A STUDY OF THE FOUNDATIONS OF ETHICAL DECISION

MAKING OF CLINICAL MEDICAL ETHICISTS

DONNIE J. SELF a AND JOY D. SKEEL b

a Department of Humanities in Medicine, Texas A&M University
College of Medicine, 164 Medical Sciences Bldg, College Station, TX 77843, USA
b Department of Psychiatry, Medical College of Ohio, CS 10008,
Toledo, OH 43699, USA

ABSTRACT. A study of clinical medical ethicists was conducted to determine the

various philosophical positions they hold with respect to ethical decision making in
medicine and their various positions' relationship to the subjective-objective controversy
in value theory. The study consisted of analyzing and interpreting data gathered from
questionnaires from 52 clinical medical ethicists at 28 major health care centers in the
United States. The study revealed that most clinical medical ethicists tend to be objectivists in value theory, i.e., believe that value judgments are knowledge claims capable of
being true or false and therefore expressions of moral requirements and normative
imperatives emanating from an external value structure or moral order in the world. In
addition, the study revealed that most clinical medical ethicists are consistent in the
philosophical foundations of their ethical decision making, i.e., in decision making
regarding values they tend not to hold beliefs which are incompatible with other beliefs
they hold about values.
Key words: consistency, ethical decision making, subjective-objective distinction, value
theory

1. INTRODUCTION
The following study is an attempt to identify and understand better the
philosophical positions which clinical medical ethicists, (i.e. ones functioning in
health care delivery settings as opposed to classroom medical ethicists)
knowingly or unknowingly, utilize in ethical decision making about health care.
This study is a companion study to two previously conducted similar studies of
physicians and medical students and of nurses and nursing students. 1 Of special
interest are the various positions in the subjective-objective controversy in value
theory, i.e., whether value judgments are purely personal, private expressions o f
one's own opinion and inner-subjective feelings or, in contrast, whether value
judgments are expressions of moral requirements and normative imperatives
emanating from an external value structure or moral order in the world. This will
be elaborated in more detail later.
The increase in interest in ethical decision making in health care has been
Theoretical Medicine 12:117-127, 1991.
1991 Kluwer Academic Publishers. Printed in the Netherlands.

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dramatic during the past two decades. 2 However, very little empirical data has
been gathered on the issue. Usually those studies that have been conducted
simply report people's opinions on controversial issues such as abortion,
euthanasia, the obligation to treat AIDS patients, and so forth. Virtually no
studies of actual data gathered on the theoretical foundations of ethical decision
making have been reported. This study was undertaken with the objective of
identifying the philosophical stances of clinical medical ethicists with respect to
ethical decision making. The study examined the following hypotheses:
(1) Most clinical medical ethicists tend to be objectivist in value theory i.e.,
believe that value judgments are knowledge claims capable of being true or false
and are expressions of moral requirements and normative imperatives emanating
from an external value structure or moral order in the world.
(2) Most clinical medical ethicists are consistent in the philosophical foundations of their ethical decision making regardless of whichever position they tend
to hold on the subjective-objective issue in value theory.
The first hypothesis relates to a fundamental issue in moral philosophy namely, the theoretical status of values. Down through the centuries value
language has been analyzed in many ways. However, the crucial issue in value
theory comes in the subjective-objective controversy because it is here that the
theoretical status of values is determined. Indeed Adams notes:
The thesis that value judgments in general and moral judgments in particular have no
objective ground, that they are subjective and private, needs to be thoroughly explored
and assessed. If it is a sound thesis, then we must face up to the consequences. If it is a
false thesis, we must look for ways to regain faith in the objectivity of values. Herein lies
the central task of moral philosophy of our age [5].
The second hypothesis relates to one of the most philosophically desirable
characteristics - namely, consistency. Whatever position one holds it must be
internally consistent in order to be a logically viable position and ought to be
applied consistently to a wide range of circumstances. This hypothesis contends
that in decision making about values, clinical medical ethicists tend to hold
beliefs which are basically compatible with other beliefs they hold about values.

2. MATERIAL AND METHODS

The study consisted of gathering, analyzing and interpreting data gathered from
questionnaires from 52 clinical medical ethicists at 28 major health care centers
in the United States. This included ethicists from clinical settings in 12 states
from all sections of the country. The study was limited to clinical medical
ethicists with either philosophical or theological educational backgrounds.
While this may sound like a small number of subjects, it actually represented a

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119

large proportion of the clinical medical ethicists in the United States. A previous
large scale study of over 3,000 questionnaires found only 152 people with
philosophical or theological educational backgrounds identifying themselves as
primarily clinical medical ethicists, that is, people who make rounds, see
patients, and work primarily in a clinical health care delivery setting as opposed
to simply teaching medical ethics in a classroom. 3 However, the number of
clinical medical ethicists appears to be increasing rapidly as reflected by the
membership of the Society for Bioethics Consultation which is devoted
specifically to issues of clinical medical ethics. This report offers no data or
conclusions about the foundations of ethical decision making of classroom
medical ethicists. Certainly there is a much larger number of classroom medical
ethicists than clinical medical ethicists, and there may be differences between
the academic and practicing medical ethicists.
The questionnaire consisted of one page containing 9 questions to be
answered affirmatively or negatively and several biographical designations. The
questions were constructed in such a way that there were three questions relating
to each of the three possible positions in the subjective-objective issue
(elaborated below in the Background Information section). The questionnaire
contained no controversial questions such as questions which would elicit the
respondent's feelings about issues of abortion, euthanasia, and so forth. Rather
the study was designed to focus on theoretical foundations of ethical decision
making in health care. However, the questions were carefully constructed in
jargon-free language so as to require no theoretical understanding of philosophical concepts such as subjectivism and objectivism. Indeed the terms "subjective"
and "objective" did not even appear on the questionnaire. The questions were
constructed in pairs in order to check for consistency in the responses. For
example, questions one and eight were essentially the same question in different
words. The instrument was developed specifically for this series of studies.

3. RESULTS
A total of 52 respondents from the 65 contacted constituted an 80.0% return.
The high percent return is accounted for in part by the fact that the study
included a personal contact and request for participation before the questionnaires were subsequently mailed out. The surveyed population consisted of 15
(28.8%) females and 37 (71.2%) males with an age range from 32 to 67 years
old. The religious background of the surveyed population consisted of 70.0%
Protestant, 16.9% Catholic, 2.4% Jewish and 10.7% others. The data gathered
from the questionnaires are shown in Tables I and II. Table III presents the data

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DONNIE J. SELFAND JOY D. SKEEL

TABLE I
Clinical ethicists decision making data

Number of
negative
responses

35

74.5

12

25.5

2. In medical decisions involving

ethical questions do you think
that there are right answers and
wrong answers?

32

72.7

12

27.3

3. Do you think that values such

as the tightness or wrongness of
an act are determined by the
facts of the context?

29

65.9

15

34.1

4. In complex medical ethical

cases can one sometimes have
ethical obligations without being
aware of them or realizing that
they are incumbent upon one?

43

93.5

6.5

5. Do you think that certain acts

are right and others wrong
regardless of the situation?

19

41.3

27

58.7

6. Do you think that rightness or

wrongness of an act is basically
determined by its consequences?

12

27.9

31

72.1

7. Do you think that in ethical

decision making in medicine
values are relative to the person
making the judgment?

19

38.0

31

62.0

8. Do you always seek the best

welfare of the patient regardless
of what effect it has on the
family, medical staff or others?

12

26.1

34

73.9

9. Do you think that value

judgments about medical ethical
situations can be either true or
false?

26

59.1

18

40.9

Questions

Number of
affirmative
responses

1. In difficult situations do you

generally seek the solution
which offers the greatest good
for all concerned - patient,
family, medical staff, etc?

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TABLE II
Biographical data
Biographical
characteristic

Percent of
respondents

Philosophical background

40.4

Theological background

59.6

Male

71.2

Female

28.8

Protestant

70.0

Catholic

16.9

Jewish

2.4

Other

10.7

T A B L E Ill
Consistency comparison

Question number
4

Response required
for consistency
yes

Pak

no

Actual
response received
Yes
No

Majority actual
responses

43

yes

or
5

yes

no

19

27

no

yes

no

32

12

yes

yes

no

26

18

yes

yes

no

29

15

yes

yes

19

31

no

no

19

27

no

yes

12

31

no

no

35

12

yes

yes

12

34

no

Pa~

or

Pa~

or
7

no

yes

Pak

or
6

no

yes

Pa

or
8

no

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DONNIEJ. SELFAND JOY D. SKEEL

regarding the consistency of the responses. Analysis of the data requires that
both hypotheses be accepted as true.

3.1. Background Information

A brief consideration of the subjective-objective issue in value theory might be
helpful in understanding the results of the survey. 4 All ethical decisions are,
implicitly or explicitly, based upon one of three possible positions in value
theory - namely, complete subjectivism, partial subjectivism-partial objectivism,
or complete objectivism. It is from these positions that the subjective-objective
controversy arises in ethics. This issue has been extensively elaborated elsewhere with arguments for and against the adequacy of the alternative positions. 5 Those arguments need not be repeated. A statement of the alternative
positions will be only summarized briefly here.
The three positions are determined by their stands on value experience and
value language. But first perhaps the distinction between value experience and
value language needs to be clarified. Value experience is the affective-conative
state that one experiences or undergoes when in evaluative or emotive circumstances. In contrast, value language is the language or terminology used to
describe, report, or express value experience. One can be a subjectivist with
regard to value experience and still be either a subjectivist or an objectivist with
regard to value language. One extreme is what is known as pure or complete
subjectivism. Existentialism is the most popular paradigm of this position.
Subjectivism is subjective with respect to both value experience and value
language. It holds that value experience is not cognitive, not epistemic or
knowledge-yielding, and not the discernment of a value structure in reality. But
also, value language as distinct from value experience is held to be subjective in
that value judgments are held to make no truth claim at all, and so cannot be true
or false. Pure subjectivism maintains that moral judgments are expressions of
emotions, preferences, or decisions and are not cognitively significant; i.e., they
literally do not make a knowledge claim. Value judgments are not even of or
about value experience. They are merely expressions of emotions or preferences.
A middle position is partially subjective and partially objective. It is subjective with respect to value experience only. It is objective with respect to value
language. Utilitarianism is the most widely known paradigm of this position.
The middle position holds that value judgments are of and about value experience in a cognitively significant manner such that they do make knowledge
claims which can be confirmed to be true or false. Value language serves a
definite function. It makes truth claims about value experience and expresses
and describes value experience. Yet it does not express the semantic or meaning
content of value experience for this middle position denies that value experience

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has a semantic content. Value language is not grounded to the world through
experience because value experience itself is subjective and not a discernment of
an external objective value structure or moral order in the world. It has no
semantic connections with the structure of reality. Value language can be
reduced to or translated into non-value language, i.e., to factual language in
terms of the descriptive-explanatory language of natural science. This is usually
done in terms of the language of psychology such that value judgments become
empirically verifiable by observation of behavior. Thus, utilitarianism, a
paradigm of this position, reduces value judgments to judgments of utility which
are ultimately explicated in terms of the production of pleasure and avoidance of
pain and therefore is subjectivistic with respect to value experience, but yet
objectivistic with respect to value language.
Lastly, pure objectivism is the exact opposite of pure subjectivism. It is
objectivistic with respect to both value experience and value language. Objectivism in value theory is the belief that values are expressions of moral requirements and normative imperatives emanating from an external value structure or
moral order in the world. To be objective simply means being independent of
experience. Objective realty is held to exist independently of one's experience of
it or one's thoughts and feelings about it. Similarly objectivism in value theory
holds that value requirements and normative imperatives exist independently of
one's experience of them or one's thoughts and feelings about them. Emotive
repulsion to cruelty such as in child abuse would be an example of an objective
normative imperative which exists independently of how one feels about it.
Indeed those persons who are not repulsed by such cruelty are considered sick
and in need of help. The formal ethics of Immanuel Kant and the JudeoChristian ethics of the Old and New Testaments are the best known paradigms
of objectivism. Objectivism holds that value judgments are objective in that they
are cognitively significant and make a knowledge claim which can be confirmed
to be true or false. They embody a significant semantic claim. The content of
value judgments is not dependent upon the peculiarities of the person but is
determinable by any rational observer appraised of the relevant facts. Pure
objectivism maintains that value language is not reducible to non-value language
since value experience discerns a dimension of reality not discernable through
any other mode of experience. Value judgments are not merely expressions of
emotions or attempts to evoke similar attitudes in others, but rather are of and
about an external value structure or moral order of the world. Values exist
independently of a discerning mind, and there are norms or value requirements
regardless of whether or not anyone is aware of them. Like necessary connections, value requirements are not dependent upon knowledge of them. Value
language is of and about these value requirements and normative imperatives in
reality. Value language is expressive of this value experience, i.e., it translates

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into language what is semantically present and felt in value experience. It relates
a dimension of experience which is not expressible through any other language.
Value language is not reducible or translatable into any other language. No other
kind of language can express the content expressed in an ordinary value
judgment. The dimension of reality discerned through value experience cannot
be discerned through any other mode of experience.

4. DISCUSSION
With the above understanding of the subjective-objective distinction in value
theory, the data collected from the questionnaires can be interpreted more
clearly. Analysis of the data requires that hypothesis number 1 be accepted and
shows that it is true that most clinical medical ethicists tend to be objectivist in
value theory, i.e., believe that value judgments are knowledge claims capable of
being true or false and are expressions of moral requirements and normative
imperatives emanating from an external value structure or moral order in the
world. This conclusion is in contrast to the notion that our culture has become
increasingly subjectivistic with respect to values. Since the turn of the century
there has been a tremendous increase in the popularity of subjectivism as
expressed in existentialist thought such as the writings of Albert Camus, JeanPaul Sartre, and so forth.
Acceptance of the first hypothesis is supported by the following evidence.
When given six opportunities to support the objectivist position, by answering
affirmatively to questions number 2, 3, 4, 5 and 9 and negatively to question
number 7, the majority of clinical medical ethicists supported the objectivist
position in five of the six opportunities. For example, an affirmative response to
question number 2 regarding the possibility of right and wrong answers to
ethical questions requires that value judgments in general and ethical judgments
in particular be cognitive or knowledge-yielding in character - a requirement
essential to the objectivist position. And a large majority of the respondents
(72.7%) answered question number 2 affirmatively.
Conversely, when given six opportunities to support the subjectivist position,
by answering affirmatively to question number 7 and negatively to questions
number 2, 3, 4, 5 and 9, the majority of clinical medical ethicists did not support
the subjectivist position in five of the six opportunities. For example, opposition
to subjectivism was found in the response to question number 7 regarding values
being relative to the person making the judgment where a negative response
(62.0%) would be philosophically incompatible with the subjectivist position.
Essentially two-thirds of the clinical medical ethicists responded that values are
not relative to the person making the judgment and are determined by objective,

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external facts. This point which is frequently misunderstood has been elaborated
in more detail elsewhere. 6 Additional support for objectivism was found in the
response to question number 9 regarding the possibility of value judgments
being either true or false where a positive response (59.1%) would be required
for support. However, the strongest support for objectivism came in response to
question number 4 regarding the existence of ethical obligations without
cognizance of them where a positive response would be philosophically required
by the objectivist position, and the positive response was almost unanimous.
(93.5%).
The responses to the three questions relating to the middle position, such as
utilitarianism, (numbers 1, 6 and 8) which is partially subjective and partially
objective indicated that clinical medical ethicists are basically not utilitarian in
ethical decision making. For example, the negative response to question number
6 (72.1%) regarding the rightness and wrongness of an act being determined by
its consequences, which is absolutely essential to utilitarianism, indicates that
most clinical medical ethicists are basically not utilitarian in their philosophical
stance to ethical decision making. However, the strongly positive response to
question number 1 (74.5%) regarding the greatest good for the greatest number
shows that when consequences are considered clinical medical ethicists are
pluralistic utilitarians with multiple foci of concern. Moreover the negative
response to question number 8 (73.9%) regarding always seeking the best
welfare of the patient corroborates this by indicating that the majority of clinical
medical ethicists are not monistic utilitarians with a singular concern. That is,
with regard to the perceived morality or rightness of their acts, clinical medical
ethicists take many factors into consideration and not just the usefulness of their
act in terms of one pre-eminent factor - not even the welfare of the patient
solely.
Further, analysis of the data requires that hypothesis number 2 be accepted
and shows that most clinical medical ethicists are consistent in the philosophical
foundations of their ethical decision making. This is to say that clinical medical
ethicists generally do not simultaneously hold some subjective beliefs and some
objective beliefs about values which are philosophically incompatible with each
other. This conclusion was demonstrated by pairing related questions and
comparing the actual responses of the clinical medical ethicists to the responses
required for consistency. Contrary findings of systematic philosophical inconsistencies in studies of physicians and nurses were reported earlier as referenced.7
However, clinical medical ethicists have studied ethics much more and had more
philosophical training in logic and critical analysis of decision making and so
would be expected to be more consistent in the philosophical foundations of
their ethical decision making.
Table llI shows the question pairings, the responses required for consistency,

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and the actual responses received. In three of the five question pairs the
responses received agreed with the theoretically consistent pattern. For example,
with questions 2 and 9, which would require two affirmative responses or two
negative responses for consistency, the actual response received was a majority
of affirmative responses to question 2 and a majority of affirmative responses to
question 9.
Additional evidence from the data which supports the contention that
hypothesis number 2 is true was found in analyzing the responses to questions 3
and 7. An affirmative response to both of these questions simultaneously is
contradictory and, appropriately, the positive and negative responses received
essentially mirror each other.

5. CONCLUSION
The acceptance of hypothesis 2 is not to say that clinical medical ethicists are
consistent in their actual ethical decisions about health care (although one would
suspect this if their philosophical foundations are consistent) but only that the
responses they give to questions about how ethical questions in health care are
to be determined, involve consistent philosophical stances in value theory. Thus,
one should be careful not to confuse ethical decisions in health care with
questions about ethical decision making in health care, i.e., with the methodology for determining the response to an ethical question in health care. Basically
the difference is in asking what to do as opposed to asking how to determine
what to do. Ethical questions in health care are 'what' questions. Methodological questions about ethical decision making in health care are 'how' questions.
For example, the question of whether or not to turn off the respirator on a
particular terminal patient is an ethical question in health care management, but
determining the grounds for turning off respirators, whether it be for the welfare
of the patient or the welfare of all concerned, is a philosophical question about
the methodology for determining ethical decisions in health care. It might be
noted here that none of the questions on the questionnaire are ethical questions
about health care, rather they are questions about the various philosophical
stances which determine the methodology for ethical decision making in health
care. Perhaps ethical questions in health care would not seem so difficult if the
philosophical questions could be agreed upon.

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NOTES
1 Similar studies of physicians and medical students and of nurses and nursing students
are reported in [ 1, 2].
2 In separate studies Bickel [3] and earlier Pellegrino and McElhinney [4] have reported
on the dramatic increase in attention given by medical schools in the United States to
teaching regarding medical ethical decision making. The enormous growth in the medical
ethics literature over the past two decades readily confirms the increased interest.
3 A preliminary report of the large scale study is found in Skeel and Self [6]. For a final
analysis of the study see [7] or contact the authors.
4 This brief description of the altemative positions in the subjective-objective distinction
comes from the similar study of physicians and medical students reported in [ 1].
5 For an extensive elaboration of the positions in the subjective-objective distinction and
the arguments for and against each position see D.J. Self [8-11].
6 The point of values being relative to the person making the judgment versus values
being relative to the facts of the circumstances is often not well understood. This issue is
addressed in D.J. Self [91.
7 See note 1.

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3. Bickel J. Integrating Human Values Teaching Programs Into Medical Students'
Clinical Education. Washington, DC: Association of American Medical Colleges,
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4. Pellegrino ED, McElhinney TK. Teaching Ethics, the Humanities, and Human
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