Empirical research

I have already postulated that doctors rarely articulate moral judgements in their daily practice. However, instead of interpreting this as a lack of moral understanding, it could be that their medical language and clinical practice are “morally loaded”; in other words, the moral dimension is always implicit in doctors’ medical judgements

in a way that makes it unnecessary to refer to a moral principle. This tacit way of handling the moral values of clinical practice makes it difficult to study the moral judgements made by doctors. Almost all of medical ethics research deals with ethics and values in an open and explicit way, yet some research does address the shortcomings of the dominant positions of medical ethics. I will not, however, attempt to provide a complete overview of the field of empirical research in medical ethics; instead, I will focus on the methods that have been used in this type of work and illustrate some of the various findings that have been made.

Most studies approach the moral aspect of medical ethics in a straightforward manner, asking doctors or other health care personnel to speak about their experiences with moral problems in their work (Hurst et al., 2005). These studies are mainly based on qualitative interviews, and provide an interesting insight into the conscious moral reasoning of health care personnel when it comes to how they approach their work. Yet, one must expect this expressed moral analysis to be heavily influenced by modern bioethical principles, and it is questionable whether such an approach accurately reflects what the participants really do in a clinical setting. One concern relates to whether doctors really speak truthfully when asked about personal judgements that may have caused patients harm, while another is the natural tendency to embellish one’s own decisions in retrospect. A more serious problem, however, is that the researcher asks directly for the doctors’ experiences of moral problems or ethical dilemmas. This provides an insight into what doctors themselves perceive as morally important or difficult, but means that the researcher cannot penetrate the doctors’ descriptions and interpretations of what constitutes a moral action. When you ask someone to describe a moral problem, it requires whoever is interviewed to have defined these experiences within the field of morality. Accordingly, by asking these particular questions, a researcher would probably identify either the more exceptional, problematic or agonising cases, or those that have involved a major degree of conflict. Studies of clinical ethics’ committees reveal that these are indeed the types of cases that health care personnel label as “ethical problems” and thus present to an ethics’ committee (Førde & Vandvik, 2005; Hurst et al., 2007).

Consequently, normal, day-to-day moral conduct or decisions would probably not be thought to be worth mentioning, or are not even thought of in terms of ethics by the respondents and so would not arise in such an interview.

While the tacit element of doctors’ moral conduct is barely touched upon by these direct questions, they do provide us with valuable knowledge of doctors’ explicit moral reasoning. Indeed, several of these studies have detected a discrepancy between bioethical categories and doctors’ actual reasoning, thereby discovering moral dimensions that were important to the participants, but are seldom addressed by bioethical discourse. We have already mentioned the studies by Holm (1997) and Arnman (2004), which drew attention to the notion of responsibility. Braunack-Mayer (2001b; 2005) focused on the gap between moral theory and moral reasoning in her interview studies with general practitioners. She found that doctors’ moral reflections are richer than those in mainstream bioethics, with issues of relationships, personal integrity, accessibility and continuity being raised. Meanwhile, by asking internal medicine residents about improper, wrong, unethical, or unprofessional experiences, Rosenbaum et al. (2004) drew attention to issues of professional self-regulation and the limits of personal competence. The focus group is another method that is commonly used for the same purpose. In their study, Ginsburg et al. (2002) utilised focus group interviews with medical students, asking them to discuss professional dilemmas and lapses in professional behaviour. It was found that issues which do not fit easily into the category of traditional moral principles, like communicative violation, role resistance and objectification, were raised. A number of quantitative approaches, and telephone questionnaires in particular, have also been used to address ethical experiences in medical practice. DuVal et al. (2004) found that nearly 90% of doctors questioned had recently faced ethical dilemmas, with end-of-life care issues and questions of justice being those that were most commonly encountered. Although these studies have a certain validity that might persuade quantitatively inclined medical professionals, they are actually even more bound to the pre-set definitions of ethics and moral reasoning. This means that they are unfit for purpose when it comes to identifying new and unexpected aspects of the reasoning of doctors.

Some studies focus on the other moral aspects involved in caring for patients, with moral distress being one example. Kälvemark et al. (2004) used focus groups to investigate the moral distress of health care personnel, and found that the entire sample had experienced this form of stress, which was often caused by conflicts

between personal moral standards and institutional or governmental regulations.

Førde and Aasland (2008), meanwhile, used a postal survey to investigate the moral distress experienced by Norwegian doctors, and found that it was widespread, particularly in relation to dilemmas concerning a lack of resources. Like research into moral experiences, these studies also rely on predefined notions of moral issues and ethical problems. Other empirical studies, however, aim to evaluate the moral competence of professionals, and many of these pieces of work apply approaches from moral psychology (Bebeau, 2002). The studies typically rely on interviews or questionnaires to identify the participants’ moral assessments through their arguments in a hypothetical moral case. Using a questionnaire and coding answers by stages of moral development, Patenaude et al. (2003) identified a significant decline in the moral development of students between their first and third years of medical school.

Similar approaches have been used to examine the moral reasoning of health care personnel. In particular, Self et al. (1993) used interviews to analyse this issue and found that the doctors in their sample had consistently lower scores for this skill than the clinical ethicists. This research probably reveals some elements of the cognitive ability of doctors to make moral judgements according to a set of bioethical principles. However, it again does not tell us much about how doctors actually behave in the clinical setting. In particular, using predefined answers in a questionnaire or hypothetical cases shapes participants’ answers to a great degree.

Moreover, such approaches do not adequately take into account the fact that the respondents may have a deeper and more complex understanding of the issues than the researcher. Accordingly, the moral understanding that comes with managing actual cases, with all of their situational nuances, is thus poorly measured by these kinds of studies.

Another common way of addressing the moral content of medical practice is by observation, using a more descriptive or ethnographic approach. Utilising participant observation, Robertson (1996) studied a psychiatric ward for geriatrics and found that while the health care professionals did not discuss issues in ethical terms, traditional ethical concepts were useful for describing their ethical approaches. However, because Robertson defined relevant events as “ethically laden decision-making”, and tested the relevance of three different moral principles on the basis of these events, his observations and analysis are closely bound to traditional bioethical concepts.

Meanwhile, Braddock et al. (1999) analysed audio taped patient-doctor encounters to explore how well the latter adhere to the requirements of informed decision-making.

Their conclusion was that patients were not adequately included in the decisions made about them, while ethical ideals were not implemented in the doctors’ routine practices. Others have used a more open approach to observation, and have not started from explicit moral principles. Reiter-Theil (2004), for example, developed the concept of the “embedded researcher”, in which researchers conducted their investigations in the relevant clinical context without participating in clinical practice.

The purpose of this approach was to enable the more rigorous observation and documentation of clinical reality. In their study of an intensive care unit, they found that ethics was understood as a matter of personal sensitivity, integrity and conscience, and did not involve the interpretation of ethical guidelines. Kaufman (1998) used an ethnographic approach to observe elderly patients who died in an intensive care unit. Although she did not focus specifically on ethical issues, she concluded that the way in which we speak about end-of-life choices and our ideas of

“a good death” are far from the practical reality of dying in hospital.

If we understand the practical morality of everyday medicine as a tacit dimension in doctors’ language and practice, we can hardly expect to expose it by direct questioning. Furthermore, using well-known ethical categories will probably hamper any attempt to reveal the novel dimensions of doctors’ moral reasoning that might reduce, or at least explain, the lacuna between medical practice and medical ethics.

While the large and varied field of research into medical ethics has provided us with some important insights into what doctors perceive as moral problems, how they use ethical concepts and how they argue about values, there seems to have been little work on the tacit moral dimensions of everyday medical practice.