”

A debate has simmered concerning the nature of clinical reasoning, especially diagnostic reasoning: Is it a “science” or an “art”? The trend since the seventeenth century has been to regard medical reasoning as scientific reasoning, and the most advanced clinical reasoning is the most scientific. However, in recent years, several scholars have argued that clinical reasoning is clearly not “science” reasoning, but is in fact a species of narratival or hermeneutical reasoning. The study reviews this dispute, and argues that in a theoretical sense, the dispute rests upon a naïve—but very popular—caricature of what constitutes “science reasoning.” But, if the dispute rests upon just such a caricature, why is it so persistent? The study concludes by suggesting that we, as patients and as physicians, have deep psychological tendencies that incline us to adopt the very naïve “science” concept/model of diagnostic reasoning, even if (or when) we understand its inaptness.     

Sexual experience, sex guilt, and sexual moral reasoning

Two studies are described in which the relations between sexual experience, sex guilt, and sexual moral reasoning were examined. Subjects were asked to articulate their opinions on each of six sexual activities, and then choose one of six statements (corresponding to Kohlberg's six stages of reasoning) that most clearly reflected why they had, or had not, engaged in three of those activities. An analysis of the moral reasoning present in each of the six articulated responses indicated that level of reasoning was inversely related to sex guilt. Analysis of the preference data indicated that subjects endorsed reasoning (statements) at a higher stage than they had articulated, and that this “gap” between articulation and preference was much greater for less experienced subjects. Results are discussed in terms of the utility of using situation-specific moral dilemmas when assessing moral reasoning, and in terms of the possible role that lack of sexual experience plays in inhibiting sexual moral development.     

Reasoning and Instruction in Medical Curricula

We describe two experiments that examine the knowledge and explanatory processes of students in two medical schools with different modes of instruction. One school had a conventional curriculum with basic science courses taught 1 '/2 years before the clinical training; the other had a problem-based learning curriculum with basic science taught in the context of clinical problems and general problem-solving strategies involving knowledge elaboration and hypothetico-deductive reasoning. Both before and after being exposed to relevant basic science information, students were asked to provide diagnostic explanations of a clinical case. In this study, students in the problem-based learning curriculum reasoned in a manner consistent with the way they were taught, using a backward directed pattern of reasoning and extensive elaborations based on detailed biomedical information. However; these students had a greater tendency to commit errors of scientific fact, to generate less coherent explanations, and to use flawed patterns of explanation, such as circular reasoning. These results are viewed as reflecting the operation of two factors: context and method of instruction. The interaction between these factors is expressed in terms of the hypothesis that basic science and clinical knowledge constitute two different worlds.