case study in ethics examples

Annual Review of Ethics Case Studies

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 23 – Authorship, Collaborations, and Mentoring (2023)
• Theme 22 – Use of Human Biospecimens and Informed Consent (2022)
• Theme 21 – Science Under Pressure (2021)
• 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)
• Theme 3 – Mentoring (2003)
• Theme 2 – Authorship (2002)
• 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 7, 2023

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Sample Case Analysis

This page shows a sample case analysis for the course  Genomics, Ethics, and Society .

Below is a "model" answer to the whitebark pine case . The case doesn't focus on genomics, but nonetheless, the way the model answer is laid out should help you to see what's being asked for. You should refer back to this model when you are writing up case studies of your own. While undergraduates should find this model useful, it's more like a graduate case study in terms of length and complexity. By a "model" answer, we don't mean that this answer is perfect; and obviously there's much more that could be said. But an answer with this kind of structure, content, and use of resources, would get a strong A.

When you analyse a case study, you're usually considering a complex situation where many different interests and values are at stake. This makes it easy to get tangled up in your answer too: so here's some tips for answering the case study well.

• Write a clear introduction in which you (a) identify what you are going to talk about (b) give some idea of how you are going to structure the paper by setting up "signposts"; and (c) outline what view or policy position you're going to argue for. (Usually case studies ask you to recommend a view, policy or position.) You may be able to say much more than you have room for; if so, be explicit at the beginning about what you're not discussing for space reasons, so the person grading knows you did think about it! 
• Stick to the structure you've outlined.
• In the course of analyzing the case, be sure to explain what values you think are at stake, where appropriate, who the stakeholders are, and why this case is likely to be contested.
• In some cases it may be useful to consider the perspectives of different stakeholders and different ethical theories: for instance, will someone who is worried about violating rights regard the ethical issues differently from someone who is concerned about maximizing overall good (say in terms of human welfare?)
• Where you use terms such as "liberty" "utilitarianism" "wildness" or "rights" make sure that you explain how you are using them as if to someone who is unfamiliar with the terms.
• Make an argument for which approach or approaches you think is/are best in the particular situation being described, and why. However, while doing so you should also explain the difficulties with the view for which you’re arguing, what someone might say who disagreed with the argument, and why their objection is not a good one/there’s a good response to it, etc. If you are really ambivalent about the case, say so and explain why.
• You should reference carefully, both in-text and in the reference section. If you quote or paraphrase anything, or you're dependent on a publication, you must provide an in-text reference. We don't mind what referencing system you use in your references, but your references should be detailed enough for us to find them (ie not just author and title).

Drawing on the whitebark pine case, here's just an example how you might find the ethics assessment process useful:

Ethics Assessment Process and the Whitebark Pine Case

1) seeing the problem.

What are the main ethical issues and conflicts presented in the case?

The case asks us to focus on the selection of rust-resistant strains and the assisted migration of WBP. While the selection of rust resistant strains doesn't raise all the ethical problems that GM does, it still means that there's enhanced human intervention and deliberate action involved in what trees end up existing (which may raise value questions about loss of wildness). Assisted migration raises a number of ethical issues and potential conflicts, primarily (a) the value of protecting a species from extinction (b) the possible ecological disvalues (and values) of deliberately introducing a species into a new area (c) the possible loss of wildness (d) cultural, historical and aesthetic values - could these be preserved? (e) questions about who owns the land where the trees would be moved (property rights, perhaps indigenous peoples, questions of environmental justice) and relevant consultative processes (f) potential effects on sentient animals, especially Clark’s Nutcrackers. From some ethical perspectives there could be "in principle" objections here. For instance, it might be argued that in principle humans shouldn't "interfere" in nature to move things, or that if moving WBP infringes on the rights of indigenous peoples, it is unethical in principle. On the other hand, an ethical approach that focuses on consequences will attempt to weigh and balance the values involved and make a decision based on what is likely to bring about the best outcome overall.

Who are the stakeholders and what are their respective positions? What decisions and/or impacts do they face?

Some of the issues here  involve very general groups of stakeholders: eg those who maintain that all species are valuable, so will want to protect the WBP; those who value the unusual aesthetics of the whitebark pine (these may be hikers and photographers) so may want it to be saved (this will depend on whether the aesthetic value is tied to current geographic location; if it is then moving it won’t save the value). It might be argued that future generations of humans are stakeholders; they would never get to see or enjoy landscapes created by this iconic species. More specific groups of stakeholders include:  biologists doing the research, both those working on genetic selection of the tree and those involved in planning assisted migration – they are likely to be in favor of both actions, and to see it as developing their research and conservation work. There are also likely to be biologists who oppose  all plans for assisted migration, primarily because they are concerned about moved organisms becoming invasive.  All those who generally oppose genetic selection of wild organisms are likely to oppose it in this case. Those who own/live near potential relocation sites have a clear stake in what may happen, though these individuals may be in favor of or opposed to the relocation, depending on the predicted ecological/cultural consequences of moving it and the forms of consultation involved. If sentient non-humans can be stakeholders, Clark’s Nutcrackers should be considered, but it’s difficult to make sense of what the relocation might mean for individual Clark’s Nutcrackers, since the relocation would not occur until the trees were mature enough to have seeds. The nutcrackers then moved will likely be harmed; but either they or their offspring may over time also be benefited. It could be argued by some that species themselves are stakeholders, though that view would be difficult to defend.

2) Empirical Issues

What empirical information is most important for addressing the main ethical questions?

What empirical facts are widely accepted, based on scientific evidence and peer review, about this issue? What empirical issues are contested or uncertain? How good is the information we have? Is it reliable?

Is there other information it would be useful to have? How could we go about obtaining this information? What should we check on or verify? Are there obvious ways of doing this?

There is some reasonably uncontested empirical information: that the WBP is threatened, that climate change means its climate envelope will move (though there is disagreement about the precision of climate models). Research suggests that rust resistant WBP is possible, and there are already strains of WBP in existence that are more resistant than others. The most important empirical information needed in terms of the relocation is: what are the ecological impacts of relocating likely to be? Also needed is empirical information about how people in recipient communities would regard the relocation. This information could be collected, though trial sites would take a long time to become established.

3) Conflicting Values

What values are at stake in the case?

Values at stake include:

• Wildness : (loss of wildness/naturalness in selecting strains; loss of wildness in human-caused relocation; possible loss of wildness in relocation site)
• Aesthetic value : whitebark pine has high aesthetic value
• Cultural/historical value:  the iconic value of the tree as a symbol of the harshness and challenges of the American West
• Justice : Might be a cause of procedural and distributional environmental injustice if transplanted onto indigenous lands without adequate consultation or against their will (or other private lands)
• Species values : If it’s thought that species have moral status, then causing extinction is wrong (and this is human-caused, even if not intentionally). On the other hand, if assisted migration of WBP threatened other species then assisted migration would be problematic for this reason.
• Suffering and welfare:  On many ethical views, suffering is a disvalue. If translocating Clark’s Nutcrackers causes them or individuals of other species suffering, that would be a problem. If translocating WBP provided habitat or food for other species eg individual bears and enhanced their welfare, that would be positive.

Which values have priority for which stakeholders?

Will particular decisions lead to the sacrifice of specific values? Is there any way of avoiding this?

Any decision here is going to involve the loss of wildness, which may be of concern to wilderness defenders – at least, those who value places fee of human influence. This wildness loss can’t be avoided. Any context-related value will be lost too, whatever is decided. It may be possible to avoid justice problems at the relocation site by adequate consultation & respect for local residents’ and indigenous peoples’ concerns and preferences. There may also be ways of minimizing suffering to Clark's nutcrackers, but this is likely to make the operation more expensive.  Not acting to save the WBP will involve loss of its aesthetic value for present and future generations.

4) Moral Imagination

Given the goals and objectives of the decision-makers, are there alternative courses of action that could be taken that fall outside the obvious parameters of this case? Can these be adopted without sacrificing any other goals or objectives?

When there are threats from climate change, organisms have to either adapt where they are or move. WBP additionally faces current problems from rust and beetles. Natural adaptation  in situ  alone is unlikely to happen, and moving the WBP without making it rust-resistant risks the same problems following it to the new location. And it’s unlikely the species will survive in its current locations, even if rust-resistant strains were introduced. So, the remaining alternative option (given that climate change is unlikely to stop) is just to let the tree become extinct and do nothing. This sacrifices species and aesthetic values, but is less ecologically risky in the reception ecosystem, is unlikely to cause new suffering (after all, the animals that lose WBP seeds for food in its current range will lose the seeds even if there is new WBP 600 miles north; and nutcrackers won’t have to be relocated) and avoids any justice concerns at the relocation site.

 5) Moral Justification

Among the available alternatives, which can be reasonably ethically defended?

Of the ethically defensible alternatives, is there one that's clearly the best? 

Both the main options (do nothing; move) can be ethically defended. For particular empirical reasons in this case, “move” may look best. However, judgment about this really depends on which values are prioritized and how precautionary you are.

6) Moral Criteria

Taking each alternative response to the case in turn (may not all be relevant to every case).

NB: In this case, whatever is done, some things are lost. For instance, those who value WBP as important cultural symbols of the American West, in their particular geographical locations, are going to lose this value whatever happens, since they can’t be preserved in their current location

Harm and Benefit :  Does this alternative cause harm? Does it cause less harm than the other alternatives? Does it bring about benefits?

• Do nothing:  Likely extinction of WBP. If species can be harmed, this causes species harm, but this argument is difficult to defend. If future people can be harmed, and if loss of a species can harm them, WBP extinction does harm them.
• Move without rust selection  This risks future harm to trees through WPBR and beetle, even in the new location. It’s possible that if ecosystems/species can be harmed that WBP in the new location could harm them (but there’s also a possibility of benefit). Possible harms to nutcrackers.
• Select and move :  Less risk of harm to trees in future. Small risk of harm to other species/systems from relocation. Also risk of harm to nutcrackers.

Justice : How does this alternative distribute harms and benefits or other natural and social goods? Are those affected meaningfully involved in decision-making?

• Do nothing : The species going extinct may affect some people’s interests, but it’s not really an injustice. It would be difficult to consult about not saving the tree, other than by surveys.
• Move (select or not) : The main location of a possible injustice to people lies in the move to new habitat without consultation or against the will of those who live there or own the land.

Other human values : Does this alternative have significant impacts on privacy, liberty, or other human values?

Moving could impact on property rights.

Environmental values : Does this alternative have significant impact on the non-human world?

All options have significant impacts on the non-human world, either by letting a species go extinct, or by selecting forms resistant to disease/ moving them to a new ecosystem. This is really a case where different environmental values are in conflict AND sometimes the same values are in conflict (eg moving WBP may save one species and threaten others, may protect one aesthetic value while changing another etc)

Ethical theories : What might different ethical theories say about what should be done?

• Consequentialist approaches will sum values; what values count will depend on the approach. Utilitarians, for instance, will sum pleasure net of pain over time; this will include humans and sentient animals. So the impacts gains/losses of values on human happiness will matter; so also impacts on Clark’s nutcrackers and other animals that use WBP for food or habitat.
• Rights theories: Relocation, if not handled appropriately, could violate property rights, or the rights of indigenous peoples to self-determination over their own land. If animals have rights, relocation of Clark’s nutcrackers, if this constituted a serious harm to individual birds, would violate their rights. If rights are regarded as inviolable or virtually inviolable, these hurdles would have to be overcome for the relocation to be ethically permissible. If it could be argued that species have rights (which is doubtful) then the WBP might be argued to have a compensatory “right” to relocation, since humans are in part at least responsible for their being endangered.
• Virtue theory: As this is primarily a policy issue rather than a personal or professional issue, virtue theory is less helpful in thinking about this case.

7) Other Criteria

Practicality : Are specific alternatives really feasible?

All the considered alternatives are at least plausible. The relocation has had trials and is short-term successful (over a couple of years); selected rust resistance is currently being trialed. There may be hurdles to both, but not evident at the moment.

Publicity : How would the public react to different alternatives?

Reactions will be mixed. Some will want to save the species. Others will regard the relocation as unacceptable interference in "nature" or the wild, with potentially bad consequences.

Collegiality : How would one's peers react to different alternatives?

Not so relevant here.

Reversibility : Can a decision made be revisited?

If the tree goes extinct, while de-extinction is perhaps possible, it’s unlikely. If it’s relocated, and proves to be invasive, it’s easy to remove (slow growing, slow to reproductively mature, easy to locate, needs nutcrackers). It seems likely that most of the potential ecological harms of any move could be reversed.

Continue to Sample Case Response

NB: The case study and case analysis here draws on: Palmer, C. & Larson, B. 2014. "Should we move the Whitebark Pine?"  Environmental Values  23: 641-662.

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This material is based upon work supported by the National Science Foundation under Award No. 2055332. Any opinions, findings, and conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the National Science Foundation.

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Videos Concepts Unwrapped View All 36 short illustrated videos explain behavioral ethics concepts and basic ethics principles. Concepts Unwrapped: Sports Edition View All 10 short videos introduce athletes to behavioral ethics concepts. Ethics Defined (Glossary) View All 58 animated videos - 1 to 2 minutes each - define key ethics terms and concepts. Ethics in Focus View All One-of-a-kind videos highlight the ethical aspects of current and historical subjects. Giving Voice To Values View All Eight short videos present the 7 principles of values-driven leadership from Gentile's Giving Voice to Values. In It To Win View All A documentary and six short videos reveal the behavioral ethics biases in super-lobbyist Jack Abramoff's story. Scandals Illustrated View All 30 videos - one minute each - introduce newsworthy scandals with ethical insights and case studies. Video Series

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Professional Ethics

Professionals work in a wide variety of settings and across many different industries including business, science, medicine, education, art, and public service.

Many professions have Codes of Conduct that specify ethical behavior and expectations particular to that industry. In addition, professionals must make ethical judgments in their area of specialty that fall outside their specific Code of Conduct.

The resources in this section offer insights that apply to a wide range of professionals as they seek to develop standards of ethical decision-making and behavior in their careers. Often, professionals need to apply moral reasoning to their interactions with co-workers, clients, and the general public to solve problems that arise in their work. Professionals also need to be on lookout for social and organizational pressures and situational factors that could cause them to err, unknowingly, in their ethical judgments and actions.

No profession is free from ethical dilemmas. All professionals will face ethical issues regardless of their career trajectory or the role they play within an organization. While Codes of Conduct are essential, and a good starting point for ethical conduct, they are no substitute for a well-rounded education in behavioral and applied ethics.

Start Here: Videos

Role Morality

Role morality is the tendency we have to use different moral standards for the different roles we play in society.

Bounded Ethicality

Bounded ethicality explains how social pressures and psychological processes cause us to behave in ways that are inconsistent with our own values.

Being Your Best Self, Part 4: Moral Action

Moral action means transforming the intent to do the right thing into reality. This involves moral ownership, moral efficacy, and moral courage.

Start Here: Cases

Freedom vs. Duty in Clinical Social Work

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

High Stakes Testing

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

Healthcare Obligations: Personal vs. Institutional

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

Teaching Notes

Begin by viewing the “Start Here” videos. They introduce key topics that commonly emerge in our careers, such as making ethical decisions based on the role we’re playing at work. The four-part video,  Being Your Best Self , describes the four components of ethical decision-making and action. To help strengthen ethical decision-making skills, watch the behavioral ethics videos in the “Additional Videos” section to learn about the psychological biases that can often lead to making poor choices.

Read through these videos’ teaching notes for details and related ethics concepts. Watch the “Related Videos” and/or read the related Case Study. The video’s “Additional Resources” offer further reading and a bibliography.

To use these resources in the classroom, show a video in class, assign a video to watch outside of class, or embed a video in an online learning module such as Canvas. Then, prompt conversation in class to encourage peer-to-peer learning. Ask students to answer the video’s “Discussion Questions,” and to reflect on the ideas and issues raised by the students in the video. How do their experiences align? How do they differ? The videos also make good writing prompts. Ask students to watch a video and apply the ethics concept to course content.

The case studies offer examples of professionals facing tough ethical decisions or ethically questionable situations in their careers in teaching, science, politics, and social services. Cases are an effective way to introduce ethics topics, and for people to learn how to spot ethical issues.

Select a case study from the Cases Series  or find one in the “Additional Cases” section that resonates with your industry or profession. Then, reason through the ethical dimensions presented, and sketch the ethical decision-making process outlined by the case. Challenge yourself (and/or your team at work) to develop strategies to avoid these ethical pitfalls. Watch the case study’s “Related Videos” and “Related Terms” for further understanding.

To use the case studies in the classroom, ask students to read a video’s “Case Study” and answer the case study “Discussion Questions.” Then, follow the strategy outlined in the previous paragraph, challenging students to develop strategies to avoid the ethical pitfalls presented in the case.

Ethics Unwrapped  blogs  are also useful prompts to engage colleagues or students in discussions about ethics. Learning about ethics in the context of real-world (often current) events can enliven conversation and make ethics relevant and concrete. Share a blog in a meeting or class or post one to the company intranet or the class’s online learning module. To spur discussion, try to identify the ethical issues at hand and to name the ethics concepts related to the blog (or current event in the news). Dig more deeply into the topic using the Additional Resources listed at the end of the blog post.

Remember to review video, case study, and blogs’ relevant glossary  terms. In this way, you will become familiar with all the ethics concepts contained in these material. Share this vocabulary with your colleagues or students, and use it to expand and enrich ethics and leadership conversations. To dive deeper in the glossary, watch “Related” glossary videos.

Many of the concepts covered in Ethics Unwrapped operate in tandem with each other. As you watch more videos, you will become more fluent in ethics and see the interrelatedness of ethics concepts more readily. You also will be able to spot ethical issues more easily – at least, that is the hope! It will also be easier to express your ideas and thoughts about what is and isn’t ethical and why. Hopefully, you will also come to realize the interconnectedness of ethics and leadership, and the essential role ethics plays in developing solid leadership skills that can advance your professional career.

Additional Videos

• Self-serving Bias
• Moral Equilibrium
• Conflict of Interest
• In It To Win: The Jack Abramoff Story
• In It To Win: Jack & Framing
• In It To Win: Jack & Rationalizations
• In It To Win: Jack & Self-Serving Bias
• In It To Win: Jack & Role Morality
• In It To Win: Jack & Moral Equilibrium
• Intro to GVV
• GVV Pillar 1: Values
• GVV Pillar 2: Choice
• GVV Pillar 3: Normalization
• GVV Pillar 4: Purpose
• GVV Pillar 5: Self-Knowledge & Alignment
• GVV Pillar 6: Voice
• GVV Pillar 7: Reasons & Rationalizations
• Obedience to Authority
• Loss Aversion
• Intro to Behavioral Ethics
• Moral Muteness
• Moral Myopia
• Being Your Best Self, Part 1: Moral Awareness
• Being Your Best Self, Part 2: Moral Decision Making
• Being Your Best Self, Part 3: Moral Intent
• Legal Rights & Ethical Responsibilities

Additional Cases

Liberal arts & fine arts.

• A Million Little Pieces
• Approaching the Presidency: Roosevelt & Taft
• Pardoning Nixon

Science & Engineering

• Retracting Research: The Case of Chandok v. Klessig
• Arctic Offshore Drilling

Social Science

• The CIA Leak
• Edward Snowden: Traitor or Hero?
• The Costco Model
• The Collapse of Barings Bank
• Teaching Blackface: A Lesson on Stereotypes
• Cyber Harassment
• Cheating: Atlanta’s School Scandal

Communication & Journalism

• Dr. V’s Magical Putter
• Limbaugh on Drug Addiction
• Reporting on Robin Williams
• Covering Yourself? Journalists and the Bowl Championship
• Sports Blogs: The Wild West of Sports Journalism?
• Cheney v. U.S. District Court
• Negotiating Bankruptcy
• Patient Autonomy & Informed Consent
• Prenatal Diagnosis & Parental Choice

Public Policy & Administration

• Gaming the System: The VA Scandal
• Krogh & the Watergate Scandal

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• 24 Oct 2023

From P.T. Barnum to Mary Kay: Lessons From 5 Leaders Who Changed the World

What do Steve Jobs and Sarah Breedlove have in common? Through a series of case studies, Robert Simons explores the unique qualities of visionary leaders and what today's managers can learn from their journeys.

• 03 Oct 2023
• Research Event

Build the Life You Want: Arthur Brooks and Oprah Winfrey Share Happiness Tips

"Happiness is not a destination. It's a direction." In this video, Arthur C. Brooks and Oprah Winfrey reflect on mistakes, emotions, and contentment, sharing lessons from their new book.

• 12 Sep 2023

Successful, But Still Feel Empty? A Happiness Scholar and Oprah Have Advice for You

So many executives spend decades reaching the pinnacles of their careers only to find themselves unfulfilled at the top. In the book Build the Life You Want, Arthur Brooks and Oprah Winfrey offer high achievers a guide to becoming better leaders—of their lives.

• 10 Jul 2023
• In Practice

The Harvard Business School Faculty Summer Reader 2023

Need a book recommendation for your summer vacation? HBS faculty members share their reading lists, which include titles that explore spirituality, design, suspense, and more.

• 01 Jun 2023

A Nike Executive Hid His Criminal Past to Turn His Life Around. What If He Didn't Have To?

Larry Miller committed murder as a teenager, but earned a college degree while serving time and set out to start a new life. Still, he had to conceal his record to get a job that would ultimately take him to the heights of sports marketing. A case study by Francesca Gino, Hise Gibson, and Frances Frei shows the barriers that formerly incarcerated Black men are up against and the potential talent they could bring to business.

• 04 Apr 2023

Two Centuries of Business Leaders Who Took a Stand on Social Issues

Executives going back to George Cadbury and J. N. Tata have been trying to improve life for their workers and communities, according to the book Deeply Responsible Business: A Global History of Values-Driven Leadership by Geoffrey Jones. He highlights three practices that deeply responsible companies share.

• 14 Mar 2023

Can AI and Machine Learning Help Park Rangers Prevent Poaching?

Globally there are too few park rangers to prevent the illegal trade of wildlife across borders, or poaching. In response, Spatial Monitoring and Reporting Tool (SMART) was created by a coalition of conservation organizations to take historical data and create geospatial mapping tools that enable more efficient deployment of rangers. SMART had demonstrated significant improvements in patrol coverage, with some observed reductions in poaching. Then a new predictive analytic tool, the Protection Assistant for Wildlife Security (PAWS), was created to use artificial intelligence (AI) and machine learning (ML) to try to predict where poachers would be likely to strike. Jonathan Palmer, Executive Director of Conservation Technology for the Wildlife Conservation Society, already had a good data analytics tool to help park rangers manage their patrols. Would adding an AI- and ML-based tool improve outcomes or introduce new problems? Harvard Business School senior lecturer Brian Trelstad discusses the importance of focusing on the use case when determining the value of adding a complex technology solution in his case, “SMART: AI and Machine Learning for Wildlife Conservation.”

• 14 Feb 2023

Does It Pay to Be a Whistleblower?

In 2013, soon after the US Securities and Exchange Commission (SEC) had started a massive whistleblowing program with the potential for large monetary rewards, two employees of a US bank’s asset management business debated whether to blow the whistle on their employer after completing an internal review that revealed undisclosed conflicts of interest. The bank’s asset management business disproportionately invested clients’ money in its own mutual funds over funds managed by other banks, letting it collect additional fees—and the bank had not disclosed this conflict of interest to clients. Both employees agreed that failing to disclose the conflict was a problem, but beyond that, they saw the situation very differently. One employee, Neel, perceived the internal review as a good-faith effort by senior management to identify and address the problem. The other, Akash, thought that the entire business model was problematic, even with a disclosure, and believed that the bank may have even broken the law. Should they escalate the issue internally or report their findings to the US Securities and Exchange Commission? Harvard Business School associate professor Jonas Heese discusses the potential risks and rewards of whistleblowing in his case, “Conflicts of Interest at Uptown Bank.”

• 17 Jan 2023

Good Companies Commit Crimes, But Great Leaders Can Prevent Them

It's time for leaders to go beyond "check the box" compliance programs. Through corporate cases involving Walmart, Wells Fargo, and others, Eugene Soltes explores the thorny legal issues executives today must navigate in his book Corporate Criminal Investigations and Prosecutions.

Doha Declaration

Education for justice.

• Agenda Day 1
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• Breakout Sessions for Primary and Secondary Level
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• Staying safe online
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• A mosaic of differences
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• UNODC-UNESCO Guide for Policymakers
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• Justice Accelerators
• Introduction
• Organized Crime
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• Crime Prevention & Criminal Justice Reform
• Crime Prevention, Criminal Justice & SDGs
• UN Congress on Crime Prevention & Criminal Justice
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• Rationale for Using the Video
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• Previewing the Video
• Criminal Justice & Crime Prevention
• Corruption & Integrity
• Human Trafficking & Migrant Smuggling
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• Introduction & Learning Outcomes
• Corruption - Baseline Definition
• Effects of Corruption
• Deeper Meanings of Corruption
• Measuring Corruption
• Possible Class Structure
• Core Reading
• Advanced Reading
• Student Assessment
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• Appendix: How Corruption Affects the SDGs
• What is Governance?
• What is Good Governance?
• Corruption and Bad Governance
• Governance Reforms and Anti-Corruption
• Guidelines for Stand-alone Course
• Corruption and Democracy
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• Hybrid Systems and Syndromes of Corruption
• The Deep Democratization Approach
• Political Parties and Political Finance
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• Manifestations and Consequences of Public Sector Corruption
• Causes of Public Sector Corruption
• Theories that Explain Corruption
• Corruption in Public Procurement
• Corruption in State-Owned Enterprises
• Responses to Public Sector Corruption
• Preventing Public Sector Corruption
• Forms & Manifestations of Private Sector Corruption
• Consequences of Private Sector Corruption
• Causes of Private Sector Corruption
• Responses to Private Sector Corruption
• Preventing Private Sector Corruption
• Collective Action & Public-Private Partnerships against Corruption
• Transparency as a Precondition
• Detection Mechanisms - Auditing and Reporting
• Whistle-blowing Systems and Protections
• Investigation of Corruption
• Introduction and Learning Outcomes
• Brief background on the human rights system
• Overview of the corruption-human rights nexus
• Impact of corruption on specific human rights
• Approaches to assessing the corruption-human rights nexus
• Human-rights based approach
• Defining sex, gender and gender mainstreaming
• Gender differences in corruption
• Theories explaining the gender–corruption nexus
• Gendered impacts of corruption
• Anti-corruption and gender mainstreaming
• Manifestations of corruption in education
• Costs of corruption in education
• Causes of corruption in education
• Fighting corruption in education
• Core terms and concepts
• The role of citizens in fighting corruption
• The role, risks and challenges of CSOs fighting corruption
• The role of the media in fighting corruption
• Access to information: a condition for citizen participation
• ICT as a tool for citizen participation in anti-corruption efforts
• Government obligations to ensure citizen participation in anti-corruption efforts
• Teaching Guide
• Brief History of Terrorism
• 19th Century Terrorism
• League of Nations & Terrorism
• United Nations & Terrorism
• Terrorist Victimization
• Exercises & Case Studies
• Radicalization & Violent Extremism
• Preventing & Countering Violent Extremism
• Drivers of Violent Extremism
• International Approaches to PVE &CVE
• Regional & Multilateral Approaches
• Defining Rule of Law
• UN Global Counter-Terrorism Strategy
• International Cooperation & UN CT Strategy
• Legal Sources & UN CT Strategy
• Regional & National Approaches
• International Legal Frameworks
• International Human Rights Law
• International Humanitarian Law
• International Refugee Law
• Current Challenges to International Legal Framework
• Defining Terrorism
• Criminal Justice Responses
• Treaty-based Crimes of Terrorism
• Core International Crimes
• International Courts and Tribunals
• African Region
• Inter-American Region
• Asian Region
• European Region
• Middle East & Gulf Regions
• Core Principles of IHL
• Categorization of Armed Conflict
• Classification of Persons
• IHL, Terrorism & Counter-Terrorism
• Relationship between IHL & intern. human rights law
• Limitations Permitted by Human Rights Law
• Derogation during Public Emergency
• Examples of States of Emergency & Derogations
• International Human Rights Instruments
• Regional Human Rights Instruments
• Extra-territorial Application of Right to Life
• Arbitrary Deprivation of Life
• Death Penalty
• Enforced Disappearances
• Armed Conflict Context
• International Covenant on Civil and Political Rights
• Convention against Torture et al.
• International Legal Framework
• Key Contemporary Issues
• Investigative Phase
• Trial & Sentencing Phase
• Armed Conflict
• Case Studies
• Special Investigative Techniques
• Surveillance & Interception of Communications
• Privacy & Intelligence Gathering in Armed Conflict
• Accountability & Oversight of Intelligence Gathering
• Principle of Non-Discrimination
• Freedom of Religion
• Freedom of Expression
• Freedom of Assembly
• Freedom of Association
• Fundamental Freedoms
• Definition of 'Victim'
• Effects of Terrorism
• Access to Justice
• Recognition of the Victim
• Human Rights Instruments
• Criminal Justice Mechanisms
• Instruments for Victims of Terrorism
• National Approaches
• Key Challenges in Securing Reparation
• Topic 1. Contemporary issues relating to conditions conducive both to the spread of terrorism and the rule of law
• Topic 2. Contemporary issues relating to the right to life
• Topic 3. Contemporary issues relating to foreign terrorist fighters
• Topic 4. Contemporary issues relating to non-discrimination and fundamental freedoms
• Module 16: Linkages between Organized Crime and Terrorism
• Thematic Areas
• Content Breakdown
• Module Adaptation & Design Guidelines
• Teaching Methods
• Acknowledgements
• 1. Introducing United Nations Standards & Norms on CPCJ vis-à-vis International Law
• 2. Scope of United Nations Standards & Norms on CPCJ
• 3. United Nations Standards & Norms on CPCJ in Operation
• 1. Definition of Crime Prevention
• 2. Key Crime Prevention Typologies
• 2. (cont.) Tonry & Farrington’s Typology
• 3. Crime Problem-Solving Approaches
• 4. What Works
• United Nations Entities
• Regional Crime Prevention Councils/Institutions
• Key Clearinghouses
• Systematic Reviews
• 1. Introduction to International Standards & Norms
• 2. Identifying the Need for Legal Aid
• 3. Key Components of the Right of Access to Legal Aid
• 4. Access to Legal Aid for Those with Specific Needs
• 5. Models for Governing, Administering and Funding Legal Aid
• 6. Models for Delivering Legal Aid Services
• 7. Roles and Responsibilities of Legal Aid Providers
• 8. Quality Assurance and Legal Aid Services
• 1. Context for Use of Force by Law Enforcement Officials
• 2. Legal Framework
• 3. General Principles of Use of Force in Law Enforcement
• 4. Use of Firearms
• 5. Use of “Less-Lethal” Weapons
• 6. Protection of Especially Vulnerable Groups
• 7. Use of Force during Assemblies
• 1. Policing in democracies & need for accountability, integrity, oversight
• 2. Key mechanisms & actors in police accountability, oversight
• 3. Crosscutting & contemporary issues in police accountability
• 1. Introducing Aims of Punishment, Imprisonment & Prison Reform
• 2. Current Trends, Challenges & Human Rights
• 3. Towards Humane Prisons & Alternative Sanctions
• 1. Aims and Significance of Alternatives to Imprisonment
• 2. Justifying Punishment in the Community
• 3. Pretrial Alternatives
• 4. Post Trial Alternatives
• 5. Evaluating Alternatives
• 1. Concept, Values and Origin of Restorative Justice
• 2. Overview of Restorative Justice Processes
• 3. How Cost Effective is Restorative Justice?
• 4. Issues in Implementing Restorative Justice
• 1. Gender-Based Discrimination & Women in Conflict with the Law
• 2. Vulnerabilities of Girls in Conflict with the Law
• 3. Discrimination and Violence against LGBTI Individuals
• 4. Gender Diversity in Criminal Justice Workforce
• 1. Ending Violence against Women
• 2. Human Rights Approaches to Violence against Women
• 3. Who Has Rights in this Situation?
• 4. What about the Men?
• 5. Local, Regional & Global Solutions to Violence against Women & Girls
• 1. Understanding the Concept of Victims of Crime
• 2. Impact of Crime, including Trauma
• 3. Right of Victims to Adequate Response to their Needs
• 4. Collecting Victim Data
• 5. Victims and their Participation in Criminal Justice Process
• 6. Victim Services: Institutional and Non-Governmental Organizations
• 7. Outlook on Current Developments Regarding Victims
• 8. Victims of Crime and International Law
• 1. The Many Forms of Violence against Children
• 2. The Impact of Violence on Children
• 3. States' Obligations to Prevent VAC and Protect Child Victims
• 4. Improving the Prevention of Violence against Children
• 5. Improving the Criminal Justice Response to VAC
• 6. Addressing Violence against Children within the Justice System
• 1. The Role of the Justice System
• 2. Convention on the Rights of the Child & International Legal Framework on Children's Rights
• 3. Justice for Children
• 4. Justice for Children in Conflict with the Law
• 5. Realizing Justice for Children
• 1a. Judicial Independence as Fundamental Value of Rule of Law & of Constitutionalism
• 1b. Main Factors Aimed at Securing Judicial Independence
• 2a. Public Prosecutors as ‘Gate Keepers’ of Criminal Justice
• 2b. Institutional and Functional Role of Prosecutors
• 2c. Other Factors Affecting the Role of Prosecutors
• Basics of Computing
• Global Connectivity and Technology Usage Trends
• Cybercrime in Brief
• Cybercrime Trends
• Cybercrime Prevention
• Offences against computer data and systems
• Computer-related offences
• Content-related offences
• The Role of Cybercrime Law
• Harmonization of Laws
• International and Regional Instruments
• International Human Rights and Cybercrime Law
• Digital Evidence
• Digital Forensics
• Standards and Best Practices for Digital Forensics
• Reporting Cybercrime
• Who Conducts Cybercrime Investigations?
• Obstacles to Cybercrime Investigations
• Knowledge Management
• Legal and Ethical Obligations
• Handling of Digital Evidence
• Digital Evidence Admissibility
• Sovereignty and Jurisdiction
• Formal International Cooperation Mechanisms
• Informal International Cooperation Mechanisms
• Data Retention, Preservation and Access
• Challenges Relating to Extraterritorial Evidence
• National Capacity and International Cooperation
• Internet Governance
• Cybersecurity Strategies: Basic Features
• National Cybersecurity Strategies
• International Cooperation on Cybersecurity Matters
• Cybersecurity Posture
• Assets, Vulnerabilities and Threats
• Vulnerability Disclosure
• Cybersecurity Measures and Usability
• Situational Crime Prevention
• Incident Detection, Response, Recovery & Preparedness
• Privacy: What it is and Why it is Important
• Privacy and Security
• Cybercrime that Compromises Privacy
• Data Protection Legislation
• Data Breach Notification Laws
• Enforcement of Privacy and Data Protection Laws
• Intellectual Property: What it is
• Types of Intellectual Property
• Causes for Cyber-Enabled Copyright & Trademark Offences
• Protection & Prevention Efforts
• Online Child Sexual Exploitation and Abuse
• Cyberstalking and Cyberharassment
• Cyberbullying
• Gender-Based Interpersonal Cybercrime
• Interpersonal Cybercrime Prevention
• Cyber Organized Crime: What is it?
• Conceptualizing Organized Crime & Defining Actors Involved
• Criminal Groups Engaging in Cyber Organized Crime
• Cyber Organized Crime Activities
• Preventing & Countering Cyber Organized Crime
• Cyberespionage
• Cyberterrorism
• Cyberwarfare
• Information Warfare, Disinformation & Electoral Fraud
• Responses to Cyberinterventions
• Framing the Issue of Firearms
• Direct Impact of Firearms
• Indirect Impacts of Firearms on States or Communities
• International and National Responses
• Typology and Classification of Firearms
• Common Firearms Types
• 'Other' Types of Firearms
• Parts and Components
• History of the Legitimate Arms Market
• Need for a Legitimate Market
• Key Actors in the Legitimate Market
• Authorized & Unauthorized Arms Transfers
• Illegal Firearms in Social, Cultural & Political Context
• Supply, Demand & Criminal Motivations
• Larger Scale Firearms Trafficking Activities
• Smaller Scale Trafficking Activities
• Sources of Illicit Firearms
• Consequences of Illicit Markets
• International Public Law & Transnational Law
• International Instruments with Global Outreach
• Commonalities, Differences & Complementarity between Global Instruments
• Tools to Support Implementation of Global Instruments
• Other United Nations Processes
• The Sustainable Development Goals
• Multilateral & Regional Instruments
• Scope of National Firearms Regulations
• National Firearms Strategies & Action Plans
• Harmonization of National Legislation with International Firearms Instruments
• Assistance for Development of National Firearms Legislation
• Firearms Trafficking as a Cross-Cutting Element
• Organized Crime and Organized Criminal Groups
• Criminal Gangs
• Terrorist Groups
• Interconnections between Organized Criminal Groups & Terrorist Groups
• Gangs - Organized Crime & Terrorism: An Evolving Continuum
• International Response
• International and National Legal Framework
• Firearms Related Offences
• Role of Law Enforcement
• Firearms as Evidence
• Use of Special Investigative Techniques
• International Cooperation and Information Exchange
• Prosecution and Adjudication of Firearms Trafficking
• Teaching Methods & Principles
• Ethical Learning Environments
• Overview of Modules
• Module Adaption & Design Guidelines
• Table of Exercises
• Basic Terms
• Forms of Gender Discrimination
• Ethics of Care
• Case Studies for Professional Ethics
• Case Studies for Role Morality
• Additional Exercises
• Defining Organized Crime
• Definition in Convention
• Similarities & Differences
• Activities, Organization, Composition
• Thinking Critically Through Fiction
• Excerpts of Legislation
• Research & Independent Study Questions
• Legal Definitions of Organized Crimes
• Criminal Association
• Definitions in the Organized Crime Convention
• Criminal Organizations and Enterprise Laws
• Enabling Offence: Obstruction of Justice
• Drug Trafficking
• Wildlife & Forest Crime
• Counterfeit Products Trafficking
• Falsified Medical Products
• Trafficking in Cultural Property
• Trafficking in Persons
• Case Studies & Exercises
• Extortion Racketeering
• Loansharking
• Links to Corruption
• Bribery versus Extortion
• Money-Laundering
• Liability of Legal Persons
• How much Organized Crime is there?
• Alternative Ways for Measuring
• Measuring Product Markets
• Risk Assessment
• Key Concepts of Risk Assessment
• Risk Assessment of Organized Crime Groups
• Risk Assessment of Product Markets
• Risk Assessment in Practice
• Positivism: Environmental Influences
• Classical: Pain-Pleasure Decisions
• Structural Factors
• Ethical Perspective
• Crime Causes & Facilitating Factors
• Models and Structure
• Hierarchical Model
• Local, Cultural Model
• Enterprise or Business Model
• Groups vs Activities
• Networked Structure
• Jurisdiction
• Investigators of Organized Crime
• Controlled Deliveries
• Physical & Electronic Surveillance
• Undercover Operations
• Financial Analysis
• Use of Informants
• Rights of Victims & Witnesses
• Role of Prosecutors
• Adversarial vs Inquisitorial Legal Systems
• Mitigating Punishment
• Granting Immunity from Prosecution
• Witness Protection
• Aggravating & Mitigating Factors
• Sentencing Options
• Alternatives to Imprisonment
• Death Penalty & Organized Crime
• Backgrounds of Convicted Offenders
• Confiscation
• Confiscation in Practice
• Mutual Legal Assistance (MLA)
• Extradition
• Transfer of Criminal Proceedings
• Transfer of Sentenced Persons
• Module 12: Prevention of Organized Crime
• Adoption of Organized Crime Convention
• Historical Context
• Features of the Convention
• Related international instruments
• Conference of the Parties
• Roles of Participants
• Structure and Flow
• Recommended Topics
• Background Materials
• What is Sex / Gender / Intersectionality?
• Knowledge about Gender in Organized Crime
• Gender and Organized Crime
• Gender and Different Types of Organized Crime
• Definitions and Terminology
• Organized crime and Terrorism - International Legal Framework
• International Terrorism-related Conventions
• UNSC Resolutions on Terrorism
• Organized Crime Convention and its Protocols
• Theoretical Frameworks on Linkages between Organized Crime and Terrorism
• Typologies of Criminal Behaviour Associated with Terrorism
• Terrorism and Drug Trafficking
• Terrorism and Trafficking in Weapons
• Terrorism, Crime and Trafficking in Cultural Property
• Trafficking in Persons and Terrorism
• Intellectual Property Crime and Terrorism
• Kidnapping for Ransom and Terrorism
• Exploitation of Natural Resources and Terrorism
• Review and Assessment Questions
• Research and Independent Study Questions
• Criminalization of Smuggling of Migrants
• UNTOC & the Protocol against Smuggling of Migrants
• Offences under the Protocol
• Financial & Other Material Benefits
• Aggravating Circumstances
• Criminal Liability
• Non-Criminalization of Smuggled Migrants
• Scope of the Protocol
• Humanitarian Exemption
• Migrant Smuggling v. Irregular Migration
• Migrant Smuggling vis-a-vis Other Crime Types
• Other Resources
• Assistance and Protection in the Protocol
• International Human Rights and Refugee Law
• Vulnerable groups
• Positive and Negative Obligations of the State
• Identification of Smuggled Migrants
• Participation in Legal Proceedings
• Role of Non-Governmental Organizations
• Smuggled Migrants & Other Categories of Migrants
• Short-, Mid- and Long-Term Measures
• Criminal Justice Reponse: Scope
• Investigative & Prosecutorial Approaches
• Different Relevant Actors & Their Roles
• Testimonial Evidence
• Financial Investigations
• Non-Governmental Organizations
• ‘Outside the Box’ Methodologies
• Intra- and Inter-Agency Coordination
• Admissibility of Evidence
• International Cooperation
• Exchange of Information
• Non-Criminal Law Relevant to Smuggling of Migrants
• Administrative Approach
• Complementary Activities & Role of Non-criminal Justice Actors
• Macro-Perspective in Addressing Smuggling of Migrants
• Human Security
• International Aid and Cooperation
• Migration & Migrant Smuggling
• Mixed Migration Flows
• Social Politics of Migrant Smuggling
• Vulnerability
• Profile of Smugglers
• Role of Organized Criminal Groups
• Humanitarianism, Security and Migrant Smuggling
• Crime of Trafficking in Persons
• The Issue of Consent
• The Purpose of Exploitation
• The abuse of a position of vulnerability
• Indicators of Trafficking in Persons
• Distinction between Trafficking in Persons and Other Crimes
• Misconceptions Regarding Trafficking in Persons
• Root Causes
• Supply Side Prevention Strategies
• Demand Side Prevention Strategies
• Role of the Media
• Safe Migration Channels
• Crime Prevention Strategies
• Monitoring, Evaluating & Reporting on Effectiveness of Prevention
• Trafficked Persons as Victims
• Protection under the Protocol against Trafficking in Persons
• Broader International Framework
• State Responsibility for Trafficking in Persons
• Identification of Victims
• Principle of Non-Criminalization of Victims
• Criminal Justice Duties Imposed on States
• Role of the Criminal Justice System
• Current Low Levels of Prosecutions and Convictions
• Challenges to an Effective Criminal Justice Response
• Rights of Victims to Justice and Protection
• Potential Strategies to “Turn the Tide”
• State Cooperation with Civil Society
• Civil Society Actors
• The Private Sector
• Comparing SOM and TIP
• Differences and Commonalities
• Vulnerability and Continuum between SOM & TIP
• Labour Exploitation
• Forced Marriage
• Other Examples
• Children on the Move
• Protecting Smuggled and Trafficked Children
• Protection in Practice
• Children Alleged as Having Committed Smuggling or Trafficking Offences
• Basic Terms - Gender and Gender Stereotypes
• International Legal Frameworks and Definitions of TIP and SOM
• Global Overview on TIP and SOM
• Gender and Migration
• Key Debates in the Scholarship on TIP and SOM
• Gender and TIP and SOM Offenders
• Responses to TIP and SOM
• Use of Technology to Facilitate TIP and SOM
• Technology Facilitating Trafficking in Persons
• Technology in Smuggling of Migrants
• Using Technology to Prevent and Combat TIP and SOM
• Privacy and Data Concerns
• Emerging Trends
• Demand and Consumption
• Supply and Demand
• Implications of Wildlife Trafficking
• Legal and Illegal Markets
• Perpetrators and their Networks
• Locations and Activities relating to Wildlife Trafficking
• Environmental Protection & Conservation
• CITES & the International Trade in Endangered Species
• Organized Crime & Corruption
• Animal Welfare
• Criminal Justice Actors and Agencies
• Criminalization of Wildlife Trafficking
• Challenges for Law Enforcement
• Investigation Measures and Detection Methods
• Prosecution and Judiciary
• Wild Flora as the Target of Illegal Trafficking
• Purposes for which Wild Flora is Illegally Targeted
• How is it Done and Who is Involved?
• Consequences of Harms to Wild Flora
• Terminology
• Background: Communities and conservation: A history of disenfranchisement
• Incentives for communities to get involved in illegal wildlife trafficking: the cost of conservation
• Incentives to participate in illegal wildlife, logging and fishing economies
• International and regional responses that fight wildlife trafficking while supporting IPLCs
• Mechanisms for incentivizing community conservation and reducing wildlife trafficking
• Critiques of community engagement
• Other challenges posed by wildlife trafficking that affect local populations
• Global Podcast Series
• Apr. 2021: Call for Expressions of Interest: Online training for academics from francophone Africa
• Feb. 2021: Series of Seminars for Universities of Central Asia
• Dec. 2020: UNODC and TISS Conference on Access to Justice to End Violence
• Nov. 2020: Expert Workshop for University Lecturers and Trainers from the Commonwealth of Independent States
• Oct. 2020: E4J Webinar Series: Youth Empowerment through Education for Justice
• Interview: How to use E4J's tool in teaching on TIP and SOM
• E4J-Open University Online Training-of-Trainers Course
• Teaching Integrity and Ethics Modules: Survey Results
• Grants Programmes
• E4J MUN Resource Guide
• Library of Resources
• Integrity & Ethics
• Module 12: Integrity, Ethics & Law
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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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• SOCIETY OF PROFESSIONAL JOURNALISTS

Home > Ethics > Ethics Case Studies

Ethics Ethics Case Studies

The SPJ Code of Ethics is voluntarily embraced by thousands of journalists, regardless of place or platform, and is widely used in newsrooms and classrooms as a guide for ethical behavior. The code is intended not as a set of "rules" but as a resource for ethical decision-making. It is not — nor can it be under the First Amendment — legally enforceable. For an expanded explanation, please follow this link .

For journalism instructors and others interested in presenting ethical dilemmas for debate and discussion, SPJ has a useful resource. We've been collecting a number of case studies for use in workshops. The Ethics AdviceLine operated by the Chicago Headline Club and Loyola University also has provided a number of examples. There seems to be no shortage of ethical issues in journalism these days. Please feel free to use these examples in your classes, speeches, columns, workshops or other modes of communication.

Kobe Bryant’s Past: A Tweet Too Soon? On January 26, 2020, Kobe Bryant died at the age of 41 in a helicopter crash in the Los Angeles area. While the majority of social media praised Bryant after his death, within a few hours after the story broke, Felicia Sonmez, a reporter for The Washington Post , tweeted a link to an article from 2003 about the allegations of sexual assault against Bryant. The question: Is there a limit to truth-telling? How long (if at all) should a journalist wait after a person’s death before resurfacing sensitive information about their past?

A controversial apology After photographs of a speech and protests at Northwestern University appeared on the university's newspaper's website, some of the participants contacted the newspaper to complain. It became a “firestorm,” — first from students who felt victimized, and then, after the newspaper apologized, from journalists and others who accused the newspaper of apologizing for simply doing its job. The question: Is an apology the appropriate response? Is there something else the student journalists should have done?

Using the ‘Holocaust’ Metaphor People for the Ethical Treatment of Animals, or PETA, is a nonprofit animal rights organization known for its controversial approach to communications and public relations. In 2003, PETA launched a new campaign, named “Holocaust on Your Plate,” that compares the slaughter of animals for human use to the murder of 6 million Jews in WWII. The question: Is “Holocaust on Your Plate” ethically wrong or a truthful comparison?

Aaargh! Pirates! (and the Press) As collections of songs, studio recordings from an upcoming album or merely unreleased demos, are leaked online, these outlets cover the leak with a breaking story or a blog post. But they don’t stop there. Rolling Stone and Billboard often also will include a link within the story to listen to the songs that were leaked. The question: If Billboard and Rolling Stone are essentially pointing readers in the right direction, to the leaked music, are they not aiding in helping the Internet community find the material and consume it?

Reigning on the Parade Frank Whelan, a features writer who also wrote a history column for the Allentown, Pennsylvania, Morning Call , took part in a gay rights parade in June 2006 and stirred up a classic ethical dilemma. The situation raises any number of questions about what is and isn’t a conflict of interest. The question: What should the “consequences” be for Frank Whelan?

Controversy over a Concert Three former members of the Eagles rock band came to Denver during the 2004 election campaign to raise money for a U.S. Senate candidate, Democrat Ken Salazar. John Temple, editor and publisher of the Rocky Mountain News, advised his reporters not to go to the fundraising concerts. The question: Is it fair to ask newspaper staffers — or employees at other news media, for that matter — not to attend events that may have a political purpose? Are the rules different for different jobs at the news outlet?

Deep Throat, and His Motive The Watergate story is considered perhaps American journalism’s defining accomplishment. Two intrepid young reporters for The Washington Post , carefully verifying and expanding upon information given to them by sources they went to great lengths to protect, revealed brutally damaging information about one of the most powerful figures on Earth, the American president. The question: Is protecting a source more important than revealing all the relevant information about a news story?

When Sources Won’t Talk The SPJ Code of Ethics offers guidance on at least three aspects of this dilemma. “Test the accuracy of information from all sources and exercise care to avoid inadvertent error.” One source was not sufficient in revealing this information. The question: How could the editors maintain credibility and remain fair to both sides yet find solid sources for a news tip with inflammatory allegations?

A Suspect “Confession” John Mark Karr, 41, was arrested in mid-August in Bangkok, Thailand, at the request of Colorado and U.S. officials. During questioning, he confessed to the murder of JonBenet Ramsey. Karr was arrested after Michael Tracey, a journalism professor at the University of Colorado, alerted authorities to information he had drawn from e-mails Karr had sent him over the past four years. The question: Do you break a confidence with your source if you think it can solve a murder — or protect children half a world away?

Who’s the “Predator”? “To Catch a Predator,” the ratings-grabbing series on NBC’s Dateline, appeared to catch on with the public. But it also raised serious ethical questions for journalists. The question: If your newspaper or television station were approached by Perverted Justice to participate in a “sting” designed to identify real and potential perverts, should you go along, or say, “No thanks”? Was NBC reporting the news or creating it?

The Media’s Foul Ball The Chicago Cubs in 2003 were five outs from advancing to the World Series for the first time since 1945 when a 26-year-old fan tried to grab a foul ball, preventing outfielder Moises Alou from catching it. The hapless fan's identity was unknown. But he became recognizable through televised replays as the young baby-faced man in glasses, a Cubs baseball cap and earphones who bobbled the ball and was blamed for costing the Cubs a trip to the World Series. The question: Given the potential danger to the man, should he be identified by the media?

Publishing Drunk Drivers’ Photos When readers of The Anderson News picked up the Dec. 31, 1997, issue of the newspaper, stripped across the top of the front page was a New Year’s greeting and a warning. “HAVE A HAPPY NEW YEAR,” the banner read. “But please don’t drink and drive and risk having your picture published.” Readers were referred to the editorial page where White explained that starting in January 1998 the newspaper would publish photographs of all persons convicted of drunken driving in Anderson County. The question: Is this an appropriate policy for a newspaper?

Naming Victims of Sex Crimes On January 8, 2007, 13-year-old Ben Ownby disappeared while walking home from school in Beaufort, Missouri. A tip from a school friend led police on a frantic four-day search that ended unusually happily: the police discovered not only Ben, but another boy as well—15-year-old Shawn Hornbeck, who, four years earlier, had disappeared while riding his bike at the age of 11. Media scrutiny on Shawn’s years of captivity became intense. The question: Question: Should children who are thought to be the victims of sexual abuse ever be named in the media? What should be done about the continued use of names of kidnap victims who are later found to be sexual assault victims? Should use of their names be discontinued at that point?

A Self-Serving Leak San Francisco Chronicle reporters Mark Fainaru-Wada and Lance Williams were widely praised for their stories about sports figures involved with steroids. They turned their investigation into a very successful book, Game of Shadows . And they won the admiration of fellow journalists because they were willing to go to prison to protect the source who had leaked testimony to them from the grand jury investigating the BALCO sports-and-steroids. Their source, however, was not quite so noble. The question: Should the two reporters have continued to protect this key source even after he admitted to lying? Should they have promised confidentiality in the first place?

The Times and Jayson Blair Jayson Blair advanced quickly during his tenure at The New York Times , where he was hired as a full-time staff writer after his internship there and others at The Boston Globe and The Washington Post . Even accusations of inaccuracy and a series of corrections to his reports on Washington, D.C.-area sniper attacks did not stop Blair from moving on to national coverage of the war in Iraq. But when suspicions arose over his reports on military families, an internal review found that he was fabricating material and communicating with editors from his Brooklyn apartment — or within the Times building — rather than from outside New York. The question: How does the Times investigate problems and correct policies that allowed the Blair scandal to happen?

Cooperating with the Government It began on Jan. 18, 2005, and ended two weeks later after the longest prison standoff in recent U.S. history. The question: Should your media outlet go along with the state’s request not to release the information?

Offensive Images Caricatures of the Prophet Muhammad didn’t cause much of a stir when they were first published in September 2005. But when they were republished in early 2006, after Muslim leaders called attention to the 12 images, it set off rioting throughout the Islamic world. Embassies were burned; people were killed. After the rioting and killing started, it was difficult to ignore the cartoons. Question: Do we publish the cartoons or not?

The Sting Perverted-Justice.com is a Web site that can be very convenient for a reporter looking for a good story. But the tactic raises some ethical questions. The Web site scans Internet chat rooms looking for men who can be lured into sexually explicit conversations with invented underage correspondents. Perverted-Justice posts the men’s pictures on its Web site. Is it ethically defensible to employ such a sting tactic? Should you buy into the agenda of an advocacy group — even if it’s an agenda as worthy as this one?

A Media-Savvy Killer Since his first murder in 1974, the “BTK” killer — his own acronym, for “bind, torture, kill” — has sent the Wichita Eagle four letters and one poem. How should a newspaper, or other media outlet, handle communications from someone who says he’s guilty of multiple sensational crimes? And how much should it cooperate with law enforcement authorities?

A Congressman’s Past The (Portland) Oregonian learned that a Democratic member of the U.S. Congress, up for re-election to his fourth term, had been accused by an ex-girlfriend of a sexual assault some 28 years previously. But criminal charges never were filed, and neither the congressman, David Wu, nor his accuser wanted to discuss the case now, only weeks before the 2004 election. Question: Should The Oregonian publish this story?

Using this Process to Craft a Policy It used to be that a reporter would absolutely NEVER let a source check out a story before it appeared. But there has been growing acceptance of the idea that it’s more important to be accurate than to be independent. Do we let sources see what we’re planning to write? And if we do, when?

SPJ News –  SPJ condemns arrest of freelance reporter at UCLA and demands charges be dropped –  SPJ-led coalition demands Texas authorities drop charges against photojournalist Carlos Sanchez –  Region 8 Mark of Excellence Awards 2023 winners announced

Case Studies

Case study discussion.

Below is a list of the case study articles that have been published in NIB , each with keywords, a set of discussion questions, and further resources. To search page contents with keywords, select "Control-F" from a PC, or "Command-F" from a Mac.

• Accommodating Religious Beliefs in the ICU: A Narrative Account of a Disputed Death
• When Ethics Consultation and Courts Collide: A Case of Compelled Treatment of a Mature Minor
• Advance Directives, Preemptive Suicide, and Emergency Medicine Decision Making
• Healing the Physician’s Story: A Case of Narrative Medicine and End-of-Life Care
• The Efficacy of Ethics Discernment in the Organizational Context: The Case of Post-Offer Nicotine Screening
• Can We Talk About Sex?
• Should We Tell Annie?: Preparing for Death at the Intersection of Parental Authority and Adolescent Autonomy
• A Case of Deceptive Mastectomy
• Do Everything
• Responding to the Refusal of Care in the Emergency Department
• I Don’t Know Why I Called You
• Undocumented and at the End of Life
• Dax’s Case Redux: When Comes the End of the Day?
• Desperately Seeking a Surrogate— For a Patient Lacking Decision-Making Capacity
• What to Say When: Responding to a Suicide Attempt in the Acute Care Setting
• Conversation and the Jehovah’s Witness Dying From Blood Loss
• Caregivers’ Role in Maternal-Fetal Conflict
• The Surgeon as Stakeholder: Making the Case Not to Operate
• The Enduring Case
• Military Health Care Dilemmas and Genetic Discrimination: A Family’s Experience with Whole Exome Sequencing
• Conflicting Values: A Case Study in Patient Choice and Caregiver Perspectives
• Ethical Dilemmas Relating to the Management of a Newborn with Down Syndrome and Severe Congenital Heart Disease in a Resource-Poor Setting
• System Failure: No Surgeon To Be Found
• Ethical Challenges in the Care of the Inpatient with Morbid Obesity
• A Life Below the Threshold? Examining Conflict Between Ethical Principles and Parental Values in Neonatal Treatment Decision Making
• The Clinical Bioethicist’s Role: Should We Aim to Relieve Suffering?
• To Enroll or Not to Enroll?: A Researcher Struggles with the Decision to Involve Study Participants in a Clinical Trial That Could Save Their Lives
• Sometimes Those Hoofbeats Are Zebras: A Narrative Analysis
• A Jehovah’s Witness Adolescent in the Labor and Delivery Unit: Should Patient and Parental Refusals of Blood Transfusions for Adolescents Be Honored?
• Reframing Medical Appropriateness: A Case Study Concerning the Use of Life-Sustaining Technologies for a Patient With Profoundly Diminished Quality of Life
• "We Didn't Consent to This"
• Screen Shots: When Patients and Families Publish Negative Health Care Narratives Online
• A Personal Narrative on Living and Dealing with Psychiatric Symptoms after DBS Surgery
• The Will Reconsidered: Hard Choices in Living Organ Donation
• Malleable Transplant Criteria: At What Cost?
• Responding to Requests for Aid-in-Dying: Rethinking the Role of Conscience
• Getting to the Heart of the Matter: Navigating Narrative Intersections in Ethics Consultation
• Speaking for Our Father
• Forcible Amputation in Delusional Patients: A Narrative Analysis of Decisional Capacity
• A Health Care Systems Approach to Improving Care for Seriously Ill Patients
• An Ethics of Unknowing: Discerning Ethical Patient-Provider Interactions in Clinical Decision-Making
• How Should Physicians Manage Neuro-prognosis with ECPR?
• The Ethics of Choosing a Surrogate Decision Maker When Equal-Priority Surrogates Disagree
• A Gay Epidemiologist and the DC Commission of Public Health AIDS Advisory Committee
• Shared Decision-Making in Palliative Care: A Maternalistic Approach
• Phantom Physicians and Medical Catfishing: A Narrative Ethics Approach to Ghost Surgery
• It Takes Time to Let Go
• An American’s Experience with End-of-Life Care in Japan: Comparing Brain Death, Limiting and Withdrawing Life-Prolonging Interventions, and Healthcare Ethics Consultation Practices in Japan and the United States
• The Sword of King Solomon
• Appreciating the Dynamicity of Values at the End of Life: A Psychological and Ethical Analysis
• Serendipity and Social Justice: How Someone with a Physical Disability Succeeds in Clinical Bioethics
• The Right to Be Childfree
• Undisclosed Placebo Trials in Clinical Practice: Undercover Beneficence or Unwarranted Deception?
• What Do We Owe to Patients Who Leave Against Medical Advice? The Ethics of AMA Discharges?
•  "Jehovah's Witnesses and the Normative Function of Indirect Consent"
• "Parental Refusals of Blood Transfusions from COVID-19 Vaccinated Donors for Children Needing Cardiac Surgery"
• "Withdrawing Life Support After Attempted Suicide: A Case Study and Review of Ethical Consideration"

1. Accommodating Religious Beliefs in the ICU: A Narrative Account of a Disputed Death

Martin L. Smith, Anne Lederman Flamm

Abstract: Despite widespread acceptance in the United States of neurological criteria to determine death, clinicians encounter families who object, often on religious grounds, to the categorization of their loved ones as “brain dead.” The concept of “reasonable accommodation” of objections to brain death, promulgated in both state statutes and the bioethics literature, suggests the possibility of compromise between the family’s deeply held beliefs and the legal, professional and moral values otherwise directing clinicians to withdraw medical interventions. Relying on narrative to convey the experience of a family and clinical caregivers embroiled in this complex dilemma, the case analyzed here explores the practical challenges and moral ambiguities presented by the concept of reasonable accommodation. Clarifying the term’s meaning and boundaries, and identifying guidelines for its clinical implementation, could help to reduce uncertainty for both health care professionals and families and, thereby, the incremental moral distress such uncertainty creates.

Keywords: Brain death, clinical ethics, ethics consultation, reasonable accommodation, religious conflict

Link to Case on MUSE

Reflection Questions:

• How might have the nurses’ and physicians’ initial frank commentary about Sarah’s condition affected the family’s interpretation of the clinicians’ opinions later on in the care process?
• In what ways might the new hospital have provided support to Sarah’s family in order to avoid the religion vs. medicine standoff that eventually developed?
• How much patience are physicians obligated to have with family members who extensively question the medical decision-making process? Was the hospital staff correct in labeling Rebekah as “manipulative”?
• Is it ethically appropriate for financial considerations to affect the family’s decision-making? Why or why not? To what extent should the healthcare team discuss the financial impact of decisions with families?

Web Resources:

• New York State Department of Health Guidelines for Determining Brain Death. (2011). Retrieved from: http://www.health.ny.gov/professionals/hospital_administrator/letters/2011/brain_death_guidelines.pdf
• Olick, RS, Braun, EA, and Potash, J. (2009). Accommodating Religious and Moral Objections to Neurological Death. The Journal of Clinical Ethics. Retrieved from: http://www.upstate.edu/bioethics/pdf/faculty/olick_accommodating-religious-and-moral-objections-to-neurological-death.pdf
• Breitowitz, YA. Jewish Medical Ethics: The Brain Death Controversy in Jewish Law. Jewish Virtual Library. Retrieved from: https://www.jewishvirtuallibrary.org/jsource/Judaism/braindead.html

2. When Ethics Consultation and Courts Collide: A Case of Compelled Treatment of a Mature Minor

Jeffrey P. Spike

Abstract: A fourteen year old is diagnosed with aplastic anemia. The teen and his parents are Jehovah’s Witnesses. An ethics consult is called on the day of admission by an ethically sophisticated social worker and attending. The patient and his parents see this diagnosis as “a test of their faith.” The ethical analysis focuses on the mature minor doctrine, i.e. whether the teen has the capacity to make this decision. The hospital chooses to take the case to court, with a result that is at odds with the ethics consultation recommendations. Ethics was never deposed or otherwise invited to be involved with the hearing. Thus the larger question of the relation of ethics and law was brought into stark relief.

Keywords: Adolescent, Capacity, Child Neglect, Decision-making Capacity, Ethics Consultation, Informed Consent, Jehovah’s Witnesses, Mature Minor, Religion, Religious Belief, Right to Refuse Treatment, Teen, Teenager

• What is the relationship between law and ethics? When they conflict, which should prevail?
• At one point, the author of this case study says, of trying to convince his young patient of the benefit of treatment: “…but that seemed coercive. In fact, far too many patients act out of fear and accept treatment that has virtually no choice of benefit.” In this case, where Luke would have greatly benefitted from treatment, where is the line to be drawn between thoroughly informing him and coercing him?
• Are there ever circumstances where it might be disadvantageous to have an ethics consultation?
• Anderson & Associates, P.C. (2015). Illinois Recognizes the “Mature Minor Doctrine” in Some Cases. Retrieved from: http://www.andersondivorcelawchicago.com/chicagodivorceattorney/2015/01/29/illinois-mature-minor-doctrine-states/

Pauley, M. (2011). National Health Care Decisions Day, Jehovah’s Witnesses & Mature Minors. Marquette University Law School Faculty Blog. Retrieved from: http://law.marquette.edu/facultyblog/2011/04/14/national-health-care-decisions-day-jehovahs-witnesses-mature-minors/

• Jehovah’s Witnesses: The Surgical/Ethical Challenge. (1981). JW.org. Retrieved from: http://www.jw.org/en/publications/books/blood/jehovahs-witnesses-the-surgical-ethical-challenge/

3. Advance Directives, Preemptive Suicide, and Emergency Medicine Decision Making

Richard L. Heinrich, Marshall T. Morgan, Steven J. Rottman

Abstract: As the United States population ages, there is a growing group of aging, elderly, individuals who may consider "preemptive suicide"(Prado, 1998). Healthy aging patients who preemptively attempt to end their life by suicide and who have clearly expressed a desire not to have life -sustaining treatment present a clinical and public policy challenge. We describe the clinical, ethical, and medical-legal decision making issues that were raised in such a case that presented to an academic emergency department. We also review and evaluate a decision making process that emergency physicians confront when faced with such a challenging and unusual situation.

Keywords: Aging, Autonomy, Advance Directives, Emergency Department, Preemptive Suicide

• Can we rely on the perspective of a patient to trust that a logical decision about preemptive suicide is being made?
• In this case, the family supported the patient’s decision, and thus gave it more credence. When the patient and family disagree, which view should prevail?
• What could the medical team have done prior to providing treatment in order to clarify their patient’s DNR wishes?
• Suicide is currently illegal in the United States. Does the fact that it is illegal mean that it is wrong? Is there an ethical right to suicide, despite the fact that it is illegal?
• Gabbatt, A. (2009). Doctors acted legally in ‘living will’ suicide case. The Guardian. Retrieved from: http://www.theguardian.com/society/2009/oct/01/living-will-suicide-legal
• Tolchin, M. (1989). When long life is too much: suicide rises among elderly. The New York Times. Retrieved from: http://www.nytimes.com/1989/07/19/us/when-long-life-is-too-much-suicide-rises-among-elderly.html?pagewanted=all&src=pm
• Appleby, J. (2014). ‘Prophylactic’ Suicide. The New York Times, Sunday Review. Retrieved from: http://www.nytimes.com/2014/11/16/opinion/sunday/prophylactic-suicide.html

4. Healing the Physician’s Story: A Case of Narrative Medicine and End-of-Life Care

Lori A. Roscoe

Abstract: Telling stories after a loved one’s death helps surviving family members to find meaning in the experience and share perceptions about whether the death was consistent with the deceased person’s values and preferences. Opportunities for physicians to evaluate the experience of a patient’s death and to expose the ethical concerns that care for the dying often raises are rare. Narrative medicine is a theoretical perspective that provides tools to extend the benefits of storytelling and narrative sense–making to physicians. This case study describes narrative writing workshops attended by physicians who care for dying patients. The narratives created revealed the physicians’ concerns about ethics and their emotional connection with patients. This case study demonstrates that even one–time reflective writing workshops might create important opportunities for physicians to evaluate their experiences with dying patients and families.

Keywords: Death and Dying, End–of–Life Issues, Healthcare Professionals, Narrative Inquiry, Stories, Storytelling

• This piece extensively discusses the effects that narrative medicine can have for a practicing physician. What potential effects can it have on the other side of the doctor-patient interaction?
• What does the Japanese physician’s story suggest about the role that culture plays in the doctor-patient experience?
• Is it possible for a physician to be truly empathetic with his or her patients? Why or why not?
• Should medical schools across the country include narrative medicine in their curriculum? Why or why not?
• Chen, PW. (2008). Stories in the Service of Making a Better Doctor. The New York Times. Retrieved from: http://www.nytimes.com/2008/10/24/health/chen10-23.html?pagewanted=all
• Geisler, SL. (2006). The Value of Narrative Ethics to Medicine. The Journal of Physician Assistant Education. Retrieved from: http://www2.paeaonline.org/index.php?ht=action/GetDocumentAction/i/25232

5. The Efficacy of Ethics Discernment in the Organizational Context: The Case of Post-Offer Nicotine Screening

David M. Belde

Abstract: This article examines the efficacy of an ethics discernment process in the organizational context, a practice referred to in the paper as "mission due diligence." This type of ethics discernment is a structured process intended to awaken the ethical concerns that a particular issue raises within moral agents and to give voice, directly and indirectly, to those who will be impacted by, and responsible for, strategic decision-making. The efficacy of this particular ethics discernment practice is contingent upon several realities, including, but not limited to 1) the timing in which it is undertaken, 2) the degree of importance and relevance attributed to it, and 3) the skills of the person leading it. This case report examines how this process was used to highlight and address the ethical issues related to a new hiring policy, namely, a mandatory nicotine screening test for prospective employees in the healthcare context. Framed by the Bon Secours Virginia Health System hiring process, the author explores the importance of diligently focusing on ethical considerations in the organizational realm while still maintaining true to the virtues of the network.

Keywords: Ethics Discernment, Nicotine Screening, Organizational Ethics

• The author says, “Virtually all organizational ethics programs have to grapple with their overall importance and relevance within an organization.” How much authority should an ethics program within a hospital be afforded?
• If an employer can show sufficient empirical results for why a drug test is necessary, is it warranted? Do the sufficient reasons have to be related to the patients’ best interests?
• What are the different ways that Catholicism affects the ethical considerations in this case? What role does religion play in ethical consultations in general?
• Why does the author say balancing advocacy and inquiry are so important?
• Tucker, M & Salazar, L. (2014). Cotinine testing may violate the American with Disabilities Act (ADA), the ADA Amendments Act (ADAAA), and state laws. Wells Fargo Insights. Retrieved from: https://wfis.wellsfargo.com/insights/clientadvisories/pages/cotininetestingmayviolateadaandotherlaws.aspx
• Our Values. Bons Secours Health System. Retrieved from: http://hso.bonsecours.com/about-us-our-mission-our-values.html
• Framework for Ethical Discernment. (2014). The Taylor University Center for Ethics. Retrieved from: http://ethics.taylor.edu/framework-for-ethical-discernment/

6. Can We Talk About Sex?

Mindy B. Statter

Abstract: A three–year–old female undergoes elective inguinal hernia repair and unexpectedly is found to have testes in the hernia sacs. A recommendation is made not to disclose the patient’s genotype to her mother. This case study addresses the ethical conflict of whether to disclose the patient’s male genotype to the parent that has been raising the child as female.

Keywords: Autonomy, Beneficence, Complete Androgen Insensitivity Syndrome, Disclosure, Informed Consent, Intersex, Nonmaleficence

• In what—if any—circumstances is it ethically acceptable to withhold medical information about a child from the primary caretaker?
• Now that disclosure of a CAIS diagnosis is mandatory, what responsibility would a parent potentially have to override a doctor’s recommendations for gender maintenance?
• This case highlights the ethical risks and potential consequences later in life of not disclosing a patient’s CAIS diagnosis and treatment. Conversely, what would the consequences be for disclosing?
• Ignoring the medical precedents set now, do you believe the doctor in this case should have felt remorse for not disclosing the full nature of the girl’s condition to her mother? Would her mother have been equipped to handle that knowledge at that time?
• Dreger, AD. (1998). “Ambiguous Sex”—or Ambivalent Medicine? The Hastings Center Report. Retrieved from: http://www.isna.org/articles/ambivalent_medicine
• Intersex Conditions, Human Diversity Resources. UConn Health Center. http://uchc.libguides.com/humandiversity/intersex
• Georgiann Davis. "Normalizing Intersex: The Transformative Power of Stories." Narrative Inquiry in Bioethics 5.2 (2015): 87-89. Project MUSE. Web. 8 Dec. 2015

7. Should We Tell Annie?: Preparing for Death at the Intersection of Parental Authority and Adolescent Autonomy

Erica K. Salter

Abstract: This case analysis examines the pediatric clinical ethics issues of adolescent autonomy and parental authority in medical decision–making. The case involves a dying adolescent whose parents request that the medical team withhold diagnosis and prognosis information from the patient. The analysis engages two related ethical questions: Should Annie be given information about her medical condition? And, who is the proper decision–maker in Annie’s case? Ultimately, four practical recommendations are offered.

Keywords: Adolescent, Decision-making Capacity, End of Life Care, Mature Minor, Parental Consent

• At what age do teens develop the ability to make autonomous decisions for themselves? What factors unique to adolescence might enhance or detract from this ability?
• What factors should be considered in deciding whether an adolescent should be given decision-making authority? Why?
• Is it ever appropriate for medical practitioners to lie to a child (or actively conceal the truth from a child)? Why or why not?
• Was it appropriate of the new attending doctor to call the palliative care physician? How could that miscommunication have been prevented?
• Hill, JB. (2012). Medical Decision Making by and on Behalf of Adolescents: Reconsidering First Principles. Faculty Publications. Retrieved from: http://scholarlycommons.law.case.edu/cgi/viewcontent.cgi?article=1081&context=faculty_publications
• Leonard, K. (2015). Case Sparks Debate About Teen Decision Making in Health. U.S. News and World Report. Retrieved from: http://www.usnews.com/news/articles/2015/01/22/case-sparks-debate-about-teen-decision-making-in-health

8. A Case of Deceptive Mastectomy

Rebecca Volpe, Maria Baker, George F. Blackall, Gordon Kauffman, Michael J. Green

Abstract: This paper poses the question, “what are providers’ obligations to patients who lie?” This question is explored through the lens of a specific case: a 26–year–old woman who requests prophylactic bilateral mastectomy with reconstruction reports a significant and dramatic family history, but does not want to undergo genetic testing. Using a conversational–style discussion, the case is explored by a breast surgeon, genetic counselor/medical geneticist, clinical psychologist, chair of a hospital ethics committee and director of a clinical ethics consultation service.

Keywords: Clinical Ethics, Deceit, Lying, Provider/Patient Relationship, Providers’ Obligations

• Do you believe that the patient-doctor relationship should be reciprocal? Does the Hippocratic Oath mandate that doctors uphold their duties regardless of patient behavior?
• This case study asks us to consider typical signals that the doctors relied on when initially deciding whether or not to trust the patient. They cite qualities like her attractiveness, her maturity, and her husband’s support in order to explain their initial trust. Should they have been more skeptical in the beginning? Why were they so willing to believe the patient’s story at face value?
• Aside from the guilt that the surgeon himself would likely have felt, what might have been some potential consequences for the ethics team and hospital in general if the surgery had been successfully performed? What if it had gone badly?
• Polta, A. (2014). Lying to the Doctor. Center for Advancing Health, Prepared Patient Blog. Retrieved from: http://www.cfah.org/blog/2014/lying-to-the-doctor
• Ludwig, M & Burke, W. (2013). Physician-Patient Relationship. Ethics in Medicine, University of Washington School of Medicine. Retrieved from: http://depts.washington.edu/bioethx/topics/physpt.html
• Observer Staff. (2000). What Should Plastic Surgeons Do When Crazy Patients Demand Work? Observer. Retrieved from: http://observer.com/2000/07/what-should-plastic-surgeons-do-when-crazy-patients-demand-work/

9. Do Everything

H. Rex Greene

Abstract: A 57–year–old with an incurable cancer suffered an abdominal catastrophe, putting him in the ICU, comatose with no chance of survival. His attending oncologist had only met him once and had no knowledge of his goals of care. Lacking an advance directive the staff turned to his family, who said, “Do everything.” This loaded statement was thought to be a demand for futile care even though it ultimately proved a reflection of their emotional response to a terrible, unanticipated event, not an irrational demand for useless care. A sympathetic exploration of the patient’s goals and expectations with his family using Buckman’s SPIKES format disclosed that their major concern was that he not die on his wife’s birthday. The family agreed to withdraw him from ventilator support the following day. Unraveling a medical conflict requires a sensitive process of shared decision–making based on a transparent process of clinical reasoning that synthesizes patient and family values with medical knowledge and ethical duties. Properly done, the outcome usually is a satisfactory experience for all concerned.

Keywords: Abandonment, Advance directives, Catastrophic Illness, Clinical Reasoning, Conflict Resolution, Decisional Capacity, Do Everything, Futility, Paternalism, Shared Decision Making, SPIKES, Substituted Judgment

• This case explains that responding appropriately to a request to “do everything” requires doctors to ensure that patients’ families “know the medical facts, delivered in a kind, caring fashion.” Sometimes, it can take many meetings over several days for the family to absorb the medical facts. How should decisions be made in the meantime?
• The conclusion of this case seems to reaffirm that emotion is more important than reason when approaching difficult conversations with patients’ families. Should emotion-based education and empathy training be offered in the modern medical school curriculum? Is it even possible to train physicians to be more emotionally intelligent?
• Why is the establishment of the goal of treatment so important to the unity of a patient, their family, and their doctor? What are the barriers to establishing goals of care?
• Baile, WF. et al. (2000). SPIKES—A Six Step Protocol for Delivering Bad News: Application to the Patient with Cancer. The Oncologist. Retrieved from: http://theoncologist.alphamedpress.org/content/5/4/302.full
• Medical Futility. (2007). ACOG Committee Opinion No. 362. American College of Obstetricians and Gynecologists. Obstet Gynecol. Retrieved from: http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Ethics/Medical-Futility
• Enhancing Communication and Coordination of Care. (2013). Cardinal Glennon. Retrieved from: http://www.cardinalglennon.com/Documents/Forms/AllItems.aspx?RootFolder=http%3a%2f%2fwww%2ecardinalglennon%2ecom%2fDocuments%2femergency-medicine&FolderCTID=0x0120000161C93D9B68B34BA6E74A98204CE2A1

10. Responding to the Refusal of Care in the Emergency Department

Jennifer Nelson, Arvind Venkat, Moira Davenport

Abstract: The emergency department (ED) serves as the primary gateway for acute care and the source of health care of last resort. Emergency physicians are commonly expected to rapidly assess and treat patients with a variety of life–threatening conditions. However, patients do refuse recommended therapy, even when the consequences are significant morbidity and even mortality. This raises the ethical dilemma of how emergency physicians and ED staff can rapidly determine whether patient refusal of treatment recommendations is based on intact decision–making capacity and how to respond in an appropriate manner when the declining of necessary care by the patient is lacking a basis in informed judgment. This article presents a case that illustrates the ethical tensions raised by the refusal of life–sustaining care in the ED and how such situations can be approached in an ethically appropriate manner.

Keywords: Decision–making Capacity, Emergency Department, Emergency Physician, Informed Consent, Treatment Refusal

• Does coming to the Emergency Department constitute implied consent to treatment? Why would a patient come to the ED if not to receive potentially life-sustaining treatments at a physician’s recommendation?
• If it is evident that a patient lacks decision-making capacity, is it paternalistic to administer life-saving treatment even if the patient refuses?
• In this case, would it be ethically appropriate for the physicians to consult the patient’s family, in order to bring in one more agent of authority?
• Cooper, S. (2010). Taking No for an Answer—Refusal of Life-Sustaining Treatment. AMA Journal of Ethics/Virtual Mentor. Retrieved from: http://journalofethics.ama-assn.org/2010/06/ccas2-1006.html
• ACEP Code of Ethics for Emergency Physicians. (2008). Retrieved from: https://www.acep.org/Clinical---Practice-Management/Code-of-Ethics-for-Emergency-Physicians/

11. I Don’t Know Why I Called You

Jeffrey S. Farroni, Colleen M. Gallagher

Abstract: This case study details a request from a patient family member who calls our service without an articulated ethical dilemma. The issue that arose involved the conflict between continuing further medical interventions versus transitioning to supportive or palliative care and transferring the patient home. Beyond the resolution of the ethical dilemma, this narrative illustrates an approach to ethics consultation that seeks practical resolution of ethical dilemmas in alignment with patient goals and values. Importantly, the family’s suffering is addressed through a relationship driven, humanistic approach that incorporates elements of compassion, empathy and dialog.

Keywords: End of life, Empathy, Relationships, Clinical Ethics

• How can healthcare providers and ethicists strike a balanced middle-ground between being too detached and too empathetic? Which side of this split should they err on? Why?
• In this case, how did the patient’s family’s expectations influence the decision-making of the ethicist and the doctors?
• How can an ethicist’s varied background bring new knowledge and insight to a collaborative ethical deliberation?
• Shelton, WN & White, BD. (2015). Realistic Goals and Expectations for Clinical Ethics Consultations: We Should Not Overstate What We Can Deliver. The American Journal of Bioethics. Retrieved from: http://www.tandfonline.com/doi/pdf/10.1080/15265161.2014.974773
• American Society for Bioethics and Humanities Clinical Ethics Task Force. Improving Competence in Clinical Ethics Consultation: A Learner’s Guide. Retrieved from: http://www-3.unipv.it/centrodibioetica/resources/Improving_Competence_in_Ethics.pdf

12. Undocumented and at the End of Life

Annette Mendola

Abstract: Three of the most contentious issues in contemporary American society—allocation of medical resources, end of life care, and immigration—converge when undocumented immigrant patients are facing the terminal phase of chronic illness. The lack of consistent, pragmatic policy in each of these spheres leaves us with little guidance for how to advocate for undocumented patients at the end of life. Limited resources and growing need compound the problem. Care for patients in this unfortunate situation should be grounded in clinical and economic reality as well as respect for the dignity of the individual to avoid exacerbating inequalities.

Keywords: Allocation of Resources, Dialysis, ESRD, End–of–Life Care, Undocumented Patients

• How does Henri’s lack of citizenship or permanent residence in the United States limit not only his access to, but his knowledge of, the full range of medical options available to him? Does this make him vulnerable, and therefore deserving of increased protections, in a way that other patients are not?
• Was it Henri’s right to refuse hospice, considering the lack of other options available? Why or why not?
• Should the ethics consulting team have made more of an effort to communicate to Henri that Lucia was no longer willing to be his caregiver? Why would this matter?
• Is a partial treatment of a severely ill patient worth the effort, or just a waste of time and resources? What is the apparent stance of the ethics committee on this question?
• Kimball, C. “End-of-Life Health Care Disparity: A Case Study”. Nursing Economics. Retrieved from: https://www.nursingeconomics.net/necfiles/news/End-Of-Life_Care_Kimball.pdf
• Ortega, AM. (2014). “Stay or Go? Terminally Ill Undocumented Immigrants Face Dilemma”. New America Media. Retrieved from: http://newamericamedia.org/2014/01/undocumented-and-dying-latinos-may-find-comfort-in-final-journey-home.php

13. Dax’s Case Redux: When Comes the End of the Day?

Ashley R. Hurst, Dea Mahanes, Mary Faith Marshall

Abstract: Forty years after Dax Cowart fought to have his voice heard regarding his medical treatment, patient autonomy and rights are at the heart of patient care today. Yet, despite its centrality in patient care, the tension between a severely burned patient’s right to stop treatment and the physician’s role in saving a life has not abated. As this case study explores, barriers remain to hearing and respecting a patient’s treatment decisions. Dismantling these barriers involves dispelling the myths that burn patients must grin and bear intense pain to recover and that a patient’s choice to discontinue treatment equals physician failure. Moreover, in these situations, sustained, direct engagement between physician and patient can reduce the moral distress of all involved and enable physicians to hear and better accept when a patient is calling for the end of the day.

Keywords: Dax Cowart, Ethics Consultation, Moral Distress, Palliative Care, Patient Autonomy

• Communication between a patient and his or her care team is crucial in cases like this. Why did the avenues of communication break down in this piece? What could have been done to improve the relationship between the patient and the medical team?
• What obligation did the physicians have to be visiting the patient and witnessing the implications of his wound care? If their behavior had been different, how might that have changed the course of treatment for the patient?
• Was the sheer number of people in the room for the patient’s first consult coercive? What could have been done differently to understand both the patient’s wishes and the team’s perspective earlier in the process?
• Does the possibility of a high quality of life post-treatment warrant or justify doctors’ prescribing painful treatment over a patient’s objections?
• “Dax’s Case” preview. (1984). Retrieved from: http://search.alexanderstreet.com/view/work/1630976
• Kavan, MG, Elsasser, GN, Barone, EJ. (2012). The Physician’s Role in Managing Acute Stress Disorder. Am Fam Physician. Retrieved from: http://www.aafp.org/afp/2012/1001/p643.html
• Requests to Die: Non-Terminal Patients. Mhhe. Retrieved from: http://novella.mhhe.com/sites/dl/free/0078038456/1037408/Pen38456_Ch02.pdf

14. Desperately Seeking a Surrogate— For a Patient Lacking Decision-Making Capacity

Martin L. Smith, Catherine L. Luck

Abstract: Our hospital’s policy and procedures for “Patients Without Surrogates” provides for gradated safeguards for managing patients’ treatment and care when they lack decision–making capacity, have no advance directives, and no surrogate decision makers are available. The safeguards increase as clinical decisions become more significant and have greater consequences for the patient. The policy also directs social workers to engage in “rigorous efforts” to search for surrogates who can potentially provide substituted judgments for such patients. We describe and illustrate the policy, procedures, and kinds of expected rigorous efforts through our narration of an actual but disguised case for which we provided clinical ethics guidance and social work expertise. Our experience with and reflection on this case resulted in four recommendations we make for health care facilities and organizations that aim to provide quality care for their own patients without surrogates.

Keywords: Clinical Ethics, Decision–Making Capacity, End–of–Life Decisions, Ethics Committee, Ethics Consultation Service, Patients Without Surrogates, Rigorous Efforts, Social Work, Surrogate Decision Maker, Unbefriended Patient, Unrepresented Patient

• While this author cautions against using social media to determine a surrogate, do you think it could be a reliable method of determining a close relationship?
• Does your state allow non-family members to serve in the role of surrogate decision-maker?
• If there had been sufficient grounds for Sally to be Jacob’s surrogate, do you think she would have come to the same conclusions as Jacob’s brother? Could the process have been expedited, and yet be just as reliable?
• Stanford Hospitals and Clinics. (2009). Health Care Decisions for Patients Who Lack Capacity and Lack Surrogates. Retrieved from: http://www.thaddeuspope.com/images/Stanford_Health_Care_Decisions_For_Patients_Who_Lack_Capacity_and_Surrogates_7_09.pdf
• Varma, S & Wendler, D. (2007). “Medical Decision Making for Patients Without Surrogates”. Arch Intern Med. Retrieved from: http://ogg.osu.edu/site_documents/sage/course3/wk8_varma.pdf

15. What to Say When: Responding to a Suicide Attempt in the Acute Care Setting

Arvind Venkat, Jonathan Drori

Abstract: Attempted suicide represents a personal tragedy for the patient and their loved ones and can be a challenge for acute care physicians. Medical professionals generally view it as their obligation to aggressively treat patients who are critically ill after a suicide attempt, on the presumption that a suicidal patient lacks decision making capacity from severe psychiatric impairment. However, physicians may be confronted by deliberative patient statements, advanced directives or surrogate decision makers who urge the withholding or withdrawal of life sustaining treatments based on the patient’s underlying medical condition or life experience. How acute care providers weigh these expressions of patient wishes versus their own views of beneficence, non–maleficence and professional integrity poses a significant ethical challenge. This article presents a case that exemplifies the medical and ethical tensions that can arise in treating a patient following a suicide attempt and how to approach their resolution.

Keywords: Advanced Directives, Critical Care, Life–sustaining Treatment, Suicide, Surrogate Decision Maker

• Can suicide ever be a rational, autonomous decision? Why or why not?
• How can patient/family relationships pose a challenge for doctors trying to establish the best course of action for a patient?
• How did the family’s perspective affect the patients’ treatment in this case? Was the outcome of their input positive or negative?
• In the absence of both a clear patient advance directive and familial knowledge of patient preferences, how should medical decisions be made? What did the doctors do in this case?

Web resources:

• Carrigan, CG & Lynch, DJ. (2003). Managing Suicide Attempts: Guidelines for the Primary Care Physician. Primary Care Comparnion to The Journal of Clinical Psychiatry. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC419387/
• Sokol, D et al. (2011). Ethical dilemmas in the acute setting: a framework for clinicians. BMJ. Retrieved from: http://www.medicalethicist.net/documents/Tattoo%20BMJ%20PDF.pdf
• Forster, PL & Wu, LH. Assessment and Treatment of Suicidal Patients in an Emergency Setting. Gateway Psychiatric Services. Retrieved from: https://www.gatewaypsychiatric.com/pdf/Assessment%20and%20Treatment%20of%20Suicidal%20Patients%20in%20an%20Emergency%20Setting.pdf

16. Conversation and the Jehovah’s Witness Dying From Blood Loss

D. Malcolm Shaner, Jateen Prema

Abstract: Religious belief can complicate the usual management of seriously ill patients when the patient is a Jehovah’s Witness and the treatment is a blood transfusion. This narrative highlights critical points in a discussion of two cases wherein the process to promote an exercise of free will also becomes an exercise for the ethics consultant and healthcare team. Despite a medical care program’s carefully considered additions to an electronic healthcare record, additional conversation, investigation, preparation, and an open mind are required. Helping conflicted family members and considering whether and in what context to contact the Jehovah’s Witness Hospital Liaison Committee complicates the approach.

Keywords: Blood Transfusion, Jehovah’s Witness, Religious Rights

• Consider the differences between the two cases with regard to how the hospital handled the patient requests. What did the hospital do well, and what could it have improved?
• In Case 1, what was the effect of attempting the surgery once the patient had changed his mind? How did that change influence the perspective of both the doctors and the patient’s mother?
• In Case 1, was the medical officer’s frankness with the patient appropriate, taking into consideration the beliefs that the patient already expressed?
• How did the doctors in Case 2 actively facilitate moral decision making on the part of the patient?
• Panico, ML et al. (2011). “When a Patient Refuses Life Saving Care”. Am J Kidney Dis. Retrieved from: http://www.medscape.com/viewarticle/751273
• Robinson, BA. (2010). “Jehovah’s Witnesses’ (WTS) opposition to blood transfusions”. Ontario Consultants on Religious Tolerance. Retrieved from: http://www.religioustolerance.org/witness11.htm

17. Caregivers’ Role in Maternal-Fetal Conflict

Abstract: The case, which occurred in a public hospital in Turkey in 2005, exhibits a striking dilemma between a mother’s and her fetus’ interests. For a number of reasons, the mother refused to cooperate with the midwives and obstetrician in the process of giving birth, and wanted to leave the hospital. The care providers evaluated the case as a matter of maternal autonomy and asked the mother to give her consent to be discharged from the hospital, which she did despite the fact that her cervix was fully open. She left the hospital and gave birth shortly thereafter. Subsequently, the baby died two days later. In light of contemporary ethical principles, the mother’s competency could be debatable due to the physical and psychological conditions the mother confronted. Furthermore, protection of the fetus’ life should have been taken into account by the caregivers when making a decision concerning discharging of the mother.

Keywords: Ability to Consent, Autonomy, Beneficence, Decision Making Capacity, Ethical Dilemma, Fetal Beneficence, Fetal Rights, Maternal Autonomy, Maternal–Fetal Conflict, Pregnancy

• Did the mother have the right to demand to leave? Would your answer to this question change if discharging the mother endangered the fetus? Why or why not?
• Was the mother in a position to make an autonomous choice? Other than autonomous patient decision-making, are there models of decision-making that might have been considered in this case? How might they be applied?
• How could the care team have done better? Should a hospital have policies to help prevent or address such a situation? If so, what would these policies look like?
• Schetter, CD & Tanner, L. (2012). Anxiety, depression, and stress in pregnancy: Implication for mothers, children, research, and practice. Current Opinion in Psychiatry. Retrieved from: http://health.psych.ucla.edu/CDS/documents/DunkelSchetterTanner-2012COPsychiatry.pdf
• Post, LF. (1996). Bioethical Consideration of Maternal-Fetal Issues. Fordham Urban Law Journal. Retrieved from: http://ir.lawnet.fordham.edu/cgi/viewcontent.cgi?article=2171&context=ulj

18. The Surgeon as Stakeholder: Making the Case Not to Operate

Abstract: Surgeons are in a unique position, serving as gatekeepers to the operating room. They determine if operations are possible, are indicated, and have a reasonable risk–to–benefit profile. When an operation is indicated and the patient is amenable to it, the conversation between surgeon and patient is usually straightforward. On the other hand, when a patient’s co–morbidities substantially increase the risk of operative intervention, surgeons often question the utility of offering their services. These situations become immensely more difficult when patients have the expectation of being offered surgical treatment. This case describes the clinical encounter between an endocrine surgeon and an 83–year–old woman who has been incidentally found to have adrenal metastasis from melanoma. The patient wants an operation that the surgeon is reluctant to offer because of her frailty and high operative risk. The case focuses on the ethical dilemma that arises when a patient wants an operation that a surgeon does not want to perform.

Keywords: Metastatic Melanoma, Palliative Care, Respect for Autonomy, Shared Decision–Making, Surgical Ethics

• What reasons are acceptable for refusing to operate on a patient? Why?
• How should surgeons approach situations in which they are consulted for operative interventions that they do not want to provide?
• When surgeons think the risk of surgery is too great and not justified but patients think the risks are worthwhile, whose assessment should prevail? Why?
• Louden, K. (2015).“Risk Calculator Does Not Alter Surgeons’ Choice to Operate". Medscape. Retrieved from: http://www.medscape.com/viewarticle/852708
• Kasman, DL. (2004).“When is Medical Treatment Futile?: A Guide for Students, Residents, and Physicians." Journal of General Internal Medicine. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1492577/

19. The Enduring Case

Craig M. Nelson

Abstract: In clinical ethics an enduring case takes on a life of its own and comes to closure over a long period of time. This essay describes the evolution of such a case over a 1–year period. The case involves a 90–year old male patient with multiple chronic medical conditions who lacked decision–making capacity, was a resident of a long–term care facility, and did not have known previously expressed wishes regarding medical treatment. The ethics consultation initially revolved around this question: What method or process must be employed so that medical treatment decisions could be ethically reviewed and could include a shared decision–making process for Mr. Smith? This case analysis describes the evolution of this case and argues that the good of the patient must remain paramount throughout an enduring case.

Keywords: Ethical Appropriateness, Ethical Process, Moral Community, Treatment Planning

• What kinds of processes might help an incapacitated patient’s voice be heard, especially when the patient’s values were never formally documented?
• Why might it be important to try to give voice to an incapacitated patient’s values?
• What went well with the process in this clinical ethics consultation? Might there be opportunities for improving the processes deployed in this case, and if so, what might they be?
• Ten Myths About Decision-Making Capacity: A Report by the Natioanl Ethics Committee Of the Veterans Health Administration. (2002). Retrieved from: http://www.ethics.va.gov/docs/necrpts/nec_report_20020201_ten_myths_about_dmc.pdf
• California Advance Health Care Directive Probate Code Section 4701. Retrieved from: https://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=PROB&division=4.7.&title=&part=2.&chapter=2.&article=

20. Military Health Care Dilemmas and Genetic Discrimination: A Family’s Experience with Whole Exome Sequencing

Benjamin M. Helm, Katherine Langley, Brooke B. Spangler, Samantha A. Schrier Vergano

Abstract: Whole–exome sequencing (WES) has increased our ability to analyze large parts of the human genome, bringing with it a plethora of ethical, legal, and social implications. A topic dominating discussion of WES is identification of “secondary findings" (SFs), defined as the identification of risk in an asymptomatic individual unrelated to the indication for the test. SFs can have considerable psychosocial impact on patients and families, and patients with an SF may have concerns regarding genomic privacy and genetic discrimination. The Genetic Information Nondiscrimination Act of 2008 (GINA) currently excludes protections for members of the military. This may cause concern in military members and families regarding genetic discrimination when considering genetic testing. In this report, we discuss a case involving a patient and family in which a secondary finding was discovered by WES. The family members have careers in the U.S. military, and a risk–predisposing condition could negatively affect employment. While beneficial medical management changes were made, the information placed exceptional stress on the family, who were forced to navigate career–sensitive “extra–medical" issues, to consider the impacts of uncovering risk–predisposition, and to manage the privacy of their genetic information. We highlight how information obtained from WES may collide with these issues and emphasize the importance of genetic counseling for anyone undergoing WES.

Keywords: Genetic Discrimination, Genetic Information Nondiscrimination Act of 2008 (GINA), Genetic Testing, Incidental Findings, Military, Secondary Findings

• It is clear that this type of genetic testing is revolutionizing diagnoses, but it comes with ethical concerns. Do the advantages of WES outweigh the possible disadvantages? Why or why not?
• Do you agree that pre–test conversations should be required in every scenario? Why or why not?
• When the SCN5A gene mutation was found, should the father have told his superiors? Why or why not?
• The SCN5A mutation is probabilistic–not all individuals who have the mutation will develop symptoms. However for some patients, the only presenting feature is sudden cardiac death. What are some reasons patients might have for—and against—wanting this information?
• National Human Genome Research Institute. (2014a). Fact sheet: Genetic discrimination. Retrieved from: http://www.genome.gov/10002077
• Majewski, J. et al., (2011). What Can Exome Sequencing Do For You? Journal of Medical Genetics. Retrieved from: http://www.medscape.com/viewarticle/749695_1
• Collins, F. (2007). The threat of genetic discrimination to the promise of personality medicine. Testimony to the United States House of Representatives Committee on Ways and Means. Retrieved from: http://waysandmeans.house.gov/Media/pdf/110/3-14-07/CollinsTestimony.pdf

21. Conflicting Values: A Case Study in Patient Choice and Caregiver Perspectives

Margot Eves, Phoebe Day Danziger, Ruth M. Farrell, Cristie M. Cole

Abstract: Decisions related to births in the “gray zone" of periviability are particularly challenging. Despite published management guidelines, clinicians and families struggle to negotiate care management plans. Stakeholders must reconcile conflicting values in the context of evolving circumstances with a high degree of uncertainty within a short time period. Even skilled clinicians may struggle to guide the patient in making value–laden decisions without imposing their own values. Exploring the experiences of one pregnant woman and her caregivers, this case study highlights how bias may undermine caregivers’ ability to meet their obligation to enhance patient autonomy and the moral distress they may experience when a patient’s values do not align with their own. Management strategies to mitigate the potential impact of bias and related moral distress are identified. The authors then describe one management strategy used in this case, facilitated ethics consultation, which is focused on thoughtful consideration of the patient’s perspective.

Keywords: Bias, Ethics Consultation, “Gray Zone", Moral Distress, Perspective–Taking

• How can we distinguish between concerns that reflect bias versus concerns that reflect legitimate differences in values?
• Does it matter if a patient’s choices reflect bias, or do patients have the right to have their decisions respected even if they are based on potentially unsubstantiated biases or beliefs?
• Given the controversial nature of the patient’s viewpoint regarding life with disabilities, did the providers have an obligation to try to mitigate the patient’s bias? Why or why not?
• What are some of the ways that the providers could have tried to address the patient’s biases regarding life with a disability? For example, should the patient have been offered the opportunity to speak to parents of children with disabilities, specifically those disabilities more likely to be a result of complications from prematurity? Would it be ethically permissible to require that she do so?
• Are there other, more effective ways to support professionals who take care of patients whose values and choices differ so significantly from their own?
• Lyerly, AD. (2008). Reframing neutral counseling. Virtual Mentor. Retrieved from: http://virtualmentor.ama–assn.org/2008/10/ccas3–0810.html
• Guttmacher Institute. (2015). State policies in brief: An overview of abortion laws. New York: Guttmacher Institute. Retrieved from: http://www.guttmacher.org/statecenter/spibs/spib_OAL.pdf

22. Ethical Dilemmas Relating to the Management of a Newborn with Down Syndrome and Severe Congenital Heart Disease in a Resource-Poor Setting

Ama K. Edwin, Frank Edwin, Summer J. McGee

Abstract: Decision-making regarding treatment for newborns with disabilities in resource-poor settings is a diffi cult process that can put parents and caregivers in confl ict. Despite several guidelines that have helped to clarify some of the medical decision-making in Ghana, there is still no clear consensus on the specifi c moral criteria to be used. This article presents the case of a mother who expressed her wish that her child with Down syndrome should not have been resuscitated at birth. It explores the ethical issues at stake in both her misgivings about the resuscitation and her unwillingness to consider surgical repair of an atrioventricular (AV) canal defect. Knowing that children born with Down syndrome are able to pursue life’s goals, should our treatment of complete AV canal defect in such children be considered morally obligatory, even in resource-poor settings like Ghana?

Keywords: Atrioventricular Septal Defect, Down Syndrome, Ethical Duty, Newborn, Withholding Treatment

• What is the difference between a substantiated concern and one that reflects bias? How can providers assess the difference?
• The mother’s views about the relative lack of value of a person with disabilities are controversial and seem to reflect an unfair or unfounded bias. In light of this, did the provider have an obligation to try to address the mother’s bias?
• If health care providers had an obligation to try to mitigate or address the mother’s bias, how should they have attempted to do so? Should the mother have been required to speak to other parents of children with disabilities?

23. System Failure: No Surgeon To Be Found

Carol Bayley

Abstract: A woman admitted to the emergency room of a hospital died because no surgeon could be found to stop the bleeding from injuries she sustained in a farming accident. The case points to ethical shortcomings both institutionally and professionally. The call system is inadequate, and physician fears of being sued or insufficiently compensated contribute to the overall problem. Potential responses include the institutional equivalent of a root cause analysis and an understanding of the pressures brought to bear on physicians to treat emergencies.

Keywords: Emergency Call, Institutional Ethics, John Glaser, Organizational Ethics, Root Cause Analysis

• Do you think a physician has an ethical obligation to try to help a patient who will otherwise die, even when the patient’s problem is not within the physician’s specialty? If so, how do you ground this obligation? If not, why not?
• If physicians have such an obligation, what ought they to do when they face barriers to fulfilling it?
• People often see themselves in the best light; it’s very human to see one’s self favorably, and to try to explain away one’s own responsibility when an error occurs. In light of this natural tendency, what structures could be set into place to help physicians and other stakeholders take responsibility in these types of situations?

24. A Life Below the Threshold?: Examining Conflict Between Ethical Principles and Parental Values in Neonatal Treatment Decision Making

Thomas V. Cunningham

Abstract: Three common ethical principles for establishing the limits of parental authority in pediatric treatment decision–making are the harm principle, the principle of best interest, and the threshold view. This paper considers how these principles apply to a case of a premature neonate with multiple significant co-morbidities whose mother wanted all possible treatments, and whose health care providers wondered whether it would be ethically permissible to allow him to die comfortably despite her wishes. Whether and how these principles help in understanding what was morally right for the child is questioned. The paper concludes that the principles were of some value in understanding the moral geography of the case; however, this case reveals that common bioethical principles for medical decision–making are problematically value-laden because they are inconsistent with the widespread moral value of medical vitalism.

Keywords: Harm Principle, Best Interests, Threshold View, Neonatal Decision Making, Values, Medical Vitalism

• How should the ethicist think through the relationship between apparently competing bioethical views in particular clinical circumstances?
• Should there be a competency evaluation for parents, guardians, surrogates, or other proxy medical decision makers?
• Should society develop policies to limit health care in circumstances where there is an appreciable likelihood of extremely poor outcomes?

25. Ethical Challenges in the Care of the Inpatient with Morbid Obesity

Paul L. Schneider, Zhaoping Li

Abstract: Objective: To provide a thorough analysis of the range of ethical concerns that may present in relation to the care of the morbidly obese inpatient over the course of several years of care. Methods: A narrative of the patient’s complex medical care is given, with particular attention to the recommendations of three separate ethics committee consultations that were sought by his health care providers. An ethical analysis of the relevant issues is given within the Principles of Biomedical Ethics framework, highlighting the principles of autonomy, beneficence, non–maleficence, and justice. Results: The case study presents a patient with morbid obesity, obesity hypoventilation syndrome, and numerous ICU admissions. The first ethics consultation was requested regarding the permissibility of forcing bariatric surgery on him against his will. The second consultation was regarding a request by nursing staff to no longer attempt to mobilize him. The third was regarding the patient’s refusal to be discharged. Conclusions and Recommendations: The care of inpatients with morbid obesity presents a unique set of practical and ethical challenges to health care personnel. A disciplined approach to ethical analysis using the Principles of Biomedical Ethics framework may be helpful in dealing with these challenges. Recommendations for improvement are made for the individual and local settings, as well as nationally.

Keywords: Autonomy, Beneficence, Ethics, Justice, Morbid Obesity, Non–Maleficence, Paternalism, Professionalism

• Sometimes in health care there is a mismatch between a units’ ideal admission criteria and the actual patients admitted. Is it appropriate to try to help health care workers feel more comfortable with patients who are not ideal in some way? If so, are there limits to this approach?
• A “hard paternalism” approach in this case might have involved placing this patient on a locked unit so that he could not have restaurant deliveries. Given his dire clinical circumstances, could this have been ethically supported?
• Do you agree that providers were overly reliant on the principle of autonomy in allowing this patient to be poorly compliant with dietary therapy in the on–campus nursing home? If not, can you suggest alternate rationales?

26. The Clinical Bioethicist’s Role: Should We Aim to Relieve Suffering?

Deborah L. Kasman

Abstract: Bioethics consultants arrive at their profession from a variety of prior experiences (e.g., as physicians, nurses, or social workers), yet all clarify ethical issues in the care of patients. The integrated bioethicist’s role often extends beyond case consultations. This case presents a young person suffering a prolonged and gruesome end–of–life journey, which raised questions regarding the bioethicist’s role in alleviating suffering as part of the health care team. The case is used to illuminate forms of suffering experienced by patients, families, and health care providers. The question arises as to whether it is in the ethicist’s jurisdiction to alleviate suffering, and if the answer is “yes,” then whose suffering should be addressed? The discussion addresses one approach taken by an integrated bioethicist toward promoting delivery of ethical and compassionate care to the patient.

Keywords: Clinical Ethics Consultation, Healing, Meaning in Death, Provider Well–Being, Suffering

• Is relief of suffering part of a clinical ethics consultation? Should it be? Why or why not?
• How do you respond to suffering? What are your most productive responses? Unproductive responses?
• Should a clinical ethicist be involved in clinical care without maintaining direct patient contact? If patients/families refuse ethics involvement, what role can the clinical ethicist play in promoting ethical medical decision–making?
• When a clinical ethicist is also trained as a licensed health provider (e.g., physician, nurse, chaplain, or social worker), can prior clinical experience affect the ethicist’s role in responding to suffering? Can this be an advantage, a hindrance, or both?

27. To Enroll or Not to Enroll?: A Researcher Struggles with the Decision to Involve Study Participants in a Clinical Trial That Could Save Their Lives

Roberto Abadie

Abstract: Hundreds of thousands of clinical trials are conducted annually around the world, working to further scientific knowledge and expand medical treatment. At the same time, clinical trials also present novel challenges to researchers who have access to large pools of research participants and are routinely approached by pharmaceutical companies seeking to recruit subjects for clinical trials. This case study discusses the ethical dilemmas faced by a community health investigator who received an invitation to enroll people who inject drugs (PWID) into a clinical trial of a drug that promised a new treatment option for Hepatitis C. The author elaborates on the ethical tensions that he confronted between “doing good” and “avoiding harm. The paper suggests that issues of distributive justice should also be considered, particularly when the drugs being tested might eventually command prices that place them out of reach of the population enrolled in the trial. This case does not attempt to provide an ethical road map to assist researchers in similar circumstances, but rather to illustrate some of the considerations involved in making a decision about whether or not to participate in clinical trials research.

Keywords: Beneficence, Clinical Trials, Enrollment, Justice, Non-Maleficence

• Since they were originally formulated a few decades ago, the principle of respect for autonomy seems to have gained priority in detriment of the principle of justice. With drug prices reaching exorbitant levels—more than eighty thousand dollars for a full HCV treatment—placing access beyond the reach of many, shouldn’t bioethicists reconsider the way we think about justice?
• The principle of beneficence establishes the requirement of a social good, as one of if its main criteria. But drug prices seem to benefit the pharmaceutical industry while depriving many of much needed drugs. With this in mind, how do you think we should interpret this principle?
• Imagine you or somebody you know has the opportunity to participate in a clinical trial. What elements would you need in order to make an informed decision? And an ethical one?

28. Sometimes Those Hoofbeats Are Zebras: A Narrative Analysis

Abstract: The case of BB, an 11-year-old girl who was hospitalized because of sudden odd seizure-like symptoms and catatonic affect, highlights several ethical issues and communication problems. The correct diagnosis was initially missed, partly because physicians are trained to think of the most common explanation for a patient’s symptoms; the medical education truism “when you hear hoofbeats, think horses, not zebras” was not helpful in BB’s case. The common habit of medical professionals to not revisit a diagnosis once one is established also led to missed opportunities to provide appropriate care for this young patient. The difficulty nurses and/or family members have in questioning a diagnosis and treatment plan are also discussed.

Keywords: Clinical Ethics, Ethical Focus, Case Study, Communication, Medical Error, Moral Distress, Two-Challenge Rule

• Hospitals are generally reluctant to admit patients known to have problematic behavior or unknown diagnoses, yet in this case, having a new physician on her case was the key to making an accurate diagnosis. How might transfers between medical facilities be reimagined to improve patient care, rather than being seen as “dumping” of undesirable problematic patients and families?
• What interventions or changes in protocol might empower nurses and family members to productively question a physician’s diagnosis and treatment plan for a patient?

29. A Jehovah’s Witness Adolescent in the Labor and Delivery Unit: Should Patient and Parental Refusals of Blood Transfusions for Adolescents Be Honored?

Johan Christiaan Bester, Martin Smith, Cynthia Griggins

Abstract: A 15-year-old was admitted to the labor and delivery unit for induction of a 41-week-gestation pregnancy. Her parents, members of Jehovah’s Witnesses, and the patient, who had been studying the religion but had not yet been baptized, were adamant that no blood transfusions would be accepted even if a life-threatening hemorrhage were to occur. In our analysis, we examine the underlying ethical conflict and issues raised by this case. We considered two important ethical questions in analyzing the dilemma: first, whether adolescents are capable of providing autonomous and authentic refusals for lifesaving interventions; and second, whether parents can refuse such interventions for their adolescent children based on their religious beliefs. We provided justifications for not considering the adolescent’s refusal as autonomous and for overruling the parental refusal, concluding that there was ethical support for providing potentially lifesaving transfusions should they become clinically indicated. We also suggested strategies to avoid blood loss and the need for transfusions in order to respect the stated values and preferences of the patient and her family to the greatest degree possible. In order to protect the privacy of the patient and her family, details in this case have been changed and no identifiable information has been used.

Keywords: Best Interests, Blood Transfusions, Jehovah’s Witnesses, Principlism, Religious Conflict

• The authors have defended a principle that it should generally be presumed that adolescents lack the necessary decision–making capacity to provide autonomous refusals for life–saving treatments, unless convincing evidence to rebut this presumptionis present. Do you agree with this principle, and if so, why? What would count as convincing evidence? If not, what reasons can you provide for dismissing this principle?
• In the article a threshold is described for parental decision–making. Beyond that threshold, it is the duty of clinicians to challenge the parental decision, and the duty of the state to overrule the parental decision. Do you agree that the threshold to overrule parental decision–making was reached in this case? Why or why not? What might have changed your view?
• Different jurisdictions have reached different conclusions in cases regarding the authority of adolescents to refuse life–saving treatments. States also have different stances on the “mature minor” rule. How does the neurodevelopment and cognitive development evidence the authors briefly discuss in the article influence your thinking on these issues, and specifically on whether states should have a “mature minor” rule and how they should interpret and apply it?

30. Reframing Medical Appropriateness: A Case Study Concerning the Use of Life-Sustaining Technologies for a Patient With Profoundly Diminished Quality of Life

Colleen M. Gallagher, Elijah Weber, Nisha Rathi

Abstract: This case study considers the clinical ethics issues of medical appropriateness and quality of life for patients who are critically ill. The case involves a terminally ill cancer patient with a profoundly diminished quality of life and an extremely poor prognosis; his spouse desires to bring him home, where she will arrange to keep him alive for as long as possible via life-sustaining interventions. The analysis engages with the complicated notion of medical appropriateness, both in general and as it pertains to life-sustaining interventions in a critical care setting, and considers the ethical implications of the various ways in which one might understand this concept. It also addresses the significance of quality-of-life determinations, emphasizing the role of individualized values in determining the importance of quality of life for clinical decision-making. The discussion concludes with a description of the two strategies employed by the ethics team in helping to alleviate the medical team’s concerns about this case.

Keywords: Case Study, Method, Clinical Ethics Focus

• Is the goal of keeping a terminally ill patient, with a profoundly diminished quality of life, alive for as long as possible via life-sustaining technologies a medically appropriate goal of care?
• Is “medical appropriateness” a useful term for conducting an ethical analysis of a particular case?
• What is the ethical significance of a profoundly diminished quality of life for determining goals of care for a particular patient?
• Do quality of life considerations ever outweigh patient or surrogate decision-maker preferences regarding the ethical justifiability of continuing with life-sustaining interventions?

31. "We Didn't Consent to This"

Shalini Dalal, Jessica A. Moore, Colleen M. Gallagher

Abstract: Patients and their families have identified the need for ongoing and effective communication as one of the important aspects of medical care, especially when the cessation of disease–modifying therapies is being considered at the end–of–life (EOL). Despite recognizing that this communication is extremely important, clinicians are uneasy and find themselves inadequately trained to “break bad news” and manage emotional responses from the patient/family. The inherent difficulties in accurately predicting prognosis and discussing potential complications make these conversations even more challenging. In most circumstances, patients and their families want to know the truth about their disease and what will be done to make them feel better, and to receive enough information to help them choose a course of action. For many terminally ill patients and their families who have elected to transfer to the palliative care unit (PCU) for EOL care, the assumption is that most of these conversations have already been held, and the ongoing focus becomes managing these patients’ physical and psychological sources of distress, validating their and their families’ emotional responses and preparing them for what is to come. This case report illustrates the need for cultural understanding and clear communication among physicians, members of the clinical team, and patients and their family members.

Keywords: Communication, Cultural Competence, End–of–Life, Palliative Care

• What can/should one do to determine if communication of a poor prognosis has been provided in a manner and to the extent that the patient or surrogate decision–maker wants and allows him/her to make a fully informed decision? How can one go about exploring the extent of patient/family understanding and goals/expectations? What would you do if you discovered that the poor prognosis has not been explained in enough detail to facilitate informed decision–making?
• What resources are available in your institution to help health care providers improve upon their cultural competence with the patient populations seen most often in your area? What resources are available to assist in the care, real–time, of patients from various faith traditions and cultures in your hospital?
• Have you experienced a situation similar to the one presented here? What did you do in that case or would you do in future cases to improve communication and outcomes? Is this a personal practice, or has it been implemented as a “standard practice/ process” in your group, when applicable?

32. "Screen Shots: When Patients and Families Publish Negative Health Care Narratives Online"

Marleen Eijkholt, Jane Jankowski, Marilyn Fisher

Abstract: Social media sites and their relationship to health care is a subject of intense debate. Common discussions regarding social media address patient privacy, or e-professionalism. This case study explores the tensions that arise for health care providers when negative patient statements surface in social media and blog forums. Recognizing that patients and families often find relief in sharing personal illness narratives, we contemplate if, and how, individual health care professionals and institutions should address complaints aired in public, unmoderated media. Our discussion begins by presenting a case of a family blogging on the Internet to share grievances (to deidentify the case, we have changed some details). Next, we offer an exploration of the impact on health care delivery when professionals become aware of specific criticisms published online. Strategies for managing electronic criticisms are then proposed. We conclude by proposing a novel E-THICS approach to address negative patient expressions via electronic word of mouth (eWOM). Our examination of this evolving issue focuses on maintaining satisfactory relationships between health care providers and patients/families when dealing with health care narratives published in open online media.

Keywords: Care-Ethics, Ethics, Internet, Negative Comments, Online, Patient Blogs, Social Media

• What strategies does your institution offer to deal with publicly displayed negative comments from patients?
• To what extent should institutional support be offered to HCPs in interacting with negative eWOM?
• Should providers communicate their distress to a patient (or to family members) about negative expressions in narrative formats, and if so, how can this be done?

33. "A Personal Narrative on Living and Dealing with Psychiatric Symptoms after DBS Surgery"

Frédéricand Gilbert, John Noel M. Viaña

Abstract: Although deep brain stimulation (DBS) may result in dramatic motor improvement in people with Parkinson's disease (PD), it has been correlated with a number of postoperative psychiatric side effects. We report a case of a person with PD experiencing depression and hypomania following DBS surgery. We provide a detailed report of the patient's personal experiences dealing with and managing these psychiatric side effects for three years. Providing a personal narrative focusing on detailed patient subjective experiences complements reports that give insight into the short- and long-term effects of DBS on established psychiatric measures and neurologic activity. But, most importantly, such a qualitative approach provides prospective patients and clinicians with a broader ethical picture of real-life challenges faced and coping strategies employed by PD patients treated with DBS who are experiencing psychiatric adverse events. This case study reinforces the ethical need to disclose the potential risk of harm to prospective patients as well as the importance of establishing a multidisciplinary postoperative supportive group.

Keywords: Deep Brain Stimulation, Identity, Neuropsychiatric Effects, Parkinson's Disease, Self, Side Effects

• What obligations do DBS providers and researchers have to offer follow-up care aimed at addressing potential personality and behavior changes that can cause patients distress?
• What are the trade-offs between the motor ben-efts of DBS and the potential psychological harm induced by treatments?
• Should decision aids be developed to help patients weigh the pros and cons? What would you put into such a decision aid?
• Should family members have a greater voice in DBS decision-making than in ordinary healthcare decision-making given the potential impact of DBS on personality and behavior?

34. "The Will Reconsidered: Hard Choices in Living Organ Donation"

Robert M. Guerin, Elizabeth O’Toole, Barbara Daly

Abstract: In the following article, we illustrate an interview between a living donor advocate and a potential living organ donor in which the donor faced a hard choice: the reasons to donate and the reasons not to donate were equally persuasive. In the discussion that follows, we analyze the act of willing, what differenti-ates coercion and willing, and how the case study highlights a different, but by no means rare, instance in which donors feel paralyzed by the choice at hand. In such cases, we suspect that donor advocates either do not approve the potential donor for transplantation or simply remain neutral. But we think that this approach benefits neither the donor nor the recipient. We conclude this study with recommendations for living donor advocates, providing questions that might solicit donors’ deeper values and suggesting that in these situations donors may benefit from additional time for reflection.

Keywords: Coercion, Donor Advocate, Hard Choice, Living Donor, Self, Willing, Persuasive Communication, Shared Decision Making, Competing Values

35. "Malleable Transplant Criteria: At What Cost?"

Angel Alsina, Rebekah Apple, Nyingi Kemmer and James P. Orlowski

Abstract: An 18-year-old male who had been diagnosed at age 7 with a rare, progressive liver disease was referred to the transplant center and received a transplant, even though he did not meet the center’s criteria for a patient with hepatopulmonary syndrome (HPS). Complications required relisting the patient urgently, but he eventually fully recovered; total hospital charges for his treatment exceeded $5 million. Reflection upon the case resulted in analysis of two ethical questions: primarily, clinician obligation to balance the provision of actuarially fair health care to society against the healing of a single patient; secondarily, the effects of malleable transplant criteria on trust in the patient selection process. We affirmed that physicians should not be principally responsible for justifying financial investment to society or for upholding beneficence beyond the individual physician and patient relationship in order to contain costs. We concluded, however, that such instances, when combined with manipulation of transplant center criteria, pose a potential threat to public trust. We therefore suggested that transplant centers maintain independent ethics committees to review such cases.

Keywords: Beneficence, Organ Donation, Organ Transplant, Rationing, Transplant Criteria, Ethics Committees, Hospital Charges, Moral Obligations, Hepatopulmonary Syndrome

• The authors mention rationing and affirm the tenet that it is unethical to withhold care because of exorbitant costs. What are the ethical implications of this practice, given that the United States has acknowledged the current system as unsustainable? Would you defend providing heroic, expensive care to every patient, regardless of the effect such behavior would have on the future of health care?
• The authors noted the difference between the allocation of organs and patient selection. A number of ethical principles are applied to donation and transplantation, and they often contradict each other. Is it possible to reconcile utilitarianism and deontology? What other principles collided in this case, and how could these conflicts have been avoided?
• A recent study in JAMA found that “prices of labor and goods, including pharmaceuticals and devices, and administrative costs appeared to be the main drivers” of high health care costs in the United States (Papanicolas, Woskie, & Jha, 2018, p. 1024). Growing attention is being paid to the income of nonclinical health care professionals, and Commins (2018) noted that compensation for nonclinician chief executive officers in over 20 US health systems almost doubled between 2005 and 2015. How much of an issue is compensation for nonclinicians, given the rising amount of health care spending in the country? Would adjustments to administrative costs necessarily result in more money being spent on patient care?

36. "Responding to Requests for Aid-in-Dying: Rethinking the Role of Conscience"

Elizabeth R. Brassfield, Manisha Mishra, and Mara Buchbinder

Abstract: This case study illustrates the complex role that a physician’s conscience can play in end-of-life care. We examine a case from Vermont in which a terminally ill patient requests aid-in-dying from her primary care physician under the state’s “Patient Choice and Control at End of Life” Act (Act 39). The physician feels conflicted: she is opposed to prescribing death-hastening medication but does not want to abandon her patient. Much of the medical ethics literature on conscience focuses on whether health care professionals should be permitted to abstain from providing morally contested medical services. Our analysis highlights the interplay of conflicting values that inform the physician’s engagement with aid-in-dying, demonstrating that the issue is often more nuanced than the question of whether or not a physician can (or should) opt out.

Keywords: Conscience; End-of-Life Care; Medical Ethics; Nonabandonment; Patient-Provider Relationship; Physician Aid-in-Dying/Physician-Assisted Suicide; Terminal Illness

• How does Dr. Jones’s response to Mary challenge conventional bioethical views of conscientious objection?
• What are the limits of a commitment to nonabandonment?
• Given a more robust understanding of the role of conscience in medical care, what form, if any, should protections for conscience take?

37. "Getting to the Heart of the Matter: Navigating Narrative Intersections in Ethics Consultation"

Leslie A. Kuhnel

Abstract: Ethics consultants can apply a narrative ethics approach to address ethical challenges that arise in critical situations. This approach recognizes how those involved in the narrative make sense of, keep faith with, and try on new identities and new understanding of their stories. This case study explores the ways in which the stories of patient, provider, and clinical ethics consultant intersect, and considers how the organic nature of the narrative ethics approach allows ethics consultants to navigate the stories of multiple stakeholders as they grapple with complex health care decisions. This essay also suggests that clinical ethics consultants applying the lens of narrative ethics have an obligation to approach consultations with courage, professional humility, intellectual curiosity, and an appreciation for the narratives of as many of the stakeholders as possible (including one’s own).

Keywords: Ethics Consultation, Intersecting Stories, Narrative Ethics

Discussion Questions:

• When have you experienced making sense, keeping faith, and trying on in your own personal or professional health care encounters?
• What narrative traps have you experienced in the course of clinical ethics consultation?
• How has your own personal narrative shaped your perceptions of this case?

38. "Speaking for Our Father"

Nico Nortjé

Abstract: A living will is a document in which an individual can communicate his or her health care choices to loved ones in the event that he or she is unable to do so directly. Many surrogate decision-makers use living wills as guides; however, the existence of such documents does not entirely relieve them of their burden. Surrogate decision-makers often need to consider the impact of the personal and family burdens entailed by their decisions, and the stress accompanying these burdens regularly creates high levels of anxiety and depression. This stress can be exacerbated when two surrogate decisionmakers are at loggerheads as to the best way forward. This case study illustrates the effects of stress accompanying disagreement among surrogate decision-makers—here, the patient’s adult sons—and demonstrates that a process of listening can help the bioethicist identify the values that are important to the patient and, consequently, to the surrogate as well, and use these values to help address the issue.

Keywords: Ethics, Intensive Care Unit, Living Will, Medical Power of Attorney, Surrogate Decision-Making

• Have you experienced similar cases where parties disagreed as to what was best for the patient? What did you do?
• Do you think it is better for surrogate decisionmakers to have leeway in interpreting the wishes of a patient, or should they have explicit instructions?
• There may be disagreement and tension within the health care team as to the best way forward. How can you assist team members in presenting a unified message to the family?

39. "Forcible Amputation in Delusional Patients: A Narrative Analysis of Decisional Capacity"

Lori A. Roscoe, David P. Schenck, Joel L. Eisenberg

Abstract: This case study concerns the predicaments faced by two women who each had been advised by her physicians to have a gangrenous foot amputated to prevent the potentially fatal spread of infection. In both cases, the determination of the patients' decisional capacity was a critical component in judging whether or not to honor their medical treatment decisions. The communicative complexity of navigating a double bind, a situation in which a person confronts a choice between two undesirable courses of action, is also discussed. The patients in these cases had no medically appropriate choice that also respected other valued outcomes, such as independence, a sense of dignity, or control over one's destiny. Taken together, these cases raise issues about the context-specific meaning of decisional capacity and its role in informed consent.

Keywords: Decisional Capacity, Double Bind, Amputation, Communication

• Under what circumstances might a decision to amputate over the patient's objections be appropriate?
• Under what circumstances can a delusional or cognitively impaired patient give informed consent for medical treatment?
• Suppose the patient was not delusional but nonetheless believed that merely washing the wound with soap and water would make it better. Would it then be ethical to perform the amputation against her will? What role does rationality play in determining competence and giving informed consent?
• How can a patient's wishes be acknowledged in a plan for treatment, even if she or he is deemed to lack decisional capacity?

40. "A Health Care Systems Approach to Improving Care for Seriously Ill Patients"

Lisa Soleymani Lehmann, Jill Lowery, Virginia Ashby Sharpe, Kenneth A. Berkowitz

Abstract: Health care systems can go beyond advance care planning to create mechanisms for eliciting and documenting the goals of care and life-sustaining treatment decisions of patients with serious life-limiting illnesses. These systems can help ensure that patients receive care that is consistent with their values and preferences. We describe a case in which even though a patient with a serious illness had completed an advance directive and had discussed preferences with family, clinicians failed to identify the patient's authentic preferences for life-sustaining treatment. We offer a stepwise framework for communication with seriously ill patients and describe a systems approach to transforming the process of eliciting, documenting, and honoring patients' life-sustaining treatment preferences in the U. S. Veterans Health Administration.

Keywords: Advance Care Planning, Communication, End-of-Life Care

41. "An Ethics of Unknowing: Discerning Ethical Patient-Provider Interactions in Clinical Decision-Making"

Abstract: There is an irreducible amount of uncertainty in clinical decision-making. Both health care providers and patients experience anxiety elicited by clinical uncertainty, and this can lead to missed opportunities for healthy shared decision-making. In order to improve the patient-provider relationship and the ethical qualities of decision-making, the provider first needs to recognize where his/her "unknowing" exists. This article presents a model for a unique ethics of unknowing by identifying three levels at which the provider's knowledge or lack thereof impacts clinical decision-making. The model illuminates ethical choices that providers can make to promote healthy patient-provider relationships. The means by which an ethics of unknowing informs shared decision-making in patient care will be exemplified through a case study of one patient's encounters with several physicians while making difficult decisions throughout her breast cancer journey.

Keywords: Clinical Ethics, Uncertainty, Epistemology, Shared-Decision Making, Patient-Provider Relationship, Patient Care, Medical Decision-Making, Breast Cancer

42. "How Should Physicians Manage Neuro-prognosis with ECPR?"

Ian J. McCurry, Jason Han, Andrew Courtwright

Abstract: Rapidly advancing technologies in the field of extracorporeal cardiopulmonary resuscitation (ECPR) have presented a new challenge in accurate neuroprognostication following cardiac arrest. Determination of brain state informs the prognostic picture and allows providers to begin effective communication regarding likelihood of meaningful neurological recovery as defined by patients or family members. The evolving role of sedation during ECPR and its impacts on ethical tension in decision-making is reviewed. Work surrounding the advancing field of neuroprognostication after cardiac arrest and hypothermia is summarized and implications of premature withdrawal of life-sustaining treatments are discussed. Advances that improve predictive value for neurological recovery are utilized in affirming and discussing the implications for end-of-life wishes of individuals in the setting of intensive resuscitative therapies.

Keywords: End Of Life, Resuscitation, Ethics, Critical Care, ECMO

43. "The Ethics of Choosing a Surrogate Decision Maker When Equal-Priority Surrogates Disagree"

Matthew Shea

Abstract: When decisionally incapable patients need a surrogate to make medical decisions for them, sometimes the patient has not appointed a healthcare agent and there is intractable disagreement among potential surrogates of equal priority, legal rank, or relation to the patient (e.g., child vs. child, sibling vs. sibling). There is no ethical, legal, or professional consensus about how to identify the appropriate surrogate in such circumstances. This article presents a case study involving an elderly female patient whose four children disagree about whether to continue life-sustaining treatment for their mother, along with an ethical analysis of various strategies for selecting the appropriate surrogate in cases of conflicting equal-rank family members. It critically examines three different strategies—chance, majority rules, and quality of relationship with the patient—and defends the third approach.

Keywords: Surrogate Decision Making, Equal-Priority Surrogates, Family Disagreement, Conflict Resolution, Substituted Judgment, Clinical Ethics, Ethics Consultation

44. "A Gay Epidemiologist and the DC Commission of Public Health AIDS Advisory Committee"

Steven S. Coughlin, Paul Mann, and Bruce Jennings

Abstract: Based upon the lead author's deep personal and professional experience, this case narrative illustrates the importance of engagement between public health practitioners and members of affected populations and their advocates. The case underscores the need to build strong coalitions to address serious public health and social issues. It also illustrates how decisions about control groups in research raise ethical issues. In addition, the case illustrates the reality that public health and social services are sometimes inadequate in the face of dire circumstances. Justice in public health has both a distributive aspect (how to allocate limited resources and distribute potential benefits as fairly as possible) and a procedural dimension (ensuring public participation, especially of those most affected). Frameworks for public health ethics, which post-date the events detailed in the autobiographical case narrative, highlight both distributive justice and procedural justice.

Keywords: African Americans, AIDS, HIV, Community Prevention, Prevention, Public Health, Social Justice

45. "Shared Decision-Making in Palliative Care: A Maternalistic Approach"

Laura Specker Sullivan, Mary Adler, Joshua Arenth, Shelly Ozark, and Leigh Vaughan

Abstract: During goals of care conversations, palliative care clinicians help patients and families determine priorities of care and align medical care with those priorities. The style and methods of communicating with families and negotiating a care plan can range from paternalistic to entirely patient driven. In this paper, we describe a case in which the palliative care clinician approached decision-making using a paradigm that is intuitive to many clinicians and which seems conceptually sound, but which has not been fully explored in the bioethics literature. This paradigm, termed maternalism, allows the clinician to direct decision-making within a relationship such that best interests and autonomy are mutually reinforced, thus reflecting relational autonomy as opposed to individual autonomy. We explore whether this method is appropriate in this case and explain how it captures significant ethical features of the case that might be missed by other approaches.

Keywords: Shared Decision-Making, Palliative Care, End of Life, Paternalism, Relational Autonomy

46. "Phantom Physicians and Medical Catfishing: A Narrative Ethics Approach to Ghost Surgery"

Saljooq M. Asif

Abstract: The concerns raised by ghost surgery, an unethical practice in which someone other than the surgeon who obtains consent performs an operative procedure without the patient’s knowledge, have long been ignored by bioethics and other related disciplines. Indeed, ghost surgery is neither tracked nor studied in the United States, and the practice itself remains underreported. Ghost surgery represents a corporeal transgression as well as a relational rift: what was communicated by physicians is rendered null and void, and the surgical narrative that patients thought they knew is disrobed as a lie and revealed to be a catfish. In order to combat this practice and prevent any form of medical catfishing, physicians must guarantee effective communication and transparency and view themselves as storytellers alongside their patients. By following such a framework, physicians can ideally end the simulation and suture an ethic of accountability within a co-constructed narrative.

Keywords: Ghost Surgery, Narrative Ethics, Accountability, Catfishing, Medical Harm

47. "It Takes Time to Let Go"

Tiffany Meyer, Laura Walther-Broussard, Nico Nortjé

Abstract: Futile or nonbeneficial treatment is often a source of contention between care teams and family members of ICU patients. This narrative describes such a case at a cancer center. In the midst of the COVID-19 crisis, the psychosocial team had to act as a bridge between a patient's surrogate decision maker and the care team. In light of COVID-19 visitor restrictions, the psychosocial team, the surrogate/family, and the care team had to respectfully work towards what was best for the patient.

Keywords: Nonbeneficial treatment, COVID-19, Psychosocial team, Values, Goals of Care

48. "An American’s Experience with End-of-Life Care in Japan: Comparing Brain Death, Limiting and Withdrawing Life-Prolonging Interventions, and Healthcare Ethics Consultation Practices in Japan and the United States"

Alexander A. Kon, Keiichiro Yamamoto, Eisuke Nakazawa, Reina Ozeki-Hayashi, Akira Akabayashi

Abstract: American and Japanese laws, customs, and practices in end-of-life decision-making differ significantly. We present a case with which one of the authors was involved to illustrate some of the key legal and cultural differences in the declaration of brain death, limiting and withdrawing life-prolonging interventions, and healthcare ethics consultation practices. The analysis presented facilitates understanding of similarities and differences between Japanese and American healthcare ethics specifically in regards to end-of-life care. Further, the analysis provides insights that can aid in developing policies and practices in regions where multiple cultures coexist.

Keywords: Brain Death, Organ Transplantation, Withholding Treatment, Japan, Ethics Consultation

49. "The Sword of King Solomon"

Maria Susana Ciruzzi

Abstract: Conjoined twin pregnancies are one of the greatest dilemmas we face in healthcare practice. Thanks to scientific knowledge and evolution, technology and the higher level of wealth in our society, conjoined twins have a chance to survive, albeit with the risk of major consequences on their lifespan and quality of life. Particularly, in the case of newborns with extreme prematurity or congenital malformations, special care must be taken in the use of treatments that offer little to no benefit. This is especially the case with procedures and techniques of unproven efficacy that could create unfounded expectations and hopes in parents and health professionals. It is within this conceptual framework that the author presents a case submitted to a bioethics committee at a pediatric hospital in a Latin American metropolis and analyzes the ethical challenges posed to the treating team and the consensual approach determined by the team.

Keywords: Conjoined Twins, Parental Decision Making, Do No Harm Principle, Ethical Dilemma, Quality of Life

50. "Appreciating the Dynamicity of Values at the End of Life: A Psychological and Ethical Analysis"

Austin Burns, Natalie Hardy & Nico Nortjé

Abstract: It can be difficult for families to accept when loved ones experience a change in saliency of values due to serious illness and inevitable death. When patients lose decision-making capacity, family members often refuse to withdraw care and insist on the continuation of non-beneficial treatment. Through a joint ethical and psychological analysis, this case study examines the narrative of a husband and wife, wed for over 50 years, and how the patient’s values, his life’s story, and the wife’s interpretation of his preferences were reconciled to achieve a resolution that respected the patient’s autonomy and previously expressed wishes.

Keywords: Ethics, Anticipatory Grief, Serious Illness, Decision-Making, Values

51. "Serendipity and Social Justice: How Someone with a Physical Disability Succeeds in Clinical Bioethics"

Kevin T. Mintz

Abstract: Trainees with disabilities in health-related professions are often subjected to structural ableism in medicine: the discriminatory manifestation of lowered expectations towards people with disabilities by medical professionals. In this case study, I reflect on my experiences as the first individual with significant disabilities to be offered a postdoctoral fellowship in clinical bioethics at the National Institutes of Health. I focus on the following question: What arrangements need to be in place in order for someone with my level of disability to thrive as a clinical bioethicist? By telling my story, I show how the process of accommodating trainees with disabilities often requires creative problem-solving and a considerable amount of institutional resources. I also describe the team-based method that my mentors and I developed to enable me to complete rotations on the NIH’s bioethics consultation service. If more trainees with disabilities are to succeed in clinical bioethics trainee programs, the field will have to grapple with how to develop an infrastructure for providing disability-related support across training programs. This article is the beginning of a dialogue about how to build such an infrastructure.

52. "The Right to Be Childfree"

Andrea Eisenberg & Abram L. Brummett

Abstract: In this manuscript, we start with a real life account of an Ob/Gyn experience with a young patient from the childfree movement requesting permanent sterilization. A narrative ethics approach invites the reader to experience the encounter in an immersive way for this growing issue. This approach allows readers to reflect on their reaction to the patient and consider how that can affect other patient encounters. Additionally, it explores the stigma these young patients encounter making a permanent decision to never have children. In the commentary, we explore the ethical issues in this case including why we question the permanent decision to refrain from having children. We also discuss informed consent and patient education along with the various approaches to physician-patient relationships with an emphasis on shared decision making, which allows space for both patient and physician to question and reason through their health decisions.

Keywords: Childfree, Permanent Sterilization, Shared Decision Making, Regret, Narrative Ethics

53. "Undisclosed Placebo Trials in Clinical Practice: Undercover Beneficence or Unwarranted Deception?"

Daniel Edward Callies

Abstract: A placebo is an intervention that is believed to lack specific pharmacological or physiological efficacy for a patient’s condition. While placebo-controlled trials are considered the gold standard when it comes to researching and testing new pharmacological treatments, the use of placebos in clinical practice is more controversial. The focus of this case study is an undisclosed placebo trial used as an attempt to diagnose a patient’s complex and unusual symptomology. In this case, the placebo was used not just as a treatment, but as a diagnostic intervention in order to determine the best course of treatment for a patient. Could the deceptive use of a placebo be justified in clinical practice on the grounds of beneficence?

Keywords: Placebo, Beneficence, Deception, Trust, Disclosure

54. " What Do We Owe to Patients Who Leave Against Medical Advice? The Ethics of AMA Discharges?"

Leenoy Hendizadeh, Paula Goodman-Crews, Jeannette Martin, Eli Weber

Abstract:  Discharges against medical advice (AMA) make up a significant number of hospital discharges in the United States, and often involve vulnerable patients who struggle to obtain adequate medical care. Unfortunately, much of the AMA discharge process focuses on absolving the medical center of liability for what happens to these patients once they leave the acute setting. Comparatively little attention is paid to the ethical obligations of the medical team once an informed decision to leave the acute care setting AMA has been made. Via a case narrative, we offer an ethical framework that we believe can help guide an ethically defensible AMA discharge process. By emphasizing our duty to provide the best care possible under the circumstances, we contend, our ethical obligations to promote the patient’s best interests can still be met despite their decision to leave the acute setting against medical advice.

Keywords:  Beneficence, Narrative Ethics, Case Study, AMA Discharges, Shared Decision-Making

  Link to Case on MUSE

55. "Jehovah's Witnesses and the Normative Function of Indirect Consent"

Joanna Smolenski

Abstract:  In this case study, I consider Mr. A, a Jehovah's Witness with chronic vertebral osteomyelitis in need of surgical debridement. Prior to proceeding to the OR, he was unwilling either to explicitly consent to or refuse blood transfusion, while indicating he was open to transfusion intraoperatively, if the team judged it necessary. Ethics was consulted to determine if it would be morally justifiable for the team to proceed with blood transfusion during the course of surgery without Mr. A's documented consent to being transfused. I argue that in this case, what might be termed indirect consent—namely, delegating decision-making regarding some possible course of action without explicitly consenting to the course of action itself—may be sufficient for discharging the clinician's ethical obligation to obtain consent. Identifying information has been changed or omitted to protect patient confidentiality.

Keywords:  Blood Transfusions, Jehovah's Witnesses, Informed Consent, Indirect Consent, Self-Sovereignty

56. "Parental Refusals of Blood Transfusions from COVID-19 Vaccinated Donors for Children Needing Cardiac Surgery"

Daniel H. Kim, Emily Berkman, Jonna D. Clark, Nabiha H. Saifee, Douglas S. Diekema, Mithya Lewis-Newby

Abstract: There is a growing trend of refusal of blood transfusions from COVID-19 vaccinated donors. We highlight three cases where parents have refused blood transfusions from COVID-19 vaccinated donors on behalf of their children in the setting of congenital cardiac surgery. These families have also requested accommodations such as explicit identification of blood from COVID-19 vaccinated donors, directed donation from a COVID-19 unvaccinated family member, or use of a non-standard blood supplier. We address the ethical challenges posed by these issues. We describe the current screening and safety processes for standard blood donation and explore the importance of donor anonymity and challenges with directed donation and non-standard blood suppliers. We present an ethical framework using the Best Interest Standard, the Zone of Parental Discretion, and the Harm Principle when considering these refusals. Finally, we provide recommendations for how to approach these requests as they potentially become more commonplace in pediatrics.

Keywords:  Medical Ethics, Critical Care, Pediatrics, Innovation, Cardiac Surgery, Cardiac Catheterization

57. “Withdrawing Life Support After Attempted Suicide: A Case Study and Review of Ethical Consideration"

David A. Oxman & Benjamin Richter

Abstract: Ethical questions surrounding withdrawal of life support can be complex. When life support therapies are the result of a suicide attempt, the potential ethical issues take on another dimension. Duties and principles that normally guide clinicians’ actions as caregivers may not apply as easily. We present a case of attempted suicide in which decisions surrounding withdrawal of life support provoked conflict between a patient’s family and the medical team caring for him. We highlight the major unresolved philosophical questions and contradictory normative values about suicide that underlie this conflict. Finally, we show how these considerations were practically applied to this particular case.

Keywords: Medical Ethics, Critical Care, Life Support Therapies, Suicide

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• “Ad”mission of guilt
• “Do I stop him?”
• Newspaper joins war against drugs
• Have I got a deal for you!
• Identifying what’s right
• Is “Enough!” too much?
• Issues of bench and bar
• Knowing when to say “when!”
• Stop! This is a warning…
• Strange bedfellows
• Gambling with being first
• Making the right ethical choice can mean winning by losing
• Playing into a hoaxster’s hands
• “They said it first”
• Is it news, ad or informercial?
• Letter to the editor
• Games publishers play
• An offer you can refuse
• An oily gift horse
• Public service . . . or “news-mercials”
• As life passes by
• Bringing death close
• A careless step, a rash of calls
• Distortion of reality?
• Of life and death
• Naked came the rider
• “A photo that had to be used”
• A picture of controversy
• Freedom of political expression
• Brother, can you spare some time?
• Columnist’s crusade OK with Seattle
• Kiss and tell
• The making of a govenor
• Past but not over
• Of publishers and politics
• To tell the truth
• Truth & Consequences
• “Truth boxes”
• When journalists become flacks
• A book for all journalists who believe
• The Billboard Bandit
• Food for thought
• Grand jury probe
• Judgement on journalists
• Lessons from an ancient spirit
• Lying for the story . . .
• Newspaper nabs Atlanta’s Dahmer
• One way to a good end
• Over the fence
• “Psst! Pass it on!”
• Rules aren’t neat on Crack Street
• “Someone had to be her advocate”
• Trial by Fire
• Trial by proximity
• Using deceit to get the truth
• When advocacy is okay
• Witness to an execution
• Are we our brother’s keeper? . . . You bet we are!
• Betraying a trust
• Broken promise
• “But I thought you were . . . ”
• “Can I take it back?”
• Competitive disadvantage
• Getting it on tape
• The great quote question
• How to handle suicide threats
• Let’s make a deal!
• A phone-y issue?
• The source wanted out
• The story that died in a lie
• Thou shalt not break thy promise
• Thou shalt not concoct thy quote
• Thou shalt not trick thy source
• Too good to be true
• Vulnerable sources and journalistic responsibility
• The way things used to be . . .
• When a story just isn’t worth it
• When a story source threatens suicide
• When public should remain private
• The ethics of “outing”
• “For personal reasons”
• Intruding on grief
• Intruding on private pain
• Privacy case settled against TV station
• Seeing both sides
• Two views on “outing”
• Unwanted spotlight
• Whose right is it anyway?
• Other views on the Christine Busalacchi case
• The death of a soldier
• Firing at Round Rock
• A kinder, gentler news media
• Operation: Buy yourself a parade
• Rallying ’round the flag
• “Salute to military” ads canceled
• Tell the truth, stay alive
• The windbags of war
• Absent with no malice
• Anonymity for rape victims . . .
• An exception to the rule
• The boy with a broken heart
• Civilly suitable
• Creating a victim
• “Everyone already knew”
• An exceptional case
• Innocent victims
• Minor infraction
• Names make news
• Naming a victim
• Naming “johns”
• Profile of controversy
• What the media all missed
• Punishing plagiarizers
• Sounding an alarm on AIDS
• Suffer the children
• Anchor’s away
• The day the earth stood still
• Doing your own ethics audit
• Good guys, bad guys and TV news
• Is it just me, or . . . ?
• The Post’s exam answer story
• TV station “teases” suicide
• Yanking Doonesbury
• The year in review
• Colorado media’s option play
• Deadly lesson
• Deciding which critically ill person gets coverage
• When journalists play God . . .
• A delicate balance
• The Fallen Servant
• Handle with care
• It’s the principle, really
• Killing news
• Maybe what seems so right is wrong
• On the line
• Protest and apology after Daily Beacon story
• Red flag for badgering
• Sharing the community’s grief
• The “super-crip” stereotype
• “And then he said *&%*!!!”
• When big is not better
• When the KKK comes calling
• Not the straight story
• Agreeing to disagree
• All in the family
• Family feud
• Author! Author!
• The Bee that roared
• Brewing controversy
• Building barriers
• Other views from librarians
• The ethics of information selling
• Close to home
• Family ties
• How now, sacred cow?
• The ties that bind
• “Like any other story”
• When your newspaper is the news
• Not friendly fire
• Overdraft on credibility?
• The problem is the writing
• Written rules can be hazardous
• Project censored, sins of omission and the hardest “W” of all – “why”
• Risking the newsroom’s image
• The Media School

Ethics Case Studies

Ethics cases online.

This set of cases has been created for teachers, researchers, professional journalists and consumers of news to help them explore ethical issues in journalism. The cases raise a variety of ethical problems faced by journalists, including such issues as privacy, conflict of interest, reporter- source relationships, and the role of journalists in their communities.

The initial core of this database comes from a series of cases developed by Barry Bingham, Jr., and published in his newsletter, FineLine. The school is grateful to Bingham for his permission to make these cases available to a wider audience.

You may download cases for classes, research or personal use. Permission is granted for academic use of these cases, including inclusion in course readers for specific college courses. This permission does not extend to the republication of the cases in books, journals or electronic form.

Note: We are indebted to Professor Emeritus David Boeyink, who developed this project several years ago.

Aiding law enforcement

• “Ad”mission of guilt: Court-ordered ads raise ethical questions
• “Do I stop him?”: Reporter’s arresting question is news
• Fairness: A casualty of the anti-drug crusade
• Newspaper joins war against drugs: Standard-Times publishes photos of all suspected drug offenders
• Have I got a deal for you!: The line between cooperation and collusion
• Identifying what’s right: Photographer’s ID used in hostage release
• Is “Enough!” too much?: Editors split on anti-drug coupons
• Issues of bench and bar: In this case, a TV reporter is the judge
• Knowing when to say “when!”: Drawing the line at cooperating with authorities
• Stop! This is a warning . . . : Suppressing news at police request
• Strange Bedfellows: Federal agents in a TV newsroom

Being first

• Gambling with being first: The media drive to score on the Isiah Thomas story
• Playing into a hoaxster’s hands: How the Virginia media got suckered
• “They said it first”: Is that reason for going for the story?

Bottom-line decisions

• Is it news, ad or infomercial?: The line between news and advertising is going, going . . .
• Games publishers play: Allowing an advertiser to call the shots
• An offer you can refuse: The selling of Cybill to the Enquirer
• An oily gift horse: saying “No!” to Exxon
• Public service. . .or “news-mercials”: The blending of television news and advertising

Controversial photos

• As life passes by: A journalist’s role: watch and wait
• Bringing death close: Publishing photographs of human tragedy
• A careless step, a rash of calls: “Unusual” photo of AIDS walkathon raises hackles” 
• Distortion of reality?: “Punk for Peace” photograph draws fire
• Of life and death: Photos capture woman’s last moments
• “A photo that had to be used”: Anatomy of a newspaper’s decision
• A picture of controversy: Pulitzer photos show diverse editorial standards

Covering politics

• Freedom of political expression: Do journalists forfeit their right?
• Brother, can you spare some time?: TV stations give candidates air time
• Columnist’s crusade OK with Seattle Times
• Kiss and tell: Publishing details of a mayor’s personal life
• The making of a governor: How media fantasy swayed an election
• Past but not over: When history collides with the Present
• Of publishers and politics: Byline protest threatened at Star Tribune
• To tell the truth: Why I didn’t; why I regret it
• Truth & Consequences: The public’s right to know . . . at what cost?
• “Truth boxes”: Media monitoring of TV campaign ads
• When journalists become flacks: Two views on what to do and when to do it

Getting the story

• A book for all journalists who believe: Accuracy is our highest ethical debate
• The Billboard Bandit: Did the newspaper get graffiti on its reputation
• Food for thought: You are what you eat . . . and do
• Grand jury probe: TV journalists indicted for illegal dogfight
• Judgment on journalists: Do they defiantly put themselves “above the law?”
• Lessons from an ancient spirit: Why I participated in a peyote ritual
• Lying for the story . . . :Or things they don’t teach in journalism school
• Newspaper nabs Atlanta’s Dahmer: Another predator who should’ve been stopped: Was it homophobia?
• One way to a good end: Reporter cuts corners to test capital drug program
• Over the fence: A case of crossing the line for a story
• “Psst! Pass it on!”: Why are journalists spreading rumors?
• Rules aren’t neat on Crack Street: Journalists know the rules; they also know that the rules don’t always apply when confronted with life-threatening situations
• “Someone had to be her advocate”: A newspaper’s crusade to keep a child’s death from being forgotten
• Trial by Fire: Boy “hero” story tests media
• Trial by proximity: How close is too close for a jury and a reporter?
• Using deceit to get the truth: When there’s just no other way
• When advocacy is okay: Access is an acceptable journalist’s cause
• White lies: Bending the truth to expose injustice
• Witness to an execution: KQED sues to videotape capital punishment

Handling sources

• Are we our brother’s keeper? . . . You bet we are!
• Betraying a trust: Our story wronged a naive subject
• Broken Promise: Breaching a reporter-source confidence
• “But I thought you were . . .”: When a source doesn’t know you are a reporter
• “Can I take it back?”: Why we told our source ‘yes’
• Competitive disadvantage: Business blindsided by unnamed sources
• Getting it on tape: What if you don’t tell them?
• The great quote question: How much tampering with quotations can journalists ethically do?
• Let’s make a deal!: The dangers of trading with sources
• A phone-y issue?: Caller ID raises confidentiality questions
• The source wanted out: Why our decision was ‘no’
• The story that died in a lie: Questions about truthfulness kill publication
• Thou shalt not break thy promise: Supreme Court rules on betraying sources’ anonymity 
• Thou shalt not concoct thy quote: Supreme Court decides on the rules of the quotation game
• Thou shalt not trick thy source: Many a slip twixt the promise and the page
• Too good to be true: Blowing the whistle on a lying source
• Vulnerable sources and journalistic responsibility: Are we our brother’s keeper?
• The way things used to be . . . : Who says this new “objectivity” is better?
• When a story just isn’t worth it: Holding information to protect a good source
• When a story source threatens suicide: “I’m going to kill myself!”

Invading privacy

• The ethics of “outing”: Breaking the silence code on homosexuality
• “For personal reasons”: Balancing privacy with the right to know
• Intruding on grief: Does the public really have a “need to know?”
• Intruding on private pain: Emotional TV segment offers hard choice
• Seeing both sides: A personal and professional dilemma
• Two views on “outing”: When the media do it for you
• Two views on “outing”: When you do it yourself
• Unwanted Spotlight: When private people become part of a public story
• Whose right is it anyway?: Videotape of accident victim raises questions about rights to privacy

Military Issues

• The death of a soldier: Hometown decision for hometown hero
• Firing at Round Rock: Editor says “unpatriotic” story led to dismissal  
• A kinder, gentler news media?: Post-war coverage shows sensitivity to families
• Operation: Buy yourself a parade: New York papers pitch in for hoopla celebrating hide-and-seek war
• Rallying ’round the flag: The press as U.S. propagandists
• “Salute to military” ads canceled
• Tell the truth, stay alive: In covering a civil war, honesty is the only policy
• The windbags of war: Television’s gung-ho coverage of the Persian Gulf situation

Naming newsmakers

• Absent with no malice: Omitting part of the story for a reason
• Anonymity for rape victims . . . : should the rules change?
• An exception to the rule: a decision to change names
• The boy with a broken heart: Special problems when juveniles are newsmakers
• Civilly suitable: If law requires less, should media reveal more?
• Creating a victim: Plot for a fair story may not be foolproof
• “Everyone already knew”: A weak excuse for abandoning standards
• An exceptional case: Hartford Courant names rape victim
• Innocent victims: Naming the guilty . . . but guiltless
• Minor infraction: A newspaper’s case for breaking the law
• Names make news: One newspaper debates when and why
• Naming a victim: When do you break your own rule?
• Naming “johns”: Suicide raises ethical questions about policy
• Profile of controversy: New York Times reporter defends story on Kennedy rape claimant 
• What the media all missed: Times reporter finally sets record straight on Palm Beach rape profile
• Punishing plagiarizers: Does public exposure fit the sin?
• Sounding an alarm on AIDS: Spreading the word about someone who’s spreading the disease
• Suffer the Children: Journalists are guilty of child misuse

Other topics

• Anchor’s away: Where in the world is she? Or does it matter?
• The day the earth stood still: How the media covered the “earthquake”
• Good guys, bad guys and TV news: How television and other media promote police violence
• The Post’s exam answer story
• TV station “teases” suicide
• The year in review: 1990’s biggest ethical headaches and journalistic bloopers

Sensitive news topics

• Colorado media’s option play: Most passed; did they also fumble?
• Deadly lesson: Warning about sexual asphyxiation
• A delicate balance: Mental breakdowns & news coverage
• The Fallen Servant: When a hero is not a hero
• Handle with care: Priest murder story required extra sensitivity
• It’s the principle, really: Timing and people’s money matter, too
• Killing news: Responsible coverage of suicides
• Maybe what seems so right is wrong: A medical condition media-generated money can’t cure
• On the line: A reporter’s job vs. human decency
• Red flag for badgering: Ombudsman takes sportswriter to task
• Sharing the community’s grief: Little Rock news coverage of three teen-age suicides
• Suffer the children: Was story on molestation worth the human cost?
• The “super-crip” stereotype: Press victimization of disabled people
• “And then he said *&%*!!!”: When sexist and vulgar remarks are new
• When big is not better: Playing down a story for the community good
• When the KKK comes calling: What’s the story?
• Not the straight story: Can misleading readers ever be justified?

Workplace issues

• Agreeing to disagree: How one newspaper handles off-hour activities
• All in the family: When a journalist’s spouse creates a conflict of interests
• Family feud: Handling conflicts between journalists and partners
• Author! Author!: Ethical dilemmas when reporters turn author
• The Bee that roared: Taking a stand for editorial independence
• Brewing controversy: The commercialization of Linda Ellerbee
• Building barriers: The case against financial involvement
• Other views from librarians: When interests of client and newsroom conflict
• The ethics of information selling: Problems for library reference services
• Close to home: When your newsroom is part of the story
• Family Ties: When are relationships relationships relevant?
• How now, sacred cow?: United Way’s favored treatment by the media
• The ties that bind: Publisher’s link to United Way raises questions
• “Like any other story”: Can it be when it’s your union vs. your paper?
• When your newspaper is the news: Editors discuss their experiences
• Not friendly fire: News director at odds with CBS over story
• Overdraft on credibility?: Reporter faces conflict-of-interest charges
• Written rules can be hazardous: A lawyer views ethics codes
• Project censored, sins of omission and the hardest “W” of all – “why”
• Risking the newsroom’s image: How editors, in a good cause, can strain independence

Ethics Case Studies resources and social media channels

Princeton Dialogues on AI and Ethics

Princeton University

Case Studies

Princeton Dialogues on AI and Ethics Case Studies

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.

Stanford Computer Ethics Case Studies and Interviews

Case studies.

• Algorithmic Decision-Making and Accountability
• Autonomous Vehicles
• Facial Recognition
• Power of Private Platforms
• Joshua Browder interview

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Cautionary Tales: Ethics and Case Studies in Science

Ethical concerns are normally avoided in science classrooms in spite of the fact that many of our discoveries impinge directly on personal and societal values. We should not leave the ethical problems for another day, but deal with them using realistic case studies that challenge students at their ethical core. In this article we illustrate how case studies can be used to teach STEM students principles of ethics.

INTRODUCTION

Americans consider morality the most essential part of self ( 11 ).

This may be true of other cultures as well. All societies have elaborate rules of conduct that are often codified into law. Some of these imperatives seem hardwired. Human infants younger than a year and a half will look longer at visual displays showing violations of social rules ( 2 ). It is part of our primate heritage; individuals are punished if they stray far from acceptable behavior. Capuchin monkeys will reject a reward if they think they are being treated unfairly; they have a clear sense of right and wrong which depends on the social situation ( 3 ). Aesop would agree—he penned many a story where animals behaved badly and paid the penalty.

If morality and ethics are so central to our beings, what are our responsibilities as STEM educators to pass along the standards of society? And if we accept this challenge, what is the best way to instruct our youthful comrades in their quest for knowledge? I argue in this article that we should accept this obligation and that case study teaching is an ideal way to deliver the message.

Case-study teaching has a long and honorable lineage ( 4 ). In academic circles we find it used 100 years ago in Harvard Law School. The instructor would bring in a true criminal or civil case that had been adjudicated and conduct a class discussion with future lawyers, asking them to justify the rationale for the final decision—challenging them every step of the way. This provided students a real-world problem as part of their training for a real world ahead. The method was soon adopted by the Harvard Business School and various schools across the country, where it is now the standard. Medical schools have their own version of the method called Problem-Based Learning. Again the idea was to use real world problems to train physicians, but in this case students work in small groups to analyze patient problems and provide diagnoses. The idea of using similar strategies to teach basic sciences to undergraduates is largely due to the efforts of faculty at the University of Delaware and the National Center for Case Study Teaching in Science, where there are hundreds of cases now published http://sciencecases.lib.buffalo.edu/cs/ .

Research has shown that minorities and women undergraduates respond well to cases ( 5 , 8 ). Among this group, cases have been shown to increase students’ understanding of science by encouraging them to make connections between science concepts and situations they may encounter in their lives ( 7 ). In addition, the case method promotes the internalization of learning and the development of analytical and decision-making skills, as well as proficiency in oral communication and teamwork ( 6 ). The method, moreover, is a flexible teaching tool. Cases can take many different forms and be taught in many different ways, ranging from the classical discussion method used in business and law schools, to the arguably strongest approaches, Problem-Based Learning and the Interrupted Case Method, with their emphasis on small-group, cooperative learning strategies ( 4 ).

The method seems ideal for teaching ethics to STEM students. We have plenty of precedents to guide us. We have legal ethics, business ethics, medical ethics, bioethics, geoethics, environmental ethics, teaching ethics, research ethics, engineering ethics, and so on. And, of course, there are religious ethics, with each faith describing canons of behavior not to be breached. Some of them are commonly held community values, such as “thou shalt not steal, lie, or cheat.” Others are more specific, such as the research tenet, “thou should replicate experiments.” While some of these “rules” are so entrenched that they are tantamount to absolutes, others are more fragile and malleable; they are subject to the changing moral landscape. Policies about smoking in public places have rapidly shifted ( 12 ). Decrees against interracial marriage, once laws of the land, are now anachronisms, as are statues against same-sex marriage ( 1 , 10 ). Such shifts in the moral topography offer wonderful opportunities for case studies as they challenge students at their central core of beliefs. There are hundreds of these case studies now available for teachers in repositories such as the National Center for Case Study Teaching in Science ( http://sciencecases.lib.buffalo.edu ), where you can find moral dilemmas depicted in cases on evolution, genetic engineering, nutrition, euthanasia, cloning, and organic farming.

Case studies can be used to show students acceptable standards of behavior within a given profession—the do’s and don’ts—and the disastrous consequences that can occur if the rules are not obeyed. We learn of breaches of research ethics such as fraud, plagiarism, and sloppy book-keeping that ruin careers. We come to know cautionary tales, like Dr. Andrew Wakefield, who misrepresented the medical histories of 12 patients and claimed that his research results showed that vaccinations caused autism. He was eventually discredited and Britain stripped him of his medical license. Unfortunately, this sensational allegation has resulted in thousands of people refusing to have their children vaccinated, with a subsequent striking rise in measles.

In the past, these stories were neglected in the STEM classroom. Questions of right or wrong belonged elsewhere—in the home, in a philosophy class, in a church or tabernacle. In the science classroom we learned how to make petroleum, shoot rockets, synthesize drugs, manipulate DNA, and clone animals, not whether we should do so. Then came the Second World War. The academic community ran squarely into two striking examples of the deep entanglement of science and ethics. Suddenly, there was a public debate about whether Truman’s decision to drop the atom bomb on Japan with the loss of millions of lives was ethical. The sensational trials of generals and scientists implicated in the atrocities at the Nazi concentration camps came to light during the Nuremberg Trials and patient bills of rights were drafted. Today our IRB committees and other ethical bodies monitor our experimental protocols involving research into issues of genetic engineering, stem cell research, three-parent embryos, etc. So my argument is that we should not ignore these disputes in the science classroom; this is where the technology is coming from—the STEM laboratories and the people in charge.

This is especially true as scientists have gained technological expertise; we see more clearly than ever how science and technological decisions can wreak havoc in our lives. Think about science in the courtroom, the public policy decisions on health and insurance, the intrusion of listening devices and the tracking of our e-mails and phone calls, the science of warfare and the use of chemical weapons and drones, the use of chemical fertilizers and organic farming, and possible designer babies. Very little that we humans do is not filled with moral or ethical conundrums. No more should we eschew these quandaries in our classrooms. When we discuss DNA genomes, we should not only speak of how the technology can be used to track potential criminals, but also how it can lead to social and personal dilemmas when we identify parentage, plot evolutionary lineages, discover genetically modified food, and detect mutations that might lead to lethal disease and the loss of insurance. How better to deal with such contentious matters than to use case studies? Case studies are stories with an educational message, and as such they are perfect vehicles to integrate science with societal and policy issues. They are ideal because of their interdisciplinary nature. They deal with real issues that students will face in the future. And people love stories.

RESOURCES FOR ETHICS CASES

There are several STEM case repositories in the world; arguably the largest is the National Center for Case Study Teaching in Science, with over 500 case studies published over the past 25 years. Its greatest strength is in the fields of biology and health-related professions. Over 100 cases are catalogued as having ethical issues, ranging in suitability from middle school student classes to faculty seminars.

We seldom find pure instances of ethical transgressions, where issues of fraud, fabrication, or plagiarism are discussed. Rather, ethical issues are more apt to be a sidebar to the main thrust of a case concentrated on a health or environmental problem. And even in these cases, an individual may not be wrestling with problems involving societal standards. Instead, they grapple with whether it is prudent to make one decision versus another. It may be as simple as whether or not to have an operation or whether it is healthy to use drugs to lose weight.

Let me give you a flavor of the kinds of issues and cases that are available:

Personal dilemma

Often such cases involve medical issues, as we see in “A Right to Her Genes” ( http://sciencecases.lib.buffalo.edu/cs/collection/detail.asp?case_id=316&id=316 ). In this true story, students examine the case of a woman, Michelle, with a family predisposition to cancer, who is considering genetic testing. The woman wishes to get some information to confirm this predisposition from a reluctant aunt so that she can better decide whether to remove her breasts and/or ovaries prophylactically. The aunt is illiterate and poor and had previously been estranged from the rest of the family. A genetic counselor is involved to help educate the aunt and hopefully obtain consent to get a DNA sample from her. Michelle must decide for herself what course of action she should take.

In “Spirituality and Health Care: A Request for Prayer” ( http://sciencecases.lib.buffalo.edu/cs/collection/detail.asp?case_id=434&id=434 ), a fourth-year medical student making hospital rounds with an attending physician is asked by a family member of a patient to pray with her. The case allows medical students to explore issues related to patients’ religious beliefs as they think through how they might respond to different expectations and requests they may receive from patients and their families in their professional career.

Social ethics

These are cases where protagonists must decide how they will respond to evolving social standards. “SNPs and Snails and Puppy Dog Tails, and That’s What People Are Made Of” ( http://sciencecases.lib.buffalo.edu/cs/collection/detail.asp?case_id=337&id=337 ) deals with questions of genome privacy. Students work together to research six lobbying groups’ views in this area and then present their insights before a mock meeting of a U.S. House of Representatives Subcommittee voting on the Genetic Information Nondiscrimination Act. In working through the case, students learn about single nucleotide polymorphisms, common molecular biology techniques, and current legislation governing genome privacy.

“A Case of Cheating?” ( http://sciencecases.lib.buffalo.edu/cs/collection/detail.asp?case_id=399&id=399 ) involves two international students who are accused of cheating at the end of the semester, and the teacher must decide how to handle the accusation so that all students see that justice is done. The case raises cultural questions in the context of the use of peer evaluation and cooperative learning strategies.

Medical ethics

Patient rights are a common concern in medical cases, whether they are the central issue of the case or a sidebar to teaching students about a particular disease syndrome. It is the central theme of the infamous “Bad Blood” case involving black men in Tuskegee, Alabama, in the 1920s ( http://sciencecases.lib.buffalo.edu/cs/collection/detail.asp?case_id=371&id=371 ). They had contracted syphilis, and public health officials studying the progress of the debilitating disease originally did not have an effective treatment. Twenty years later, the antibiotic penicillin was discovered, yet treatment was withheld to maintain the integrity of the study, whose purpose was to follow the progression of the disease. The study was immediately stopped when this transgression was made public.

Often there are competing concerns, as when a person is confronted with a decision where their personal morality may be at odds with the decrees of a society or institution. “The Plan: Ethics and Physician Assisted Suicide” ( http://sciencecases.lib.buffalo.edu/cs/collection/detail.asp?case_id=436&id=436 ) is based on an article published in 1991 in the New England Journal of Medicine in which Dr. Timothy E. Quill described his care for a patient suffering from acute leukemia, including how he prescribed a lethal dose of barbiturates knowing that the woman intended to commit suicide. As a consequence of the article’s publication, a grand jury was convened to consider a charge of manslaughter against Dr. Quill. Students read the case and then, as part of a classroom-simulated trial, discuss physician-assisted suicide in terms of fundamental medical ethics principles.

Research ethics

Courses in experimental design are frequently part of psychology curricula. They seldom are part of the typical undergraduate programs in other STEM fields, although there is an excellent resource in the text Research Ethics ( 9 ). Apparently, students in STEM disciplines are supposed to absorb the proper canons of behavior by observation and osmosis.

“A Rush to Judgment” ( http://sciencecases.lib.buffalo.edu/cs/collection/detail.asp?case_id=250&id=250 ) deals with a typical psychological experiment, where a faculty professor is inattentive to his student assistants, one of whom is misrepresenting the results of an experiment. Another student is confronted with a moral dilemma of whether to report this infraction at a potential cost to herself. Involved in the case is a consideration of proper research protocol when dealing with human participants: informed consent, freedom from harm, freedom from coercion, anonymity, and confidentiality. Students are referred to the American Psychological Association's Ethical Principles of Psychologists and Code of Conduct.

“How a Cancer Trial Ended in Betrayal” ( http://sciencecases.lib.buffalo.edu/cs/collection/detail.asp?case_id=233&id=233 ) begins with a quote from a news item.

Birmingham, Alabama —After Bob Lange spent 8 weeks rubbing an experimental cream, BCX-34, from a prominent biotech company BioCryst on the fiery patches on his body, researchers at the University of Alabama at Birmingham told him the drug was defeating the killer inside him. He felt grateful. “I believed it,” he recalls. “I actually thought I might be cured.” But it was a lie. The drug had no effect on Lange’s rare and potentially fatal skin cancer. And the two key people testing the drug knew it. Lange and 21 other patients were victims of fraud—a scheme made possible by the close tie between the university and the state’s most prominent biotech company. — The Baltimore Sun , June 24, 2001

The authors of this fascinating case state that the learning objectives are to learn the basics of scientific research in a clinical trial; to learn the principles of the scientific method; and to consider the ethical issues involved in clinical trials. Ethical potholes litter the road when universities travel with businesses, and millions of dollars and fame are at stake.

Socio-environmental ethics

Conflicting concerns are the norm when dealing with the environmental problems that beset our world. They not only involve scientific principles, but invariably policy and hurly burly politics as well.

“One Glass for Two People: A Case of Water Use Rights in the Eastern United States” ( http://sciencecases.lib.buffalo.edu/cs/collection/detail.asp?case_id=603&id=603 ) focuses on the growing issue of water use. Approximately 1.3 million people in North and South Carolina depend on the Catawba-Wateree River for water and electricity. The river is also important for recreation and real estate development. To meet growing water demands, elected officials in Concord and Kannapolis, NC, petitioned their state government to approve an inter-basin transfer of 25 million gallons of water a day from the Catawba River. Other towns in North Carolina and South Carolina that are part of the Catawba-Wateree watershed fought this request for water transfer. For this exercise, students are divided into teams that take the role of different stakeholders trying to negotiate a settlement to this lawsuit. In the course of the debate, students address fundamental legal, ethical, and environmental questions about water use.

“Ecotourism: Who Benefits?” ( http://sciencecases.lib.buffalo.edu/cs/collection/detail.asp?case_id=359&id=359 ) critically examines the costs and the benefits of visiting fragile, pristine, and relatively undisturbed natural areas. Although ecotourism has among its goals to provide funds for ecological conservation as well as economic benefit and empowerment to local communities, it can result in the exploitation of the natural resources (and communities) it seeks to protect. Students assess ecotourism in Costa Rica by considering the viewpoints of a displaced landowner, banana plantation worker, environmentalist, state official, U.S. trade representative, and national park employee.

Legal ethics

“The Slippery Slope of Litigating Geologic Hazards” ( http://sciencecases.lib.buffalo.edu/cs/collection/detail.asp?case_id=385&id=385 ) is based on a lawsuit brought against the County of Los Angeles by homeowners suing over damage to their homes in the wake of the Portuguese Bend Landslide. It teaches students principles of landslide movement while illustrating the difficulties involved with litigation resulting from natural hazards. Students first read a newspaper article based on the actual events and then receive details about the geologic setting and landslide characteristics. They are then asked to evaluate the possible causes of the disaster and the responsibilities involved.

“The Sad But True Case of Earl Washington: DNA Analysis and the Criminal Justice System” ( http://sciencecases.lib.buffalo.edu/cs/collection/detail.asp?case_id=725&id=725 ) recounts how, in 1983, Earl Washington “confessed” to a violent crime that he did not commit and was sentenced to death row. After spending 17 years in prison for something he did not do, Earl was released in 2001 after his innocence was proven through the use of modern DNA technology. The case guides students through the wrongful incarceration of Earl and explores the biological mechanisms behind DNA profiling and the ethical issues involved.

“Complexity in Conservation: The Legal and Ethical Case of a Bird-Eating Cat and its Human Killer” ( http://sciencecases.lib.buffalo.edu/cs/collection/detail.asp?case_id=664&id=664 ) presents the true story of a Texas man who killed a cat that was killing piping plovers, a type of endangered bird species, and was prosecuted for it. In Texas, it is a crime to kill an animal that “belongs to another,” and there was evidence that another person was feeding the cat, which otherwise appeared to be feral. Students engage in a role-playing activity as jurors; they discuss the case and collectively decide whether the cat killer should be acquitted or convicted. This role-playing coupled with follow-up discussions helps students examine and articulate their own views on a controversial environmental issue and gain a better understanding about the complex interdisciplinary nature of conservation science and practice.

There are plenty of ethical issues in every science classroom to discuss; they are not in short supply. They are hovering around every scientific study that reaches the public eye. Pick any news item with science as its theme and there will be the central question that is often not spoken: should we be doing this research at all, not only because of its economic cost, but because of the social, environmental, or health costs? Surely this should be always a pivotal question in the minds of all citizens. It is sometimes asserted that scientific discovery cannot or should not be stopped—that all knowledge is good. But even if we accept that premise, it seems worthwhile to consider the consequences of our actions. Where else to start than in our classrooms?

Acknowledgments

This material is based upon work supported by the National Science Foundation (NSF) under Grant Nos. DUE-0341279, DUE-0618570, DUE-0920264, and DUE-1323355. Any opinions, findings, conclusions, or recommendations expressed in this material are those of the author and do not necessarily reflect the views of the NSF. The author declares that there are no conflicts of interest.

Using the Evolution of the Instagram User Interface as a Case Study into the Ethical Implications of Infinite Scroll Interface Design

For my thesis portfolio, I chose to write about entirely separate subjects. For the capstone technical report, I chose to write about my experience working a remote, asynchronous job doing AI code training. I was interested in concretely reflecting on the position as it was an incredibly unique experience, with both a very difficult—almost nonexistent–work culture and complex long-term moral implications. For my STS research paper, I chose to write about the ethical implications of Infinite Scroll Interfaces. This interested me because I have struggled a lot with technology addiction and screen time in recent years, especially since the emergence of Tik Tok and widespread Infinite Scrolling applications. Researching and understanding the applications from a design perspective ultimately helped me a lot with my own social media use. In my technical report, I described the unique experience of working for the worker-facing subsidiary of a larger corporation, specifically designed to treat its work force as a fungible, renewable, and ultimately expendable resource. While frustrating given the impersonal nature of the job, the experience also allowed me technical practice in lots of hard skills such as Javascript, C++, SQL, etc. Additionally, the experience offered me the opportunity to become much more confident navigating uncertain work environments. Lastly, it was also a difficult job to wrestle with ethically, given that I was helping improve coding LLMs that have the potential to replace my future jobs. In my STS research paper, I showed how the evolution of Instagram, both from a front-end and back-end design perspective, is emblematic of the disregard for consumer-ethics present in the current social media attention-economy. I argued that Infinite Scroll interfaces have an unparalleled ability to enrapture users into continued use, and how this negatively impacts user well-being. I then described the ethical facets to Infinite Scroll, specifically within the context of treating it as “Engineering as Social Experimentation”. Especially, I highlighted that subject-monitoring, a virtue of ethical engineering that is normally beneficial, in IS media like Instagram is instead used maliciously to increase user-use, target susceptible demographics for advertisements, and generally oppose the other virtues of ethical engineering as social experimentation. Altogether, through writing both essays I learned how cultural, technical and organizational elements all interact together to create a holistic understanding of ethical impact. In my technical report and predating work experience, I was incredibly disappointed with how the lack of company culture and siloed organization led to difficult and ambiguous situations in my technical work. In my research paper, I was disgruntled to discover how the technical implementations of Infinite Scroll interfaces produce negative user-experience and culture. In both essays, considering the STS perspectives of the subject matter helped illuminate ethical concerns that, when looked at surface-level, had been previously easy to miss.

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Research: Negotiating Is Unlikely to Jeopardize Your Job Offer

• Einav Hart,
• Julia Bear,
• Zhiying (Bella) Ren

A series of seven studies found that candidates have more power than they assume.

Job seekers worry about negotiating an offer for many reasons, including the worst-case scenario that the offer will be rescinded. Across a series of seven studies, researchers found that these fears are consistently exaggerated: Candidates think they are much more likely to jeopardize a deal than managers report they are. This fear can lead candidates to avoid negotiating altogether. The authors explore two reasons driving this fear and offer research-backed advice on how anxious candidates can approach job negotiations.

Imagine that you just received a job offer for a position you are excited about. Now what? You might consider negotiating for a higher salary, job flexibility, or other benefits , but you’re apprehensive. You can’t help thinking: What if I don’t get what I ask for? Or, in the worst-case scenario, what if the hiring manager decides to withdraw the offer?

• Einav Hart is an assistant professor of management at George Mason University’s Costello College of Business, and a visiting scholar at the Wharton School. Her research interests include conflict management, negotiations, and organizational behavior.
• Julia Bear is a professor of organizational behavior at the College of Business at Stony Brook University (SUNY). Her research interests include the influence of gender on negotiation, as well as understanding gender gaps in organizations more broadly.
• Zhiying (Bella) Ren is a doctoral student at the Wharton School of the University of Pennsylvania. Her research focuses on conversational dynamics in organizations and negotiations.

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Study Suggests Genetics as a Cause, Not Just a Risk, for Some Alzheimer’s

People with two copies of the gene variant APOE4 are almost certain to get Alzheimer’s, say researchers, who proposed a framework under which such patients could be diagnosed years before symptoms.

By Pam Belluck

Scientists are proposing a new way of understanding the genetics of Alzheimer’s that would mean that up to a fifth of patients would be considered to have a genetically caused form of the disease.

Currently, the vast majority of Alzheimer’s cases do not have a clearly identified cause. The new designation, proposed in a study published Monday, could broaden the scope of efforts to develop treatments, including gene therapy, and affect the design of clinical trials.

It could also mean that hundreds of thousands of people in the United States alone could, if they chose, receive a diagnosis of Alzheimer’s before developing any symptoms of cognitive decline, although there currently are no treatments for people at that stage.

The new classification would make this type of Alzheimer’s one of the most common genetic disorders in the world, medical experts said.

“This reconceptualization that we’re proposing affects not a small minority of people,” said Dr. Juan Fortea, an author of the study and the director of the Sant Pau Memory Unit in Barcelona, Spain. “Sometimes we say that we don’t know the cause of Alzheimer’s disease,” but, he said, this would mean that about 15 to 20 percent of cases “can be tracked back to a cause, and the cause is in the genes.”

The idea involves a gene variant called APOE4. Scientists have long known that inheriting one copy of the variant increases the risk of developing Alzheimer’s, and that people with two copies, inherited from each parent, have vastly increased risk.

The new study , published in the journal Nature Medicine, analyzed data from over 500 people with two copies of APOE4, a significantly larger pool than in previous studies. The researchers found that almost all of those patients developed the biological pathology of Alzheimer’s, and the authors say that two copies of APOE4 should now be considered a cause of Alzheimer’s — not simply a risk factor.

The patients also developed Alzheimer’s pathology relatively young, the study found. By age 55, over 95 percent had biological markers associated with the disease. By 65, almost all had abnormal levels of a protein called amyloid that forms plaques in the brain, a hallmark of Alzheimer’s. And many started developing symptoms of cognitive decline at age 65, younger than most people without the APOE4 variant.

“The critical thing is that these individuals are often symptomatic 10 years earlier than other forms of Alzheimer’s disease,” said Dr. Reisa Sperling, a neurologist at Mass General Brigham in Boston and an author of the study.

She added, “By the time they are picked up and clinically diagnosed, because they’re often younger, they have more pathology.”

People with two copies, known as APOE4 homozygotes, make up 2 to 3 percent of the general population, but are an estimated 15 to 20 percent of people with Alzheimer’s dementia, experts said. People with one copy make up about 15 to 25 percent of the general population, and about 50 percent of Alzheimer’s dementia patients.

The most common variant is called APOE3, which seems to have a neutral effect on Alzheimer’s risk. About 75 percent of the general population has one copy of APOE3, and more than half of the general population has two copies.

Alzheimer’s experts not involved in the study said classifying the two-copy condition as genetically determined Alzheimer’s could have significant implications, including encouraging drug development beyond the field’s recent major focus on treatments that target and reduce amyloid.

Dr. Samuel Gandy, an Alzheimer’s researcher at Mount Sinai in New York, who was not involved in the study, said that patients with two copies of APOE4 faced much higher safety risks from anti-amyloid drugs.

When the Food and Drug Administration approved the anti-amyloid drug Leqembi last year, it required a black-box warning on the label saying that the medication can cause “serious and life-threatening events” such as swelling and bleeding in the brain, especially for people with two copies of APOE4. Some treatment centers decided not to offer Leqembi, an intravenous infusion, to such patients.

Dr. Gandy and other experts said that classifying these patients as having a distinct genetic form of Alzheimer’s would galvanize interest in developing drugs that are safe and effective for them and add urgency to current efforts to prevent cognitive decline in people who do not yet have symptoms.

“Rather than say we have nothing for you, let’s look for a trial,” Dr. Gandy said, adding that such patients should be included in trials at younger ages, given how early their pathology starts.

Besides trying to develop drugs, some researchers are exploring gene editing to transform APOE4 into a variant called APOE2, which appears to protect against Alzheimer’s. Another gene-therapy approach being studied involves injecting APOE2 into patients’ brains.

The new study had some limitations, including a lack of diversity that might make the findings less generalizable. Most patients in the study had European ancestry. While two copies of APOE4 also greatly increase Alzheimer’s risk in other ethnicities, the risk levels differ, said Dr. Michael Greicius, a neurologist at Stanford University School of Medicine who was not involved in the research.

“One important argument against their interpretation is that the risk of Alzheimer’s disease in APOE4 homozygotes varies substantially across different genetic ancestries,” said Dr. Greicius, who cowrote a study that found that white people with two copies of APOE4 had 13 times the risk of white people with two copies of APOE3, while Black people with two copies of APOE4 had 6.5 times the risk of Black people with two copies of APOE3.

“This has critical implications when counseling patients about their ancestry-informed genetic risk for Alzheimer’s disease,” he said, “and it also speaks to some yet-to-be-discovered genetics and biology that presumably drive this massive difference in risk.”

Under the current genetic understanding of Alzheimer’s, less than 2 percent of cases are considered genetically caused. Some of those patients inherited a mutation in one of three genes and can develop symptoms as early as their 30s or 40s. Others are people with Down syndrome, who have three copies of a chromosome containing a protein that often leads to what is called Down syndrome-associated Alzheimer’s disease .

Dr. Sperling said the genetic alterations in those cases are believed to fuel buildup of amyloid, while APOE4 is believed to interfere with clearing amyloid buildup.

Under the researchers’ proposal, having one copy of APOE4 would continue to be considered a risk factor, not enough to cause Alzheimer’s, Dr. Fortea said. It is unusual for diseases to follow that genetic pattern, called “semidominance,” with two copies of a variant causing the disease, but one copy only increasing risk, experts said.

The new recommendation will prompt questions about whether people should get tested to determine if they have the APOE4 variant.

Dr. Greicius said that until there were treatments for people with two copies of APOE4 or trials of therapies to prevent them from developing dementia, “My recommendation is if you don’t have symptoms, you should definitely not figure out your APOE status.”

He added, “It will only cause grief at this point.”

Finding ways to help these patients cannot come soon enough, Dr. Sperling said, adding, “These individuals are desperate, they’ve seen it in both of their parents often and really need therapies.”

Pam Belluck is a health and science reporter, covering a range of subjects, including reproductive health, long Covid, brain science, neurological disorders, mental health and genetics. More about Pam Belluck

The Fight Against Alzheimer’s Disease

Alzheimer’s is the most common form of dementia, but much remains unknown about this daunting disease..

How is Alzheimer’s diagnosed? What causes Alzheimer’s? We answered some common questions .

A study suggests that genetics can be a cause of Alzheimer’s , not just a risk, raising the prospect of diagnosis years before symptoms appear.

Determining whether someone has Alzheimer’s usually requires an extended diagnostic process . But new criteria could lead to a diagnosis on the basis of a simple blood test .

The F.D.A. has given full approval to the Alzheimer’s drug Leqembi. Here is what to know about i t.

Alzheimer’s can make communicating difficult. We asked experts for tips on how to talk to someone with the disease .

• Journalism and Media Ethics Cases
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