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Ethical Dilemma: 10 Heartbreaking Case Studies

Last updated on April 2, 2024 by Alex Andrews George

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

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

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

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

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

Table of Contents

What is an ethical dilemma?

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

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

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

Definition of ethical dilemma

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

It’s characterized by:

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

5 Cases of Ethical Dilemma

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

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

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

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

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

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

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

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

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

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

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

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

Moral Conflicts

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

Ethical Dilemma

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

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

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

Moral Conflict

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

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

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

Key Differences Between Ethical Dilemmas and Moral Conflict

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

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

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

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

5 Cases of Moral Conflicts

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

1. Honesty vs. Compassion

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

2. Loyalty vs. Justice

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

3. Self-sacrifice vs. Self-preservation

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

4. Equality vs. Meritocracy

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

5. Freedom vs. Security

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

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

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

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

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

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

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

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

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

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

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

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About Alex Andrews George

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

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

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

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

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• Volume 43 , pages 36–63, ( 2021 )

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

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

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

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

Embodied Ethical Decision-Making

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

Clinical Case

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

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

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

Culture Interfaces in Ethical Decision Making

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

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

Theoretical Orientation

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

Exploration of Ethical Decision-Making with Juan

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

Step One: Become Familiar

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

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

Embodiment of Step One

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

Step Two: Define the Dilemma

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

Embodiment of Step Two

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

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

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

Identifying the Options

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

Step Three and Four: Search, Evaluate, and Determine

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

Codes and Scholarship

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

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

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

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

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

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

Embodiment of Steps Three and Four

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

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

Step Five: Ethical Principles

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

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

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

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

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

Nonmaleficence

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

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

Beneficence

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

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

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

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

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

Step Six: Consult and Share

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

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

Embodiment of Step Six

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

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

Step Seven and Eight: Deliberate, Decide, and Rehearse

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

Decision Made for the Case with Juan

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

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

Embodiment of Steps Seven and Eight

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

Step Nine: Reflect and Evaluate

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

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

Embodiment of Step Nine

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

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

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

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

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

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

Active multicultural diversity in ethical decision-making

Movement Towards Mutuality

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

Mutual Empathy

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

Mutual Empowerment

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

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

Active Multicultural Diversity for Juan’s Case

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

Limitations and Possibilities

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

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

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

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

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

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The development of artificial intelligence (AI) systems and their deployment in society gives rise to ethical dilemmas and hard questions. By situating ethical considerations in terms of real-world scenarios, case studies facilitate in-depth and multi-faceted explorations of complex philosophical questions about what is right, good and feasible. Case studies provide a useful jumping-off point for considering the various moral and practical trade-offs inherent in the study of practical ethics.

Case Study PDFs : The Princeton Dialogues on AI and Ethics has released six long-format case studies exploring issues at the intersection of AI, ethics and society. Three additional case studies are scheduled for release in spring 2019.

Methodology : The Princeton Dialogues on AI and Ethics case studies are unique in their adherence to five guiding principles: 1) empirical foundations, 2) broad accessibility, 3) interactiveness, 4) multiple viewpoints and 5) depth over brevity.

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Case study: an ethical dilemma involving a dying patient

Affiliation.

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

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

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Case Study UT Star Icon

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.

On September 8, 2016, Wells Fargo, one of the nation’s oldest and largest banks, admitted in a settlement with regulators that it had created as many as two million accounts for customers without their permission. This was fraud, pure and simple. It seems to have been caused by a culture in the bank that made unreasonable demands upon employees. Wells Fargo agreed to pay $185 million in fines and penalties.

Employees had been urged to “cross-sell.” If a customer had one type of account with Wells Fargo, then top brass reasoned, they should have several. Employees were strongly incentivized, through both positive and negative means, to sell as many different types of accounts to customers as possible. “Eight is great” was a motto. But does the average person need eight financial products from a single bank? As things developed, when employees were unable to make such sales, they just made the accounts up and charged customers whether they had approved the accounts or not. The employees used customers’ personal identification numbers without their knowledge to enroll them in various products without their knowledge. Victims were frequently elderly or Spanish speakers.

Matthew Castro, whose father was born in Colombia, felt so bad about pushing sham accounts onto Latino customers than he tried to lessen his guilt by doing volunteer work. Other employees were quoted as saying “it’s beyond embarrassing to admit I am a current employee these days.”

Still other employees were moved to call company hotlines or otherwise blow the whistle, but they were simply ignored or oftentimes punished, frequently by being fired. One employee who sued to challenge retaliation against him was “uncomfortable” and “unsettled” by the practices he saw around him, which prompted him to speak out. “This is a fraud, I cannot be a part of that,” the whistleblower said.

Early prognostications were that CEO John Stumpf would not lose his job over the fiasco. However, as time went on and investigations continued, the forms and amount of wrongdoing seemed to grow and grow. Evidence surfaced that the bank improperly changed the terms of mortgage loans, signed customers up for unauthorized life insurance policies, overcharged small businesses for credit-card processing, and on and on.

In September of 2016, CEO Stumpf appeared before Congress and was savaged by Senators and Representatives of both parties, notwithstanding his agreement to forfeit $41 million in pay. The members of Congress denounced Wells Fargo’s actions as “theft,” “a criminal enterprise,” and an “outrage.” Stumpf simultaneously took “full responsibility,” yet blamed the fraud on ethical lapses of low-level bankers and tellers. He had, he said, led the company with courage. Nonetheless, by October of 2016 Stumpf had been forced into retirement and replaced by Tim Sloan.

Over the next several months, more and more allegations of wrongdoing arose. The bank had illegally repossessed cars from military veterans. It had modified mortgages without customer authorization. It had charged 570,000 customers for auto insurance they did not need. It had ripped off small businesses by charging excessive credit card fees. The total number of fake accounts rose from two million to 3.5 million. The bank also wrongly fined 110,000 mortgage clients for missing a deadline even though the party at fault for the delay was Wells Fargo itself.

At its April 2017 annual shareholders meeting, the firm faced levels of dissent that a Georgetown business school professor, Sandeep Dahiya, called “highly unusual.”

By September, 2017, Wells Fargo had paid $414 million in refunds and settlements and incurred hundreds of millions more in attorneys’ and other fees. This included $108 million paid to the Department of Veterans Affairs for having overcharged military veterans on mortgage refinancing.

In October 2017, new Wells Fargo CEO Tim Sloan was told by Massachusetts Senator Elizabeth Warren, a Democrat, that he should be fired: “You enabled this fake-account scandal. You got rich off it, and then you tried to cover it up.” Republicans were equally harsh. Senator John Kennedy Texas said: “I’m not against big. With all due respect, I’m against dumb.”

Sloan was still CEO when the company had its annual shareholders meeting in April 2018. Shareholder and protestors were both extremely angry with Wells Fargo. By then, the bank had paid an additional $1 billion fine for abuses in mortgage and auto lending. And, in an unprecedented move, the Federal Reserve Board had ordered the bank to cap its asset growth. Disgust with Wells Fargo’s practices caused the American Federation of Teachers, to cut ties with the bank. Some whistleblowers resisted early attempts at quiet settlements with the bank, holding out for a public admission of wrongdoing.

In May 2018, yet another shoe dropped. Wells Fargo’s share price dropped on news that the bank’s employees improperly altered documents of its corporate customers in an attempt to comply with regulatory directions related to money laundering rules.

Ultimately, Wells Fargo removed its cross-selling sales incentives. CEO Sloan, having been informed that lower level employees were suffering stress, panic attacks, and other symptoms apologized for the fact that management initially blamed them for the results of the toxic corporate culture, admitting that cultural weaknesses had caused a major morale problem.

Discussion Questions

1. What moral emotions seem to have been at play in this case? On the part of the bank’s employees? The bank’s victims? The bank’s regulators? The bank’s shareholders?

2. What factors contributed particularly to the outrage and anger that legislators, regulators, customers, and shareholders felt?

3. Clearly inner-directed emotions such as guilt and embarrassment affected the actions of Wells Fargo employees. Were they always sufficient to overcome the employees’ utilitarian calculation: “I need this job”?

4. Did moral emotions motivate some of the whistleblowers? How?

5. In the wake of everything described in the case study, Wells Fargo has fired many employees, clawed back bonuses from executives, replaced many of its directors, dismantled its sales incentive system and made other changes.

• Do you think these changes were made out of a utilitarian calculation designed to avoid further monetary penalties, or a desire to avoid the shame and embarrassment the bank’s managers and employees were feeling?
• Or was it a combination of both of these things?
• If a combination, which do you think played a bigger role? Why?

Related Videos

Moral Emotions

Moral emotions are the feelings and intuitions that play a major role in most of our ethical decision making and actions.

Bibliography

“Elizabeth Warren to Wells Fargo CEO: “You Should Be Fired,” http://money.cnn.com/2017/10/03/investing/wells-fargo-hearing-ceo/index.html

“It’s Been a Year Since the Wells Fargo Scandal Broke—and New Problems Are Still Surfacing,” http://www.latimes.com/business/la-fi-wells-fargo-one-year-20170908-story.html

“Wells Fargo’s Reaction to Scandal Fails to Satisfy Angry Lawmakers,” https://www.nytimes.com/2016/09/30/business/dealbook/wells-fargo-ceo-john-stumpf-house-hearing.html

“’Wells Fargo, You’re the Worst’: Scenes from Testy Annual Meeting,” https://www.americanbanker.com/news/wells-fargo-youre-the-worst-scenes-from-testy-annual-meeting

“How Wells Fargo’s Cutthroat Corporate Culture Allegedly Drove Bankers to Fraud,” https://www.vanityfair.com/news/2017/05/wells-fargo-corporate-culture-fraud

“Outburst by Angry Wells Fargo Shareholder Halts Annual Meeting,” http://money.cnn.com/2017/04/25/investing/wells-fargo-shareholder-meeting/index.html

“Wells Fargo Shares Slip on Report that Employees Altered Customer Documents in Its Business-Banking Unit,” https://www.cnbc.com/2018/05/17/wells-fargo-shares-sink-on-report-that-employees-altered-customer-documents-in-its-business-banking-unit.html

“Wells Fargo to Pay $108 Million for Allegedly Overcharging Veterans on Refis,” https://www.housingwire.com/articles/40925-wells-fargo-to-pay-108-million-for-allegedly-overcharging-veterans-on-refis

“For Wells Fargo, Angry Questions About Profiling Latinos,” http://www.chicagotribune.com/business/ct-wells-fargo-fake-accounts-latinos-20161019-story.html

“More Former Wells Fargo Employees Allege They Were Fired After They Tried to Blow the Whistle on Shady Activity at the Bank,” http://money.cnn.com/2017/11/06/investing/wells-fargo-retaliation-whistleblower/index.html

“Inside Wells Fargo, Workers Say the Mood is Grim,” http://money.cnn.com/2016/11/03/investing/wells-fargo-morale-problem/index.html

“Disgust With Wells Fargo You Can Take to the Bank,” https://goodmenproject.com/business-ethics-2/disgust-with-wells-fargo-you-can-take-to-the-bank-wcz/

“The Former Khmer Rouge Slave Who Blew the Whistle on Wells Fargo,” https://www.nytimes.com/2018/03/24/business/wells-fargo-whistleblower-duke-tran.html

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What are research ethics cases.

For additional information, please visit Resources for Research Ethics Education

Research Ethics Cases are a tool for discussing scientific integrity. Cases are designed to confront the readers with a specific problem that does not lend itself to easy answers. By providing a focus for discussion, cases help staff involved in research to define or refine their own standards, to appreciate alternative approaches to identifying and resolving ethical problems, and to develop skills for dealing with hard problems on their own.

Research Ethics Cases for Use by the NIH Community

• Theme 24 – Using AI in Research and Ethical Conduct of Clinical Trials (2024)
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• Theme 22 – Use of Human Biospecimens and Informed Consent (2022)
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• Theme 20 – Data, Project and Lab Management, and Communication (2020)
• Theme 19 – Civility, Harassment and Inappropriate Conduct (2019)
• Theme 18 – Implicit and Explicit Biases in the Research Setting (2018)
• Theme 17 – Socially Responsible Science (2017)
• Theme 16 – Research Reproducibility (2016)
• Theme 15 – Authorship and Collaborative Science (2015)
• Theme 14 – Differentiating Between Honest Discourse and Research Misconduct and Introduction to Enhancing Reproducibility (2014)
• Theme 13 – Data Management, Whistleblowers, and Nepotism (2013)
• Theme 12 – Mentoring (2012)
• Theme 11 – Authorship (2011)
• Theme 10 – Science and Social Responsibility, continued (2010)
• Theme 9 – Science and Social Responsibility - Dual Use Research (2009)
• Theme 8 – Borrowing - Is It Plagiarism? (2008)
• Theme 7 – Data Management and Scientific Misconduct (2007)
• Theme 6 – Ethical Ambiguities (2006)
• Theme 5 – Data Management (2005)
• Theme 4 – Collaborative Science (2004)
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• Theme 1 – Scientific Misconduct (2001)

For Facilitators Leading Case Discussion

For the sake of time and clarity of purpose, it is essential that one individual have responsibility for leading the group discussion. As a minimum, this responsibility should include:

• Reading the case aloud.
• Defining, and re-defining as needed, the questions to be answered.
• Encouraging discussion that is “on topic”.
• Discouraging discussion that is “off topic”.
• Keeping the pace of discussion appropriate to the time available.
• Eliciting contributions from all members of the discussion group.
• Summarizing both majority and minority opinions at the end of the discussion.

How Should Cases be Analyzed?

Many of the skills necessary to analyze case studies can become tools for responding to real world problems. Cases, like the real world, contain uncertainties and ambiguities. Readers are encouraged to identify key issues, make assumptions as needed, and articulate options for resolution. In addition to the specific questions accompanying each case, readers should consider the following questions:

• Who are the affected parties (individuals, institutions, a field, society) in this situation?
• What interest(s) (material, financial, ethical, other) does each party have in the situation? Which interests are in conflict?
• Were the actions taken by each of the affected parties acceptable (ethical, legal, moral, or common sense)? If not, are there circumstances under which those actions would have been acceptable? Who should impose what sanction(s)?
• What other courses of action are open to each of the affected parties? What is the likely outcome of each course of action?
• For each party involved, what course of action would you take, and why?
• What actions could have been taken to avoid the conflict?

Is There a Right Answer?

Acceptable solutions.

Most problems will have several acceptable solutions or answers, but it will not always be the case that a perfect solution can be found. At times, even the best solution will still have some unsatisfactory consequences.

Unacceptable Solutions

While more than one acceptable solution may be possible, not all solutions are acceptable. For example, obvious violations of specific rules and regulations or of generally accepted standards of conduct would typically be unacceptable. However, it is also plausible that blind adherence to accepted rules or standards would sometimes be an unacceptable course of action.

Ethical Decision-Making

It should be noted that ethical decision-making is a process rather than a specific correct answer. In this sense, unethical behavior is defined by a failure to engage in the process of ethical decision-making. It is always unacceptable to have made no reasonable attempt to define a consistent and defensible basis for conduct.

This page was last updated on Friday, July 26, 2024

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Find case studies illustrating dilemmas in technology and ethics.

Case studies are also available on Internet Ethics .

For permission to reprint cases, submit requests to [email protected] .

Looking to draft your own case studies?  This template provides the basics for writing ethics case studies in technology (though with some modification it could be used in other fields as well).

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Concern is high over possible misuses of new AI technology which generates text without human intervention.

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University Module Series: Integrity & Ethics

Module 12: integrity, ethics and law.

  This module is a resource for lecturers  

Case studies.

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

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

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Supported by the state of qatar, 60 years crime congress.

AMA Journal of Ethics ®

Illuminating the art of medicine, why can’t we be friends a case-based analysis of ethical issues with social media in health care, “a george divided against itself cannot stand” [1].

This quote comes from the ever-popular ’90s sitcom  Seinfeld . In this classic scene, the always-put-upon George Costanza complains to his best friend Jerry about his two selves—Independent George and Relationship George. Independent George is the George that both George and Jerry love (bawdy, lying, etc.), whereas Relationship George is the identity that George maintains with his girlfriend, Susan. His concern is that if he does not create a firewall between these two identities, Relationship George will subsume Independent George. The exchange between George and Jerry humorously illustrates the real-life challenges of our brave new world of social media. Like George, who wants to maintain a boundary between his two personal (“bawdy” and relationship) identities, health care professionals are concerned about keeping their professional identities separate from their personal identities online [2]. The issue of boundaries is but one of many that the use of social media raises. In fact, the ubiquitous use of social media has created a number of potential ethical and legal challenges, some of which we will cover in this article. Specifically, we will:

• Define social media;
• highlight some recent instances of the good, bad, and ugly—social media used for good purposes, bad purposes, and plain ugly purposes;
• outline salient professional and ethical issues;
• review some illustrative case examples; and
• highlight where to find recent policy recommendations.

In many ways, social media is a liberating tool for millions of people throughout the world. The challenge for health care professionals is how to use social media in a responsible and thoughtful way. In this essay, we hope to foster a more reflective dialogue on both the benefits and potential risks of using social media in the health care context, particularly through a series of case vignettes.

What is Social Media?

A technical description of how social media works is as follows:

social network sites…[are] web-based services that allow individuals to (1) construct a public or semi-public profile within a bounded system, (2) articulate a list of other users with whom they share a connection, and (3) view and traverse their list of connections and those made by others within the system. The nature and nomenclature of these connections may vary from site to site [3].

The term “social media” includes such personal and professional platforms as Facebook, Twitter, LinkedIn, Tumblr, and Pinterest, to name just a few. Although Facebook is still the social media juggernaut with more than a billion active users [4], new social media technologies appear on an almost daily basis.

The existence of social media has not-so-quietly revolutionized the way human beings interact and connect with one another both personally and professionally. For thousands of years, geographic distance and lack of technologies for communication across that distance posed significant barriers to how people connected with one another. The invention of the Gutenberg printing press in the fifteenth century was the beginning of the revolution that made the printed word accessible. The second revolution was the creation in the nineteenth and twentieth centuries of mass communication technologies such as the telephone, radio, and television. The third revolution was the recent creation of social media outlets through which anyone with a smart phone can circulate a story or update to anyone else in the world. As of October 2014, 64 percent of US adults had a smartphone [5].

The Good, the Bad, and the Ugly

Social media has the potential to truly improve health behaviors, allow governments to respond to public health emergencies, and even alert pharmaceutical companies to adverse drug reactions more rapidly than current reporting mechanisms (perhaps even in real time). It also allows those with rare diseases to have more expansive  networks  to learn about their condition and treatments and gain helpful psychosocial support. As one disease advocate put it, “the internet has made our small disease larger and we are able to educate many more people now” [6]. These groups can be a much-needed source of emotional support and information exchange.

Unfortunately, irresponsible use of social media is fraught with hazards. There have been reports of patients stalking their physicians [7], health care professionals disclosing private information about patients [8], and students  blogging  denigrating descriptions of patients under their care [9]. A 2009 study published in  JAMA  revealed that 60 percent of medical schools surveyed “reported incidents of students posting unprofessional online content” [10]. The now-infamous  Yoder  case highlighted the hazards of students inappropriately blogging about their patients [9]. There have even been reports of medical residents losing their jobs for taking inappropriate photos, none perhaps more salaciously than the  BBC News  headline, “US ‘Penis Photo Doctor’ Loses Job” [11]. As one ethics commentator in the  Journal of Clinical Ethics  stated: “You can’t make this stuff up. And unfortunately, you don’t have to” [12]. These behaviors are ethically problematic and could possibly trigger libel suits or other legal actions.

Professional Ethical Issues

The use of social media in the health care setting raises a number of professionalism issues including concerns related to privacy and confidentiality; professional boundaries; recruitment; the integrity, accountability, and trustworthiness of health care professionals; and the line between professional and personal identity [13]. Below we discuss the first issue, which is foundational to the others.

Privacy and confidentiality are often used interchangeably but they have some crucial differences. Privacy is typically focused on the person—how and when an individual may share of him or herself. This is patient-controlled. Confidentiality, on the other hand, is focused on information that has been shared with someone else in a relationship of trust. This is controlled by the physician (or other health care professional).

Maintaining privacy and confidentiality are integral to the patient-health care professional relationship, since preserving patient trust is essential for competent clinical care. Without some commitment to confidentiality, many patients would be disinclined to share intimate information about themselves or their health histories, which could compromise the delivery of health care. With the advent of the Health Insurance Portability and Accountability Act (HIPAA) enacted in 2003 [14], health care entities were legally allowed to disclose protected health information (PHI) only to facilitate “treatment, payment, and health care operations” [15].

In the remaining part of this essay, we consider several case studies (some taken from the news and some hypothetical) that highlight the more salient ethical and legal issues that arise with the proliferation of social media use in health care.

Case Study One: The Global Health Student

A medical student is on an immersion trip to the Dominican Republic during the summer after her first year. She wishes to document her experience with the patients she encounters by photographing them in the clinical setting. She speaks fluent Spanish and asks for verbal consent from a patient to take her picture before doing so. She does not tell the patient what she plans to do with it. She uploads the photo to her Facebook account, describing the patient’s clinical issues.

What are some of the issues this case raises? Although legal norms governing privacy and confidentiality in the US and the Dominican Republic may differ, one could argue that ethical norms should not. The first question to ask is what does consent mean here? Is it a simple verbal consent that is not documented? Does the patient have a right to know the intended use of the photos and whether it is public or relatively private? Will the photos be used for educational purposes or will they simply be shared through a personal Facebook account? These are all important considerations to reflect upon before the student takes these photos during her immersion trip, and they highlight the necessity of distinguishing between personal use and professional use of social media. Opinion 5.045 of the American Medical Association (AMA)  Code of Medical Ethics  discusses filming patients in health care settings. Although it does not squarely address social media, one could look to it for some guidance. For instance, this opinion states that “filming patients without consent is a violation of the patient’s privacy.” By this logic, taking a photo of a patient and then uploading it to Facebook without consent is also a violation of the patient’s privacy. In a recent  AMA Journal of Ethics  article,  Terry Kind  cites the American College of Physicians and the Federation of State Medical Boards guidelines’ injunction to pause: “Trust yourself, but pause before posting to reflect on how best to protect and respect patients, their privacy, and your professional relationships and responsibilities” [16]. This student would do well to do likewise.

Case Study Two: The Tweeting Physician

A physician who works in a private practice is openly critical of health care reform. He tweets: "I don’t support Obamacare or Obama; patients who voted for him can seek care elsewhere.” His colleagues are concerned that his political views may hurt their practice; moreover, they wonder if it’s ethical for a physician to refuse to see someone because of his or her political views  [17].

This scenario raises many concerns. First of all, we have a First Amendment-protected right to free speech. Various forms of social media have facilitated the ability of many more people to publicly exercise this right. And, indeed, this physician has a First Amendment right to express his political views. For instance, a physician may submit a letter to the editor of a newspaper, expressing his or her political views. Presumably such a letter would be vetted by an editor. Social media has no editor. Therefore, it’s even more incumbent upon a practicing physician to be careful about expressing political views online. The AMA  Code of Medical Ethics  allows physicians to discuss political matters directly with their patients unless “patients and their families are emotionally pressured by significant medical circumstances” [18], but “communications by telephone or other modalities with patients and their families about political matters must be conducted with the utmost sensitivity to patients’ vulnerability and desire for privacy.” Current patients of this physician may find his behavior contrary to sensitivity to their vulnerabilities. And the physician’s own colleagues may view such behavior as inappropriate or even contrary to whatever contractual terms the physician signed. Furthermore, the AMA  Code  also proscribes discriminating against patients because of their “race, gender, sexual orientation, or any other criteria that would constitute invidious discrimination” [19]. Is it permissible, then, for a physician to refuse to care for someone because of his or her political views?

Case Study Three: The Googling Program Director

A residency program director is overwhelmed with resident applications. He has started to search applicants on Google to learn about their online identities. He discovers that a few of the students applying to his program have photos in their Facebook profiles that show them in an unflattering light. One is holding a drink at a party, appearing to be inebriated. Most disturbing is one set of photos in which the students (and even some physicians) are brandishing weapons on what appears to be an international immersion trip  [20].

Human resources departments and hiring committees are increasingly turning to the Internet to learn more about  applicants’ online activities . They may acquire certain personal information via social media outlets such as Twitter or Facebook or they may even learn about an applicant’s professional disciplinary history. Indeed, employers routinely retain services to check an applicant’s criminal background. They also follow up with references supplied by applicants.

This scenario raises questions about conducting such searches through the use of social media: Are such searches ethically permissible? How reliable is the information found? Do job applicants have any expectations of privacy? It may be incumbent upon an employer to screen applicants by doing a simple Google search to ensure that nothing troubling is uncovered, but the reliability of the information remains questionable, and it may be that such information should not be used in decision making without first allowing the applicant the opportunity to provide an explanation. Perhaps, then, prospective applicants should be notified that such searches will be conducted. We must all remember that no consent is required for someone to post photos of another person on Facebook, so, even if an applicant is not a Facebook user, others still may post identifying information and photos that are not all that flattering.

Case Study Four: Connecting on LinkedIn

A young pediatrician has recently finished his training and is now a newly minted attending physician. He is building his practice and has active accounts with Facebook and LinkedIn. A mother of one of his patients has recently sent a request to be his “friend” on Facebook. He declines this friend request, believing that this may impair his clinical judgment. He wonders, however, if it would be appropriate to connect with this patient’s mother through LinkedIn, since it is a site for professional networking as opposed to personal friendships.

As the opening anecdote about George Costanza suggests, the boundaries between our professional and personal lives have become increasingly blurred. Nonetheless, many people will attempt to construct some kind of boundaries with various forms of social media. For instance, many think of LinkedIn as strictly a professional networking site and would never post personal information there. The pediatrician in this scenario may think that connecting with a patient’s mother on LinkedIn is purely a professional connection. A challenge arises, however, if the mother of the child reaches out to the pediatrician through LinkedIn with a question about her child’s health. Is the pediatrician obligated to respond? If he does not, is he potentially liable? Are privacy issues raised if various patients are connecting with the physician through social media and all become aware of one another’s identity and that they are, in fact, patients? Although they are voluntarily connecting with their physician, it may not be transparent to users that they may be connected to that physician’s other patients.

Case Study Five: Patient Targeted Googling [21]

A physician treating an elderly woman for shortness of breath began looking for the cause of her worsening condition. He sent for a drug screen, on which she tested positive for cocaine. She told him she had no idea how cocaine could be in her system, which made him concerned she might be a victim of abuse. One of the nurses involved in her care Googled her and discovered that she had a previous police record for cocaine possession [22].

This kind of activity has garnered increasing attention, especially among psychiatrists and other practitioners in mental health. The situation is not unlike the residency program director Googling applicants—information on the Internet is freely available. Why shouldn’t a responsible health care practitioner Google a patient to learn more  potentially helpful information about him or her? The issue here is one of trust. Currently, patients expect that what they share with a physician is the sum total of the doctor’s information about them. It has been argued that such online research about patients should be avoided, unless there is a significant health or safety issue at stake [23].

Guidelines for the Responsible Use of Social Media

In response to the proliferation of social media use among health professionals and students in training, various educational institutions and professional organizations have developed guidelines. For instance, Loyola University Chicago Stritch School of Medicine [24], Northwestern University Feinberg School of Medicine [25], and the Mayo Clinic [26] have all responded with formal policies on the use of social media by students, faculty, and staff. In addition, both the  American Medical Association  [27] and the British Medical Association [28] have developed formal guidelines on the use of social media in health care.

Lastly, the Federation of State Medical Boards has developed “Model Policy Guidelines for the Appropriate Use of Social Media and Social Networking in Medical Practice” [29]. Although ethics and law often lag behind technological innovation, we now have a burgeoning set of policies to help health care professionals more thoughtfully use social media in their work and in their private lives. These new policies address a number of issues raised by the cases discussed here: privacy, boundaries, professional identity, and one’s reputation. We highly recommend that such policies be promoted and that institutions seriously consider developing their own internal policies.

Various forms of social media have transformed the way human beings interact with one another. Anyone with Internet access or a smartphone can now transmit tweets, Facebook postings, and Instagram images to hundreds, even thousands, of other people, all of whom can share this same information with their own network of contacts. This kind of technology can be liberating, but it also can create potential ethical and legal challenges for health care professionals. To address some of these challenges while availing our profession of some of the benefits, we recommend the following:

• Have a clear understanding of local, state, and national laws concerning privacy.
• Have a working knowledge of professional society guidelines.
• Know your institutional culture.
• Be prepared to make changes to stay current with the rapid developments in technology.
• Circulate policies, including updates, in writing to all who are required to abide by them.
• Differentiate between guidelines for education and guidelines for practice, if appropriate.
• Educate all (students, staff, faculty) about the policies.

Because all forms of social media have become so integrated into the social fabric, managing social media use on both a personal and professional level has become imperative. As Greysen et al. have concluded in an article in the  Journal of General Internal Medicine :

Certainly, the principle of “first, do no harm” should apply to physicians’ use of social media, but we can do better. Just as we must look beyond harm reduction towards health promotion in clinical practice, we must go farther than curtailing unprofessional behavior online and embrace the positive potential for social media: physicians and health care organizations can and should utilize the power of social media to facilitate interactions with patients and the public that increase their confidence in the medical profession. If we fail to engage this technology constructively, we will lose an important opportunity to expand the application of medical professionalism within contemporary society. Moreover, a proactive approach on the part of physicians may strengthen our patients’ understanding of medical professionalism [30].

As health care professionals, we all need to accept, adapt, and amend policies, practices, and professional obligations to use social media with good outcomes and avoid the bad or even the ugly.

• Ethics/Practice
• Social media/Use by students
• Social media/Use by clinicians
• Social media/Use by patients

The pool guy.  Seinfeld . NBC television. November 16, 1995. Cited by: Terry NP. Physicians and patients who "friend" or "tweet": constructing a legal framework for social networking in a highly regulated domain. Indiana Law Rev. 2010;43(2):286.

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Dredge S. Zuckerberg: one in seven people on the planet used Facebook on Monday.  Guardian . August 28, 2015.  http://www.theguardian.com/technology/2015aug/27/facebook-1bn-users-day-mark-zuckerberg . Accessed September 14, 2015.

PEW Research Center. Mobile technology fact sheet.  http://www.pewinternet.org/fact-sheets/mobile-technology-fact-sheet/ . Accessed August 11, 2015.

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Campbell D. Infatuated patients use Facebook to stalk doctors.  Guardian . October 17, 2012.  http://www.theguardian.com/society/2012/oct/28/lovesick-patients-stalk-doctors-online . Accessed September 14, 2015.

Doctors caught revealing secret patient information in Facebook posts.  News.com.au.  September 25, 2010.  http://www.news.com.au/technology/doctors-caught-revealing-secret-information-on-facebook/story-e6frfrnr-1225929424789 . Accessed September 14, 2015.

Yoder v University of Louisville, et al , No. 12-5354 (6th Cir 2013).  http://www.ca6.uscourts.gov/opinions.pdf/13a0488n-06.pdf  Accessed August 11, 2015.

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US Department of Health and Human Services. Uses and disclosures for treatment, payment, and health care operations [45 CFR 164.506]. Revised April 3, 2003.  http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/usesanddisclosuresfortpo.html . Accessed August 11, 2015.

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Muskus J. Dr. Jack Cassell tells Obama supporters to seek help elsewhere.  Huffington Post . June 2, 2010.  http://www.huffingtonpost.com/2010/04/02/jack-cassell-doctor-refus_n_523076.html . Accessed August 11, 2015.

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

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

What is an Ethical Dilemma in Nursing?

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

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

How to Identify Ethical Dilemmas in Nursing?

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

How to analyze an ethical dilemma?  Here is some background in six 30-minute videos:

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

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

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

Dónal O’Mathúna and Ron Iphofen .

Affiliations

Published online: November 3, 2022.

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

1.1. Judging the Ethics of Research

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

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

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

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

1.2. The Case for Cases

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

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

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

1.3. Research Design and Causal Inference

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

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

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

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

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

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

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

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

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

1.4. Devil’s in the Detail

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

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

1.5. Cases and Policymaking

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

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

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

1.6. The Moral Gain

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

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

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

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

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

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

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

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

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

1.7. Into the Future

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

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

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

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

• Cite this Page O’Mathúna D, Iphofen R. Making a Case for the Case: An Introduction. 2022 Nov 3. In: O'Mathúna D, Iphofen R, editors. Ethics, Integrity and Policymaking: The Value of the Case Study [Internet]. Cham (CH): Springer; 2022. Chapter 1. doi: 10.1007/978-3-031-15746-2_1
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In this Page

• Judging the Ethics of Research
• The Case for Cases
• Research Design and Causal Inference
• Devil’s in the Detail
• Cases and Policymaking
• The Moral Gain
• Into the Future

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